Performance of Noninvasive Assessment in the Diagnosis of Right Heart Failure After Left Ventricular Assist Device.

Right heart failure (RHF) after left ventricular assist device (LVAD) is associated with poor outcomes. Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) defines RHF as elevated right atrial pressure (RAP) plus venous congestion. The purpose of this study was to examine the diagnostic performance of the noninvasive Intermacs criteria using RAP as the gold standard. We analyzed 108 patients with LVAD who underwent 341 right heart catheterizations (RHC) between January 1, 2006, and December 31, 2013. Physical exam, echocardiography, and laboratory data at the time of RHC were collected. Conventional two-by-two tables were used and missing data were excluded. The noninvasive Intermacs definition of RHF is 32% sensitive (95% cardiac index (CI), 0.21-0.44) and 97% specific (95% CI, 0.95-0.99) for identifying elevated RAP. Clinical assessment failed to identify two-thirds of LVAD patients with RAP > 16 mm Hg. More than half of patients with elevated RAP did not have venous congestion, which may represent a physiologic opportunity to mitigate the progression of disease before end-organ damage occurs. One-quarter of patients who met the noninvasive definition of RHF did not actually have elevated RAP, potentially exposing patients to unnecessary therapies. In practice, if any component of the Intermacs definition is present or equivocal, our data suggest RHC is warranted to establish the diagnosis.

High Right Atrial Pressure and Low Pulse Pressure Predict Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device.

BACKGROUND: Gastrointestinal bleeding (GIB) remains a major morbid event during continuous flow left ventricular assist device (LVAD) support. This study investigated whether a common hemodynamic profile is associated with GIB in patients with LVADs. METHODS AND RESULTS: A single institution analysis reviewed all patients who underwent right heart catheterization (RHC) following LVAD implant between January 1, 2006, and December 31, 2013, with follow-up through June 2015. Kaplan-Meier and multiphase hazard statistical methods were employed. Among 108 patients with 341 RHC, 55 hospitalizations for GIB occurred within 1 year of RHC. Freedom from GIB at 6 months was 92% in patients with pulse pressure ≥35 mmHg, compared with 76% with pulse pressure <35 mmHg. By multivariable analysis, the significant predictors of GIB were: older age at implant, number of prior GIB, lower pulse pressure, lower mean arterial pressure, and higher right atrial pressure (all P < .05). The magnitude of effect is influenced by pulse pressure. CONCLUSIONS: Greater pulsatility and less venous congestion, along with other factors, are associated with a lower risk for GIB. It is reasonable to adjust therapeutic strategies to target this hemodynamic profile in patients with a propensity for GIB.