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

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• 作者：E. Wilson Grandin ; MD ; MPH^a ; ^{edward.grandin@uphs.upenn.edu} ; Payman Zamani ; MD ; MTR^a ; Jeremy A. Mazurek ; MD^a ; Gregory S. Troutman ; BS^a ; Edo Y. Birati ; MD^a ; Esther Vorovich ; MD ; MSCE^b ; Julio A. Chirinos ; MD ; PhD^a ; Ryan J. Tedford ; MD^c ; Kenneth B. Margulies ; MD^a ; Pavan Atluri ; MD^d ; J. Eduardo Rame ; MD ; MPhil^a
• 关键词：LVAD ; pulmonary arterial compliance ; pulsatile load ; right heart failure ; survival
• 刊名：The Journal of Heart and Lung Transplantation
• 出版年：2017
• 出版时间：January 2017
• 年：2017
• 卷：36
• 期：1
• 页码：97-105
• 全文大小：334 K
• 卷排序：36

文摘

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.MethodsDuring 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.ResultsSixty-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).ConclusionsA hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.