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

Joly, Joanna M.*; El-Dabh, Ashraf*; Marshell, Ramey*; Chatterjee, Arka*; Smith, Michelle G.; Tresler, Margaret; Kirklin, James K.; Acharya, Deepak*; Rajapreyar, Indranee N.*; Tallaj, José A.*; Pamboukian, Salpy V.*

doi: 10.1097/MAT.0000000000000830
Adult Circulatory Support
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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.

From the *Division of Cardiovascular Diseases, Department of Medicine

Division of Cardiothoracic Surgery, Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama.

Submitted for consideration December 2017; accepted for publication in revised form April 2018.

Disclosure: James K. Kirklin is the Xeltis Trial Chair of DSMB-A Clinical Trial of bioprosthetic heart conduit. This author paid a one-time fee of $2500 (financial relationship outside of current manuscript).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.asaiojournal.com).

Correspondence: Joanna M. Joly, Division of Cardiovascular Diseases, Department of Medicine, The University of Alabama at Birmingham, 1900 University Blvd, Tinsley Harrison Tower, Suite 311, Birmingham, AL 35233. Email: jjoly@uabmc.edu.

Copyright © 2019 by the American Society for Artificial Internal Organs