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Volume status assessment in left ventricular assist device (LVAD) patients remains challenging. Cardiac resynchronization therapy (CRT) devices are common in LVAD patients, and the impedance across the CRT leads may be associated with hemodynamics and serve as a tool for noninvasive estimation of volume status. Ninety-one sets of measurements including cardiac filling pressures and lead impedances were prospectively obtained during ramp tests from 11 LVAD patients (65.5 ± 9.7 years old; nine male) with CRT devices. Right atrial (RA), right ventricular (RV), and left ventricular (LV) lead impedances were all significantly associated with central venous pressure (CVP) (p < 0.05). We derived the following equation: estimated CVP = 47.90-(0.086 × RA lead impedance) + (0.013 × RV lead impedance)-(0.020 × LV lead impedance). The estimated CVP had a significant correlation (r = 0.795) and good agreement with the measured CVP (mean difference -0.14 ± 1.77 mmHg). Applying the above equation on the validation cohort of twenty-one patients also maintained a strong association with measured CVP (r = 0.705). In conclusion, we have derived a novel equation to estimate CVP using lead impedance measurements. This finding may allow noninvasive monitoring of volume status in LVAD patients.

Introduction: Left ventricular assist device (LVAD) insertion is an increasingly common intervention for patients with advanced heart failure; however, published literature on the emergency department (ED) presentation of this population is limited. The objective of this study was to characterize ED presentations of patients with LVADs with a focus on device-specific complications to inform provider education and preparation initiatives. Methods: This was a retrospective chart review of all patients with LVADs followed at an urban academic medical center presenting to the ED over a five-year period (July 1, 2009, to June 30, 2014). Two abstractors reviewed 45 randomly selected charts to standardize the abstraction process and establish a priori categories for reason for presentation to the ED. Remaining charts were then divided evenly for review by one of the two abstractors. Primary outcomes for this study were (1) frequency of and (2) reason for presentation to the ED by patients with LVADs. Results: Of 349 patients with LVADs identified, 143 (41.0%) had ED encounters during the study period. There were 620 total ED encounters, (range 1 to 32 encounters per patient, median=3, standard deviation=5.3). Among the encounters, 431 (69.5%) resulted in admission. The most common reasons for presentation were bleeding (e.g., gastrointestinal, epistaxis) (182, 29.4%); infection (127, 20.5%); heart failure exacerbation (68, 11.0%); pain (56, 9.0%); other (45, 7.3%); and arrhythmias (40, 6.5%). Fifty-two encounters (8.4%) were device-specific; these patients frequently presented with abnormal device readings (37, 6.0%). Interventions for device-specific presentations included anticoagulation regimen adjustment (16/52, 30.8%), pump exchange (9, 17.3%), and hardware repair (6, 11.5%). Pump thrombosis occurred in 23 cases (3.7% of all encounters). No patients required cardiopulmonary resuscitation or died in the ED. Conclusion: This is the largest study known to the investigators to report the rate of ED presentations of patients with LVADs and provide analysis of device-specific presentations. In patients who do have device-specific ED presentations, pump thrombosis is a common diagnosis and can present without device alarms. Specialized LVAD education and preparation initiatives for ED providers should emphasize the recognition and management of the most common and critical conditions for this patient population, which have been identified in this study as bleeding, infection, heart failure, and pump thrombosis.

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. [ABSTRACT FROM AUTHOR]

Objectives: The intraaortic balloon pump (IABP) is currently an essential tool to improve hemodynamics in patients with advanced heart failure (HF). This study investigated predictors for hemodynamic improvement or stabilization with IABP therapy in patients with advanced HF., Methods: Patients with advanced HF and hemodynamic deterioration treated with IABP were enrolled in this retrospective study. Invasive hemodynamics were measured before IABP implantation and 2 weeks after IABP initiation. Significant degree of hemodynamic improvement was defined as 30% improvement in all three of the following variables: central venous pressure (CVP); pulmonary capillary wedge pressure (PCWP); and cardiac index (CI). Hemodynamic stabilization was counted in patients reaching CVP <12 mm Hg, PCWP <18 mm Hg, and CI >2.0 L/min/m² or CI >2.2 L/min/m² on inotropes., Results: Ninety-one patients (55 ± 12 years; 78% males) were evaluated. Seventeen patients (18.7%) achieved significant hemodynamic improvement, and baseline CVP >16 mm Hg was associated with this endpoint (P<.05). Thirty-two patients (35.2%) achieved hemodynamic stabilization; lower baseline heart rate (HR) and PCWP were associated with this stabilization (P<.05). Patients with HR <92 beats/min and PCWP <25 mm Hg achieved hemodynamic stabilization more frequently than those without HR <92 beats/min and PCWP <25 mm Hg (66.7% vs 19.7%; P<.05)., Conclusion: Elevated CVP and lower HR and PCWP before IABP initiation help predict high response to IABP.