Predictors of Severe Right Ventricular Failure After Implantable Left Ventricular Assist Device Insertion: Analysis of 245 Patients

Abstract

Background Insertion of an implantable left ventricular assist device (LVAD) complicated by early right ventricular (RV) failure has a poor prognosis and is largely unpredictable. Prediction of RV failure after LVAD placement would lead to more precise patient selection and optimal device selection. Methods and Results We reviewed data from 245 patients (mean age, 54±11 years; 85% male) with 189 HeartMate (77%) and 56 Novacor (23%) LVADs. Ischemic cardiomyopathy predominated (65%), and 29% had dilated cardiomyopathy. Overall, RV assist device (RVAD) support was required after LVAD insertion for 23 patients (9%). We compared clinical and hemodynamic parameters before LVAD insertion between RVAD (n=23) and No-RVAD patients (n=222) to determine preoperative risk factors for severe RV failure. By univariate analysis, female gender, small body surface area, nonischemic etiology, preoperative mechanical ventilation, circulatory support before LVAD insertion, low mean and diastolic pulmonary artery pressures (PAPs), low RV stroke work (RVSW), and low RVSW index (RVSWI) were significantly associated with RVAD use. Elevated PAP and pulmonary vascular resistance were not risk factors. Risk factors by multivariable logistic regression were preoperative circulatory support (odds ratio [OR], 5.3), female gender (OR, 4.5), and nonischemic etiology (OR, 3.3). Conclusions The need for circulatory support, female gender, and nonischemic etiology were the most significant predictors for RVAD use after LVAD insertion. Regarding hemodynamics, low PAP and low RVSWI, reflecting low RV contractility, were important parameters. This information may lead to better patient selection for isolated LVAD implantation.

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

“…Finally, we identified an elevated early post-op CVP as independent “modifiable” risk factor for the development of RHF, which has already been described as preoperative risk factor pre-LVAD implantation [ 24 , 25 ]. 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.…”

Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients

“…Similarly, high RVSWI in patients undergoing lung transplantation has been associated with poor outcomes [28]. Studies conducted on HFrEF patients have shown that low RVSWI is associated with postoperative RV failure in those under- going LVAD implantation [15,29,30]. In 2 studies, Cesini et al [26] and Kochav et al [23] found that RVSWI was not associated with primary outcomes including LVAD implantation, urgent HT, and death.…”

A standardized definition for right ventricular failure in cardiac surgery patients

“…Various studies have demonstrated RV stroke work index (RVSWI), defined as work performed by RV each contraction indexed to heart rate and mean arterial pressure, 66 was predictive of RVF when RVSWI < 4. 55,57,60 Additionally, a PAPi < 1.85 has also been shown to be a sensitive predictor of RVF after LVAD implantation. 45,67 To date, the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria stand as the only formally accepted definition of RVF in the setting of LVAD implantation.…”

“…Similarly, the need for inotropic therapy for >14 days 29,35,56,58 is confounded by practice variations across institutions. Various studies have demonstrated RV stroke work index (RVSWI), defined as work performed by RV each contraction indexed to heart rate and mean arterial pressure, 66 was predictive of RVF when RVSWI < 4 55,57,60 . Additionally, a PAPi < 1.85 has also been shown to be a sensitive predictor of RVF after LVAD implantation 45,67 …”

“…66 Studies using some or all of these criteria also reported higher rates of short-term and long-term mortality in those who developed RVF 57 (Table 1). In some cases, the diagnosis of RVF was based solely on the need for RVAD support, 55,60 although criteria for RVAD varied widely between studies. 35,56,58,59 Similarly, the need for inotropic therapy for >14 days 29,35,56,58 is confounded by practice variations across institutions.…”