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Left ventricular assist devices (LVAD) are utilized in patients diagnosed with advanced heart failure. Right ventricular (RV) failure can affect up to 20% of patients undergoing LVAD implantation. In this case study, we evaluated perioperative RV performance with simultaneous use of Swan-Ganz catheterization and high-fidelity conductance catheters to generate real time RV pressure- volume (PV) loops. A 75- year old male patient undergoing LVAD implantation was chosen for evaluation. A high-fidelity conductance catheter was advanced into the RV. The catheter was removed on postoperative day one. Data obtained from the catheter were used to evaluate RV work, contractility, diastolic function, and compliance. These results were compared to standard measurements of the patient's clinical status and biventricular performance. Consent and IRB approval was obtained as part of an ongoing study. The patient developed RV dysfunction in the immediate perioperative period, as demonstrated by increasing central venous pressure to pulmonary artery pressure ratio, decreased cardiac index, and evidence of elevated filling pressures by echocardiogram. Using a high-fidelity catheter, we demonstrated a uniform reduction in preload recruitable stroke work and Starling contractile index on postoperative day one. Pressure-volume loops initially demonstrated appropriate ventricular unloading, however RV dysfunction was exposed with changes in loading conditions over time (figure 1). Pressure-volume loop analysis represents a novel method for evaluation of RV performance during LVAD implantation. Compared to standard monitoring, PV loops provide increased granularity in understanding RV function. [ABSTRACT FROM AUTHOR]

Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. We investigated whether blood urea nitrogen to creatinine ratio (BCR) at time of HT listing among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) is associated with higher risk of post-HT death or dialysis. We identified 159 patients who underwent HT alone at our institution between 1/2009 and 2/2018. Univariate and multivariate Cox-proportional regression analyses were used to investigate the association between BCR and composite risk of post-HT death or dialysis at 1 year. At listing, average age was 55±10 years (74% male and 28% African American) and eGFR was 47 ± 8. Mean eGFR did not differ between those with the composite outcome (46 ± 8) and those without (47 ± 8; p = 0.60). Overall, 14 patients (9%) died and 25 (16%) needed dialysis by 1 year post-HT. The univariate and multivariate adjusted hazard ratios for continuous variable BCR as a predictor of the composite outcome were 1.05 [95% confidence interval (CI): 1.02, 1.09; p < 0.01) and 1.04 [95% CI: 1.01, 1.09; p = 0.02), respectively. Additional regression analyses and Kaplan-Meier survival curves are shown in the figure. Heart transplant candidates with stage 3 CKD and elevated BCR at time of listing are at increased risk of post-HT mortality or dialysis. Further investigation of HKT outcomes among those with stage 3 CKD and elevated BCR at listing is warranted. [ABSTRACT FROM AUTHOR]

Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. The Model for End-Stage Liver Disease Excluding INR (MELD-XI) score at the time of HT has been shown to predict early post-HT mortality. We investigated whether trends in the MELD-XI score between listing and transplant among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or dialysis. We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. The following groups were created: Group 1 - MELD-XI ≤ 16 at listing and HT, Group 2 - MELD-XI ≤ 16 at listing and > 16 at HT, Group 3 - MELD-XI > 16 at listing and ≤ 16 at HT, Group 4 - MELD-XI > 16 at listing and HT. A cutoff of 16 was chosen based on the 75th percentile in a normal distribution among those without a composite outcome of post-HT death or dialysis at 1 year. Cox-proportional regression and survival analyses were performed to assess risk of this outcome. Average MELD-XI at listing was 14.0 ± 4.9 and at HT was 12.8 ± 4.5 (p < 0.01); MELD-XI >16 was present in 51 (32.1%) at listing and 38 (23.9%) at HT. Group 4 incurred highest risk of composite outcome relative to Group 1 (adjusted hazard ratio 3.67 (95% confidence interval: 1.38-9.76, p < 0.01); see figure). Notably, Groups 2 and 3 had a statistically nonsignificant trend toward higher risk of the composite outcome compared to Group 1. Changes in MELD-XI between listing and transplantation offer additional risk stratification beyond absolute MELD-XI at time of transplant for death or dialysis at 1 year in patients with stage 3 CKD. [ABSTRACT FROM AUTHOR]

Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at higher risk of mortality and poor renal outcomes compared to those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT. We investigated whether interval changes in blood urea nitrogen to creatinine ratio (BCR) between listing and transplant in those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) 30 - 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or worsening renal function (WRF). We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. Absolute changes in BCR between listing and transplant were categorized as improved (BCR decreased) or worsened (BCR increased). Next, the following groups were created: Group 1 - improved BCR and BCR ≤ 21 at HT, Group 2 - worsened BCR but remained ≤21 at HT, Group 3 - worsened BCR and BCR >21 at HT, and Group 4 - improved BCR but remained >21 at HT. WRF was defined as a decrease in eGFR by >25% or need for dialysis between HT and 1-year follow up. One-year composite risk of death or dialysis was our primary outcome of interest; WRF in survivors was our secondary outcome of interest. By 1 year, a total of 14 patients died and 43 had WRF, including 15 who needed dialysis. The BCR improved in 98 patients (62%) and worsened in 61 (38%); BCR was >21 at HT in 25 patients (16%). Group 4 incurred highest risk of both the primary and secondary outcomes (see figure) with adjusted hazard ratio of 3.81 (95% confidence interval (CI): 1.45-10.00; p<0.01) for the primary outcome and odds ratio of 9.21 (95% CI: 2.13-39.76; p<0.01) for the secondary outcome. High BCR at listing that remained >21 at HT despite interval improvement was associated with increased risk of death or dialysis and WRF. These findings warrant further pathophysiologic explanation. [ABSTRACT FROM AUTHOR]