Task Force 4: Inpatient Management of Patients with MCSD - The ...

RV dysfunction, pulmonary capillary wedge pressure is normal or low. An elevated
pulmonary capillary wedge pressure indicates ineffective unloading by the LVAD and
warrants further evaluation. When RV dysfunction occurs, admission to the hospital for
medical optimization including inotropic support may be required. In some cases,
inotropic support cannot be weaned off and is continued in the outpatient setting.
Recommendations for Right Ventricular Function:
Class I:
1. Right ventricular dysfunction after LVAD placement may occur as a late
manifestation with symptoms and signs of right heart failure and changes in LVAD
parameters including drop in flows and pulsatility. Further evaluation should include
echocardiogram and right heart catheterization.
Level of Evidence: C.
2. When evidence of RV dysfunction exists, MCS patients may need to be admitted to
the hospital for optimization, which may include initiation of inotropic support.
Inotropic support may need to be continued as an outpatient.
Level of Evidence: C.
Device Malfunction
A major limitation of first-generation pulsatile MCSDs was durability. Failure rates
for the HeartMate XVE were in the order of 31% to 35% largely due to internal bearing
wear and degradation of the valved inflow cannula. 93,94 With the advent of continuous
flow MCSD, incidence of device failure has decreased dramatically compared to
pulsatile pumps. In a comparison of the continuous flow HeartMate II with the pulsatile
HeartMate XVE in a DT cohort, the need for device repair or replacement strongly
favored the continuous-flow device: 10% versus 36% (P=0.001) at 2 years. 95
Experience with HeartMate II BTT cohorts has demonstrated no or low instances, 0% to
1.2%, of primary mechanical pump failure. 77,96,97
Although incidence of pump failure requiring replacement is low, when this event
occurs it can be catastrophic. The most common reasons for pump stoppage are
thrombus formation in the rotor or mechanical failure. Unlike the pulsatile devices that
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