Right ventricular response to pulsatile load is associated with early right heart failure and mortality after left ventricular assist device

E. Wilson Grandin, Payman Zamani, Jeremy A. Mazurek, Gregory S. Troutman, Edo Y. Birati, Esther Vorovich, Julio A. Chirinos, Ryan J. Tedford, Kenneth B. Margulies, Pavan Atluri, J. Eduardo Rame

Research output: Contribution to journalArticle

Abstract

Background Right ventricular (RV) adaptation to afterload is crucial for patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. We hypothesized that stratifying patients by RV pulsatile load, using pulmonary arterial compliance (PAC), and RV response to load, using the ratio of central venous to pulmonary capillary wedge pressure (CVP:PCWP), would identify patients at high risk for early right heart failure (RHF) and 6-month mortality after cf-LVAD. Methods During the period from January 2008 to June 2014, we identified 151 patients at our center with complete hemodynamics prior to cf-LVAD. Pulsatile load was estimated using PAC indexed to body surface area (BSA), according to the formula: indexed PAC (PACi) = [SV / (PAsystolic – PAdiastolic)] / BSA, where SV is stroke volume and PA is pulmonary artery. Patients were divided into 4 hemodynamic groups by PACi and CVP:PCWP. RHF was defined as the need for unplanned RVAD, inotropic support ≥14 days or death due to RHF within 14 days. Risk factors for RHF and 6-month mortality were examined using logistic regression and Cox proportional hazards modeling. Results Sixty-one patients (40.4%) developed RHF and 34 patients (22.5%) died within 6 months. Patients with RHF had lower PACi (0.92 vs 1.17 ml/mm Hg/m2, p = 0.008) and higher CVP:PCWP (0.48 vs 0.37, p = 0.001). Higher PACi was associated with reduced risk of RHF (adjusted odds ratio [adj-OR] 0.61, 95% confidence interval [CI] 0.39 to 0.94, p = 0.025) and low PACi with increased risk of 6-month mortality (adjusted hazard ratio [adj-HR] 3.18, 95% CI 1.40 to 7.25, p = 0.006). Compared to patients with low load (high PACi) and adequate right heart response to load (low CVP:PCWP), patients with low PACi and high CVP:PCWP had an increased risk of RHF (OR 4.74, 95% CI 1.23 to 18.24, p = 0.02) and 6-month mortality (HR 8.68, 95% CI 2.79 to 26.99, p < 0.001). Conclusions A hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.

Original languageEnglish (US)
Pages (from-to)97-105
Number of pages9
JournalJournal of Heart and Lung Transplantation
Volume36
Issue number1
DOIs
StatePublished - Jan 1 2017

Keywords

  • LVAD
  • pulmonary arterial compliance
  • pulsatile load
  • right heart failure
  • survival

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine
  • Transplantation

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  • Cite this

    Grandin, E. W., Zamani, P., Mazurek, J. A., Troutman, G. S., Birati, E. Y., Vorovich, E., Chirinos, J. A., Tedford, R. J., Margulies, K. B., Atluri, P., & Rame, J. E. (2017). Right ventricular response to pulsatile load is associated with early right heart failure and mortality after left ventricular assist device. Journal of Heart and Lung Transplantation, 36(1), 97-105. https://doi.org/10.1016/j.healun.2016.06.015