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PubMed2000

Late arrhythmia in adults with the mustard procedure for transposition of great arteries: a surrogate marker for right ventricular dysfunction?

OBJECTIVE: To examine the relation between ventricular dysfunction and late clinical arrhythmia in adults who underwent the Mustard procedure for transposition of the great arteries. DESIGN: Observational study based on periodic outpatient assessment of biventricular function. SETTING: Tertiary referral centre. INTERVENTIONS: Analysis of data from 12 lead ECGs, echocardiography, exercise radionuclide ventriculography, and magnetic resonance imaging. MAIN OUTCOME MEASURES: Clinical outcome and late onset clinical arrhythmia during follow up. ECG and ventricular function indices obtained before arrhythmia onset were used for analysis. RESULTS: 51 patients (mean (SD) age 25.7 (5.0) years) fulfilled entry criteria at a mean of 23.4 (4.0) years after the Mustard procedure. Late arrhythmia occurred in 11 (22%): sustained atrial flutter/fibrillation in 10, ventricular tachycardia in one. Compared with patients who remained arrhythmia free, patients with arrhythmia had longer QRS (129 (26) v 112 (16) ms, p = 0.01), greater QT dispersion (107 (28) v 51 (24) ms, p < 0.001), and increased ratio of right to left ventricular end diastolic diameter (2.4 (0.9) v 1.7 (0.7), p = 0.02), but no difference in wall thickness. Systemic ejection fraction was also reduced in the arrhythmia subgroup (at rest: 34.1 (13)% v 47 (16)%, p = 0.04; during exercise: 37.8 (12)% v 52 (17)%, p = 0.03). QRS duration correlated with right ventricular end diastolic diameter (r = 0.59, p < 0.001), suggesting a possible mechano-electric relation after the Mustard procedure. QT dispersion was the only predictor of clinical arrhythmia in multivariate analysis. CONCLUSIONS: Impaired ventricular function in adults with the Mustard procedure for transposition of the great arteries relates to clinical arrhythmia. Late atrial flutter/fibrillation may be a surrogate marker for ventricular dysfunction, and these patients may also be at risk of ventricular tachycardia.

Adult↗
PubMed1986

Effects of elevated coronary sinus pressure on left ventricular function after the Fontan operation. An experimental and clinical correlation.

An experimental model was devised to evaluate the effects of elevated coronary sinus pressure on left ventricular performance. Thirteen mongrel dogs were used. The coronary sinus was cannulated and its entire blood flow diverted into a reservoir. The pressure in the coronary sinus was increased from 5 to 25 torr by elevating the drainage reservoir in a stepwise fashion. Cardiac index, coronary arteriovenous difference, rate of rise of left ventricular pressure, left ventricular systolic time intervals, and coronary blood flow were measured. When the coronary sinus pressure reached 15 torr, there was a significant decrease in cardiac index (3.60 +/- 0.5 to 2.70 +/- 0.6 L/min/m2, p less than 0.001), coronary blood flow (13.7 +/- 3.1 to 7.0 +/- 2.1 ml/min, p less than 0.001), rate of rise of left ventricular pressure (1,567 +/- 275 to 1,331 +/- 314, p less than 0.05), and an increase in coronary arteriovenous difference (62.8% +/- 9.3% to 70.5% +/- 5.4% saturation, p less than 0.03). These experimental results were correlated with postoperative catheterization findings in 24 patients with the Fontan procedure. Patients with a mean right atrial pressure less than 15 torr had a left ventricular ejection fraction of 93% +/- 6% of predicted, whereas patients with a right atrial pressure of 15 torr or more had a left ventricular ejection fraction of 75% +/- 13% of predicted (p less than 0.001). These experimental and clinical data strongly suggest that elevated coronary sinus pressure has deleterious effects on ventricular function after the Fontan procedure. Modifications of the procedure, such as using the rudimentary right ventricle when feasible or diverting coronary sinus flow to the pulmonary venous atrium, might decrease coronary sinus hypertension and improve long-term results.

Animals↗
PubMed1997

Prejunctional neuropeptide Y receptors in human kidney and atrium.

