title: Right heart failure and "failure to thrive" after left ventricular assist device: clinical predictors and outcomes.
abstract: BACKGROUND
  This study determined predictors of early post-operative right heart failure (RHF) and its consequences, as well as predictors of those who clinically thrive longer term after insertion of a continuous-flow left ventricular assist device (LVAD).
  
  
  METHODS
  Pre-operative and latest follow-up data were analyzed for 40 consecutive patients who received third-generation centrifugal-flow LVADs. RHF was defined using previously described criteria, including post-operative inotropes, pulmonary vasodilator use, or right-sided mechanical support. Patients were also categorized according to clinical outcomes after LVAD insertion.
  
  
  RESULTS
  LVADs were implanted as a bridge to transplantation (BTT) in 33 patients and as destination therapy in 7. Before LVAD implant, 22 patients were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 1, and 17 were at level 2. Temporary mechanical assistance was present in 50% of the cohort at LVAD implantation. The 6-month survival/progression to transplant was 92.5%. Average LVAD support time was 385 days (range, 21-1,011 days). RHF developed postoperatively in 13 of 40 patients (32.5%). RHF patients had more severe pre-operative tricuspid incompetence than non-RHF patients. The BTT patients with evidence of RHF had poorer survival to transplant (6 of 11 [54.5%]) than those without RHF (20 of 22 [90.9%]), p = 0.027). There were no other hemodynamic or echocardiographic predictors of short-term RHF. After LVAD, 22 of the 40 patients (55%) thrived clinically. For BTT patients, 20 of 21 (95%) of those who thrived progressed to transplant or were alive at latest follow-up vs 6 of 12 (50%) of those who failed to thrive (FTT; p < 0.005). The thrivers had lower New York Heart Association class (1.5 vs 2.9, p < 0.001), spent less time in the hospital, and had less ventricular tachycardia than the FTT patients. However, no differences were noted in pre-operative INTERMACS level, echocardiographic, hemodynamic, and biochemical indices, or in early post-operative RHF. Age was the only significant predictor: the thrivers were significantly younger (43.7 ± 15.9 vs 60.3 ± 12.6 years; p < 0.001). This age difference was unchanged after exclusion of destination strategy patients. RV function deteriorated in the FTT patients and remained stable in those who thrived.
  
  
  CONCLUSIONS
  Early post-operative RHF results in poorer survival/progression to transplantation for BTT patients and is predicted by greater pre-operative tricuspid incompetence. The most important predictor for those who will clinically thrive longer-term after LVAD insertion is younger age.
authors.affiliation: Heart Failure and Transplant Unit, St. Vincent's Hospital, Victoria St, Darlinghurst, New South Wales, Australia.
authors.forename: Jay
authors.initials: J
authors.lastname: Baumwol
authors.forename: Peter S
authors.initials: PS
authors.lastname: Macdonald
authors.forename: Anne M
authors.initials: AM
authors.lastname: Keogh
authors.forename: Eugene
authors.initials: E
authors.lastname: Kotlyar
authors.forename: Phillip
authors.initials: P
authors.lastname: Spratt
authors.forename: Paul
authors.initials: P
authors.lastname: Jansz
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Hayward
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D005183:Failure to Thrive / Q000453:epidemiology* / Q000503:physiopathology; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008875:Middle Aged; D011237:Predictive Value of Tests; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D018497:Ventricular Dysfunction, Right / Q000453:epidemiology* / Q000503:physiopathology; D055815:Young Adult