Journey of the Right Heart Following Left Ventricular Assist Device Implantation

Introduction Right heart function impacts outcomes in left ventricular assist devices (LVADs) but a comprehensive exploration of changes in right heart function over time and its effects on outcomes has not been fully elucidated. We sought to characterize changes in right heart function according to hemodynamic, imaging, and laboratory data at multiple time points and evaluate how pre-implant function compares to postoperative function in predicting heart failure (HF) outcomes. We hypothesized that postoperative (pre-discharge) right ventricular (RV) systolic function would be more predictive of HF readmissions compared to preoperative RV function. Methods In this single-center study, we included consecutive patients (n=298) who received primary LVADs between May 2008 and December 2018. Invasive hemodynamics, echocardiography (ECHO), and laboratory data were collected preoperatively, postoperatively, and at 3, 6, and 12 months following LVAD implantation. Post-implant readmission data were also collected up to 12 months post hospital discharge. Results Compared to pre-implant values, significant and persistent improvements in right atrial pressure (RAP), pulmonary artery (PA) pressures, pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistance (PVR), and RAP/PCWP occurred at 3, 6, and 12 months post-implant respectively (figure 1a). On the other hand, PA pulsatility index (PAPi) fluctuated over time and RV stroke work index (RVSWI) decreased over time (figure 1a). In addition, the proportion of patients with moderate-severe/severe RV dilation, tricuspid regurgitation (TR), and RV systolic function reduction eventually decreased on average by 12 months post-implant (figure 1b). Significant improvements in BNP and bilirubin levels occurred (figure 1c). Finally, we found that postoperative (pre-discharge) RV systolic function by ECHO was significantly predictive of readmissions due to HF (p=.03) whereas preoperative RV systolic function was not (p=0.81). Conclusions Right heart function metrics generally improve and persist at various time points post-implant compared to preoperative values. However, normalization of right heart function is rarely achieved, highlighting the need to redefine “normal” in LVAD patients. Additionally, the superior predictive value of postoperative RV function on HF readmissions underscores the importance of re-assessing right heart function post-implant for improved risk stratification.