Use Of Right Ventricular Assist Device Research Articles

Tricuspid Valve Surgery in Patients Receiving Left Ventricular Assist Devices

Tricuspid regurgitation (TR) is common and related to poor prognosis in patients after left ventricular assist device (LVAD) implantation. The concomitant tricuspid valve surgery (TVS) at the time of LVAD implantation on short and long-term outcomes are controversial in current evidence. This is a single-center, observational, retrospective study. We enrolled patients with moderate-to-severe TR who received LVAD implantations from 2009 to 2020. Postoperative right ventricular failure (RVF), right ventricular assist device (RVAD) use, hospital mortality, new-onset renal replacement therapy (RRT), and acute kidney injury (AKI) were evaluated retrospectively. Sixty-eight patients were included, 36 with and 32 without concomitant TVS. Baseline characteristics did not differ between the two groups. Patients receiving TVS had significantly increased incidences of postoperative RVF (52.8 vs. 25.0%, p = 0.019), RVAD implantation (41.7 vs. 18.8%, p = 0.041), and new-onset RRT (22.2 vs. 0%, p = 0.004). No difference in the incidence of AKI and hospital mortality was detected. Besides, these associations remained consistent in patients who underwent LVAD implantation via median sternotomy. During a median follow-up of 2.76 years, Kaplan-Meier analysis and competing-risk analysis showed that TVS was not associated with better overall survival in patients after LVAD implantation compared with the no-TVS group. Our study suggests that concomitant TVS failed to show benefits in patients receiving LVAD implantation. Even worse, concomitant TVS is associated with significantly increased incidences of RVF, RVAD use, and new-onset of RRT. Considering the small sample size and short follow-up, these findings warrant further study.

Pre-operative atrial fibrillation and early right ventricular failure after left ventricular assist device implantation: a systematic review and meta-analysis

Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD). Atrial fibrillation (AF) is known for its deleterious effects on cardiac function and hemodynamics. The association of pre-operative AF with the risk of early post-LVAD RVF has not been well described. A comprehensive literature search was performed through April, 9 2021. Cohort studies comparing the risk of post-operative RVF and/or need for right ventricular assist device (RVAD) after LVAD in patients with or without AF were included. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic were calculated using the random-effects model. Six studies were included in the analysis. Post-operative RVF was reported in 5 studies (1,841 patients) and RVAD use was reported in 4 studies (1,355 patients). There is a non-significant trend toward a higher risk of post-operative RVF in the AF group (pooled OR=1.25, 95%CI=0.99-1.58). No significant association between AF and RVAD use is noted (pooled OR=1.17, 95%CI=0.82-1.66). Pre-operative AF is not significantly associated with higher risks of post-operative RVF and RVAD use after LVAD implantation, although the trend toward higher post-operative RVF is observed in patients with pre-operative AF. Additional research using a larger study population is warranted to better understand the association of pre-operative AF and the development of post-LVAD RVF.

An Analysis of Post-Implant Severe Right Heart Failure in Real-World Use of the HeartWareTM HVADTM System in Destination Therapy

Purpose Clinical trials of the HeartWare™ HVADTM System have demonstrated a low rate of post-implant severe right ventricular failure (RVF) requiring implantation of a right ventricular assist device (RVAD). In an analysis of the North American clinical trials of the HVAD System, including the ADVANCE BTT+CAP Trial (N=382), the ENDURANCE Trial (N=296), the ENDURANCE Supplemental Trial (N=308) and the Lateral Trial (N=144), RVADs were implanted in 2.7% of patients (31/1130) over 2 years of support. However, the overall percentage of patients in INTERMACS profile 1 at implant was only 4.2% and those with anticipated need for post-operative RVAD were excluded. We will present an analysis of severe RVF requiring an RVAD in the real-world post-approval study of the HVAD System when used in destination therapy patients (DT-PAS and Apogee International study). Methods The objective of this analysis is to examine the rate of RVAD use in the prospective DT PAS study (n=212) and the Apogee International study (n=46). At the time of presentation, we will have 258 patients with follow-up data through at least 6 months of support. Results Data is currently being collected from 50 centers in the US, EMEA, and Australia. Descriptive data and severe RVF data will be presented, and a comparison, accounting for baseline differences, to the HVAD clinical trials will be performed. Baseline parameters of the 258 patients includes mean age 58.3 years, with 15.4% INTERMACS profile 1 and 44.6% with ischemic etiology. Preliminary data from 212 patients in the US DT PAS cohort (with 16.3% INTERMACS 1) reveals an incidence of RVAD use of 6.1% over a mean time on support of 5 months. Data collection and analysis is ongoing. Conclusion Analyses of real-world use of the HVAD System reveals its increasing use in higher risk and more complex patients. Final data on RVAD use in 258 patients through 6 months will be available at the time of presentation.

