Destination LVAD in INTERMACS 3 With Borderline RV Function
56-year-old man with nonischemic cardiomyopathy (LVEF 18%) has been hospitalized 6 days with NYHA class IV symptoms. He is on milrinone 0.375 mcg/kg/min and furosemide infusion; norepinephrine was stopped yesterday. Exam: warm extremities, JVP 12 cm, minimal edema. PA catheter: RA 12 mmHg, PCWP 26 mmHg, CI 2.0 L/min/m2, PVR 3.2 WU, TAPSE 12 mm, RVSP 45 mmHg. Lactate 1.2 mmol/L, creatinine 1.4 mg/dL, sodium 132 mmol/L, bilirubin 1.1 mg/dL. BMI 32, no frailty, strong family support. INTERMACS profile 3. He is not on the transplant list because of active tobacco use and center BMI criteria.
1. How would you frame his transplant candidacy, INTERMACS profile, and the role of durable LVAD?
Read the worked answer
His INTERMACS 3 profile means he is stable on continuous inotropes but still has NYHA IV symptoms and high mortality without advanced therapy. He is not currently a transplant candidate at this center because of active tobacco use and BMI criteria, so durable LVAD as destination therapy is the default pathway if he has no other contraindications. Before committing, confirm tobacco cessation and assess whether BMI is modifiable; a short period of rehabilitation and nutrition may improve candidacy, but he should not remain on inotropes indefinitely. Key judgment: do not list him for transplant while actively smoking, but also do not use that as a reason to delay LVAD evaluation. Assess psychosocial support, cognition, compliance, and right ventricular function. If he is truly fixed at INTERMACS 3 and not improving, LVAD referral should proceed now rather than after recurrent shock.
2. What is his risk of right ventricular failure after LVAD, and how would you modify the surgical plan?
Read the worked answer
He is at moderate-to-high risk for post-LVAD RV failure: TAPSE 12 mm, RVSP 45 mmHg, RA 12 mmHg, CI 2.0 L/min/m2, and PVR 3.2 WU all point to impaired RV reserve, though warm extremities and low lactate are favorable. A RA/PCWP ratio of 0.46 and low RV stroke work would further increase concern. I would optimize volume with diuretics, continue milrinone or add inhaled pulmonary vasodilator (inhaled milrinone or nitric oxide) in the operating room, correct anemia and electrolytes, and assess tricuspid regurgitation and aortic insufficiency. Plan for a HeartMate 3 LVAD but have a temporary RVAD circuit available. If severe RV dysfunction persists despite optimization, consider biventricular support or defer isolated LVAD. Postoperatively, monitor CVP, CI, lactate, urine output, and echo frequently; early RVAD rescue is better than late.
3. What pre-LVAD optimization and post-implant monitoring would you prioritize?
Read the worked answer
Preop: complete dental and infection screening, nutrition, physical therapy, smoking cessation, and psychosocial evaluation; optimize diuresis to dry weight without causing AKI; continue inotrope; treat AF rate; ensure no active infection. Check aortic valve for insufficiency and consider concomitant repair if significant. Postop: manage anticoagulation with heparin bridge to warfarin, monitor for pump thrombosis and GI bleeding; assess RV function with echo and PA catheter; treat arrhythmias; early mobility; and watch for vasoplegia. Avoid excessive IV fluids. If he remains INTERMACS 3 and is not a transplant candidate, LVAD is appropriate; if he deteriorates to INTERMACS 1-2 with end-organ failure, temporary MCS and urgent evaluation are needed.