*Purpose: Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation is a common complication and associated with increased mortality. Clinical predictors contributing to post-LVAD RVF remain largely unknown in patients who have received the recently FDA approved Heartmate III (HM3) LVAD. Our objective was to evaluate potential predictors of RVF.

*Methods: In this single-center retrospective analysis of patients who received a HM3 LVAD from January 2017 – December 2018, RVF was defined as the need for inotropic support ≥14 days, inhaled nitric oxide ≥2 days, and/or right-sided circulatory support post-LVAD implantation. Hemodynamics, kidney/liver function, LVAD settings prior to discharge, and mortality were compared between patients with and without RVF. Risk factor associations with RVF were investigated using univariate logistic regression.

*Results: Baseline patient demographics and characteristics did not differ significantly between patients with and without RVF. Of the 59 patients, 30 (51%) patients had RVF post-LVAD implantation despite low risk preoperative hemodynamic variables with a median central venous pressure (CVP) of 11.0 mmHg [7.0, 23.0], median CVP/pulmonary capillary wedge pressure (PCWP) ratio of 0.37 [0.27, 0.66], and median pulmonary artery pulsatility index (PAPi) of 2.92 [1.53, 4.8]; [Q1, Q3], which were not significantly different from those without RVF. Similarly, CVP/PCWP > 0.6 was evident in 13 (43%) vs 8 (28%); p=0.32 and PAPi ≤ 2 seen in 9 (30%) vs 5 (17%); p=0.40 were not significantly different between those with and without RVF. RVF was associated with a significantly higher mortality (20% vs 0%; p=0.02). Importantly, patients with RVF had significantly lower LVAD speed (5100 rpm [5000, 5400] vs 5400 rpm [5200, 5500]; p<0.0001). LVAD mortality was coupled with significantly lower LVAD speed (4900 rpm [4725, 5075] vs 5300 rpm [5100, 5400]; p < 0.005]. Preoperative echocardiographic RV function did not predict postoperative RVF (OR 0.91 [0.49, 1.68], p=0.49).

*Conclusions: RVF was not prevented by optimizing traditional preoperative hemodynamic risk factors for RVF (CVP≤12, CVP/wedge ratio≤0.6, and PAPi>2) and occurred irrespective of echocardiographically guided preoperative RV function. The development of RVF after HM3 LVAD implant was highly associated with lower LVAD speed in this study. Further prospective studies are warranted to determine whether speed optimization might become a relevant measure to reduce postoperative RV failure.

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