Prediction of right ventricular failure after left ventricular assist device implantation in patients with heart failure: a meta-analysis comparing echocardiographic parameters

Abstract

OBJECTIVES Between 10% and 40% of patients who receive a left ventricular assistance device (LVAD) suffer from right ventricular failure (RVF) shortly after the device is implanted. Patients with post-LVAD RVF tend to have poor outcomes. Only a few predictive factors concerning the right ventricle (RV) have been investigated. Our goal was to search for non-invasive variables that correlate with RV function, focusing on echocardiographic parameters of the RV. METHODS We selected 3 parameters: tricuspid annular plane systolic excursion, right ventricular fractional area change and right ventricular global longitudinal strain. We searched the literature and pooled relevant studies in a meta-analysis. Finally, we performed a statistical analysis to confirm whether each parameter was a reliable predictor of RVF after LVAD implantation. RESULTS We retained 19 articles involving a total of 1561 patients. We found a pooled standardized mean deviation of −0.13 cm for the tricuspid annular plane systolic excursion, with the lower and upper tails of −0.21 and −0.04 cm, respectively. Concerning the right ventricular fractional area change, the averaged standardized mean deviation was equal to −2.61%, with the lower and upper extremities of −4.12% and −1.09%, respectively. Finally, regarding the global longitudinal strain, the standardized mean deviation was equal to −2.06% with an uncertainty value between −3.23% and −0.88%. CONCLUSIONS The tricuspid annular plane systolic excursion could be a reliable parameter in RVF prediction. The right ventricular fractional area change and global longitudinal strain are likely to be stronger predictors of RVF after LVAD implantation. Prospective studies should be carried out to confirm this observation.

Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy

“…Meta-analysis did show that moderate to severe RV dysfunction (assessed qualitatively) was associated with higher risk of RHF (OR 2.82) [ 21 ], though performance of these specific models was still modest at best [ 36 ]. Tricuspid annular plane systolic excursion (TAPSE) has not borne out as a predictive factor due to the fact of its heterogeneity and dependence on loading conditions [ 39 , 40 , 41 ]; it also does not account for the septal contribution to RV function. Tissue doppler imaging for the systolic velocity (S’) of the tricuspid annulus could pose an alternative to TAPSE, with a small study showing lower preoperative S’ in LVAD patients who developed RHF [ 42 ].…”

“…However, utility of this measure in predicting RHF is unclear, and reproducibility and availability of the software package are known challenges [ 22 , 40 ]. RV free wall strain has been predictive of RHF following LVAD implantation [ 38 , 41 , 45 , 46 ] and is a promising marker for clinical use.…”

Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review

“…Despite the existence of different cutoffs for RVF risk, all predictors should be approached as a continuum of risk rather than a dichotomous value. Tricuspid annular plane systolic excursion (TAPSE) less than 8 mm has been consistently associated with RVF risk, increasing the predictive capacity of different risk scores ( 79 – 81 ). The suggested cutoff to predict RVF for RV’s tissue Doppler s′ was <5–8 cm/s ( 82 , 83 ).…”

“…The suggested cutoff to predict RVF for RV’s tissue Doppler s′ was <5–8 cm/s ( 82 , 83 ). RV fractional area change (FAC) accounts for radial contraction in addition to longitudinal contraction, and is associated with RVF <25–30% ( 79 , 84 ). RV dilatation can be assessed with the ratio between RV and LV end-diastolic diameters in a 4-chamber view, or right-to-left ratio.…”

“…The contribution of septal fibers to RV contractility is severely reduced after LVAD implant, and the assessment of RV free wall contractility with deformation techniques predicts RVF with accuracy similar to conventional RV systolic assessment. However, the cutoffs for RV free wall longitudinal strain for predicting RVF vary widely across studies, ranging from <5 to <15%, which precludes practical implementation ( 46 , 79 , 89 – 93 ). The capacity of simultaneous multiplanar echocardiography and 3-dimensional imaging to evaluate the complex RV anatomy may improve discrimination ( 88 , 94 – 96 ).…”