Accurate assessment of right heart function before and after long-term left ventricular assist device implantation

ABSTRACT

Introduction

Because end-stage heart failure (HF) often involves both ventricles even if its initial cause was left-sided heart disease, assessment of RV size, geometry and function before, during and after LVAD implantation is of crucial importance.

Areas covered

This review discusses the usefulness, benefits, particular challenges and limits of RV assessment in patients with end-stage HF due to primarily impaired LV function who necessitate LVAD support, with or without an additional RV mechanical support.

Expert opinion

Although LV unloading often induces reduction of the pulmonary vascular resistance facilitating RV reverse remodeling and functional improvement, drug-refractory RVF after LVAD implantation is not always avoidable. Therefore, patients who need a temporary or long-term biventri-cular mechanical support should already be identified preoperatively or at the latest intraoperatively. Proper assessment of RV function and its adaptability to hemodynamic overloading before LVAD implantation can predict post-implant RVF, thus helping to avoid complications generated by unforeseen RVF in LVAD recipients. Close monitoring of RV size, geometry and function in LVAD recipients with and without additional RV mechanical support is essential for early recognition of imminent RVF in those without RV support and for detection of RV recovery and weaning decision-making in those with a RV support.

KEYWORDS:

• Echocardiography
• hemodynamic monitoring
• right ventricular function
• recovery of function
• right heart failure
• ventricular assist devices

Article Highlights

• Close and comprehensive monitoring of right heart function before and after LVAD implantation plays a crucial role in achieving a maximum benefit for patients from LVAD therapy.

• RV assessment remains challenging despite the multitude of tools and methods available for use.

• Currently, no single imaging or hemodynamic parameter related to the pre-implant right-sided heart anatomy and function can reliably predict RHF after LVAD implantation.

• The most critical predictors of RVF are right-sided heart chamber dilation with high filling pressures and relevant secondary tricuspid regurgitation associated with a reduced ability of the RV to withstand even slight to moderate hemodynamic overloading.

• Integrative approaches using combinations of parameters, which include in addition to RV anatomical and/or functional parameters also measures related to RV afterload, are necessary for achieving the best possible evaluation of RV function before and after LVAD implantation.

• Preoperative prediction of RV function after LVAD implantation is complex and challenging because certain risk factors for postoperative RHF (e.g. insufficient reversibility of congestive heart failure-related circulatory and metabolic alterations or implantation-related complications) may not often be foreseen.

• Combinations of echocardiography and right heart catheterization parameters allow distinguishing between hemodynamic overloading-induced and impaired myocardial contractility-induced RV dysfunction and help in decision-making with regards to the necessity of a mechanical support for the RV during LVAD therapy.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultations, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.