Optimal haemodynamics during left ventricular assist device support are associated with reduced haemocompatibility‐related adverse events

Abstract

Aims Left ventricular assist device (LVAD) therapy improves the haemodynamics of advanced heart failure patients. However, it is unknown whether haemodynamic optimization improves haemocompatibility‐related adverse events (HRAEs). This study aimed to assess HRAEs in patients with optimized haemodynamics. Methods and results Eighty‐three outpatients [aged 61 (53–67) years, 50 male] underwent a haemodynamic ramp test at 253 (95–652) days after LVAD implantation, and 51 (61%) had optimized haemodynamics (defined as central venous pressure < 12 mmHg, pulmonary artery wedge pressure < 18 mmHg, cardiac index > 2.2 L/min/m2) following LVAD speed adjustment. One‐year survival free of any HRAEs (non‐surgical bleeding, thromboembolic event, pump thrombosis, or neurological event) was achieved in 75% of the optimized group and in 44% of the non‐optimized group (hazard ratio 0.36, 95% confidence interval 0.18–0.73, P = 0.003). The net haemocompatibility score, using four escalating tiers of hierarchal severity to derive a total score for events, was significantly lower in the optimized group than the non‐optimized group (1.02 vs. 2.00 points/patient; incidence rate ratio 0.51, 95% confidence interval 0.29–0.90, P = 0.021). Conclusion Left ventricular assist device patients in whom haemodynamics can be optimized had greater freedom from HRAEs compared to those without optimized haemodynamics.

Hemodynamics of concomitant tricuspid valve procedures at LVAD implantation

“…To our knowledge, this is the first study to address the impact of concomitant TVR on hemodynamics and LVAD performance. Hemodynamic optimization following LVAD implantation is associated with improved patient quality of life and a reduction in comorbidities . The hemodynamics of this study cohort improved significantly following LVAD implantation irrespective of concomitant TVR.…”

Omega‐3 and hemocompatibility‐related adverse events

“…We have recently demonstrated that omega‐3, an unsaturated fatty acid, decreased the incidence of GIB during LVAD support, probably due to its suppressive effect on the development of arteriovenous malformation by inhibition of an angiogenesis‐related signal cascade . Considering that the treatment of bleeding, in general, has a negative impact on thrombotic events, we investigated in this study the impact of omega‐3 therapy on overall HRAEs including thrombotic events, as an expansion from our previous study, by using hemocompatibility score (HCS), which was originally proposed by Mehra and then used in the sub‐study of MOMENTUM 3 trial and the optimized hemodynamic comparison study …”

Comment on: Implication of pulmonary artery pressure monitoring during left ventricular assist device supports

“…We read with great interest the protocol design of HEMO‐VAD pilot study proposed by Veenis and colleagues, in which the feasibility and implication of pulmonary artery pressure (PAP) guidance with CardioMEMS in patients with left ventricular assist device (LVAD) is prospectively investigated. Our team recently demonstrated the implications of hemodynamic optimization in LVAD patients, with the observed association of abnormal hemodynamics and heart failure (HF) readmissions along with hemocompatibility‐related adverse events …”

“…However, the physiology of RVF during LVAD support is unique and complex. Increased right ventricular preload and anatomical changes experienced by the RV due to leftward shifting of the intraventricular septum both contribute maladaptive structure and function . Therefore, in patients with LVADs, RVF often exists in the absence of elevated left‐sided filling pressures, and as a result, PAP monitoring alone might not be an appropriate method to assess for the presence of RVF.…”

“…Central venous pressure monitoring in the context of PAP measurements would be the most optimal method to hemodynamically assess for RVF, although technology to accurately assess central venous pressure through minimally invasive yet durable means has yet to be developed. Using a combination of these assessments may also be useful in predicting potential LVAD‐related adverse events, specifically gastrointestinal bleeding, which is known to be associated with RVF …”