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. 2022 Jun;15(6):e008706.
doi: 10.1161/CIRCHEARTFAILURE.121.008706. Epub 2022 Jun 6.

Right Heart Failure Following Left Ventricular Device Implantation: Natural History, Risk Factors, and Outcomes: An Analysis of the STS INTERMACS Database

Chris J Kapelios  1   2 , Lars H Lund  3 , Omar Wever-Pinzon  1 , Craig H Selzman  1 , Susan L Myers  4 , Ryan S Cantor  4 , Josef Stehlik  1 , Themistocles Chamogeorgakis  5 , Stephen H McKellar  1 , Antigone Koliopoulou  1 , Rami Alharethi  6 , Abdallah G Kfoury  6 , Michael Bonios  7 , Stamatis Adamopoulos  7 , Edward M Gilbert  1 , James C Fang  1 , James K Kirklin  4 , Stavros G Drakos  1   2
Affiliations

Right Heart Failure Following Left Ventricular Device Implantation: Natural History, Risk Factors, and Outcomes: An Analysis of the STS INTERMACS Database

Chris J Kapelios et al. Circ Heart Fail. 2022 Jun.

Abstract

Background: Our current understanding of right heart failure (RHF) post-left ventricular assist device (LVAD) is lacking. Recently, a new Interagency Registry for Mechanically Assisted Circulatory Support definition of RHF was introduced. Based on this definition, we investigated natural history, risk factors, and outcomes of post-LVAD RHF.

Methods: Patients implanted with continuous flow LVAD between June 2, 2014, and June 30, 2016 and registered in the Interagency Registry for Mechanically Assisted Circulatory Support/Society of Thoracic Surgeons Database were included. RHF incidence and predictors, and survival after RHF were assessed. The manifestations of RHF which were separately analyzed were elevated central venous pressure, peripheral edema, ascites, and use of inotropes.

Results: Among 5537 LVAD recipients (mean 57±13 years, 49% destination therapy, support 18.9 months) prevalence of 1-month RHF was 24%. Of these, RHF persisted at 12 months in 5.3%. In contrast, de novo RHF, first identified at 3 months, occurred in 5.1% and persisted at 12 months in 17% of these, and at 6 months occurred in 4.8% and persisted at 12 months in 25%. Higher preimplant blood urea nitrogen (ORs,1.03-1.09 per 5 mg/dL increase; P<0.0001), previous tricuspid valve repair/replacement (ORs, 2.01-10.09; P<0.001), severely depressed right ventricular systolic function (ORs,1.17-2.20; P=0.004); and centrifugal versus axial LVAD (ORs,1.15-1.78; P=0.001) represented risk factors for RHC incidence at 3 months. Patients with persistent RHF at 3 months had the lowest 2-year survival (57%) while patients with de novo RHF or RHF which resolved by 3 months had more favorable survival outcomes (75% and 78% at 2 years, respectively; P<0.001).

Conclusions: RHF at 1 or 3 months post-LVAD was a common and frequently transient condition, which, if resolved, was associated with relatively favorable prognosis. Conversely, de novo, late RHF post-LVAD (>6 months) was more frequently a persistent disorder and associated with increased mortality. The 1-, 3-, and 6-month time points may be used for RHF assessment and risk stratification in LVAD recipients.

Keywords: edema; heart failure; hepatomegaly; prevalence; prognosis.

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Figures

Figure 1.
Figure 1.. Incidence of de novo right heart failure and prevalence of right heart failure following LVAD implantation.
Follow-up was performed at 1, 3 and 6 months, and every 6 months thereafter.
Figure 2.
Figure 2.. Bar chart depicting persistence of post-LVAD right heart failure (RHF) according to timing of onset.
RHF presenting for the first time at 1 month resolves during follow-up in most patients, persisting up to 12 months in only 3.5%. RHF presenting at 3 months persists up to 12 months in 11% of patients. Contrary, RHF presenting for the first time at 6 months is more often a persistent condition, continuing to affect 25% of patients at 12 months post-implant.
Figure 3.
Figure 3.. Survival by RHF groups for patients who are alive at 1 month post-implant according to number of RHF manifestations.
Panel A. No vs one vs two vs three RHF manifestations. Panel B. No vs one vs more than one RHF manifestations. Patients alive at 1 month were N=5176. Event was death censored at transplant, recovery or exchange. Patients with vena cava distension (n=17, deaths=8) and patients with missing RHF information (n=329, deaths=75) were excluded from the analysis.
Figure 3.
Figure 3.. Survival by RHF groups for patients who are alive at 1 month post-implant according to number of RHF manifestations.
Panel A. No vs one vs two vs three RHF manifestations. Panel B. No vs one vs more than one RHF manifestations. Patients alive at 1 month were N=5176. Event was death censored at transplant, recovery or exchange. Patients with vena cava distension (n=17, deaths=8) and patients with missing RHF information (n=329, deaths=75) were excluded from the analysis.
Figure 4.
Figure 4.
Panel A. Survival by RHF groups for patients who are alive at 3 months post-implant and have completed both 1- and 3-month follow-up according to subtype of RHF. Curves estimated using Kaplan-Meier survival analysis with transplant, and recovery or exchange as censoring events. Panel B. Mortality by RHF groups for patients who are alive at 3 months post-implant and have completed both 1- and 3-month follow-up according to subtype of RHF.
Figure 4.
Figure 4.
Panel A. Survival by RHF groups for patients who are alive at 3 months post-implant and have completed both 1- and 3-month follow-up according to subtype of RHF. Curves estimated using Kaplan-Meier survival analysis with transplant, and recovery or exchange as censoring events. Panel B. Mortality by RHF groups for patients who are alive at 3 months post-implant and have completed both 1- and 3-month follow-up according to subtype of RHF.
See this image and copyright information in PMC

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