Long Term Outcomes for LVAD Patients Who Underwent Speed Optimization Using Pre-Discharge Ramp Test

Abstract

Purpose The influence of speed optimization on long term outcome among Continuous Flow (CF) Left Ventricular Assist Device (LVAD) pts is still unknown. Current guidelines recommend setting device speed that will ensure intermittent Aortic Valve (AV) opening during support. This study sought to determine the feasibility of achieving this parameter prior to discharge using a ramp test and its potential role in preventing long-term device complications. Methods and Materials A prospective study on pre-discharge speed optimization via Ramp Protocol was conducted post-device implantation. Right and left Heart Failure (HF), Gastrointestinal (GI) bleeding, arrhythmia, device thrombosis, and ECHO parameters of aortic insufficiency (AI) were collected. Results 37 pts had speed optimization Ramp tests before discharge with a mean follow-up time of 9.6±6.7 months. Mean age was 59±12 years old and 84% were male. 49% (n=18) were discharged with a speed that allowed for intermittent AV opening while 32% (n=12) were discharged with a closed AV. 19% (n=7) had AV surgery (Park stitch) at the time of implant. The frequency of right and left HF, ventricular arrhythmia and GI bleeding were similar among all 3 groups. 28% (n=5) of the AV opening group had device exchange due to obstruction to pump flow, whereas none of the 19 pts in the AV closed and AV surgery groups experienced device thrombosis (OR = 6.92, p=0.094). None of the pts in the AV opening group developed significant AI as compared to 1 pt who developed AI from the AV-closed group. Conclusions Intermittent opening of the AV via speed optimization was achieved in only 49% of the pts. Pts with AV opening may be at higher risk for developing obstructions to flow. Pts with intermittent AV opening may be better protected from developing significant AI. This study implies a differential speed setting for Bridge-To-Transplant pts since long-term consequences of AI is of less concern than protecting them from experiencing obstruction to pump flow events. Larger cohorts with longer follow up times are warranted.