Resolution of Right Atrial Congestion before LVAD Implantation is Associated with Improved Outcomes

Abstract

Purpose Increased right atrial pressure is known to be a predictor of poor outcomes after LVAD implantation. Whether resolution of right heart congestion prior to LVAD implantation is associated with more favorable outcomes is not well understood. Methods We analyzed LVAD recipients from our institution from 1/1/2015 to 2/28/2018. We excluded patients bridged to LVAD with ECMO support. Patients with admission right atrial pressure (RAPadmit) and implant RAP (RAPimplant) ≥ 14 mmHg were defined as having persistent congestion, while patients with RAPadmit ≥ 14 mmHg and RAPimplant unpaired t-tests . Time to death or RVAD was compared between groups using Cox proportional hazards models . Results Of 57 LVAD recipients with RAPadmit ≥ 14 mmHg, 14 (25%) had persistent congestion at the time of LVAD implantation. While there were no statistically significant differences between groups, patients with persistent congestion were more likely to be INTERMACS profile 1 (21.4% vs 9.5%), less likely to have a destination therapy device strategy (28.6% vs 34.9%), less likely to have moderate or severe right ventricular (RV) dysfunction (64.3% vs 83.7%), and had similar RAPadmit (20.4 mmHg vs 18.9 mmHg) compared to patients with resolved congestion. Median follow up was 307 days. Patients with persistent congestion had a higher frequency of death or RVAD implantation compared to those with resolved congestion (50% vs 14%, HR 3.75, 95% CI 1.25-11.25, p=0.02, Figure). Conclusion Among patients with elevated RAP at admission, patients with persistently elevated RAP at the time of LVAD implantation had worse outcomes than patients who were able to be decongested prior to surgery. These data support optimization of RV filling pressures prior to LVAD surgery.