Risk Of Right Ventricular Failure Research Articles

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.

Cardiovascular implantable electronic device therapy in patients with left ventricular assist devices: insights from TRAViATA

BackgroundThere is conflicting observational data on the survival benefit cardiac implantable electronic devices (CIED) in patients with LVADs. MethodsPatients in whom an LVAD was implanted between January 2008 and April 2017 in the multinational Trans-Atlantic Registry on VAD and Transplant (TRAViATA) registry were separated into four groups based on the presence of CIED prior to LVAD implantation: none (n = 146), implantable cardiac defibrillator (ICD) (n = 239), cardiac resynchronization without defibrillator (CRT-P) (n = 28), and CRT with defibrillator (CRT-D) (n = 111). ResultsA total of 524 patients (age 52 years ±12, 84.4% male) were followed for 354 (interquartile range: 166–701) days. After multivariable adjustment, there were no differences in survival across the groups. In comparison to no device, only CRT-D was associated with late right ventricular failure (RVF) (hazard ratio 2.85, 95% confidence interval [CI] 1.42–5.72, p = 0.003). There was no difference in risk of early RVF across the groups or risk of ICD shocks between those with ICD and CRT-D. ConclusionIn a multinational registry of patients with LVADs, there were no differences in survival with respect to CIED subtype. However, patients with a pre-existing CRT-D had a higher likelihood of late RVF suggesting significant long-term morbidity in those with devices capable of LV‑lead pacing post LVAD implantation.

Does Size Matter for Female Continuous-flow LVAD Recipients? A Translational Approach to a Decade Long Question.

Females have increased risk of right-ventricular failure (RVF) and 3 month mortality after left-ventricular assist device (LVAD) implantation. In this translational study, we tested the hypothesis that sex differences in outcomes are driven by pump-induced LV size-volume mismatch, due to a negative impact on interventricular septal (IVS) interdependence. Adult continuous-flow LVAD recipients from the International Society For Heart And Lung Transplantation Mechanically Assisted Circulatory Support registry (n = 15,498) were studied to determine association of female sex with outcomes of 3 month mortality and RVF. Female sex was associated with smaller preimplant left-ventricular end-diastolic diameter (6.5 vs. 6.9 cm, p < 0.001), increased 3 month mortality (odds ratio [OR]: 1.42, p < 0.001) and RVF (OR: 1.18, p = 0.005). Smaller left-ventricular end-diastolic diameter was associated with worse outcomes after LVAD implantation (OR for mortality: 1.20, p < 0.001; RVF: 1.09, p < 0.001), and attenuated the association of female sex with these outcomes. In test bench heart phantoms (n = 4), the IVSs of smaller hearts demonstrated abnormal leftward shift earlier than larger hearts (volume change at IVS shift: 40 [95% confidence interval: 30-52] vs. 50 [95% confidence interval: 48-69] ml). Smaller LV size partially mediates worse post-LVAD outcomes for female patients, due to lower volume thresholds for adverse IVS shifting.

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.

A new hemodynamic index to predict late right failure in patients implanted with last generation centrifugal pump.

Right ventricular failure (RVF) is a severe event that increases perioperative mortality after left ventricle assist device (LVAD) implantation. Right ventricular (RV) function is particularly affected by the LVAD speed by altering RV preload and afterload as well as the position of the interventricular septum. However, there are no studies focusing on the relationship between pump speed optimization and risk factors for the development of late RVF. Between 2015 and 2019, 50 patients received LVAD implantation at San Camillo Hospital in Rome. Of these, 38 who underwent pump speed optimization were included. Post-optimization hemodynamic data were collected. We assessed a new Hemodynamic Index (HI), calculated as follows: ,to determine the risk of late RVF, which was defined as the requirement for rehospitalization and inotropic support. Ten patients had late RVF after LVAD implantation. Five patients required diuretic therapy and speed optimization. Three patients required inotropic support with adrenaline 0.05 μg/kg/min. Two patients needed prolonged continuous venovenous hemofiltration and high dose inotropic support. Multivariate analysis revealed that a low HI (odds ratio 11.5, 95% confidence interval, 1.85-65.5, p[.003]) was an independent risk factor for late RVF after LVAD implantation. We demonstrated a low HI being a significant risk factor for the development of RVF after LVAD implantation. We suggest implementing HI as a decision support tool for goal-direct optimization of the device aiming to reduce the burden of late-onset RVFduring the follow-up.

