Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta‐analysis of observational studies

Abstract

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with increased morbidity and mortality, but the identification of LVAD candidates at risk for RVF remains challenging. We undertook a systematic review and meta-analysis of observational studies of risk factors associated with RVF after LVAD implant. Thirty-six studies published between 1 January 1995 and 30 April 2015, comprising 995 RVF patients out of a pooled final population of 4428 patients, were identified. Meta-analysed prevalence of post-LVAD RVF was 35%. A need for mechanical ventilation [odds ratio (OR) 2.99], or continuous renal replacement therapy (CRRT; OR 4.61, area under the curve 0.78, specificity 0.91) were the clinical variables with the highest effect size (ES) in predicting RVF. International normalized ratio [INR; standardized mean difference (SMD) 0.49] and N-terminal pro-brain natriuretic peptide (NT-proBNP) (SMD 0.52) were the biochemical markers that best discriminated between RVF and No-RVF populations, though NT-proBNP was highly heterogeneous. Right ventricular stroke work index (RVSWI) and central venous pressure (CVP) (SMD -0.58 and 0.47, respectively) were the haemodynamic measures with the highest ES in identifying patients at risk of post-LVAD RVF; CVP was particularly useful in risk stratifying patients undergoing continuous-flow LVAD implant (SMD 0.59, P < 0.001, I = 20.9%). Finally, pre-implant moderate to severe right ventricular (RV) dysfunction, as assessed qualitatively (OR 2.82), or a greater RV/LV diameter ratio (SMD 0.51) were the standard echocardiographic measurements with the highest ES in comparing RVF with No-RVF patients. Longitudinal systolic strain of the RV free wall had the highest ES (SMD 0.73) but also the greatest heterogeneity (I = 74%) and was thus only marginally significant (P = 0.05). Patients on ventilatory support or CRRT are at high risk for post-LVAD RVF, similarly to patients with slightly increased INR, high NT-proBNP or leukocytosis. High CVP, low RVSWI, an enlarged right ventricle with concomitant low RV strain also identify patients at higher risk.

Atrial fibrillation and right ventricular failure: reply

“…We are grateful to Dr Cerit for his interest in our paper and we concur that atrial rhythm and performance may play important roles in the pathophysiology of right ventricular failure (RVF), specifically in patients referred for left ventricular assist device (LVAD) implant.…”

A novel, highly discriminatory risk model predicting acute severe right ventricular failure in patients undergoing continuous‐flow left ventricular assist device implant

“…Variables identified to predict RV failure after LVAD placement vary widely and reflect the complexity in the multifactorial mechanism of the RV failure onset. While no single best predictor variable has been identified, some form of RV hemodynamics or tricuspid valve function surrogates are most commonly used alone or as part of a predictive risk score .…”

“…We chose to use a RVAD as the primary outcome due to varying definitions of RVF at our institutions, many of which are dependent on institutional practice variation in management of inotropes or nitric oxide after CF-LVAD as opposed to an RVAD which is only employed in the sickest cohort of patients with acute severe RVF. Variables identified to predict RV failure after LVAD placement vary widely 1,9,10,14,15 and reflect the complexity in the multifactorial mechanism of the RV failure onset. While no single best predictor variable has been identified, some form of RV hemodynamics 9,10,16 or tricuspid valve function 6,8 surrogates are most commonly used alone 6,[8][9][10]16 or as part of a predictive risk score.…”

Prevalence, Predictors, and Prognostic Value of Residual Tricuspid Regurgitation in Patients With Left Ventricular Assist Device

“…Hemodynamic parameters were not independently associated with residual TR in this study. Because recent studies showed that preoperative pulmonary artery pulsatility index32, 33 and RV stroke work index34, 35 are associated with early right heart failure after LVAD implantation, future studies are needed whether these parameters predict the residual TR in patients with mid‐ to long‐term LVAD support. In addition, ischemic cardiomyopathy tended to have more residual TR in this study, although previous work showed that nonischemic cardiomyopathy is a risk factor for early right heart failure 34.…”