Right heart function paradoxically predicts systemic circulatory failure during ventricular tachyarrhythmias in LVAD-supported patients

Background

Ventricular tachyarrhythmias (VAs) can lead to systemic circulatory failure (SCF) in some patients supported by left ventricular assist devices (LVADs), whereas others remain haemodynamically stable. The mechanisms underlying this variability remain unclear.

Object

To identify haemodynamic and echocardiographic predictors of SCF during VA episodes in LVAD-supported patients.

Methods

We conducted a retrospective, single-centre case–control study involving 156 consecutive patients who underwent LVAD implantation between January 2008 and September 2024. SCF was defined as the presence of low cardiac output-related symptoms (fatigue, dyspnoea, pre-syncope, appetite loss, abdominal bloating, abdominal pain), signs of organ dysfunction (renal or hepatic impairment, elevated lactate) or hypotension (mean arterial pressure <50 mmHg) occurring exclusively during sustained VA episodes. We evaluated the associations between SCF and clinical parameters. Echocardiographic and right heart catheterization data were collected from the most recent examinations performed closest to the date of VA onset.

Results

VAs after LVAD occurred in 24 of 156 patients during the mean follow-up period of 1497±671 days. The patients were 47.6 ± 11.7 years and 20 patients (83%) were male. A total of 32 VA episodes were documented in 24 patients, and SCF was observed in 18 episodes. Higher right ventricular fractional area change (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.01–1.27), lower mean right atrial pressure (OR: 0.80, 95% CI: 0.64–0.96), and higher pulmonary artery pulsatility index (PAPi; OR: 2.93, 95% CI: 1.43–8.45) were associated with SCF occurrence during VAs (Table 1).

In contrast, VT rate (OR: 1.01; 95% CI: 0.99–1.03; p = 0.52) and PVR (OR: 0.73; 95% CI: 0.30–1.67; p = 0.45) were not associated with SCF in this cohort. ROC curve analysis for PAPi yielded an AUC of 0.80 and a cut-off value of 2.4 provided 72.2% sensitivity and 92.9% specificity, best predicting SCF (Figure 1).

Conclusions

Paradoxically, better right heart function was associated with a higher risk of SCF during VAs in LVAD-supported patients. PAPi may serve as a useful predictor of SCF in this setting, warranting further investigation.Table.1:Predictors of SCF during VAFigure.1:ROC for predicting SCF during VA