Pulmonary Artery Pulsatility Index (PAPi) is a Predictor of Right Ventricular Assist Device (RVAD) Use Following HeartMate 3 LVAD Implantation

Pulmonary artery pulsatility index (PAPi) recently emerged as a predictor of right ventricular failure after Heartmate II LVAD Implantation. Clinical utility of this marker in Heartmate 3 patients is unknown. We hypothesized that PAPi is a stronger predictor of RV failure compared to central venous pressure to pulmonary artery capillary wedge pressure ratio (CVP/PCWP) or RV stroke work index (RVSWI) in Heartmate 3 population. 175 patients who received a Heartmate 3 LVAD at a single academic center between 2014 - 2019 were included in the study. Primary outcome was right ventricular assist device (RVAD) use following HM3 implant. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis determined predictors of RVAD use in HM3 patients. 55 patients (31.4%) required RVAD following HM3 implantation including 19 percutaneous, 24 paracorporeal, and 2 durable RVADs. Age, gender, and implant strategy were comparable between RVAD and no RVAD groups. Patients requiring RVAD were more likely to be INTERMACS Class I or II (78.2% vs. 56.6%), have a higher WBC count (9.2±3.4 vs. 8.1±2.8) and C-reactive protein (57.7±59.2 vs. 38.4±34.7) prior to device implant (all p <0.05). RVAD group had significantly lower PAPi (3.4±2.0 vs. 6.0±6.8, p=0.001), higher CVP/PCWP ratio (0.50±0.27 vs. 0.42±0.25, p=0.036) and comparable RVSWI (0.534±0.285 vs. 0.572±0.240, p=0.368) before device implant. ROC curve analysis provided higher AUC for PAPi compared to CVP/PCWP ratio or RVSWI (Figure). After adjusting for age, etiology of HF, creatinine, bilirubin, WBC count, INTERMACS Class, RVSWI, and CVP/PCWP ratio, PAPi was the only significant predictor of RVAD use in multivariable model (OR 0.913 [95%CI: 0.835 - 0.999], p=0.049). PAPi is an independent predictor of RV failure in Heartmate 3 patients. Incorporating PAPi in clinical decision-making may improve patient selection and perioperative outcomes in this population.

Placement of a Fully Magnetically Levitated Left Ventricular Assist Device: Intrathoracic versus Intrapericardial

