Pulmonary Artery Pulsatility Index Early Post-LVAD Implantation Predicts Severe Right Ventricular Failure

Abstract

Purpose Early identification of right ventricular failure (RVF) after LVAD implantation is critical to reducing morbidity and mortality. The pre-operative pulmonary artery pulsatility index (PAPi) is associated with severe right ventricular failure (RVF) after LVAD implantation. We set out to assess if the PAPi in the immediate post-operative period is also predictive of severe RVF. Methods A single-center retrospective study of 230 patients who received a continuous-flow durable LVAD between 1/2006 and 9/2016. PAPi was defined as: [(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started after 14 days of implant, RVAD placement during implant admission, or death from RVF during implant admission. The hemodynamics pre-implant and post-operatively were documented. A multivariate analysis for predictors of severe RVF was performed, and ROC curves were created. Results In our 230-patient cohort, 62 patients (27%) were found to have severe RVF. Patients in the severe RVF group had higher INTERMACS profile, were more likely to receive pre-operative vasopressors, have lower total bilirubin and lower PAPi. The multivariable model (which included age, INTERMACS level, creatinine over 1.5 mg/dL, total bilirubin over 2.5 mg/dL, and gender) found that a PAPi 16 at 6 hours post-op (OR 3.1 [1.1, 8.6], p = 0.03, n = 208) were significant predictors of severe RVF. The pulmonary artery (PA) pressure at 6 hours and the CVP, PAPi, and PA pressure at 24 hours were not predictive of severe RVF in our model. A PAPi 16 (ROC c-statistic 0.71) at 6 hours post-op. Conclusion The PAPi at 6 hours is a significant predictor of severe RVF and adds value to standard hemodynamic measurements.