Predicting early right heart failure after left ventricular assist device implantation based on resting and overload dual-state assessment_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHU Weiyi , ZHAO Shuanglei , WEN Mingxiu , LU Yifan , CHEN Zhengji , LI Qianxian , HU Yi , CHEN Siji , ZHANG Hongjia ,  GONG Ming

Heart Failure and Valvular Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P. R. China;

Corresponding?author：

GONG Ming, Email: gongming@mail.ccmu.edu.cn

Keywords：

Left ventricular assist device; right heart failure; risk prediction; stress testing; hemodynamics; perioperative period; mechanical circulatory support; review

DOI：

10.7507/1007-4848.202511038

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Post-implantation early right heart failure (RHF) following left ventricular assist device (LVAD) placement is characterized by a high incidence and poor prognosis. Current risk stratification models primarily rely on hemodynamic, imaging, and organ function parameters obtained under resting conditions, but their external validation and generalizability are limited. In contrast, stress testing, which increases cardiac load through vasodilators or exercise, offers incremental value in predicting postoperative RHF. This review centers on a dual-state assessment (rest and stress), summarizing the strengths and limitations of indices such as the ratio of central venous pressure to pulmonary artery wedge pressure (CVP/PAWP) and the pulmonary artery pulsatility index (PAPi). It further compares established risk models like CRITT score and European Registry for Patients with Mechanical Circulatory Support (EUROMACS), demonstrating the augmented predictive power of pharmacological or exercise stress testing. A stratified strategy is proposed, involving initial screening with static parameters followed by confirmatory stress testing. Furthermore, an integrated approach of incorporating stress-derived parameters into these models is suggested. Finally, the paper advocates for prospective validation studies in the cohort of patients receiving domestically-produced LVAD, with the aim of establishing a systematic framework to guide perioperative decision-making and enhance individualized prediction.

