Late Right Heart Failure Research Articles

Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis.

Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.

Right Heart Reserve Function Assessed With Fluid Loading Predicts Late Right Heart Failure After Left Ventricular Assist Device Implantation

BackgroundA left ventricular assist device (LVAD) is an effective therapeutic option for advanced heart failure. Late right heart failure (LRHF) is a complication after LVAD implantation that is associated with increasing morbidity and mortality; however, the assessment of right heart function, including right heart reserve function after LVAD implantation, has not been established. We focused on a fluid-loading test with right heart catheterization to evaluate right heart preload reserve function and investigate its impact on LRHF. MethodsPatients aged > 18 years who received a continuous-flow LVAD between November 2007 and December 2022 at our institution, and underwent right heart catheterization with saline loading (10 mL/kg for 15 minutes) 1 month after LVAD implantation, were included. ResultsOverall, 31 cases of LRHF or death (right heart failure [RHF] group) occurred in 149 patients. In the RHF vs the non-RHF groups, the pulmonary artery pulsatility index (PAPi) at rest (1.8 ± 0.89 vs 2.5 ± 1.4, P = 0.02) and the right ventricular stroke work index (RVSWi) change ratio with saline loading (0.96 ± 0.32 vs 1.1 ± 0.20, P = 0.03) were significantly different. The PAPi at rest and the RVSWi change ratio with saline loading were identified as postoperative risks for LRHF and death. The cohort was divided into 3 groups based on whether the PAPi at rest and the RVSWi change ratio were low. The event-free curve differed significantly among the 3 groups (P < 0.001). ConclusionsHemodynamic assessment with saline loading can evaluate the right ventricular preload reserve function of patients with an LVAD. A low RVSWi change with saline loading was a risk factor for LRHF following LVAD implantation.

Incidence and risk factors of late right heart failure in chronic mechanical circulatory support.

Late right heart failure (LRHF) is a common complication during long-term left ventricular assist device (LVAD) support. We aimed to identify risk factors for LRHF after LVAD implantation. Patients undergoing primary LVAD implantation between 2006 and 2019 and surviving the perioperative period were included for this study (n = 261). Univariate Cox proportional hazards analysis was used to assess the association of clinical covariates and LRHF, stratified for device type. Variables with p < 0.10 entered the multivariable model. In a subset of patients with complete echocardiography or right catheterization data, this multivariable model was extended. Postoperative cardiopulmonary exercise test data were compared in patients with and without LRHF. Nineteen percentage of patients suffered from LRHF after a median of 12 months, of which 67% required hospitalization. A history of atrial fibrillation (AF) (HR: 2.06 [1.08-3.93], p = 0.029), a higher preoperative body mass index (BMI) (HR: 1.07 [1.01-1.13], p = 0.023), and intensive care unit (ICU) duration (HR: 1.03 [1.00-1.06], p = 0.025) were independent predictors of LHRF in the multivariable model. A significant relation between the severity of tricuspid regurgitation (TR) and LRHF (HR: 1.91 [1.13-3.21], p = 0.016) was found in patients with echocardiographic data. Patients with LRHF demonstrated a lower maximal workload and peak VO2 at 6 months postoperatively. A history of AF, BMI, and longer ICU stay may help identify patients at high risk for LRHF. Severity of TR was significantly related to LRHF in a subset of patients.

Abstract 12180: Post-Implant Beta Blocker Use and Late Right Heart Failure After LVAD Implantation: An STS-INTERMACS Analysis

