Pre-operative Speckle-tracking Imaging to Predict the Need for Right Ventricular Support in Patients Undergoing Left Ventricular Assist Device Implantation

Abstract

Background: Right ventricular (RV) dysfunction after left ventricular assist device (LVAD) implantation significantly complicates post-device management and has been shown to be associated with increased mortality. Pre-operative identification of patients who may develop post-LVAD RV dysfunction is challenging. This study was designed to evaluate pre-operative echocardiographic speckle tracking imaging as a predictor of post operative RV dysfunction. Methods: Thirty-nine patients who underwent Heartmate II LVAD placement in a single center were studied. Pre-and post-operative clinical, hemodynamic, laboratory, and echocardiographic data were prospectively collected as part of an ongoing institutional LVAD database. RV strain parameters were measured retrospectively using off-line speckletracking analysis software. Results: Twenty five of 39 LVAD recipients developed acute RV failure during the early post-operative period. RV function in 14 of these recipients improved with inotropes and judicious adjustment of LVAD parameters. Eleven patients, however, expired despite aggressive medical therapy including 7 patients who underwent placement of an RVAD. These 11 individuals were identified as having significantly lower global RV strain prior to device placement (p<0.05). Seventy two percent of the patients with a peak longitudinal systolic RV strain higher than-3%, expired. Twenty-four of 27 (88%) patients with a global RV strain of-3% or lower survived without need for an RVAD (p<0.001). Hemodynamic, laboratory and traditional echocardiographic data were not predictive of post-LVAD RV dysfunction or survival. Multivariate analysis showed RV longitudinal strain, especially global strain, to be the only significant predictor of severe RV dysfunction. Conclusion: Poor intrinsic RV myocardial function is associated with a higher mortality in LVAD patients. Speckle-tracking echocardiography imaging, particularly, peak systolic global RV strain appears to be promising in predicting LVAD patients who require RVAD.

Assessment of right ventricular function following left ventricular assist device (LVAD) implantation—The role of speckle‐tracking echocardiography: A meta‐analysis

“…The type of LVAD device varied across the studies, including HeartMate II, HeartMate III, and HeartWare (Table 4). Five studies provided both the RVGLS and RVFWS 8,21,28,29,33 …”

“…RVGLS was reported in 11 studies (9 TTE and 2 TEE studies). 8,[20][21][22][23][27][28][29][31][32][33] The RVGLS was significantly reduced preoperatively in the RVF group as compared to non-RVF group when analyzed for the whole cohort (TEE and TTE). The SMD between the RVF and the non-RVF groups was −2.79 (95% CI: −4.07 to −1.50; P-value < .001), I 2 = 91.31%.…”

“…RVFWS was reported in 12 studies (9 TTE and 3 TEE). 8,19,21,22,[24][25][26][28][29][30]33,34 The RVFWS for the whole cohort (TEE and TTE) was found to be significantly lower preoperatively in patients who suf- Figure 3. The OR for RVF with percentage increase in FWS was reported in 3 studies, OR: 1.63, 95% CI 1.07-2.47…”

“…Seventeen studies, with a total number of 1085 LVAD recipients, fulfilled our inclusion criteria. 8,13,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] Study characteristics and outcomes are summarized in Tables 1 and 2. Thirteen studies used transthoracic echocardiography (TTE) strain, while four studies utilized transesophageal echocardiography (TEE).…”