**3. Management of Recurrent Heart Failure**

Recurrent HF is a morbid event that limits functional capacity and survival, and therefore warrants aggressive treatment. However, management depends on the underlying etiology (**Figure 9**). Importantly, assessment of post-LVAD HF should begin prior to implant, with attention given to optimization of RV function and planning for the management of significant valvular disease at the time of surgery.

The simplest tenet of LVAD management is ensuring an appropriate LVAD speed, the only pump parameter that can be adjusted by providers. If the speed is too low, cardiac output will remain insufficient, resulting in persistent HF. By contrast, if the speed is too high, HF can result from worsening RV dysfunction (**Figure 5**) and/or worsening valve disease. Though widely used and given a Class I recommendation in the MCS guidelines [68], data supporting the utility of ramp echocardiographic studies are limited. Further, recent evidence suggests that hemodynamic-guided management by right heart catheterization may be superior to echo-guided ramp testing [84]. Ultimately, more data are needed.

## **3.1 Management of right heart failure**

Preemptive strategies to mitigate right HF post-LVAD (whether early or late) are an essential component in management. Preoperatively, this consists of optimizing RV preload (lowering CVP), and afterload (lowering PVR and left heart filling pressures). Intraoperative strategies include judicious fluid and blood product use, and limiting time on CPB. Immediately post-LVAD, RV support with inotropes and pulmonary vasodilators is routine, as is managing vasoplegia to limit myocardial ischemia, and optimizing LVAD speed [85].

Chronic management of the LVAD patient includes maintenance of proper RV preload with diuretics, treatment of hypertension to permit optimal pump function and resumption of neurohumoral blockade, which can improve functional capacity and survival [86, 87]. Collectively these approaches are likely to limit the incidence of recurrent HF, though little data exists to support this indication. Once right HF develops, management differs depending on timing: more aggressive strategies are favored early and can frequently yield good outcomes, while late right HF usually merits a more conservative approach and has a more uniformly poor prognosis.
