Natural History and Prognosis of Patients with Unrepaired Tricuspid Regurgitation Undergoing Implantation of Left Ventricular Assist Device

Abstract

We aimed to describe the natural history of left ventricular assist device (LVAD)-supported patients with preimplantation significant tricuspid regurgitation (TR) in a single-center retrospective analysis of LVAD-implanted patients (2008–2019). TR severity was assessed semiqualitatively using color-Doppler flow: insignificant TR (iTR) was defined as none/mild TR and significant TR (sTR) as ≥moderate TR. Included were 121 LVAD-supported patients of which 53% (n = 64) demonstrated sTR preimplantation. Among patients with pre-LVAD implantation sTR and available echocardiographic data, 55% (n = 26) ameliorated their TR severity grade to iTR during the first-year postsurgery and 55% (n = 17) had iTR at 2-year follow-up. On univariate analysis, predictors for TR severity improvement post-LVAD implantation were preimplant lack of atrial fibrillation, reduced inferior vena cavae diameter, and elevated pulmonary vascular resistance. In patients who failed to improve their TR severity grade, we observed a deterioration in right ventricular (RV) function (pulmonary artery pressure index 2.0 [1.7, 2.9], a decline in RV work index 242 [150, 471] mm Hg·L/m2) and higher loop-diuretics dose requirement. At a median of 21 (IQR 8, 40) months follow-up, clinical LVAD-related complications, heart failure-hospitalizations, and overall survival were similar among patients who improved versus failed to improve their TR severity-grade post-LVAD implantation. In conclusion, LVAD implantation is accompanied by a reduction in TR severity in approximately 50% of patients. In patients who failed to improve their TR severity grade, progressive RV dysfunction was observed. Overall, an isolated LVAD implantation in patients with sTR does not adversely affect survival.

Concomitant tricuspid valve surgery in patients undergoing left ventricular assist device: a systematic review and meta-analysis

“…Thus, the RV afterload can be decompressed during the process, resulting in improved RV function and reduced TR severity 11 . Studies have observed that TR would be reduced after isolated LVAD implantation 10 – 12 , leading TR intervention during the implantation into debate.…”

“…Initially, TVS was identified as instrumental in promoting reverse remodeling of the right ventricle (RV), reducing the incidence of right heart failure (RHF), and improving clinical outcomes 3 , 8 , 9 . With the deepening of research, some studies found that isolated LVAD could improve RV function, and reduce the severity of pulmonary hypertension (PHT) and TR 10 – 12 . Other studies demonstrated that concomitant TVS alongside LVAD implantation failed to improve survival or quality of life, but was associated with increased risks of adverse events 13 – 15 .…”

Tricuspid regurgitation in the setting of LVAD support

“…In examining the effect of LVAD placement in offloading the LV, significant reverse cardiac remodeling was noted within 40 days of implant in hearts explanted at the time of transplant (23). Multiple studies have demonstrated improvements after LVAD placement in pulmonary artery pressures, pulmonary vascular resistance (PVR), pulmonary capillary wedge pressures, and in RV and TV function (22,(24)(25)(26)(27)(28)(29)(30). TR improvement after LVAD placement was seen more in patients with a higher PVR, which is likely, as such patients gain from LVAD placement through a substantial decline in PVR (29).…”

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

“…Predictors of persistent TR or de novo TR are tricuspid annulus dilatation >41 mm ( 153 , 155 , 156 ), atrial fibrillation ( 157 – 159 ) and normal PVR ( 159 ). Despite the risks, repair in these cases is justified to minimize the likelihood of late RVF.…”