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Hormonal replacement therapy is administered to many brain-dead organ donors to improve hemodynamic stability. Previous clinical studies present conflicting results with several randomized studies reporting no benefit.Consecutive adult donors (N = 199) were randomized to receive high-dose levothyroxine, high-dose methylprednisolone, both (Combo), or no hormonal therapy (Control). Vasopressor requirements using the vasoactive-inotropic score (VIS) were assessed at baseline, 4 h, and at procurement. Crossover to the Combo group was sufficient to require separate intention-to-treat and per-protocol analyses.In the intention-to-treat analysis, the mean (±SD) reduction in VIS from baseline to procurement was 1.6 ± 2.6, 14.9 ± 2.6, 10.9 ± 2.6, and 7.1 ± 2.6 for the levothyroxine, methylprednisolone, Combo, and Control groups, respectively. While controlling for the baseline score, the reduction in VIS was significantly greater in the methylprednisolone and Combo groups and significantly less in the levothyroxine group compared with controls. Results were similar in the per-protocol analysis.High-dose methylprednisolone alone or in combination with levothyroxine allowed for significant reduction in vasopressor support in organ donors. Levothyroxine alone offered no advantage in reducing vasopressor support. Organ yield, transplantation rates, and recipient outcomes were not adversely affected.

Both operative and hemodynamic mechanisms have been implicated in right heart failure (RHF) following surgical left ventricular assist device (LVAD) implantation. We investigated the effects of percutaneous LVAD (pLVAD; Impella®, Abiomed) support on right ventricular (RV) load and adaptation. We reviewed all patients receiving a pLVAD for cardiogenic shock at our institution between July 2014 and April 2017, including only those with pre- and post-pLVAD invasive hemodynamic measurements. Hemodynamic data was recorded immediately prior to pLVAD implantation and up to 96 h post-implantation. Twenty-five patients were included. Cardiac output increased progressively during pLVAD support. PAWP improved early post-pLVAD but did not further improve during continued support. Markers of RV adaptation (right ventricular stroke work index, right atrial pressure (RAP), and RAP to pulmonary artery wedge pressure ratio (RAP:PAWP)) were unchanged acutely implant but progressively improved during continued pLVAD support. Total RV load (pulmonary effective arterial elastance; EA) and resistive RV load (pulmonary vascular resistance; PVR) both declined progressively. The relationship between RV load and RV adaptation (EA/RAP and EA/RAP:PAWP) was constant throughout. Median vasoactive-inotrope score declined after pLVAD placement and continued to decline throughout support. Percutaneous LVAD support in patients with cardiogenic shock did not acutely worsen RV adaptation, in contrast to previously described hemodynamic effects of surgically implanted durable LVADs. Further, RV load progressively declined during support, and the noted RV adaptation improvement was load-dependent as depicted by constant EA/RA and EA/RAP:PAWP relationships. These findings further implicate the operative changes associated with surgical LVAD implantation in early RHF following durable LVAD.

Continuous-flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24-h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow-up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.

Background: Acute right heart failure (RHF) after left ventricular assist device implantation remains a major source of morbidity and mortality, yet the definition of RHF and the preimplant variables that predict RHF remain controversial. This study evaluated the ability of (1) INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) RHF classification to predict post-left ventricular assist device survival and (2) preoperative characteristics and hemodynamic parameters to predict severe and severe acute RHF. Methods and Results: An international, multicenter study at 4 large academic centers was conducted between 2008 and 2016. All subjects with hemodynamics measured by right heart catheterization within 30 days before left ventricular assist device implantation were included. RHF was defined using the INTERMACS definition for RHF. In total, 375 subjects were included (mean age, 57.4±13.2 years, 54% bridge-to-transplant). Mild RHF was most common (34%), followed by moderate RHF (16%), severe RHF (13%), and severe acute RHF (9%). Estimated on-device survival rates at 2 years were 72%, 71%, and 55% in the patients with none, mild-to-moderate, and severe-to-severe acute RHF, respectively ( P =0.004). In addition, the independent hazard ratio for mortality was only increased in the patients with severe-to-severe acute RHF (hazard ratio, 3.95; 95% CI, 2.16–7.23; P Conclusions: The INTERMACS RHF classification correctly identifies patients at risk for mortality, though this risk is only increased in patients with severe-to-severe acute RHF. Several predictors for RHF were identified, of which ratio of systolic pulmonary artery pressure to stroke volume was the strongest hemodynamic predictor. Coupling ratio of systolic pulmonary artery pressure to stroke volume with right atrial pressure may be most helpful in identifying patients at risk for severe-to-severe acute RHF.