Predicting Significant Right Ventricular Failure Post-LVAD Implantation Using CMR Compared to Echocardiography and Right Heart Catheterisation

Purpose Right ventricular failure (RVF) complicates 10-40% of LVAD implants. Significant RVF is associated with increased mortality and reduced chance of being bridged to transplant. It is therefore crucial to identify patients at high risk of RVF using pre-operative investigations. We investigated markers of RV function on pre-LVAD echocardiography (echo), right heart catheterization (RHC) and cardiovascular magnetic resonance imaging (CMR) in predicting significant post-LVAD RVF. Methods We performed a single centre retrospective analysis of 220 patients who underwent LVAD implantation between 2011-18. 33 patients had CMR within 15 months pre-LVAD implantation. CMR was used to derive RV volumes, TAPSE, RV ejection fraction, strain and scar burden. RV function parameters were derived from echo and RHC just prior the LVAD implantation. INTERMACS criteria was used to categorize RVF based on duration of pharmaceutical support (post-implant IV inotropes/vasodilators/inhaled nitrous oxide) - mild ( 14 days). The latter also included the need for RVAD or death due to RVF. Moderate and severe RVF were considered as significant RVF. Results The median age was 49 (IQR 39-56). 31 were males. 18 patients had no/mild RVF; 14 had significant RVF (8 moderate RVF, 6 severe RVF); 1 patient was not categorised due to incomplete data. 29 survived to discharge. Dilated cardiomyopathy was the commonest aetiology of heart failure (17/33) followed by ischaemic heart disease (11/33). Echo derived pulmonary hypertension (42 vs 36mmHg) and proportion of those with tricuspid regurgitation (83.3% vs 92.8%) were not different in the two groups. PVR on RHC was not different between the groups (2.82 vs 3.68 WU). CMR derived volumes, TAPSE (12.2 vs 12.1mm), Global longitudinal strain (-9.1% vs -7.2%) and radial strain (-12.4% vs -10.0%) and the presence of scar were not different between the two groups. CMR-RVEF however was lower in the group significant RVF (23.5 ± 8.2%) when compared to the group with no/mild RVF (31.0 ± 10.7%) (p=0.03). Conclusion When compared to indices from RHC and echo, pre-operative RVEF on CMR is the only marker that differentiated the group who developed significant post-LVAD RVF from the group that did not. A larger study with CMR closer to the time of LVAD implant is needed to validate this.

Predicting Right Ventricular Failure Following Left Ventricular Assist Device Support: A Derivation-Validation Multicenter Risk Score

<h3>Purpose</h3> Despite several models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support, poor performance when externally validated has limited their widespread use. We sought to derive a predictive model for RVF after LVAD implantation, and ascertain its performance in an independent cohort. <h3>Methods</h3> End-stage heart failure (HF) patients requiring continuous-flow LVAD were prospectively enrolled at one US program (n=477, derivation cohort), with two other US medical centers forming the validation cohort (n=321). The primary outcome was RVF incidence, defined as the need for right ventricular assist device or inotropes for >14 days. Multivariable logistic regression in the derivation set yielded a RVF predictive model, which was subsequently applied to the validation cohort, and a risk score was ultimately developed. <h3>Results</h3> Derivation cohort included patients less likely to be African-Americans (7% vs 37%; p<0.001), Hispanics (7% vs 30%; p<0.001), have a remote history of hypertension (49% vs 60%; p=0.002) or be bridged with short-term MCS (8% vs 16%; p=0.001), compared to the validation set. RVF incidence was 16% in the derivation and 36% in the validation cohort (p<0.001). Multivariable analysis identified 7 variables <b>(Figure)</b> as predictive of RVF, with the model achieving a C statistic of 0.734 (95% CI=0.674-0.794) in the derivation and 0.709 (95% CI=0.651-0.767) in the heterogeneous validation cohort. Patients were stratified into 3 RVF risk groups (all comparisons; p<0.001) <b>(Figure)</b>. <h3>Conclusion</h3> We propose a novel scoring system to predict post-LVAD RVF, achieving high discriminative performance in distinct, heterogeneous LVAD cohorts.

