Late right heart failure during support with continuous-flow left ventricular assist devices adversely affects post-transplant outcome

doi:10.1016/j.healun.2014.10.005

The Journal of Heart and Lung Transplantation

Volume 34, Issue 5, May 2015, Pages 667-674

https://doi.org/10.1016/j.healun.2014.10.005 Get rights and content

Background

Right heart failure (RHF) is an unresolved issue during continuous-flow left ventricular assist device (LVAD) support. Little is known about post-transplant outcomes in patients complicated by late RHF during LVAD support.

Methods

Between May 2004 and December 2013, 141 patients underwent cardiac transplantation after isolated LVAD bridging at our center. Late RHF was defined as heart failure requiring medical intervention >4 weeks after LVAD implantation.

Results

The patients’ mean age was 53 ± 13 years, 82% were men, and 36% had an ischemic etiology. The mean duration of LVAD support before transplantation was 0.75 years. Late RHF developed in 21 patients (15%) during LVAD support. Of these patients, 11 were supported with inotropic agents at the time of transplantation. Patients with RHF had higher creatinine (1.6 ± 0.88 mg/dL vs 1.3 ± 0.67 mg/dL, p = 0.07), higher blood urea nitrogen (32 ± 17 mg/dL vs 24 ± 10 mg/dL, p = 0.0013), higher total bilirubin (0.96 ± 0.46 mg/dL vs 0.78 ± 0.42 mg/dL, p = 0.07), and lower albumin (3.8 ± 0.60 g/dL vs 4.1 ± 0.46 g/dL, p = 0.0019) at the time of transplantation compared with patients who did not develop RHF. In-hospital mortality was significantly higher in patients with late RHF during LVAD support (29% vs 6.7%, p = 0.002). Overall post-transplant survival rates were 87% at 1 year, 83% at 3 years, and 77% at 5 years. The 5-year post-transplant survival was significantly worse in patients who developed late RHF during LVAD support compared with survival in patients who did not develop RHF (26% vs 87%, p < 0.0001).

Conclusions

Late RHF during LVAD support adversely affects post-transplant survival.

Section snippets

Methods

Our institutional review board approved this study. We retrospectively reviewed our experiences with continuous-flow LVADs at Columbia University Medical Center between April 2004 and December 2013. During this period, an isolated continuous-flow LVAD was inserted as a BTT in 247 consecutive patients with advanced heart failure. Of these patients, 141 (57%) underwent cardiac transplantation, 40 (16%) died before transplantation, 58 (23%) remained listed for transplantation with ongoing LVAD

Baseline characteristics at the time of LVAD implantation

Preoperative and intraoperative patient characteristics at the time of LVAD implantation are shown in Table 1. The mean age of subjects was 53 years. The cohort included 115 men (82%) and 51 patients (36%) with an ischemic etiology.

During the early postoperative period, 3 patients (2.1%) required RVAD support, at 0, 3, and 7 days after LVAD implantation. All were successfully weaned from the RVAD after 11, 11, and 9 days of support.

We identified 21 patients (15%) who met the late RHF criteria

Discussion

Numerous studies have proved that RHF after LVAD insertion is a serious complication that is associated with poor outcomes.6, 7, 8 However, there are no data concerning the post-transplant outcomes of patients who experience late RHF. The major findings of this study are that patients with late RHF had impaired end-organ function at the time of transplantation, despite longer support with LVADs, and had diminished post-transplant survival.

The BTT strategy with LVADs has become a standard option

Disclosure statement

U.P.J. and Y.N. have received consulting fees from Thoratec Corp. The remaining authors have no conflicts of interest to disclose.

