Perspective:

This study examines a number of echocardiographic and clinical variables in a very complex patient population, that is patients with end-stage heart disease requiring LVAD support, either as destination or bridge therapy. It has long been recognized that RV function may be the limiting factor in how well these patients, who preoperatively have predominate LV failure symptoms, become the limiting factor once an LVAD has provided replacement therapy for LV dysfunction. The link between a relatively small LV cavity (<63 mm) and short-term mortality is unclear, and the authors’ suggestion that the smaller LV may set the patient up for a 'suction event' in which the LVAD, by decompressing the LV to an excess degree, results in septal shift and worsening RV function is one plausible explanation. Of note, the survival curves suggest the relatively small LV has an impact on adverse events only in the first 3 months after which a small LV appeared not to confer further excess mortality. RV dysfunction is often concurrent with severe LV dysfunction and may become the limiting factor in preload for the LVAD, thereby compromising its effectiveness. RV dysfunction has been previously described as a marker of an adverse outcome, both short- and long-term in patients with congestive heart failure including those undergoing LVAD therapy. Of note in this study, evidence of significant RV dysfunction, as manifest by relatively short TRDc, had both a short- and long-term effect on outcome, which was noticeable immediately after implant and continued to exert an adverse influence over the course of follow-up with these patients.