Abstract 13494: Lncrna Khps1 Regulates Hif-1a-dependent Pulmonary Vascular Remodeling by Targeting Mir-1, Sphk1 and S1pr2

Rationale: Pulmonary vascular remodeling is common in pulmonary arterial hypertension (PAH) and is associated with increased risk of right ventricular failure and death. We have previously reported that sphingosine kinase 1 (Sphk1), sphingosine 1 phosphate receptor 2 (S1PR2), microRNA-1-3p (miR-1-3p) and hypoxia-inducible factor-1α (HIF-1α) are involved in the regulation of pulmonary vascular remodeling and the development of PAH. Recently, it has been reported that the long noncoding RNA (LncRNA) Khps1 is required for Sphk1 expression and cell proliferation. However, whether Khps1 plays a role in PAH is unclear. Here, we tested the hypothesis that Khps1 has an impact on pulmonary vascular remodeling in PAH by regulating Sphk1/S1PR2/HIF-1α signaling pathway. Methods and Results: Using qRT-PCR, our data showed that Khps1 expression levels were up-regulated in pulmonary artery smooth muscle cells (PASMCs) from PAH patients. Increased Khps1 expression levels were also observed in human PASMCs exposed to hypoxia and in lungs obtained from monocrotaline (MCT)-treated rats or hypoxia exposed mice. Luciferase reporter assays showed that Khps1 expression is dependent on E2F1-mediated promoter activation. In silico analysis and luciferase reporter assays also suggested that Khps1 can directly bind to miR-1-3p, suggesting that Khps1 functions as a competing endogenous RNA. Similar studies also showed that miR-1-3p regulates expression of Sphk1 and S1PR2 by binding to their 3’UTR regions. Concurrent E2F1 overexpression and khps1 silencing resulted in a decrease in Sphk1 and S1PR2 expression levels, reduced HIF-1α stabilization and suppressed PASMCs proliferation. Finally, over expression of Sphk1 increased HIF-1α and that in turn increased E2F1 expression in human PASMCs. Conclusion: These data reveal a novel regulatory loop between E2F1, Khps1, miR-1-3p and Sphk1/S1PR2 in the regulation of PASMC proliferation and pulmonary vascular remodeling in PAH. These data also suggest Khps1 regulates pulmonary vascular remodeling in a HIF-1α-dependent manner through targeting Sphk1 and S1PR2.

Abstract 15339: Prediction of Severe Right Ventricular Failure After Left Ventricle Assist Device Using Echocardiographic Right Ventricular Dp/dt

Introduction: Right ventricular failure (RVF) remains a major cause of morbidity and mortality after continuous flow Left Ventricle Assist Device (CF-LVAD) implantation. Previous risk assessments using pre-operative data to predict RVF have performed only modestly well. Methods: We retrospectively studied the potential of echocardiographic RV dP/dt - a non-invasive measure of right ventricular contractility derived from the Doppler signal of tricuspid regurgitation, to predict post-LVAD RVF in patients who were inotrope-independent and those who were on inotropic therapy prior to LVAD. Sixty-five consecutive CF-LVAD recipients at Vanderbilt University Medical Center from 2013-2019 who had a baseline echocardiogram without inotrope support within 3 months prior to LVAD implantation were included. Forty patients from the cohort were started on inotropes prior to LVAD implantation. Baseline off-inotrope and on-inotrope RV dP/dt data were analyzed. Severity of post-LVAD RVF was defined by INTERMACS criteria. Results: Of the 65 studied patients, 30 patients had none or mild RVF, 17 had moderate RVF, and 18 had severe RVF. Patients with severe RVF had markedly poorer survival outcome than no/mild and moderate RVF patients. Baseline RV dP/dt was significantly lower in patients who developed post-LVAD severe RVF. A baseline off-inotrope, or on-inotrope RV dP/dt ≥ 300 mmHg/s predicted a low risk of severe RVF with high sensitivity (89% and 80%, respectively) and negative predictive value (91% and 88% respectively); while the presence of both off-inotrope and on-inotrope RV dP/dt &lt; 300 mmHg/s was associated with a high likelihood of post-LVAD RVF (OR 10.5, 95% 1.8-59.4 compared to the rest of the cohort on inotrope therapy). Conclusion: Echocardiographic RV dP/dt may be a valuable adjunct tool for prediction of post-LVAD severe RVF in patients undergoing evaluation for LVAD implantation.

