Implications of Early Hemodynamic Profiling after Continuous-Flow Left Ventricular Assist Device Implantation

Purpose Optimal hemodynamics is associated with improved outcomes in patients with continuous-flow left ventricular assist device (CF-LVAD). Our primary aim was to define the hemodynamic profiles of patients on CF-LVADs, and explore the impact of partial LV unloading on the prevalence of elevated right atrial pressure (RAP) in these patients. Methods Retrospective data on demographics and invasive hemodynamics (early post-implant during index hospitalization and late post-discharge at median 4.7 months) were extracted on patients at our institution with CF-LVAD implants from January 2017-July 2019. Hemodynamic profiles are categorized as optimal or non-optimal (Table 1), and partial LV unloading is defined as pulmonary capillary wedge pressure (PCWP) >15 mm Hg. Statistical analyses used the Fisher's exact test (SAS, version 9.4). Results Two hundred fifty-nine patients had CF-LVAD implants. Seventy-eight patients (mean age 57.1 ± 10.2 years) had invasive hemodynamics at both time-points early post-implant and late post-discharge (Table 1). Early post-implant, 15 patients (32.1%) had optimal hemodynamics and 71 patients (68%; 18 LHF, 28 BiV HF, and 7 RHF) had non-optimal hemodynamics. The majority of patients with RAP >12 mm Hg had a coexisting elevated PCWP [early post-implant (28 of 35 patients, 80%) or late post-discharge (22 of 28 patients, 78.6%)]. The absence (hazard ratio 2.99, p=0.01) versus presence (hazard ratio 0.72 p=0.34) of early partial LV unloading in the setting of an elevated RAP is associated with an increased risk of death and hospitalizations at 6-months post-implant. Conclusion Partial LV unloading with concomitant elevated RAP early post-implant is associated with better event-free survival in comparison to patients with isolated elevated RAP. Future analysis of a validation cohort on these observations and their association with long-term outcomes is warranted.