Association between early post-implantation pulmonary vascular resistance and clinical outcomes after LVAD implantation
H Oh, A Kim, D Hong, D Kim, K Kim, J Hyun, J Yang, S Lee, Y Cho, J Choi, S Jung, M KimAbstract
Background
Pulmonary vascular resistance (PVR) is associated with mortality, right heart failure (HF), and heart transplantation eligibility in patients undergoing left ventricular assist device (LVAD) implantation. Although LVAD implantation markedly unloads the left ventricle, persistent elevation of PVR after LVAD implantation remains a major clinical challenge. While post-LVAD PVR has been studied mainly in relation to transplant outcomes, its prognostic significance for clinical outcomes during ongoing LVAD support remains poorly defined.
Purpose
We aimed to evaluate the prognostic value of early post-implantation PVR during LVAD support and to compare the clinical outcomes according to post-implantation PVR levels.
Methods
Among 345 patients who underwent LVAD implantation at two tertiary centers, 71 patients with available right heart catheterization data at 1 month after implantation were included. Cox proportional hazards models were used to assess the association between PVR and time-to-event outcomes. Baseline and 1-month PVR were simultaneously included to evaluate their independent prognostic value. Patients were stratified according to a 1-month PVR cutoff of 3 Wood units (WU) into a high PVR group (> 3 WU) and a low PVR group (≤ 3 WU). Clinical outcomes included all-cause mortality, cardiovascular (CV) mortality, any readmission, HF readmission, and hemocompatibility-related adverse events (HRAEs), right HF. Logistic regression and Firth Cox regression were applied as appropriate.
Results
The mean age of the cohort was 56 years, and 92% of patients were male. Baseline clinical and hemodynamic characteristics were largely comparable between groups, although ischemic cardiomyopathy was more prevalent in the low PVR group (50.0% vs. 25.5%, p = 0.029). In Cox proportional hazards models including both baseline PVR and 1-month PVR, baseline PVR was not significantly associated with all-cause or CV mortality. In contrast, higher 1-month PVR was independently associated with risk of all-cause mortality (hazard ratio [HR] 2.87, 95% confidence interval [CI] 1.39–5.91, p = 0.004). Patients with high 1-month PVR group had significantly higher all-cause mortality compared with those with low PVR group (HR 9.18, 95% CI 1.33–63.24, p = 0.014). Higher post-implantation PVR was also associated with an increased risk of HRAEs.
Conclusions
Early post-implantation PVR, but not baseline PVR, was strongly associated with adverse clinical outcomes during LVAD support. Assessment of PVR after LVAD implantation may provide important prognostic information beyond baseline hemodynamic measurements.For image description, please refer to the figure legend and surrounding text.