title: Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies.
abstract: 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 N-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, P < 0.001, I2= 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 (I2= 74%) and was thus only marginally significant (P = 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.
authors.affiliation: 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.
authors.forename: Diego
authors.initials: D
authors.lastname: Bellavia
authors.affiliation: Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy.
authors.forename: Attilio
authors.initials: A
authors.lastname: Iacovoni
authors.affiliation: 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.
authors.forename: Cesare
authors.initials: C
authors.lastname: Scardulla
authors.affiliation: University of Milano 'Bicocca', Milan, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Moja
authors.affiliation: 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.
authors.forename: Michele
authors.initials: M
authors.lastname: Pilato
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN, USA.
authors.forename: Sudhir S
authors.initials: SS
authors.lastname: Kushwaha
authors.affiliation: Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Senni
authors.affiliation: 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.
authors.forename: Francesco
authors.initials: F
authors.lastname: Clemenza
authors.affiliation: 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.
authors.forename: Valentina
authors.initials: V
authors.lastname: Agnese
authors.affiliation: 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.
authors.forename: Calogero
authors.initials: C
authors.lastname: Falletta
authors.affiliation: 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.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Romano
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Maalouf
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Dandel
mesh_terms: D009202:Cardiomyopathies / Q000601:surgery*; D014943:Global Health; D006333:Heart Failure / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D064887:Observational Studies as Topic; D011379:Prognosis; D015996:Survival Rate / Q000639:trends; D017211:Treatment Failure
keywords: Echocardiography; Heart failure; Prognosis; Right ventricle; Strain imaging; Ventricular assist device