Echo and Hemodynamic-Guided Ramp Test in a Left Ventricular Assist Device Carrier With Right Ventricular Failure and Aortic Regurgitation

The clinical outcomes of patients with left ventricular assist devices (LVAD) have steadily improved, unveiling late right ventricular failure (RVF) and aortic regurgitation (AR) as drivers of long-term mortality. The continuous-flow LVAD physiology and the patient's pre-existing features predispose to these complications, recently labeled hemodynamic-related events (HDREs). We present the case of an LVAD carrier complicated by both late RVF and AR, in which a comprehensive hemodynamic and echo-guided ramp test was carried out. A step-by-step standardized ramp test protocol is described with a focus on the interpretation of longitudinal changes in hemodynamic and echocardiographic parameters at different LVAD speeds. We emphasize the clinical relevance of a dynamic evaluation to stage these complex hemodynamic scenarios and to guide individualized management. The ramp test was instrumental to unmask the relative contribution of several morphofunctional components as limiting factors to optimal hemodynamics at different LVAD speeds and identified RVF as the prevailing limiting factor, suggesting the futility of aortic valve replacement. We highlight the coexistence of AR and RVF as a hard conundrum to face, with an ominous clinical impact. An in-depth characterization of HDRE's natural history will be pivotal to build preventive and mitigation strategies to improve the durability of pump-patient continuum.