Risk Of Right Ventricular Failure Research Articles

Machine Learning Multicenter Risk Model to Predict Right Ventricular Failure After Mechanical Circulatory Support

The existing models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support might be limited, partly due to lack of external validation, marginal predictive power, and absence of intraoperative characteristics. To derive and validate a risk model to predict RVF after LVAD implantation. This was a hybrid prospective-retrospective multicenter cohort study conducted from April 2008 to July 2019 of patients with advanced heart failure (HF) requiring continuous-flow LVAD. The derivation cohort included patients enrolled at 5 institutions. The external validation cohort included patients enrolled at a sixth institution within the same period. Study data were analyzed October 2022 to August 2023. Study participants underwent chronic continuous-flow LVAD support. The primary outcome was RVF incidence, defined as the need for RV assist device or intravenous inotropes for greater than 14 days. Bootstrap imputation and adaptive least absolute shrinkage and selection operator variable selection techniques were used to derive a predictive model. An RVF risk calculator (STOP-RVF) was then developed and subsequently externally validated, which can provide personalized quantification of the risk for LVAD candidates. Its predictive accuracy was compared with previously published RVF scores. The derivation cohort included 798 patients (mean [SE] age, 56.1 [13.2] years; 668 male [83.7%]). The external validation cohort included 327 patients. RVF developed in 193 of 798 patients (24.2%) in the derivation cohort and 107 of 327 patients (32.7%) in the validation cohort. Preimplant variables associated with postoperative RVF included nonischemic cardiomyopathy, intra-aortic balloon pump, microaxial percutaneous left ventricular assist device/venoarterial extracorporeal membrane oxygenation, LVAD configuration, Interagency Registry for Mechanically Assisted Circulatory Support profiles 1 to 2, right atrial/pulmonary capillary wedge pressure ratio, use of angiotensin-converting enzyme inhibitors, platelet count, and serum sodium, albumin, and creatinine levels. Inclusion of intraoperative characteristics did not improve model performance. The calculator achieved a C statistic of 0.75 (95% CI, 0.71-0.79) in the derivation cohort and 0.73 (95% CI, 0.67-0.80) in the validation cohort. Cumulative survival was higher in patients composing the low-risk group (estimated <20% RVF risk) compared with those in the higher-risk groups. The STOP-RVF risk calculator exhibited a significantly better performance than commonly used risk scores proposed by Kormos et al (C statistic, 0.58; 95% CI, 0.53-0.63) and Drakos et al (C statistic, 0.62; 95% CI, 0.57-0.67). Implementing routine clinical data, this multicenter cohort study derived and validated the STOP-RVF calculator as a personalized risk assessment tool for the prediction of RVF and RVF-associated all-cause mortality.

Regional Strain of Right Ventricle From Computed Tomography Improves Risk Stratification of Right Ventricle Failure.

Patients who undergo implantation of a left ventricular assist device (LVAD) are at a high risk for right ventricular failure (RVF), presumably due to poor right ventricular (RV) function before surgery. Cine computerized tomography (cineCT) can be used to evaluate RV size, function, and endocardial strain. However, CT-based strain measures in patients undergoing workup for LVAD implantation have not been evaluated. We quantified RV strain in the free wall (FW) and septal wall (SW) in patients with end-stage heart failure using cineCT. Compared to controls, both FW and SW strains were significantly impaired in heart failure patients. The difference between FW and SW strains predicted RV failure after LVAD implantation (area-under-the curve [AUC] = 0.82). Cine CT strain can be combined with RV volumetry to risk-stratify patients. In our study, patients with preserved RV volumes and poor strain had a higher rate of RV failure (57%), than those with preserved volume and preserved strain (0%). This suggests that CT could improve risk stratification of patients receiving LVADs and that strain metrics were particularly useful in risk-stratifying patients with preserved RV volumes.

