Right heart failure after left ventricular assist device: From mechanisms to treatments.
Right heart failure after left ventricular assist device: From mechanisms to treatments.
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DOI：
10.3389/fcvm.2022.1023549
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发表时间：
2022
影响因子：
3.6
通讯作者：
中科院分区：
文献类型：
--
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左心室辅助装置（LVAD）治疗是药物治疗难治性晚期心力衰竭患者的救命选择。根据定义，5-44%的LVAD患者发生右心衰竭（RHF），这与较差的结果相关。与RHF相关的机制包括患者、手术和血流动力学因素。尽管在了解这些因素的作用以及手术技术和LVAD技术的改进方面取得了重大进展，但这一并发症仍然是LVAD患者发病和死亡的重要原因。此外，针对这一并发症的特异性药物治疗仍然缺乏，使得心脏移植或支持性治疗成为发生RHF的LVAD患者的唯一选择。虽然已经做出了巨大的努力来创建算法，旨在对LVAD植入患者的RHF风险进行分层，但这些算法的预测价值有限，特别是在进行外部验证的尝试时。外部验证性能差的原因之一可能与外部队列中RHF的不同定义有关。此外，该领域的大多数研究都集中在LVAD植入后早期（即≤1个月）发生的RHF。然而，人们逐渐认识到晚发性RHF（即术后10 - 1个月）是发病率和死亡率的重要原因。迟发性RHF可能具有独特的生理和致病机制，但目前对其知之甚少。在这篇文献综述中，我们将描述独特的右心室生理学和由左心室辅助装置引起的可能导致早发性和晚发性RHF的变化。最后，我们将分析目前可用的RHF治疗方法，包括机械循环支持选择和药物治疗。
Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5–44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.