Right Ventricular Failure After Left Ventricular Assist Device Placement-The Beginning of the End or Just Another Challenge?

Left ventricular assist device (LVAD) therapy has greatly improved outcomes in patients with end-stage heart failure. However, development of right ventricular failure (RVF) in LVAD recipients is associated with increased long- and short-term morbidity and mortality. The incidence of RVF after LVAD placement is difficult to assess due to the lack of a common definition. Risk-score models attempting to identify patients at risk for RVF prior to the placement of LVADs had equivocal outcomes. With the exception of cardiac magnetic resonance, right ventricle (RV) imaging lacks accuracy. Echocardiographic evaluation is expanded to 3D technology and deformation imaging in an attempt to get further insight into the functional reserve of the RV in states of abnormal RV function. Beyond commonly use agents, pharmacological treatment for RVF and post-bypass vasoplegia in LVAD patients include the off-label use of methylene blue and/or hydroxycobalamin. Communication among the perioperative team may be beneficial for early initiation of temporary right-sided mechanical support in order to avoid RVF-related complications. As long-term RVADs are unavailable, currently approved treatment of prolonged RVF is limited to heart transplantation or the placement of a total artificial heart as bridge-to-transplant. Strategies to improve outcome in this patient population should include better risk stratification for RVF prior to LVAD placement as well as frank discussions about LVAD candidacy in patients ineligible for transplantation. The development of durable right-sided mechanical support would improve the scope of care of LVAD patients developing persistent RVF.