Impact mechanisms, assessment methods, and prevention and management of right heart failure associated with left ventricular assist devices_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Kunsheng ^1,2,3 , WANG Yumeng ¹ , MI Lin ¹ , JI Wenjie ¹ , CHENG Yongqing ¹ , XU Zhenjun ¹ , WANG Dongjin ¹ ,  PAN Jun ¹

1. Department of Cardiac Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, P. R. China;
2. Gulou Clinical College of Nanjing Medical University, Nanjing, 210008, P. R. China;
3. Gulou Clinical College, Nanjing University of Chinese Medicine, Nanjing, 210008, P. R. China;

Corresponding author：

PAN Jun, Email: nangonghongliu@163.com

Keywords：

Left ventricular assist; heart failure; mechanism of action; review

DOI：

10.7507/1007-4848.202502056

Video：

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Abstract Full text Figures/Tables Video References Cited by

Left ventricular assist device (LVAD) serves as a critical therapeutic option for patients with end-stage heart failure, significantly enhancing survival rates and quality of life. However, LVAD implantation exerts complex and profound effects on right ventricular (RV) function, with RV dysfunction emerging as a key factor influencing the prognosis of LVAD patients. This article systematically reviews the relationship between LVAD and RV function, exploring the importance of RV function in LVAD patients, assessment methods, underlying mechanisms of impact, and strategies for prevention and management. Comprehensive evidence suggests that preoperative evaluation of RV function is crucial for predicting the risk of RV dysfunction, while effective prevention and management rely on preoperative optimization, meticulous intraoperative techniques, rigorous postoperative monitoring, and multidisciplinary collaboration. Furthermore, this review discusses the potential and future directions of emerging technologies, such as improved LVAD designs, biventricular assist devices, gene therapy, and personalized medicine, in ameliorating RV dysfunction. In conclusion, RV function is one of the key determinants of successful LVAD therapy. Through comprehensive assessment, prevention, and management of RV function, coupled with the application of novel technologies, the clinical outcomes of LVAD patients can be further improved.

Citation： LI Kunsheng, WANG Yumeng, MI Lin, JI Wenjie, CHENG Yongqing, XU Zhenjun, WANG Dongjin, PAN Jun. Impact mechanisms, assessment methods, and prevention and management of right heart failure associated with left ventricular assist devices. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(11): 1655-1663. doi: 10.7507/1007-4848.202502056 Copy