Pre-emptive ECMO cannulation in a patient with severe pulmonary hypertension and acute appendicitis undergoing appendectomy

A 30-year-old woman presented with a 2-day history of abdominal pain, nausea, vomiting and fever. She had a medical history of severe pulmonary hypertension, bilateral pulmonary emboli, right heart failure,...

Unsupervised Machine Learning of LGE Patterns on Cardiac MRI Identifies Patients at Risk for Right Ventricular Failure After LVAD

Introduction Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD), however predicting RVF remains challenging. Hypothesis We hypothesized that an analysis of late gadolinium enhancement (LGE) patterns on pre-operative cardiac MRI (cMRI) could identify patients at risk for RVF after LVAD. Methods We analyzed reports for cMRIs performed on patients within one year prior to LVAD at our institution and abstracted LGE patterns using the 17-segment model. Patients were then grouped into clusters by similarities in LGE patterns using an unsupervised machine learning (ML) algorithm of hierarchical agglomerative clustering. Statistical comparison of the resulting clusters was then performed. Results Patients (N=31) were grouped into 3 clusters (Figure) with varying patterns of LGE. Cluster 1 patients (n=16) had no LGE or atypical LGE patterns and were significantly younger (age 42 ± 18) than other clusters (p=0.029). Cluster 2 patients (n=11) had extensive transmural LGE patterns and were more likely to have hypertension (p=0.006) and dyslipidemia (p=0.002) than other groups. Cluster 3 patients (n=4) had some degree of subendocardial LGE but no extensive transmural LGE patterns. No patients in cluster 2 developed RVF after LVAD, while 4 patients (25%) in cluster 1 and 2 patients in cluster 3 (50%) had RVF after LVAD, though the difference between groups did not reach statistical significance due to small number of patients in the cohort overall (p=0.058). Importantly, traditional factors associated with RVF including hemodynamics and echocardiographic/MRI parameters of LV and RV function were not significantly different between clusters. Further, LGE enhancement of the RV myocardium or RV insertion points were not associated with RVF after LVAD. Conclusions Unsupervised ML of LGE patterns on cMRI can identify clusters of patients at risk for RVF. LGE patterns on cMRI may identify patients with non-ischemic (cluster 1) and mixed (cluster 3) etiologies of their heart failure who are at higher risk for developing RVF due to global biventricular myocardial involvement than patients with a truly ischemic etiology of their heart failure (cluster 2). Future research in a larger cohort is needed to confirm this hypothesis. Figure: Dendrogram produced from agglomerative hierarchal clustering of LGE analysis of cardiac MRIs using standardized myocardial segmentation

A Novel Risk Score Predicts Early Right Ventricular Failure after Lvad: A Derivation-validation Multicenter Study

Introduction Right ventricular failure (RVF) after LVAD implantation is associated with increased morbidity and mortality. Despite several RVF predictive models, poor performance in external validation cohorts has limited their widespread clinical adoption. Objective To develop a novel RVF predictive model, ascertain its performance in an independent validation cohort, and develop an RVF risk score. Methods Consecutive LVAD patients were prospectively enrolled at the Utah Transplantation Affiliated Hospitals (U.T.A.H) Cardiac Transplant Program (n=477, Derivation cohort). LVAD patients from Inova Heart & Vascular Institute and Henry Ford Medical Center formed the external dataset (n=321, Validation cohort). The primary outcome was early RVF, defined as the need for RVAD or intravenous inotropes for >14 days. The secondary outcome was 3-year all-cause mortality. Multivariable logistic regression analysis was used to develop a predictive model. An RVF risk score was developed using weighted points based on the β-regression coefficients of the multivariable predictors. Results The study included 798 patients, with a mean age of 56y, 84% male, and 30% INTERMACS Profile 1-2. Compared to the derivation cohort, the validation cohort had a higher proportion of African-Americans (37% vs 7%; p 35mg/dL, PA pulse pressure 0.5). The model had a c-statistic of 0.73 ([95% CI:0.67-0.79]; p Conclusion We propose a novel scoring system to predict post-LVAD RVF, achieving high discriminative performance after being tested in distinct and highly heterogeneous populations. This simple predictive tool could impact patient selection and perioperative management of LVAD patients.

