title: Right ventricular response to pulsatile load is associated with early right heart failure and mortality after left ventricular assist device.
abstract: Right ventricular (RV) adaptation to afterload is crucial for patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. We hypothesized that stratifying patients by RV pulsatile load, using pulmonary arterial compliance (PAC), and RV response to load, using the ratio of central venous to pulmonary capillary wedge pressure (CVP:PCWP), would identify patients at high risk for early right heart failure (RHF) and 6-month mortality after cf-LVAD.
  
  
  
  During the period from January 2008 to June 2014, we identified 151 patients at our center with complete hemodynamics prior to cf-LVAD. Pulsatile load was estimated using PAC indexed to body surface area (BSA), according to the formula: indexed PAC (PACi) = [SV / (PAsystolic- PAdiastolic)] / BSA, where SV is stroke volume and PA is pulmonary artery. Patients were divided into 4 hemodynamic groups by PACi and CVP:PCWP. RHF was defined as the need for unplanned RVAD, inotropic support ≥14 days or death due to RHF within 14 days. Risk factors for RHF and 6-month mortality were examined using logistic regression and Cox proportional hazards modeling.
  
  
  
  Sixty-one patients (40.4%) developed RHF and 34 patients (22.5%) died within 6 months. Patients with RHF had lower PACi (0.92 vs 1.17 ml/mm Hg/m2, p = 0.008) and higher CVP:PCWP (0.48 vs 0.37, p = 0.001). Higher PACi was associated with reduced risk of RHF (adjusted odds ratio [adj-OR] 0.61, 95% confidence interval [CI] 0.39 to 0.94, p = 0.025) and low PACi with increased risk of 6-month mortality (adjusted hazard ratio [adj-HR] 3.18, 95% CI 1.40 to 7.25, p = 0.006). Compared to patients with low load (high PACi) and adequate right heart response to load (low CVP:PCWP), patients with low PACi and high CVP:PCWP had an increased risk of RHF (OR 4.74, 95% CI 1.23 to 18.24, p = 0.02) and 6-month mortality (HR 8.68, 95% CI 2.79 to 26.99, p < 0.001).
  
  
  
  A hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA. Electronic address: edward.grandin@uphs.upenn.edu.
authors.forename: E Wilson
authors.initials: EW
authors.lastname: Grandin
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Payman
authors.initials: P
authors.lastname: Zamani
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Jeremy A
authors.initials: JA
authors.lastname: Mazurek
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Troutman
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Edo Y
authors.initials: EY
authors.lastname: Birati
authors.affiliation: Division of Cardiovascular Medicine, Northwestern University, Chicago, Illinois, USA.
authors.forename: Esther
authors.initials: E
authors.lastname: Vorovich
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Julio A
authors.initials: JA
authors.lastname: Chirinos
authors.affiliation: Division of Cardiovascular Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Ryan J
authors.initials: RJ
authors.lastname: Tedford
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Kenneth B
authors.initials: KB
authors.lastname: Margulies
authors.affiliation: Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Pavan
authors.initials: P
authors.lastname: Atluri
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: J Eduardo
authors.initials: JE
authors.lastname: Rame
mesh_terms: D004868:Equipment Failure; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006352:Heart Ventricles / Q000503:physiopathology*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery / Q000503:physiopathology*; D011669:Pulmonary Wedge Pressure; D011673:Pulsatile Flow / Q000502:physiology*; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D018497:Ventricular Dysfunction, Right / Q000209:etiology / Q000401:mortality / Q000628:therapy*
keywords: LVAD; pulmonary arterial compliance; pulsatile load; right heart failure; survival