Predictiveness of Pre-Operative Cardiac Function Hemodynamics, Passive and Active Cardiac Index on Outcomes Following Left Ventricular Assist Device Implantation
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Rochester, MN
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General Surgery PGY - 4 at Mayo Clinic Rochester. Originally from Bogota, Colombia and interested in aortic surgery, and structural heart disease
Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Description
Objective: To evaluate the predictive ability of pre-operative hemodynamic parameters on postoperative right ventricular failure (RVF), long-term survival and readmissions for heart failure (HF) after implantation of continuous-flow left ventricular assist devices (LVAD).
Methods: Retrospective review of 399 consecutive patients who underwent primary continuous flow LVAD implantation at our institution between 2007 and 2023. Pre-operative hemodynamics were used to estimate the relative contributions of the right heart to the cardiac index via its passive and active components. Pre-operative passive cardiac index (PasCI) was calculated by dividing right atrial pressure (RAP) by mean pulmonary artery pressure (mPAP), multiplied by total cardiac index. The active cardiac index (ActCI) was calculated by subtracting the RAP from the mPAP, divided by the mPAP, and multiplying by the total cardiac index. To assess the impact of PasCI and ActCI on outcomes, separate unadjusted logistic regression models were fitted for early postoperative RVF and multivariable Cox regression models were fitted for long-term outcomes of all-cause mortality and readmission for heart failure. The model for readmission for HF used the Andersen-Gill formulation to allow for multiple events. Partial effects plots were derived from these models to display the risk relationships (Figure 1).
Results: Majority of patients were male (79%), and the median age was 63 (IQR: 55, 69) years. LVAD was used as destination therapy in 136 (65%), bridge to transplant in 136 (34%), and bridge to decision in 2 (0.5%). Etiology of HF was ischemic cardiomyopathy in 189 (47%). Median RAP was 13 (IQR: 9, 18) mmHg and median mPAP was 35 (IQR: 30, 42) mmHg; median PasCI was 0.64 (IQR: 0.45, 0.89) L/min/m2 and median ActCI was 1.11 (IQR: 0.78, 1.45) L/min/m2. Operative mortality occurred in 34 (9%) patients, and postoperative RVF in 28 (7%). On unadjusted analysis, lower ActCI was found to be associated with early postoperative RVF (p=0.021, Figure 1B). On multivariable analysis, higher PasCI scores were associated with worse long-term survival (p=0.004, Figure 1C) and with borderline increased risk of readmissions for HF (p=0.052, Figure 1E).
Conclusions: In patients who underwent LVAD implantation, indices derived from the preoperative hemodynamics to assess the relative contributions of the right heart to the cardiac index showed some association with early postoperative RVF, long-term survival, and readmissions for HF. This study serves as a platform for future development of risk score calculators and inform therapeutic decision-making.
Authors
Rolando Calderon (1), John Stulak (2), Mauricio Villavicencio (3), Richard Daly (4), Philip Spencer (5), Andrew Rosenbaum (2), Sina Danesh (2), Hossam Elbenawi (2), Brian D. Lahr (2), Alexander Lee (2), Paul Tang (6)
Institutions
(1) N/A, Rochester, MN, (2) Mayo Clinic, Rochester, MN, (3) Department of Cardiovascular Surgery, Mayo Clinic, Boston, MA, (4) Mayo Clinic College of Medicine and Science, Rochester, MN, (5) Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, (6) Mayo Clinic (Rochester, MN), Rochester, MN
Methods: Retrospective review of 399 consecutive patients who underwent primary continuous flow LVAD implantation at our institution between 2007 and 2023. Pre-operative hemodynamics were used to estimate the relative contributions of the right heart to the cardiac index via its passive and active components. Pre-operative passive cardiac index (PasCI) was calculated by dividing right atrial pressure (RAP) by mean pulmonary artery pressure (mPAP), multiplied by total cardiac index. The active cardiac index (ActCI) was calculated by subtracting the RAP from the mPAP, divided by the mPAP, and multiplying by the total cardiac index. To assess the impact of PasCI and ActCI on outcomes, separate unadjusted logistic regression models were fitted for early postoperative RVF and multivariable Cox regression models were fitted for long-term outcomes of all-cause mortality and readmission for heart failure. The model for readmission for HF used the Andersen-Gill formulation to allow for multiple events. Partial effects plots were derived from these models to display the risk relationships (Figure 1).
Results: Majority of patients were male (79%), and the median age was 63 (IQR: 55, 69) years. LVAD was used as destination therapy in 136 (65%), bridge to transplant in 136 (34%), and bridge to decision in 2 (0.5%). Etiology of HF was ischemic cardiomyopathy in 189 (47%). Median RAP was 13 (IQR: 9, 18) mmHg and median mPAP was 35 (IQR: 30, 42) mmHg; median PasCI was 0.64 (IQR: 0.45, 0.89) L/min/m2 and median ActCI was 1.11 (IQR: 0.78, 1.45) L/min/m2. Operative mortality occurred in 34 (9%) patients, and postoperative RVF in 28 (7%). On unadjusted analysis, lower ActCI was found to be associated with early postoperative RVF (p=0.021, Figure 1B). On multivariable analysis, higher PasCI scores were associated with worse long-term survival (p=0.004, Figure 1C) and with borderline increased risk of readmissions for HF (p=0.052, Figure 1E).
Conclusions: In patients who underwent LVAD implantation, indices derived from the preoperative hemodynamics to assess the relative contributions of the right heart to the cardiac index showed some association with early postoperative RVF, long-term survival, and readmissions for HF. This study serves as a platform for future development of risk score calculators and inform therapeutic decision-making.
Authors
Rolando Calderon (1), John Stulak (2), Mauricio Villavicencio (3), Richard Daly (4), Philip Spencer (5), Andrew Rosenbaum (2), Sina Danesh (2), Hossam Elbenawi (2), Brian D. Lahr (2), Alexander Lee (2), Paul Tang (6)
Institutions
(1) N/A, Rochester, MN, (2) Mayo Clinic, Rochester, MN, (3) Department of Cardiovascular Surgery, Mayo Clinic, Boston, MA, (4) Mayo Clinic College of Medicine and Science, Rochester, MN, (5) Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, (6) Mayo Clinic (Rochester, MN), Rochester, MN