*3.1.2 Late right heart failure*

There is almost no substantive data guiding management of late right HF. First, it is important to identify the cause of right HF (**Figure 2**). LVAD speed should be optimized and arrhythmias managed as indicated [89]. Importantly, the only manifestation of ventricular tachyarrhythmias in an LVAD patient may be HF. Pulmonary hypertension usually improves with offloading of the LV, but could worsen in the setting of MR. However, most cases of late right HF are likely due to intrinsic RV dysfunction in the myopathic heart.

As with early right HF, the cornerstone of therapy is diuresis. However, this is often insufficient and many patients require initiation of inotropic therapy. In patients developing late right HF in the STS-INTERMACS database, 33–50% required inotropic support [45]. Unfortunately, inotrope use portends a very poor prognosis with substantially elevated mortality even beyond those with late right HF that do not require inotropes [33, 45]. The need for extended inotrope use also increases the risk of infection due to chronic indwelling intravenous catheter placement, and may be associated with poorer functional status and QOL, though data are lacking. As no pumps are approved for hospital discharge, RVAD support is virtually never employed in late right HF, being used in <0.2% of those in the STS-INTERMACS database [45].