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2.	Lund LH, Khush KK, Cherikh WS, et al. The Registry of the International Society for Heart and Lung Transplantation: thirty-fourth Adult Heart Transplantation Report-2017; Focus theme: allograft ischemic time. J Heart Lung Transplant, 2017, 36(10): 1037-1046.
3.	Boulet J, Wanderley MRB, Mehra MR. Contemporary left ventricular assist device therapy as a bridge or alternative to transplantation. Transplantation, 2024, 108(6): 1333-1341.
4.	Aaronson KD, Slaughter MS, Miller LW, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation, 2012, 125(25): 3191-3200.
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6.	Lowey SE. Palliative care in the management of patients with advanced heart failure. Adv Exp Med Biol, 2018, 1067: 295-311.
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1. Chioncel O, Čelutkienė J, Bělohlávek J, et al. Heart failure care in the Central and Eastern Europe and Baltic region: status, barriers, and routes to improvement. ESC Heart Fail, 2024, 11(4): 1861-1874.
2. Lund LH, Khush KK, Cherikh WS, et al. The Registry of the International Society for Heart and Lung Transplantation: thirty-fourth Adult Heart Transplantation Report-2017; Focus theme: allograft ischemic time. J Heart Lung Transplant, 2017, 36(10): 1037-1046.
3. Boulet J, Wanderley MRB, Mehra MR. Contemporary left ventricular assist device therapy as a bridge or alternative to transplantation. Transplantation, 2024, 108(6): 1333-1341.
4. Aaronson KD, Slaughter MS, Miller LW, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation, 2012, 125(25): 3191-3200.
5. Wang J, Okoh AK, Chen Y, et al. Association of psychosocial risk factors with quality of life and readmissions 1 year after LVAD implantation. J Card Fail, 2025, 31(1): 40-48.
6. Lowey SE. Palliative care in the management of patients with advanced heart failure. Adv Exp Med Biol, 2018, 1067: 295-311.
7. Lee S, Kamdar F, Madlon-Kay R, et al. Effects of the HeartMate Ⅱ continuous-flow left ventricular assist device on right ventricular function. J Heart Lung Transplant, 2010, 29(2): 209-215.
8. Morgan JA, Paone G, Nemeh HW, et al. Impact of continuous-flow left ventricular assist device support on right ventricular function. J Heart Lung Transplant, 2013, 32(4): 398-403.
9. Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular failure in patients with the HeartMate Ⅱ continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg, 2010, 139(5): 1316-1324.
10. Hayashi H, Kirschner M, Vinogradsky A, et al. Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients. J Heart Lung Transplant, 2024, 43(4): 642-651.
11. Atluri P, Fairman AS, MacArthur JW, et al. Continuous flow left ventricular assist device implant significantly improves pulmonary hypertension, right ventricular contractility, and tricuspid valve competence. J Card Surg, 2013, 28(6): 770-775.
12. Giannakoulas G, Klok FA. The ESC working group on pulmonary circulation and right ventricular function. Eur Heart J, 2024, 45(31): 2805-2807.
13. Bravo CA, Navarro AG, Dhaliwal KK, et al. Right heart failure after left ventricular assist device: from mechanisms to treatments. Front Cardiovasc Med, 2022, 9: 1023549.
14. Hayek S, Sims DB, Markham DW, et al. Assessment of right ventricular function in left ventricular assist device candidates. Circ Cardiovasc Imaging, 2014, 7(2): 379-389.
15. Drakos SG, Kfoury AG, Selzman CH, et al. Left ventricular assist device unloading effects on myocardial structure and function: current status of the field and call for action. Curr Opin Cardiol, 2011, 26(3): 245-255.
16. Chamogeorgakis T, Toumpoulis I, Bonios MJ, et al. Treatment strategies and outcomes of right ventricular failure post left ventricular assist device implantation: an INTERMACS analysis. ASAIO J, 2024, 70(4): 264-271.
17. Kalogeropoulos AP, Kelkar A, Weinberger JF, et al. Validation of clinical scores for right ventricular failure prediction after implantation of continuous-flow left ventricular assist devices. J Heart Lung Transplant, 2015, 34(12): 1595-1603.
18. Bellavia D, Iacovoni A, Scardulla C, et al. Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies. Eur J Heart Fail, 2017, 19(7): 926-946.
19. Lampert BC, Teuteberg JJ. Right ventricular failure after left ventricular assist devices. J Heart Lung Transplant, 2015, 34(9): 1123-1130.
20. Kirklin JK, Naftel DC, Kormos RL, et al. The Fourth INTERMACS Annual Report: 4, 000 implants and counting. J Heart Lung Transplant, 2012, 31(2): 117-126.
21. Song N, Hungerford SL, Barua S, et al. The right ventricular-arterial compliance index: a novel hemodynamic marker to predict right heart failure following left ventricular assist device. ASAIO J, 2025, 71(2): 111-119.
22. Fitzpatrick JR, Frederick JR, Hiesinger W, et al. Early planned institution of biventricular mechanical circulatory support results in improved outcomes compared with delayed conversion of a left ventricular assist device to a biventricular assist device. J Thorac Cardiovasc Surg, 2009, 137(4): 971-977.
23. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr, 2010, 23(7): 685-713.
24. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging, 2015, 16(3): 233-270.
25. Abbas AE, Fortuin FD, Schiller NB, et al. A simple method for noninvasive estimation of pulmonary vascular resistance. J Am Coll Cardiol, 2003, 41(6): 1021-1027.
26. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg, 2014, 118(1): 21-68.
27. Grapsa J, O'Regan DP, Pavlopoulos H et al. Right ventricular remodelling in pulmonary arterial hypertension with CMR imaging: clinical and prognostic implications. Eur J Clin Invest, 2015, 45: 914-924.
28. Bogaert J, Francone M. Cardiovascular magnetic resonance in pericardial diseases. J Cardiovasc Magn Reson, 2009, 11(1): 14.
29. Meineri M, Van Rensburg AE, Vegas A. Right ventricular failure after LVAD implantation: prevention and treatment. Best Pract Res Clin Anaesthesiol, 2012, 26(2): 217-229.
30. Patel ND, Weiss ES, Schaffer J, et al. Right heart dysfunction after left ventricular assist device implantation: a comparison of the pulsatile HeartMate Ⅰ and axial-flow HeartMate Ⅱ devices. Ann Thorac Surg, 2008, 86(3): 832-840.
31. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med, 2002, 347(3): 161-167.
32. Sandek A, Edelmann F, Gertler C, et al. Transition from asymptomatic to symptomatic systolic chronic heart failure: rationale and design of TransitionCHF. ESC Heart Fail, 2024, 11(4): 2366-2378.
33. Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol, 2003, 41(10): 1797-1804.
34. Atluri P, Goldstone AB, Fairman AS, et al. Predicting right ventricular failure in the modern, continuous flow left ventricular assist device era. Ann Thorac Surg, 2013, 96(3): 857-863.
35. Soliman OII, Akin S, Muslem R, et al. Derivation and validation of a novel right-sided heart failure model after implantation of continuous flow left ventricular assist devices: the EUROMACS (European Registry for Patients with Mechanical Circulatory Support) right-sided heart failure risk score. Circulation, 2018, 137(9): 891-906.
36. Fitzpatrick JR, Frederick JR, Hsu VM, et al. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant, 2008, 27(12): 1286-1292.
37. Koprivanac M, Kelava M, Sirić F, et al. Predictors of right ventricular failure after left ventricular assist device implantation. Croat Med J, 2014, 55(6): 587-595.
38. Klotz S, Barbone A, Reiken S, et al. Left ventricular assist device support normalizes left and right ventricular beta-adrenergic pathway properties. J Am Coll Cardiol, 2005, 45(5): 668-676.
39. Takeda K, Takayama H, Colombo PC, et al. Incidence and clinical significance of late right heart failure during continuous-flow left ventricular assist device support. J Heart Lung Transplant, 2015, 34(8): 1024-1032.
40. Haddad F, Hunt SA, Rosenthal DN, et al. Right ventricular function in cardiovascular disease, part Ⅰ: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation, 2008, 117(11): 1436-1448.
41. Mauritz GJ, Kind T, Marcus JT, et al. Progressive changes in right ventricular geometric shortening and long-term survival in pulmonary arterial hypertension. Chest, 2012, 141(4): 935-943.
42. Noguchi M, Kasai K, Honda S, et al. Jugular venous response for risk stratification in heart failure. Cureus, 2024, 16(4): e58423.
43. Konstam MA, Kiernan MS, Bernstein D, et al. Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association. Circulation, 2018, 137(20): e578-e622.
44. Tie H, Li T, Huang B, et al. Presence and impact of anemia in patients supported with left ventricular assist devices. J Heart Lung Transplant, 2023, 42(9): 1261-1274.
45. Ayyagari K, Mulvoy WP, Bracey AW, et al. Perioperative management of LVAD patients. In: Morgan JA, Civitello AB, Frazier OH, eds. Mechanical Circulatory Support for Advanced Heart Failure: a Texas Heart Institute/Baylor College of Medicine Approach. Springer International Publishing, 2018: 95-127.
46. Yost G, Tatooles A, Bhat G. Preoperative nutritional assessment with the prognostic nutrition index in patients undergoing left ventricular assist device implantation. ASAIO J, 2018, 64(1): 52-55.
47. Genev I, Yost G, Gregory M, et al. Improved nutrition status in patients with advanced heart failure implanted with a left ventricular assist device. Nutr Clin Pract, 2019, 34(3): 444-449.
48. Huang D, Lacombe P, Gulati G, et al. Association of diuretic requirement and right heart failure post-LVAD implantation. JHLT Open, 2024, 4: 100082.
49. Tedford RJ, Hemnes AR, Russell SD, et al. PDE5A inhibitor treatment of persistent pulmonary hypertension after mechanical circulatory support. Circ Heart Fail, 2008, 1(4): 213-219.
50. Haddad F, Doyle R, Murphy DJ, et al. Right ventricular function in cardiovascular disease, part Ⅱ: pathophysiology, clinical importance, and management of right ventricular failure. Circulation, 2008, 117(13): 1717-1731.
51. Potapov EV, Antonides C, Crespo-Leiro MG, et al. 2019 EACTS expert consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg, 2019, 56(2): 230-270.
52. Zhang B, Guo S, Fu Z, et al. Minimally invasive versus conventional continuous-flow left ventricular assist device implantation for heart failure: a meta-analysis. Heart Fail Rev, 2022, 27(4): 1053-1061.
53. Quader M, LaPar DJ, Wolfe L, et al. Blood product utilization with left ventricular assist device implantation: a decade of statewide data. ASAIO J, 2016, 62(3): 268-273.
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Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Impact mechanisms, assessment methods, and prevention and management of right heart failure associated with left ventricular assist devices

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