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Luo Y, Leng J, Shi R, Jiang Y, Chen D, Wu Q, Tie H. Concomitant tricuspid valve surgery in patients undergoing left ventricular assist device: a systematic review and meta-analysis. Int J Surg 2024; 110:3039-3049. [PMID: 38348836 DOI: 10.1097/js9.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION This study aims to investigate the effect of concomitant tricuspid valve surgery (TVS) during left ventricular assist device (LVAD) implantation due to the controversy over the clinical outcomes of concomitant TVS in patients undergoing LVAD. METHODS A systematic literature search was performed in PubMed and EMbase from the inception to 1 August 2023. Studies comparing outcomes in adult patients undergoing concomitant TVS during LVAD implantation (TVS group) and those who did not (no-TVS group) were included. The primary outcomes were right heart failure (RHF), right ventricular assist device (RVAD) implantation, and early mortality. All meta-analyses were performed using random-effects models, and a two-tailed P <0.05 was considered significant. RESULTS Twenty-one studies were included, and 16 of them were involved in the meta-analysis, with 660 patients in the TVS group and 1291 in the no-TVS group. Patients in the TVS group suffered from increased risks of RHF [risk ratios (RR)=1.31, 95% CI: 1.01-1.70, P =0.04; I2 =38%, pH =0.13), RVAD implantation (RR=1.56, 95% CI: 1.16-2.11, P =0.003; I2 =0%, pH =0.74), and early mortality (RR=1.61, 95% CI: 1.07-2.42, P =0.02; I2 =0%, pH =0.75). Besides, the increased risk of RHF holds true in patients with moderate to severe tricuspid regurgitation (RR=1.36, 95% CI: 1.04-1.78, P =0.02). TVS was associated with a prolonged cardiopulmonary bypass time. No significant differences in acute kidney injury, reoperation requirement, hospital length of stay, or ICU stay were observed. CONCLUSIONS Concomitant TVS failed to show benefits in patients undergoing LVAD, and it was associated with increased risks of RHF, RVAD implantation, and early mortality.
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Affiliation(s)
- Yuxiang Luo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jiajie Leng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Rui Shi
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yingjiu Jiang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qingchen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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Right Ventricular Failure Post-Implantation of Left Ventricular Assist Device: Prevalence, Pathophysiology, and Predictors. ASAIO J 2021; 66:610-619. [PMID: 31651460 DOI: 10.1097/mat.0000000000001088] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Despite advances in left ventricular assist device (LVAD) technology, right ventricular failure (RVF) continues to be a complication after implantation. Most patients undergoing LVAD implantation have underlying right ventricular (RV) dysfunction (either as a result of prolonged LV failure or systemic disorders) that becomes decompensated post-implantation. Additional insults include intra-operative factors or a sudden increase in preload in the setting of increased cardiac output. The current literature estimates post-LVAD RVF from 3.9% to 53% using a diverse set of definitions. A few of the risk factors that have been identified include markers of cardiogenic shock (e.g., dependence on inotropes and Interagency Registry for Mechanically Assisted Circulatory Support profiles) as well as evidence of cardiorenal or cardiohepatic syndromes. Several studies have devised multivariable risk scores; however, their performance has been limited. A new functional assessment of RVF and a novel hepatic marker that describe cholestatic properties of congestive hepatopathy may provide additional predictive value. Furthermore, future studies can help better understand the relationship between pulmonary hypertension and post-LVAD RVF. To achieve our ultimate goal-to prevent and effectively manage RVF post-LVAD-we must start with a better understanding of the risk factors and pathophysiology. Future research on the different etiologies of RVF-ranging from acute post-surgical complication to late-onset RV cardiomyopathy-will help standardize definitions and tailor therapies appropriately.