Predicting the Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review.

Right ventricular failure (RVF) is a cause of major morbidity and mortality after left ventricular assist device (LVAD) implantation. It is, therefore, integral to identify patients who may benefit from biventricular support early post-LVAD implantation. Our objective was to explore the performance of risk prediction models for RVF in adult patients undergoing LVAD implantation. A systematic search was performed on Medline, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until August 2019 for all relevant studies. Performance was assessed by discrimination (via C statistic) and calibration if reported. Study quality was assessed using the Prediction Model Risk of Bias Assessment Tool criteria. After reviewing 3878 citations, 25 studies were included, featuring 20 distinctly derived models. Five models were derived from large multicenter cohorts: the European Registry for Patients With Mechanical Circulatory Support, Interagency Registry for Mechanically Assisted Circulatory Support, Kormos, Pittsburgh Bayesian, and Mechanical Circulatory Support Research Network RVF models. Seventeen studies (68%) were conducted in cohorts implanted with continuous-flow LVADs exclusively. The definition of RVF as an outcome was heterogenous among models. Seven derived models (28%) were validated in at least 2 cohorts, reporting limited discrimination (C-statistic range, 0.53-0.65). Calibration was reported in only 3 studies and was variable. Existing RVF prediction models exhibit heterogeneous derivation and validation methodologies, varying definitions of RVF, and are mostly derived from single centers. Validation studies of these prediction models demonstrate poor-to-modest discrimination. Newer models are derived in cohorts implanted with continuous-flow LVADs exclusively and exhibit modest discrimination. Derivation of enhanced discriminatory models and their validations in multicenter cohorts is needed.

Heart failure etiology and risk of right heart failure in adult left ventricular assist device support: the European Registry for Patients with Mechanical Circulatory Support (EUROMACS)

Objectives: Development of right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation remains a leading cause of perioperative morbidity, end-organ dysfunction and mortality. The objective of this study was to investigate whether the etiology of HF (ischemic HF versus non-ischemic HF) affects the risk of RVF within admission for LVAD implantation and during long-term follow-up. Methods: Between January 2011 and June 27, 2018, 3536 patients were prospectively enrolled into EUROMACS registry. Adult patients (>18 years) who received a first time LVAD were included. When excluding patients with congenital, restrictive, hypertrophic, valvular cardiomyopathies, and myocarditis the total population consisted of 2404 patients. Results: The total cohort consists of 2404 patients. Mean age were 55 years and predominantly male sex [2024 (84.2%)]. At the time of LVAD implantation 1355 (56.4%) patients had ischemic HF and 1049 (43.6%) patients had non-ischemic HF. The incidence of RVF was significantly increased in the non-ischemic HF group in the adjusted model (p = .026). The relative risk difference for RVF in patients with non-ischemic HF was in the adjusted model increased by an absolute value of 5.1% (95% CI: 0.61–9.6). In the ischemic HF group 76 patients (13.4%) developed late RVF and 62 patients (14.8%) in the non-ischemic HF group (p = .56). No differences in occurrence of RVF between HF etiology was observed after 2 and 4 years of follow-up, respectively (crude: p = .25, adjusted (sex and age) p = .2 and crude: p = .59, adjusted (sex and age) p = .44). Conclusions: Patients with non-ischemic HF undergoing LVAD had an increased incidence of early RVF compared to patients with ischemic HF in a large European population. During follow-up after discharge 14% patients developed RVF. We recommend HF etiology to be considered in identifying patients who are at risk for postoperative RVF after LVAD implantation.