Introduction: Late right heart failure (LRHF) after left ventricular assist device (LVAD) implant is associated with increased morbidity and mortality. Whether post-implant beta-blocker (BB) use can mitigate the incidence of LRHF is unknown. Methods: We queried the STS-INTERMACS registry from 2008-2018 for adults receiving a primary, continuous-flow LVAD and surviving to 3 months without ongoing RHF, defined as presence of a right ventricular assist device (RVAD) or inotropic support. We excluded patients with atypical LVAD cannulation, bridge-to-recovery strategy, ongoing renal replacement therapy, or missing BB status at 3 months. At 3 months post-implant, patients receiving BB were propensity-matched 1:1 to those not receiving BB using a nearest-neighbor method without replacement. The primary outcome was a composite of all-cause mortality or LRHF, including the need for RVAD, inotropic support, or hospitalization for RHF or fluid overload, and was compared between groups with the Kaplan-Meier method and log-rank testing. Results: Among 14,317 patients meeting inclusion criteria, 4,880 patients receiving BB at 3 months were matched with 4,880 not receiving BB. Baseline covariates were well-balanced (Figure, panel A) and 11.2% of patients experienced early RHF. Over 3-years of follow up, patients receiving BB had a lower incidence of the primary outcome hazard ratio (HR) 0.91 (95% CI: 0.85-0.97), p=0.007 (Figure, panel B). This difference was driven primarily by lower rates of hospitalization for RHF or fluid overload (HR 0.83, 95% CI: 0.72-0.95, p=0.008) and all-cause mortality (HR 0.91, 95% CI: 0.82-1.02, p=0.11) while rates of late RVAD or inotropic support were similar. Conclusions: In this retrospective, propensity-matched analysis, the use of beta blockers after LVAD implant was associated with a modest reduction in the composite of all-cause mortality and LRHF. These data suggest BB may mitigate LRHF and should be confirmed with prospective studies.

Abstract 12924: The Role of Cardiac Magnetic Resonance Imaging Derived-Right Ventricular Ejection Fraction in Predicting the Risk of Right Heart Failure in Patients Who Underwent Left Ventricular Assist Device Implantation

Introduction: Despite the advancement in the left ventricular assist devices (LVADs), right heart failure (RHF) remains a challenging adverse event after LVAD implantation and is associated with increased morbidity and mortality. Cardiac magnetic resonance (CMR)-derived right ventricular ejection fraction (RVEF) is a promising surrogate of the right ventricular function and is an independent predictor of major cardiovascular events. In this study, we aim to assess the role of CMR-derived RVEF in predicting the risk of post-LVAD RHF. Methods: We retrospectively assessed adult patients (&gt;18 years) who underwent CMR prior to LVAD implantation at our center from 2016 to 2021. Overall baseline characteristics and clinical outcomes were compared between the patients who developed post-LVAD RHF and those who did not. Results: A total of 42 patients were included in this study. Nine patients (21%) developed RHF; four had early post-implant RHF, and five had late RHF. The mean age was 47±14 years, and 76% were males. Most of the patients were on milrinone infusion at LVAD implantation (69%). The mean cardiac index (using the thermodilution method) was 1.5±0.8 ml/kg/m2, and CMR-derived LVEF was 17±7%. About half of the patients were on destination therapy, and half were on a bridge-to-transplant strategy. The mean CMR-derived RVEF was 25±13%, with no statistically significant difference between the two groups. The mean of the CMR-derived right ventricular volume index trend was higher in those with post-LVAD RHF but did not achieve statistical significance (76±28 ml/m2 vs. 65±25 ml/m2; p=0.31). Patients with post-LVAD RHF had lower mean arterial pressure (MAP) at the time of the right heart catheterization (77±10 vs. 85±12 mmHg; p0.039) and had more HF hospitalizations (2.7±2.2 vs. 0.7±1.5 hospitalizations; p=0.001). Conclusions: In patients who underwent CMR prior to LVAD implantation, CMR-derived RVEF was not an independent predictor of post-LVAD RHF. Larger multicenter studies are needed to confirm this finding.

Right Heart Failure Following Left Ventricular Device Implantation: Natural History, Risk Factors, and Outcomes: An Analysis of the STS INTERMACS Database.

