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Optimal Hemodynamics and Risk of Severe Outcomes Post-Left Ventricular Assist Device Implantation

Andrew N Rosenbaum1,2, Bradley W Ternus3, John M Stulak4

  • 1From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

ASAIO Journal (American Society for Artificial Internal Organs : 1992)
|February 25, 2022
PubMed

Insights

Optimizing pre-implant hemodynamics, including right ventricular stroke work index, right atrial pressure, and blood urea nitrogen, significantly improves outcomes for continuous flow left ventricular assist device patients. Achieving full optimization reduces adverse events and enhances survival.

Area of Science:

  • Cardiology
  • Mechanical Circulatory Support
  • Medical Devices

Background:

  • Limited data exists on pre-implant hemodynamic optimization for continuous flow left ventricular assist device (CF-LVAD) patients regarding patient-centered outcomes.
  • Hemodynamic status before CF-LVAD implantation is critical for post-operative success.

Purpose of the Study:

  • To identify pre-implant hemodynamic predictors of adverse outcomes in CF-LVAD patients.
  • To establish optimal hemodynamic parameters for improved patient-centered outcomes after CF-LVAD implantation.

Main Methods:

  • A retrospective analysis of consecutive patients undergoing CF-LVAD implantation between 2007 and 2017.
  • Logistic regression modeling to identify predictors of a composite endpoint including need for right ventricular assist device, hemodialysis at 90 days, and 30-day mortality.
  • Evaluation of hemodynamic variables (right ventricular stroke work index, right atrial pressure) and laboratory studies (blood urea nitrogen) immediately pre-LVAD.

Main Results:

  • Right ventricular stroke work index (RVSWI), right atrial pressure (RAP), and blood urea nitrogen (BUN) were significant predictors of the composite endpoint (p < 0.01).
  • Optimal dichotomization points were identified as RVSWI ≤ 500 mmHg*ml*m-2, RAP ≤ 12 mmHg, and BUN ≤ 40 mg/dL.
  • A model incorporating these three parameters showed an AUC of 0.77 for predicting the composite endpoint. Patients with fewer optimized parameters had significantly higher odds of adverse outcomes and lower 1-year survival.

Conclusions:

  • Low RVSWI, high RAP, and high BUN are independently associated with adverse outcomes and mortality after CF-LVAD implantation.
  • Pre-implant optimization of these hemodynamic parameters is crucial for improving patient-centered outcomes.
  • A stepwise association exists between the number of optimized parameters and the severity of post-implant adverse events, highlighting the importance of comprehensive hemodynamic management.

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