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Cavopulmonary anastomosis improves left ventricular assist device support in acute biventricular failure

Cardiothoracic Surgery Division of the Heart Institute (Incor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Received 17 June 2008; received in revised form 12 November 2008; accepted 14 November 2008.

^_* Corresponding author. Address: Division of Surgery, Heart Institute (Incor), Av. Dr. Enéas Carvalho Aguiar, 44, 2° Level, Block 2, Room 13, São Paulo, SP 05403-000, Brazil. Tel.: +55 11 30695075; fax: +55 11 30695075. (Email: dcimoreira{at}incor.usp.br).

Objective: Right ventricular failure during left ventricular assist device (LVAD) support can result in severe hemodynamic compromise with high mortality. This study investigated the acute effects of cavopulmonary anastomosis on right ventricular loading and LVAD performance in a model of severe biventricular failure. Methods: LVAD support was performed by means of centrifugal pump implantation in 14 anesthetized dogs (20–30 kg) with severe biventricular failure obtained by ventricular fibrillation induction. Animals were randomized to be submitted to classical cavopulmonary anastomosis (Glenn shunt) or to control group and were maintained under LVAD support for 2 h. Left and right atrial, right ventricular and systemic pressures were monitored, while total pulmonary flow was simultaneously recorded by transonic flowmeters located on the superior vena cava and pulmonary trunk. Blood gas and venous lactate determinations were also obtained. Results: Ventricular fibrillation maintenance resulted in acute LVAD performance impairment after 90 min in the control group, while animals with Glenn circuit maintained normal LVAD pump flow (55 ± 13 ml kg^–1 min^–1 vs 21 ± 4 ml kg^–1 min^–1, p < 0.001) and better peripheral perfusion (blood lactate of 29 ± 10 pg/ml vs 46 ± 9 pg/ml, p < 0.001). Left and right atrial pressures did not change significantly, while right ventricular pressure was lower in animals with Glenn circuit (13 ± 3 mmHg vs 22 ± 8 mmHg, p = 0.005). Right ventricular unloading with Glenn shunt also resulted in superior total pulmonary flow (59 ± 13 ml kg^–1 min^–1 vs 17 ± 3 ml kg^–1 min^–1, p < 0.001). Conclusion: The concomitant use of cavopulmonary anastomosis during LVAD support in a model of severe biventricular failure limited right ventricular overloading and resulted in better hemodynamic performance.

Key Words: Circulatory support • Assisted circulation • Biventricular failure • Cavopulmonary anastomosis • Right ventricle