Poster 1019: Early Right Ventricular Failure Post-LVAD Implantation Rescued with Right-Sided Microaxial Circulatory Support (Impella RP Flex): A Case Report

Background: Right ventricular failure (RVF) is a known potential complication for patients undergoing durable left ventricular assist device (LVAD) implantation. RVF can occur at various timepoints but most commonly occurs in the early postoperative period. While early recognition and intervention of RVF is crucial, support strategy timing and selection remains challenging.

Methods: A 44-year-old male with new diagnosis of idiopathic non-ischemic cardiomyopathy was referred to the cardiac catheterization lab given progressive symptoms and poor tolerance of medical therapy concerning for low-output heart failure. Echocardiography was significant for a severely dilated left ventricle with an internal diameter at end-diastole of 7.8 cm, an ejection fraction of 15-20%, and moderate-severe right ventricular dysfunction. Right heart catheterization noted mildly elevated left- and right-sided filling pressures with decreased cardiac index of 1.62 L/min/m2. Calculated RV functional parameters included a right atrial to wedge pressure ratio of 0.5, a pulmonary artery pulsatility index (PAPi) of 1.45, and a right ventricular stroke work index (RVSWI) of 4.4 g/m/beat/m2. The patient was started on single inotrope and admitted for expedited advanced therapies evaluation, opting for destination therapy-modifiable LVAD implantation given psychosocial constraints and history of substance use. With decongestion and inotrope titration, pre-LVAD hemodynamics revealed favorable RV parameters including a right atrial pressure of 7 mmHg and PAPi of 3.43. The patient underwent uncomplicated LVAD implantation via sternotomy, with intraoperative course notable for moderate vasoplegia and separated from cardiopulmonary bypass with LVAD at 4800 RPMs on moderate vasoactive and inotropic support.

Outcome: Our patient was extubated on post-operative day 1, initially exhibiting adequate end-organ function and early ambulation. On post-operative day 3, symptomatic hypotension and a rising CVP prompted an echocardiogram that noted intraventricular septal flattening and overt RV dysfunction. Despite serial LVAD speed adjustments, escalating inotrope, and aggressive decongestion attempts, there was acute decline in CI from 3.1 to 2.1 L/min/m2, oliguria, and recurrent low flow alarms. Following multidisciplinary discussion with cardiothoracic surgery, cardiac anesthesia, interventional cardiology, and heart failure cardiology, the decision was made to place an Impella RP Flex (Abiomed, Danvers, MA) via right internal jugular venous access. Following this intervention, invasive hemodynamic markers dramatically improved, and volume status was optimized, avoiding the need for renal replacement therapy. The Impella RP Flex was gradually weaned and explanted after 10 days. Notably, our patient remained ambulatory, including while temporary RV mechanical circulatory support was in place, maintaining mobility and progressing with post-cardiac surgery rehabilitation while resting the RV. Inotropes were gradually weaned and our patient ultimately discharged home.

Conclusion: This case illustrates the utilization and unique advantages of a right internal jugular-access microaxial flow device following durable LVAD implantation. While early RVF recognition remains paramount, implanting centers should consider patient-specific factors including vascular access, mobility status, and timing of intervention when considering temporary mechanical circulatory RV support needs.