Biventricular Assist Devices for Acute Heart Failure After Orthotopic Liver Transplantation

Background: Medical comorbidities augment surgical risk of liver transplantation. This is a report of immediate post-operative biventricular failure following liver transplant requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent conversion to minimally invasive biventricular assist devices (BIVAD) for cardiac recovery and liver graft preservation. Case Report: 66-year-old male decompensated alcoholic cirrhotic with a pre-operative stress echocardiogram (ECHO) showing no significant valvular or coronary disease and a left ventricular ejection fraction (LVEF) of 65% underwent liver transplantation. Transesophageal echocardiogram at the conclusion of the case demonstrated a LVEF of 10% with biventricular dysfunction and severe mitral regurgitation requiring four pressors. VA-ECMO was initiated for temporary stabilization with subsequent transition to biventricular support using an Impella® 5.5 left ventricular device (VAD) via axillary artery graft and a Protek-Duo percutaneous right VAD via the right internal jugular vein, both placed peripherally through a minimally invasive approach. Serial echocardiograms showed recovery of myocardial function. BIVAD were removed on day 8 and day 13. Excellent liver function was maintained. Conclusion: This is the first report of minimally invasive BIVAD used for acute cardiogenic shock after liver transplantation. A multidisciplinary team approach to prompt mechanical support ensured preservation of liver graft while allowing for cardiac recovery.