Successful management of biventricular heart failure due to cardiac arrest with isolated left ventricular assist device therapy: a case series

Background: The treatment of patients with biventricular heart failure using a left ventricular assist device (LVAD) remains a significant challenge. For patients with cardiac arrest (CA), biventricular assist device (BiVAD) support is necessary; however, it severely impacts their quality of life. We present three patients with CA who initially required BiVAD but were successfully weaned to isolated LVAD therapy. Case Summary: Three men with acute lymphocytic fulminant myocarditis developed cardiogenic shock and CA. After temporary mechanical circulatory support, they received extracorporeal BiVAD, followed by HeartMate3 (HM3) LVAD implantation with continued extracorporeal right ventricular assist device (ex-RVAD) support. Management was focused on ex-RVAD removal by minimizing pulmonary vascular resistance (PVR) with sildenafil (60 mg daily), incrementally adjusting the HM3 pump speed, and intensive lower leg training. The first patient underwent an adjunctive extracardiac total cavopulmonary connection at the time of ex-RVAD removal and has been stable for 27 months. The other two patients underwent ex-RVAD removal without the Fontan procedure and have been stable for 12 and 11 months, respectively. All patients received prophylactic aortic valvuloplasty using Park's stitch (AVP) and multiple diuretics, which enabled hospital discharge. Discussion: These cases demonstrate that long-term isolated LVAD support can be established in patients with CA regardless of adjunctive Fontan procedure. The key principles for successful isolated LVAD support include: (i) minimizing PVR; (ii) incremental adjustment of the LVAD pump speed; and (iii) proactive AVP. This approach enables the hospital discharge of patients who would otherwise require permanent hospitalization with BiVAD.