Acute Right Heart Failure Following Left Coronary Myocardial Infarction in Left Ventricular Assist Device–Supported Patients: A Case Series and Mechanistic Insight

Right heart failure (RHF) is a major cause of morbidity and mortality in patients supported with durable left ventricular assist devices (LVADs). While right coronary artery infarction is a recognized cause of acute RHF, the ventricular consequences of left coronary system infarction in LVAD-supported patients are not well characterized. We describe two patients supported with HeartMate III LVADs who developed acute RHF within 24-48 hours after successful revascularization of acute left coronary system occlusions (mid-left anterior descending artery and left main coronary artery). Both had previously stable LVAD function and no evidence of advanced RHF. After revascularization, each developed hypotension, rising central venous pressure, reduced LVAD flows, and echocardiographic evidence of severe right ventricular (RV) dilation and dysfunction with septal shift toward the left ventricle. Hemodynamic deterioration reversed with inotropic support, diuresis, and LVAD speed adjustment, without mechanical RV support. These cases suggest left coronary acute myocardial infarction (AMI) may precipitate acute RHF in LVAD-supported patients through septal ischemia with impaired ventricular interdependence, acute increases in RV afterload, and relative RV ischemia despite patent right coronary arteries. Heightened surveillance and early echocardiographic assessment after left-sided AMI in LVAD recipients may enable prompt recognition and timely intervention.