Assessment of Right Ventricular Function in Left Ventricular Assist Device Candidates
- decision support techniques
- heart-assist devices
- heart failure
- right ventricle
- ventricular-assist device
As a result of the improved survival of patients with heart failure (HF) and the overall rise in the prevalence of HF,1 the number of patients in advanced (stage D) HF continues to increase, thus exceeding the limited availability of donor organs by a wide margin.2 Initially used primarily as a bridge to heart transplantation, mechanical circulatory support is now increasingly offered as a destination therapy to patients with advanced HF in clinical deterioration who are not candidates for transplantation. Improvement in survival to 80% at 1-year postimplantation3 has steadily followed the development of new technologies such as the continuous-flow pump, which now encompasses 99% of left ventricular assist devices (LVADs),3 and improvements in patient and device management. Far from being a panacea, mechanical circulatory support is still fraught with challenges. Among them, post-LVAD right ventricular failure (RVF) is a major cause of morbidity and mortality.
Despite (1) overall improved outcomes and lower rates of RVF with the use of the newer, continuous-flow LVADs over pulsatile-flow devices,4 and (2) development of clinical prediction scores to facilitate preoperative identification of patients at risk for RVF after implantation,5–9 RVF still occurs in 13% to 40% of continuous-flow device.10 LVAD function relies heavily on right ventricular (RV) function for adequate preload. Severe RVF cannot only lead to systemic hypoperfusion, multiorgan failure, and death but also to prolonged or recurrent hospitalization and poor quality of life even in less extreme cases. LVAD recipients who develop RVF have poor outcomes,11–13 including higher perioperative, short- and long-term mortality,5,14,15 and reduced survival to transplantation.11,13–20 RVF has also been associated with higher risk of bleeding, renal failure, and hypotension,13,14,19 and longer …