The aim of our study was to characterize functionally prejunctional neuropeptide Y (NPY) receptors in human and rabbit renal cortex, as well as in human right atrium. Segments of human atrial appendages and of human and rabbit renal cortex were preincubated with [3H]noradrenaline, superfused with Krebs-Henseleit solution and stimulated electrically in superfusion chambers. The stimulation-induced outflow of radioactivity was taken as an index of endogenous noradrenaline release. The effects of subtype-selective NPY analogs on the stimulation-induced noradrenaline release were studied. NPY, its endogenous analog, peptide YY, and its C-terminal fragment, NPY13-36, but not its analog, [Leu31,Pro34]NPY, concentration dependently (1-100 nM) inhibited [3H]noradrenaline release in all tissues studied. NPY-induced inhibition of [3H]noradrenaline release in human and rabbit kidney was abolished by pretreatment with pertussis toxin. We conclude that prejunctional inhibition of noradrenaline release in human heart and human and rabbit kidney occurs through NPY receptors of the Y2 subtype, which appear to couple to a pertussis toxin-sensitive G protein.

Animals↗
PubMed1984

Entrainment of atrioventricular nodal reentrant tachycardias during overdrive pacing from high right atrium and coronary sinus. With special reference to atrioventricular dissociation and 2:1 retrograde block during tachycardias.

Entrainment was attempted during electrophysiologic evaluation of 8 patients with atrioventricular (AV) nodal reentrant tachycardia. Entrainment could be performed while pacing from the high right atrium in 35 of 35 episodes, from proximal coronary sinus in 9 of 21 episodes and from distal coronary sinus in 10 of 20 episodes. The minimal rates required were 8 to 40 beats/min faster than those of the tachycardias. That the atria (as defined in electrophysiologic studies) were not a necessary component of the reentry circuit was suggested by the occurrence, during tachycardia, of short episodes of AV dissociation and of 1 episode of 2:1 retrograde block. For the tachycardia to be interrupted, the pacing rate usually had to be slightly faster than that required to entrain, as well as sufficiently rapid to produce anterograde block of an atrial impulse in the slow AV nodal pathway. Moreover, termination of tachycardia apparently was a function of the pacing site. In some episodes, either because of a proximity effect or because of a preferential input into the upper common pathway, coronary sinus pacing terminated the tachycardia at slower rates or with fewer stimuli than high right atrial pacing. Thus, patients with drug-resistant AV nodal reentrant tachycardias may benefit from recently introduced pacing techniques for termination of tachycardia through entrainment.

Adolescent↗
PubMed1989

Autoperfusing ectothermic heart-lung preservation system.

A portable heart-lung preservation system was developed to enable distant organ procurement. In 8 dogs, a functioning heart-lung system was isolated, cannulated in situ, removed en bloc, and placed into a Plasmalyte-filled, temperature-controlled (15-38 degrees C) chamber. The perfusion circuit consisted of an adjustable-height, autologous-blood reservoir. The heart ejected through the aortic cannula with venous return (VR) into the superior vena cava. Respiration was maintained with a positive pressure ventilator. Intramyocardial tissue pressure (IMP), tissue pH, right atrial (RAP), aortic pressure (AOP), and cardiac output (CO) were monitored. Autoperfusion at normothermia and CO of 50 mL/min/kg resulted in early (3 h) deterioration of pulmonary function with progressive interstitial lung edema. Pulmonary dysfunction always preceded changes in regional myocardial contractile viability (peak IMP and d(IMP)/dt) and global function (CO, AOP). When tissue pH was regulated ectothermically (as in cold-blooded animals) (delta pH/degrees C = -0.015) the heart maintained a stable pumping mode (greater than 6 h) at myocardial temperatures of 17-28 degrees C, pH = 7.70-7.55, and heart rate of 25-50 bpm, respectively. The results indicate that a viable (greater than 6 h) autoperfused, working heart-lung system can be achieved by reducing the circulating blood flow to 30-50% of normal CO. More significantly, ectothermic alpha-stat modulation of perfusate pH and pCO2 allows a substantial reduction in organ temperature and metabolic demand without endangering induction of fibrillation and ultimate allograft failure.

Animals↗
PubMedDate not supplied

[Ebstein's anomaly related with significant pericardial effusion. Report and analysis of a case].

