Air in the Right Ventricle During Mechanical Circulatory Support: How to Proceed?

ANESTHESIOLOGISTS PLAY a crucial role in the evaluation of intracardiac air, especially during separation from cardiopulmonary bypass (CPB). This is particularly important during left ventricular assist device (LVAD) insertion and intraoperative initiation of extracorporeal membrane oxygenation (ECMO) because systemically embolized air can have devastating neurologic and hemodynamic consequences. 1 Chumnanvej S. Wood M.J. MacGillivray T.E. et al. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg. 2007; 105: 583-601 Crossref PubMed Scopus (131) Google Scholar , 2 Reed H. Pal J. Lombaard S. Air in the left heart: A perilous situation in the presence of a left ventricular assist device. J Cardiothorac Vasc Anesth. 2016; 30: 1636-1638 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar , 3 Hockings L. Vuylsteke A. et al. Troubleshooting common and less common problems. in: Sangalli F Patroniti N Pesenti A ECMO-extracorporeal life support in adults. Springer, Milano2014: 425-441 Crossref Scopus (2) Google Scholar After LVAD implantation, impaired right ventricular (RV) function can occur due to changes in RV loading conditions and morphology, which may necessitate mechanical circulatory support. 4 Lampert B.C. Teuteberg J.J. Right ventricular failure after left ventricular assist devices. J Heart Lung Transplant. 2015; 34: 1123-1130 Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar One such RV assist device (RVAD) used at the authors’ institution is an extracorporeal centrifugal pump (Thoratec Centrimag, Pleasanton, CA) with inflow cannulation in the right atrium (RA) and outflow cannulation in the main pulmonary artery (PA) via a tunneled Dacron graft with an oxygenator in-circuit. 5 Kapur N.K. Esposito M.L. Bader Y. et al. Mechanical circulatory support devices for acute right ventricular failure. Circulation. 2017; 136: 314-326 Crossref PubMed Scopus (87) Google Scholar In the modern era of heart failure surgery, there is an increasing prevalence of LVAD implantation with sequential RVAD placement. 6 Kirklin J.K. Pagani F.D. Kormos R.L. et al. Eighth annual INTERMACS report: Special focus on framing the impact of adverse events. J Heart Lung Transplant. 2017; 36: 1080-1086 Abstract Full Text Full Text PDF PubMed Scopus (690) Google Scholar Herein the authors present a case of biventricular assist device placement with a transesophageal echocardiography (TEE) finding of persistent air in the right side of the heart after CPB that required a thoughtful approach to its origin and clinical management.