title: Echocardiographic Ramp test for continuous-flow left ventricular assist devices: do loading conditions matter?
abstract: OBJECTIVE
  This study investigated whether continuous AI and/or elevated mean arterial pressure (MAP) were associated with false positive results for flow obstruction in echocardiographic ramp speed tests in patients with a continuous-flow left ventricular assist device.
  
  
  BACKGROUND
  Failure to reduce the left ventricular end-diastolic diameter (LVEDD) with increasing device speeds in a ramp test is predictive of pump obstruction. Aortic insufficiency (AI) or increased MAP can diminish the ability to unload the left ventricle.
  
  
  METHODS
  LVEDD was plotted against device speed, and a linear function slope was calculated. A flat LVEDD slope (≥-0.16) was considered abnormal (suggestive of obstruction). Ramp test results were compared in patients with or without either AI or increased MAP at baseline speed, and receiver-operator characteristic (ROC) curves were constructed for predictors of device obstruction. Device thrombosis was confirmed by direct visualization of clot at explantation or on inspection by the manufacturer.
  
  
  RESULTS
  Of 78 ramp tests (55 patients), 36 were abnormal (18 true positive, 18 false positive), and 42 were normal (37 true negative, 5 false negative). In patients with AI, LVEDD slope was -0.14 ± 0.17, which was consistent with device obstruction (vs. -0.25 ± 0.11 in patients without AI; p < 0.001), despite no difference in mean lactate dehydrogenase concentration between the 2 groups (1,301 ± 1,651 U/l vs. 1,354 ± 1,365 U/l; p = 0.91). Area under the ROC curve (AUC) for LVEDD slope was 0.76 and improved to 0.88 after removal of patients with AI from the study. LVEDD slope in patients with MAP ≥85 mm Hg was similar to that for device obstruction (-0.18 ± 0.07) and was abnormal in 6 of the 12 ramp tests performed. Combining LVEDD slope with lactate dehydrogenase concentration increased the AUC to 0.96 as an indicator of device obstruction.
  
  
  CONCLUSIONS
  Abnormal loading conditions due to AI or elevated MAP may result in false positive ramp tests.
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota. Electronic address: snadatya@umn.edu.
authors.forename: Sirtaz
authors.initials: S
authors.lastname: Adatya
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Holley
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Samit S
authors.initials: SS
authors.lastname: Roy
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Hirad
authors.initials: H
authors.lastname: Yarmohammadi
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Amy
authors.initials: A
authors.lastname: Feng
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Peter
authors.initials: P
authors.lastname: Eckman
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Monica
authors.initials: M
authors.lastname: Colvin-Adams
authors.affiliation: Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Ranjit
authors.initials: R
authors.lastname: John
authors.affiliation: Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington.
authors.forename: Carolina
authors.initials: C
authors.lastname: Masri
mesh_terms: D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging; D062186:Arterial Pressure / Q000502:physiology; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011475:Prosthesis Failure; D012372:ROC Curve; D013927:Thrombosis / Q000000981:diagnostic imaging
keywords: aortic insufficiency; continuous-flow left ventricular assist device; echocardiographic ramp test; heart failure; hemodynamics; mean arterial pressure thrombosis