Pectus Excavatum and Risk of Right Ventricular Failure in Left Ventricular Assist Device Patients

Pectus Excavatum and Risk of Right Ventricular Failure in Left Ventricular Assist Device Patients

Preoperative passive venous pressure-driven cardiac function determines left ventricular assist device outcomes

BackgroundRight heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether the magnitude of this “passive cardiac output” can predict LVAD outcomes. MethodsThis was a retrospective review of 383 patients who received a continuous-flow LVAD at the University of Michigan between 2012 and 2021. Pre-LVAD cardiac output driven by venous pressure was determined by dividing right atrial pressure by mean pulmonary artery pressure, multiplied by total cardiac output. Normalization to body surface area led to the passive cardiac index (PasCI). The Youden J statistic was used to identify the PasCI threshold, which predicted LVAD death by 2 years. ResultsIncreased preoperative PasCI was associated with reduced survival (hazard ratio [HR], 2.27; P < .01), and increased risk of right ventricular failure (RVF) (HR, 3.46; P = .04). Youden analysis showed that a preoperative PasCI ≥0.5 (n = 226) predicted LVAD death (P = .10). Patients with PasCI ≥0.5 had poorer survival (P = .02), with a trend toward more heart failure readmission days (mean, 45.09 ± 67.64 vs 35.13 ± 45.02 days; P = .084) and increased gastrointestinal bleeding (29.2% vs 20.4%; P = .052). Additionally, of the 97 patients who experienced readmissions for heart failure, those with pre-LVAD implantation PasCI ≥0.5 were more likely to have more than 1 readmission (P = .05). ConclusionsAlthough right heart output can be augmented by raising venous pressure, this negatively impacts end-organ function and increases heart failure readmission days. Patients with a pre-LVAD PasCI ≥0.5 have worse post-LVAD survival and increased RVF. Using the PasCI metric in isolation or incorporated into a predictive model may improve the management of LVAD candidates with RV dysfunction.

Inhaled Epoprostenol Compared With Nitric Oxide for Right Ventricular Support After Major Cardiac Surgery.

Right ventricular failure (RVF) is a leading driver of morbidity and death after major cardiac surgery for advanced heart failure, including orthotopic heart transplantation and left ventricular assist device implantation. Inhaled pulmonary-selective vasodilators, such as inhaled epoprostenol (iEPO) and nitric oxide (iNO), are essential therapeutics for the prevention and medical management of postoperative RVF. However, there is limited evidence from clinical trials to guide agent selection despite the significant cost considerations of iNO therapy. In this double-blind trial, participants were stratified by assigned surgery and key preoperative prognostic features, then randomized to continuously receive either iEPO or iNO beginning at the time of separation from cardiopulmonary bypass with the continuation of treatment into the intensive care unit stay. The primary outcome was the composite RVF rate after both operations, defined after transplantation by the initiation of mechanical circulatory support for isolated RVF, and defined after left ventricular assist device implantation by moderate or severe right heart failure according to criteria from the Interagency Registry for Mechanically Assisted Circulatory Support. An equivalence margin of 15 percentage points was prespecified for between-group RVF risk difference. Secondary postoperative outcomes were assessed for treatment differences and included: mechanical ventilation duration; hospital and intensive care unit length of stay during the index hospitalization; acute kidney injury development including renal replacement therapy initiation; and death at 30 days, 90 days, and 1 year after surgery. Of 231 randomized participants who met eligibility at the time of surgery, 120 received iEPO, and 111 received iNO. Primary outcome occurred in 30 participants (25.0%) in the iEPO group and 25 participants (22.5%) in the iNO group, for a risk difference of 2.5 percentage points (two one-sided test 90% CI, -6.6% to 11.6%) in support of equivalence. There were no significant between-group differences for any of the measured postoperative secondary outcomes. Among patients undergoing major cardiac surgery for advanced heart failure, inhaled pulmonary-selective vasodilator treatment using iEPO was associated with similar risks for RVF development and development of other postoperative secondary outcomes compared with treatment using iNO. URL: https://www. gov; Unique identifier: NCT03081052.

Should we touch tricuspid valve at the time of LVAD implantation? A young patient series.

