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Hemodynamic monitoring plays a critical role in the perioperative management of patients supported by continuous-flow left ventricular assist devices (CF-LVAD). Data published on left atrial pressure monitoring (LAPm) in patients with CF-LVAD support is limited. Our primary aim was to examine the safety and impact of direct LAPm in patients undergoing CF-LVAD implantation. Retrospective data on demographics, LAPm, hemodynamics, and endpoints were extracted on patients at our institution with CF-LVAD implants from January 2017-June 2019. The decision to use a LAPm is based on institutional standards related to right ventricular failure risk and/or presence of severe pulmonary hypertension. The primary safety endpoint of LAPm was a composite of mediastinal bleeding requiring transfusion, cardiac tamponade, and LA thrombus. Secondary endpoints were LAPm device malfunction leading to premature LAPm removal and lack of hemodynamic trends, air embolism, surrogates of left ventricular (LV) unloading, inhaled epoprostenol use, and post-implant ICU and hospital length of stay (LOS). Statistical analyses were by two-tailed Student's t -test or chi-square tests (SAS, version 9.4). Of the 242 patients (mean age 58.1 ± 11.0 years), 88.4% had durable centrifugal pumps for destination therapy (58.3%). Most had Intermacs status 2-4 (95.5%) at implant. One hundred fifty-three patients (63.2%) had LAPm for a median of 20h. Prior to LAPm explant, 90.2% had an LAP <15 mm Hg and 8.5% had LAPm device malfunction. The primary safety endpoint in patients with and without LAPm was 14.4% versus 19.1% (p=0.34), respectively. There were no cases of air embolism related to LAPm use. Inhaled epoprostenol use in patients with and without LAPm was 3.5 ± 7.3 days versus 2.0 ± 2.9 days (p=0.23), respectively. There was no difference in post-implant LOS in the ICU (5 (1, 117) versus 6 (2, 320) days, p=0.22) and hospital (18 (2, 171) versus 21 (1, 320) days, p=0.32)) in patients with and without LAPm. Use of LAPm to guide management is both safe and feasible in patients requiring CF-LVADs. In the vast majority of this cohort, we were able to achieve optimal LV unloading. Future analyses are warranted to better understand the clinical outcomes' associations of LAPm on CF-LVAD parameters. [ABSTRACT FROM AUTHOR]

Purpose PAPi (pulmonary artery pulsatility index) is a predictor of early right ventricular failure (RVF) post left ventricular assist device (LVAD) implantation and has been studied using hemodynamics from single, isolated time points. Since multiple clinical factors and therapies are known to impact RV function in pre-LVAD patients, we hypothesized that serial PAPi measurements would provide incremental risk stratification for early post-LVAD RVF. Methods A total of 394 consecutive patients undergoing primary durable LVAD implantation at our center from 2004 to 2017 were retrospectively enrolled. Serial invasive hemodynamics obtained during inpatient swan guided therapy (77%) or consecutive outpatient right heart catheterizations were recorded. The lowest, highest ("Best"), change ("Delta") and most proximal PAPi to LVAD implant were calculated. RVF was defined as need for RVAD or prolonged inotrope use > 14 days post-operatively. Multivariate logistic regression determining independent associates of early RVF was performed. Results RVF occurred in 82 of the 394 patients (21%). Those who developed early RVF had significantly lower mean Delta PAPi (2.0 vs 5.3, p<.001) and a significantly reduced Best PAPi (3.4 vs 7.4, p<.001) following optimization. In addition to sex, Michigan RVF risk score, INTERMACS profile, and Fick cardiac index, Best PAPi was independently associated with early RVF post-LVAD (OR.71, CI.62-.81, p<.0001). On receiver operating characteristics curve analysis, Best PAPi added significant incremental value for risk prediction of early RVF to a model containing clinical, echocardiographic and basic hemodynamic parameters (Figure). Conclusion The best PAPi achieved during medical optimization prior to LVAD implantation provides independent and incremental risk stratification for early RVF, likely identifying RV reserve. [ABSTRACT FROM AUTHOR]

