Mechanical circulatory support for the right ventricle in combination with a left ventricular assist device

ABSTRACT

Introduction: Right heart failure (RHF) in patients with a left ventricular assist device (LVAD) carries a poor prognosis although the treatment strategy including mechanical circulatory support for the failing right ventricle (RV) has not been well established.

Areas covered: In this review, we describe an overview of RHF post-LVAD implant including natural history, prevalence, pathophysiology, outcomes, and challenges to predict RHF post-LVAD implant. Then, we focus on right ventricular assist devices (RVADs) and their clinical outcomes. Recently developed percutaneous RVADs are the major advance in this field. Finally, we discuss future perspectives to overcome limitations of the current treatment options.

Expert opinion: In the absence of dedicated RVAD system RHF post-LVAD implant may have been undertreated. Now that dedicated percutaneous RVADs have emerged, surgeons are encouraged to use these new devices to improve outcomes of LVAD therapy. As experience accumulates, we should be able to establish the best possible strategy to treat early RHF post-LVAD implant. Late RHF is another form of RHF post-LVAD implant and has been underappreciated. Further research is mandatory to clarify the mechanism and risk factors. There are still unmet needs for a dedicated implantable RVAD for a subset of patients who need long-term RV support.

KEYWORDS:

• Extracorporeal membrane oxygenation
• heart failure
• mechanical circulatory support
• right heart failure
• right ventricular failure
• right ventricular recovery
• temporary right ventricular support
• ventricular assist device

Article highlights

• RHF has been a leading cause of early mortality post-LVAD implant and its prevalence has been unchanged for the last decade.

• The current rates of RVAD requirement for durable CF-LVAD recipients are relatively low with a range of 3–5%, and temporary support suffices for greater than 60% of patients.

• Recently temporary percutaneous RVADs are introduced and expected to play a vital role in patients with RHF post-LVAD implant, but clinical data is still scarce.

• Preemptive use of these less-invasive devices may reduce early mortality post-LVAD implant.

• Studies comparing these devices and traditional surgical RVADs are needed to establish the best possible strategy to treat early RHF.

• Late RHF post-LVAD implant is a potentially distinct pathology from early RHF and its mechanism remains elusive.

• Future studies to reduce the burden of late RHF are required.

• There are unmet needs for a dedicated durable RVAD system.

Declaration of interest

K Nawata belongs to a department endorsed by Nipro Corporation. The authors have no other 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 apart from those disclosed.

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.