1.	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.
2.	Soriano-Colomé T, Barrabés JA, Gevaert S, et al. Editorial: management of right ventricular failure: pathophysiology, medical treatment and use of ventricular assist devices. Front Cardiovasc Med, 2023, 10: 1297652.
3.	Baxter RD, Tecson KM, Still S, et al. Predictors and impact of right heart failure severity following left ventricular assist device implantation. J Thorac Dis, 2019, 11(Suppl 6): S864-S870.
4.	Kapelios CJ, Lund LH, Wever-Pinzon O, et al. Right heart failure following left ventricular device implantation: natural history, risk factors, and outcomes: an analysis of the STS INTERMACS database. Circ Heart Fail, 2022, 15(6): e008706.
5.	LaRue SJ, Raymer DS, Pierce BR, et al. Clinical outcomes associated with INTERMACS-defined right heart failure after left ventricular assist device implantation. J Heart Lung Transplant, 2017, 36(4): 475-477.
6.	Rodenas-Alesina E, Brahmbhatt DH, Rao V, et al. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: a comprehensive review. Front Cardiovasc Med, 2022, 9: 1040251.
7.	Lo Coco V, De Piero ME, Massimi G, et al. Right ventricular failure after left ventricular assist device implantation: a review of the literature. J Thorac Dis, 2021, 13(2): 1256-1269.
8.	Adamopoulos S, Bonios M, Ben Gal T, et al. Right heart failure with left ventricular assist devices: preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail, 2024, 26(11): 2304-2322.
9.	Dang NC, Topkara VK, Mercando M, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant, 2006, 25(1): 1-6.
10.	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.
11.	Rajagopalan N, Borlaug BA, Bailey AL, et al. Practical guidance for hemodynamic assessment by right heart catheterization in management of heart failure. JACC Heart Fail, 2024, 12(7): 1141-1156.
12.	Kang G, Ha R, Banerjee D. Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. J Heart Lung Transplant, 2016, 35(1): 67-73.
13.	Schramm R, Kirchner J, Ibrahim M, et al. Pulmonary vascular resistance to predict right heart failure in patients undergoing left ventricular assist device implantation. J Clin Med, 2024, 13(2): 462.
14.	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.
15.	Shad R, Quach N, Fong R, et al. Predicting post-operative right ventricular failure using video-based deep learning. Nat Commun, 2021, 12(1): 5192.
16.	Liang LW, Jamil A, Mazurek JA, et al. Right ventricular global longitudinal strain as a predictor of acute and early right heart failure post left ventricular assist device implantation. ASAIO J, 2022, 68(3): 333-339.
17.	Isaza N, Gonzalez M, Saijo Y, et al. Incremental value of global longitudinal strain to Michigan risk score and pulmonary artery pulsatility index in predicting right ventricular failure following left ventricular assist devices. Heart Lung Circ, 2022, 31(8): 1110-1118.
18.	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.
19.	Lambert DS, Picó AM, Vincent JD, et al. Model for End Stage Liver Disease excluding international normalized ratio predicts severe right ventricular failure after HeartMate 3 implantation in a contemporary cohort. J Am Heart Assoc, 2025, 14(7): e037553.
20.	Janssen E, Jukema JW, Beeres SLMA, et al. Prognostic value of natriuretic peptides for all-cause mortality, right ventricular failure, major adverse events, and myocardial recovery in advanced heart failure patients receiving a left ventricular assist device: a systematic review. Front Cardiovasc Med, 2021, 8: 699492.
21.	Benjamin MM, Sundararajan S, Sulaiman S, et al. Association of preoperative duration of inotropy on prevalence of right ventricular failure following LVAD implantation. ESC Heart Fail, 2020, 7(4): 1949-1955.
22.	Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular failure in patients with the HeartMateⅡ continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg, 2010, 139(5): 1316-1324.
23.	Cacioli G, Polizzi V, Ciabatti M, et al. Prediction of right ventricular failure after left ventricular assist device implantation: role of vasodilator challenge. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 629-639.
24.	Read JM, Azih NI, Peters CJ, et al. Hemodynamic reserve predicts early right heart failure after LVAD implantation. J Heart Lung Transplant, 2022, 41(12): 1716-1726.
25.	Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: Executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2022, 79(17): 1757-1780.
26.	Grinstein J, Sawalha Y, Medvedofsky DA, et al. VE/VCO2 slope predicts RV dysfunction and mortality after left ventricular assist device: a fresh look at cardiopulmonary stress testing for prognostication. J Artif Organs, 2021, 24(4): 425-432.
27.	Kato TS, Jiang J, Schulze PC, et al. Serial echocardiography using tissue Doppler and speckle tracking imaging to monitor right ventricular failure before and after left ventricular assist device surgery. JACC Heart Fail, 2013, 1(3): 216-222.
28.	Gudejko MD, Gebhardt BR, Zahedi F, et al. Intraoperative hemodynamic and echocardiographic measurements associated with severe right ventricular failure after left ventricular assist device implantation. Anesth Analg, 2019, 128(1): 25-32.
29.	Gebhardt BR, Abdulaziz A, Kawabori M, et al. Intraoperative central venous pressure and diastolic pulmonary artery pressure as a marker of severe right ventricular failure after left ventricular assist device implantation. J Cardiothorac Vasc Anesth, 2020, 34(3): 847-849.
30.	Rodenas-Alesina E, Brahmbhatt DH, Mak S, et al. Value of invasive hemodynamic assessments in patients supported by continuous-flow left ventricular assist devices. JACC Heart Fail, 2024, 12(1): 16-27.
31.	Matthews JC, Koelling TM, Pagani FD, et al. 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(22): 2163-2172.
32.	Loghmanpour NA, Kormos RL, Kanwar MK, et al. A Bayesian model to predict right ventricular failure following left ventricular assist device therapy. JACC Heart Fail, 2016, 4(9): 711-721.
33.	Drakos SG, Janicki L, Horne BD, et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol, 2010, 105(7): 1030-1035.
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.	Taleb I, Kyriakopoulos CP, Fong R, et al. Machine learning multicenter risk model to predict right ventricular failure after mechanical circulatory support: the STOP-RVF score. JAMA Cardiol, 2024, 9(3): 272-282.
37.	Wang X, Zhou X, Chen H, et al. Long-term outcomes of a novel fully magnetically levitated ventricular assist device for the treatment of advanced heart failure in China. J Heart Lung Transplant, 2024, 43(11): 1806-1815.
38.	Lu Y, Zhao S, Han J, et al. Multicenter study for CH-VAD as a fully magnetically levitated left ventricular assist device. iScience, 2025, 28(2): 111764.
39.	Crespo-Diaz R, Mudy K, Khan N, et al. Right ventricular assist device placement during left ventricular assist device implantation is associated with improved survival. ASAIO J, 2024, 70(7): 570-577.
40.	Gonzalez MH, Wang Q, Yaranov DM, 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(7): 777-785.
41.	Sacks S, Feinman J. A 2024 update from the American Society of Echocardiography: multimodality imaging for patients with left ventricular assist devices and temporary mechanical circulatory support. J Cardiothorac Vasc Anesth, 2025, 39(8): 1919-1923.
42.	Balcioglu O, Ozgocmen C, Ozsahin DU, et al. The role of artificial intelligence and machine learning in the prediction of right heart failure after left ventricular assist device implantation: a comprehensive review. Diagnostics (Basel), 2024, 14(4): 380.
43.	Thut TLZ, Petrou A, Meboldt M, et al. The impact of right ventricular hemodynamics on the performance of a left ventricular assist device in a numerical simulation model. Biomed Tech (Berl), 2023, 68(5): 503-510.
44.	Ahmed MM, Grant H, Martinez J, et al. Patient-specific hemodynamic modeling to optimize LVAD speed and right heart health. JHLT Open, 2024, 7: 100190.
45.	趙雙雷, 劉彤, 溫明修, 等. 植入式左心室輔助裝置在我國的應用與發展. 中國醫刊, 2023, 58(12): 1282-1285.Zhao SL, Liu T, Wen MX, et al. Application and development of implantable left ventricular assist device in China. Chin J Med, 2023, 58(12): 1282-1285.

