Hypotensive Response on Cardiopulmonary Stress Test is Associated with Increased One Year Mortality After Continuous Flow Left Ventricular Assist Device Implantation

Purpose Cardiopulmonary stress testing (CPX) is widely used to evaluate patients with end stage heart failure who may benefit from advanced therapies, such as durable left ventricular assist devices (LVAD). A hypotensive systolic blood pressure response on CPX may identify a subpopulation with the highest risk physiology. We sought to evaluate long term outcomes among LVAD recipients with a pre-implantation hypotensive response. Methods This was a retrospective single center study using consecutive patients implanted with a continuous flow LVAD between 1/2011 and 1/2019 at our Institution. Patients with CPX performed within 12 months before implantation were included. Hypotensive response was defined as a peak exercise systolic blood pressure lower than the resting systolic blood pressure. The primary outcome was 1-year mortality. Multivariable cox regression analysis was performed to evaluate the relationship between hypotensive exercise blood pressure response and mortality. Multivariate linear regression analysis was used to determine pre-implant variables and mortality. Results 313 patients were enrolled in the study and 123 were identified to meet our inclusion criteria. The mean age was 60.1 years, 58% had ischemic cardiomyopathy and 85% were classified as INTERMACS 3-5. 54 patients had a hypotensive response on CPX (44%). A total of 14 patients died at 1 year, 10 from the hypotensive cohort (p=0.043), hazard ratio 3.54 with 95% CI (1.1, 11.3, p=0.033). Post-implantation ICU and overall hospital length of stay were similar to the group with normal blood pressure response. There was also no significant difference in post-operative complications and the risk of re-hospitalization at 1 month, 6 months and 1 year. Conclusion Hypotensive blood pressure response on the CPX performed pre-LVAD implantation is independently associated with increased 1-year mortality. Additional studies are needed to further characterize this high-risk patient population and to identify strategies to improve survival rates.