Minimally invasive surgery for left ventricular assist device implantation is safe and associated with a decreased risk of right ventricular failure

BackgroundRight ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with significant mortality and morbidity. The objective of this study was to determine pre- and postoperative risk factors associated with the occurrence of RVF after LVAD implantation.MethodsThis retrospective study included 68 patients who received LVADs between 2010 and 2018 either for bridge to transplant (40 patients, 58.8%) or bridge to destination therapy (28 patients, 41.2%). RVF after LVAD implantation was defined according to the INTERMACS classification. The primary endpoint was the occurrence of RVF. The secondary endpoints were hospital mortality and morbidity and long-term survival.ResultsThe majority of patients (61.8%) had an INTERMACS profile 1 (36.8%) or 2 (25.0%). The LVAD was implanted either by sternotomy (37 patients, 54.4%) or thoracotomy (31 patients, 45.6%). RVF after LVAD implantation was observed in 32 patients (47.1%). In univariate analysis, an elevated serum glutamic oxaloacetic transaminase (SGOT) (P=0.028) and a high preoperative vasoactive inotropic score (VIS) (P=0.028) were significantly associated with an increased risk of RVF, whereas the implantation of LVAD through a thoracotomy approach was associated with a significant reduction in this risk (P=0.006). The multivariate analysis demonstrated that only the thoracotomy approach was significantly associated with decreased risk of RVF (odds ratio =0.33, 95% confidence interval: 0.17–0.96; P=0.042). Hospital mortality was 53.1% and 5.6% in the RVF and control groups, respectively (P<0.0001). The incidence of stroke and postoperative acute renal failure were significantly increased in the RVF group compared with the control group. The survival after LVAD implantation was 33.5%±9.0% and 85.4%±6.0% at 1 year in the RVF and control groups, respectively (P<0.0001).ConclusionsLVAD implantation by thoracotomy significantly reduced the risk of postoperative RVF. This surgical approach should, therefore, be favored.

Pre-LVAD CT-Derived Measures of RV Size and Function May Be Strong Identifiers of Right Ventricular Failure

LVADs are a commonly used treatment for patients with end stage heart failure, though these patients are at a high risk of right ventricular failure (RVF) after implantation. ECG-gated, contrast enhanced functional CT provides quantitative volumetric and functional measures that may prove more useful in predicting RVF than traditional measures. Since September 2017, ECG-gated CT scans of the heart were acquired on a Revolution Scanner (GE Healthcare) as part of a work-up in heart failure patients with GFR > 40. For this study, we included patients who received a functional CT scan and went on to receive an LVAD. RVF classification and severity was assessed within 6 months of the implant as per INTERMACs criteria for LVAD patients. Prognostic values for previously published risk scores and common predictors were compared to RV size and function. Area Under the curve (AUC) values, accuracy, sensitivity and specificity were used to compare CT RV EDVI and RVEF to CVP, Creatinine, PAPI, Michigan Score, and CRITT score. Of the 62 scanned, 12 received LVADs. Post implantation, 7 patients had RVF (5 moderate, 2 severe). Patients were evaluated for their RV EDVI (131 ± 34 mL/m2), RVEF (30 ± 13%), CVP (9 ± 4 mmHg), Creatinine (1.17 ± 0.25 mg/dL), PAPI (2.74 ± 1.91), Michigan Score (2 ± 2), and CRITT score (0.5 ± 0.7). RV EDVI, RVEF, and PAPI were the strongest predictors (AUC = 0.75, 0.725, 0.714 respectively), with ideal cutoff of 144 ml/m2 for RVEDVI, 27% for RVEF, and 1.88 for PAPI. Creatinine was less predictive (AUC = 0.7), and the Michigan Score, CRITT score, and CVP were not predictive(AUC = 0.575, 0.5, 0.5). For this small cohort, functional CT derived parameters had high AUC in predicting RVF in LVAD patients, and may prove useful in future risk assessment.

