Revascularization of the Occluded Right Coronary Artery During Left Ventricular Assist Device Implantation Evgenij V. Potapov, MD, a Ralf Sodian, MD, a Matthias Loebe, MD, PhD, c Thorsten Drews, MD, a Stephan Dreysse, MD, b and Roland Hetzer, MD, PhD a A 62-year-old man with end-stage ischemic cardiomyopathy and left ventricular function of 20% was evaluated for heart transplantation. Cardiac catheterization revealed proximal occlusion of the dominant right coronary artery (RCA) with collateral blood flow and significant stenosis in the distal part, but no significant re- occlusions of the stented left coronary artery and no significant stenosis of the left circumflex artery. When the patient became catecholamine dependent, Novacor left ventricular assist device (LVAD) implantation, as a bridge to transplantation, was considered and the patient operated upon. To avoid ischemic right heart failure after LVAD implantation, a concomitant re-vascularization of the distal RCA was performed. The post-operative course was uneventful. Five weeks later, a control angiogram showed the patent bypass graft. The distal stenosis of the RCA was treated successfully with dilation and stent implantation. The patient is presently in stable condition on LVAD and awaits transplantation as an outpatient. J Heart Lung Transplant 2001;20:918–922. Right heart failure is a most feared complica- tion after left ventricular assist device (LVAD) implantation, with a reported incidence of be- tween 20% and 52%. 1,2 As possible origins, a change in the right ventricular geometry and interaction, 2,3 increased right ventricular preload, 3 decreased contractility 3 and ischemia 4,5 have been postulated. Its prevention is limited to careful selection of patients with preserved right heart function, which is pre-operatively difficult to esti- mate, 6 and treatment by post-operative use of inhaled nitric oxide, 7 careful volume substitution and use of catecholamines to maintain optimal organ perfusion without right heart overload. 7 One case of emergency right coronary revascular- ization 4 and as ultima ratio an RVAD implanta- tion 1 have been reported. The most important factor in preserving adequate right heart function is minimizing intraoperative damage to the right ventricle, particularly ischemia caused by malper- fusion, air embolism or volume overload. We report a patient scheduled for Novacor LVAD implantation with high risk for right heart failure. In this case, preventive steps were taken during and after surgery (performed by M.L.) and led to an uneventful post-operative course. CASE REPORT A 62-year-old man with end-stage ischemic cardiomyopathy was admitted to our unit in evolv- ing cardiogenic shock despite optimal medical treatment, including diuretics, digitalis, nitroglyc- From the a Department of Cardiothoracic and Vascular Surgery, b Department of Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany; and c Michael E. DeBakey Department of Surgery, Division of Transplantation and Assist Devices, Bay- lor College of Medicine, Houston, Texas. Submitted November 10, 2000; accepted January 25, 2001. Reprint requests: Evgenij V. Potapov, MD, Deutsches Herz- zentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Telephone: +49-30-4593-1000. Fax: +49-30- 4593-2100. E-mail: potapov@dhzb.de. Copyright © 2001 by the International Society for Heart and Lung Transplantation. 1053-2498/01/$–see front matter PII S1053-2498(01)00266-2 918