A fully magnetically levitated centrifugal-flow left ventricular assist device can be placed in either the intra-thoracic cavity or the intra-pericardial cavity. This study aimed to investigate the clinical impact of pump location in patients following fully magnetically levitated left ventricular assist device (LVAD) placement. We retrospectively reviewed 161 patients who received fully magnetically levitated centrifugal-flow LVAD at our center between November 2014 and August 2019. Pump location was determined from the operative record and CT scan images if available. We identified 77 patients (48%) with intra-thoracic placement (Group T) and 84 patients (52%) with intra-pericardial placement (Group P). Clinical outcomes were compared between the groups. Patients in Group T were older (61 vs. 57 years, p=0.05), more likely to have prior sternotomy (27% vs. 11%, p=0.008), and more frequently INTERMACS class I (21% vs. 5.9%, p=0.008) compared with patients in Group P. Incidence of perioperative right ventricular assist device (RVAD) was significantly lower in Group T (23% vs. 38%, p=0.045). In-hospital mortality was 8.6% in Group T vs. 3.6% in Group P (p=0.15). Kaplan-meier curve analysis showed 2-year survival of 83% in Group T and 93% in Group P (p=0.15). Multivariate logistic regression analysis demonstrated INTERMACS class I was an independent predictor of RVAD use (OR 16.9, 95% CI 5.09-56.2, p<0.01) but Group P was not a predictor (p=0.2). In our study, intrathoracic vs. intrapericardial fully magnetically levitated centrifugal-flow pump placement did not affect overall clinical outcomes.

Increased Right Ventricular Assist Device (RVAD) Utilization in Patients with HeartMate 3 Left Ventricular Assist Device (LVAD) in the Post-Approval Era

MOMENTUM 3 trial excluded patients with planned biventricular support prior to enrollment and 4.2% right ventricular failure requiring RVAD in Heartmate 3 (HM 3) patients. The aim of this study was to assess the use of RVAD in the real-world post-approval era. HM3 implantation at a major academic center were categorized into two era: HM 3 implanted 1) before FDA approval (8/23/2017) [N=67] and 2) after FDA approval [N=107]. Baseline patient characteristics, RVAD utilization patterns, and LVAD complications and mortality were analyzed in the pre- vs. post-approval era. In the post-approval era, HM3 patients were younger (57.5±14.1 vs 61.7±11.2 yrs, p=0.031), more likely to have ischemic etiology of heart failure (55.6% vs 34.3%, p=0.006), to be INTERMACS Class I (21.3% vs. 1.5%, p=0.002), and to have VA-ECMO or paracorporeal VAD support (12.0% vs 0.0%, p=0.012) prior to HM3 implant. 8 (11.9%) patients out of 67 required RVAD in the pre-approval era as opposed to 47 patients out of 108 (43.5%) in the post-approval era (p<0.001). All patients in the pre-approval era received unplanned RVAD (8, 100%) compared to 16 patients (34.0%) in the post-approval era (p<0.001). Despite increased utilization of RVADs, the risk of CVVHD (6.0% vs 10.2%, p=0.413), post-LVAD length of stay (34.3±32.9 vs 41.7±40.0 days), and in-hospital mortality (4.5% vs 6.9%, p=0.741) were comparable in pre- vs. post-approval era. There was no difference in post-implant survival (89.7% vs. 84.7%, log-rank p=0.357), freedom from gastrointestinal bleeding (70.0% vs. 70.4%, log-rank p =0.831) or freedom from stroke (93.2% vs. 92.2% log-rank p = 0.547) at 2-year follow-up in the pre- vs. post- approval period. Level of sickness at the time of device implantation as well as need for RVAD utilization increased substantially in HM3 patients following the FDA approval. However, the change in practice did not adversely affect post-LVAD morbidity or mortality.

Superior Vena Cava Syndrome from Percutaneous Right Ventricular Assist Device Use in Right Ventricular Failure

Percutaneous right ventricular assist device (RVAD) support with right internal jugular (IJ) vein access has emerged as a viable solution for treating refractory RV failure. Recent reports have shown that RVAD support with this approach can be beneficial in a variety of clinical scenarios including post cardiotomy RV failure, cardiogenic shock, and severe acute hypoxemic respiratory failure with associated RV dysfunction, as well as decreased mortality compared to surgically implanted RVADs. However, the safety profile of such devices has not been characterized. A comprehensive retrospective review was completed for all patients receiving percutaneous RVAD support via a right internal jugular route with either 28 or 31F cannula at our institution between April 2017 and December 2018. Preoperative patient demographics, intraoperative, and postoperative outcomes, with specific focus on device related complications. Fourty patients (27 men, 67.5%) with mean age of 52 years ± 15.6 and refractory RV failure were managed with a percutaneous RVAD inserted through the right IJ. Of these 40 patients, 3 (7.5%) patients demonstrated device related superior vena cava (SVC) syndrome resulting from obstruction of the SVC with the RVAD cannula. One patient managed by head of bed elevation and early removal of the device (I believe). Two were treated by connecting a "venting" tubing to the side port on the introducer sheath and placing into the ECMO circuit to for decompression. Symptoms resolved in all 3 patients and no deaths resulted from SVC syndrome. SVC syndrome related to percutaneous RVAD placement is an important, but previously undescribed postoperative complication of RVAD use. Early identification allows safe management of this complication, which does not detract from the safety of percutaneous RVAD support.

Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure

BackgroundThe effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. MethodsWe performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. ResultsCluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). ConclusionsAfter cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.

Predictors of Early Unplanned RVAD Use in Patients Undergoing LVAD Implantation

Purpose Severe early right heart failure is a life-threatening complication of left ventricular assist device (LVAD) implantation that may require unplanned temporary right ventricular assist device (RVAD) support. There are limited data on preoperative predictors of RVAD use within only 48 hours of LVAD implantation. Methods We studied 343 patients who underwent continuous-flow LVAD implantation at a single center. Forty-eight (14%) received unplanned temporary RVAD support within 48 hours following LVAD placement. Multivariate logistic regression was used to identify independent predictors for the need of early RVAD support. Results Patients who required early temporary RVAD support had significantly different preoperative clinical characteristics compared to those who did not require support, including a younger age (53 vs. 58 years, respectively), a higher proportion of women (33% vs. 18%, respectively) and higher risk INTERMACS Profile of 1 or 2 (50% vs. 15%, respectively; p 2-fold risk-increase); INTERMACS Profile 1 or 2 (>4-fold risk-increase); the need for IABP or ECMO before LVAD implantation (>3-fold risk-increase); and increased AST levels (4% risk-increase per 10-unit increment). Conclusion Preoperative predictors of temporary, unplanned RVAD use within 48 hours of LVAD implantation include clinical and laboratory markers of hemodynamic instability and end-organ dysfunction. Female gender is a risk factor for RVAD use in this analysis and requires further study in a larger cohort.

Long-Term Survival of Patients Requiring Early Temporary RVAD Support Following LVAD Implantation

Purpose Severe early right heart failure is a life-threatening complication of left ventricular assist device (LVAD) implantation that may require unplanned temporary right ventricular assist device (RVAD) support. There are limited data on the association between the need for early RVAD support and long-term survival following LVAD implantation. Methods We studied 348 patients who underwent continuous-flow LVAD implantation in a single center Registry. Forty-eight (14%) patients received an unplanned temporary RVAD within 48 hours following LVAD implantation. Multivariate Cox proportional hazards regression modeling was used to assess long-term mortality in patients who did vs. did not receive a RVAD. Results Patients (mean age 57 years, 80% male) were supported by a LVAD for a mean of 2.5 years, and 137 (39%) patients died during the follow-up period. Multivariate analysis showed that RVAD use was associated with a significant 3-fold increase in the risk of short-term (6-month) mortality (HR 2.99 [95% CI: 1.39-6.43]). However, among early RVAD patients who survived to 6 months, the risk for subsequent long-term mortality was significantly reduced (HR 0.41 [95% CI 0.14-1.14]; p value for the difference in mortality-risk associated with early RVAD support before and after 6 months = 0.002 [figure]). Conclusion Temporary, unplanned RVAD use within 48 hours of LVAD implantation is independently associated with increased short-term (6-month) mortality. However, the mortality risk associated with the need for RVAD support is significantly attenuated thereafter during long-term follow-up.

Liberal Right Ventricular Assist Device Extracorporeal Membrane Oxygenation Support for Right Ventricular Failure after Implantable Left Ventricular Assist Device Placement.

