Abstract
Left ventricular assist device (LVAD) is being used increasingly in recent years for end stage heart failure as a bridge to transplant (BTT) and also as a destination therapy (DT). Patients with end stage heart failure have some degree of elevated pulmonary capillary wedge pressure, causing right ventricular hypertrophy which in due course leads to decreased dilatation of the RV and fall in cardiac output & severe tricuspid regurgitation (TR) presenting with features of RV failure (RVF). Implantation of LVAD improves left heart function at the cost of right ventricular output with an incidence of 25%-30%. RVF may lead to impaired LVAD flow, difficulty in weaning from cardio-pulmonary bypass (CPB), decreased tissue perfusion and multi-organ failure. In this article we comprehended the pathophysiology leading to RVF post LVAD implantation and its preoperative predictors and the various treatment modalities for managing RVF post LVAD implantation.
Highlights
Increasing incidence of heart failure and limited availability of donor heart for transplantation made mechanical assist devices an important alternative which substitutes the pumping action of the failing ventricle and provides circulatory support maintaining the blood to flow to various organ systems of the body
Patients with end stage heart failure have some degree of elevated pulmonary capillary wedge pressure, causing right ventricular hypertrophy which in due course leads to decreased dilatation of the right ventricle (RV) and fall in cardiac output & severe tricuspid regurgitation (TR) presenting with features of RV failure (RVF)
RVF may lead to impaired Left ventricular assist device (LVAD) flow, difficulty in weaning from cardio-pulmonary bypass (CPB), decreased tissue perfusion and multi-organ failure, which are associated with increased morbidity and mortality [4]
Summary
Increasing incidence of heart failure and limited availability of donor heart for transplantation made mechanical assist devices an important alternative which substitutes the pumping action of the failing ventricle and provides circulatory support maintaining the blood to flow to various organ systems of the body. Patients with end stage heart failure have some degree of elevated pulmonary capillary wedge pressure, causing right ventricular hypertrophy which in due course leads to decreased dilatation of the RV and fall in cardiac output & severe tricuspid regurgitation (TR) presenting with features of RV failure (RVF). Improved left-sided forward flow with the help of implanted LVAD increases RV preload and alters the Frank-Starling mechanics for the already decompensated RV. This acute changes in RV hemodynamics worsen tricuspid regurgitation (TR), cause leftward bowing of the interventricular septum, and ventriculo-arterial uncoupling [5]. For the purpose of maintaining uniformity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) defined criteria for the diagnosis of RVF post LVAD implantation in 2012 (Table 1) [9]
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