Remember that Right Heart Failure is a Common And Important Complication/Management Challenge Following Placement of a Left Ventricular Assist Device



Remember that Right Heart Failure is a Common And Important Complication/Management Challenge Following Placement of a Left Ventricular Assist Device


Andrew L. Rosenberg MD



Left ventricular assist devices (LVADs) including intra-aortic balloon pumps, percutaneous Tandem Heart devices, extracorporeal, and implanted ventricular assist devices have significantly improved the management and outcome for patients with the most severe forms of heart failure. Acute or chronic right ventricular failure, however, remains one of the most serious and difficult conditions to manage for patients with heart failure, especially following LVAD placement.


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Causes of right ventricular dysfunction include pre-existing myocardial disease, increased preload and/or right ventricular dilatation, ischemia, arrhythmias, increased intrathoracic pressures from mechanical ventilation, and especially acute or chronic forms of pulmonary hypertension. Frequently a positive feedback cycle exists, initiated by something that causes right ventricular pressure overload, interventricular septum displacement, increased wall tension with or without reduced right ventricular perfusion of decreased right ventricular cardiac output. Experienced implant programs evaluate ventricular device candidates for the presence of severe right ventricular dysfunction prior to LVAD/RVAD placement using some combination of echocardiography and measures of right ventricular function including central venous pressures and the presence of upstream organ failure due to right ventricular dysfunction including renal insufficiency and hepatic synthetic failure with elevated prothrombin times, aminotransferase levels, and hyperbilirubinemia.

In addition to the older modalities, newer measures of right ventricular dysfunction include right ventricular stroke work index: (mean pulmonary artery pressure — right atrial pressure [or central venous pressure]/(cardiac index × heart rate) RVSWI = [(PAPm – RAP) × CI]/HR = (mm Hg·mL)/m2. Several studies have suggested that RVSWI values less than 300 (mm Hg·mL)/m2 are independent predictors of the need for an RVAD. A more recent measure of right
ventricular failure is the tricuspid annular plane systolic excursion (TAPSE) of the lateral edge of the tricuspid annulus on a standard four-chamber echo view of the heart. A normal TAPSE is 20 to 25 mm and is usually easy to obtain. Significant decreases in the TAPSE suggest the presence of severe right ventricular dysfunction. In most cases, patients with pre-existing biventricular dysfunction will also have an RVAD inserted at the time of LVAD placement. For those patients who do not, recognizing and treating new right ventricular dysfunction is among the most important perioperative management challenges in the intensive care unit (ICU).

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Remember that Right Heart Failure is a Common And Important Complication/Management Challenge Following Placement of a Left Ventricular Assist Device
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