1. 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.
2. Soriano-Colomé T, Barrabés JA, Gevaert S, et al. Editorial: management of right ventricular failure: pathophysiology, medical treatment and use of ventricular assist devices. Front Cardiovasc Med, 2023, 10: 1297652.
3. Baxter RD, Tecson KM, Still S, et al. Predictors and impact of right heart failure severity following left ventricular assist device implantation. J Thorac Dis, 2019, 11(Suppl 6): S864-S870.
4. Kapelios CJ, Lund LH, Wever-Pinzon O, et al. Right heart failure following left ventricular device implantation: natural history, risk factors, and outcomes: an analysis of the STS INTERMACS database. Circ Heart Fail, 2022, 15(6): e008706.
5. LaRue SJ, Raymer DS, Pierce BR, et al. Clinical outcomes associated with INTERMACS-defined right heart failure after left ventricular assist device implantation. J Heart Lung Transplant, 2017, 36(4): 475-477.
6. Rodenas-Alesina E, Brahmbhatt DH, Rao V, et al. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: a comprehensive review. Front Cardiovasc Med, 2022, 9: 1040251.
7. Lo Coco V, De Piero ME, Massimi G, et al. Right ventricular failure after left ventricular assist device implantation: a review of the literature. J Thorac Dis, 2021, 13(2): 1256-1269.
8. Adamopoulos S, Bonios M, Ben Gal T, et al. Right heart failure with left ventricular assist devices: preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail, 2024, 26(11): 2304-2322.
9. Dang NC, Topkara VK, Mercando M, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant, 2006, 25(1): 1-6.
10. 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.
11. Rajagopalan N, Borlaug BA, Bailey AL, et al. Practical guidance for hemodynamic assessment by right heart catheterization in management of heart failure. JACC Heart Fail, 2024, 12(7): 1141-1156.
12. Kang G, Ha R, Banerjee D. Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. J Heart Lung Transplant, 2016, 35(1): 67-73.
13. Schramm R, Kirchner J, Ibrahim M, et al. Pulmonary vascular resistance to predict right heart failure in patients undergoing left ventricular assist device implantation. J Clin Med, 2024, 13(2): 462.
14. 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.
15. Shad R, Quach N, Fong R, et al. Predicting post-operative right ventricular failure using video-based deep learning. Nat Commun, 2021, 12(1): 5192.
16. Liang LW, Jamil A, Mazurek JA, et al. Right ventricular global longitudinal strain as a predictor of acute and early right heart failure post left ventricular assist device implantation. ASAIO J, 2022, 68(3): 333-339.
17. Isaza N, Gonzalez M, Saijo Y, et al. Incremental value of global longitudinal strain to Michigan risk score and pulmonary artery pulsatility index in predicting right ventricular failure following left ventricular assist devices. Heart Lung Circ, 2022, 31(8): 1110-1118.
18. 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.
19. Lambert DS, Picó AM, Vincent JD, et al. Model for End Stage Liver Disease excluding international normalized ratio predicts severe right ventricular failure after HeartMate 3 implantation in a contemporary cohort. J Am Heart Assoc, 2025, 14(7): e037553.
20. Janssen E, Jukema JW, Beeres SLMA, et al. Prognostic value of natriuretic peptides for all-cause mortality, right ventricular failure, major adverse events, and myocardial recovery in advanced heart failure patients receiving a left ventricular assist device: a systematic review. Front Cardiovasc Med, 2021, 8: 699492.
21. Benjamin MM, Sundararajan S, Sulaiman S, et al. Association of preoperative duration of inotropy on prevalence of right ventricular failure following LVAD implantation. ESC Heart Fail, 2020, 7(4): 1949-1955.
22. Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular failure in patients with the HeartMateⅡ continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg, 2010, 139(5): 1316-1324.
23. Cacioli G, Polizzi V, Ciabatti M, et al. Prediction of right ventricular failure after left ventricular assist device implantation: role of vasodilator challenge. Eur Heart J Acute Cardiovasc Care, 2022, 11(8): 629-639.
