Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes

Rame, J. Eduardo; Pagani, Francis D.; Kiernan, Michael S.; Oliveira, Guilherme H.; Birati, Edo Y.; Atluri, Pavan; Gaffey, Ann C.; Grandin, E. Wilson; Myers, Susan; Collum, C.; Kormos, Robert L.; Kirklin, James K.; Teuteberg, Jeffrey J.

doi:10.1016/j.jacc.2021.09.1362

Cited by 63 publications

(73 citation statements)

References 19 publications

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“…Furthermore, our results clearly demonstrated that the occurrence of RHF was no risk factor for mortality in our cohort ( Table 4 ), suggesting that development of late RHF was well manageable without a reduction in survival, at least in the first year after LVAD implantation. Our findings are in contrast to a previous published multicenter study [ 21 ] where LVAD patients suffering from late RHF had worse survival and a higher cumulative incidence of major adverse events. A possible reason for our divergent results could be the more pragmatic use of the tempRVAD at the time of LVAD implantation in patients with mild to moderate preoperative right ventricular failure, whereas Rame et al [ 21 ] did not include such patients.…”

Section: Discussioncontrasting

confidence: 99%

“…Our findings are in contrast to a previous published multicenter study [ 21 ] where LVAD patients suffering from late RHF had worse survival and a higher cumulative incidence of major adverse events. A possible reason for our divergent results could be the more pragmatic use of the tempRVAD at the time of LVAD implantation in patients with mild to moderate preoperative right ventricular failure, whereas Rame et al [ 21 ] did not include such patients. It could be hypothesized that the perioperative use of tempRVADs has a beneficial effect on the development of late RHF.…”

Section: Discussioncontrasting

confidence: 99%

“…Moreover, analysis of laboratory parameters showed a significantly higher pre-operative total bilirubin in patients who developed RHF postoperatively, which has also been previously described [ 17 , 26 ]. Thirty days after LVAD implantation, patients who later developed RHF had significantly reduced serum levels of hemoglobin and platelets, and elevated CRP compared to patients without RHF, possibly implicating a higher incidence of bleeding events in these patients, which is in line with the findings of Rame et al [ 21 ], who reported an increased likelihood of gastrointestinal bleeding in patients with late RHF. Terzic et al [ 27 ] recently found that proBNP and LDH levels may be useful prognostic indicators for the development of early RHF, which was not demonstrated for late RHF in our study.…”

Section: Discussionsupporting

confidence: 83%

“…Another inherent problem in all studies published on this topic is that there remains no universally accepted definition and classification of RHF after LVAD implantation. Therefore, we tried to match our definition closely to that defined by other registries and studies [ 16 , 17 , 21 ] and refrained from analyzing echocardiographic data because the validity of isolated echocardiographic parameters should be taken with caution [ 28 ] because of the potential influence of high pulmonary vascular resistance, the presence of secondary tricuspid regurgitation, and dynamic changes in volume (over)load.…”

Section: Discussionmentioning

confidence: 99%

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When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation

Schlöglhofer

Wittmann

Paus

et al. 2022

Life

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Right heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation. The aim of this study was to analyze the incidence, risk factors, and biomarkers for late RHF including the possible superiority of the device and implantation method. This retrospective, single-center study included patients who underwent LVAD implantation between 2014 and 2018. Primary outcome was freedom from RHF over one-year after LVAD implantation; secondary outcomes included pre- and postoperative risk factors and biomarkers for RHF. Of the 145 consecutive patients (HeartMate 3/HVAD: n = 70/75; female: 13.8%), thirty-one patients (21.4%) suffered RHF after a mean LVAD support of median (IQR) 105 (118) days. LVAD implantation method (less invasive: 46.7% vs. 35.1%, p = 0.29) did not differ significantly in patients with or without RHF, whereas the incidence of RHF was lower in HeartMate 3 vs. HVAD patients (12.9% vs. 29.3%, p = 0.016). Multivariate Cox proportional hazard analysis identified HVAD (HR 4.61, 95% CI 1.12–18.98; p = 0.03), early post-op heart rate (HR 0.96, 95% CI 0.93–0.99; p = 0.02), and central venous pressure (CVP) (HR 1.21, 95% CI 1.05–1.39; p = 0.01) as independent risk factors for RHF, but no association of RHF with increased all-cause mortality (HR 1.00, 95% CI 0.99–1.01; p = 0.50) was found. To conclude, HVAD use, lower heart rate, and higher CVP early post-op were independent risk factors for RHF following LVAD implantation.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussioncontrasting

confidence: 99%

Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 99%

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When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation

Schlöglhofer

Wittmann

Paus

et al. 2022

Life

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“…A more liberal right ventricular support may be the way forward [31] when considering different support strategies for a failing right ventricle [32]. Late onset of right ventricular failure remains associated with worse survival and higher cumulative incidence of major adverse events [33].…”

