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Right heart interaction with the mechanically assisted left heart

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Abstract

Right ventricular (RV) failure has been reported to be a problem in 49 of 213 patients who received left ventricular assist devices (LVAD) at 12 different centers. Although the pathology of the problem is not understood, it is clear that the effect of an LVAD on hemodynamic ventricular interactions due to the right and left hearts being in series, and on mechanical ventricular interactions due to the anatomic coupling between the ventricles, could play a role in determining the ultimate fate of the right ventricle. Six hypotheses were generated concerning beneficial and detrimental effects of an LVAD on the determinants of right ventricular function (preload, afterload, contractility). The major potential effect on RV preload is increased venous return produced by the LVAD which can overload a marginal RV; but beneficial effects on RV preload and filling also can be produced by the LVAD unloading a dilated LV, thereby shifting the interventricular septum, which had encroached into the RV, back to the left. A significant beneficial effect on RV afterload can be produced with an LVAD by passive reductions in pulmonary artery (PA) pressure secondary to reductions in left atrial pressure; with pulmonary obstructive disease, however, PA pressures can increase due to the greater blood flow through the fixed pulmonary vascular resistance. The major effects on RV contractility produced by an LVAD are significantly beneficial since aortic and, therefore, coronary perfusion pressure is maintained. There also is a potential detrimental effect on RV contractility produced by decreased septal contribution to RV contraction during complete LV unloading with an LVAD. The initial therapy for the failing right ventricle in patients with an LVAD is volume loading. Isoproterenol, dobutamine, and dopamine can be used for inotropic support, and atrial pacing can improve the atrial contribution to filling. If these modalities fail, surgical techniques including pulmonary artery balloon pump or extracorporeal membrane oxygenation can be tried, but the recommended mechanical support is a right ventricular assist device.

Résumé

Parmi 213 patients de 12 centres différents qui ont bénéficié d'un système d'assistance du ventricule gauche (SAVG), 49 ont posé le problème d'une défaillance ventriculaire droite. Bien que la physiopathologie du problème ne soit pas comprise, il est clair que l'effet d'un système d'assistance du ventricule gauche sur les interactions ventriculaires hémodynamiques liées au fait que ventricule droit et gauche sont en série, ainsi que des interactions mécaniques entre les deux ventricules (liées à leur couplage anatomique) peuvent jouer un rôle dans le devenir du ventricule droit. Six hypothèses ont été avancées concernant les avantages et les inconvénients d'un système d'assistance du ventricule gauche pour les déterminants de la fonction ventriculaire droite (précharge, postcharge, contractilité). Le principal effet potentiel sur la précharge ventriculaire droite est un retour veineux accru provoqué par le système d'assistance du ventricule gauche et qui peut constituer une surcharge pour le ventricule droit. En revanche, un effet bénéfique sur la précharge et le remplissage du ventricule droit peut résulter d'une décharge par le système d'assistance d'un ventricule gauche dilaté en ramenant vers la gauche le septum interventriculaire. Un effet bénéfique sur la postcharge du ventricule droit peut également être obtenu grâce au système d'assistance du ventricule gauche par diminution passive des pressions de l'artère pulmonaire liée à la baisse de la pression auriculaire gauche; cependant en cas maladie pulmonaire obstructive, les pressions dans l'artère pulmonaire peuvent augmenter en raison d'un débit cardiaque accru au travers de résistances vasculaires pulmonaires fixées. Les effets du système d'assistance du ventricule gauche sur la contractilité du ventricule droit sont essentiellement bénéfiques dans la mesure ou le débit aortique et ainsi la pression de perfusion coronaire sont maintenus. Un éventuel effet délétère sur la contractilité du ventricule droit est lié à la diminution de la contribution du septum dans la contraction du ventricule droit, phénomène dû à la décharge complète du ventricule gauche par le système d'assistance.

Le traitement initial de la défaillance ventriculaire droite chez les patients sous assistance ventriculaire gauche est le remplissage.

