Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Advanced Medical Center for Heart Failure, The University of Tokyo Hospital, Tokyo, Japan.
Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan.
J Cardiol. 2022 Aug;80(2):110-115. doi: 10.1016/j.jjcc.2021.12.009. Epub 2021 Dec 30.
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.
随着植入式左心室辅助装置（LVAD）的广泛应用，右心室衰竭（RVF）已成为一个严重的问题，在 LVAD 植入后数周或更晚才会显现。然而，术前没有明显的 RVF 迹象。这被称为迟发性 RVF，目前是导致植入式 LVAD 使用后长期并发症的主要问题。从病理上看，这可能是 LVAD 对左心室的抽吸导致间隔向左侧移位的结果。这会导致右心室形态发生变化，从而导致右心室功能受损。主动脉瓣关闭不全和室性心律失常也是 LVAD 植入后长期并发症的重要因素，被认为与 RVF 的发生和进展密切相关。一旦发生迟发性 RVF，运动能力就会下降，可能需要使用正性肌力药物。迟发性 RVF 也与死亡率升高显著相关。已经提出了一些 RVF 的预测因素，例如术前左心室舒张末期直径<64mm、三尖瓣瓣环直径≥41mm 等。然而，一些报告并未确定预测因素。迟发性 RVF 的基本治疗策略是通过使用利尿剂优化容量状态，并根据需要确保使用正性肌力药物。β受体阻滞剂和抗心律失常药物通常需要减少剂量，甚至停止使用，因为这可能会降低右心室功能。尽管其疗效尚不清楚，但肺血管扩张剂可用于减轻右心室后负荷。降低 LVAD 的转速以尽量减少间隔的移位可能会更好；然而，由于无法保证所需的流速，这通常很难做到。需要在迟发性 RVF 的预防和管理方面取得进展，因为随着作为终末期治疗的 LVAD 的应用普及，需要长期 LVAD 支持的患者数量将会增加。