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Left ventricular assist devices (LVADs) have been implanted as bridge to transplantation (BTT), bridge to candidacy (BTC) or destination therapy (DT) on the basis of relative and absolute contraindications to transplantation. Multiple factors may lead to changes in the strategy of support after LVAD implantation.
Based on INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) 2012–2020 data, 11,262 patients survived to 3 months on continuous-flow LVADs with intent of BTT or DT. Preimplant characteristics and early events post-LVAD were analyzed in relation to changes in BTT or DT strategy during the next 12 months.
Among 3216 BTT patients at 3 months, later transplant delisting or death without transplant occurred in 536 (16.7%) and was more common with age, profiles 1–2, renal dysfunction, and independently for prior cardiac surgery (HR 1.25, 95% CI 1.04–1.51; P = 0.02). Post-LVAD events of infections, gastrointestinal bleeding, stroke, and right heart failure as defined by inotropic therapy, predicted delisting and death, as did in-hospital location at 3 months (HR 1.67, 95% CI 1.20–2.33; P = 0.0024). Of 8046 patients surviving to 3 months with the intent of destination therapy, 750 (9.3%) subsequently underwent listing or transplantation, often with initial histories of acute HF (HR 1.70, 95% CI 1.27–2.27; P = 0.0012) or malnutrition-cachexia (1.73, 95% CI 1.14–2.63; P = 0.0099). Multiple gastrointestinal bleeding events (≥ 4) with LVAD increased transition from BTT to DT (HR 4.22, 95% CI 1.46–12.275; P = 0.0078) but also from DT to BTT (HR 5.17, 95% CI 1.92–13.9; P = 0.0011).
Implant strategies change over time in relation to preimplant characteristics and adverse events post implant. Preimplant recognition of factors predicting later change in implant strategy will refine initial triage, whereas further reduction of post-LVAD complications will expand options, including eventual consideration of heart transplantation.
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This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.
A case of progressive right ventricular failure with ventricular arrhythmia and aortic insufficiency after implantable left ventricular assist device implantation
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Right ventricular failure (RVF) is a serious complication after left ventricular assist device (LVAD) implantation. In this report, a case of RVF that developed over two years after LVAD implantation is presented. The patient was a 12-year-old male with dilated phase of hypertrophic cardiomyopathy. He had no risk factors for early or late-onset RVF. However, his right ventricular function worsened after he developed ventricular arrhythmia (VA), and right ventricular dysfunction became exacerbated with an increasing frequency of VAs. He also developed moderate aortic insufficiency (AI), which became severe. Two years after implantation, he was admitted for treatment of recurrent ventricular tachycardia and became inotropic-dependent during hospitalization. Finally, he underwent successful heart transplantation 2 years and 9 months after LVAD implantation. This case suggests that vicious cycle of RV dysfunction, recurrent VAs and severe AI could lead to RVF in patients without known risk factors for RVF, even long after LVAD implantation.
This report shows a progressive right ventricular failure (RVF) two years after left ventricular assist device (LVAD) implantation. Although the patient had no known risk factor, vicious circle of RV dysfunction, ventricular arrhythmias (VAs) and aortic insufficiency (AI) lead to RVF. Patients with LVAD as destination therapy will increase and require long-term LVAD management. We should recognize that these patients could develop RVF even years after LVAD implantation in association with VAs and AI.
Late Right Heart Failure After Left Ventricular Assist Device Implantation: Contemporary Insights and Future Perspectives
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Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.
Residual mitral regurgitation in patients with left ventricular assist device support – An INTERMACS analysis
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Left ventricular assist device (LVAD) placement frequently leads to a reduction in the severity of functional mitral regurgitation (MR). However, a significant number of LVAD supported patients have residual MR. We sought to assess the impact of residual MR in LVAD patient outcomes.
Patients in the INTERMACS registry who received a continuous flow LVAD between 2006 and 2017 without a prior mitral valve repair were included for analysis. Residual MR was defined as moderate or severe MR within the first 3 months device support. Baseline characteristics, echocardiographic and hemodynamic variables, and clinical outcomes were comparatively analyzed between those with or without residual MR.
A total of 8,364 patients were included in the study, of which 18.8% demonstrated residual MR. Younger age, female gender, and non-ischemic heart failure were predictors of residual MR, as were increased LVEDD, RV dysfunction, severe baseline MR or TR, and elevated right heart pressures. Concomitant mitral valve repair reduced the risk of residual MR. Those with residual MR demonstrated worse LV remodeling, more right ventricular dysfunction, and higher right heart pressures at almost all time points analyzed. Residual MR was associated with increased risk of right heart failure and renal failure, and a trend toward increased mortality on LVAD support.
Residual MR is associated with worse clinical outcomes on LVAD support. Strategies to minimize MR including medical and device optimization as well as valve repair should be considered in LVAD patients with residual MR.
Late-onset right ventricular failure after continuous-flow left ventricular assist device implantation: case presentation and review of the literature
2022, Journal of Cardiology
With the widespread use of implantable left ventricular assist device (LVAD), right ventricular failure (RVF) has become a serious problem that becomes apparent several weeks or later after LVAD implantation. However, there are no marked preoperative signs of RVF. This is called late-onset RVF and is currently a major problem leading to long-term complications following implantable LVAD use. Pathogenically, this could be the result of left ventricular suction by LVAD that causes the septum shift to the left ventricular side. This causes a change in morphology of the right ventricle, resulting in impaired right ventricular function. Aortic insufficiency and ventricular arrhythmia, which are also important as long-term complications after LVAD implantation, are considered to be closely involved in the onset and progression of RVF. Once late-onset RVF develops, exercise capacity declines and inotrope administration may be required. Late-onset RVF was also reported to be significantly associated with increased mortality. Several predictors of RVF have been proposed such as preoperative left ventricular diastolic dimension <64 mm, tricuspid valve annulus diameter ≥41 mm, and so on. However, some reports identified no predictors. The basic treatment strategy for late-onset RVF is to optimize volume status by administering diuretics and ensuring inotrope as needed. β-blockers and antiarrhythmic agents often need to be reduced in terms of dosage or even discontinued because these might reduce right ventricular function. Although their efficacy is unclear, pulmonary vasodilators may be used to reduce right ventricular afterload. It is better to decrease the rotation speed of LVAD to minimize the displacement of the septum; however, this is often difficult because the required flow rate cannot be secured. Progress in the prevention and management of late-onset RVF is required because the number of patients who require longer-term LVAD support will increase with the spread of LVAD use as destination therapy.

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Late right heart failure during support with continuous-flow left ventricular assist devices adversely affects post-transplant outcome

Background

Methods

Results

Conclusions

Section snippets

Methods

Baseline characteristics at the time of LVAD implantation

Discussion

Disclosure statement

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Heart Lung Circ

J Thorac Cardiovasc Surg

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

J Am Coll Cardiol

JACC Heart Fail