The aim of the study is to compare the results of patients who had moderate or severe tricuspid insufficiency (TI) at the time of left ventricular assist device (LVAD) implantation that did not undergo intervention. Between October 2013 and December 2019, 144 patients who did not undergo tricuspid valve repair (TVR) during LVAD implantation in our department were included in the study. The patients were divided into two groups according to the TI grade; Group 1: 106 patients (73.6%) with moderate TI and Group 2: 38 patients (26.4%) with severe TI. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, duration of mechanical ventilation, and early and late right ventricular failure (RVF). Minimally invasive technique was favored in patients with worse right ventricular (RV) function to prevent the need for postoperative RV support and bleeding. The mean ages of the patients in the Group 1 and Group 2 were 46 ± 15 years (82% male), and 45 ± 11.2 years (81.5% males), respectively. Post-operative duration of mechanical ventilation, ICU stay, blood loss, and reoperations were similar (p > 0.05). There was no significant difference in early RVF, pump thrombosis, stroke, bleeding, and 30-day mortality between groups (p > 0.05). Incidence of late RVF was higher in Group 2 (p < 0.05). Although the risk of late RVF may increase in patients with preoperative severe TI, not intervening in TI during LVAD implantation does not cause adverse clinical outcomes in the early period.

P63: Preemptive Temporary Right Ventricular Assist Device Implantation For Severe Biventricular Heart Failure: A Case Series

Purpose: We sought to investigate the clinical results of preemptive temporary right ventricular assist device (RVAD) placement with left ventricular assist device (LVAD) implantation for anticipated right ventricular failure. Methods: Patients at risk for right ventricular failure were identified by the heart team. After median sternotomy, Protec-duo (LivaNova, London, UK) dual-stage cannula was inserted from the right internal jugular vein under fluoroscopy guidance, and advanced into the pulmonary artery to the bifurcation of the main pulmonary artery. This was then connected to the venous drainage from the right atrium for cardio pulmonary bypass (CPB). After LVAD implantation, we connected the Protec-duo cannula to the RVAD with oxygenator, and weaned CPB (Figure). Results: A total of 11 patients have received BiVAD implantation with this technique. The median age of patients was 55 years [Interquartile range (IQR): 51 – 63.5] and all patients were male. 63.6 % (7/11) of the patients were INTERMACS profile 1 or 2. Preoperatively, the median pulmonary artery pulsatility index was 4.0 [1.5 – 4.9] and median right ventricular stroke work index was 454.1 g/m/beat/m2 [436.5 – 530.2]. Postoperatively, the oxygenators were removed on median postoperative day (POD) 3.5 [3 – 5]. Patients received mechanical ventilation for a median of 4 days [1.5 – 12] and RVADs were explanted on median POD 8 [7 – 19) with local anesthesia. Perioperative complications included delayed sternal closure [54.5% (6/11)], re-exploration for bleeding [18% (2/11)], acute kidney injury [36% (4/11)], and heparin induced thrombocytopenia [18% (2/11)]. 30-day mortality was 0% (0/11). Conclusion: Preemptive temporary RVAD implantation strategy for right heart failure post-LVAD showed acceptable clinical outcomes without any 30-day mortality.

P62: A Unique case of Transcatheter aortic valve replacement dislodgement in the presence of a durable left ventricular assist device

Background: Transcatheter aortic valve replacement [TAVR] for severe pure aortic insufficiency [AI] in the presence of a durable left ventricular assist device [LVAD] is fraught with challenges. We report an interesting case of TAVR valve dislodgement by the LVAD that was treated with redeployment of another TAVR valve, and redo surgery for extraction of the intraventricular TAVR valve. Methods and Results: A 46-year-old man presented to our unit in cardiogenic shock [CS] and severe pulmonary hypertension [PH] of 72/45mmHg. He underwent placement of an Impella 5.5 [Abiomed, Danvers, MA] as a bridging strategy to treat his CS and PH while transplant candidacy was being assessed. However, he remained pulmonary hypertensive with a trans-pulmonary gradient 26mmHg and pulmonary vascular resistance 5.3 wood units, despite 14 days of impella 5.5 therapy combined with aggressive management with milrinone 0.25 mcg/kg/min and bumetanide infusion 1mg/hr. He therefore underwent implantation of heart mate 3 [HM3] LVAD [Abbott Laboratories, Chicago, IL] by a limited left thoracotomy in the 5th intercostal space and upper ‘inverse-T’ hemi-sternotomy into the fourth intercostal space. His postoperative course was complicated by requirement for 31mm percutaneous Protek Duo [LivaNova, London, UK] Right VAD [RVAD] for 32 days, and gastrointestinal bleeding requiring cessation of heparin therapy, which prompted formation of thrombus in the left coronary cusp of the aortic valve. Organization of this thrombus and consequent retraction of the left coronary leaflet led to severe AI and consequent CS, requiring inotropic support and discussion on optimal management strategy. He underwent TAVR with a 29mm Edwards Sapien 3 valve [Edwards Lifesciences, Irvine, CA] with 20% over-sizing, which got dislodged and migrated into the LV. Another 29mm Edwards Sapien 3 TAVR valve was successfully deployed. The patient was then placed on cardiopulmonary bypass via the femoral vessels, and the left thoracotomy was reopened. The LVAD was temporarily stopped, and the latch mechanism on the HM3 was opened. The HM3 was removed from the sewing cuff, and the TAVR valve was ‘fished-out’ from the cavity of the LV. The HM3 was reinserted and restarted after thorough de-airing through the outflow graft. The incisions were closed in a standard manner and the patient was discharged home on the 20th postoperative day. Conclusions: TAVR for severe AI in the presence of a durable LVAD is fraught with challenges due to the constant suction action of the LVAD, and the absence of calcium in the native annulus to anchor the prosthesis. Our case highlights the feasibility of extricating a dislodged TAVR valve through simple redo-surgery. With this approach, we managed to avoid a more conventional redo procedure involving administration of cardioplegia for a surgical AVR or for extricating the prosthesis, with its inherent risk of right ventricular failure requiring RVAD. Figure showing dislodged TAVR on the left and redeployment on the right