Optimal hemodynamics is associated with improved outcomes in patients with continuous-flow left ventricular assist device (CF-LVAD). Our primary aim was to define the hemodynamic profiles of patients on CF-LVADs, and explore the impact of partial LV unloading on the prevalence of elevated right atrial pressure (RAP) in these patients. Retrospective data on demographics and invasive hemodynamics (early post-implant during index hospitalization and late post-discharge at median 4.7 months) were extracted on patients at our institution with CF-LVAD implants from January 2017-July 2019. Hemodynamic profiles are categorized as optimal or non-optimal (Table 1), and partial LV unloading is defined as pulmonary capillary wedge pressure (PCWP) >15 mm Hg. Statistical analyses used the Fisher's exact test (SAS, version 9.4). Two hundred fifty-nine patients had CF-LVAD implants. Seventy-eight patients (mean age 57.1 ± 10.2 years) had invasive hemodynamics at both time-points early post-implant and late post-discharge (Table 1). Early post-implant, 15 patients (32.1%) had optimal hemodynamics and 71 patients (68%; 18 LHF, 28 BiV HF, and 7 RHF) had non-optimal hemodynamics. The majority of patients with RAP >12 mm Hg had a coexisting elevated PCWP [early post-implant (28 of 35 patients, 80%) or late post-discharge (22 of 28 patients, 78.6%)]. The absence (hazard ratio 2.99, p=0.01) versus presence (hazard ratio 0.72 p=0.34) of early partial LV unloading in the setting of an elevated RAP is associated with an increased risk of death and hospitalizations at 6-months post-implant. Partial LV unloading with concomitant elevated RAP early post-implant is associated with better event-free survival in comparison to patients with isolated elevated RAP. Future analysis of a validation cohort on these observations and their association with long-term outcomes is warranted. [ABSTRACT FROM AUTHOR]

Heart failure-related hospitalization (HFH) after continuous-flow left ventricular assist device (CF-LVAD) implant remains prevalent. Our primary aim was to better elucidate the extent of HFH in patients supported by HM3 resulting from predominant right (RHFS) versus left (LHFS) HF syndrome. We also re-classified INTERMACS-defined RHF by the underlying HFS phenotype. Retrospective data were extracted on patients with HFH post-HM3 implant at our institution (January 2017-May 2019) for demographics, hemodynamics by echocardiogram and/or right heart catheterization, and detailed physical exam findings. Data from each HFH were used to categorize the underlying HFS phenotypes (Table 1). HFH is defined as re-hospitalization post-index implant with a fluid overload syndrome and use of parenteral diuretics. INTERMACS RHF is defined by elevated right atrial pressure requiring the use of varying degrees of right ventricular support, including the sole use of parenteral diuretics. Statistical analyses used the Fisher exact t -test (SAS, version 9.4). One hundred forty-three patients defined the HM3 study cohort. Twenty-three patients (mean age 57.7 ± 11.2 years) had HFH (16.1% prevalence), with a median time to first HFH of 65.6 days post-implant. HFH was due to LHFS in 11 patients (47.8%; 2 LHFS and 9 BiV HFS) and predominant RHFS in 12 patients (52.2%). Twenty-one patients met criteria for INTERMACS-defined RHF (14.7% prevalence). By categorical phenotyping, an elevated pulmonary capillary wedge pressure (PCWP) >15 mm Hg was noted in 42.9% of these cases. BiV HFS and predominant RHFS account for most HFH post-HM3 implant. LHFS account for nearly half of the post-discharge INTERMACS-defined RHF re-hospitalizations. Further examination of the predictors and underlying causes of partial LV unloading, and the implications on long-term outcomes including survival and functional capacity is warranted. [ABSTRACT FROM AUTHOR]