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

Abstract

Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.

Keywords: heart failure (HF); hemocompatibility adverse events (HRAE); left ventricular assist device (LVAD); right ventricle (RV); right ventricular assist device (RVAD); right ventricular failure (RVF).

FIGURE 1

Definition of right ventricular failure after LVAD implantation according to INTERMACS from 2015 and from 2021. INTERMACS, interagency registry for mechanically assisted circulatory support; MCS-ARC, mechanical circulatory support–academic research consortium; CVP, central venous pressure; IVC, inferior vena cava; JVP, jugular venous pressure; iNO, nitric oxide; IV, intravenous; RVAD, right ventricular assist device; RVF, right ventricular failure; ULN, upper limit of normal; Svo2, central venous oxygen saturation; CI, cardiac index; ECMO, extracorporeal membrane oxygenator; LVAD, left ventricular assist device.

FIGURE 2

Risk factors for right ventricular failure after LVAD implantation not related to the intrinsic right ventricular function. LVEDD, left ventricular end-diastolic diameter; NICM, non-ischemic cardiomyopathy; ARVC, arrhythmogenic right ventricular cardiomyopathy; VT, ventricular tachycardia; BSA, body surface area; BMI, body mass index; NRI, nutrition risk index; PNI, prognostic nutrition index; ECMO, extracorporeal membrane oxygenation; RRT, renal replacement therapy; IMV, invasive mechanical ventilation; INTERMACS, interagency registry for mechanically assisted circulatory support; VE, minute ventilation; VCO2, carbon dioxide production; DLCO, carbon monoxide diffusion capacity; eGFR, estimated glomerular filtration rate; NGAL, neutrophil gelatinase-associated lipocalin; MELD, model for end-stage liver disease; INR, international normalized ratio; BNP, brain natriuretic peptide; ET1, endothelin 1; IL6, interleukin-6; PCT, procalcitonin; CCR, CC chemokine receptor.

FIGURE 3

Risk factors for right ventricular failure after LVAD implantation obtained using echocardiography. RA, right atrial; TAPSE, tricuspid annular plane systolic excursión; RV, right ventricle; FAC, fractional área change; RVFWLS, right ventricular free wall longitudinal strain; PSSrL, peak systolic longitudinal strain rate; PA, pulmonary artery.

FIGURE 4

Risk factors for right ventricular failure after LVAD implantation obtained using pulmonary artery catheterization. DTPG, diastolic transpulmonary gradient; PA, pulmonary artery; Ees, end-systolic elastance; Ea, arterial elastance; RVSWI, right ventricular stroke work index; RV, right ventricle; RA, right atrium; CVP, central venous pressure; PCWP, pre-capillary wedge pressure; MAP, mean arterial pressure; PAPI, pulmonary artery pulsatility index; pVAD, percutaneous ventricular assist device; iSV, indexed stroke volume.

FIGURE 5

Prevalence, risk factors for progression and management for valvular regurgitation at the time of LVAD implant to minimize the risk of right ventricular dysfunction. TR, tricuspid regurgitation; MR, mitral regurgitation; AR, aortic regurgitation; TV, tricuspid valve; PVR, pulmonary vascular resistance; LVEDD, left ventricular end-diastolic diameter; NICM, non-ischemic cardiomyopathy; STJ, sinotubular junction.

FIGURE 6

Adverse events associated with right ventricular failure after LVAD implantation.

FIGURE 7

Proposed algorithm for management of early right ventricular failure. ^aSigns of hypoperfusion (lactate >2 mmol/L, MAP <60 mmHg, drop in pump flows, mottled skin, oliguria) supported by hemodynamic (CVP >15, PAPI <1, RV stroke work index <300, CI <2 ml/min/m², mixed venous oxygen saturation <50%), echocardiographic (dilated RV, leftwards septal bulge, severe TR, fixed and distended IVC) or laboratory data (rise in creatinine, blood urea nitrogen or liver enzymes). ^bCorrect hypoxemia (if significant, rule out intracardiac shunts), hypercarbia and acidosis. ^cCommon causes for VT are metabolic derangements^b, ischemia (supply demand but also direct damage during surgery), pacing-related issues, scar-mediated or suction events. ^dAim for low positive end-expiratory pressure (just enough to minimize atelectasis), low mean airway pressure and avoid air entrapment. Plan for early extubation if possible. ^eMilrinone (0.125–0.75 μg/kg/min) is usually preferred to dobutamine or epinephrine given their deleterious on PVR. Low dose dobutamine (2–5 μg/kg/min) may not affect PVR. Epinephrine can be used if patient is hypotensive. ^fNorepinephrine (0.01–0.5 μg/kg/min) is the most used pressor, but vasopressin (0.01–0.06 U/min) should be added at low dose as it has less vasoconstrictive effect on the pulmonary vasculature. RV, right ventricular; TEE, transesophageal echocardiography; PA, pulmonary artery; HR, heart rate; PCWP, pulmonary capillary wedge pressure; DCCV, direct current cardioversion; VT, ventricular tachycardia; VF, ventricular fibrillation; ATP, antitachycardia pacing; ICD, internal cardiac defibrillator; RVAD, right ventricular assist device; PVR, pulmonary vascular resistance; LVAD, left ventricular assist device; iNO, nitric oxide; CVP, central venous pressure; RRT, renal replacement therapy; MAP, mean arterial pressure.