Refractory right ventricular failure (RVF) after implantation of left ventricular assist device (LVAD) is a dramatic complication. The addition of right ventricular assist device (RVAD) may improve RV recovery and lead to improve outcomes. From February 2012 to September 2014, 44 patients received a HeartMate II. These patients were retrospectively compared in two groups according to early liberal implantation of an extracorporeal membrane oxygenation (ECMO) used as a RVAD established between a femoral vein and the pulmonary artery. Of the 44 patients, 22 required addition of a temporary RVAD (t-RVAD group). Patients are sicker in the t-RVAD group with significantly higher rate of preoperative extracorporeal life support (46% vs. 9%; p = 0.016) or any mechanical circulatory support (55% vs. 14%; p = 0.01), more preoperative hemofiltration (23% vs. 0%; p = 0.048), and more inotrope support by dobutamine (68.2% vs. 27.3%; p = 0.015). Likewise Michigan risk score was significantly higher in t-RVAD group (2.61 ± 2.2 vs. 1.0 ± 1.6 pts; p = 0.013) and INTERMACS clinical profile (2.1 ± 0.6 vs. 3.4 ± 1.3 pts; p = 0.0001). Despite severity of preimplant conditions in t-RVAD group, clinical outcomes did not differ in both groups with similar survival rate at 6 months (60.4 ± 12 vs. 71.4 ± 9.9%; p = 0.585). Early and liberal use of temporary RVAD in patients with risk factors of RVF could improve the prognostic after LVAD implantation.

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support.

To investigate preimplant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (LVAD) surgery. Patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent primary continuous-flow-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined end point of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9976 patients undergoing continuous-flow-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Preimplant characteristics associated with RVAD use included interagency registry for mechanically assisted circulatory support patient profiles 1 and 2, the need for preoperative extracorporeal membrane oxygenation or renal replacement therapy, severe preimplant tricuspid regurgitation, history of cardiac surgery, and concomitant procedures other than tricuspid valve repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (area under the curve, 0.78) and the combined end point of RVAD or death within 14 days (area under the curve, 0.73). Compared with patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9%, respectively (P<0.0001 for both). The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction, and profiles of hemodynamic instability.

Invited Commentary

There is an ongoing debate for optimal device selection in patients with acute heart failure requiring mechanical cardiac assist systems. Options reach from short-term univentricular support up to complete heart replacement devices. Implantable, durable, continuous-flow pumps have revolutionized left ventricular assist device (LVAD) long-time support by low complication and excellent survival rates. Heterogeneity of underlying cardiac problems challenge appropriate and optimal device selection or possible device combinations, especially in patients with refractory cardiogenic shock and expected but unknown recovery potential of the right ventricle (RV). In these patients, primary implantation of a pulsatile biventricular assist device or a total artificial heart might be invasive overtreatment, and isolated LVAD support alone might result in undertreatment in both situations, with different, but high risks for possible devastating complications. Lazar and colleagues [1Lazar J.F. Swartz M.F. Schiralli M.P. et al.Survival after left ventricular assist device with and without temporary right ventricular support.Ann Thorac Surg. 2013; 96: 2155-2160Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] show their excellent clinical results over 5 years with temporary biventricular assist devices in a hybrid approach using two different support systems, the HeartMate II (Thoratec, Pleasanton, CA) LVAD in combination with the CentriMag (Levitronix, Waltham, MA) RVAD. They showed in patients with increased risk of right heart failure that short-term RVAD use during LVAD implantation improves survival dramatically, decreases potential postoperative circulatory collapse, and avoids subsequent emergent RVAD implantation with known severely decreased outcome. Their surgical treatment concept with well-defined preoperative and intraoperative assessment of the RV and LV, foresighted cannulation techniques, and prompt closure of the chest after the operation allows early recovery and deescalates intensive care treatment. After RV recovery, the RVAD weaning process can be accomplished under controlled circumstances, and explantation of the outflow graft can be performed by a less invasive minithoracotomy; again, allowing the patients to recover faster and to maintain nonintensive care status more early. Their initially more invasive hybrid biventricular assist device concept results in a less invasive and safer postoperative treatment. Finally, at 1 year, these high-risk patients nearly reach the excellent survival results of lower-risk patients with primary LVAD therapy only. In conclusion, a “more liberal” use of temporary RVAD in acute cardiac shock patients is highly recommended: when in doubt—pump! Survival After Left Ventricular Assist Device With and Without Temporary Right Ventricular SupportThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewRight ventricular (RV) failure after the insertion of a left ventricular assist device (LVAD) historically results in poor outcomes. Patients requiring temporary RV support after LVAD insertion are a heterogeneous group of patients consisting of those in cardiogenic shock after myocardial infarction, to those with chronic decompensated heart failure. For patients requiring biventricular support, we have used a hybrid system consisting of a HeartMate II LVAD and CentriMag right ventricular assist device (RVAD). Full-Text PDF

