Load Dependency of Right Ventricular Performance Is a Major Factor to be Considered in Decision Making Before Ventricular Assist Device Implantation

Abstract

Background-Left ventricular assist devices (LVADs) provide better outcome than biventricular devices, but it is a challenge to predict the impact of LV mechanical unloading on postoperative right ventricular (RV) function preoperatively. We assessed the load dependency in RV performance before and after LVAD implantation aiming to improve preoperative decision making. Methods and Results-Laboratory, echocardiography, and right heart catheterization data collected from 205 patients before LVAD implantation were tested for relationship with postoperative RV function. Comparing patients with different time-course of RV function after LVAD implantation, we found significant differences (P<0.01) in preoperative RV enddiastolic short-/long-axis and long-axis/length-area ratios, tricuspid annulus peak systolic velocity, RV peak longitudinal global systolic strain rate, systolic pressure gradient between RV and right atrium (ΔP RV−RA ), tricuspid regurgitation velocity-time integral, and pulmonary arterial pressure between patients with and without postoperative RV failure. High predictive values for postoperative RV failure were found for end-diastolic short-/long-axis ratio ≥0.6, tricuspid annulus peak systolic velocity <8 cm/s, and peak systolic longitudinal strain rate <0.6/s in patients with maximum ΔP RV−RA <35 mm Hg. These parameters also seemed predictive for RV failure in patients with tricuspid regurgitation grade >2 and pulmonary arterial pressure <50 mm Hg. End-diastolic short-/long-axis ratio <0.6, tricuspid annulus peak systolic velocity ≥8 cm/s, and peak systolic longitudinal strain rate ≥0.6 in patients with maximum ΔP RV−RA ≥35 mm Hg showed high predictive values for postoperative freedom from RV failure. The RV load adaptation index seemed particularly predictive for RV function after LVAD implantation. Conclusions-RV geometry and velocity of contraction before LVAD implantation become more predictive for postoperative RV function and can improve decision making before VAD implantation if preoperative RV pressure load and tricuspid regurgitation are also considered. (Circulation. 2013;128[suppl 1]:S14-S23.)Key Words: echocardiography ◼ heart failure ◼ heart-assist device ◼ hemodynamics ◼ risk factors ◼ surgery ◼ ventricles © 2013 American Heart Association, Inc.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.112.000335From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.).Presented at the 2012 American Heart Association meeting in Los Angeles, CA, November 3-7, 2012 Dandel et alDecision Before Ventricular Assist Device Implantation S15 reduction of pulmonary vascular resistance (PVR) subsequent to LVAD implantation, as long as the postoperative outcome is not impaired by irreversibly poor end-organ function, and LV unloading is properly optimized to avoid excessive interventricu...

Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation

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Left ventricular vs. biventricular mechanical support: Decision making and strategies for avoidance of right heart failure after left ventricular assist device implantation

“…The high load-sensitivity of RV performance, related to the impact of preload and afterload on RV geometry and TR, explains RV ability for reverse remodeling and functional improvement after normalization of loading conditions [17,18]. Mechanical LV unloading often induces acute PVR reduction accompanied by RV geometry and function improvement.…”

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