Preoperative Predictors of Right Ventricular Assist Device Requirement After Left Ventricular Assist Device Implantation: A Systematic Review and Meta Analysis

Background: Right ventricular failure (RVF) remains a major determinant of morbidity and mortality following left ventricular assist device (LVAD) implantation. In its most severe form, RVF necessitates right ventricular assist device (RVAD) support, which is associated with markedly worse early and long-term outcomes. While numerous studies have examined predictors of post-LVAD RVF, few have focused specifically on RVAD implantation as a discrete and clinically decisive endpoint. We therefore performed a systematic review and meta-analysis to identify robust preoperative predictors of RVAD requirement following LVAD implantation. Methods: A systematic literature search of MEDLINE, EMBASE, SCOPUS, and PubMed was conducted from inception to August 2025 in accordance with PRISMA guidelines. Studies enrolling adult patients undergoing durable or temporary LVAD implantation and reporting preoperative predictors of postoperative RVAD requirement were included. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I2 statistic, with predefined sensitivity and subgroup analyses based on LVAD era and study size. Results: Twenty studies met inclusion criteria, of which nineteen comprising 31,591 patients were included in the meta-analysis. Several consistent preoperative predictors of RVAD requirement were identified across clinical, haemodynamic, echocardiographic, and laboratory domains. Patients requiring RVAD were younger (MD –3.57 years) and more frequently female, had a higher likelihood of prior cardiac surgery, INTERMACS Profile 1 status, and need for preoperative mechanical support including ventilation and intra-aortic balloon pump. Haemodynamic predictors included elevated central venous pressure, higher CVP/PCWP ratio, lower cardiac index, and reduced right ventricular stroke work index. Echocardiographic predictors included severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. Laboratory markers of hepatic dysfunction, coagulopathy, malnutrition, anaemia, thrombocytopenia, and elevated natriuretic peptides were also significantly associated with RVAD implantation. Subgroup analyses demonstrated consistent direction of effects across LVAD eras and study sizes. Conclusion: RVAD requirement after LVAD implantation is driven by a constellation of high clinical acuity, haemodynamic compromise, and end-organ dysfunction rather than any single isolated variable. A comprehensive, multi-parameter preoperative assessment is essential to identify patients at highest risk and to guide patient selection, preoperative optimisation, and consideration of planned biventricular support strategies.