Tricuspid Valve Regurgitation and Right Ventricular Dysfunction During Left Ventricular Assist Device Implantation
Significant right ventricular dysfunction occurs in approximately 22% of patients undergoing left ventricular assist device (LVAD) implantation and is a predictor of early and late mortality [1, 2]. Despite previously described predictors of RV failure such as right ventricular stroke work index (RVSWI) and central venous pressure to pulmonary capillary wedge pressure (CVP/PCWP) ratio [1], reliable identification of patients who will require mechanical RV support has been challenging. Early failure of right ventricular (RV) output in the operating room may be evidenced by an elevated central venous pressure (CVP) >16 mmHg, poor RV performance parameters (e.g., tricuspid annular plane systolic excursion (TAPSE) <16 mm), reduced mixed venous oxygen saturation (SVO2 <55%), and cardiac index <2 L/min/m2, in the presence of low pulmonary capillary wedge pressures (PCWP) as assessed by invasive monitoring [3]. Resultant insufficient delivery of volume to the left heart leads to low LVAD pump output. Delayed RV failure in the intensive care or step down unit can manifest as LVAD suction events with insufficient forward flow, hypotension, as well as elevated CVP with secondary renal or hepatic dysfunction. Potential treatment options include the use of pulmonary vasodilators and intravenous inotropic therapy with potential escalation to right-sided mechanical support.