Our current understanding of right heart failure (RHF) post-left ventricular assist device (LVAD) is lacking. Recently, a new Interagency Registry for Mechanically Assisted Circulatory Support definition of RHF was introduced. Based on this definition, we investigated natural history, risk factors, and outcomes of post-LVAD RHF. Patients implanted with continuous flow LVAD between June 2, 2014, and June 30, 2016 and registered in the Interagency Registry for Mechanically Assisted Circulatory Support/Society of Thoracic Surgeons Database were included. RHF incidence and predictors, and survival after RHF were assessed. The manifestations of RHF which were separately analyzed were elevated central venous pressure, peripheral edema, ascites, and use of inotropes. Among 5537 LVAD recipients (mean 57±13 years, 49% destination therapy, support 18.9 months) prevalence of 1-month RHF was 24%. Of these, RHF persisted at 12 months in 5.3%. In contrast, de novo RHF, first identified at 3 months, occurred in 5.1% and persisted at 12 months in 17% of these, and at 6 months occurred in 4.8% and persisted at 12 months in 25%. Higher preimplant blood urea nitrogen (ORs,1.03-1.09 per 5 mg/dL increase; P<0.0001), previous tricuspid valve repair/replacement (ORs, 2.01-10.09; P<0.001), severely depressed right ventricular systolic function (ORs,1.17-2.20; P=0.004); and centrifugal versus axial LVAD (ORs,1.15-1.78; P=0.001) represented risk factors for RHC incidence at 3 months. Patients with persistent RHF at 3 months had the lowest 2-year survival (57%) while patients with de novo RHF or RHF which resolved by 3 months had more favorable survival outcomes (75% and 78% at 2 years, respectively; P<0.001). RHF at 1 or 3 months post-LVAD was a common and frequently transient condition, which, if resolved, was associated with relatively favorable prognosis. Conversely, de novo, late RHF post-LVAD (>6 months) was more frequently a persistent disorder and associated with increased mortality. The 1-, 3-, and 6-month time points may be used for RHF assessment and risk stratification in LVAD recipients.

Outcomes With Phosphodiesterase-5 Inhibitor Use After Left Ventricular Assist Device: An STS-INTERMACS Analysis.

Elevated right ventricular afterload following continuous-flow left ventricular assist device (CF-LVAD) may contribute to late right heart failure (LRHF). PDE5i (phosphodiesterase-5 inhibitors) are used to treat pulmonary hypertension and right heart dysfunction after CF-LVAD, but their impact on outcomes is uncertain. We queried Interagency Registry for Mechanically Assisted Circulatory Support from 2012 to 2017 for adults receiving a primary CF-LVAD and surviving ≥30 days from index discharge. Patients receiving early PDE5i (ePDE5i) at 1 month were propensity-matched 1:1 with controls. The primary outcome was the cumulative incidence of LRHF, defined using prevailing Interagency Registry for Mechanically Assisted Circulatory Support criteria; secondary outcomes included all-cause mortality and major bleeding. Among 9627 CF-LVAD recipients analyzed, 2463 (25.6%) received ePDE5i and 1600 were propensity-matched 1:1 with controls. Before implant, ePDE5i patients had more severe RV dysfunction (13.1% versus 9.6%) and higher pulmonary vascular resistance (2.8±2.7 versus 2.2±2.4 WU), both P<0.001, but clinical factors were well-balanced after propensity-matching. In the unmatched cohort, ePDE5i patients had a higher 3-year cumulative incidence of LRHF, mortality, and major bleeding, but these differences were attenuated in the propensity-matched cohort: LRHF 40.8% versus 35.7% (hazard ratio, 1.14 [95% CI, 0.99-1.32]; P=0.07); mortality 38.6% versus 35.8% (hazard ratio, 0.99 [95% CI, 0.86-1.15]; P=0.93); major bleeding 51.2% versus 46.0% (hazard ratio, 1.12 [95% CI, 0.99-1.27]; P=0.06). Compared with propensity-matched controls, adult CF-LVAD patients receiving ePDE5i had similar rates of LRHF, mortality, and major bleeding. While intrinsic patient risk factors likely account for more adverse outcomes with ePDE5i in the unmatched cohort, there is no obvious benefit of ePDE5i in the LVAD population.

