Left needs Right – Two unequal but interdependent sides of the Heart. How can we improve Patient Selection to prevent Acute Right Ventricular Failure after Left Ventricular Assist Device Implantation?

Abstract Implantation of left ventricular assist devices (LVAD) is now an established treatment in patients with end-stage heart failure (HF). Despite improvements in technology and perioperative care, right ventricular failure (RVF) is still a common, poorly predictable, and often fatal complication. Planned biventricular assist device (BiVAD) therapy results in better patient outcome than delayed right ventricular assist device (RVAD) implantation in response to RVF after isolated LVAD implantation. Therefore, the evaluation of right ventricular (RV) function prior to surgery is crucial and diverse scoring systems have been proposed. However, they sensitivity and specificity are not yet satisfactory. RV imaging is an attractive adjunct to clinical RV evaluation because it is noninvasive and may offer greater sensitivity to change than markers of pre-existing RV failure. But despite an increasing number of studies, standard echocardiographic predictors of RVF remain inconsistent. In the normal heart, the left ventricle (LV)generates between40 – 65% of the work of the RV through the interventricular septum and the shared myofibers. Following LVAD implantation, this ventricular contribution is diminished, while the RV output has to increase in order to provide forward flow and fill the LVAD. This might unmask a previously asymptomatic RV dysfunction. To predict the response of the RV to the changed hemodynamic environment, we have to evaluate the functional reserve of the RV. The concept of using stressto evaluate this ventricular functional reserve is frequently applied in aortic stenosis to predict LV recovery. Dobutamineinduced changes in echocardiographic parameters such as RV longitudinal strain and systolic pulmonary artery pressure might best simulate the post-LVAD period and thereby predict how the RV will respond