Right heart failure after left ventricular assist device: From mechanisms to treatments

Abstract

Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5–44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.

Adaptive ECMO Therapeutics: The Integral Role of the ProtekDuo® Cannula

“…RVF following implantation of an LVAD is a common problem in which up to one-third of patients may require MCS [52][53][54]. Application of the ProtekDuo® cannula as a component of an RVAD system without an ML in a (dl)VxP configuration is well-documented in this patient group [55].…”

Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta‐analysis

“…Furthermore, right heart failure is a relatively common complication following LVAD implantation, implicated in approximately 20% of cases 31 . This has been attributed to increased right ventricular preload following amelioration of left ventricular ejection fraction after LVAD implantation 32 alongside a rightwards interventricular shift disrupting right ventricle morphology due to high CF–LVAD pump speeds 33 . Moreover, RVADs are predominantly used in the short term following cardiac surgery, including LVAD implantation 34 .…”

Impact of diastolic pulmonary gradient and pulmonary vascular remodeling on survival after left ventricular assist device implantation and heart transplantation

“…Recently, Grupper et al [ 18 ] have studied 85 adult patients with LVAD (HeartMate II and III) and reported the improvement of pulmonary hemodynamics and echocardiographic parameters after LVAD regardless of the pre-LVAD PVR. Despite the LVAD decreases the severity of MR and pulmonary pressures, RVF may occur due to increased preload, loss of the ventricular interdependence and left-sided deviation of septum with possible right ventricular dilatation and worsening of tricuspid regurgitation [ 19 ]. RVF occurred in 32.9% of our study patients and almost half of them required the right ventricular assist device (RVAD).…”