(835) Preoperative Levosimendan to Reduce Risk of Right Ventricular Failure after LVAD Surgery

(835) Preoperative Levosimendan to Reduce Risk of Right Ventricular Failure after LVAD Surgery

Meta-Analysis on the Impact of Ventricular Arrhythmias on Mortality in Patients With Continuous Flow Left Ventricular Assist Devices

Patients with continuous flow left ventricular assist devices (CFLVADs) have an increased risk of ventricular arrhythmias (VA), but the impact of VA on survival is unclear. A systematic search of electronic databases was conducted to identify studies that reported the impact of VA on all-cause mortality and right ventricular failure (RVF) in patients with CFLVAD. The Mantel-Haenszel method was used to calculate the 95% confidence interval (CI) and pooled risk ratio (RR) with a random-effects model. A total of 19 observational studies with 4,544 patients and a median follow-up of 18.5months (interquartile range 11.5 to 26.4) were included. There was statistically significantly higher mortality in patients with any VA than in those with no VA after CFLVAD implantation (RR 1.33, 95% CI 1.01 to 1.75, p=0.04, I2=78%). On sensitivity analysis, after removing the largest study by Rehorn etal,10 the association between overall mortality and VA was lost, suggesting that these results should be interpreted with caution. Early VA developing within 30days after implantation was associated with a higher risk of mortality (RR 1.37, 95% CI 1.15 to 1.63, p <0.01, I2=52%), whereas late VA developing after 30days after CFLVAD implantation was not associated with any significant difference in mortality (RR: 1.00; 95% CI: 0.80 to 1.24; p=0.98, I2=35%). In addition, there was a statistically significant higher risk of RVF in patients with VA than in those with no VA (RR 1.58, 95% CI 1.20 to 2.08, p <0.01, I2=0%). In conclusion, in patients with CFLVAD, the development of any VA was associated with a 33% higher risk of all-cause mortality. Early VA developing within 30days after implantation was significantly associated with a higher risk of mortality, whereas late VA was not associated with mortality. VA after left ventricular assist device was significantly associated with a higher risk of developing RVF.

Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation

Perioperative mortality and complications still remain high after left ventricular assist device (LVAD) implantation, especially in highly compromised patient cohorts. Here, we evaluate the effects of preoperative Levosimendan therapy on peri- and postoperative outcomes after LVAD implantation. We retrospectively analysed 224 consecutive patients with LVAD implantation for end-stage heart failure between November 2010 and December 2019 in our centre with regard to short- and longer-term mortality as well as incidence of postoperative right ventricular failure (RV-F). Out of these, 117 (52.2%) received preoperative i.v. Levosimendan therapy within 7 days before LVAD implantation (Levo group). In-hospital, 30-day and 5-year mortality was comparable (in-hospital mortality: 18.8% vs 23.4%, P = 0.40; 30-day mortality: 12.0% vs 14.0%, P = 0.65; Levo vs control group). However, in the multivariate analysis, preoperative Levosimendan therapy significantly reduced postoperative RV-F but increased postoperative vasoactive inotropic score ([RV-F: odds ratio 2.153, confidence interval 1.146-4.047, P = 0.017; vasoactive inotropic score 24 h post-surgery: odds ratio 1.023, confidence interval 1.008-1.038, P = 0.002). These results were further confirmed by 1:1 propensity score matching of 74 patients in each group. Especially in the subgroup of patients with normal preoperative RV function, the prevalence of postoperative RV-F was significantly lower in the Levo- group as compared to the control group (17.6% vs 31.1%, P = 0.03; respectively). Preoperative Levosimendan therapy reduces the risk of postoperative RV-F, especially in patients with normal preoperative RV function without effects on mortality up to 5 years after LVAD implantation.

