Limitations of Preoperative Right Ventricular Failure Assessment in Patients Undergoing LVAD Insertion

Abstract

Purpose Early right ventricular (RV) failure after LVAD is associated with increased morbidity and mortality. Several hemodynamic indices have been suggested to identify patients at risk for RV failure, however their predictive value remains unclear. Methods We retrospectively identified patients at our center who required mechanical RV support following LVAD between 2007-2018, with either surgical (Centrimag RVAD) or percutaneous (Impella RP, Protek Duo) devices. Those receiving RVAD at time of LVAD insertion were excluded. Predictors of RV failure were calculated with preoperative hemodynamics, including RA/PCWP (low risk (LR) 0.64), PAPI (LR >2, medium risk (MR) 1.5-2, HR 600 mmHg*mL/m2, MR 300-600, HR 5.5), and EUROMACS-RHF (LR 4). Results 37 patients required mechanical RV support. 18 received percutaneous RVAD and 19 surgical RVAD. Figure 1 summarizes the proportion of patients who would have been identified as low, medium, or high risk of RV failure. Mean RA/PCWP was 0.43 ± 0.19, with 13.5% of patients identified as high risk. 70.3% of patients had PAPI suggestive of low risk, with only 10.8% and 18.9% identified as medium or high risk, respectively. RVSWI identified 51.3% of patients as medium risk of RV failure and 21.6% as high risk, with mean 519 ± 316 mmHg*mL/m2. EUROMACS-RHF classified 51.3% as medium risk and 22% as high risk, while the RVFRS identified the majority of patients as low risk (83.8%). Conclusion Among patients who ultimately required mechanical support for RV failure following LVAD insertion, the majority would not have been identified as at risk using most currently available preoperative risk assessments. RVSWI and EUROMACS-RHF best predicted RV failure, identifying the majority of patients as at medium risk. In patients not identified as at risk preoperatively, easily deployed RV support may be an important means to rapidly address RV failure after LVAD insertion.