Right Ventricular Pressure-Volume Analysis During a Left Ventricular Assist Device Speed Optimization Study.

Abstract

HomeCirculation: Heart FailureVol. 14, No. 4Right Ventricular Pressure-Volume Analysis During a Left Ventricular Assist Device Speed Optimization Study Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBRight Ventricular Pressure-Volume Analysis During a Left Ventricular Assist Device Speed Optimization Study Manreet K. Kanwar, MD, Michael I. Brener, MD, Masaki Tsukashita, MD, PhD, Srinivas Murali, MD and Daniel Burkhoff, MD, PhD Manreet K. KanwarManreet K. Kanwar Correspondence to: Manreet K. Kanwar, Cardiovascular Institute, Allegheny Health Network, 320 E N Ave, 16th Floor S Tower, Pittsburgh, PA 15212. Email E-mail Address: [email protected] https://orcid.org/0000-0002-7280-5268 Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA (M.K.K., M.T., S.M.). Search for more papers by this author , Michael I. BrenerMichael I. Brener https://orcid.org/0000-0002-2606-055X Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital (M.I.B.). Search for more papers by this author , Masaki TsukashitaMasaki Tsukashita https://orcid.org/0000-0001-9387-4759 Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA (M.K.K., M.T., S.M.). Search for more papers by this author , Srinivas MuraliSrinivas Murali Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA (M.K.K., M.T., S.M.). Search for more papers by this author and Daniel BurkhoffDaniel Burkhoff https://orcid.org/0000-0003-3995-2466 Cardiovascular Research Foundation, New York, NY (D.B.). Search for more papers by this author Originally published15 Mar 2021https://doi.org/10.1161/CIRCHEARTFAILURE.120.008014Circulation: Heart Failure. 2021;14:e008014Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 15, 2021: Ahead of Print Significant gaps remain in our understanding of right ventricular (RV) dysfunction after left ventricular assist device (LVAD) implantation.1 Persistent RV dilation and dysfunction due to increased venous return likely plays a key role. Another suggested mechanism implicates changes in RV geometry and orientation of the interventricular septum that result from postimplantation LV decompression (interventricular interaction). We present a case where the pressure-volume loops suggest against this interaction contributing to the development of post-LVAD RV failure.A 22-year-old female presented with cardiogenic shock following a viral respiratory illness and underwent a HeartMate 3 (Abbott Laboratories, Abbott Park, IL) LVAD implant. Guideline-directed medical therapy was initiated and optimized over the following months with ongoing LV reverse remodeling noted on echocardiography (LV ejection fraction 45%–50%). About 4 months later, she presented with low-flow alarms. Echocardiogram identified increasing RV dilation and a shift of the interventricular septum towards the LV. Her LVAD speed was sequentially decreased from 5400 to 5000 rpm, diuretics discontinued and fluid intake was encouraged, but the alarms persisted.Right heart catheterization was notable for low filling pressures (right atrial pressure 5, pulmonary artery pressure 18/9 [mean of 13], and pulmonary capillary wedge pressur 9 mm Hg, respectively, with a cardiac index of 2.5 L/min per m2). A conductance catheter (CD Leycom, Hengelo, the Netherlands) was placed in the RV, and the LVAD speed was incrementally reduced from 5000 to 4100 rpm. At 4100 rpm, hemodynamic parameters were unchanged, although the echocardiogram showed the septum to be midline with a visibly less dilated RV. With increasing speed, there was increased compliance and a fixed systolic function despite the significant differences in septal position (Figure). Additionally, RV stroke work increased considerably with increased LVAD speeds, further indicating increased overall RV pump performance.Download figureDownload PowerPointFigure. Right ventricular (RV) pressure-volume (PV) loops performed during a left ventricular assist device speed ramp test. With increasing left ventricular assist device speed, the end-diastolic PV relationship (dashed lines going through the bottom right corner of each loop) shifts rightward indicating increased compliance. The end-systolic PV relationship (dashed lines going through left upper corner of loops) is relatively unchanged, indicating preserved systolic function. Correspondingly, RV stroke work (the area inside the PV loop) increases, indicating increased overall RV contractile performance.Despite LV reverse remodeling during LVAD support, the RV may not exhibit the same reductions of size.2 Hence, a dilated RV on an echocardiogram is not synonymous with RV failure or congestion. In our patient, we have demonstrated evidence that LV unloading by LVAD support increases RV compliance. Moreover, LV unloading during LVAD support did not impair RV systolic function, reiterating that interventricular interactions are substantially less during systole than diastole.3 If confirmed in additional studies and RV phenotypes, these findings are paradigm shifting in that they show interventricular interactions are not a major cause of post-LVAD RV failure.Disclosures None.FootnotesCorrespondence to: Manreet K. Kanwar, Cardiovascular Institute, Allegheny Health Network, 320 E N Ave, 16th Floor S Tower, Pittsburgh, PA 15212. Email manreet.[email protected]org