The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Right ventricular function and cardiopulmonary performance among patients with heart failure supported by durable mechanical circulatory support devices

Published:November 22, 2020DOI:


      Patients with continuous-flow left ventricular assist devices (CF-LVADs) experience limitations in functional capacity and frequently, right ventricular (RV) dysfunction. We sought to characterize RV function in the context of global cardiopulmonary performance during exercise in this population.


      A total of 26 patients with CF-LVAD (aged 58 ± 11 years, 23 males) completed a hemodynamic assessment with either conductance catheters (Group 1, n = 13) inserted into the right ventricle to generate RV pressure‒volume loops or traditional Swan‒Ganz catheters (Group 2, n = 13) during invasive cardiopulmonary exercise testing. Hemodynamics were collected at rest, 2 sub-maximal levels of exercise, and peak effort. Breath-by-breath gas exchange parameters were collected by indirect calorimetry. Group 1 participants also completed an invasive ramp test during supine rest to determine the impact of varying levels of CF-LVAD support on RV function.


      In Group 1, pump speed modulations minimally influenced RV function. During upright exercise, there were modest increases in RV contractility during sub-maximal exercise, but there were no appreciable increases at peak effort. Ventricular‒arterial coupling was preserved throughout the exercise. In Group 2, there were large increases in pulmonary arterial, left-sided filling, and right-sided filling pressures during sub-maximal and peak exercises. Among all participants, the cardiac output‒oxygen uptake relationship was preserved at 5.8:1. Ventilatory efficiency was severely abnormal at 42.3 ± 11.6.


      Patients with CF-LVAD suffer from limited RV contractile reserve; marked elevations in pulmonary, left-sided filling, and right-sided filling pressures during exercise; and severe ventilatory inefficiency. These findings explain mechanisms for persistent reductions in functional capacity in this patient population.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mehra MR
        • Goldstein DJ
        • Uriel N
        • et al.
        Two-year outcomes with a magnetically levitated cardiac pump in heart failure.
        N Engl J Med. 2018; 378: 1386-1395
        • Rogers JG
        • Pagani FD
        • Tatooles AJ
        • et al.
        Intrapericardial left ventricular assist device for advanced heart failure.
        N Engl J Med. 2017; 376: 451-460
        • Cornwell 3rd, WK
        • Ambardekar AV
        • Tran T
        • et al.
        Stroke incidence and impact of continuous-flow left ventricular assist devices on cerebrovascular physiology.
        Stroke. 2019; 50: 542-548
        • Kormos RL
        • Cowger J
        • Pagani FD
        • et al.
        The Society of Thoracic Surgeons INTERMACS database annual report: evolving indications, outcomes, and scientific partnerships.
        J Heart Lung Transplant. 2019; 38: 114-126
        • Kirklin JK
        • Pagani FD
        • Kormos RL
        • et al.
        Eighth annual INTERMACS report: special focus on framing the impact of adverse events.
        J Heart Lung Transplant. 2017; 36: 1080-1086
        • Hayek S
        • Sims DB
        • Markham DW
        • Butler J
        • Kalogeropoulos AP
        Assessment of right ventricular function in left ventricular assist device candidates.
        Circ Cardiovasc Imaging. 2014; 7: 379-389
        • Lampert BC
        • Teuteberg JJ
        Right ventricular failure after left ventricular assist devices.
        J Heart Lung Transplant. 2015; 34: 1123-1130
        • Stainback RF
        • Estep JD
        • Agler DA
        • et al.
        Echocardiography in the management of patients with left ventricular assist devices: recommendations from the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2015; 28: 853-909
        • Tedford RJ
        • Mudd JO
        • Girgis RE
        • et al.
        Right ventricular dysfunction in systemic sclerosis-associated pulmonary arterial hypertension.
        Circ Heart Fail. 2013; 6: 953-963
        • Hsu S
        • Houston BA
        • Tampakakis E
        • et al.
        Right ventricular functional reserve in pulmonary arterial hypertension.
        Circulation. 2016; 133: 2413-2422
        • Rommel KP
        • von Roeder M
        • Oberueck C
        • et al.
        Load-independent systolic and diastolic right ventricular function in heart failure with preserved ejection fraction as assessed by resting and handgrip exercise pressure-volume loops.
        Circ Heart Fail. 2018; 11e004121
        • Cornwell WK
        • Tran T
        • Cerbin L
        • et al.
        New insights into resting and exertional right ventricular performance in the healthy heart through real-time pressure-volume analysis.
        J Physiol. 2020; 598: 2575-2587
        • Cornwell III, WK
        • Coe G
        • Ambardekar AV
        • et al.
        New insights into right ventricular performance during exercise using high-fidelity conductance catheters to generate pressure volume loops.
        J Physiol. 2020; 598: 2575-2587
        • Uriel N
        • Sayer G
        • Addetia K
        • et al.
        Hemodynamic ramp tests in patients with left ventricular assist devices.
        JACC Heart Fail. 2016; 4: 208-217
        • Kass DA
        • Midei M
        • Graves W
        • Brinker JA
        • Maughan WL
        Use of a conductance (volume) catheter and transient inferior vena caval occlusion for rapid determination of pressure-volume relationships in man.
        Cathet Cardiovasc Diagn. 1988; 15: 192-202
        • Abraham D
        • Mao L
        Cardiac pressure-volume loop analysis using conductance catheters in mice.
        J Vis Exp. 2015; 103: 1-10
        • Baan J
        • Jong TT
        • Kerkhof PL
        • et al.
        Continuous stroke volume and cardiac output from intra-ventricular dimensions obtained with impedance catheter.
        Cardiovasc Res. 1981; 15: 328-334
        • Nielsen JM
        • Kristiansen SB
        • Ringgaard S
        • et al.
        Left ventricular volume measurement in mice by conductance catheter: evaluation and optimization of calibration.
        Am J Physiol Heart Circ Physiol. 2007; 293: H534-H540
        • Herrera MC
        • Olivera JM
        • Valentinuzzi ME
        Parallel conductance determination in cardiac volumetry using dilution manoeuvres: theoretical analysis and practical implications.
        Med Biol Eng Comput. 1999; 37: 169-174
        • Brimioulle S
        • Wauthy P
        • Ewalenko P
        • et al.
        Single-beat estimation of right ventricular end-systolic pressure-volume relationship.
        Am J Physiol Heart Circ Physiol. 2003; 284: H1625-H1630
        • Takeuchi M
        • Igarashi Y
        • Tomimoto S
        • et al.
        Single-beat estimation of the slope of the end-systolic pressure-volume relation in the human left ventricle.
        Circulation. 1991; 83: 202-212
        • Nozawa T
        • Yasumura Y
        • Futaki S
        • Tanaka N
        • Uenishi M
        • Suga H
        Efficiency of energy transfer from pressure-volume area to external mechanical work increases with contractile state and decreases with afterload in the left ventricle of the anesthetized closed-chest dog.
        Circulation. 1988; 5: 1116-1124
      1. Centers for Disease Control and Prevention. Perceived exertion (borg rating of perceived exertion scale). Available at:

