Redefining echocardiographic optimization profile six months after LVAD implantation: the role of estimated right atrial pressure
J Guzman Bofarull, G Gallone, V A R Thirupathirajan, J B Guichard, A Maestro Benedicto, J Ibero, E Karapedi, A Bollas Becerra, F Imam, M Monteagudo Vela, D Garcia Saez, F Fiorelli, O Dar, A Morley-Smith, F Riesgo GilAbstract
Background
Despite evidence that echocardiography-guided optimization improves long-term clinical outcomes in patients with left ventricular assist devices (LVADs), the specific echocardiographic parameters that define an optimal optimization profile remain poorly defined.
Purpose
We aimed to evaluate the long-term prognostic impact of different echocardiographic optimization profiles assessed six months after LVAD implantation, including estimated right atrial pressure (eRAP) assessed by inferior vena cava size.
Methods
We retrospectively analyzed all consecutive patients undergoing durable LVAD implantation at a single center between 2010 and 2025 who survived at least six months post-implant and had an echocardiographic assessment available at six months. Three echocardiographic optimization profiles were defined. Optimal profile 1 (OP1) included less than moderate mitral regurgitation (MR) and a centrally positioned interventricular septum (IVS). Optimal profile 2 (OP2) included OP1 criteria plus at least partial aortic valve (AV) opening. Optimal profile 3 (OP3) included only less than moderate MR and an eRAP <15 mmHg. The primary endpoint was a composite of cardiovascular death or heart failure (HF) hospitalization. Secondary endpoints included HF hospitalization, late right ventricular failure (RVF), all-cause mortality, hemocompatibility-related adverse events (HRAEs), and long-term renal dysfunction assessed by serum creatinine at 18 months post-implantation.
Results
Among the study population, 45.5% met criteria for OP1, 24.7% for OP2, and 63.6% for OP3. In unadjusted Cox analyses, OP3 was consistently associated with a significantly lower risk of adverse outcomes across all endpoints compared with OP1 and OP2 (all p < 0.01), except for HRAEs (p = 0.14). Achievement of OP3 criteria was associated with an 80% reduction in the risk of cardiovascular death or HF hospitalization, an 82% reduction in HF hospitalization, an 83% reduction in late RVF, a 70% reduction in all-cause mortality, a 37% reduction in HRAEs, and a −33 µmol/L change in serum creatinine at 18 months follow-up compared with those not meeting OP3. Adjusted effect estimates for each optimization profile are presented in forest plots (Figure).
Conclusion
An echocardiographic optimization profile defined by less than moderate MR and eRAP <15 mmHg—although the most frequently achieved—was consistently and strongly associated with improved clinical and laboratory outcomes, including reduced mortality and HF hospitalization, compared with profiles incorporating IVS position and AV opening. These findings highlight the prognostic importance of right-sided filling pressures in LVAD optimization.For image description, please refer to the figure legend and surrounding text.