Validation of non‐invasive ramp testing for HeartMate 3

Abstract

Aims Ramp testing in the postoperative period can be used to optimize left ventricular assist device (LVAD) speed for optimal left ventricular (LV) unloading. We tested the hypothesis that a non-invasive echocardiographic ramp test post-HeartMate 3 implantation improves LV unloading immediately after and 1-3 months after as compared with before the test. We also tested a secondary hypothesis that speed adjustments during echocardiography-guided ramp testing do not worsen right ventricular (RV) function immediately after and 1-3 months after. Methods and resultsWe retrospectively reviewed data from patients who underwent an echocardiographic ramp test. A total of 14 out of 19 patients were clinically stable and were enrolled. Adequate LV unloading was defined as no more than mild mitral regurgitation, and intermittent aortic valve (AV) opening or closed AV, and reduction of left ventricular end-diastolic diameter (LVEDD); and for the follow-up measurement, decreased NT-proBNP. Median (interquartile range) time from implantation to ramp test was 27 (16; 56) days, and median time from ramp test to follow-up echocardiography was 55 (47; 102) days. Median LVAD speed achieved during ramp testing was 5550 (5375; 6025) revolutions per minute (rpm), and median final LVAD speed was 5200 (5000; 5425) rpm. Ramp testing resulted in final LVAD speed increase in 11 (79%) patients and a median net change of 200 (200; 300) rpm. Speed adjustments after ramp testing resulted in improved LVAD unloading that was achieved in additional 3 (21%) patients who were not originally optimized. RV function did not worsen significantly during ramp testing or at final LVAD speed. Conclusions The echocardiographic ramp test allowed LVAD speed adjustment and optimization and improved LV unloading during ramp testing and at final speed with no evidence of worsening of RV function.

Cardiac remodeling in patients with centrifugal left ventricular assist devices assessed by serial echocardiography

“…Some centers prefer routine ramp protocols for LVAD speed optimization. 3,24 This may be performed before discharge and under surveillance echocardiography. However, ramp protocols are complex and time-consuming, and their impact on the outcome is unknown.…”

Implication of Hemodynamic Assessment during Durable Left Ventricular Assist Device Support

“…Elevated central venous pressures in the setting of normal pulmonary capillary wedge pressure are one of the hallmarks of right heart failure and tend to be difficult to correct alone through mechanical unloading [39]. Right heart failure is also associated with above-discussed hemocompatibility-related adverse events including bleeding and systemic thromboembolism ( Figure 3) [11].…”

“…Second, we can adjust the device speed to better optimize the patient's hemodynamic profile with a primary target of right atrial pressure < 12 mmHg, pulmonary capillary wedge pressure < 18 mmHg, and cardiac index > 2.2 L/min/m 2 . We simultaneously perform echocardiography to assess for aortic valve opening, to understand the interventricular septum position, and to determine the presence of mitral valve regurgitation at each speed interval [39]. The Ramp-it-up trial demonstrated the prognostic implications of this specific test in a prospective randomized control setting [16].…”

Optimal echocardiographic ramp testing during left ventricular assist device supports

“…3 In the same manner, the goal of device speed adjustment in their study might be unclear: adequate left ventricular unloading, which was defined as (i) no more than mild mitral regurgitation, (ii) intermittent aortic valve opening or closed aortic valve, and (iii) reduction in left ventricular end-diastolic diameter. 1 On the basis of their protocol, we might increase device speed up to the maximum setting unless any sucking events.…”

“…However, the optimal strategy to adequately adjust device speed remains controversial. Najjar et al 1 demonstrated that the echocardiographic ramp test with LVAD speed adjustment improved left ventricular unloading. As an author of Ramp-it-Up study that prospectively compared haemodynamics vs. echocardiographic ramp tests, 2 I have several concerns.…”