Ebstein's anomaly is a malformation of the tricuspid valve characterized from the clinical view point by dysnea, evolutive cyanosis and fatigue. Is it characterized anatomically by a downward displacement of the tricuspid valve into the right ventricle due to anomalous attachment of the tricuspid leaflets. Because of the abnormally situated tricuspid orifice, a portion of the right ventricle lies between the atrioventricular ring and the origin of the valve, that is, an "atrialized" segment of the ventricle, and they have a functionally small ventricular chamber. Roentgenographic studies, usually demonstrate a characteristic enlarged heart. The globular-shaped heart on a chest X-ray may closely resemble the picture usually associated with a large pericardial effusion. The ecocardiographic study is more specific for the differential diagnosis, and usually eliminates one pathology but confirms the other. The patient that we are presenting is unusual, and, as far as we know, it is the only in the literature case in which there is a coexistence of the important pericardial effusion and the Ebstein's anomaly. We review the functional abnormalities of the right ventricle with Doppler and two-dimensional echocardiography in this patient.

Adult↗
PubMed1992

Combined invasive and noninvasive study of left ventricular systolic and diastolic function following acute administration of cicloprolol to subjects with normal cardiac function.

Cicloprolol is a new beta-blocking agent with high selectivity for beta 1 receptors and high intrinsic sympathomimetic activity. We studied the acute hemodynamic effects of cicloprolol in nine subjects with no evidence of left ventricular dysfunction who underwent cardiac catheterization for the evaluation of chest pain. All patients had normal coronary angiography and left ventriculography. Left ventricular pressure was determined throughout the cardiac cycle using a Millar 8Fr Minotip catheter; an echocardiogram, phonocardiogram, and ECG were simultaneously recorded to obtain left ventricular pressure-diameter loops. All the measurements were repeated before and after the intravenous administration of cicloprolol. Cicloprolol was administered at increasing doses of 0.05, 0.10, and 0.25 mg/kg until a cardiac output increase of at least 15% over basal values was achieved. A decrease of mean arterial pressure or cardiac output after cicloprolol was not observed in any patient. Cicloprolol administration significantly increased cardiac output (24%), stroke volume (22%), and peak positive dP/dt (25%); no significant changes in heart rate, systemic blood pressure, right atrial pressure, or pulmonary artery pressures were observed. No significant change in the echocardiographic parameters occurred. Among the indices of left ventricular diastolic function, the time constant of isovolumetric relaxation was significantly decreased (-43%) after cicloprolol; moreover, the left ventricular pressure-diameter loop in the protodiastolic phase was shifted to the left following cicloprolol infusion. This study confirms that in subjects with normal left ventricular function cicloprolol can improve resting left ventricular systolic function, and it shows that this action can also be attended by a more rapid isovolumetric relaxation, similar to what has been observed with other sympathomimetic amines.

Adrenergic beta-Agonists↗
PubMed1994

Transcatheter ablation of posteroseptal accessory pathways using a venous approach and radiofrequency energy.

BACKGROUND: The efficacy of transcatheter ablation of atrioventricular (AV) accessory pathways (APs) located in the posteroseptal region using a right atrial approach and radiofrequency energy was evaluated. METHODS AND RESULTS: Fifty consecutive patients with APs in the posteroseptal region underwent radiofrequency catheter ablation. Manifest preexcitation was present in 36 patients and a concealed AP in 14. In 18 patients (group 1), the ventriculoatrial (VA) interval during orthodromic tachycardia was prolonged by 21 +/- 7 milliseconds (range, 10 to 30 milliseconds) with functional left bundle-branch block. In 16 patients (group 2), functional left bundle-branch block caused no VA interval prolongation. The remaining 16 patients (group 3) had no inducible left bundle-branch block during orthodromic tachycardia. Functional right bundle-branch block was induced in 30 patients with no effect on the VA interval. In group 1, of 14 patients with manifest preexcitation during sinus rhythm, 10 patients had a positive delta wave in lead V1. Of 10 group 2 patients with manifest preexcitation, only 5 had a positive delta wave in lead V1. In group 3, of 12 patients with manifest preexcitation, 7 exhibited a positive delta wave in lead V1. All posteroseptal APs were successfully ablated, and this was achieved via a right atrial approach in 48 patients and left ventricular approach in only 2. Successful sites were at the posteroseptal region of the tricuspid annulus (30 patients), within the terminal 1 cm of the coronary sinus including its ostium (16 patients), and at the inferomedial aspect of the right atrium posterior to the coronary sinus ostium (2 patients). The posteroseptal region of the left ventricle was the site of successful ablation in 2 patients. Six patients with a recurrence of AP conduction required a repeat ablation, with successful results in 5. Thirty-five patients had a complete electrophysiological evaluation 2 to 3 months after their successful ablation and were found to have no functioning AP. In 49 patients with a final successful ablation, no recurrence of symptoms was noted during a mean follow-up period of 12 +/- 9 months. Complications occurring in 3 patients were cardiac tamponade requiring surgical drainage and repair of a right ventricular tear, pericardial effusion with no hemodynamic consequence that spontaneously resolved, and a transient 2:1 atrioventricular block. CONCLUSIONS: These data suggest that posteroseptal APs are amenable to successful ablation using a right atrial approach. Success was achieved in 47 cases (94%) in this series even though the ECG and/or electrophysiological characteristics of the posteroseptal APs of some patients were suggestive of "left-sided" pathways.

