Prognostication of Residual Mitral Regurgitation or Aortic Insufficiency after Invasive Hemodynamic Ramp Optimization

Abstract

LVAD speed optimization via invasive ramp studies have been shown to reduce LVAD related morbidity. Many LVAD implanting centers use non-invasive echocardiographic (TTE) ramp studies for optimization and use mitral (MR) and aortic insufficiency (AI) severity as surrogates for unloading and optimization. We examined the prognostic value of residual MR and AI after invasive hemodynamic optimization. Patients underwent simultaneous TTE and hemodynamic LVAD ramp study with hemodynamic and TTE measurements at each incremental speed increase. The device was set at a speed that demonstrated an optimized hemodynamic profile with target CVP <12mmHg, PCWP <18mmHg, and cardiac index> 2.2L/min/m2. MR and AR severity at the optimized speed was quantified by TTE and the impact of residual regurgitant lesions on heart failure (HF) readmission-free survival and hemocompatibility related adverse events (HRAE) free survival and overall survival at 3 years was determined. After hemodynamic optmization, mean PCWP was 13.7mmHg, CI was 2.73L/min/m2 and RAP was 9.4mmHg for the entire cohort. 24 patients had residual mild/moderate or greater AI and 27 patients had mild or greater MR after optimization. Freedom from HRAE was higher in those without residual AI (45% vs 24%, p =0.05) at 3 years with no difference in overall survival or HF admission (Figure Top). Patients without residual MR had higher 3 year survival compared to those with residual MR (75% vs 51%, p =0.03). There was a trend toward higher HRAE and HF readmission rates in those with residual MR (Figure Bottom). Residual AI and MR after LVAD hemodynamic speed optimization has negative consequences with regard to HRAE and HF readmission-free survival and overall mortality at 3 years. Additional speed optimization may be needed in this cohort to mitigate morbidity and mortality.