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Hulde N, Koster A, von Dossow V. Perioperative management of patients with undergoing durable mechanical circulatory support. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:830. [PMID: 32793675 PMCID: PMC7396234 DOI: 10.21037/atm-20-2527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Durable mechanical circulatory support (MCS) devices revolutionized the treatment options for patients with end-stage heart failure (HF). Implantation of durable mechanical support has become an integral treatment modality in end-stage HF patients and it is associated with improved quality of life and survival. There is no doubt that this needs an interdisciplinary and interprofessional approach of cardiac surgeons, cardiologists, cardiac anesthesiologists, perfusionists, intensivists, psychologists, assist device coordinators as well as physiotherapists and intensive care. Implantation of durable MCS is a challenging procedure for the anesthesiologist due to the patient’s characteristics and comorbid diseases. It demands comprehensive training, high vigilance and quick response during the acute hemodynamic changes occurring during the surgery. Preoperative risk stratification is of major importance to guide perioperative medical treatment strategies. Most of these patients have several comorbidities and multiple medications. Therefore, to anticipate postoperative end-organ dysfunction such as cognitive dysfunction, pulmonary or renal failure, an interdisciplinary approach is necessary to optimize patient’s prior surgery. Transthoracic and transesophageal echocardiography (TTE and TEE), both play an invaluable role in diagnosing the cause and guiding the management in different unstable clinical situations. Especially prevention of postoperative right HF with subsequent necessity of temporary MCS is important as it is associated with higher mortality. The aim of this review is to provide an overview about the current concepts of perioperative management for durable MCS. A multimodal standard operating procedure supports early recovery after surgery and intensive care stay. Standardized perioperative care helps to ensure optimal medical treatment. This review focusses on several major skills of perioperative management of these high-risk surgical patients.
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Affiliation(s)
- Nikolai Hulde
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
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Dandel M, Javier MFDM, Javier Delmo EMD, Hetzer R. Accurate assessment of right heart function before and after long-term left ventricular assist device implantation. Expert Rev Cardiovasc Ther 2020; 18:289-308. [DOI: 10.1080/14779072.2020.1761790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Michael Dandel
- Department of Cardiology, Cardio Centrum Berlin, Berlin, Germany
| | | | | | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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Cruz Rodriguez JB, Stewart GC, Pamboukian SV, Tallaj JA, Rajapreyar I, Kirklin JK, Holman WL, Hoopes CW, Mukherjee D, Mallawaarachchi I, Dwivedi A, Acharya D. Clinical characteristics and outcomes of patients requiring prolonged inotropes after left ventricular assist device implantation. Artif Organs 2020; 44:E382-E393. [PMID: 32242954 DOI: 10.1111/aor.13692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 01/14/2023]
Abstract
Limited data exist regarding patients with continuous-flow left ventricular assist device (LVAD) support who require long-term inotropes. Our primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU). Secondary endpoints were to compare predictors of PIU, mortality, risk of late re-initiation of inotropes, time to gastrointestinal bleed (GIB), infection, and arrhythmias. Retrospective cohort study was conducted on adult patients with primary continuous-flow LVADs implanted from January 2008 to February 2017 and the patients were followed up through February 2018. We defined PIU as ≥14 days of inotrope support. Kaplan-Meier method, competing risk models and Cox proportional hazard models were used. Final analytic sample was 203 patients, 58% required PIU, and 10% were discharged on inotropes. There was no difference in preimplant characteristics. One-year survival rate was 87% if no PIU required, 74% if PIU required, and 72% if discharged on inotropes. PIU was associated with longer length of stay and higher incidence of GIB. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. Adjusted hazard risk of death was increased in patients with PIU (HR = 1.66, P = .046), older age (HR = 1.28, P = .031), and higher creatinine levels (HR = 1.60, P = .007). Prolonged inotrope use is frequently encountered following LVAD implantation and is associated with adverse prognosis but remains a therapeutic option. Inability to wean inotropes prior to hospital discharge is a marker of patients at particularly higher risk of mortality following LVAD implantation.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jose A Tallaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William L Holman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles W Hoopes
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Indika Mallawaarachchi
- Department of Epidemiology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Alok Dwivedi
- Department of Epidemiology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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A right ventricular state of mind in the progression of heart failure with reduced ejection fraction: implications for left ventricular assist device therapy. Heart Fail Rev 2020; 26:1467-1475. [DOI: 10.1007/s10741-020-09935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Lee JH, Park JH. Strain Analysis of the Right Ventricle Using Two-dimensional Echocardiography. J Cardiovasc Imaging 2018; 26:111-124. [PMID: 30310878 PMCID: PMC6160817 DOI: 10.4250/jcvi.2018.26.e11] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/11/2018] [Accepted: 08/28/2018] [Indexed: 01/12/2023] Open
Abstract
Right ventricular (RV) systolic dysfunction has been identified as an independent prognostic marker of many cardiovascular diseases. However, there are problems in measuring RV systolic function objectively and identification of RV dysfunction using conventional echocardiography. Strain echocardiography is a new imaging modality to measure myocardial deformation. It can measure intrinsic myocardial function and has been used to measure regional and global left ventricular (LV) function. Although the RV has different morphologic characteristics than the LV, strain analysis of the RV is feasible. After strain echocardiography was introduced to measure RV systolic function, it became more popular and was incorporated into recent echocardiographic guidelines. Recent studies showed that RV global longitudinal strain (RVGLS) can be used as an objective index of RV systolic function with prognostic significance. In this review, we discuss RVGLS measurement, normal reference values, and the clinical importance of RVGLS.
