Mechanical support for isolated right ventricular failure in patients after cardiotomy.

BACKGROUND: Patients with acute right ventricular (RV) failure after cardiotomy have a poor prognosis. We evaluated the surgical and long-term outcomes of patients with isolated RV failure that required right ventricular assist device (RVAD) support. METHODS: Between 1991 and 2002, a total of 30 patients received RVAD support for isolated RV dysfunction. We evaluated survival, duration of mechanical support, post-RVAD hemodynamics, and RV function. RESULTS: Right ventricular failure developed in patients after coronary artery bypass surgery alone or combined with valve surgery (12 patients), valvular surgery (5), ascending aortic replacement (6), heart transplantation (3), and pulmonary endarterectomy (4). Mean age was 58 +/- 15 years, and 17 (57%) were women. Surgery was emergent in 5 (73%) patients. Centrifugal pumps were used in 21, extra corporeal membrane oxygenation in 8, and as Abiomed pump in 1 patient. Overall, 17 (57%) patients died while receiving assist device support, 3 of sepsis, 2 of stroke, and 12 of inability to wean from the device. We successfully weaned RVAD support in 13 (43%) patients, with a median duration of support of 5 days (range, 2-8 days). Ten survived to hospital discharge. After RVAD removal, mean pulmonary artery pressure was 25.1 +/- 6.5 mmHg, cardiac output was 4.8 +/- 2.0 liters, and central venous pressure was 16.5 +/- 3.7 mmHg. Echocardiogram after RVAD removal showed normal RV function in 2 patients and in 11 patients demonstrated improvement. CONCLUSION: After cardiotomy, patients with RV failure who require mechanical support continue to have increased mortality. For patients successfully weaned from the RVAD, residual RV dysfunction is compatible with survival. More liberal use of RV mechanical support may be indicated for patients with acute RV failure.

Does functional mitral regurgitation improve with isolated aortic valve replacement?

BACKGROUND: The surgical treatment of mitral valve regurgitation (MR) at the time of aortic valve replacement (AVR) remains controversial. The purpose of this study was to evaluate the change in severity of MR following isolated AVR, and to determine survival benefit. METHODS: Between 1991 and 2001, 250 patients underwent isolated AVR; 196 patients had concomitant functional MR. Follow-up transthoracic echocardiography (TTE) was available on 107 patients, with a median of 818 +/- 752 days. Aortic valve was stenotic in 77 and regurgitant in 30 patients. RESULTS: Mean age was 67 +/- 15 years and 57 (53%) were male. Preoperative MR was trivial (1+) in 27 (25%), mild (2+) in 44 (41%), moderate (3+) in 29 (27%), and severe (4+) in 7 (7%). At follow-up TTE, MR improved by 1 or 2 grades in 48 patients (45%). Of patients with preoperative 2+ MR, 19 (43%) improved, 16 (36%) remained unchanged, and 9 (21%) worsened. Although some patients with preoperative 3+ MR exhibited improvement, 11 (38%) remained with moderate-to-severe MR. Of those with a preoperative MR of 4+, 3 (71%) improved, and 4 remained with 3-4+ MR. For patients with preoperative 1 to 2+ MR, survival at 3 years was 98% compared to 78% for those with 3 to 4+ MR (p = 0.038). CONCLUSION: Functional MR does not always improve after isolated AVR. Survival is lower for patients with preoperative 3 to 4+ MR. Moderate-to-severe MR should be repaired at the time of aortic valve surgery.