title: Clinical Outcomes of Patients Treated With Pulmonary Vasodilators Early and in High Dose After Left Ventricular Assist Device Implantation.
abstract: Right ventricular failure (RVF) is common after left ventricular assist device (LVAD) implantation and a major determinant of adverse outcomes. Optimal perioperative right ventricular (RV) management is not well defined. We evaluated the use of pulmonary vasodilator therapy during LVAD implantation. We performed a retrospective analysis of continuous-flow LVAD implants and pulmonary vasodilator use at our institution between September 2004 and June 2013. Preoperative RVF risk was assessed using recognized variables. Sixty-five patients (80% men, 50 ± 14 years) were included: 52% HeartWare ventricular assist device (HVAD), 11% HeartMate II (HMII), 17% VentrAssist, 20% Jarvik. Predicted RVF risk was comparable with contemporary LVAD populations: 8% ventilated, 14% mechanical support, 86% inotropes, 25% BUN >39 mg/dL, 23% bilirubin ≥2 mg/dL, 31% RV : LV (left ventricular) diameter ≥0.75, 27% RA : PCWP (right atrium : pulmonary capillary wedge pressure) >0.63, 36% RV stroke work index <6 gm-m/m(2)/beat. The majority (91%) received pulmonary vasodilators early and in high dose: 72% nitric oxide, 77% sildenafil (max 200 ± 79 mg/day), 66% iloprost (max 126 ± 37 μg/day). Median hospital stay was 26 (21) days. No patient required RV mechanical support. Of six (9%) patients meeting RVF criteria based on prolonged need for inotropes, four were transplanted, one is alive with an LVAD at 3 years, and one died on day 35 of intracranial hemorrhage. Two-year survival was 77% (92% for HMII/HVAD): transplanted 54%, alive with LVAD 21%, recovery/explanted 2%. A low incidence of RVF and excellent outcomes were observed for patients treated early during LVAD implantation with combination, high-dose pulmonary vasodilators. The results warrant further investigation in a randomized controlled study.
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Critoph
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Gillian
authors.initials: G
authors.lastname: Green
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Helen
authors.initials: H
authors.lastname: Hayes
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Jay
authors.initials: J
authors.lastname: Baumwol
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Kaitlyn
authors.initials: K
authors.lastname: Lam
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Larbalestier
authors.affiliation: Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Wellington Street, Perth, Western Australia, Australia.
authors.forename: Sharon
authors.initials: S
authors.lastname: Chih
mesh_terms: D000328:Adult; D004334:Drug Administration Schedule; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011651:Pulmonary Artery / Q000187:drug effects* / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014664:Vasodilation / Q000187:drug effects*; D014665:Vasodilator Agents / Q000008:administration & dosage*; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis / Q000503:physiopathology / Q000517:prevention & control*; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right / Q000187:drug effects*
chemical_list: D014665:Vasodilator Agents
keywords: Left ventricular assist device; Pulmonary vasodilators; Right heart failure