Background

Early right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict early RHF have proven only modestly successful. Pharmacologic unloading of the left ventricle may be a risk stratification approach allowing for assessment of right ventricular and hemodynamic reserve.

Methods

We performed a multicenter, retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. Only those who underwent vasodilator testing with nitroprusside during their preimplant right heart catheterization were included (n = 70). Multivariable logistic regression was used to determine independent predictors of early RHF as defined by Mechanical Circulatory Support–Academic Research Consortium.

Results

Twenty-seven patients experienced post-LVAD early RHF (39%). Baseline clinical characteristics were similar between patients with and without RHF. Patients without RHF, however, achieved higher peak stroke volume index (SVI) (30.1 ± 8.8 vs 21.7 ± 7.4 mL/m²; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m²) during nitroprusside administration. Multivariable analysis revealed that peak SVI was significantly associated with early RHF, demonstrating a 16% increase in risk of early RHF per 1 ml/m² decrease in SVI. A follow up cohort of 10 consecutive patients from July 2020 to October 2021 resulted in all patients being categorized appropriately in regards to early RHF versus no RHF according to peak SVI.

Conclusion

Peak SVI with nitroprusside administration was independently associated with post-LVAD early RHF while resting hemodynamics were not. Vasodilator testing may prove to be a strong risk stratification tool when assessing LVAD candidacy though additional prospective validation is needed.

中文翻译：

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血流动力学储备可预测 LVAD 植入后早期右心衰竭

 背景

早期右心衰竭 (RHF) 仍然是左心室辅助装置 (LVAD) 植入后发病率和死亡率的主要来源，但预测早期 RHF 的努力已被证明只取得了一定的成功。左心室药物卸载可能是一种风险分层方法，可以评估右心室和血流动力学储备。

 方法

我们对 2011 年 10 月至 2020 年 4 月接受连续流 LVAD 植入的患者进行了多中心回顾性分析。仅纳入了在植入前右心导管插入术期间接受硝普钠血管扩张测试的患者(n = 70)。多变量逻辑回归用于确定机械循环支持学术研究联盟定义的早期 RHF 的独立预测因素。

 结果

27 名患者经历 LVAD 后早期 RHF (39%)。患有和不患有 RHF 的患者的基线临床特征相似。然而，无 RHF 的患者在硝普钠给药期间达到了更高的峰值每搏输出量指数 (SVI)（30.1 ± 8.8 vs 21.7 ± 7.4 mL/m 2 ； p < 0.001；AUC：0.78；最佳切点：22.1 mL/m ^{2 ）} 。多变量分析显示，SVI 峰值与早期 RHF 显着相关，SVI 每降低 1 ml/m ² ，早期 RHF 风险就会增加 16%。从 2020 年 7 月到 2021 年 10 月，对 10 名连续患者进行了随访，根据峰值 SVI，所有患者都被适当分类为早期 RHF 与无 RHF。

 结论

硝普钠给药后的峰值 SVI 与 LVAD 后早期 RHF 独立相关，而静息血流动力学则不然。尽管需要额外的前瞻性验证，但在评估 LVAD 候选资格时，血管扩张剂测试可能被证明是一个强大的风险分层工具。