Intracardiac Shunt Reversal and Early Right Ventricular Failure after Left Ventricular Assist Device Implantation

TL;DR

A patient developed right ventricular failure and a reversed heart shunt after a left ventricular assist device was implanted, highlighting the complex interactions between heart devices and intracardiac shunts.

Contribution

This case highlights the reversal of a patent foramen ovale shunt and early right ventricular failure following LVAD implantation, offering insights into device-specific hemodynamic effects.

Findings

A right-to-left shunt through a patent foramen ovale was unmasked after LVAD implantation due to early right ventricular failure.

The patient showed improved hypoxia but worsening RVF after percutaneous PFO closure.

The study outlines potential reasons for PFO-related shunting differences between LVAD and Impella pump use.

Abstract

Right ventricular failure (RVF) is a common complication that occurs after a left ventricular assist device (LVAD) is implanted. We report an interesting case of severe and refractory hypoxia during the early postoperative period after HeartMate3 (HM3) (Abbott Laboratories, Lake Forest, IL) implantation resulting in the unmasking of a right-to-left intracardiac shunt through a patent foramen ovale (PFO), triggered by early RVF. Importantly, the patient had a small left-to-right shunt after receiving a left-sided Impella 5.5 micro-axial pump (Abiomed, Danvers, MA, USA) pre-LVAD implantation. We observed improved hypoxia but worsening RVF after percutaneous PFO closure, necessitating right-sided mechanical circulatory support. We outline potential reasons for the significant PFO-related shunting seen after HM3 implantation, but not after Impella 5.5 placement. Uncertainty exists regarding the approach to a PFO in patients undergoing LVAD implantation. We propose an approach based on existing literature.

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