Impact of Inhalation of Nitric Oxide and Extubation on Hemodynamics of Right Heart in Acute Phase after Left Ventricular Assist Device Implantation

Right ventricular failure (RVF) is one of the major complications after LVAD implantation. In acute phase after LVAD implantation, inhalation of nitric oxide (NO) and mechanical respiratory support and extubation causes hemodynamic changes on right heart dramatically. Although perioperative management is crucial to prevent RVF, there was no study which analyzed the impact of NO, mechanical respiratory support and extubation on hemodynamics of right heart in detail. Between December 2014 and September 2018, consecutive 102 patients underwent LVADs implantation in Osaka University Hospital. Patients below 18 years were excluded. Patients with right ventricular assist device support, and/or tracheostomy without trying of extubation after LVAD implantation were also excluded. Finally, 75 patients were included in this study (mean age, 45 ± 14 years; 30% were women). We used 5 different types of LVADs. We assessed the perioperative course of central venous pressure (CVP), pulmonary vascular resistance (PVR), and cardiac index (CI) before and after discontinuation of NO and extubation. Mean duration of NO inhalation was 2.0(0-3.3) days and final concentration of NO was 5ppm. The changes of CVP and CI before and after discontinuation of NO were not significantly (CVP: 10.0±2.7 to 10±2.7 mmHg, p=0.436, CI: 2.8±0.6 to 2.6±0.4 l/min/m2, p=0.999). Mean duration of intubation was 2.7(1.8-6.2) days. Just before extubation, respiratory rate was 17±4rpm and PaO2/FiO2 ratio was 341±71 under 5 cmH20 of positive end-expiratory pressure. The changes of CVP, PVR and CI before and after extubation were significantly (CVP: 9.1±2.9 to 8.2±3.0 mmHg, p=0.001, PVR: 1.1±0.4 to 1.2±0.5 wood, p=0.014, CI: 2.8±0.6 to 3.0±0.6 l/min/m2, p=0.004). Furthermore, patients with elevated CVP(≧10mmHg, n=31) also increased their CI significantly after extubation (CI:2.9±0.5 to 3.1±0.6 l/min/m2, p=0.007). Among adult patients with LVAD, discontinuation of NO inhalation caused minor decrease of CI but not significant. Extubation improves CI even patients with elevated CVP, who are higher risk for suffering from RVF. These analysis of hemodynamic changes imply that after respiratory condition become stable, extubation could be one important choice to improve hemodynamics even in patients with higher risk for RVF.

Right heart failure with left ventricular assist device implantation in children: An analysis of the Pedimacs registry database

The use of ventricular assist device (VAD) in children has increased, but the decision of left VAD (LVAD) vs biventricular support remains a challenge. Children who undergo LVAD placement are at risk for right ventricular failure (RHF), but the incidence has not been described. Analysis was performed for patients <18 years old who underwent durable LVAD placement within the Pedimacs registry (September 19, 2012-February 28, 2017), excluding single ventricle morphology and temporary devices. RHF was defined as the need for right ventriculalr assist device (RVAD) or prolonged inotrope use between 1 week to 1 month and 1 to 3 months. End-points included death, heart transplant (HT), and recovery. A total of 272 durable LVAD were placed of which 37 died on device over 24 month follow-up, primarily from multiorgan failure and neurologic dysfunction. RVAD occurred in 12 children at median 8.5 days, with 9 undergoing HT and 3 dying on device. In patients with only LVAD, RHF was present in 111/207 (55%) between 1 week to 1 month and 28/116 (25%) between 1 and 3 months. Younger age, smaller weight, Intermacs profile 1, chemical paralysis, and pulsatile flow VAD were associated with RHF. RHF was associated with increased risk of death on device at both >1 month (hazard ratio 3.2, 95% CI 1.4-7.7, p = 0.007) and >3 month (hazard ratio 6.9, 95% CI 2-23.1, p = 0.002). In children, RHF is common after durable LVAD implantation, but subsequent RVAD is relatively rare. RHF in children, as indicated by prolonged inotrope support, was associated with an increased risk of death on the device. Whether early RVAD support and higher waitlist status may improve the outcome remains unknown.

P3440Can pre-operative echocardiography predict RV failure post-LVAD implantation in children?

