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. 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.