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Echocardiographic Ramp test for continuous-flow left ventricular assist devices: do loading conditions matter?

Sirtaz Adatya1, Christopher T Holley1, Samit S Roy1

  • 1Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.

JACC. Heart Failure
|March 16, 2015
PubMed
Summary

Aortic insufficiency (AI) and elevated mean arterial pressure (MAP) can cause false positive results for flow obstruction during echocardiographic ramp speed tests in patients with continuous-flow left ventricular assist devices.

Keywords:
aortic insufficiencycontinuous-flow left ventricular assist deviceechocardiographic ramp testheart failurehemodynamicsmean arterial pressure thrombosis

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Area of Science:

  • Cardiology
  • Medical Devices
  • Echocardiography

Background:

  • Ramp speed tests assess left ventricular assist device (LVAD) function by measuring left ventricular end-diastolic diameter (LVEDD) changes with increasing device speeds.
  • Failure to reduce LVEDD indicates potential pump obstruction, a critical complication in LVAD patients.
  • Aortic insufficiency (AI) and elevated mean arterial pressure (MAP) can impair the ability to effectively unload the left ventricle during ramp tests.

Purpose of the Study:

  • To determine if continuous aortic insufficiency (AI) or elevated mean arterial pressure (MAP) are associated with false positive results for flow obstruction in echocardiographic ramp speed tests.
  • To evaluate the impact of abnormal loading conditions on the interpretation of LVAD ramp tests.
  • To identify predictors of device obstruction in continuous-flow LVADs.

Main Methods:

  • Echocardiographic ramp speed tests were performed on patients with continuous-flow LVADs.
  • Left ventricular end-diastolic diameter (LVEDD) was plotted against device speed, and the slope of the linear function was calculated.
  • Receiver-operator characteristic (ROC) curves were used to assess the predictive value of LVEDD slope and other parameters for device obstruction, with device thrombosis confirmed by direct visualization.

Main Results:

  • Abnormal LVEDD slopes (≥-0.16), indicative of obstruction, were observed in 36 out of 78 ramp tests (46%), with 18 true positives and 18 false positives.
  • Patients with AI exhibited significantly flatter LVEDD slopes (-0.14 ± 0.17) compared to those without AI (-0.25 ± 0.11), suggesting obstruction despite similar lactate dehydrogenase levels.
  • Elevated MAP (≥85 mm Hg) also correlated with abnormal LVEDD slopes, and combining LVEDD slope with lactate dehydrogenase concentration yielded a high area under the ROC curve (0.96) for predicting device obstruction.

Conclusions:

  • Abnormal loading conditions, specifically AI and elevated MAP, can lead to false positive interpretations of flow obstruction during LVAD ramp speed tests.
  • These findings highlight the importance of considering hemodynamic factors when interpreting ramp test results in LVAD patients.
  • Accurate assessment of LVAD function requires accounting for conditions that affect left ventricular filling and unloading.