Asad Ali Usman

Patients requiring a right ventricular assist device (RVAD) after durable left ventricular assist device (LVAD) surgery have historically worse outcomes than those with isolated LVADs. Preoperative mechanical circulatory support (MCS) with venoarterial extracorporeal membrane oxygenation (ECMO) or micro-axial pumps complicates right heart assessment by altering loading conditions. We examined 1 year outcomes of patients receiving temporary RVADs at the time of durable LVAD. From February 2017 to August 2025, 102 patients were reviewed. Right ventricular assist device decannulation, ventilator liberation, and intensive care unit (ICU) discharge were assessed using Fine–Gray subdistribution analysis with death as a competing risk; 1 year survival was evaluated by Kaplan–Meier analysis. Analysis included 59 planned, 28 unplanned, and 15 delayed RVADs (45 percutaneous, 57 surgical). One year survival was 64.0 ± 6.5% for planned, 50.2 ± 10.3% for unplanned, and 50.3 ± 13.6% for delayed RVAD. Percutaneous and surgical RVAD survival were 60.1 ± 7.5% and 55.1 ± 7.1%. Preoperative MCS was independently associated with improved survival (hazard ratio [HR]: 0.36, confidence interval [CI]: 0.17–0.83), with micro-axial pump showing the strongest association. Preoperative micro-axial support and planned RVAD were associated with improved 1 year survival after durable LVAD surgery; whether this reflects a causal relationship where the preconditioning of the right ventricle improves postoperative outcomes cannot be determined from this retrospective design.

Mechanical circulatory support (MCS) as a bridge to lung transplant is an infrequent but accepted pathway in patients who have refractory end-stage pulmonary failure. The American Association of Thoracic Surgeons Expert Consensus Guidelines, published in 2023, recommends venovenous (VV) extracorporeal membrane oxygenation (ECMO) as the initial configuration for those patients who have failed conventional medical therapy, including mechanical ventilation, while waiting for lung transplantation and needing MCS. Alternatively, venoarterial (VA) ECMO can be used in patients with acute right ventricular failure, hemodynamic instability, or refractory respiratory failure. With the advancement in percutaneous venopulmonary (VP) ECMO cannulation techniques, this option is becoming an attractive configuration as bridge to lung transplantation. This configuration enhances stability of the right ventricle, prevents recirculation with direct introduction of pulmonary artery oxygenation, and promotes hemodynamic stability during mobility, rehabilitation, and sedation-weaning trials before lung transplantation. Here, we present a case series of eight percutaneous VP ECMO as bridge to lung transplant with all patients mobilized, awake, and successfully transplanted with survival to hospital discharge.

COVID–19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.