Strategies for Mechanical Right Ventricular Support During Left Ventricular Assist Device Implant

Area of Science:

• Cardiology
• Mechanical Circulatory Support
• Cardiac Surgery

Background:

• Refractory right ventricular failure is a complication during left ventricular assist device (LVAD) implantation.
• Optimal mechanical circulatory support strategies for this condition are not well-defined.

Purpose of the Study:

• To compare the outcomes of right ventricular assist device (RVAD) versus venoarterial extracorporeal membrane oxygenation (VA-ECMO) for patients with refractory right ventricular failure undergoing LVAD implantation.
• To evaluate the impact of the timing of RVAD/VA-ECMO initiation (intraoperative vs. postoperative) on patient outcomes.

Main Methods:

• Analysis of The Society of Thoracic Surgeons National Database (2011-2019) for patients undergoing first-time durable LVAD implantation.
• Stratification of patients requiring RVAD or VA-ECMO by device type and timing of placement.
• Propensity score analysis to adjust for baseline differences between patient groups.

Main Results:

• Of 18,423 LVAD implants, 940 (5.1%) required RVAD (n=750) or VA-ECMO (n=190) support.
• RVAD patients had higher preoperative inotrope requirement and severe tricuspid regurgitation but lower rates of postoperative renal failure, limb ischemia, and operative mortality compared to VA-ECMO patients.
• VA-ECMO support was associated with a higher risk of mortality (RR 1.46) compared to RVAD.
• Postoperative initiation of right ventricular support was linked to higher mortality (RR 1.43) than intraoperative initiation.

Conclusions:

• Right ventricular assist device (RVAD) may offer better outcomes than venoarterial extracorporeal membrane oxygenation (VA-ECMO) for severe right ventricular failure during LVAD implantation.
• Initiating right ventricular support during the index operation is associated with improved survival outcomes.