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

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Presentation on theme: "Right Heart Failure in Left Ventricular Assist Device Recipients Michael Kiernan, MD, MS Assistant Professor of Medicine, Tufts University School of Medicine."— Presentation transcript:

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 Kormos. J Thorac Cardiovasc Surg 2010;39:1316 Total RVF 20% 6 % RVAD 7% early extended inotropes 7% late inotropes (N=484) 78% 59% Survival 12 mo

3 Fukamachi 1 Michigan RVFRS 2 Kormos 3 Device TypePulsatilePulsatile (84%) & cf-LVAD (16%) cf-LVAD # of LVAD patients RVF DefinitionRVADRVAD, inotropes, iNORVAD, inotropes Incidence of RVF11%35%20% Incidence RVAD11%15%6% InstitutionSingle center Multicenter PredictorsUnivariateMultivariable RVSWI < 300Vasopressor supportVentilator support Mean PAP < 40Bilirubin > 2.0 mg/dL BUN > 39 mg/dL ASTAST > 80 IU/L RA/PCWP > 0.63 Creatinine > 2.3 mg/dL 1. Fukamachi. Ann Thorac Surg 1999;68: Kormos. J Thorac Cardiovasc Surg 2010;139: Mathews. J Am Coll Cardiol 2008;51:2163 Identifying risk for RVF

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

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

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

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

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 < PaPi (per 1 unit larger) LVEDD (per 1 mm increase) RV dysfunction by echo (any) Primary Diagnosis CAD Hemoglobin (per 1 gm/dl increase) Concomitant surgery INTERMACS Patient Profile Level Kiernan. ISHLT 2012

9 PA Systolic Pressure – PA Diastolic Pressure Right Atrial Pressure PaPi = Pulmonary Artery Pulsatility Index Korabathina. Catheter Cardiovasc Interv 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: ISHLT 2013 MCS Guidelines. JHLT 2013;32:

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

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

13 Impact of Tricuspid Valve Repair at time of LVAD LVAD Only N=81 LVAD + TVR N=34 P-value Baseline Characteristics SCr BUN CVP/PCWP *<0.01 CVP Severe TR33%62% OUTCOMES RVAD10%3%0.27 Inotrope10d (8,17)8d (7,12)0.04 Post-op renal insuff 39%21%0.05 Hosp LOS23d (16,46)19d (14,25)0.02 Piacentino (Duke). Ann Thorac Surg 2011;92:1414 LVAD LVAD + TVR Survival

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

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

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

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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