When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation.

Right heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation. The aim of this study was to analyze the incidence, risk factors, and biomarkers for late RHF including the possible superiority of the device and implantation method. This retrospective, single-center study included patients who underwent LVAD implantation between 2014 and 2018. Primary outcome was freedom from RHF over one-year after LVAD implantation; secondary outcomes included pre- and postoperative risk factors and biomarkers for RHF. Of the 145 consecutive patients (HeartMate 3/HVAD: n = 70/75; female: 13.8%), thirty-one patients (21.4%) suffered RHF after a mean LVAD support of median (IQR) 105 (118) days. LVAD implantation method (less invasive: 46.7% vs. 35.1%, p = 0.29) did not differ significantly in patients with or without RHF, whereas the incidence of RHF was lower in HeartMate 3 vs. HVAD patients (12.9% vs. 29.3%, p = 0.016). Multivariate Cox proportional hazard analysis identified HVAD (HR 4.61, 95% CI 1.12–18.98; p = 0.03), early post-op heart rate (HR 0.96, 95% CI 0.93–0.99; p = 0.02), and central venous pressure (CVP) (HR 1.21, 95% CI 1.05–1.39; p = 0.01) as independent risk factors for RHF, but no association of RHF with increased all-cause mortality (HR 1.00, 95% CI 0.99–1.01; p = 0.50) was found. To conclude, HVAD use, lower heart rate, and higher CVP early post-op were independent risk factors for RHF following LVAD implantation.

Impact of Right Heart Failure on Clinical Outcome of Left Ventricular Assist Devices (LVAD) Implantation: Single Center Experience.

The aim of this study was to examine the incidence and significance of right heart failure (RHF) in the early and late phase of left ventricular assist device (LVAD) implantation with the identification of predictive factors for the development of RHF. This was a prospective observational analytical cohort study. The study included 92 patients who underwent LVAD implantation and for whom all necessary clinical data from the follow-up period were available, as well as unambiguous conclusions by the heart team regarding pathologies, adverse events, and complications. Of the total number of patients, 43.5% died. The median overall survival of patients after LVAD implantation was 22 months. In the entire study population, survival rates were 88.04% at one month, 80.43% at six months, 70.65% at one year, and 61.96% at two years. Preoperative RHF was present in 24 patients, 12 of whom died and 12 survived LVAD implantation. Only two survivors developed early RHF (ERHF) and two late RHF (LRHF). The most significant predictors of ERHF development are brain natriuretic peptide (BNP), pre-surgery RHF, FAC < 20%, prior renal insufficiency, and total duration of ICU stay (HR: 1.002, 0.901, 0.858, 23.554, and 1.005, respectively). RHF following LVAD implantation is an unwanted complication with a negative impact on treatment outcome. The increased risk of fatal outcome in patients with ERHF and LRHF after LVAD implantation results in a need to identify patients at risk of RHF, in order to administer the available preventive and therapeutic methods.

Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes

BackgroundA revised definition of right heart failure (RHF) for the Society of Thoracic Surgeons Intermacs database of left ventricular assist devices (LVADs) was introduced in June 2014. ObjectivesThe purpose of this study was to determine the prevalence and severity of RHF over time and the association of RHF status at 3 months with 12-month outcomes after LVAD. MethodsAll patients in Society of Thoracic Surgeons Intermacs with follow-up and supported at least 3 months with a continuous flow LVAD implanted between June 2, 2014 and March 31, 2017 without a simultaneous RVAD. RHF was defined as both documentation and manifestations of elevated central venous pressures. ResultsThere were 6,118 patients included with an incidence of RHF at 3, 6, and 12 months postimplant categorized as mild in 5%, 6%, and 6% and moderate in 5%, 3%, and 3%, respectively. For those with no RHF at 3 months, there was a low incidence of subsequent RHF at 6 and 12 months. The lack of RHF at 3 months, compared with mild and moderate RHF, was associated with a lower 12-month cumulative incidence of mortality (6.9% vs 16.7% vs 28.1%; P < 0.0001) and a lower 12-month cumulative incidence of stroke (7.4% vs 9.5% vs 11.0%; P = 0.0095), gastrointestinal bleeding (14.8% vs 24.2% vs 23.6%; P < 0.0001), and rehospitalization (65.2% vs 73.2% vs 71.2%; P < 0.0001). ConclusionsIn patients surviving 3 months with LVAD support alone, mild or moderate RHF occurred in nearly 1 of 10 patients at 12 months. Patients with late RHF had worse survival and a higher cumulative incidence of major adverse events.

