Prediction of Right Heart Failure After Left Ventricular Assist Device: Opening Pandora's Box

Continuous-flow left ventricular assist devices (LVADs) represent a leading option in the treatment of end-stage heart failure (HF), provided that right ventricular (RV) contractile function is sufficiently preserved to ensure cardiac output after LVAD implantation. In this context, evaluating the RV before surgery is crucial, as the onset of early right heart failure (RHF) following LVAD placement is linked to increased mortality and morbidity. Unfortunately, the contractile performance of the RV is a difficult issue to evaluate and requires a multimodal approach based on the application of multiple diagnostic tools, including clinical assessment, echocardiography, right heart catheterization (RHC), and risk models, all of which have variable predictive power in the currently available literature. Pre-implantation RV assessment is even more challenging and misleading in patients with hemodynamic instability under extracorporeal membrane oxygenation (ECMO) support, a situation characterized by complete right heart unloading, which renders most assessment techniques unreliable. The present paper proposes a simple and comprehensive preoperative appraisal strategy for the RV, which is adapted to the clinical status (critical or more stable) of the patient, based on a review of the advantages and limitations of each diagnostic modality and derived parameters.