Hemodynamic reserve predicts early right heart failure after LVAD implantation

https://doi.org/10.1016/j.healun.2022.07.003Get rights and content

Background

Early right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict early RHF have proven only modestly successful. Pharmacologic unloading of the left ventricle may be a risk stratification approach allowing for assessment of right ventricular and hemodynamic reserve.

Methods

We performed a multicenter, retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. Only those who underwent vasodilator testing with nitroprusside during their preimplant right heart catheterization were included (n = 70). Multivariable logistic regression was used to determine independent predictors of early RHF as defined by Mechanical Circulatory Support–Academic Research Consortium.

Results

Twenty-seven patients experienced post-LVAD early RHF (39%). Baseline clinical characteristics were similar between patients with and without RHF. Patients without RHF, however, achieved higher peak stroke volume index (SVI) (30.1 ± 8.8 vs 21.7 ± 7.4 mL/m2; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m2) during nitroprusside administration. Multivariable analysis revealed that peak SVI was significantly associated with early RHF, demonstrating a 16% increase in risk of early RHF per 1 ml/m2 decrease in SVI. A follow up cohort of 10 consecutive patients from July 2020 to October 2021 resulted in all patients being categorized appropriately in regards to early RHF versus no RHF according to peak SVI.

Conclusion

Peak SVI with nitroprusside administration was independently associated with post-LVAD early RHF while resting hemodynamics were not. Vasodilator testing may prove to be a strong risk stratification tool when assessing LVAD candidacy though additional prospective validation is needed.

Section snippets

Methods

After IRB approval, we performed a multicenter retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. The three centers included were the Medical University of South Carolina (2016-2020), the University of Pennsylvania (2017-2020) and the University Health Network in Toronto (2011-2020). Only patients who underwent clinically indicated vasodilator testing with nitroprusside within one year of LVAD implant as part of their advanced

Results

Of the 70 patients included, 27 patients developed early RHF (39%) after LVAD implantation, including 14 patients who required right ventricular assist device (RVAD) support (20%). The mean age of the cohort was 49 ± 14 years with the majority of patients being men (77%) and with nonischemic cardiomyopathy (74%). Early RHF differed by centers, device type, and time between RHC and LVAD implant. There were no other significant difference in demographics, preimplant clinical characteristics, RHF

Discussion

The major findings of our study can be summarized as follows: (1) Early postimplant RHF was common in our cohort, (2) baseline clinical characteristics, echocardiographic and hemodynamic measures were not strongly and independently predictive of early RHF, and (3) hemodynamics at the peak of nitroprusside vasodilator administration, particularly peak SVI, was a good discriminator of those who did and did not develop early postimplant RHF. These findings suggest that vasodilator testing and

Conclusions

In summary, peak SVI during nitroprusside infusion was significantly associated with post-LVAD early RHF. These findings suggest vasodilator testing and acute pharmacologic LV unloading may be useful in risk stratification prior to LVAD implantation in patients with elevated pulmonary pressures and should be prospectively studied.

Author contributions

Jacob M. Read, MD: Study Conception/Design, Data Acquisition, Data Analysis, Data Interpretation, Drafting of manuscript, Final approval of manuscript. Nnamdi I. Azih, MD: Study Conception/Design, Data Acquisition, Data Analysis, Data Interpretation, Drafting of manuscript, Final approval of manuscript. Carli J. Peters, MD: Data Acquisition, Data Analysis, Critical revision of manuscript, Final approval of manuscript. Vikram Gurtu, MD: Data Acquisition, Data Analysis, Critical revision of

Disclosures

All authors report no direct conflicts of interest related to this manuscript. Dr. Tedford reports general disclosures to include consulting relationships with Medtronic, Abbott, Aria CV Inc., Arena Pharmaceuticals, Acceleron, Itamar, Edwards LifeSciences, Eidos Therapeutics, Lexicon Pharmaceuticals, Gradient and United Therapeutics. Dr. Tedford is on a steering committee for Acceleron and Abbott as well as a research advisory board for Abiomed. He also does hemodynamic core lab work for

Financial disclosures

No grants, contracts, or other financial support was received for this manuscript.

Acknowledgments

We wish to acknowledge our mechanical circulatory support teams who help us care for this complex patient population.

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