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

Hemodynamic reserve predicts early right heart failure after LVAD implantation


      Early right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict early RHF have proven only modestly successful. Pharmacologic unloading of the left ventricle may be a risk stratification approach allowing for assessment of right ventricular and hemodynamic reserve.


      We performed a multicenter, retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. Only those who underwent vasodilator testing with nitroprusside during their preimplant right heart catheterization were included (n = 70). Multivariable logistic regression was used to determine independent predictors of early RHF as defined by Mechanical Circulatory Support–Academic Research Consortium.


      Twenty-seven patients experienced post-LVAD early RHF (39%). Baseline clinical characteristics were similar between patients with and without RHF. Patients without RHF, however, achieved higher peak stroke volume index (SVI) (30.1 ± 8.8 vs 21.7 ± 7.4 mL/m2; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m2) during nitroprusside administration. Multivariable analysis revealed that peak SVI was significantly associated with early RHF, demonstrating a 16% increase in risk of early RHF per 1 ml/m2 decrease in SVI. A follow up cohort of 10 consecutive patients from July 2020 to October 2021 resulted in all patients being categorized appropriately in regards to early RHF versus no RHF according to peak SVI.


      Peak SVI with nitroprusside administration was independently associated with post-LVAD early RHF while resting hemodynamics were not. Vasodilator testing may prove to be a strong risk stratification tool when assessing LVAD candidacy though additional prospective validation is needed.



      CI (cardiac index), Ea (elastance), MCS-ARC (Mechanical Circulatory Support–Academic Research Consortium), PAWP (pulmonary artery wedge pressure), RHC (right heart catheterization), RHF (right heart failure), RVAD (right ventricular assist device), SVI (stroke volume index)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      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


        • Rose EA
        • Gelijns AC
        • Moskowitz AJ
        • Heitjan DF
        • Stevenson LW
        • Dembitsky W
        • et al.
        Long-term use of a left ventricular assist device for end-stage heart failure.
        N Engl J Med. 2001; 345: 1435-1443
        • Kadakia S
        • Moore R
        • Ambur V
        • Toyoda Y
        Current status of the implantable LVAD.
        Gen Thorac Cardiovasc Surg. 2016; 64: 501-508
        • Kavarana MN
        • Pessin-Minsley MS
        • Urtecho J
        • Catanese KA
        • Flannery M
        • Oz MC
        • et al.
        Right ventricular dysfunction and organ failure in left ventricular assist device recipients: a continuing problem.
        Ann Thorac Surg. 2002; 73: 745-750
        • Takeda K
        • Naka Y
        • Yang JA
        • Uriel N
        • Colombo PC
        • Jorde UP
        • et al.
        Outcome of unplanned right ventricular assist device support for severe right heart failure after implantable left ventricular assist device insertion.
        J Heart Lung Transplant. 2014; 33: 141-148
        • Baxter RD
        • Tecson KM
        • Still S
        • Collier JDG
        • Felius J
        • Joseph SM
        • et al.
        Predictors and impact of right heart failure severity following left ventricular assist device implantation.
        J Thorac Dis. 2019; 11: S864-S870
        • Fukamachi K
        • McCarthy PM
        • Smedira NG
        • Vargo RL
        • Starling RC
        • Young JB.
        Preoperative risk factors for right ventricular failure after implantable left ventricular assist device insertion.
        Ann Thorac Surg. 1999; 68: 2181-2184
        • Drakos SG
        • Janicki L
        • Horne BD
        • Kfoury AG
        • Reid BB
        • Clayson S
        • et al.
        Risk factors predictive of right ventricular failure after left ventricular assist device implantation.
        Am J Cardiol. 2010; 105: 1030-1035
        • Matthews JC
        • Koelling TM
        • Pagani FD
        • Aaronson KD.
        The right ventricular failure risk score a pre-operative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates.
        J Am Coll Cardiol. 2008; 51: 2163-2172
        • Boegershausen N
        • Zayat R
        • Aljalloud A
        • Musetti G
        • Goetzenich A
        • Tewarie L
        • et al.
        Risk factors for the development of right ventricular failure after left ventricular assist device implantation-a single-centre retrospective with focus on deformation imaging.
        Eur J Cardiothorac Surg. 2017; 52: 1069-1076
        • Wagner T
        • Bernhardt AM
        • Magnussen C
        • Reichenspurner H
        • Blankenberg S
        • Grahn H.
        Right heart failure before LVAD implantation predicts right heart failure after LVAD implantation - is it that easy?.
        J Cardiothorac Surg. 2020; 15: 113
        • Muslem R
        • Ong CS
        • Tomashitis B
        • Schultz J
        • Ramu B
        • Craig ML
        • et al.
        Pulmonary Arterial Elastance and INTERMACS-Defined Right Heart Failure Following Left Ventricular Assist Device.
        Circ Heart Fail. 2019; 12e005923
        • D'Alto M
        • Pavelescu A
        • Argiento P
        • Romeo E
        • Correra A
        • Di Marco GM
        • et al.
        Echocardiographic assessment of right ventricular contractile reserve in healthy subjects.
        Echocardiography. 2017; 34: 61-68
        • Opasich C
        • Cioffi G
        • Gualco A.
        Nitroprusside in decompensated heart failure: what should a clinician really know?.
        Curr Heart Fail Rep. 2009; 6: 182-190
        • Mehra MR
        • Kobashigawa J
        • Starling R
        • Russell S
        • Uber PA
        • Parameshwar J
        • et al.
        Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates–2006.
        J Heart Lung Transplant. 2006 Sep; 25: 1024-1042
        • Costard-Jäckle A
        • Fowler MB.
        Influence of preoperative pulmonary artery pressure on mortality after heart transplantation: testing of potential reversibility of pulmonary hypertension with nitroprusside is useful in defining a high risk group.
        J Am Coll Cardiol. 1992 Jan; 19: 48-54
        • Soliman OII
        • Akin S
        • Muslem R
        • Boersma E
        • Manintveld OC
        • Krabatsch T
        • 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.
        Circ. 2018; 137: 891-906
        • Kiernan MS
        • Grandin EW
        • Brinkley Jr, M
        • Kapur NK
        • Pham DT
        • Ruthazer R
        • et al.
        Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support.
        Circ Heart Fail. 2017; 10e003863
        • Atluri P
        • Goldstone AB
        • Fairman AS
        • MacArthur JW
        • Shudo Y
        • Cohen JE
        • et al.
        Predicting right ventricular failure in the modern, continuous flow left ventricular assist device era.
        Ann Thorac Surg. 2013; 96 (discussion 863-4): 857-863
        • Kalogeropoulos AP
        • Kelkar A
        • Weinberger JF
        • Morris AA
        • Georgiopoulou VV
        • Markham DW
        • 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: 1595-1603
        • Frankfurter C
        • Molinero M
        • Vishram-Nielsen JKK
        • Foroutan F
        • Mak S
        • Rao V
        • et al.
        Predicting the Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review.
        Circ Heart Fail. 2020; 13e006994
        • Houston BA
        • Shah KB
        • Mehra MR
        • Tedford RJ.
        A new "twist" on right heart failure with left ventricular assist systems.
        J Heart Lung Transplant. 2017; 36: 701-707
      1. N Kremer, Z Rako, P Douschan, et al., Unmasking right ventricular-arterial uncoupling during fluid challenge in pulmonary hypertension [e-pub ahead of print], J Heart Lung Transplant, 41, 2022, 345–355, doi:10.1016/j.healun.2021.11.019, accessed August 1, 2022.

