Percutaneous circulatory support for biventricular failure.

B iventricular (BiV) failure is associated with a high rate of in-hospital mortality despite advances in therapeutic interventions. 1 Multiorgan system dysfunction (MOSD) is a frequent complication of BiV shock and often prohibits surgical ventricular assist device (VAD) placement. Patients with refractory cardiogenic shock may benefit from temporary BiV support to allow for organ recovery and to assess right ven-tricular (RV) function better with mechanical decompression of the left ventricle (LV). 2 We report 2 cases of percutaneous BiV circulatory support with refractory cardiogenic shock. A 67-year-old man with a nonischemic dilated cardiomyopathy presented with acutely decompensated heart failure. An echo-cardiogram showed an LV ejection fraction of 10%, moderately depressed RV function, and moderate tricuspid regurgitation (Movie I in the online-only Data Supplement). Right heart catheterization demonstrated a severely reduced cardiac output, elevated BiV filling pressures, and pulmonary hypertension (Table). The patient eventually developed MOSD refractory to dual inotropes, vasopressors, and a Mega (50 mL) intra-aortic balloon pump (Maquet, Inc). Because of MOSD, the patient was deemed a poor candidate for surgical VAD implantation. An Impella 5.0 axial-flow device was then deployed via the right axillary artery into the LV (Figure 1) to allow for organ recovery and improve RV function (Movie II in the online-only Data Supplement). Despite improved hemodynamics, the patient required increasing inotropic support (Table). Within 48 hours of Impella deployment, a TandemHeart centrifugal flow pump was implanted via the femoral veins as a right atrial to pulmonary artery bypass circuit to support RV function (Movie III in the online-only Data Supplement; Figure 1). Within 24 hours of BiV support, the patient's systemic perfusion improved, ino-trope requirements decreased, and renal function normalized (Table). Definitive surgical biventricular assist device (BiVAD) placement was discussed with the patient's family, who decided that long-term support was not consistent with the patient's wishes and requested withdrawal of care. A 53-year-old woman presented with new onset acutely decompensated heart failure. An echocardiogram showed severe BiV failure with an LV ejection fraction of 10%. Right heart catheterization confirmed the diagnosis of cardiogenic shock despite dual inotropes and an intra-aortic balloon pump (Table). Within 24 hours of admission, the patient developed MOSD. An Impella 5.0 device was deployed via the right femoral artery into the LV and a TandemHeart pump deployed to support RV function. Within 12 hours of BiV support, her hemodynamic parameters and MOSD improved, thereby permitting successful implantation of a surgical HeartWare …