Department of Medicine.
Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
J Heart Lung Transplant. 2022 Dec;41(12):1716-1726. doi: 10.1016/j.healun.2022.07.003. Epub 2022 Jul 16.
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.
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.
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/m; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m) 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/m 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.
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.
左心室辅助装置（LVAD）植入后早期右心衰竭（RHF）仍然是发病率和死亡率的主要原因，但预测早期 RHF 的努力证明效果甚微。左心室的药物卸载可能是一种风险分层方法，可评估右心室和血液动力学储备。
我们对 2011 年 10 月至 2020 年 4 月期间接受连续血流 LVAD 植入的患者进行了多中心回顾性分析。仅纳入在植入前右心导管检查期间接受硝普钠血管扩张剂测试的患者（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 的独立预测因子。
27 例患者发生 LVAD 后早期 RHF（39%）。RHF 患者和无 RHF 患者的基线临床特征相似。然而，无 RHF 患者在硝普钠给药时达到更高的峰值每搏输出量指数（SVI）（30.1±8.8 vs 21.7±7.4 ml/m；p<0.001；AUC：0.78；最佳切点：22.1 ml/m）。多变量分析显示，峰值 SVI 与早期 RHF 显著相关，SVI 每降低 1 ml/m，早期 RHF 的风险增加 16%。2020 年 7 月至 2021 年 10 月连续 10 例患者的随访队列，根据峰值 SVI 将所有患者恰当地分类为早期 RHF 与无 RHF。
硝普钠给药时的峰值 SVI 与 LVAD 后早期 RHF 独立相关，而静息血液动力学则无。血管扩张剂测试在评估 LVAD 候选者时可能成为一种强有力的风险分层工具，但需要进一步的前瞻性验证。
