title: Right ventricular afterload sensitivity dramatically increases after left ventricular assist device implantation: A multi-center hemodynamic analysis.
abstract: Right ventricular (RV) failure is a source of morbidity and mortality after left ventricular assist device (LVAD) implantation. In this study we sought to define hemodynamic changes in afterload and RV adaptation to afterload both early after implantation and with prolonged LVAD support.
  
  
  
  We reviewed right heart catheterization (RHC) data from participants who underwent continuous-flow LVAD implantation at our institutions (n = 244), excluding those on inotropic or vasopressor agents, pulmonary vasodilators or additional mechanical support at any RHC assessment. Hemodynamic data were assessed at 5 time intervals: (1) pre-LVAD (within 6 months); (2) early post-LVAD (0 to 6 months); (3) 7 to 12 months; (4) 13 to 18 months; and (5) very late post-LVAD (18 to 36 months).
  
  
  
  Sixty participants met the inclusion criteria. All measures of right ventricular load (effective arterial elastance, pulmonary vascular compliance and pulmonary vascular resistance) improved between the pre- and early post-LVAD time periods. Despite decreasing load and pulmonary artery wedge pressure (PAWP), RAP remained unchanged and the RAP:PAWP ratio worsened early post-LVAD (0.44 [0.38, 0.63] vs 0.77 [0.59, 1.0], p < 0.001), suggesting a worsening of RV adaptation to load. With continued LVAD support, both RV load and RAP:PAWP decreased in a steep, linear and dependent manner.
  
  
  
  Despite reducing RV load, LVAD implantation leads to worsened RV adaptation. With continued LVAD support, both RV afterload and RV adaptation improve, and their relationship remains constant over time post-LVAD. These findings suggest the RV afterload sensitivity increases after LVAD implantation, which has major clinical implications for patients struggling with RV failure.
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Brian A
authors.initials: BA
authors.lastname: Houston
authors.affiliation: Osler Medical Residency, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Rohan J
authors.initials: RJ
authors.lastname: Kalathiya
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Hsu
authors.affiliation: Osler Medical Residency, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Rahul
authors.initials: R
authors.lastname: Loungani
authors.affiliation: Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee, USA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Davis
authors.affiliation: Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Coffin
authors.affiliation: Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Haglund
authors.affiliation: Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee, USA.
authors.forename: Simon
authors.initials: S
authors.lastname: Maltais
authors.affiliation: Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Keebler
authors.affiliation: Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Leary
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Judge
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Gerin R
authors.initials: GR
authors.lastname: Stevens
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: John
authors.initials: J
authors.lastname: Rickard
authors.affiliation: Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Chris M
authors.initials: CM
authors.lastname: Sciortino
authors.affiliation: Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Glenn J
authors.initials: GJ
authors.lastname: Whitman
authors.affiliation: Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Russell
authors.affiliation: Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA. Electronic address: ryan.tedford@jmhi.edu.
authors.forename: Ryan J
authors.initials: RJ
authors.lastname: Tedford
mesh_terms: D006333:Heart Failure; D006353:Heart-Assist Devices; D006439:Hemodynamics; D006801:Humans; D012189:Retrospective Studies; D018497:Ventricular Dysfunction, Right
keywords: LVAD; pulmonary effective arterial elastance; pulmonary vascular compliance; right ventricular adapation; right ventricular load