Temporal interplay between right ventricular failure and aortic insufficiency after left ventricular assist device implantation
J Guzman Bofarull, G Gallone, V A R Thirupathirajan, J B Guichard, A Maestro Benedicto, J Ibero, E Karapedi, A Bollas Becerra, G Edwards, M Monteagudo Vela, D Garcia Saez, F Fiorelli, O Dar, A Morley-Smith, F Riesgo GilAbstract
Background
Right ventricular failure (RVF) and aortic insufficiency (AI) are well-recognized hemodynamic-related adverse events (HRAE) following left ventricular assist device (LVAD) implantation and are associated with poor prognosis. RVF may reduce left ventricular (LV) preload, limiting aortic valve (AV) opening and promoting progressive AI. Conversely, restricted AV opening and significant AI may reflect impaired LV reserve, potentially predisposing patients to RVF, and AI itself may increase right ventricular (RV) wall stress by elevating RV afterload. Despite this plausible bidirectional relationship, the temporal interaction between RVF and AI after LVAD implantation remains incompletely characterized.
Purpose
We aimed to evaluate whether early RVF (≤6 months post-implantation) increases the risk of subsequent AI and, conversely, whether early AI or lack of AV opening predisposes patients to late RVF (>6 months post-implantation).
Methods
We retrospectively analyzed consecutive patients who underwent durable LVAD implantation at a single tertiary center between 2010 and 2025, survived ≥6 months post-implantation, and had available echocardiography at 1, 6, and 18 months. In the first analysis, patients were stratified by the occurrence of early RVF. Outcomes included development of significant AI (≥moderate) and absence of AV opening at 6 and/or 18 months. In the second analysis, patients were categorized based on the presence of early significant AI and based on the absence of AV opening at 1 and/or 6 months, with late RVF as the outcome of interest.
Results
Among 235 patients, 116 (49.4%) developed early RVF. Early RVF was not associated with subsequent significant AI (OR 0.94, 95% CI 0.51–1.72; p=0.84) or absence of AV opening (OR 1.19, 95% CI 0.67–2.13; p=0.54) at 6 and/or 18 months. In contrast, 35 patients (14.9%) had early significant AI, and 60 patients (25.5%) exhibited early absence of AV opening. Both early significant AI (OR 2.30, 95% CI 1.06–4.85; p=0.031) and early absence of AV opening (OR 2.49, 95% CI 1.25–5.36; p=0.013) were independently associated with an increased risk of late RVF (Figure).
Conclusion
Significant AI and absence of AV opening within the first six months after LVAD implantation are associated with an increased risk of late RVF, whereas early RVF does not appear to predispose patients to subsequent AI. These findings suggest that early identification of moderate or greater AI or persistently closed AV may help identify patients at higher risk for late RVF and could support consideration of early therapeutic optimization.For image description, please refer to the figure legend and surrounding text.