L'isoproterenol, la dobutamùine et la dopamine peuvent être utilisées pour leur effet inotrope positif et le pacing auriculaire peut améliorer la contribution de l'oreillette au remplissage du ventricule; si ces mesures thérapeutiques sont insuffisantes des techniques chirurgicales incluant le ballon de contrepulsion de l'artère pulmonaire ou l'assistance circulatoire avec oxygénation extra-corporelle peuvent être tentées mais un système d'assistance mécanique du ventricule droit paraît plus recommandé.

Resumen

La falla del ventrículo derecho (VD) ha sido informada como problema real en 49 de 213 patientes sometidos a sistemas de asistencia mecánica del ventrículo izquierdo (AMVI) en 12 centros médicos diferentes. A pesar de que aún no se conoce bien la patología del problema, parece claro que el efecto de la AMVI sobre las interacciones hemodinámicas ventriculares (que se deben a que el corazón derecho y el corazón izquierdo están en serie) y sobre las interacciones mecánicas ventriculares (que se deben al acoplamiento anatómico entre los ventrículos) puede tener influencia en la determinación del destino final del VD. Se generaron seis hipótesis relativas a los efectos benéficos o nocivos de una AMVI sobre los factores determinantes de la función ventricular derecha (precarga, postcarga, contractilidad). El mayor efecto potencial sobre la precarga del VD es el aumento en al retorno venoso producido por la AMVI, que puede sobrecargar un VD con función marginal; pero los efectos benéficos sobre la precarga y llenamiento del VD también pueden ser ejercidos por la AMVI al descargar un VI dilatado, con lo cual se restituye la posición normal del septo interventricular que desviado hacia la derecha, protruía sobre el VD. Un efecto benéfico de significación sobre la postcarga del VD puede ser producido por la AMVI mediante las reducciones pasivas de la presión de la arteria pulmonar (AP) secundarias a las reducciones en la presión de la aurícula izquierda; sinembargo, en presencia de enfermedad pulmonar obstructiva, las presiones en la AP pueden verse aumentadas debido al mayor flujo sanguíneo a través de una resistencia vascular pulmonar fija. Los mayores efectos sobre la contractilidad del VD que produce la AMVI son significativamente benéficos, puesto que se mantiene la perfusión aórtica y por consiguiente la perfusión coronaria. También hay un efecto potencialmente desventajoso sobre la contractilidad del VD, producido por una disminuída contribución septal a la contracción del VD durante la descarga total del VI por la AMVI. La terapia inicial para el ventrículo derecho que falla en pacientes con AMVI, es la carga de volumen. El isoproterenol, la dobutamina y la dopamina pueden ser utilizados para soporte inotrópico, y el control de la contracción auricular puede mejorar la contribución atrial al llenamiento ventricular. Si estas modalidades fallan, pueden ensayarse técnicas de tratamiento quirúrgico que incluyen el balón de bombeo en la arteria pulmonar y la oxigenación extracorpórea por oxigenador de membrana. Pero el sistema recomendable de soporte mecánico es un sistema de asistencia ventricular derecha.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Pacific Medical Center, Room P3378, P.O. Box 7999, 94120, San Francisco, California, USA

    David J. Farrar Ph.D., Peter G. Compton M.S., James J. Hershon M.D., James D. Fonger M.D. & J. Donald Hill M.D.

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  1. David J. Farrar Ph.D.
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  2. Peter G. Compton M.S.
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  3. James J. Hershon M.D.
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  4. James D. Fonger M.D.
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  5. J. Donald Hill M.D.
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Supported in part by National Heart, Lung and Blood Institute grant #HL27275.

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Farrar, D.J., Compton, P.G., Hershon, J.J. et al. Right heart interaction with the mechanically assisted left heart. World J. Surg. 9, 89–102 (1985). https://doi.org/10.1007/BF01656260

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