Preemptive Versus Reactive Use of a Right Ventricular Assist Device in HeartMate 3 Patients

Severe right ventricular failure (RVF) is a morbid complication of left ventricular assist device insertion. The optimal timing of right ventricular assist device (RVAD) support remains controversial. We sought to evaluate outcomes associated with preemptive versus delayed RVAD insertion at the time of HeartMate 3 (HM3) implantation. We retrospectively reviewed 293 patients who underwent HM3 implantation between November 2014 and December 2022. A preemptive RVAD strategy was applied to select patients. Outcomes were compared to patients who did not require an RVAD and who required an RVAD after HM3 insertion (reactive RVAD). Thirty-three patients (11.3%) underwent preemptive RVAD insertion, whereas 229 (78.2%) had no RVAD, and 31 (10.5%) had a reactive RVAD. Reasons for preemptive RVADs were cardiogenic shock (n = 22, 66.7%), severe biventricular failure (n = 7, 21.2%), or refractory ventricular tachycardia (n = 4, 12.1%). In-hospital mortality was highest in the reactive group (None: 2.2 versus Preemptive: 3.0 versus Reactive: 25.8%, p < 0.001). Kaplan-Meier analysis showed the lowest 3 year survival in the reactive group, whereas the preemptive and non-RVAD groups had comparable survival rates (83.5% vs. 85.5% vs. 46.6%, p < 0.001). In multivariable Cox analysis, reactive RVAD was an independent risk factor for mortality (hazard ratio [HR]: 2.7, p < 0.001). In our study, preemptive RVAD insertion was associated with improved outcomes.