Adolescent↗
PubMed1991

Left ventricular myocardial edema. Lymph flow, interstitial fibrosis, and cardiac function.

We hypothesized that both acute and chronic accumulation of myocardial interstitial edema (extravascular fluid [EVF]) would compromise cardiac function. We also postulated that excess fluid within the myocardial interstitial space would potentiate interstitial fibrosis, thus further compromising function. Dogs were divided into three groups: 1) control, 2) chronic pulmonary hypertensive with right heart failure, and 3) chronic arterial hypertensive. The quantity of EVF, expressed as the unitless blood-free (wet weight-dry weight)/dry weight ratio, and interstitial fibrosis (collagen content) were determined and correlated with cardiac function at baseline and after acute elevation of coronary venous pressure and reduction of cardiac lymph flow. Control EVF was 2.90 +/- 0.20 (mean +/- SD), which increased to 3.45 +/- 0.16 after acute (3-hour) elevation of coronary sinus pressure. This EVF significantly compromised cardiac function. The EVF in chronically hypertensive dogs and in dogs with chronic right heart pressure elevations was 3.50 +/- 0.30 and 3.50 +/- 0.08, respectively. End-diastolic left ventricular interstitial fluid pressure increased from a control value of 14.9 +/- 3.1 (at EVF = 2.9) to 24.8 +/- 3.7 (at EVF = 3.5). An EVF of 3.5 produced approximately 30% reduction of the heart's ability to maintain cardiac output at a left atrial pressure of 15 mm Hg. The compromised function in these chronic models is exacerbated after acute elevation of coronary venous pressure and reduction of cardiac lymph flow. Collagen levels were elevated by at least 20% in the chronic hypertensive dogs and in the nonhypertrophied left ventricles of dogs with chronic right heart pressure elevation.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1996

Effects of right ventricular failure on renal function during pneumatic left ventricular assist.

In an experiment dog model of acute biventricular failure, the effects of left ventricular (LV) assist on renal hemodynamics and function were evaluated. After the induction of severe cardiac failure by multiple ligation of the coronary arteries, LV assist with a 40 ml pneumatic pulsatile pump was initiated, and the aortic flow was maintained at control values. The right atrial pressure (RAP) rose to 21.3 mm Hg with the appearance of profound right ventricular (RV) failure. Renal arterial blood flow (RAF) decreased to about 60% of the control value after 2 h of LV assist. The urine volume decreased and renal function deteriorated progressively. RV assist decreased the RAP to 4.8 mm Hg, and the reduced RAF recovered. After 3 h of RV assist, the RAF returned to initial values and the urine volume increased, but renal function did not recover. Advanced biventricular failure with elevated RAP during LV assist reduced renal perfusion and impaired renal function and may be an indication for early RV assist.

Animals↗
PubMed2004

Double-counting of intracardiac electrogram during biatrial pacing.

BACKGROUND: Biatrial pacing has a significant problem with memory function that misinterprets normal sinus rhythm as atrial tachyarrhythmias and in addition estimation of the atrial pacing thresholds (biatrial and uniatrial pacing thresholds) is sometimes difficult because of small P waves. METHODS AND RESULTS: The intracardiac electrograms recorded by a pacemaker in 10 patients (age, 66.7+/-10.7 (SD) years) with implanted biatrial pacemakers were analyzed. Atrial sensing within the atrial refractory period after atrial pacing was counted in 6 of the 10 patients (timing of the double counting was 143+/-64 ms) when pacing failed in the left or right atrium. Atrial sensing within the atrial refractory period after atrial pacing disappeared when biatrial pacing was successfully performed. Atrial double-counts depend on interatrial conduction delay. The memory function of implanted pacemaker devices misinterpreted normal sinus rhythm as atrial tachyarrhythmias because of atrial double-counts. On the other hand, the biatrial pacing threshold was easily recognized using this phenomenon. CONCLUSIONS: The memory function of pacemaker devices is unreliable because of atrial double-counting during sinus rhythm in patients with biatrial pacing. However, the biatrial pacing threshold is easily checked using this phenomenon.

