Upfront RVAD Strategy and Early Clinical Outcomes in LVAD Patients

Purpose Right ventricular failure (RVF) after LVAD is associated with increased morbidity and mortality. “Delayed right ventricular assist device (RVAD)”, as a surgical or percutaneous rescue strategy, carries high complication rates. We recently changed our practice and use “Upfront RVAD” (concurrent with LVAD implant) in selected high-risk pts (INTERMACS 1, severe RVF and renal failure). We sought to investigate the effect of this novel strategy on in-hospital mortality and adverse events. Methods We retrospectively reviewed consecutive pts who received primary LVAD implant between 1/2015 and 8/2019. This cohort was divided into 4 groups (Gs): G1- no evidence of RVF and no RVAD; G2 - RVF treated with inotropes >2 wks; G3 - Delayed RVAD; G4 - Upfront RVAD. Clinical outcomes included in-hospital mortality, renal replacement therapy (RRT), stroke and length of stay (LOS). Results 225 pts were enrolled in the study: G1 (n=117, 52%); G2 (n=48, 21.3%); G3 (n=26, 11.6%); G4 (n=34, 15.1%). Frequency of INTERMACS 1 profile was significantly different among groups: G1 10.3%; G2 8.3%; G3 11.5%; G4 51.4%; p=0.001. G4 had significantly lower albumin and longer bypass time compared to the other groups. RVAD strategy (Delayed (G3) vs. Upfront (G4)) and type (surgical vs. percutaneous) varied by implant year (Fig 1a). Mean time to Delayed RVAD (G3) was 2.54 (1-15) days. In-hospital mortality of pts in G4 was similar to G2 and numerically lower than G3. RRT and stroke were the highest in G3 and were similar in G4 vs.G2 (Fig 1b-d). Median (IQR) ICU LOS was G1 7(6-10); G2 15(10-21); G3 22(14-28); G4 20(14-41) days (p Conclusion In-hospital mortality, RRT and stroke events were markedly lower in pts who received Upfront compared to Delayed RVAD. Notably, despite the majority of Upfront RVAD pts being INTERMACS 1, mortality and adverse events were similar to those of pts treated with prolonged inotropes for RVF without RVAD support (