        • Uriel N
        • Adatya S
        • Malý J
        • et al.
        Clinical hemodynamic evaluation of patients implanted with a fully magnetically levitated left ventricular assist device (HeartMate 3).
        J Heart Lung Transplant. 2017; 36: 28-35
        • Rogers JG
        • Aaronson KD
        • Boyle AJ
        • et al.
        Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients.
        J Am Coll Cardiol. 2010; 55: 1826-1834
        • Jung MH
        • Gustafsson F.
        Exercise in heart failure patients supported with a left ventricular assist device.
        J Heart Lung Transplant. 2015; 34: 489-496
        • Jung MH
        • Hansen PB
        • Sander K
        • et al.
        Effect of increasing pump speed during exercise on peak oxygen uptake in heart failure patients supported with a continuous-flow left ventricular assist device.
        A double-blind randomized study. Eur J Heart Fail. 2014; 16: 403-408
        • Rowell LB
        Human circulation, regulation during physical stress.
        Oxford University Press, New York1986
        • Proctor DN
        • Beck KC
        • Shen PH
        • Eickhoff TJ
        • Halliwill JR
        • Joyner MJ
        Influence of age and gender on cardiac output-VO2 relationships during submaximal cycle ergometry.
        J Appl Physiol. 1998; 84: 599-605
        • Gledhill N
        • Cox D
        • Jamnik R
        Endurance athletes’ stroke volume does not plateau: major advantage is diastolic function.
        Med Sci Sports Exerc. 1994; 26: 1116-1121
        • Spruijt OA
        • de Man FS
        • Groepenhoff H
        • et al.
        The effects of exercise on right ventricular contractility and right ventricular-arterial coupling in pulmonary hypertension.
        Am J Respir Crit Care Med. 2015; 191: 1050-1057
        • McCabe C
        • White PA
        • Hoole SP
        • et al.
        Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter.
        J Appl Physiol (1985). 2014; 116: 355-363
        • Lambermont B
        • Segers P
        • Ghuysen A
        • et al.
        Comparison between single-beat and multiple-beat methods for estimation of right ventricular contractility.
        Crit Care Med. 2004; 32: 1886-1890