Planned Combo Strategy for LVAD Implantation in ECMO Patients: A Proof of Concept to Face Right Ventricular Failure

We propose a patient-tailored strategy that considers the risk for postoperative right heart failure, utilizing the percutaneous ProtekDuo cannula (Livanova, London, UK) in an innovative way to perform cardiopulmonary bypass during LVAD implantation in ECMO patients. Our novel protocol is based on the early intra-operative use of the ProtekDuo cannula, adopting the distal lumen as the pulmonary vent and the proximal lumen as the venous inflow cannula during cardiopulmonary bypass. This configuration is rapidly switched to the standard fashion to provide planned postoperative temporary right ventricular support, in selected patients at high risk of right ventricular failure. From September 2020 to June 2022, six patients were supported with the ProtekDuo cannula during and after an intracorporeal LVAD implantation (five of which were minimally invasive): four HeartMate III (Abbott, U.S.A.) and two HVAD (Medtronic Inc, MN). In all cases, the ProtekDuo cannula was correctly positioned and removed without complications after a median period of 8 days. Non-fatal bleeding (bronchial hemorrhage) occurred in one patient (17%) during biventricular support. Thirty-day mortality was 0%. From this preliminary work, our novel strategy demonstrated to be a feasible solution for planned minimally invasive right ventricular support in ECMO patients scheduled for a durable LVAD implantation.

Abstract 15585: Myocardial Reserve After Milrinone to Predict Right Ventricular Failure After LVAD Implantation

Introduction: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a common complication associated with increased morbidity and mortality. Identifying patients at risk for RVF remains challenging. We sought to assess pre-operative right ventricular myocardial reserve after milrinone loading as a risk predictor for post-LVAD RVF. Methods: Adult patients implanted with LVADs from 2013-2019 at a single center who had right heart catherization with milrinone drug study within 30-days preoperatively were included. In addition to standard hemodynamic variables, pulmonary artery pulsatility index (PAPI), right atrial to pulmonary capillary wedge pressure ratio (RA/PCWP), right ventricular stroke work index (RVSWI), pulmonary vascular resistance index (PVRi), and stroke volume index (SVI) were recorded before and after milrinone bolus (50 mcg/kg over ten minutes). Incidence of RVF defined by MCS-ARC criteria within one-year post LVAD were recorded. Student’s unpaired t-tests were used to compare mean of hemodynamic markers to RVF outcome. Results: A total 34 patients were included; 38% women, 50% African American, 68% had non-ischemic cardiomyopathy, 47% implanted with HeartMate 3 LVAD, 20.5% with HeartMate 2, and 32% with HeartWare HVAD. Final right atrial pressure (RAP) after milrinone was higher in those with post-LVAD RVF (15.5 + 7.8mmHg vs 9.2 + 3.9mmHg, p=0.005), as was final diastolic PA pressure (34.3 + 9.2mmHg vs 25.6 + 7.7mmHg, p=0.006). SVI post-milrinone was numerically higher in those without post-LVAD RVF (32.3 + 9.2 vs 26.0 + 7.9mL/m 2 , p=0.06). Percent change in PAPI (p=0.26), RA/PCWP (p=0.35), RVSWI (p=0.10), or PVRi (p=0.92) after milrinone were not associated with RVF. Conclusions: Persistently elevated RAP and diastolic PA pressure, despite milrinone infusion, are associated with RVF after LVAD implantation. Continued reduction in SVI post milrinone may also identify patients at risk for post-LVAD RVF.