24. Read JM, Azih NI, Peters CJ, et al. Hemodynamic reserve predicts early right heart failure after LVAD implantation. J Heart Lung Transplant, 2022, 41(12): 1716-1726.
25. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: Executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2022, 79(17): 1757-1780.
26. Grinstein J, Sawalha Y, Medvedofsky DA, et al. VE/VCO2 slope predicts RV dysfunction and mortality after left ventricular assist device: a fresh look at cardiopulmonary stress testing for prognostication. J Artif Organs, 2021, 24(4): 425-432.
27. Kato TS, Jiang J, Schulze PC, et al. Serial echocardiography using tissue Doppler and speckle tracking imaging to monitor right ventricular failure before and after left ventricular assist device surgery. JACC Heart Fail, 2013, 1(3): 216-222.
28. Gudejko MD, Gebhardt BR, Zahedi F, et al. Intraoperative hemodynamic and echocardiographic measurements associated with severe right ventricular failure after left ventricular assist device implantation. Anesth Analg, 2019, 128(1): 25-32.
29. Gebhardt BR, Abdulaziz A, Kawabori M, et al. Intraoperative central venous pressure and diastolic pulmonary artery pressure as a marker of severe right ventricular failure after left ventricular assist device implantation. J Cardiothorac Vasc Anesth, 2020, 34(3): 847-849.
30. Rodenas-Alesina E, Brahmbhatt DH, Mak S, et al. Value of invasive hemodynamic assessments in patients supported by continuous-flow left ventricular assist devices. JACC Heart Fail, 2024, 12(1): 16-27.
31. Matthews JC, Koelling TM, Pagani FD, et al. 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(22): 2163-2172.
32. Loghmanpour NA, Kormos RL, Kanwar MK, et al. A Bayesian model to predict right ventricular failure following left ventricular assist device therapy. JACC Heart Fail, 2016, 4(9): 711-721.
33. Drakos SG, Janicki L, Horne BD, et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol, 2010, 105(7): 1030-1035.
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. Taleb I, Kyriakopoulos CP, Fong R, et al. Machine learning multicenter risk model to predict right ventricular failure after mechanical circulatory support: the STOP-RVF score. JAMA Cardiol, 2024, 9(3): 272-282.
37. Wang X, Zhou X, Chen H, et al. Long-term outcomes of a novel fully magnetically levitated ventricular assist device for the treatment of advanced heart failure in China. J Heart Lung Transplant, 2024, 43(11): 1806-1815.
38. Lu Y, Zhao S, Han J, et al. Multicenter study for CH-VAD as a fully magnetically levitated left ventricular assist device. iScience, 2025, 28(2): 111764.
39. Crespo-Diaz R, Mudy K, Khan N, et al. Right ventricular assist device placement during left ventricular assist device implantation is associated with improved survival. ASAIO J, 2024, 70(7): 570-577.
40. Gonzalez MH, Wang Q, Yaranov DM, 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(7): 777-785.
41. Sacks S, Feinman J. A 2024 update from the American Society of Echocardiography: multimodality imaging for patients with left ventricular assist devices and temporary mechanical circulatory support. J Cardiothorac Vasc Anesth, 2025, 39(8): 1919-1923.
42. Balcioglu O, Ozgocmen C, Ozsahin DU, et al. The role of artificial intelligence and machine learning in the prediction of right heart failure after left ventricular assist device implantation: a comprehensive review. Diagnostics (Basel), 2024, 14(4): 380.
43. Thut TLZ, Petrou A, Meboldt M, et al. The impact of right ventricular hemodynamics on the performance of a left ventricular assist device in a numerical simulation model. Biomed Tech (Berl), 2023, 68(5): 503-510.
44. Ahmed MM, Grant H, Martinez J, et al. Patient-specific hemodynamic modeling to optimize LVAD speed and right heart health. JHLT Open, 2024, 7: 100190.
45. 趙雙雷, 劉彤, 溫明修, 等. 植入式左心室輔助裝置在我國的應用與發展. 中國醫刊, 2023, 58(12): 1282-1285.Zhao SL, Liu T, Wen MX, et al. Application and development of implantable left ventricular assist device in China. Chin J Med, 2023, 58(12): 1282-1285.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesPredicting early right heart failure after left ventricular assist device implantation based on resting and overload dual-state assessment

Abstract Full text Figures/Tables Video References Cited by

Format

Content