Pulmonary Artery Pulsatility Index (PAPi) is a Predictor of Right Ventricular Assist Device (RVAD) Use Following HeartMate 3 LVAD Implantation

Abstract

Pulmonary artery pulsatility index (PAPi) recently emerged as a predictor of right ventricular failure after Heartmate II LVAD Implantation. Clinical utility of this marker in Heartmate 3 patients is unknown. We hypothesized that PAPi is a stronger predictor of RV failure compared to central venous pressure to pulmonary artery capillary wedge pressure ratio (CVP/PCWP) or RV stroke work index (RVSWI) in Heartmate 3 population. 175 patients who received a Heartmate 3 LVAD at a single academic center between 2014 - 2019 were included in the study. Primary outcome was right ventricular assist device (RVAD) use following HM3 implant. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis determined predictors of RVAD use in HM3 patients. 55 patients (31.4%) required RVAD following HM3 implantation including 19 percutaneous, 24 paracorporeal, and 2 durable RVADs. Age, gender, and implant strategy were comparable between RVAD and no RVAD groups. Patients requiring RVAD were more likely to be INTERMACS Class I or II (78.2% vs. 56.6%), have a higher WBC count (9.2±3.4 vs. 8.1±2.8) and C-reactive protein (57.7±59.2 vs. 38.4±34.7) prior to device implant (all p <0.05). RVAD group had significantly lower PAPi (3.4±2.0 vs. 6.0±6.8, p=0.001), higher CVP/PCWP ratio (0.50±0.27 vs. 0.42±0.25, p=0.036) and comparable RVSWI (0.534±0.285 vs. 0.572±0.240, p=0.368) before device implant. ROC curve analysis provided higher AUC for PAPi compared to CVP/PCWP ratio or RVSWI (Figure). After adjusting for age, etiology of HF, creatinine, bilirubin, WBC count, INTERMACS Class, RVSWI, and CVP/PCWP ratio, PAPi was the only significant predictor of RVAD use in multivariable model (OR 0.913 [95%CI: 0.835 - 0.999], p=0.049). PAPi is an independent predictor of RV failure in Heartmate 3 patients. Incorporating PAPi in clinical decision-making may improve patient selection and perioperative outcomes in this population.