Left Ventricular Assist Device in Right Ventricular Failure

Abstract

Purpose Left ventricular (LV) assist device (AD) placement for end-stage LV failure (F) is contraindicated with co-existing right ventricular (RV) F. We propose a strategic pre-op management (“HF tune up”) prior to LVAD allowing safe LVAD implant despite RVF. Methods and Materials This single center study identified 47 patients (pts) who underwent Heart Mate II implant from 2009 to 2011. Pre-op hemodynamics were analyzed at three time points: presentation (T0), 1 day pre-op (T1) and 3 days post-op (T2). Pre-op RVF was defined visually by 2D-echocardiography &/or by RV Stroke Work Index (RVSWI 14 days &/or RVAD placement. All pts underwent escalating pre-op “HF tune up” (diuresis, vasodilators, inotropes). Results Mean INTERMACS score for all HF pts who underwent HMII LVAD insertion was 1.7 ±0.6. Mean age was 61±16 yrs. 62% (n=29) of pts had preexisting RVF by echocardiography (51% moderate, 11% severe) with markedly elevated CVP at T0 compared to non-RVF. Of those, 24% (n=7) pts had RVF by RVSWI criteria. HF tune up significantly improved CVP and PCWP (T1) without change in RVSWI (T0: 0.6 ±0.5 vs T1: 0.3±0.3; p=ns). Despite marked pre-op RVF, post-op RVF rate were markedly low with 2% (n=1) suggesting that under ideal hemodynamics (Fontan physiology) the LVAD can support both, LV & RV. 1-year morbidity and mortality was excellent and not different between RVF vs non-RVF. Conclusions Effective pre-op HF tune up targeting CVP ≤ 8, PCWP ≤18, and PVR≤1.2 in end-stage HF pts with refractory pre-op RVF can greatly reduce post-op RVF. In this setting, LVAD placement appears to be safe and supports both ventricles via a “Fontan” circuit. LVAD and Hemodynamics at different time points Variables No RVF(n=18) RVF(n=29) CVP (mmHg) T0 13.8 ± 4.5 17.7 ± 4.1 0.004 T1 8.6 ± 3.9 9.1 ± 2.1 NS NS T2 12.4±4.9 11.5±4.2 NS PCWP(mmHg) T0 23.2±4.3 22.9±5.0 NS T1 17.6±5.6 15.43±3.7 NS NS NS T2 19.3±5.6 14±5.6 0.02 PVR (WU) T1 3.1±2.0 2.53±1.7 NS NS T2 1.95±4.2 1.14±1.8 NS