B.5. What is part of the LVAD assessment process?
Answer:
Prognosis and patient selection for patients with advanced heart failure under consideration for LVAD implantation are similar to heart transplant. Briefly, this includes key assessments of cardiac function and standardized categorization of functional limitation and adverse prognostic markers. Good right heart function is essential and is assessed by echocardiography and cardiac catheterization. After LVAD implantation, the RV must be able to deliver 4 to 5 L/min of blood to the left heart while maintaining reasonable right atrial pressures to avoid renal and liver dysfunction. Poor preoperative right heart function is associated with poor postoperative outcomes after LVAD implantation. Table 6.2 delineates important echocardiographic and hemodynamic parameters in assessing suitability of LVAD implantation.
Table 6.2: Left Ventricular Assist Device (LVAD) Considerations and Relative Contraindications and Parameters Associated With Poor Outcomes
| Criteria | Relative Contraindications/Parameter Associated With Poor Outcomes |
|---|---|
| Age | >65 y |
| Psychosocial factors | Poor social network/noncompliance with medical advice, substance abuse |
| Coagulation | Bleeding disorder/unable to tolerate anticoagulation |
| Liver | Congested hepatopathy/elevated bilirubin |
| Renal | Advanced/end-stage renal dysfunction |
| Pulmonary function test | Advanced lung disease |
| Hemodynamics | CVP> 15 mm Hg |
| -PAPi (units) | <1.85 |
| -RVSWi (mm Hg·L/m2) | <0.3 |
| -RAP/PCWP (units) | >0.63 |
| Echocardiography parameters | |
| -TAPSE (units) | <7.5 |
| -RV-to-LV end-diastolic diameter ratio | >0.75 |
| -RV peak longitudinal strain | >-9.6% |
CI, cardiac index; dPA, pulmonary artery diastolic pressure; HR, heart rate; LV, left ventricle; mPA, pulmonary artery mean pressure; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary artery wedge pressure; RAP, right atrial pressure; RV, right ventricle; RVSWi, right ventricular stroke work index; sPA, pulmonary artery systolic pressure; TAPSE, tricuspid annular plane systolic excursion.
References
- Bhagra SK, Pettit S, Parameshwar J. Cardiac transplantation: indications, eligibility and current outcomes. Heart. 2019;105:252-260.
- Grant ADM, Smedira NG, Starling RC, et al. Independent and incremental role of quantitative right ventricular evaluation for the prediction of right ventricular failure after left ventricular assist device implantation. J Am Coll Cardiol. 2012;60:521-528.
- Morine KJ, Kiernan MS, Pham DT, et al. Pulmonary artery pulsatility index is associated with right ventricular failure after left ventricular assist device surgery. J Card Fail. 2016;22:110-116.
- Vivo RP, Cordero-Reyes AM, Qamar U, et al. Increased right-to-left ventricle diameter ratio is a strong predictor of right ventricular failure after left ventricular assist device. J Heart Lung Transplant. 2013;32:792-799.