Pump Speed Optimization in Stable Patients with a Left Ventricular Assist Device

Abstract

Optimal left ventricular assist device (LVAD) functioning and preservation of right ventricular (RV) function are major survival determinants in destination therapy (DT)-LVAD recipients. Currently, the indication for routine pump speed optimization in stable patients and its effect on RV function at follow-up remain underexplored. Hemodynamically stable patients (N = 17, age 61 [interquartile range {IQR} 51-66] years; 13 [77%] male) underwent a routine speed ramp test. Echocardiographic images were obtained at incremental speed settings to determine optimal pump speed. In 8 patients (47%), LVAD speed could be optimized. In these patients, RV fractional area change (26% [IQR 23-31] to 35% [IQR 27-45], p = 0.04) and RV longitudinal peak systolic strain (-13% [IQR -16 to -9] to -17% [IQR -18 to -11], p = 0.02) at 3 months follow-up improved without RV dilatation. Furthermore, N-terminal pro-brain natriuretic peptide level decreased (3,162 [IQR 1,336-4,487] ng/L to 2,294 [IQR 1,157-3,810] ng/L, p = 0.02). No significant follow-up changes were found in patients without indication for speed adjustment. In conclusion, routine evaluation of optimal LVAD speed reveals the potential of speed optimization in a substantial proportion of stable LVAD-DT patients and can improve RV function.

Clinical implications of hemodynamic assessment during left ventricular assist device therapy

“…The efficacy of speed optimization on RV function was also reported in a small number of HVAD patients. At 3 months following speed optimization by echocardiographic ramp test, RV fractional area change and RV longitudinal peak systolic strain were improved, along with a significant decrease in N-terminal pro-brain natriuretic peptide level [66]. Whether hemodynamic optimization is associated with prevention of chronic RVF and better survival remains unknown.…”

Changes in left and right ventricular two-dimensional echocardiographic speckle-tracking indices in pediatric LVAD population: A retrospective clinical study

“…Results evidenced that the benefits provided by LVAD decreased over time for both LV and RV in accordance with our previous work conducted using standard echocardiographic parameters. 14,22,23 In fact, LVEF increase was followed by an improvement in RVFAC at 1 and 3 months follow-up, while LVEF worsening was followed by a decrease in RVFAC at 6 months (Figure 4). Similarly, LV-GLS increase was followed by RVFW-LS increase at 1 month, while LV-GLS worsening was followed by RVFW-LS worsening at 6 months (Figure 5).…”

“…However, most of these studies are focused on the research of predictors of RV failure post LVAD implantation, and most important, all of them are focused on adults. [11][12][13][14][15][16] Our objective was to study the changes in 2DSTEderived myocardial tissue deformation indices of LV and RV during short-term and long-term support in children with pulsatile-flow LVAD.…”

Commentary: Optimize the speed, enhance the patient's life

“…Current evidence suggests that a significant number of patients with VADs may be living with suboptimal device settings from a hemodynamic standpoint, which may lead to limited activity or to more frequent heart failure exacerbations. 7,8 The solution to this problem requires recognizing that left VAD therapy is a dynamic process. Although to an extent device function is inherently sensitive to the patient's preload, afterload, and native contractility, device parameters also need to be adjusted by clinicians in accordance with the patient's physiology, including volume status and right heart function.…”

“…As such, conceptualizing hemodynamically guided VAD speed changes before a patient's condition deteriorates further as a preemptive optimization strategy may lead to overall reduction in VAD-related adverse events and an improvement in quality of life, although its true effect remains to be evaluated prospectively in larger cohorts. 8,9 This preemptive strategy has been an integral practice at our institution during the last 5 years, as we have grown more enthusiastic about evaluating hemodynamics in our patients with VADs, which has often led to changes in our management that would not have been apparent with other modalities.…”