Left ventricular distention (LVD) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is increasingly recognized but seldom reported in the literature. The current study defined LVD as not present (LVD-); subclinical (LVD+, evidence of pulmonary edema on chest radiograph AND pulmonary artery diastolic blood pressure greater than 25 mm Hg within the first 2 hours of intensive care unit admission); or clinical (LVD++, need for decompression of the left ventricle immediately following VA-ECMO initiation). Among 226 VA-ECMO device runs, 121 had sufficient data to define LVD retrospectively. Nine patients (7%) developed LVD++ requiring immediate decompression, and 27 patients (22%) met the definition of LVD+. Survival to discharge was similar among groups (LVD++: 44%, LVD+: 41%, LVD-: 44%). However, myocardial recovery appeared inversely related to the degree of LVD (LVD++: 11%, LVD+: 26%, LVD-: 40%). When death or transition to device was considered as a composite outcome, event-free survival was diminished in LVD++ and LVD+ patients compared with LVD-. Multivariable analysis identified cannulation of VA-ECMO during extracorporeal cardiopulmonary resuscitation (ECPR) as a risk factor for decompression (odds ratio [OR]: 3.64, confidence interval [CI]: 1.21-10.98; p = 0.022). Using a novel definition of LVD, the severity LVD was inversely related to the likelihood of myocardial recovery. Survival did not differ between groups. Extracorporeal cardiopulmonary resuscitation was associated with need for mechanical intervention.

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Objectives: To evaluate the impact of moderate to severe aortic insufficiency (AI) on continuous flow left ventricular assist device (CF-LVADs) outcomes. Background: The development of worsening AI is a common complication of prolonged CFLVAD support and portends poor prognosis in single-center studies. Predictors of worsening AI and its impact on clinical outcomes have not been examined in a large cohort. Methods: We conducted a retrospective analysis of CF-LVAD patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Development of significant AI was defined as the first instance of at least moderate AI. Primary outcomes of interest were survival after development of significant AI and time to adverse events including device complications and rehospitalizations. Results: Among 10603 eligible patients, 1399 developed moderate to severe AI on CF-LVAD support. Prevalence of significant AI progressively increased over time. Predictors of worsening AI included older age, female gender, smaller BMI, mild pre-implant AI, and destination therapy strategy. Moderate to severe AI was associated with significantly higher left ventricular enddiastolic diameter, reduced cardiac output, and higher brain natriuretic peptide levels. Significant AI was associated with higher rates of rehospitalization (32.1% vs 26.6% at 2-years, p=0.015) and mortality (77.2% vs 71.4% at 2-years, p=0.005) conditional upon survival to 1 year. Conclusion: Development of moderate to severe AI negatively impacts hemodynamics, hospitalizations, and survival on CF-LVAD support. Pre- and post- implant management strategies should be developed to prevent and treat this complication.

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