Postoperative Pulmonary Hypertension and Right Ventricular Dysfunction are Independently Associated with Poor Outcomes after LVAD Implantation

<h3>Purpose</h3> While preoperative hemodynamic risk factors associated with right ventricular (RV) dysfunction after LVAD are well-established, the relationship between postoperative hemodynamics and subsequent outcomes is poorly defined. <h3>Methods</h3> We analyzed adult patients from the STS-INTERMACS registry with hemodynamic data available at 1 or 3 months after LVAD implant. Hemodynamic parameters analyzed included measures of RV afterload (mean PA pressure [mPAP] and pulmonary vascular resistance [PVR]) and RV function (right atrial pressure [RAP], RAP:PCWP, and pulmonary artery pulsatility index [PAPi]). The primary outcome was the composite of death or late right heart failure (LRHF), and the secondary outcome was gastrointestinal bleeding (GIB), both conditional on survival to 1 month. Associations were assessed using Cox proportional hazards modeling, adjusted for 10 relevant clinical covariates. <h3>Results</h3> Among 1328 patients meeting inclusion criteria, postoperative mean RAP was 9.6 ± 6.0 mmHg and mean PCWP was 13.1 ± 6.9 mmHg. Post-LVAD pulmonary hypertension was common, with 775 (58.4%) patients having mPAP ≥ 20 mmHg and 227 (17.1%) having PVR ≥ 3 WU. mPAP (HR 1.1 per 5 mmHg increase), PVR (HR 1.1 per 1 WU increase), PAPi (HR 1.26 per log-decrease), and RAP:PCWP (HR 1.37 per log-increase) were independently associated with death or LRHF (p < 0.05 for all). When stratified by tertiles of mPAP and either PAPi or RAP:PCWP, risk varied 4-5 fold between patients with the most vs least favorable hemodynamic profiles (Figure). RAP (HR 1.21 per 5 mmHg increase), PAPi (HR 1.3 per log-decrease) and RAP:PCWP (HR 1.39 per log-increase) were associated with GIB (p < 0.01 for all). <h3>Conclusion</h3> Postoperative RV dysfunction and elevated RV afterload are associated with mortality, LRHF, and GIB after LVAD implantation. Whether strategies aimed at optimizing RV function and afterload can reduce the burden of adverse events requires prospective study.

Late Right Heart Failure after Left Ventricular Assist Device Implantation: Characteristics, Predictors, and Outcomes

