Preoperative pulmonary artery pulsatility index and early right ventricular failure after left ventricular assist device implantation: A systematic review and meta-analysis.

BACKGROUND

Right ventricular failure (RVF) remains a major complication after left ventricular assist device (LVAD) implantation. The pulmonary artery pulsatility index (PAPi) is increasingly used as a hemodynamic marker of right ventricular function and reserve, but measurement conditions, thresholds, and RVF definitions vary. We evaluated the association between lower preoperative PAPi and early RVF after LVAD implantation.

METHODS

We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines. PubMed, Embase, Cochrane CENTRAL, and Scopus were searched from inception through March 22, 2026. Eligible studies evaluated preoperative pulmonary artery pulsatility index and early right ventricular failure after left ventricular assist device implantation. The primary analysis was restricted to baseline measurements with comparable effect estimates. Expanded exploratory analyses incorporated dynamic and optimized measurements.

RESULTS

Eight studies met the inclusion criteria, of which 6 were included in the quantitative synthesis. In the primary analysis, lower baseline pulmonary artery pulsatility index was associated with higher odds of early right ventricular failure (odds ratio, 8.20; 95% confidence interval, 1.29-52.26; p=0.026), with substantial heterogeneity. Leave-one-out sensitivity analysis showed a consistent association with reduced heterogeneity (odds ratio, 3.31; 95% confidence interval, 1.87-5.85; p<0.001). Expanded exploratory analysis confirmed the direction of association.

CONCLUSIONS

Lower pulmonary artery pulsatility index is associated with early right ventricular failure after left ventricular assist device implantation. Substantial heterogeneity in thresholds, measurement conditions, and outcome definitions limits interpretation. We propose a standardized framework for hemodynamic assessment and outcome reporting in future studies.