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Right-to-left veno-arterial shunting for right-sided circulatory failure
J P Slater1, D J Goldstein, R C Ashton
1Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
Background:
Right-sided circulatory failure, a complication of heart transplantation and left ventricular assist device use, results in decreased cardiac output due to diminished flow across the pulmonary circuit. We hypothesized that creation of a controlled right-to-left shunt would result in decompression of the right ventricle and improved systemic cardiac output at tolerable oxygen saturations. We also hypothesized that a peripheral veno-arterial shunt is physiologically superior to a central shunt.
Methods:
Right atrial-femoral artery and right atrial-left atrial shunts were created in a large animal model (calf). Right-sided circulatory failure was induced by banding the pulmonary artery. Hemodynamic measures and blood gas determinations were obtained during nonshunted and shunted states.
Results:
Peripheral and central shunts resulted in decreased right-sided pressures and increased cardiac output. Arterial oxygen saturation remained greater than 90% during shunting. The peripheral shunt had the added advantage of decreasing left ventricular end-diastolic pressure and left ventricular stroke work.
Conclusions:
A controlled right-to-left shunt improved hemodynamics and cardiac output in a large animal model with right-sided circulatory failure. This strategy may be useful in the management of transplant and left ventricular assist device recipients with perioperative right-sided circulatory failure. Our studies also indicate that creation of a peripheral shunt has both physiologic and technical advantages over a central shunt.