Background Late right heart failure (LRHF) in patients with left ventricular assist device (LVAD) remains inadequately understood. We sought to evaluate characteristics, predictors, and outcomes of patients who develop LRHF following LVAD. Methods We studied a single-center retrospective cohort of 108 consecutive LVAD patients from 2010-2016. Late right heart failure (LRHF) was defined as evidence of elevated right atrial pressure (RAP > 16 mmHg or jugular venous distention), with concomitant peripheral edema, elevated bilirubin or creatinine, occurring 30 days following LVAD implantation. LRHF was excluded if underlying left heart failure was present (e.g. elevated left-sided filling pressures or medication/speed adjustment alleviated symptoms). Results Seventeen patients (15%) developed LRHF at a median of 60 (IQR 30,150) days after LVAD implantation. LRHF patients demonstrated higher right atrial pressure (14±6 vs 9±4 mmHg, P=0.002) and pulmonary vascular resistance (3.4±1.7 vs 2.5±1.0 WU, P=0.03), without significant difference in wedge pressure (15±6 vs 13±6 mmHg, P=0.15). LRHF patients required significantly higher diuretic doses at 6 months post-LVAD (furosemide equivalent 184±148 vs 60±78 mg/day, P Conclusion LRHF is a relatively rare complication in LVAD patients. Early post-op RHF and 1-month diuretic requirements predict progression to LRHF. LRHF is associated with increased mortality but no difference in transplant rates.

Women Have More Early Right Heart Failure But No Increase in Later Right Heart Failure After LVAD Implantation: An INTERMACS Analysis

Introduction Despite an increase in the prevalence of advanced heart failure in women, women are less likely to be treated with durable LVAD therapy and may have increased risk of early post LVAD complications. Previous studies have shown that women have increased risk of post LVAD early right heart failure (ERHF) and need for RVAD support. However, it is unclear if women have a higher risk of developing late right heart failure (LRHF). Hypothesis We sought to investigate whether women are more likely to develop ERHF and LRHF post LVAD implantation and further assess whether sex modifies the relationship between ERHF and long term outcomes. Methods We included 12,923 patients from the INTERMACS registry who received primary continuous-flow (CF)-LVAD between 2012-2017. ERHF was defined as death due to RHF by one month, need for RVAD by one month, or need for inotropes for more than 2 weeks. Cox regression was used to model the relationship of sex and both ERHF and LRHF, adjusting for the competing risk of death and receiving a heart transplantation using Fine-Gray methods. The interaction of sex and the relationship of ERHF and LRHF as well as sex and the relationship of ERHF and mortality were evaluated. Results Of those included, 22% were women and 78% were men. Women were younger (55 vs 58 y, p Conclusion Among those in the INTERMACS registry receiving primary CF-LVAD, females had a higher risk of ERHF but not LRHF. Further studies are needed to investigate reasons for the observed discrepancies.

Right Heart Failure While on Left Ventricular Assist Device Support Is Associated with Primary Graft Dysfunction.

Primary graft dysfunction (PGD) is a potentially devastating complication of heart transplantation. Understanding the risk factors for PGD in the modern era of heart transplantation is of vital importance. This study investigated the relationship between post-left ventricular assist device (LVAD) right heart failure (RHF) and transplant outcomes. Patients with durable, continuous-flow LVADs who were transplanted between 2010 and 2016 at Barnes-Jewish Hospital were included in the study. Data collection was performed through retrospective chart review. The primary outcome was the incidence of PGD stratified by pretransplant incidence of RHF while on LVAD support. Among the 141 patients included in the study, 41 developed RHF. In the RHF cohort, 18 patients developed PGD as compared to 14 patients in the group without RHF (44% vs. 14%; p < 0.001). Mortality was significantly higher in the RHF group at 30 days (20% vs. 1%; p < 0.001) and 1 year (22% vs. 6%; p = 0.013). In a multivariable logistic regression model adjusted for confounding variables, RHF was associated with a nearly fourfold increased risk of PGD (odds ratio, 3.91; p = 0.003). The results of this study show that patients supported with LVADs who develop early severe RHF or late RHF are at increased risk of PGD and death following cardiac transplantation.