Aged↗
PubMed2004

Clinical significance of brain natriuretic peptide in primary pulmonary hypertension.

OBJECTIVES: The aim of this study was to investigate the potential role of brain natriuretic peptide (BNP) levels in the assessment of functional status and right heart performance in primary pulmonary hypertension (PPH). BACKGROUND: Primary pulmonary hypertension is a progressive disease leading to right heart failure and death. Right heart catheterization and maximal or submaximal exercise tests are employed to assess the course of the disease and the effect of therapeutic interventions. Additional noninvasive and reproducible parameters would be helpful to assess the status of patients with PPH. The natriuretic peptide system is up-regulated in PPH patients. Brain natriuretic peptide (BNP) is produced from the cardiac ventricles and elevated in PPH. The aim of our study was to evaluate the clinical significance of BNP in PPH patients. METHODS: Correlation analysis was performed for plasma BNP levels of 28 PPH patients and World Health Organization (WHO) functional class (WHO-class), distance walked in 6 min, peak oxygen uptake (peak Vo(2)), and oxygen pulse during spiroergometry and various hemodynamic parameters, including pulmonary vascular resistance (PVR), pulmonary artery pressure (PAP), right atrial pressure (RAP), and cardiac index. RESULTS: The BNP levels were inversely correlated with the 6-min walk (r = -0.70; p < 0.001) and peak Vo(2) (r = -0.61; p < 0.01), and positive correlation was observed with WHO-class (r = 0.79; p < 0.001). Moreover, BNP levels were also correlated to PVR (r = 0.61; p < 0.01), PAP (r = 0.48; p < 0.05), and RAP (r = 0.78; p < 0.01), and were inversely related to cardiac index (r = -0.48; p < 0.05). CONCLUSIONS: Our data suggest that plasma BNP levels are closely related to the functional impairment of PPH patients and parallel the extent of pulmonary hemodynamic changes and right heart failure. Serial measurements of plasma BNP concentrations may help improve the management of PPH patients.

Exercise Test↗
PubMed1988

Application of a time varying elastance model to right ventricular performance in man.

To evaluate instantaneous right ventricular pressure-volume relations we studied nine patients with normal coronary anatomy and ventricular function with simultaneous high fidelity pressure, flow-velocity, and biplane cineventriculographic volumes (60 frames.s-1) during atrial pacing at 93(SD5) beats-min-1, partial autonomic blockade, and pharmacologically altered ventricular loading. The maximum time varying elastance, Emax, was defined as the maximum slope of isochronal, simultaneous pressure-volume data points derived by linear regression analysis from three loading conditions. The slope of the non-isochronal maximum pressure/volume ratio, pressure at minimum volume, end ejection pressure/volume, and peak right ventricular pressure/minimum volume were also derived from the three loading conditions. The mean slope for Emax was 1.30(0.84) mm Hg.ml-1 (range 0.62-2.87) and the volume axis intercept at zero pressure (Vo) was 46(21) ml (range 24-89 ml). Time dependent Emax was characterised by a series of parallel shifting lines of best fit with large changes in Vo in addition to changes in the slope of the pressure volume relations. Only maximum pressure/volume ratio and peak pressure/minimum volume were linearly related to Emax (r = 0.82 and 0.84 respectively, p = 0.05) while pressure at minimum volume and end ejection pressure/volume did not correlate with Emax. We conclude that in normal human subjects (1) right ventricular systolic function may be approximated using a time varying elastance model characterised by a time dependent Vo; (2) end systolic pressure-volume relations using maximum pressure/volume ratio and peak pressure/minimum volume systematically estimate Emax; and (3) other right ventricular end systolic pressure-volume relations near end ejection bear no obvious relation to Emax because of the wide temporal separation between peak systolic elastance and end ejection in this chamber.

Adult↗
PubMed1988

Pimobendane (UD-CG 115 BS) in the treatment of severe congestive heart failure. An acute haemodynamic cross-over and double-blind study with two different doses.

