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Ventricular assist devices are used in patients with heart failure refractory to standard management. Though left ventricular assist devices are more often used, patients with severe right ventricular dysfunction may also be treated with mechanical support. This case presents a patient with mixed cardiogenic and septic shock requiring placement of a percutaneous right ventricular assist device. A 38-year-old obese male with a medical history of alcoholism presented to the hospital with a complaint of dyspnea. He was found to have volume overload and was given intravenous diuretics. However, he had progressive renal insufficiency, hypotension requiring vasopressor support, and worsening respiratory status requiring mechanical ventilation. An echocardiogram showed a severely enlarged right ventricle, reduced RV function, normal RV wall thickness, moderate to severe tricuspid regurgitation, a severely dilated right atrium, ventricular septal flattening, and mild pulmonary hypertension. Left ventricular ejection fraction was 65-70%, LV diastolic function was normal, and there were no other significant valvular abnormalities. Troponin levels, ECG, and CT pulmonary angiography were unrevealing. Right heart catheterization showed a right atrial pressure of 29 mmHg (2 – 6 mmHg), right ventricular pressures of 50/24 mmHg (15-25/0-8 mmHg), pulmonary artery pressures of 56/35/43 mmHg (15-25/8-15/10-20 mmHg), a pulmonary capillary wedge pressure of 22 mmHg (6-12 mmHg), and a Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) score of 0.3 to 0.6 (>1). Cardiac chamber oxygen saturations did not demonstrate intracardiac shunting. A right-sided mechanical circulatory support device was placed. The hospital course was complicated by sepsis due to pneumonia and presumed central line-associated bloodstream infection requiring antibiotic therapy, anemia secondary to device-related hemolysis requiring blood transfusions, renal failure requiring renal replacement therapy, and candidemia requiring antifungal therapy. Due to concern for device-associated infection, his central lines were replaced. The mechanical circulatory support device was able to be removed after ten days. Subsequent cardiac imaging did not reveal any other structural abnormalities, and a definitive cause for the right heart failure was not determined. Etiologies of right-sided heart failure include left-sided heart failure, pulmonary hypertension, chronic pulmonary disease, myocardial infarction, pulmonary embolism, myocarditis, valvular dysfunction, and congenital anomalies. Mechanical circulatory support may be used to support cardiac function, to allow the ventricular function to improve. Potential complications of mechanical circulatory support include infection, hemolysis, bleeding, device migration, and malfunction. RVAD therapy should be considered for patients with isolated right ventricular failure refractory to less invasive therapy. |
