Optimization Prior to Left Ventricular Assist Device Implantation is Associated with Reduced Risk of Severe Early Post-Implant Complications

Abstract

<h3>Purpose</h3> Although hemodynamic status prior to continuous flow left ventricular assist device placement (CF-LVAD) is an important determinant of outcomes, data on pre-implant optimization and patient-oriented outcomes are sparse. <h3>Methods</h3> We identified consecutive patients undergoing CF-LVAD implant between 2007 and 2017 at a single institution. Hemodynamic variables at three time points and laboratory studies were evaluated pre-LVAD implant in a logistic regression model to identify predictors of the primary composite endpoint: need for right ventricular assist device (RVAD) therapy, requirement for hemodialysis at 90 days, and 30-day mortality. <h3>Results</h3> Multivariate modeling identified three variables significantly associated with the primary endpoint: right ventricular stroke work index (RVSWI), right atrial pressure (RAP), and blood urea nitrogen (BUN); all immediately pre-LVAD, <i>P</i><.01. Optimal dichotomization points (rounded) were 500 mmHg*ml*m⁻², 12 mmHg, and 40 mg/dL, respectively. The three-component model identified an AUC of 0.77 (<i>P</i><.0001) for the composite endpoint. Optimization of 2/3 parameters, 1/3, and 0/3 was associated with of odds ratios of 2.4 (95% CI 0.8-7.6), 5.5 (1.8-17.0), and 18.9 (4.9-73.1), respectively, for the primary endpoint relative to those patients who were fully optimized (3/3 parameters). Number of optimized parameters was also associated with 1-year overall survival (<i>P</i>=.02). <h3>Conclusion</h3> Low RVSWI, high RAP, and high BUN were independently associated with adverse outcomes after CF-LVAD implant, and demonstrated a stepwise association with severe post-implant adverse events. Prospective, protocol-driven hemodynamic optimization should be tested to improve outcomes after CF-LVAD implantation.