Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Abstract

Background To investigate pre-implant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) surgery. Methods and Results Patients in the INTERMACS registry who underwent primary CF-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined endpoint of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9,976 patients undergoing CF-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Pre-implant characteristics associated with RVAD use included INTERMACS patient profiles 1 and 2, the need for preoperative ECMO or renal replacement therapy, severe pre-implant tricuspid regurgitation, history of prior cardiac surgery, and concomitant procedures other than TV repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (AUC 0.78) and the combined end-point of RVAD or death within 14 days (AUC 0.73). Compared to patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9% respectively (p<0.0001 for both). Conclusions The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction and profiles of hemodynamic instability.

Comparative Analysis of Established Risk Scores and Novel Hemodynamic Metrics in Predicting Right Ventricular Failure in Left Ventricular Assist Device Patients

“…Notably, previous work has shown that clinical variables reflecting hemodynamic instability and end-organ dysfunction (and thereby severity of RV dysfunction) drive much of the ability of scores to predict RVF. (34,35) The incidence of RVF in our study was lower than that reported in some other published studies, (18,19,27) but was similar to the recently published Euromacs study. (22) The wide variation in the reported incidence of RVF in previous studies has been attributed to heterogeneities in RVF definitions.…”

Cardiac Assist Devices: Early Concepts, Current Technologies, and Future Innovations

“…The clinical settings in which RVAD therapy are most commonly employed include acute myocardial infarction, pulmonary embolism, pulmonary hypertension, myocarditis, post-cardiotomy shock, cardiac transplantation, and LVAD implantation. As the frequency of LVAD use continues to rise, this last scenario is becoming increasingly common as nearly half of all CHF patients show right heart failure after LVAD implantation and 4% require RV support within the first two weeks post-operation [27,28]. Because RV complications after LVAD surgery are both relatively frequent and highly significant in terms of morbidity and mortality, the means to provide right ventricular mechanical support is now considered an essential capability in medical centers where LVAD therapy is performed [18,28].…”

“…As the frequency of LVAD use continues to rise, this last scenario is becoming increasingly common as nearly half of all CHF patients show right heart failure after LVAD implantation and 4% require RV support within the first two weeks post-operation [27,28]. Because RV complications after LVAD surgery are both relatively frequent and highly significant in terms of morbidity and mortality, the means to provide right ventricular mechanical support is now considered an essential capability in medical centers where LVAD therapy is performed [18,28]. Today, some RVADs like SynCardia (SynCardia Systems, Tucson, AZ, USA) serve as BTT while some others like Impella RP (AbioMed, Danvers, MA, USA), TandemHeart (CardiacAssist, Pittsburgh, PA, USA), and CentriMag RVAD (Thoratec) serve as peri-operative bridges to mechanical support [17,29].…”

Reply: Advantage of leadless pacemaker over the conventional pacemaker in patients with left ventricular assist device

“…1 We agree that the right ventricle dysfunction associated with LVAD implantation poses a frequent and serious challenge in both the early and late stages of LVAD support. 2,3 The role of the tricuspid valve and preservation of the structure of the tricuspid valve annulus seems to play a role in late right ventricular failure after LVAD implantation as patients who suffer failure of a tricuspid valve repair have higher incidence of late right ventricular failure after LVAD implant. 4 Tricuspid valve regurgitation is a known complication of transvenous pacing by several potential mechanisms, and we agree with you that theoretically a leadless pacing system could reduce tricuspid valve regurgitation and potentially alter outcomes in LVAD patients, although this has not been substantiated by any published literature.…”