C52-42 Right Ventricular Failure After Radical Pericardiectomy: Recovery Through Sequential Mechanical Circulatory Support

Abstract Introduction This case highlights the complex management of refractory right ventricular (RV) failure following radical pericardiectomy, demonstrating the value of sequential and hybrid mechanical circulatory support (MCS), including concurrent use of Impella RP Flex and VA-ECMO and escalation to surgical RVAD for recovery. Clinical Case A 44-year-old male with chronic constrictive pericarditis, recurrent ascites requiring weekly paracentesis for two years, congestive hepatopathy, and RV failure presented for a second opinion. Following extensive evaluation, he underwent radical pericardiectomy on cardiopulmonary bypass, complicated intraoperatively by progressive RV failure. An Impella RP Flex was inserted via the right internal jugular vein for RV support.On post-op day 1, he developed worsening hemodynamics and multiorgan dysfunction despite the addition of several vasopressors. Following multi-disciplinary team discussion, venoarterial extra membranous oxygenation (VA-ECMO) was placed via femoral cannulation for biventricular support and intra-aortic balloon pump (IABP) was placed for afterload reduction and left ventricular venting. The Impella RP was maintained to optimize RV decompression.Despite this triple-support configuration, he developed renal failure and arrhythmias requiring continuous renal replacement therapy (CRRT) and amiodarone. By POD 6, clinical improvement allowed removal of VA-ECMO and IABP, with Impella RP continued as sole support.On POD 7, Impella RP flows abruptly declined with unrealiable console readings , raising concern for device thrombosis despite optimal anticoagulation. He underwent urgent RP Impella removal and placement of a surgical Centrimag right-sided ventricular assist device (RVAD) with right atrial drainage and pulmonary artery return.Over the next two weeks, hemodynamics stabilized. . Echocardiograms showed progressive RV recovery. After successful turndown, he was decannulated from RVAD on POD 23.He transitioned to intermittent dialysis, recovered renal function and required diuresis for pleural and ascites fluid management. Left ventricular ejection fraction was 35-40%, RV size normalized, and RV function continued to improve. Discussion This case illustrates the challenges of managing acute RV failure post-pericardiectomy, particularly in patients with chronic pericardial constriction. Sudden removal of pericardial restraint can result in RV decompensation, requiring aggressive hemodynamic support.The initial use of Impella RP, followed by VA-ECMO and IABP, provided stabilization. Maintaining Impella RP during VA-ECMO enabled targeted RV unloading—reflecting emerging hybrid MCS strategies. Thrombosis necessitated escalation to Centrimag RVAD, which offered durable support and enabled recovery.According to SCAI shock staging, the patient progressed from Stage E to recovery through structured de-escalation. This case underscores the importance of early shock team involvement, close monitoring of device performance, and flexible MCS strategies in managing complex RV failure. This abstract is funded by: none