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Affiliation(s)
- Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae-Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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Dandel M, Hetzer R. Evaluation of the right ventricle by echocardiography: particularities and major challenges. Expert Rev Cardiovasc Ther 2018. [PMID: 29521112 DOI: 10.1080/14779072.2018.1449646] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Compared with the left ventricle (LV), the right ventricle (RV) is less suited for evaluation by echocardiography (ECHO). Nevertheless, RV ECHO-assessment has currently emerged as an important diagnostic tool with meaningful prognostic value and essential contribution to therapeutic decisions. Although significant progress has been made, including generation of higher-quality normative data, validation of several two-dimensional measurements and improvements in three-dimensional ECHO-techniques, many challenges in RV ECHO-assessment still persist. Areas covered: This review discusses the particular challenges and limits in obtaining accurate measurements of RV anatomical and functional parameters and focuses primarily on the difficulties in proper interpretation of the highly load dependent RV ECHO-parameters which complicates the use of this valuable diagnostic and surveillance technique. Expert commentary: There is increasing evidence that RV assessment in relation with its actual loading conditions by ECHO-derived composite variables, which either incorporate a certain functional parameter and load, or incorporate measures which reflect the relationship between RV dilation and RV load, considering also the right atrial pressure (i.e. 'load adaptation index'), is particularly suited for clinical decision-making. Load dependency of RV ECHO-parameters must be taken into consideration especially in patients with advanced RV dysfunction scheduled for LV assist device implantation or lung transplantation.
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Affiliation(s)
- Michael Dandel
- a German Centre for Heart and Circulatory Research (DZHK) , Partner site Berlin , Germany.,b Deutsches Herzzentrum Berlin , Germany
| | - Roland Hetzer
- b Deutsches Herzzentrum Berlin , Germany.,c Cardio Centrum Berlin , Germany
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Venkatachalam S, Wu G, Ahmad M. Echocardiographic assessment of the right ventricle in the current era: Application in clinical practice. Echocardiography 2017; 34:1930-1947. [PMID: 28833543 DOI: 10.1111/echo.13651] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The right ventricle has unique structural and functional characteristics. It is now well recognized that the so-called forgotten ventricle is a key player in cardiovascular physiology. Furthermore, there is accumulating evidence that demonstrates right ventricular dysfunction as an important marker of morbidity and mortality in several commonly encountered clinical situations such as heart failure, pulmonary hypertension, pulmonary embolism, right ventricular myocardial infarction, and adult congenital heart disease. In contrast to the left ventricle, echocardiographic assessment of right ventricular function is more challenging as volume estimations are not possible without the use of three-dimensional (3D) echocardiography. Guidelines on chamber quantification provide a standardized approach to assessment of the right ventricle. The technique and limitations of each of the parameters for RV size and function need to be fully understood. In this era of multimodality imaging, echocardiography continues to remain a useful tool for the initial assessment and follow-up of patients with right heart pathology. Several novel approaches such as 3D and strain imaging of the right ventricle have expanded the usefulness of this indispensable modality.
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Affiliation(s)
- Sridhar Venkatachalam
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Geru Wu
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Masood Ahmad
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Houston BA, Shah KB, Mehra MR, Tedford RJ. A new “twist” on right heart failure with left ventricular assist systems. J Heart Lung Transplant 2017; 36:701-707. [DOI: 10.1016/j.healun.2017.03.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/22/2017] [Indexed: 12/31/2022] Open
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