Section: Discussionmentioning

confidence: 99%

Ventricular and Atrial Pressure-Volume Loops: Analysis of the Effects Induced by Right Centrifugal Pump Assistance

Lazzari

Iacovoni

Capoccia

et al. 2022

Preprint

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Background and Objective: The main indications for right ventricular assist device (RVAD) support are right heart failure after implantation of a left ventricular assist device (LVAD) or early graft failure following heart transplantation. About 30-40% of patients will need RVAD support after LVAD implantation. Pulmonary hypertension is also an indication for right heart assistance. Several types of RVAD generating pulsatile or continuous flow are available on the market. These assist devices can be connected to the cardiovascular system in different ways. We sought to analyse the effects induced by different RVAD connections when right ventricular elastance is modified using a numerical simulator. The analysis was based on the behaviour of both left and right ventricular and atrial loops in the pressure-volume plane. Methods: New modules of the cardiovascular network and a right ventricular centrifugal pump were implemented in CARDIOSIM software simulator platform. The numerical pump model generated continuous flow when connected in series or parallel to the right ventricle. When the RVAD was connected in series (parallel), the pump removed blood from the right ventricle (atrium) and ejected it into the pulmonary artery. In our study, we analysed the effects induced by RVAD support on left/right ventricular/atrial loops when right ventricular elastance slope (EesRIGHT) changed from 0.3 to 0.8 mmHg/ml with the pump connected either in series or parallel. The effect of low and high rotational pump speed was also addressed. Results: Percentage changes up to 60% were observed for left ventricular pressure-volume area and external work during in-parallel RVAD support at 4000 rpm with EesRIGHT = 0.3mmHg/ml. The same pump setting and connection type led to percentage variation up to 20% for left ventricular ESV and up to 25% for left ventricular EDV with EesRIGHT = 0.3mmHg/ml. Again the same pump setting and connection generated up to 50% change in left atrial pressure-volume loop area (PVLAL-A ) and only 3% change in right atrial pressure-volume loop area (PVLAR-A) when EesRIGHT = 0.3mmHg/ml. Percentage variation was lower when EesRIGHT was increased up to 0.8 mmHg/ml. Conclusion: Early recognition of right ventricular failure followed by aggressive treatment is desirable to achieve a more favourable outcome. RVAD support remains an option for advanced right ventricular failure although onset of major adverse events may preclude its use.

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Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device

Akamkam,

Galand,

Jungling

et al. 2024

ESC Heart Failure

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AimsRight ventricular failure after left ventricular assist device (LVAD) implantation is a major concern that remains challenging to predict. We sought to investigate the relationship between preoperative pulmonary artery pulsatility index (PAPi) and mortality after LVAD implantation.Methods and resultsA retrospective analysis of the ASSIST‐ICD multicentre registry allowed the assessment of PAPi before LVAD according to the formula [(systolic pulmonary artery pressure − diastolic pulmonary artery pressure)/central venous pressure]. The primary endpoint was survival at 3 months, according to the threshold value of PAPi determined by the receiver operating characteristic (ROC) curve. A multivariate analysis including demographic, echographic, haemodynamic, and biological variables was performed to identify predictive factors for 2 year mortality. One hundred seventeen patients were included from 2007 to 2021. The mean age was 58.45 years (±13.16), with 15.4% of women (sex ratio 5.5). A total of 53.4% were implanted as bridge to transplant and 43.1% as destination therapy. Post‐operative right ventricular failure was observed in 57 patients (48.7%), with no significant difference between survivors and non‐survivors at 1 month (odds ratio 1.59, P = 0.30). The median PAPi for the whole study population was 2.83 [interquartile range 1.63–4.69]. The threshold value of PAPi determined by the ROC curve was 2.84. Patients with PAPi ≥ 2.84 had a higher survival rate at 3 months [PAPi < 2.84: 58.1% [46.3–72.8%] vs. PAPi ≥ 2.84: 89.1% [81.1–97.7%], hazard ratio (HR) 0.08 [0.02–0.28], P < 0.01], with no significant difference after 3 months (HR 0.67 [0.17–2.67], P = 0.57). Other predictors of 2 year mortality were systemic hypertension (HR 4.22 [1.49–11.97], P < 0.01) and diabetes mellitus (HR 4.90 [1.83–13.14], P < 0.01). LVAD implantation as bridge to transplant (HR 0.18 [0.04–0.74], P = 0.02) and heart transplantation (HR 0.02 [0.00–0.18], P < 0.01) were associated with a higher survival rate at 2 years.ConclusionsPreoperative PAPi < 2.84 was associated with a higher risk of early mortality after LVAD implantation without impacting 2 year outcomes among survivors.

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Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes

Cited by 63 publications

References 19 publications

When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation

When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation

Ventricular and Atrial Pressure-Volume Loops: Analysis of the Effects Induced by Right Centrifugal Pump Assistance

Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device

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