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.