Inadequate left ventricular unloading during ramp is associated with hospitalization or death during left ventricular assist device support

Abstract

A combined right and left‐sided heart catheterization (RHC/LHC) protocol was recently reported to optimize patients supported by left ventricular assist device (LVAD). Using this platform, we sought to evaluate the prognostic significance of several hemodynamic indices, including left ventricular end‐diastolic pressure (LVEDP) and transaortic gradient (peak aortic pressure ‐ peak left ventricular pressure in systole, TAG). We evaluated all patients undergoing RHC/LHC at our institution from 2015 through 2018, and comprehensive clinical data were obtained. Primary end points were (1) a composite outcome that included hospitalization or death and (2) 1‐year overall survival after catheterization. Forty‐two patients were included in the analysis. Optimization resulted in normalization of hemodynamic parameters; all variables were significantly improved from baseline (P ≤ .05). On univariate modeling, final LVEDP was associated with the primary end point (hazard ratio [HR], 1.2 per 1‐mm Hg increase; 95% CI, 1.1‐1.3; P = .002). After adjusting for LVAD speed, TAG, and cardiac index in a multivariate model, the association between LVEDP and the composite end point remained significant (HR, 1.2 per 1‐mm Hg increase; 95% CI, 1.1‐1.4; P = .001). In the setting of LVAD support, inadequate LV unloading was a significant marker of poor outcomes with time, suggesting that LVEDP is a central prognostic marker in this population.

Impella^®-Assisted Revascularization of Unprotected Left Main Coronary Artery-Acute Myocardial Infarction Leading to Cardiogenic Shock

“…The hazard ratio of cardiovascular events increases by 1.2 for every 1-mmHg increase in the LVEDP 12) . Since the diastolic pressure time index, a useful index of myocardial oxygen supply, is calculated by integrating the difference between the instantaneous aortic diastolic BP and LV diastolic pressure with diastolic time 13) , an increase in LV diastolic pressure, including LVEDP, may result in a decrease in the myocardial oxygen supply.…”

Considerations of valvular heart disease in children with ventricular assist devices

“…The extra regurgitant volume may also lead to increased mitral regurgitation (MR), less emptying and decompression of the left atrium and pulmonary venous bed, increased pulmonary artery pressure and right ventricle workload, right ventricular failure, and congestive heart failure symptoms. Aortic insufficiency in left ventricle assist device (LVAD) patients can lead to an increase in left ventricle end-diastolic pressures, which has been associated with poorer clinical outcomes ( 8 ). Aortic valve insufficiency in adult VAD patients develops over time and has been associated with poor clinical outcomes including increased mortality ( 9 , 10 ).…”

Implication of hemodynamic ramp tests in patients with left ventricular assist devices

“…Rosenbaum and colleagues demonstrated that the inadequate left ventricular unloading, defined as left ventricular end-diastolic pressure (LVEDP) >16 mm Hg, despite device speed adjustment, was associated with poor clinical outcomes during LVAD supports. 1 Several concerns have been raised.…”