Management of Right Ventricular Failure in Pulmonary Hypertension (and After LVAD Implantation)

Abstract

Right ventricular failure (RVF) is increasingly recognized as a complicating feature of a number of disease states, including pulmonary arterial hypertension (PAH) and advanced heart failure. It not only contributes to symptoms and complicates management, but also dramatically impacts prognosis. In PAH, early disease detection and institution of PAH therapy can prevent or delay RVF. Once established, therapy for RVF focuses on optimizing afterload reduction with PAH therapy, controlling volume, and judiciously using inotropic support when needed. In patients undergoing implantation of a LVAD, preoperative assessment and management of RVF is critical. Risk factors for the development of RVF after LVAD have been described, and may identify a population best managed with biventricular support. Postoperative management of RVF focuses on supportive therapy, judicious use of inotropes and volume management. Ongoing research may yield insights into specific therapies to prevent or reverse RVF.

Monitoring pulmonary pressures during long‐term continuous‐flow left ventricular assist device and fixed pulmonary hypertension: redefining alleged pathophysiological mechanisms?

“…When HTx is performed in a patient with fixed PH, the stunned RV of the donor could not overcome the high afterload and fails owing to elevated PVR. RV failure is a major cause of both mortality and morbidity after LVAD implantation as well (20–50% of patients) . By lowering PAP, there is more potential to improve or maintain RV function at long‐term LVAD support, which is essential, especially in destination therapy.…”

Management of Pulmonary Hypertension in Patients on Left Ventricular Assist Device Support

“…Arrhythmias should be managed properly to maintain atrial-ventricular synchrony. LVAD speed should be optimized to allow proper positioning of the interventricular septum which helps RV contractility [ 135 ]. Despite medical treatment, 4–6% of patients with RVF post-LVAD are unresponsive and these patients require temporary right ventricular assist device support (RVAD) [ 83 , 136 ].…”

“…Biventricular temporary mechanical circulatory support device (veno-arterial extracorporeal membrane oxygenation) may be considered for crashing patients [ 137 , 138 ]. Renal replacement therapy should be instituted for volume removal in case of concomitant renal failure and unresponsiveness to diuretics [ 135 ].…”

Left ventricular assist device as destination therapy in cardiac end-stage dystrophinopathies: Midterm results

“…In the preoperative assessment for LVAD surgery, particular care was taken to evaluate right ventricle (RV) function because, as reported elsewhere, 19,20 RV failure is one of the most important complications of postoperative LVAD implantation. Before surgery in our center, all patients underwent echocardiography, magnetic resonance imaging, right and left catheterization, pulmonary function testing, and full laboratory work-up.…”