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Decoupling Between Diastolic Pulmonary Arterial Pressure and Pulmonary Arterial Wedge Pressure at Incremental Left Ventricular Assist Device (LVAD) Speeds Is Associated With Worse Prognosis After LVAD Implantation.

ABSTRACT: BACKGROUND:Decoupling between diastolic pulmonary arterial pressure (dPAP) and pulmonary arterial wedge pressure (PAWP) is an index of pulmonary vasculature remodeling and provides prognostic information. Furthermore, decoupling may change during incremental left ventricular assist device (LVAD) speed changes. METHODS AND RESULTS:In this prospective study, patients underwent an echocardiographic and hemodynamic ramp test after LVAD implantation and were followed for 1 year. The change in decoupling (dPAP?-?PAWP) between the lowest and highest LVAD speeds during the ramp test was calculated. Survival and heart failure admission rates were assessed by means of Kaplan-Meier analysis. Eighty-seven patients were enrolled in the study: 54 had a Heartmate II LVAD (60.8 ± 9.3 years of age and 34 male) and 33 had an HVAD LVAD (58.6 ± 13.2 years of age and 20 male). Patients who experienced greater changes in decoupling (?decoupling >3 mm Hg) had a persistently elevated dPAP at incremental LVAD speed and had worse 1-year heart failure readmission-free survival compared with the group without significant changes in the degree of decoupling (41% vs 75%; P?=?.001). CONCLUSIONS:An increase in decoupling between dPAP and PAWP at incremental LVAD speed changes was associated with worse prognosis in LVAD patients.

SUBMITTER: Imamura T

PROVIDER: S-EPMC6221832 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Decoupling Between Diastolic Pulmonary Arterial Pressure and Pulmonary Arterial Wedge Pressure at Incremental Left Ventricular Assist Device (LVAD) Speeds Is Associated With Worse Prognosis After LVAD Implantation.

Imamura Teruhiko T Kim Gene G Raikhelkar Jayant J Sarswat Nitasha N Kalantari Sara S Smith Bryan B Rodgers Daniel D Chung Ben B Nguyen Ann A Ota Takeyoshi T Song Tae T Juricek Colleen C Jeevanandam Valluvan V Burkhoff Daniel D Sayer Gabriel G Uriel Nir N

Journal of cardiac failure 20180810 9

<h4>Background</h4>Decoupling between diastolic pulmonary arterial pressure (dPAP) and pulmonary arterial wedge pressure (PAWP) is an index of pulmonary vasculature remodeling and provides prognostic information. Furthermore, decoupling may change during incremental left ventricular assist device (LVAD) speed changes.<h4>Methods and results</h4>In this prospective study, patients underwent an echocardiographic and hemodynamic ramp test after LVAD implantation and were followed for 1 year. The ch ...[more]

PMID: 30103020

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Project description:A substantial shift in the field of pulmonary hypertension (PH) is ongoing, as the previous practice of mean pulmonary arterial wedge pressure (PAWPM ) is no longer supported. Instead, aiming for a better estimate of end-diastolic pressures (EDP), instantaneous PAWP at mid-A-wave (PAWPmid-A ) or, in the absence of an A-wave, at 130-160 ms following QRS onset has recently been recommended. Electrocardiogram-gated PAWP (PAWPQRS ) has also been proposed. The quantitative differences as well as the diagnostic and prognostic utility of these novel PAWP measurements have not been evaluated. We set out to address these issues. Pressure tracings of 141 patients with PH due to left heart disease (PH-LHD) and 43 with primary pulmonary arterial hypertension (PAH) were analysed. PAWP was measured as follows: (i) mean pressure (PAWPM ); (ii) per the latest consensus approach [PAWPmid-A , or in atrial fibrillation 130, 140, 150, and 160 ms following QRS onset (PAWP130-160 )]; (iii) at QRS onset (PAWPQRS ); and (iv) Z-point (PAWPZ ). For each PAWP, the corresponding pulmonary vascular resistance (PVR) and diastolic pressure gradient were calculated. The cohort comprised 45% female. Mean age was 66 ± 15. PAWPmid-A was in good agreement with PAWPZ (17.3 [14.5 to 21.2] vs. 17.6 [14.2 to 21.6] mmHg, P = 0.63), whereas PAWPQRS provided significantly lower values (15.3 [12.5 to 19.2] mmHg, P < 0.001). In atrial fibrillation, PAWP130 and PAWPQRS yielded the optimal temporal and quantitative analyses of EDPs. The ability to differentiate PAH from PH-LHD was similar for the various PAWP measurements [PAWPM : area under the curve (AUC) 0.98, confidence interval (CI) 0.96-0.99; PAWPmid-A/130 : AUC 0.94, CI 0.91-0.98; PAWPQRS : AUC 0.96, CI 0.94-0.99, P < 0.001 for all]. PVR based on instantaneous PAWP measurements failed to provide superior prognostic information in PH-LHD as compared with conventional PVR. Although instantaneous PAWP measurement might better represent EDP, they nevertheless fail to yield incremental diagnostic or prognostic information in PH-LHD as compared with conventional measurements.

Project description:Right ventricular failure from increased pulmonary vascular loading is a major cause of morbidity and mortality, yet its modulation by disease remains poorly understood. We tested the hypotheses that, unlike the systemic circulation, pulmonary vascular resistance (R(PA)) and compliance (C(PA)) are consistently and inversely related regardless of age, pulmonary hypertension, or interstitial fibrosis and that this relation may be changed by elevated pulmonary capillary wedge pressure, augmenting right ventricular pulsatile load.Several large clinical databases with right heart/pulmonary catheterization data were analyzed to determine the R(PA)-C(PA) relationship with pulmonary hypertension, pulmonary fibrosis, patient age, and varying pulmonary capillary wedge pressure. Patients with suspected or documented pulmonary hypertension (n=1009) and normal pulmonary capillary wedge pressure displayed a consistent R(PA)-C(PA) hyperbolic (inverse) dependence, C(PA)=0.564/(0.047+R(PA)), with a near-constant resistance-compliance product (0.48±0.17 seconds). In the same patients, the systemic resistance-compliance product was highly variable. Severe pulmonary fibrosis (n=89) did not change the R(PA)-C(PA) relation. Increasing patient age led to a very small but statistically significant change in the relation. However, elevation of the pulmonary capillary wedge pressure (n=8142) had a larger impact, significantly lowering C(PA) for any R(PA) and negatively correlating with the resistance-compliance product (P<0.0001).Pulmonary hypertension and pulmonary fibrosis do not significantly change the hyperbolic dependence between R(PA) and C(PA), and patient age has only minimal effects. This fixed relationship helps explain the difficulty of reducing total right ventricular afterload by therapies that have a modest impact on mean R(PA). Higher pulmonary capillary wedge pressure appears to enhance net right ventricular afterload by elevating pulsatile, relative to resistive, load and may contribute to right ventricular dysfunction.

Dataset Information

Decoupling Between Diastolic Pulmonary Arterial Pressure and Pulmonary Arterial Wedge Pressure at Incremental Left Ventricular Assist Device (LVAD) Speeds Is Associated With Worse Prognosis After LVAD Implantation.

Publications

Decoupling Between Diastolic Pulmonary Arterial Pressure and Pulmonary Arterial Wedge Pressure at Incremental Left Ventricular Assist Device (LVAD) Speeds Is Associated With Worse Prognosis After LVAD Implantation.

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