Abstract Background One of the most frequent complications of left ventricular assist device (LVAD) implantation is the development of right ventricular (RV) failure, which occurs in 10%-40% of patients. It is, therefore, essential to identify which LVAD candidates are at risk for RV failure and will require additional RV mechanical support with a biventricular assist device (BiVAD). However, the echocardiographic assessment of the RV is challenging due to its complex geometry and marked load dependence of its function indices. To our knowledge, there is no published evidence regarding which specific RV echocardiographic parameters should inform this decision in the paediatric population. Aims We sought to determine which pre-operative RV echocardiographic parameters best correlate with the need for a BiVAD, as opposed to LVAD alone, in a paediatric population undergoing VAD insertion at a tertiary care institution. Methods Retrospective review of the pre-operative echocardiograms of children (&lt;18 years) with dilated cardiomyopathy undergoing elective VAD implantation at our institution, from November 2007 to December 2018. Preoperative quantitative and qualitative RV echocardiographic parameters described in the literature to be associated with RV failure after LVAD implantation in adults were collected. Moreover, qualitative RV function was independently assessed by three echocardiographers, blinded to the outcome of the patients. Results 89 patients were included, 39 (43.8%) males, median age = 1.7 years (IQR = 6.9), median weight = 11.6 kg (IQR = 13.8). 49 (55.1%) patients had an LVAD implanted, whereas 40 (44.9%) were deemed to need biventricular support. 45 (50.6%) patients received an EXCOR Berlin Heart, 16 (18%) a HeartWare HVAD and 28 (31.4%) a Levitronix Centrimag device. Requirement of BiVAD support was significantly more common in patients with moderate to severe RV impairment, as per expert assessment (OR = 2.864; 95% CI: 1.188–6.903, p=0.018), and tricuspid regurgitation &gt; grade III (OR = 3.154; 95% CI: 1.124–8.850, p=0.025). All the other parameters collected – tricuspid annular plane systolic excursion (TAPSE), tricuspid regurgitant jet velocity, tricuspid regurgitation duration corrected for heart rate, RV tissue Doppler indices, RV fractional area change, and RV/LV diameter ratio– were not significantly different among groups. Conclusions In our paediatric population, expert assessment of RV function and degree of tricuspid regurgitation were strong predictors of RV failure among patients undergoing LVAD implantation, allowing for pre-emptive RVAD implantation and improving patient outcomes.

Longer Duration of Milrinone Associated with Higher Risk for Right Ventricular Failure Following Left Ventricular Assist Device Implantation in Stage D Heart Failure Patients

Background Milrinone is a phosphodiesterase inhibitor that is used for the management of end stage heart failure (HF) patients, either as a palliative treatment or as a bridge to advanced HF therapies. Left ventricular assist device (LVAD) implantation has become a mainstay of advanced HF therapies, due to the limited number of available hearts for transplant. Unfortunately, up to 20% to 40% of device implantations are complicated by right ventricular failure (RVF), which results in significant morbidity and mortality. We aimed to investigate whether the duration on milrinone infusion is an independent risk factor for RVF following LVAD implantation. Methods This was a retrospectively review of medical records. We included all adult with ACC/AHA stage D HF patients who underwent LVAD implantation at our institution between January, 2010 and December, 2018. Patients were divided into two groups, those on short term ( 30 days) milrinone infusion. The primary endpoint for this study was the incidence of severe RVF (need for RV assist device or inotropic support for more than 14 days after LVAD) within 30 days post LVAD implantation. Results Total of 104 patients underwent LVAD implantation. Short term (STM) group had 55 pts and long term (LTM) had 49 patients. There were no significant differences between STM and LTM patients at baseline demographic, echocardiographic and right heart catheterization data. Following LVAD implantation, 5 (9.1%) patients in the STM group versus 9 (18.4%) in the LTM group needed RVAD support, and, 9 (16.4%) patients versus 22 (44.9%) needed inotropic support for more than 14 days (Figure 1). Overall, 45 (43.3%) patients developed RVF. LTM patients had a higher incidence of RVF; OR= 5.04 (95% CI 2.18 - 11.68), P=0.0002. After adjusting for age, gender, baseline RV function, atrial fibrillation, coronary artery disease, cerebrovascular disease, chronic kidney disease, and diabetes mellitus, the OR was 6.33 (95% CI 2.51 - 15.93), P Conclusion Longer duration on inotropes was associated with significantly higher incidence of early right ventricular failure following LVAD implantation.