Right Ventricular Strain as a Predictor of Post-LVAD Early Right Ventricular Failure

Abstract

Purpose Early right ventricular failure (RVF) occurs in up to 40% of patients following left ventricular assist device (LVAD) implantation and is associated with increased peri-operative mortality and prolonged hospitalization. We sought to determine the effectiveness of RV longitudinal strain (RVLS) in predicting post-LVAD RVF. Methods We retrospectively analyzed 55 patients who underwent LVAD implantation between 2013-2018 in an academic hospital. Global longitudinal and segmental (septum and free wall) RV strain in the 4-chamber, right ventricular outflow tract (RVOT), and subcostal views were measured on pre-LVAD echocardiograms using 2D strain software (TomTec, Chicago, USA). Early RVF was defined as the requirement of more than two weeks of ionotropic support post LVAD implantation or the need for right ventricular assist device (RVAD). Results 27 patients (49%) suffered from RVF. RV global longitudinal strain (RVLS) was significantly reduced in patients who developed RVF compared to those who did not (Table 1). At a cutoff of -10.0%, RVLS measured in the 4-chamber view had a sensitivity of 88% and specificity of 75% in predicting early RVF, with an AUC of 0.84 and an OR of 1.4. Segmental analysis of free wall and septal strain in the apical 4-chamber and subcostal views were also significantly reduced in patients with RVF. ROC calculations were performed on previously described metrics including pulmonary artery pulsatility index (PAPi), right ventricular stroke work index (RVSWI), and Michigan risk score demonstrating an AUC of 0.46 for PAPi, 0.41 for RVSWi, and 0.58 for Michigan risk score. Conclusion Pre-operative RVLS was a useful predictor of RVF in multiple views. In this cohort study, 2D RVLS outperformed previously used clinical, hemodynamic, and echocardiographic based metrics as a predictive marker for early RVF and may be a useful tool in risk stratification of pre-operative LVAD patients.