More Frequent Hospitalizations and Worse Quality of Life with Late Right Heart Failure Compared to Early Right Heart Failure after Left Ventricular Assist as Destination Therapy

Right heart failure (RHF) is a common adverse event (AE) after left ventricular assist device (LVAD) implantation in destination therapy (DT) patients. However, the timing of RHF may have differential impact on outcomes, AEs and functionality in this population. All HVAD patients enrolled in the ENDURANCE and ENDURANCE Supplemental trials (n=604) were assessed for RHF as defined by Intermacs (IM) and separated into two groups: (1) early RHF (ERHF) - RHF prior to discharge, but not afterwards or (2) late RHF (LRHF) - RHF only after discharge. Patients were followed for 2 years. Overall, patients with ERHF (n=176) and LRHF (n=33) had similar pre-implant characteristics: Mean Age 62.7 years, Male 75.6%, White 68.9%, Ischemic 52.2%, IM 1: 4.8% , and IM 2-3: 73.9%. Baseline hemodynamics were also similar: RA 11.6 mmHg, PA s/d/m 49.6/23.5 (32.6) mmHg, and PVR 3.0. There was no difference in 2-year survival in ERHF v. LRHF (64.2% v. 63.6%, p=0.96), despite more non-device infections in the ERHF group (Figure 1a), and significantly higher all-cause rehospitalizations in the LRHF group (4.1 vs 26.0 eppy, p<0.0001). Although baseline quality of life (QoL) and 6-minute walk (6MW) were similar, both were significantly worse at 3 and 12 months in LRHF (Figure 1b). Baseline characteristics, including hemodynamics, QOL and functional capacity were similar between ERHF and LRHF. LRHF is associated with more frequent all-cause hospitalizations, worse quality of life and functionality post-discharge despite a similar 2-year survival.

Impact of Tricuspid Valve Repair for Moderate Tricuspid Regurgitation at the Time of Left Ventricular Assist Device Implantation on the Occurrence of Right Heart Failure

Significant tricuspid regurgitation (TR) in patients undergoing durable left ventricular assist device (LVAD) implantation has been associated with increased incidence of right heart failure (RHF). There is great surgical practice variability related to moderate TR repair at the time of LVAD implantation. In this single-center study, we investigated whether moderate TR repair concurrent with LVAD implantation has impact on late RHF occurrence. We gathered data on adult patients undergoing durable LVAD implantation between 2009 and 2017. Only patients with moderate TR at the time of LVAD implantation constituted the study cohort. Patients were separated in two groups, concurrent tricuspid valve repair (TVr group) and no-TVr group. LateRHF was defined as any readmission for HF, requiring treatment with diuretics or inotropes or implantation of a right ventricular assist device. Unrepaired TR was categorized as improved if it was persistently graded as mild or less on post-operative echocardiographic studies. TVr failure was defined as moderate or severe TR on any post-operative echocardiographic study. Kaplan-Meier curves were used to analyze freedom from late RHF between the two groups. Out of 140 patients, 92 (65%) were in the TVr group. TVr failure was present in 35 (38%) of these patients. Out of the 48 patients in the no-TVr group, 22 (45%) experienced improvement of TR. Late RHF occurred in 12 (25%) patients in the no-TVr group and 35 (38%) patients in the TVr group. There was no event-free survival difference between the two groups (log rank p=0.678)(Figure). In our study cohort, we found no benefit in concurrent TVr for moderate TR at LVAD implantation on late RHF occurrence. Moreover, 45% of the patients with unrepaired moderate TR experienced improvement of TR, while 38% of patients with TVr experienced repair failure. Future randomized studies should address and confirm these results.

Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation

ObjectivesThis study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BackgroundSurgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. MethodsA retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors’ institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. ResultsA total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). ConclusionsFailure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.

Tricuspid Regurgitation Predicts Late Onset Right Heart Failure after Left Ventricular Assist Device Implantation

