Clinical impact of an upfront RVAD strategy in HeartMate 3 LVAD recipients with severe early right ventricular failure requiring temporary mechanical support
Marta Lorente‐Ros, Mohammad S. Husain, Miguel Pinilla-Vera, Richa Gupta, Rosaria S. Prasad, Blanca Simon Frances, Jiling Chou, Ajay Kadakkal, Alexander Papolos, Benjamin B. Kenigsberg, M.J. Hockstein, Ezequiel Molina, Keki Balsara, Farooq H. Sheikh, Phillip H. Lam
Abstract
Background Left ventricular assist device (LVAD) recipients are at risk of developing severe early right ventricular failure (RVF), at times necessitating temporary mechanical support with right ventricular assist device (RVAD). The optimal timing of RVAD implantation in these patients is unclear. The aim of this study is to compare clinical outcomes between upfront RVAD (U-RVAD) and rescue RVAD (R-RVAD) strategies in LVAD recipients with early RVF. Methods In this single-center retrospective cohort study, we included all patients who underwent HeartMate 3 (HM3) LVAD implant and required temporary RVAD support for severe early RVF, defined as <30 days of LVAD implantation, from January 1, 2019 to September 30, 2024. U-RVAD was defined as RVAD use during the index LVAD operation. R-RVAD was defined as RVAD implanted outside of the intra-operative period. Baseline characteristics, peri-operative outcomes, and mortality were compared between patients with U-RVAD and those with R-RVAD. Results During the study period, 402 patients underwent HM3 LVAD implantation, of whom 64 LVAD recipients received temporary RVAD for severe early RVF (mean age 57 years, 27 % female). Of these, 36 received U-RVAD. The incidence of peri-operative atrial arrhythmia and renal replacement therapy were lower in patients who received U-RVAD compared to those who received R-RVAD (p=0.041 and 0.008, respectively). In-hospital and 90-day all-cause mortality occurred in 11 (31%) and 12 (33%) patients receiving U-RVAD and 16 (57%) and 19 (68%) patients receiving R-RVAD, respectively. On binary logistic regression, U-RVAD was associated with lower 90-day all-cause mortality (adjusted odds ratio 0.23, 95% confidence interval 0.06-0.80; p=0.020). Conclusion In HM3 LVAD recipients with severe early RVF requiring RVAD, U-RVAD was associated with improved clinical outcomes. Prospective studies should focus on the optimal timing of RVAD implantation in this high-risk patient population.