Pulmonary artery pulsatility index predicts prolonged inotrope/pulmonary vasodilator use after implantation of continuous flow left ventricular assist device.
Varun Aggarwal, Sebastian C Tume, Marco Rodriguez, Iki Adachi, Antonio G Cabrera, Hari Tunuguntla, Athar M Qureshi
Author Information
Varun Aggarwal: The Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Sebastian C Tume: Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Marco Rodriguez: The Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Iki Adachi: Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Antonio G Cabrera: The Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Hari Tunuguntla: The Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Athar M Qureshi: The Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
OBJECTIVE: Predictors of right ventricle (RV) dysfunction after continuous-flow left ventricular assist device (CF-LVAD) implantation in children are not well described. We explored the association of preimplantation Pulmonary Artery Pulsatility index (PAPi) and other hemodynamic parameters as predictors of prolonged postoperative inotropes/pulmonary vasodilator use after CF-LVAD implantation. DESIGN: Retrospective chart review. SETTING: Single tertiary care pediatric referral center. PATIENTS: Patients who underwent CF-LVAD implantation from January 2012 to October 2017. INTERVENTIONS: Preimplantation invasive hemodynamic parameters were analyzed to evaluate the association with post-CF-LVAD need for prolonged (>72 hours) use of inotropes/pulmonary vasodilators. MEASUREMENTS AND MAIN RESULTS: Preimplantation cardiac catheterization data was available for 12 of 44 patients who underwent CF-LVAD implant during the study period. Median (IQR) age and BSA of the cohort were 15.3 years (10.2, 18) and 1.74 m (0.98, 2.03). Group 1 (n = 6) included patients with need for prolonged inotropes/pulmonary vasodilator use after CF-LVAD implantation and Group 2 (n = 6) included those without. Baseline demographic parameters, cardiopulmonary bypass time, and markers of RV afterload (pulmonary vascular resistance, PA compliance and elastance) were similar among the two groups. PAPi was significantly lower in group 1 compared to group 2 (0.96 vs 3.6, respectively; P = .004). Post-LVAD stay in the intensive care unit was longer for patients in group 1 (46 vs 23 days, P = .52). Brain natriuretic peptide was significantly higher at 3 months after implantation in group 1; P = .01. CONCLUSIONS: The need for inotropes/pulmonary vasodilators in the postoperative period can be predicted by the preimplantation intrinsic RV contractile reserve as assessed by PAPi rather than the markers of RV afterload. Further investigation and correlation with clinical outcomes is needed.
Blume ED, VanderPluym C, Lorts A, et al. Second annual Pediatric interagency registry for mechanical circulatory support (pedimacs) report: pre-implant characteristics and outcomes. J Heart Lung Transplant. 2018;37(1):38-45.
Dang N, Topkara V, Mercando M, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant. 2006;25:1-6.
Ochiai Y, McCarthy PM, Smedira NG, et al. Predictors of severe right ventricular failure after implantable left ventricular assist device insertion: analysis of 245 patients. Circulation. 2002;106(12 Suppl 1):I-198-I-202.
Frazier OH, Rose EA, Oz MC, et al. Ventricular assist system. Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation. J Thorac Cardiovasc Surg. 2001;122(6):1186-1195.
Kavarana MN, Pessin-Minsley MS, Urtecho J, et al. Right ventricular dysfunction and organ failure in left ventricular assist device recipients: a continuing problem. Ann Thorac Surg. 2002;73:745-750.
Fan Y, Zhang A-M, Weng Y-G, et al. Factors associated with the need of biventricular mechanical circulatory support in children with advanced heart failure. Eur J Cardiothorac Surg. 2013;43(5):1028-1035.
Deng MC, Edwards LB, Hertz MI, et al. Mechanical circulatory support device database of the International Society for Heart and Lung Transplantation: third annual report-2005. J Heart Lung Transplant. 2005;24(9):1182-1187.
Drakos SG, Janicki L, Horne BD, et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol. 2010;105:1030-1035.
Korabathina R, Heffernan KS, Paruchuri V, et al. The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. Catheter Cardiovasc Interv. 2012;80(4):593-600.
Kang G, Ha R, Banerjee D. Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. J Heart Lung Transplant. 2016;35(1):67-73.
Morine KJ, Kiernan MS, Pham DT, Paruchuri V, Denofrio D, Kapur NK. Pulmonary artery pulsatility index is associated with right ventricular failure after left ventricular assist device surgery. J Card Fail. 2016;22(2):110-116.
Pediatric Registry for Mechanically Assisted Circulatory Support: Quarterly Statistical Report 2017 2nd Quarter. http://www.uab.edu/medicine/intermacs/reports/public-statistical-reports. Accessed November 17, 2017.
Soliman OII, Akin S, Muslem R, et al. Derivation and validation of a novel right-sided heart failure model after implantation of continuous flow left ventricular assist devices. Circulation. 2018;137:891-906.
Lopez-Sendon J, Coma-Canella I, Gamallo C. Sensitivity and specificity of hemodynamic criteria in the diagnosis of acute right ventricular infarction. Circulation. 1981;64(3):515-525.
Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg. 2010;139(5):1316-1324.
Korabathina R, Heffernan KS, Paruchuri V, et al. The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. Catheter Cardiovasc Interv. 2012;80(4):593-600.
Amin A, Taghavi S, Esmaeilzadeh M, Bakhshandeh H, Naderi N, Maleki M. Pulmonary arterial elastance for estimating right ventricular afterload in systolic heart failure. Congest Heart Fail. 2011;17(6):288-293.
Yasue H, Yoshimura M, Sumida H, et al. Localization and mechanism of secretion of B-type natriuretic peptide in comparison with those of A-type natriuretic peptide in normal subjects and patients with heart failure. Circulation. 1994;90(1):195-203.
Epstein FH, Levin ER, Gardner DG, Samson WK. Mechanisms of disease: natriuretic peptides. NEJM. 1998;339(5):321-328.
Sareyyupoglu B, Boilson BA, Durham LA, et al. B-type natriuretic peptide levels and continuous-flow left ventricular assist devices. ASAIO J. 2010;56(6):527-531.
Sato T, Seguchi O, Iwashima Y, et al. Serum brain natriuretic peptide concentration 60 days after surgery as a predictor of long-term prognosis in patients implanted with a left ventricular assist device. ASAIO J. 2015;61(4):373-378.
Argenziano M, Choudhri AF, Moazami N, et al. Randomized, double-blind trial of inhaled nitric oxide in LVAD recipients with pulmonary hypertension. Ann Thorac Surg. 1998;65:340-345.
Tedford RJ, Hemnes AR, Russell SD, et al. PDE5A inhibitor treatment of persistent pulmonary hypertension after mechanical circulatory support. Circ Heart Fail. 2008;1:213-219.
Cleveland JC Jr, Naftel DC, Reece TB, et al. Survival after biventricular assist device implantation: an analysis of the interagency registry for mechanically assisted circulatory support database. J Heart Lung Trans. 2011;30:862-869.
