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Challenges of Right Heart Failure Following LVAD Implantation: Risk Factors and Management Strategies

Understand the complexities of post-LVAD right ventricular failure, risk factors such as RV dysfunction, hemodynamic considerations, and various management strategies including temporary RV mechanical circulatory support.

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Challenges of Right Heart Failure Following LVAD Implantation: Risk Factors and Management Strategies

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  1. Right Heart Failure in Left Ventricular Assist Device Recipients Michael Kiernan, MD, MS Assistant Professor of Medicine, Tufts University School of Medicine Medical Director, Ventricular Assist Device Program, Tufts Medical Center

  2. The problem with right heart failure following LVAD implantation 12 mo 78% Total RVF 20% • 6 % RVAD • 7% early extended inotropes • 7% late inotropes Survival (N=484) 59% Kormos. J Thorac Cardiovasc Surg 2010;39:1316

  3. Identifying risk for RVF 1. Fukamachi. Ann Thorac Surg 1999;68:2181. 3. Kormos. J Thorac Cardiovasc Surg 2010;139:1316 2. Mathews. J Am Coll Cardiol 2008;51:2163

  4. Complex etiology of post-LVAD RV failure • High flow RVD LVAD & IVS • Chronic • Intra-op ischemia RVF • CPB • PRBCs • Hypoxia • Acidosis • PRBCs • TR • Hepatic/renal congestion RAP PVR Stroke Volume RV LV McDonald. Curr Opin Card. 2009;24 Pressure vessel (mmHg) Meineri. Best Pract & Res Clin Anesth 2012 (26):217

  5. Severe RV Failure in INTERMACS Continuous Flow LVAD N =2900 Return to OR for RVAD N = 26 (1%) RVAD at time of LVAD Implant N = 84 (3%) RVAD: Durable N = 5 (20%) RVAD: Temporary N = 21 (80%) RVAD: Durable N = 5 (6%) RVAD: Temporary N = 79 (94%) Kiernan. ISHLT 2012

  6. 56% Cleveland. J Heart Lung Transplant 2011;30(8):862

  7. Survival until Discharge P = 0.001 P = 0.054 P = 0.046 Early management:Outcomes with planned versus delayed BiVAD Median time to delayed RVAD 2 days Fitzpatrick (UPenn). J Thorac Cardiovasc Surg 2009;137(4):971

  8. Risk Factors for Early RVAD Following LVAD Surgery Adult Primary Continuous Flow Implants (N=2900) Multivariable Logistic Regression (Event=RVAD) Risk Factors (pre-implant) Odds Ratio p – value INTERMACS Patient Profile Level 1 3.11 < 0.0001 PaPi (per 1 unit larger) 0.71 0.0003 LVEDD (per 1 mm increase) 0.78 0.01 RV dysfunction by echo (any) 3.17 0.01 Primary Diagnosis CAD 1.78 0.03 Hemoglobin (per 1 gm/dl increase) 0.89 0.03 Concomitant surgery 1.55 0.03 INTERMACS Patient Profile Level 2 1.81 0.03 Kiernan. ISHLT 2012

  9. PA Systolic Pressure – PA Diastolic Pressure Right Atrial Pressure PaPi = Pulmonary Artery Pulsatility Index Korabathina. Catheter Cardiovasc Interv. 2011 Sep 27.

  10. Therapy (Preload, Afterload, Inotropy): • Diuresis • Renal Replacement • Vasodilators • Inotropes • IABP/short term MCS • Vitamin K • Surgical technique • ? RCA/LAD revascularization Goals: • RA < 15 mmHg • Euvolemia • Correction metabolic derangements and end-organ function Prevention?: Pre-op optimization Class I (LOE C) Piazza. Chest 2005;128:1836-52 ISHLT 2013 MCS Guidelines. JHLT 2013;32:157-187

  11. Implants June 2006 – March 2011: RHF Analysis Adult Primary Continuous Flow Implants N=2900 By Right Heart Failure Level Severe Right Heart Failure, n= 110 Moderate or Worse Right Heart Failure, n= 398 % Freedom RHF Mild or Worse Right Heart Failure, n=1284 Overall p < 0.0001 Event: Right Heart Failure Months post implant

  12. Readmission rate by cause following LVAD implantation 7-12m 0-6m Readmission rate Hospitalization/(patient*yr) Hasin (Mayo). JACC 2013;61(2):153

  13. Impact of Tricuspid Valve Repair at time of LVAD LVAD + TVR Survival LVAD Piacentino (Duke). Ann Thorac Surg 2011;92:1414

  14. 2196 patients with mod-severe TR--27% TVR • TVR associated with: • No difference in death or RVAD • Increased renal failure • Greater transfusion requirement • Increased LOS JHLT 2014

  15. Effect of digoxin on RV function in primary pulmonary hypertension with symptomatic heart failure Class IIb (LOE C) Rich (Rush). Chest 1998;114:787-792.

  16. Effect of PDE-5A inhibition on PVR and RV hemodynamics post LVAD Control Sildenafil PVR (WU) dP/dtmax/IP Class IIb (LOE C) Tedford (Hopkins). Circ Heart Fail 2008;1:213

  17. Control PHTN Effect of RV pacing on RV function in model of pulmonary hypertension induced RVD RV dP/dt max RVSP Class IIb (LOE C) Handoko. Am J Physiol Heart Circ Physiol 2009:297:H1752

  18. Conclusions & Future Directions • RVF post LVAD remains common • Need multi-disciplinary pre-op evaluation • Need data/trials investigate operative techniques • Need trials investigate strategies for management of chronic RVF • Trials of temporary RV MCS support ongoing pre- and post-LVAD • Emerging biventricular mechanical support devices

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