Right ventricular adaptation to isolated temporary left ventricular support for cardiogenic shock

Abstract

Abstract Background Acute right ventricular (RV) failure is a well-described, yet not completely understood, complication of durable left ventricular assist device (LVAD) implantation. Although temporary percutaneous LVAD may have a similar hemodynamic impact on the RV, evidence in this setting is minimal. Purpose This study aims to assess the acute adaptation of the RV to isolated left side support with the Impella device in cardiogenic shock (CS). Methods Consecutive patients assisted with an Impella device and monitored with a pulmonary artery catheter in two tertiary centres between September 2018 and November 2021 were included. Clinical and hemodynamic data were retrospectively recorded at the baseline and up to 72 hours after the implantation of the pLVAD and analysed. Two subgroups analysis were performed to test the chance of a different trend on the basis of baseline RV hemodynamics and of the cause of CS. Results Forty-eight consecutive patients were included; median age was 61 (51.5–70.5) years, 83.3% were male. 54.2% presented with SCAI (Society for Cardiovascular Angiography and Interventions) stage D cardiogenic shock [1], mostly due to myocardial infarction (AMI-CS 56.3%). Impella support was associated with a relevant improvement of the systemic perfusion and left ventricular (LV) loading condition (Table 1). At 24 hours, cardiac output improved from 3.4 (2.6–4.2) to 4.0 (3.0–5.5) L/min, p<0.01; lactate decreased from 3.2 (1.65–6.3) to 1.55 (1.25–2.35) mmol/L, p<0.01. An improvement of RV afterload, reflected by a mean pulmonary arterial pressure dropping from 31.5 (25–38.5) to 25.5 (22–32.5) mmHg, p<0.01, was associated with a trend toward an improvement of the right atrial pressure (RAP, from 15.8±7.3 to 13.3±5.9 mmHg, p=0.05) and a stability of the pulmonary artery pulsatility index (PAPi) from 1.08 (0.72–1.5) to 1.19 (0.83–1.64), p=0.11. When stratifying patients by RV hemodynamic parameters at baseline [2], a significantly more pronounced improvement of RAP, RAP/pulmonary capillary wedge pressure (PCWP) and PAPi in the first 24 and 48 hours was seen in those who had poor RV hemodynamics at the baseline (Table 2). Thus, at 24 and 48-hours no differences were detectable anymore in RV hemodynamic parameters between the subgroup with and without RV dysfunction at the baseline evaluation. When stratifying patients by CS aetiology, those with a non-ischemic cause of CS showed a trend toward progressively better parameters of RV function than patients with AMI-CS [median PAPi at 48 hours 1.55 (0.85–2.89) versus 1 (0.73–1.47) in AMI-CS, p=0.1; median RAP/PCWP at 48 hours 0.68 (0.55–0.81) versus 0.89 (0.77–0.92) in AMI-CS, p=0.01]. Conclusion In this cohort of patients with cardiogenic shock undergoing isolated LV support a significant improvement of systemic perfusion and LV loading condition was followed by a tendency towards an improvement of right ventricular function, even in patients with compromised RV hemodynamic profiles at baseline. Funding Acknowledgement Type of funding sources: None.