Background Right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict RHF have proved only modestly successful. Acute pharmacologic unloading of the LV to assess ventricular and hemodynamic reserve may better predict post-implant RHF. Objectives To compare pre-implant baseline and post-vasodilator hemodynamic predictors of INTERMACS defined severe or severe-acute RHF after LVAD implantation. Methods After IRB approval, we performed a retrospective analysis of all subjects implanted with a durable LVAD at our institution between February 2017 and April 2020 (n=108). Only those who underwent vasodilator testing with nitroprusside during their pre-implant right heart catheterization were ultimately included (n=29). Continuous variables were compared with t-test and Levene's test of equality of variances; categorical via Fisher's Exact test. Logistic regression was used to determine predictors of severe or severe-acute RHF. Results Ten subjects met criteria for severe or severe-acute RHF (34%) after implant. There were no significant differences in demographics, HF etiology, INTERMACS profile, echo assessment of LV/RV function, or pre-implant baseline hemodynamics including RAP:PAWP ratio and PAPi between groups (TABLE). Both groups saw a similar reduction in systemic mean arterial pressure with nitroprusside, which led to significant and similar reductions in PAWP and pulmonary pressures. Compared to the group with severe or severe-acute RHF, those without significant RHF achieved higher peak cardiac index (CI) with nitroprusside infusion, suggesting better cardiac reserve. Peak CI was a significant predictor of RHF (p= 0.022), even after controlling for baseline values (p=0.048). No subject achieving a peak CI > 2.66 L/min/m2 developed severe or severe-acute RHF, and every 0.25 L/min/m2 decrease in peak CI was associated with 2.3 fold increased risk. Mortality was higher and hospital length of stay longer in the severe or severe-acute RHF group. Conclusion Peak CI with nitroprusside infusion predicts post-implant LVAD RHF better than resting hemodynamics in this small cohort. Hemodynamic reserve measurements may prove to be an important risk stratification tool when assessing LVAD candidacy.

Congestive heart failure (HF) remains one of the leading causes of hospitalization in adults in the United States. The direct and indirect costs associated with this illness are estimated at $32 billion for 2013 and projected to reach $70 billion by 2030. The majority of this financial burden arises from the over one million hospitalizations that occur annually for acute decompensated HF (Go et al. Circulation 127:e6–245, 2013). Advances in pharmacologic and device therapy for HF, and their associated reductions in morbidity and mortality, have led to increasing numbers of patients progressing to advanced heart failure. Of the nearly six million adults with congestive heart failure, it is has been estimated that 20 % have ACC Stage D disease—the group of patients who should be considered for advanced heart failure therapies. Unfortunately, this potential pool far exceeds the roughly 2300 cardiac transplantations that are performed yearly in the United States, and the 3700 performed worldwide, in each of the last several years (Stehlik et al. J Heart Lung Transplant 30:1078–94, 2011) .

