Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy

Andrew N. Rosenbaum, Robert Frantz, Sudhir S. Kushwaha, John M. Stulak, Simon Maltais, Atta Behfar

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background Left ventricular (LV) hemodynamic assessment has been sparsely performed in patients supported on continuous-flow LV assist devices (cf LVADs ). Insight into dynamic changes of left heart parameters during ramp studies may improve LV assist device optimization and evaluate pathology. Methods and Results To complement right heart catheterization, a novel technique for left heart catheterization in patients with a cf LVAD was developed. Patients implanted with cf LVAD s underwent hemodynamic ramp left heart catheterization and right heart catheterization with transthoracic echocardiography. Continuous aortic and LV pressures were measured along with right atrial, pulmonary artery, and pulmonary capillary wedge pressures. A novel index, the transaortic gradient ( TAG ) was established. Thirty eight patients with cf LVADs were evaluated at a median of 446 days (interquartile range, 183-742) after device implant. During left heart catheterization performed for hemodynamic optimization, drop-in LV end-diastolic pressure and pulmonary capillary wedge pressure were associated with a rise in TAG . A range was identified for TAG (20-40 mm Hg) as providing the most optimal level of hemodynamic offloading. Pathologic states deviated from normal responses to ramp. LV assist device thrombosis was associated with an inability to increase in TAG during speed ramp. Significant aortic insufficiency was associated with a marked increase in LV end-diastolic pressure despite a concomitant decrease in pulmonary capillary wedge pressure with increasing LV assist device speeds. Conclusions Inclusion of left heart catheterization to a typical right heart catheterization LV assist device ramp protocol imparted unique insights to optimize cf LVAD speeds in different clinical scenarios. A novel index, the TAG was defined and provided additional resolution to optimized offloading.

Original languageEnglish (US)
Pages (from-to)e010232
JournalJournal of the American Heart Association
Volume8
Issue number4
DOIs
StatePublished - Feb 19 2019

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Architectural Accessibility
Heart-Assist Devices
Cardiac Catheterization
Hemodynamics
Pulmonary Wedge Pressure
Equipment and Supplies
Therapeutics
Blood Pressure
Ventricular Pressure
Pulmonary Artery
Echocardiography
Thrombosis
Pathology

Keywords

  • catheterization
  • hemodynamics
  • left ventricular assist device
  • transaortic gradient

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy. / Rosenbaum, Andrew N.; Frantz, Robert; Kushwaha, Sudhir S.; Stulak, John M.; Maltais, Simon; Behfar, Atta.

In: Journal of the American Heart Association, Vol. 8, No. 4, 19.02.2019, p. e010232.

Research output: Contribution to journalArticle

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N2 - Background Left ventricular (LV) hemodynamic assessment has been sparsely performed in patients supported on continuous-flow LV assist devices (cf LVADs ). Insight into dynamic changes of left heart parameters during ramp studies may improve LV assist device optimization and evaluate pathology. Methods and Results To complement right heart catheterization, a novel technique for left heart catheterization in patients with a cf LVAD was developed. Patients implanted with cf LVAD s underwent hemodynamic ramp left heart catheterization and right heart catheterization with transthoracic echocardiography. Continuous aortic and LV pressures were measured along with right atrial, pulmonary artery, and pulmonary capillary wedge pressures. A novel index, the transaortic gradient ( TAG ) was established. Thirty eight patients with cf LVADs were evaluated at a median of 446 days (interquartile range, 183-742) after device implant. During left heart catheterization performed for hemodynamic optimization, drop-in LV end-diastolic pressure and pulmonary capillary wedge pressure were associated with a rise in TAG . A range was identified for TAG (20-40 mm Hg) as providing the most optimal level of hemodynamic offloading. Pathologic states deviated from normal responses to ramp. LV assist device thrombosis was associated with an inability to increase in TAG during speed ramp. Significant aortic insufficiency was associated with a marked increase in LV end-diastolic pressure despite a concomitant decrease in pulmonary capillary wedge pressure with increasing LV assist device speeds. Conclusions Inclusion of left heart catheterization to a typical right heart catheterization LV assist device ramp protocol imparted unique insights to optimize cf LVAD speeds in different clinical scenarios. A novel index, the TAG was defined and provided additional resolution to optimized offloading.

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