Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta‐analysis of observational studies

  • Diego Bellavia
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Attilio Iacovoni
    Cardiovascular Department Papa Giovanni XXIII Hospital Bergamo Italy
  • Cesare Scardulla
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Lorenzo Moja
    University of Milano ‘Bicocca’ Milan Italy
  • Michele Pilato
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Sudhir S. Kushwaha
    Division of Cardiovascular Diseases Mayo Clinic and Foundation Rochester MN USA
  • Michele Senni
    Cardiovascular Department Papa Giovanni XXIII Hospital Bergamo Italy
  • Francesco Clemenza
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Valentina Agnese
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Calogero Falletta
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Giuseppe Romano
    Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy
  • Joseph Maalouf
    Division of Cardiovascular Diseases Mayo Clinic and Foundation Rochester MN USA
  • Michael Dandel
    Department of Cardiothoracic and Vascular Surgery Deutsches Herzzentrum Berlin Germany

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<jats:title>Abstract</jats:title><jats:p>Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with increased morbidity and mortality, but the identification of LVAD candidates at risk for RVF remains challenging. We undertook a systematic review and meta‐analysis of observational studies of risk factors associated with RVF after LVAD implant. Thirty‐six studies published between 1 January 1995 and 30 April 2015, comprising 995 RVF patients out of a pooled final population of 4428 patients, were identified. Meta‐analysed prevalence of post‐LVAD RVF was 35%. A need for mechanical ventilation [odds ratio (OR) 2.99], or continuous renal replacement therapy (CRRT; OR 4.61, area under the curve 0.78, specificity 0.91) were the clinical variables with the highest effect size (ES) in predicting RVF. International normalized ratio [INR; standardized mean difference (SMD) 0.49] and <jats:italic>N</jats:italic>‐terminal pro‐brain natriuretic peptide (NT‐proBNP) (SMD 0.52) were the biochemical markers that best discriminated between RVF and No‐RVF populations, though NT‐proBNP was highly heterogeneous. Right ventricular stroke work index (RVSWI) and central venous pressure (CVP) (SMD −0.58 and 0.47, respectively) were the haemodynamic measures with the highest ES in identifying patients at risk of post‐LVAD RVF; CVP was particularly useful in risk stratifying patients undergoing continuous‐flow LVAD implant (SMD 0.59, <jats:italic>P</jats:italic> < 0.001, <jats:italic>I</jats:italic><jats:sup><jats:italic>2</jats:italic></jats:sup> = 20.9%). Finally, pre‐implant moderate to severe right ventricular (RV) dysfunction, as assessed qualitatively (OR 2.82), or a greater RV/LV diameter ratio (SMD 0.51) were the standard echocardiographic measurements with the highest ES in comparing RVF with No‐RVF patients. Longitudinal systolic strain of the RV free wall had the highest ES (SMD 0.73) but also the greatest heterogeneity (<jats:italic>I</jats:italic><jats:sup><jats:italic>2</jats:italic></jats:sup> = 74%) and was thus only marginally significant (<jats:italic>P</jats:italic> = 0.05). Patients on ventilatory support or CRRT are at high risk for post‐LVAD RVF, similarly to patients with slightly increased INR, high NT‐proBNP or leukocytosis. High CVP, low RVSWI, an enlarged right ventricle with concomitant low RV strain also identify patients at higher risk.</jats:p>

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