        • Kormos RL
        • Antonides CFJ
        • Goldstein DJ
        • Cowger JA
        • Starling RC
        • Kirklin JK
        • et al.
        Updated definitions of adverse events for trials and registries of mechanical circulatory support: A consensus statement of the mechanical circulatory support academic research consortium.
        J Heart Lung Transplant. 2020; 39: 735-750
        • Nochioka K
        • Querejeta Roca G
        • Claggett B
        • Biering-Sørensen T
        • Matsushita K
        • Hung CL
        • et al.
        Right Ventricular Function, Right Ventricular-Pulmonary Artery Coupling, and Heart Failure Risk in 4 US Communities: The Atherosclerosis Risk in Communities (ARIC) Study.
        JAMA Cardiol. 2018; 3: 939-948
        • Saeed D
        • Muslem R
        • Rasheed M
        • Caliskan K
        • Kalampokas N
        • Sipahi F
        • et al.
        Less invasive surgical implant strategy and right heart failure after LVAD implantation.
        J Heart Lung Transplant. 2021; 40: 289-297
        • Teuteberg JJ
        • Cleveland Jr, JC
        • Cowger J
        • Higgins RS
        • Goldstein DJ
        • Keebler M
        • et al.
        The Society of Thoracic Surgeons Intermacs 2019 Annual Report: The Changing Landscape of Devices and Indications.
        Ann Thorac Surg. 2020 Mar; 109: 649-660
        • Rivas-Lasarte M
        • Kumar S
        • Derbala MH
        • Ferrall J
        • Cefalu M
        • Rashid SMI
        • et al.
        Prediction of right heart failure after left ventricular assist implantation: external validation of the EUROMACS right-sided heart failure risk score.
        Eur Heart J Acute Cardiovasc Care. 2021 Oct 1; 10: 723-732
        • Deswarte G
        • Kirsch M
        • Lesault PF
        • Trochu JN
        • Damy T.
        Right ventricular reserve and outcome after continuous-flow left ventricular assist device implantation.
        J Heart Lung Transplant. 2010; 29: 1196-1198
        • Gonzalez MH
        • Wang Q
        • Yaranov DM
        • Albert C
        • Wolski K
        • Wagener J
        • et al.
        Dynamic Assessment of Pulmonary Artery Pulsatility Index Provides Incremental Risk Assessment for Early Right Ventricular Failure after Left Ventricular Assist Device.
        J Card Fail. 2021; 27: 777-785
        • Molina EJ
        • Shah P
        • Kiernan MS
        • Cornwell 3rd, WK
        • Copeland H
        • Takeda K
        • et al.
        The Society of Thoracic Surgeons Intermacs 2020 Annual Report.
        Ann Thorac Surg. 2021; 111: 778-792