Abstract 11629: Multicenter Development and Validation of a Machine Learning Risk Model to Predict Right Ventricular Failure Following Mechanical Circulatory Support: The STOP-RVF Score

Introduction: Existing models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support are limited due to lack of multicenter validation, absence of intraoperative characteristics, and marginal predictive power. We sought to derive and validate a risk model to predict post-LVAD RVF. Methods: Advanced heart failure (HF) patients (N=798) requiring continuous-flow LVAD were enrolled at the Utah Transplant Affiliated Hospitals (n=477), Inova Heart &amp; Vascular Institute (n=183), and Henry Ford Medical Center (n=138). Baseline clinical and intraoperative characteristics were recorded. The primary outcome was RVF incidence, defined as the need for right VAD (RVAD) or intravenous inotropes for &gt;14 days. Bootstrap imputation and lasso variable selection were used to derive a predictive model which was then validated. A risk calculator was developed classifying patients into risk groups, and survival was compared. Results: Patients were predominantly white (72%), males (84%), aged 56±13 years. Patients in the RVF and non-RVF groups were comparable in terms of sex, age, and LVAD indication, while RVF patients more commonly had a history of systemic hypertension, non-ischemic cardiomyopathy, lower INTERMACS profiles, and more commonly required inotropic or temporary circulatory support pre-LVAD. Overall, 193 (24.2%) patients developed RVF with 109 (56.5%) requiring inotropes and 84 (43.5%) an RVAD. Multivariable predictors for RVF are shown in the Figure and achieved a c-statistic of 0.74 (95% CI: 0.70-0.78). Inclusion of intraoperative characteristics did not improve model performance. Cumulative survival was higher in the minimal risk group compared to low, moderate, and high. Conclusions: The STOP-RVF calculator effectively stratifies the risk for RVF after LVAD support by implementing routinely collected clinical data. It could impact patient selection and peri-operative management of advanced HF patients.

Impact of Pre-Operative Right Ventricular Response to Hemodynamic Optimization on Outcomes in Patients with LVADs.

Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ± 12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14–16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24–13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6–25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation.

Pulmonary artery pulsatility index as a predictor of right ventricular failure in left ventricular assist device recipients: A systematic review.

It is critical to identify patients at increased risk of right ventricular failure (RVF) before left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter that is a specific measure of right ventricular function and may better identify LVAD recipients at risk for RVF. This systematic review analyzes the predictive value of preoperative PAPi to RVF in the setting of LVAD implantation. Databases were searched for all studies reporting on PAPi and RVF after LVAD implantation. Data collected included: number of patients, patient characteristics, incidences of RVF, PAPi, central venous pressure (CVP), CVP/pulmonary capillary wedge pressure, tricuspid annular plane systolic excursion, and right ventricular stroke work index. Thirty-two studies (4,756 patients) were included in this review. The incidence of RVF was found to be 27.48% (1,307 patients). The weighted mean (standard deviation) of preoperative PAPi associated with RVF vs No RVF was 2.17 (2.36) and 2.87 (3.21), respectively. When comparing LVAD recipients with RVF and No RVF, patients who developed RVF had a significantly lower preoperative PAPi by a WMD (95% CI) of -0.74 [-1.00, -0.49] (p < .001). The remaining variables (CVP; CVP/pulmonary capillary wedge pressure; tricuspid annular plane systolic excursion; and right ventricular stroke work index) were also confirmed as predictors of RVF after LVAD implantation. This systematic review demonstrates the utility of PAPi as a clinical predictor of RVF after LVAD implantation. Based on our findings, we recommend that PAPi be used in conjunction with traditional hemodynamic parameters when risk stratifying LVAD recipients for RVF.

Impact of surgical approach for left ventricular assist device implantation on postoperative invasive hemodynamics and right ventricular failure.