Introduction Respirophasic hemodynamic patterns are prognostic in the setting of heart failure (e.g. Kussmaul's sign), though the implications of hemodynamic respirophasic variation patterns in patients supported with a left ventricular assist device (LVAD) are unknown. Many LVAD patients remain poorly hemodynamically optimized, and the ability to optimize these patients with ramp speed increase is a positive prognostic marker. However, the response to ramp speed increase may be unpredictable. Alterations in hemodynamics with respiration may predict ramp speed response by reproducing pre-load alterations during respiration similar to LVAD speed manipulation. Hypothesis Absence of pulmonary artery wedge pressure (PAWP) respiratory variation in patients with LVADs is associated with an inability to reduce the PAWP with increasing pump speed. Absence of right atrial pressure (RAP) respiratory variation is a marker of right ventricular (RV) dysfunction. Methods We retrospectively collected data from 16 separate, consecutive hemodynamic ramp studies on 12 patients with HeartMate II LVADs (average 880 ± 483 days of LVAD support). All PAWP and RAP at inspiration and expiration were independently measured in a blinded fashion. Patient demographic and clinical data was obtained from chart review. No patient had clinically significant pulmonary disease. Results The degree of respiratory variation of PAWP correlated with PAWP reduction with speed increase (R = 0.81). PAWP respiratory variation also correlated with the LV transmural pressure (PAWP - RAP) (R = 0.87) (Figure) . Patients admitted for RV failure (n=6) within 60 days of the ramp study did not have significantly different RAP respiratory variation at baseline compared to those not admitted for RV failure (n=6) (27% versus 40%, p = 0.09). However, there was a difference in RAP respiratory variation at the peak speed of the ramp study (36% RAP respiratory variation in RV failure patients compared to 61% for non-RV failure patients, p = 0.045). Conclusions The degree of PAWP respiratory variation is correlated with the ability to unload the LV by increasing LVAD speed. PAWP respiratory variation is a marker of a favorable hemodynamic response to speed changes during ramp study. In addition, patients with reduced RAP respiratory variation were more likely to have RV failure requiring hospital admission. Right and left-sided filling pressure respiratory variation patterns can provide valuable clinical information to the treating physician regarding the LVAD patient's underlying biventricular physiology.

Background Ventricular assist device (VAD) recipients are at high risk of depression and anxiety, and poor psychosocial functioning is associated with worse medical outcomes. Purpose We present a case of a 31-year-old depressed patient who demonstrated passive suicidal behavior through multiple episodes of noncompliance, including temporarily discontinuing warfarin (Coumadin) several months after VAD implantation. The patient's psychosocial and medical histories and outcomes are presented. Conclusions This case underscores the importance of pre-VAD as well and ongoing psychosocial evaluation and management for this unique patient population. Clinical implications Medical teams who are treating patients with cardiovascular disease who are under consideration for VAD or heart transplantation need to be aware of the multitude of ways in which patients can express depressed and suicidal mood and work with a multidisciplinary team to treat such symptoms to optimize patients' success with VAD/heart transplantation.

Right heart catheterization (RHC) has remained the gold standard in diagnosing elevated cardiac filling pressures. Despite advances in medical therapy, patients with persistent volume overload and heart failure (HF) have a poor prognosis. The diagnosis of volume overload can be difficult in advanced HF with clinical symptoms and signs often lacking sensitivity and specificity. Hemodynamic measurements at rest, especially pulmonary capillary wedge pressure and change in pulmonary capillary wedge pressure, have been closely linked to prognosis. However, RHC is invasive with attendant risks of complications. Noninvasive models without using catheterization-derived values have been shown to be equally predictive of survival. In selected clinical situations, especially the cardiorenal syndrome, RHC continues to play an important role. Newer invasive and noninvasive techniques to assess volume status are available, but large prospective trials are lacking. The advantage with continuous hemodynamic monitoring could be the development of an early warning system prior to the onset of symptomatic decompensation.

The increasing incidence of patients with advanced heart failure, limited donor availability, and continued advancements in the field of mechanical circulatory support have made implantation of left ventricular assist device therapy (LVAD) an attractive option for patients with end-stage heart failure. Perioperative right ventricular failure (RVF) occurs frequently in patients undergoing LVAD implantation and is associated with significant morbidity and mortality. This review will discuss the pathophysiology of RVF, recent efforts to risk-stratify patients preoperatively, and current preoperative, perioperative, and postoperative management strategies.