Right Ventricular Dysfunction During Intensive Pharmacologic Unloading Persists After Mechanical Unloading

Palardy, Maryse; Nohria, Anju; Rivero, Jose; Lakdawala, Neal; Campbell, Patricia; Kato, Mahoto; Griffin, Leslie M.; Smith, Colleen M.; Couper, Gregory S.; Stevenson, Lynne W.; Givertz, Michael M.

doi:10.1016/j.cardfail.2009.11.002

« Previous Next »Journal of Cardiac Failure
Volume 16, Issue 3 , Pages 218-224, March 2010

Right Ventricular Dysfunction During Intensive Pharmacologic Unloading Persists After Mechanical Unloading

Maryse Palardy, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Anju Nohria, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Jose Rivero, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Neal Lakdawala, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Patricia Campbell, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Mahoto Kato, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Leslie M. Griffin, NP
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Colleen M. Smith, NP
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Gregory S. Couper, MD
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Lynne W. Stevenson, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Michael M. Givertz, MD
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Reprint requests: Michael M. Givertz, MD, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Tel: 617-732-7367; Fax: 617-264-5265.

Received 25 June 2009; received in revised form 13 October 2009; accepted 4 November 2009. published online 11 December 2009.

Abstract

Background

Right ventricular (RV) dysfunction is associated with adverse outcomes in heart failure (HF). Mechanical unloading should be more effective than pharmacologic therapy to reduce RV afterload and improve RV function. We compared RV size and function after aggressive medical unloading therapy to that achieved in the same patients after 3 months of left ventricular assist device (LVAD) support.

Methods and Results

We studied 20 patients who underwent isolated LVAD placement (9 pulsatile and 11 axial flow). Echocardiograms were performed after inpatient optimization with diuretic and inotropic therapy and compared with studies done after 3 months of LVAD support. After medical optimization right atrial pressure was 11 ± 5 mm Hg, mean pulmonary artery pressure 36 ± 11 mm Hg, pulmonary capillary wedge pressure 23 ± 9 mm Hg, and cardiac index 2.0 ± 0.6 L·min·m². Preoperatively, RV dysfunction was moderate (2.6 ± 0.9 on a 0 to 4 scale), RV diameter at the base was 3.1 ± 0.6 cm, and mid-RV was 3.5 ± 0.6 cm. After median LVAD support of 123 days (92 to 170), RV size and global RV dysfunction (2.6 ± 0.9) failed to improve, despite reduced RV afterload.

Conclusions

RV dysfunction seen on intensive medical therapy persisted after 3 months of LVAD unloading therapy. Selection of candidates for isolated LV support should anticipate persistence of RV dysfunction observed on inotropic therapy.

Key Words: Left ventricular assist device, echocardiogram, right ventricle, inotropic agent