Predicting Right Ventricular Failure in the Modern, Continuous Flow Left Ventricular Assist Device Era

Abstract

Background In the era of destination continuous flow left ventricular assist devices (LVAD), the decision of whether a patient will tolerate isolated LVAD support or will need biventricular support (BIVAD) can be challenging. Incorrect decision making with delayed right ventricular (RV) assist device implantation results in increased morbidity and mortality. Continuous flow LVADs have been shown to decrease pulmonary hyper-tension and improve RV function. We undertook this study to determine predictors in the continuous flow LVAD era that identify patients who are candidates for isolated LVAD therapy as opposed to biventricular support. Methods We reviewed demographic, hemodynamic, laboratory, and echocardiographic variables for 218 patients who underwent VAD implant from 2003 through 2011 (LVAD = 167, BIVAD = 51), during the era of continuous flow LVADs. Results Fifty preoperative risk factors were compared between patients who were successfully managed with an LVAD and those who required a BIVAD. Seventeen variables demonstrated statistical significance by univariate analysis. Multivariable logistic regression analysis identified central venous pressure >15 mmHg (OR 2.0, “C”), severe RV dysfunction (OR 3.7, “R”), preoperative intubation (OR 4.3, “I”), severe tricuspid regurgitation (OR 4.1, “T”), heart rate >100 (OR 2.0, Tachycardia - “T”) -CRITT as the major criteria predictive of the need for biventricular support. Utilizing these data, a highly sensitive and easy to use risk score for determining RV failure was generated that outperformed other established risk stratification tools. Conclusions We present a preoperative risk calculator to determine suitability of a patient for isolated LVAD support in the current continuous flow ventricular assist device era.

Predictors and Management of Right Heart Failure after Left Ventricular Assist Device Implantation

“…7,11,12 Surrogates of reduced RV contractility, i.e., low pulmonary artery systolic pressure, and RV stroke work index remain markers of risk but have not yielded substantial predictive information. 8,10,12,16 A CVP/PCWP ratio > 0.63 was shown to be an independent predictor of early RVF risk in the HeartMate II Bridge-to-Transplantation Pivotal Trial population with overall low discrimination (0.68).…”

“…[5][6][7][8][9] Most studies have reported the incidence encompassing the need for inotropic support with or without RVAD (≥ 14 days) after LVAD implant, with a range of between 20.2% to 44%. [10][11][12] We know that prolonged RV failure (i.e., extended inotrope support) for more than 2 weeks is associated with adverse subsequent outcomes.…”

Heart transplantation versus left ventricular assist devices as destination therapy or bridge to transplantation for 1-year mortality: a systematic review and meta-analysis

“…For instance, pulmonary hypertension is a significant contraindication for transplantation but not for LVAD therapy (22). In contrast, patients with severe right ventricular failure are less optimal candidates for LVAD, but may experience good outcomes with transplantation (23)(24)(25)(26). With regards to renal dysfunction, current data show that LVAD implantation can lead to an improvement (27).…”

Ventricular assist devices for heart failure: a focus on patient selection and complications

“…A score less than 2 is highly predictive of the ability to tolerate an isolated LVAD. 14 In conclusion, while we fully acknowledge the importance of our clinical judgment, risk scores represent an additional tool to predict survival after LVAD implantation and to identify targets for therapy before surgery.…”