Right ventricular failure (RVF) remains one of the major causes of morbidity and mortality after left ventricular assist device (LVAD) implantation. We sought to compare immediate postoperative invasive hemodynamics and the risk of RVF following two different surgical approaches: less invasive surgery (LIS) versus full sternotomy (FS). The study population comprised all 231 patients who underwent implantation of a HeartMate 3 (Abbott) LVAD at our institution from 2015 to 2020, utilizing anLIS (n = 161; 70%) versus FS (n = 70; 30%) surgical approach. Outcomes included postoperative invasive hemodynamic parameters, vasoactive-inotropic score (VIS), RVF during index hospitalization, and 6-month mortality. Baseline clinical characteristics of the two groups were similar. Multivariate analysis showed that LIS, compared with FS, was associated with the improved cardiac index(CI) at the sixth postoperative hour (p = .036) and similar CI at 24 h, maintained by lower VIS at both timepoints (p = .002). The LIS versus FS approach was also associated with a three-fold lower incidence of in-hospital severe RVF (8.7% vs. 28.6%, p < .001) and need for RVAD support (5.0% vs. 17.1%, p = .003), and with 68% reduction in the risk of 6-month mortality after LVAD implantation (Hazard ratio, 0.32; CI, 0.13-0.78; p = .012). Our findings suggest that LIS, compared with FS, is associated with a more favorable hemodynamic profile, as indicated by similar hemodynamic parameters maintained by lower vasoactive-inotropic support during the acute postoperative period. These findings were followed by a reduction in the risk of severe RVF and 6-month mortality in the LIS group.

Predicting Right Ventricular Failure Following Left Ventricular Assist Device Support: An INTERMACS Validation Study

<h3>Introduction</h3> : The Utah Right Ventricular Failure (RVF) Risk score is a 7-factor predictive model (African American, history of HTN, INTERMACS profile 1-2, Na <130mEq/L, BUN >35mg/dL, PA pulse pressure <36mmHg and RA/PCWP >0.5) that achieved a high discriminative performance (AUC 0.73) for predicting RVF in a three-center study of patients undergoing left ventricular assist device (LVAD) implantation and was validated in an external two-center cohort (AUC 0.71). <h3>Objective</h3> : Validate a modified Utah RVF (mRVF) Risk score on a larger U.S. geographical scale. <h3>Methods</h3> : INTERMACS data were requested for patients (age ≥19 years) undergoing isolated continuous flow LVAD implant between January 1, 2012 to through December 31, 2017. A modified (mRVF) score was computed without "history of hypertension" due to omission of variable on INTERMACS database. We excluded cases that were missing any of the 7-factor predictor variables. Primary outcome was early RVF, defined as the need for RVAD (BiVAD) support. Secondary outcomes were 90-day all-cause mortality. Multivariable logistic regression analysis was used to validate the predictive model. <h3>Results</h3> : The study included 12550 (59.9%) INTERMACS cases that had all variables of the novel predictive model available. Of those cases, incidence of RVF was 3.37% with a median [25^th, 75^th] predictive mRVF score of 5 [3.38, 6.62]. In the patient population who did not have RVF post-LVAD implantation, their median [25^th, 75^th] predictive mRVF score was 4 [2.22, 5.78]. The novel predictive model had modest accuracy for predicting the risk of RVF post-LVAD implantation (AUC 0.678). The modified Utah RVF score was poorly predictive of 90-day mortality (area under the ROC curve 0.571). <h3>Conclusion</h3> : The modified Utah RVF Risk score offered modest accuracy when applied to a large real world LVAD registry. Further studies examining the impact of unanticipated intra-operative and post-operative events on risk stratification are necessary.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Preoperative Computed Tomography Assessment of Risk of Right Ventricle Failure After Left Ventricular Assist Device Placement.

Identification of patients who are at a high risk for right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is of critical importance. Conventional tools for predicting RVF, including two-dimensional echocardiography, right heart catheterization (RHC), and clinical parameters, generally have limited sensitivity and specificity. We retrospectively examined the ability of computed tomography (CT) ventricular volume measures to identify patients who experienced RVF after LVAD implantation. Between September 2017 and November 2021, 92 patients underwent LVAD surgery at our institution. Preoperative CT-derived ventricular volumes were obtained in 20 patients. Patients who underwent CT evaluation had a similar demographics and rate of RVF after LVAD as patients who did not undergo cardiac CT imaging. In the study cohort, seven of 20 (35%) patients experienced RVF (2 unplanned biventricular assist device, 5 prolonged inotropic support). Computed tomography-derived right ventricular end-diastolic and end-systolic volume indices were the strongest predictors of RVF compared with demographic, echocardiographic, and RHC data with areas under the receiver operating curve of 0.79 and 0.76, respectively. Computed tomography volumetric assessment of RV size can be performed in patients evaluated for LVAD treatment. RV measures of size provide a promising means of pre-LVAD assessment for postoperative RV failure.