270. Preemptive Use of a Right Ventricular Assist Device in High-Risk Patients Undergoing Implantation of a Magnetically Levitated Left Ventricular Assist Device

15 Minutes 

Metro Toronto Convention Center 

Objective: Right ventricular failure is a morbid complication after LVAD implantation which may be treated with a right ventricular assist device (RVAD). We sought to determine the effect of preemptive RVAD insertion at the time of HeartMate 3 (HM3) implantation in patients at high risk for post-LVAD RV failure.
Methods: We retrospectively reviewed 294 consecutive patients undergoing HM3 implantation at our center from November 2014 to December 2022. A preemptive RVAD strategy was applied to select patients. Outcomes were compared to patients who did not require an RVAD and who required an RVAD after HM3 insertion (reactive).
Results: Of the cohort, 33 (11.2%) patients had preemptive CentriMag (CM) RVAD insertion, while 230 (78.2%) had no RVAD and 31 (10.5%) had a reactive RVAD [CM (n=8, 25.8%) or ProTek Duo (n=23, 74.2%)]. Reasons for a preemptive RVAD were INTERMACS 1TCS (n=22, 66.7%), intractable ventricular tachycardia (n=4, 12.1%), or severe biventricular failure (n=7, 21.2%); 24.2% (n=8) of patients had an eGFR less than 45 mL/min/1.73m2. Preemptive RVAD patients were more frequently INTERMACS 1TCS (None: 10.9% vs Preemptive: 63.6% vs Reactive: 6.5%, P<0.001), had a higher CVP (9 vs 13 vs 9 mmHg, P=0.01) and higher rate of severe RV dysfunction (12.2 vs 30.3 vs 16.1%, P=0.02). In-hospital mortality was highest in the reactive group (2.2 vs 3.0 vs 25.8%, P<0.001). With a BiVAD configuration in place, 3 patients (9.1%) in the preemptive group were bridged to a heart transplant vs. 0 in the reactive group, and there were 0 mortalities for preemptive patients vs. 5 (16.1%) in the reactive group. All others (87.5%) were successfully weaned off RVAD support. Median duration of RVAD support was not different between preemptive and reactive groups (14 vs 13 days, P=0.798). Kaplan-Meier analysis showed lowest 3-year survival in the reactive group, while preemptive and non-RVAD groups had comparable survival (84.7 vs 85.5 vs 46.6%, P<0.001; Figure 1). In multivariable Cox analysis, a reactive RVAD was an independent risk factor for 3-year mortality (HR: 3.7, P<0.001). Among survivors to discharge, 3-year freedom from RV failure readmission was not different between groups (80.8 vs 85.2 vs 71.2%, P=0.23). At latest follow-up, significantly more RVAD patients had moderate or worse RV dysfunction (46.9 vs 70.4 vs 76.0%, P=1).
Conclusions: Preemptive RVAD insertion at time of HM3 may improve outcomes in patients who are at high risk for developing RV failure.

Authors
Krushang Patel (1), Alice Vinogradsky (2), Melissa Hynds (3), Yuji Kaku (4), Melana Yuzefpolskaya (4), Paolo Colombo (5), Gabriel Sayer (6), Nir Uriel (5), Yoshifumi Naka (7), Koji Takeda (3)
Institutions
(1) N/A, N/A, (2) Columbia University, United States, (3) Columbia University, New York, NY, (4) Columbia University Medical Center, New York, NY, (5) Columbia University Irving Medical Center, New York, NY, (6) Columbia University Medical Center, NYC, NY, (7) New york presbyterian, New York, NY

You will have a 6 minute presentation followed by 6 minutes of discussion with an assigned commentator. All presenters must adhere to the presentation and discussion times provided. The AATS will begin to play music once your speaking time is exceeded.