Right atrial versus right ventricular HeartWare HVAD position in patients on biventricular HeartWare HVAD support: A systematic review

Abstract

In patients with biventricular heart failure or refractory right heart failure following HeartWare HVAD placement, off‐label placement of a right‐sided HeartWare HVAD has been described both in the right ventricular (RV) and right atrial (RA) positions. We sought to evaluate and compare the outcomes of right‐sided HeartWare HVAD using the RA versus RV approach. An electronic search was performed in the English literature to identify all reports of left‐ and right‐heart support with HeartWare HVAD. Of the 1,288 articles identified, 13 articles with 56 cases met inclusion criteria. Patient‐level data were extracted and analyzed. The median patient age was 52 years (IQR 33.0‐59.0) and 40/50 (80.0%) were male. Overall, 21/56 patients (37.5%) had RA HVAD, while 35/56 (62.5%) had RV HVAD. Most underwent concomitant HVAD placement [RA: 17/21 (81.0%) vs. RV: 31/35 (88.6%), P = .69]. In those who did not, the median time between left and right HVAD was 10 days (IQR 7‐14) for RA HVAD and 12 days (IQR 8‐30) for RV HVAD (P = .77). The median time of support was 351 days (IQR 136‐626) for RA HVAD compared to 135 days (IQR 61‐244) for RV HVAD (P = .02). Pump thrombosis occurred at a similar rate [RA: 3/10 (30.0%) vs. RV: 6/20 (30.0%), P = 1], as did GI bleeding [RA: 10/35 (28.6%) vs. RV: 5/21 (23.8%), P = .94] during the follow‐up time period. Kaplan‐Meier analysis when censored for transplant showed higher survival with RA HVAD compared to RV HVAD (P = .036), with an estimated survival at 1 year of 91.7% (95% CI 77.3‐100.0) in RA HVAD versus 66.2% (95% CI 48.9‐89.6) for RV HVAD. RA HVAD appears to be a viable option for durable right‐sided support with outcomes at least comparable to RV HVAD.

Contemporary outcomes of continuous-flow biventricular assist devices

“…Fourteen studies with a total of 399 CF-BiVAD recipients were reviewed. One study was a systematic review (16), and all others were observational studies. Three studies were registry reviews, one Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), one European Registry of patients with Mechanically Assisted Circulatory Support (EUROMACS), and one of the United Network for Organ Sharing (UNOS) database.…”

“…Although device numbers were not consistently reported, most studies delineated which devices were utilized on their participants (Table 3). Eleven of these studies (15,16,(23)(24)(25)(26)(27)(28)(29)(30)(31) utilized the HeartWare HVAD (Medtronic, Minnesota MN) whereas only three studies reported the use of the HeartMate 3 (Abbott, Chicago, IL) (27,32,33) (Figure 2). Timing of RVAD implantation as either concomitant with LVAD versus delayed was reported in most studies (12 of 14) and was predominantly implanted concomitantly (median 82%, IQR 62-84%).…”

“…However, the TAH does not fall into the classification of biventricular assist device (BiVAD) as it replaces the failing ventricles as opposed to assisting them (15). Hence, without an on-label solution, clinicians have resorted to using left-sided continuous-flow ventricular assist devices (VADs) in the right sided position for patients with severe biventricular failure (16).…”

Bridge to transplantation from mechanical circulatory support: a narrative review

“…BiVAD strategies have also utilized off-label placement of continuous flow LVADs in a right atrial or RV position. A systematic review of right-sided use of the HeartWare found that right atrial VAD placement results in a survival advantage compared to RV VAD placement (50). Overall, BiVAD support remains infrequent and is only utilized in approximately 5% of patients with MCS devices (35).…”

In vitro Hemocompatibility Evaluation of the HeartWare Ventricular Assist Device Under Systemic, Pediatric and Pulmonary Support Conditions

“…6,16 In biventricular failure patients, low pump speed of the HVAD as RVAD is used typically 1900 RPM in order to produce low pressure output between 14 -23 mmHg and normal cardiac output between 4 -5 L/min. 9,10,17 While appropriate adjustments to HVAD's operating specifications have reported success supporting right heart failure and pediatric patients, it is potentially associated with a high rates of major adverse events; multisystem organ failure, neurological dysfunction, respiratory failure, pump thrombosis, infection, stroke, and major bleeding. 10,[18][19][20][21][22] This study was designed to evaluate the effect of HVAD on hemolysis, platelet activation and vWF degradation in adult systemic, pediatric systemic and adult pulmonary flow conditions.…”