1. We compared the effects of two doses (5 and 10 mg) of oral pimobendane (UD-CG 115) on haemodynamics in eight patients suffering from chronic congestive heart failure. The two doses were given according to a randomized cross-over double-blind protocol; haemodynamics and plasma levels of pimobendane and its main metabolite UD-CG 212, were determined 1, 2, 3, 5, 7, 9, 11 and 12 h after each dose. 2. Both doses significantly improved the left and right ventricular functions of these patients, with a peak action 3 h after drug intake and long duration (more than 12 h). A significant dose-effect relationship was observed only for pulmonary wedge pressure and right atrial pressure. Significant correlations were found between UD-CG 212 plasma levels and cardiac index (r = 0.54, P less than 0.05), and pulmonary wedge pressure (r = 0.74, P less than 0.001); no correlation was found between these haemodynamic variables and pimobendane plasma levels. 3. One patient developed a transient drop in blood platelets together with a cutaneous rash, while three others had a transient and mild decrease of thrombocytes. 4. In conclusion, pimobendane improved right and left ventricular functions in severe heart failure. Both doses (5 and 10 mg) were effective. The higher dose induced marked improvement of the haemodynamic variables but the difference between doses was only significant for right atrial and pulmonary wedge pressures.

Aged↗
PubMed1997

Resolution of exercise intolerance secondary to ischemic sinus node dysfunction following percutaneous transluminal angioplasty.

We report on a case of significant exertional symptoms secondary to occlusion of a nondominant right coronary artery proximal to the sino-atrial branch, with associated exercise-induced sinus node dysfunction. Successful angioplasty of the occluded right coronary artery restored a normal functional capacity and sinus tachycardia response to exercise.

Angioplasty, Balloon, Coronary↗
PubMed2005

Dynamic relations between right and left atrial pressure shifts induced by catecholamines.

Acute experiments on cats showed that injection of catecholamines induced unidirectional shifts in right and left atrial pressure in 70% cases (these shifts were positive in one half of cats and negative in the other half). In 30% cases, the left and right atrial pressures changed in opposite direction: right atrial pressure decreased, while left atrial pressure increased (19%), or vice versa (11%). The pressure changes in the left atrium had greater amplitude and longer duration compared to those in the right atrium.

Animals↗
PubMed1977

Congenital pulmonary atresia with tricuspid insufficiency: morphologic study.

In an anatomic study of 21 cases of pulmonary atresia with tricuspid insufficiency (pulmonary atresia with intact ventricular septum, type II), the morphologic features of the tricuspid valve and the right ventricle were found to differ greatly from those seen in pulmonary atresia with tricuspid stenosis (pulmonary atresia with intact ventricular septum, type I). Morphologically, pulmonary atresia with tricuspid insufficiency (type II) has a greater resemblance to Ebstein's disease with pulmonary atresia than to type I pulmonary atresia. The anomaly may be more amenable to surgery than pulmonary atresia with tricuspid stenosis because the right ventricle in the former may be converted into a functional chamber by a valvotomy combined with a shunting procedure and atrial septostomy.

Female↗
PubMed2001

Preliminary result of an algorithm to select proper ventricular assist devices for high-risk patients with extracorporeal membrane oxygenation support.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is not suitable for long-term support because of its high incidence of complications. Conversion from ECMO to ventricular assist device (VAD) is reasonable, and we have developed a simple algorithm for selecting proper VADs for these ECMO-supported patients. METHODS: We converted 12 patients who were receiving ECMO support to VAD for bridge to transplantation. Group I (n = 6) was converted directly from ECMO to VAD. Group II (n = 6) underwent stage conversion. We added left atrial drainage to ECMO because of lung edema or marked left heart distension. We discontinued drainage after recovery of right heart function. Group II had more unfavorable risk factors for VAD before ECMO. RESULTS: Three patients (50%) in Group I received biventricular VADs. The other 3 patients were converted to left ventricular assist device (LVAD), but only 1 (16.7%) experienced successful conversion. We successfully converted 5 patients (83.3%) in Group II to LVAD without right VAD, and 4 of them could be weaned from the ventilator. The multiple-organ dysfunction score gradually improved in Group II despite additional surgery. Two patients in each group received heart transplantation and survived long term. CONCLUSION: Using a conversion protocol provides a good guideline for making decisions. According to the protocol, right heart and pulmonary function can be clearly assured before shifting to LVAD in these critical ECMO-supported patients.

Algorithms↗