Purpose Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is a significant cause of morbidity and mortality. Multiple factors have been identified in order to predict early RHF, though information is scarce regarding late RHF. The aim of this study was to analyse and identify predictors of late RHF in LVAD patients. Methods A retrospective analysis of adult patients who underwent HeartWare-VAD implantation from 2009 to 2017 in a single-centre was performed. Late RHF was defined as RHF after 30 days of implantation requiring hospital admission. Clinical data, echocardiographic and haemodynamic parameters before implantation, data regarding the early post-operative phase and echocardiographic parameters at discharge were analysed. Results A total of 22 (10.7%) patients from 206 implantations developed late RHF during follow-up. Time to first RHF admission was 202.5 (IQR 130-682) days. Patients presenting with late RHF had a higher incidence of pre-operative significant tricuspid regurgitation (p Conclusion Late RHF was more prevalent in patients with dilated cardiomyopathy or congenital heart disease, and is not predicted by early RHF. Significant tricuspid regurgitation at discharge post-implantation predicted the occurrence of late RHF. Prospective studies are needed to determine whether tricuspid valve interventions may reduce late RHF.

Post-Implant Phosphodiesterase-5 Inhibitor Use is Associated with Increased Rates of Late Right Heart Failure after LVAD: An INTERMACS Analysis

Purpose Late right heart failure (LRHF) is a major cause of morbidity after LVAD. Phosphodiesterase-5 inhibitors (PDE5i) are often used for post-LVAD right heart dysfunction, but their impact on LRHF is unknown. Methods We identified adult patients from the INTERMACS registry undergoing continuous-flow LVAD (CFLVAD) after 2012 and stratified them by use of PDE5i at 1 month. Early RHF (ERHF) was defined as the need for RVAD within 1 month or inotropes for > 2 weeks. Among patients surviving > 1 month after discharge from the index LVAD implant, LRHF was defined as any of the following: death from RHF, need for RVAD or inotropes, re-hospitalization for RHF or volume overload , or fulfilling INTERMACS criteria of documentation and manifestation of RHF. Freedom from LRHF was compared with the Kaplan-Meier method and Cox proportional hazards modeling. Results Among 9627 CFLVAD patients surviving >1 month after discharge, 2463 (26%) were treated with PDE5i at 1 month. Patients on PDE5i were more likely to require >2 weeks of inotropic support (27% vs 14%), be INTERMACS Profile 1 or 2 (52% vs 46%), and have higher pulmonary vascular resistance (2.8 vs 2.2 WU), p Conclusion Irrespective of ERHF, post-implant PDE5i use is associated with an increased risk of LRHF after LVAD. Further studies are required to determine if selective pulmonary vasodilator therapy has a role in preventing LRHF after LVAD.

Timing of Right Heart Failure after Left Ventricular Assist Device is Associated with Survival after Heart Transplantation

Purpose Right heart failure (RHF) after left ventricular assist device (LVAD) occurs in a spectrum of severity and can occur both early and late after implant. Our recent work demonstrated that patients requiring IS after LVAD have reduced survival following heart transplant (OHT), but whether this extends to patients with early and late RHF is unknown. Methods We queried the UNOS registry from 1/00 - 9/17 for adults bridged to OHT with LVAD, excluding those with total artificial heart, dual-organ transplant, prior transplant, or congenital heart disease. We divided patients into 4 groups based on the need for IS at listing and at OHT: 1) No RHF = LVAD; LVAD, 2) early RHF = LVAD + IS; LVAD, 3) persistent RHF = LVAD + IS; LVAD + IS, and 4) late RHF = LVAD; LVAD + IS. We compared 1-year post-OHT survival using the Kaplan-Meier method and Cox proportional hazards models. Results Among 5080 patients bridged to OHT with LVAD, 4348 (86%) had no RHF, 343 (7%) early RHF, 194 (4%) persistent RHF, and 195 (4%) late RHF. Compared to patients without RHF at the time of OHT, those with persistent and late RHF had similar creatinine and total bilirubin but a higher proportion of ventilator support and lower Karnofsky performance scores (Table). Compared to patients with no RHF, 1-year post-OHT survival was similar for patients with isolated early RHF but was significantly lower among those with persistent and late RHF, and this relationship persisted in multivariate modeling (Figure). Conclusion Patients with persistent or late RHF requiring IS after LVAD have reduced post-OHT survival, similar to patients bridged with BiVAD.