Severe pulmonary valve insufficiency caused by transjugular cannulation of pulmonary artery for right ventricular assist device: diagnosis and surgical solution—a case report

Abstract Implantation of a temporary percutaneous right ventricular assist device (RVAD) in patients with right heart failure after left ventricular assist device (LVAD) implantation is an established technique that may cause complications. We present a 60-year-old male patient who underwent urgent LVAD implantation. On the second postoperative day the patient developed acute right heart failure. We implanted a temporary percutaneous RVAD with two cannulas via the right internal jugular vein and the right femoral vein. Transesophageal echocardiography revealed severe pulmonary insufficiency. After performing re-sternotomy we anastomosed a prosthetic graft to the pulmonary trunk (PT), performed subxiphoid tunneling of the graft and replaced the transjugular outflow cannula. The pulmonary regurgitation caused by the percutaneous transvalvular cannula disappeared. In such case a direct anastomosis to the PT is the solution.


INTRODUCTION
Right heart failure after left ventricular assist device (LVAD) implantation presents a major challenge. Early right heart failure affects up to 15% of patients post LVAD implantation [1]. Mechanical support of the right ventricle is considered mandatory. Implantation of a temporary percutaneous right ventricular assist device (RVAD) with a centrifugal pump is an established technique to treat postoperative right heart failure in this setting [2,3].

CASE PRESENTATION
A 60-year-old male patient (172 cm, 70 kg, body mass index 23.7 kg/m 2 ) with a history of ischemic cardiomyopathy, first diagnosed 23 months ago, was admitted with acute on chronic heart failure. He presented with progressive dyspnea for 2 days and persistent nausea that was linked to a history of chronic gastritis. The patient's history included paroxysmal atrial fibrillation under oral anticoagulation with rivaroxaban, as well as arterial hypertension, chronic kidney disease and hepatomegaly. Coronary artery disease had been treated with percutaneous transluminal coronary angioplasty and drug-eluting stents and currently required no intervention.
The transthoracic echocardiogram revealed severe dilatation of the left ventricle with a left ventricular end-diastolic diameter of 7.4 cm and a left ventricular systolic function of 15-20% (using Simpson's biplane method of disks). The size of the right ventricle was normal. The right ventricular systolic function was mildly reduced by visual estimation. There was moderate to severe mitral regurgitation. The aortic valve was normal. The pulmonary and tricuspid valves showed trivial regurgitation (Fig. 1, Video S1 in the Supplementary Material online).
While inotropic support continuously declined, the decision was made to proceed with urgent LVAD implantation (HeartWare, HVAD) via full median sternotomy using an off-pump technique. Intraoperative transesophageal echocardiography confirmed a correct position of the inf low cannula and a moderately reduced right ventricular function with moderate tricuspid regurgitation despite the use of nitric oxide ventilation and continuous application of inotropes.
Initially inotropes could be discontinued and nitric oxide ventilation tapered adequately. The patient was extubated 6 h after arrival at the intensive care unit.  On the second postoperative day the patient showed hemodynamic impairment with signs of right ventricular failure. A temporary percutaneous RVAD was implanted with two cannulas via the right internal jugular vein (IJV) and the right femoral vein (FV). Despite RV support, LVAD f low did not increase and hemodynamic instability failed to improve. Transthoracic echocardiography revealed severe pulmonary insufficiency caused by the cannula of the RVAD. The blood recirculated in the congested right ventricle (Fig. 2, Videos S2 and S3 in the Supplementary Material online).
Re-sternotomy was performed. The pulmonary trunk (PT) was clamped. A 10-mm prosthetic polyester graft was anastomosed to the PT. After subxiphoid tunneling of the graft the transjugular outf low cannula was replaced by a cannula in the anastomosed graft. The cannula in the right FV remained in position in the right atrium (Figs 3 and 4). The hemodynamic situation with LVAD and RVAD f low improved immediately.
After 23 days of RVAD support both cannulas were explanted. The cannula in the FV was only punctured, allowing pull it out simply. The subxiphoid tunneled graft was stretched, ligated and cut very short to allow it to retract into the thorax.   In conclusion, the pulmonary artery cannula of the percutaneous RVAD may cause severe pulmonary insufficiency. In such case, a direct anastomosis to the PT is the solution.

SUPPLEMENTARY MATERIAL
Supplementary material is available at Journal of Surgical Case Reports online.

DATA AVAILABILITY
Data is available upon request.