Clinical implications of late-onset right ventricular failure after implantation of a continuous-flow left ventricular assist device as bridge to transplantation

Abstract

OBJECTIVES The development of late-onset right ventricular failure (LoRVF) that occurs months after a continuous-flow left ventricular assist device (LVAD) is implanted is a clinical problem that warrants investigation. Our goal was to study the incidence, clinical manifestations and prognosis of LoRVF in a population of patients who received an LVAD as bridge to transplantation. METHODS Data were analysed from 97 consecutive patients who received an LVAD as bridge to transplantation and underwent a right heart catheterization at least 3 months after receiving an LVAD implantation. LoRVF was defined if both haemodynamic criteria of a central venous pressure >16 mmHg and a cardiac index <2.3 l/min/m2 were present. Clinical and echocardiographic variables, hospitalizations for heart failure and survival were compared between patients with and without LoRVF. RESULTS LoRVF was diagnosed in 13% of patients after a median time of 11 months. Patients with LoRVF presented preoperative worse right ventricular (RV) dilatation and severe tricuspid regurgitation. LORVF was also associated with postoperative RV dilatation, moderate to severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. LoRVF resulted in increased brain natriuretic peptide levels and the need for diuretics, lower haemoglobin levels and a higher rate of atrial fibrillation and gastrointestinal bleeding. The rate of hospitalizations for heart failure in patients with LoRVF was 46%, and 15% required an urgent transplantation due to refractory RV failure. LoRVF decreased global survival and survival free from hospitalizations for heart failure (P < 0.0001). CONCLUSIONS LoRVF after the implantation of an LVAD as bridge to transplantation is associated with higher morbidity and lower survival. The results suggest that the routine use of a right heart catheterization and transthoracic echocardiography may contribute to an early diagnosis before further severe complications due to refractory RV failure might occur. ID number of the IRB approval AZ-2019-521 on 10 July 2019.

Sympathetic vasoconstrictor activity before and after left ventricular assist device implantation in patients with end‐stage heart failure

“… TAPSE was >12 mm in all patients indicating stable right ventricular function 15 (for unassisted hearts, TAPSE cutoff is 17 mm 16 ). …”

“…Haemodynamics and MSNA before and after LVAD implantation are presented in Table 2 15,16 . Cardiac output, mean arterial pressure, and O‐wave amplitudes were all improved following LVAD implantation while heart‐generated pulse pressure significantly decreased.…”

Ex-Vivo Preservation with the Organ Care System in High Risk Heart Transplantation

“…Thus, an increasing number of patients are now frequently bridged to transplantation with left ventricular assist devices (LVAD) [26]. Despite the fact that LVAD therapy has dramatically improved during the past two decades, there are still many VAD-associated complications like stroke, aortic valve insufficiency, right heart failure, pump thrombosis, gastrointestinal bleeding or infection that make urgent transplantation necessary and are common indications for priority on the waiting list [27][28][29]. Thus, LVAD therapy can be considered both blessing and curse, on one hand saving patients from imminent death due to a failing heart, but also generating complex transplant candidates with increased surgical risk profiles and ongoing complications, capable of jeopardize transplant outcomes.…”

Late-onset right ventricular failure after continuous-flow left ventricular assist device implantation: case presentation and review of the literature

“…c) The readmission occurred more than 30 days after discharge from the index LVAD implant hospitalization in an effort to avoid capturing cases that may be more consistent with early RHF. • When the following parameters were found [12][13][14] : a) Leftward shift of the interventricular septum (SIV), mean arterial pressure (MAP) < 65 mmHg; CVP > 15 mmHg b) LVAD flow < 3.5 L/min c) Moderate-to-severe TR d) Frequent suction events Late-onset RVF has been reported to occur in 8% to 45% of patients with LVAD implantation ( Table 1 ) [6][7][8][9][10][11][12][13] . The incidence of RVF has been increased with time after LVAD implantation, with almost 59% of patients who have been implanted with LVAD for more than 1 year suffering from this [11] .…”

“…Several predictors of late-onset RVF have been proposed, such as preoperative LVDd < 64 mm [6] , tricuspid valve annulus diameter ≥41 mm [8] , right ventricular dilatation [9] , severe TR [9] , low tricuspid valve velocity time integral (VTI TR ) [13] , diabetes mellitus [7] , body mass index > 29 kg/m 2 [7] , higher blood urea nitrogen level [ 7 , 11 , 13 ], high creatinine concentration [13] , and increased CVP/PCWP ratio [11] . Other reports identified no predictors ( Table 1 ) [ 10 , 12 ].…”