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Intraoperative Hemodynamic and Echocardiographic Measurements Associated With Severe Right Ventricular Failure After Left Ventricular Assist Device Implantation

Gudejko, Michael D. BS*; Gebhardt, Brian R. MD, MPH*; Zahedi, Farhad MD*; Jain, Ankit MBBS, MD*; Breeze, Janis L. MPH; Lawrence, Matthew R. BS; Shernan, Stanton K. MD§; Kapur, Navin K. MD; Kiernan, Michael S. MD, MS; Couper, Greg MD; Cobey, Frederick C. MD, MPH, FASE*

doi: 10.1213/ANE.0000000000003538
Cardiovascular and Thoracic Anesthesiology: Original Clinical Research Report
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BACKGROUND: Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF.

METHODS: A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure − pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics.

RESULTS: A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm2; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64–0.86).

CONCLUSIONS: Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.

From the *Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts

Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston Massachusetts

Department of Cardiology, Tufts Medical Center, Boston, Massachusetts

§Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Department of Surgery, Tufts Medical Center, Boston, Massachusetts.

Published ahead of print 30 April 2018.

Accepted for publication April 30, 2018.

Funding: This study was supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health, Award Number UL1TR001064.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

M. D. Gudejko and B. R. Gebhardt contributed equally and share first authorship.

Reprints will not be available from the authors.

Address correspondence to Frederick C. Cobey, MD, MPH, FASE, Department of Anesthesiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111. Address e-mail to FCobey@tuftsmedicalcenter.org.

Copyright © 2018 International Anesthesia Research Society
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