Timing of Temporary Right Ventricular Assist Device Insertion for Severe Right Heart Failure After Left Ventricular Assist Device Implantation

Data on how the timing of a temporary right ventricular assist device (RVAD) insertion affects outcome are limited in patients receiving left ventricular assist device (LVAD). Of the 282 patients who underwent LVAD placement between January 2000 and November 2010, 40 (14%) required concomitant (n = 26) or delayed (n = 14) RVAD insertion as temporary support. We analyzed early and 1-year outcomes. Preoperative variables were similar in the concomitant and delayed RVAD groups. The hospital mortality rate was approximately 50% in both groups (p = 0.82). The 1-year actuarial survival was similar in both groups (p = 0.42). Patients who required RVAD support had higher in-hospital mortality and worse 1-year survival rates than those who received LVAD only (48% vs. 9.5%, p < 0.0001; 40% vs. 82%, p < 0.0001). Multivariate logistic regression analysis indicated RVAD use as a significant risk factor for 1-year mortality (odds ratio, 18; p = 0.0003; 95% confidence interval, 3.765-86.74). Timing of temporary RVAD insertion did not affect overall survival. Necessity of RVAD support is associated with significantly worse early and late mortality at any rate. The decision to place the RVAD can be made once it is clinically necessary.

Predictors of Severe Right Ventricular Failure After Implantable Left Ventricular Assist Device Insertion: Analysis of 245 Patients

Insertion of an implantable left ventricular assist device (LVAD) complicated by early right ventricular (RV) failure has a poor prognosis and is largely unpredictable. Prediction of RV failure after LVAD placement would lead to more precise patient selection and optimal device selection. We reviewed data from 245 patients (mean age, 54+/-11 years; 85% male) with 189 HeartMate (77%) and 56 Novacor (23%) LVADs. Ischemic cardiomyopathy predominated (65%), and 29% had dilated cardiomyopathy. Overall, RV assist device (RVAD) support was required after LVAD insertion for 23 patients (9%). We compared clinical and hemodynamic parameters before LVAD insertion between RVAD (n=23) and No-RVAD patients (n=222) to determine preoperative risk factors for severe RV failure. By univariate analysis, female gender, small body surface area, nonischemic etiology, preoperative mechanical ventilation, circulatory support before LVAD insertion, low mean and diastolic pulmonary artery pressures (PAPs), low RV stroke work (RVSW), and low RVSW index (RVSWI) were significantly associated with RVAD use. Elevated PAP and pulmonary vascular resistance were not risk factors. Risk factors by multivariable logistic regression were preoperative circulatory support (odds ratio [OR], 5.3), female gender (OR, 4.5), and nonischemic etiology (OR, 3.3). The need for circulatory support, female gender, and nonischemic etiology were the most significant predictors for RVAD use after LVAD insertion. Regarding hemodynamics, low PAP and low RVSWI, reflecting low RV contractility, were important parameters. This information may lead to better patient selection for isolated LVAD implantation.