Early-Phase Trajectory of Right Ventricular Hemodynamics during Microaxial Flow Pump Support for Cardiogenic Shock

Right ventricular dysfunction (RVD) is common in cardiogenic shock and associated with poor outcomes. However, early RVD trajectories after initiation of percutaneous ventricular assist device (PVAD) support and their prognostic implications remain unclear.

The objectives of the study was to characterize the trajectory of hemodynamic RVD (hRVD) during the first 24 hours after PVAD initiation and evaluate its association with outcomes.

This study included patients with cardiogenic shock treated with PVAD from the UNLOADERS-PVAD registry. RVD was hemodynamically defined by an elevated right atrial pressure ≥15 mm Hg and/or a low pulmonary artery pulsatility index <0.9. Hemodynamic assessments were performed pre-PVAD, early post-PVAD, and 24 h post-PVAD. The primary endpoint was a composite of all-cause mortality or reintroduction of mechanical circulatory support after PVAD discontinuation within 30 days.

Among 463 patients with available data, hRVD was present in 52% (63/121) pre-PVAD, decreased to 48% (211/443) early post-PVAD, and further to 39% (169/436) at 24 h post-PVAD. hRVD trajectories were heterogeneous, with improvement predominating over deterioration. The median follow-up from PVAD implantation was 27 (12-30) days. Persistent or worsening hRVD at 24 h post-PVAD was associated with a higher risk of the primary endpoint. Elevated right atrial pressure was associated with adverse outcomes only at 24 h post-PVAD, whereas low pulmonary artery pulsatility index was consistently associated with adverse outcomes across all time points.

In patients with cardiogenic shock supported by PVAD, the early trajectory of hRVD provides prognostic information. Persistent or worsening hRVD at 24 hours identifies high-risk patients and may guide timely escalation of right-heart-targeted therapies. (UNLOADERS-PVAD [Unloading and Heart Recovery with Advanced Mechanical Circulatory Support: Optimal Management of Percutaneous Ventricular Assist Device] UMIN000052966).