Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support

Michael S Kiernan; E Wilson Grandin; Marshall Brinkley Jr; Navin K Kapur; Duc Thinh Pham; Robin Ruthazer; J Eduardo Rame; Pavan Atluri; Edo Y Birati; Guilherme H Oliveira; Francis D Pagani; James K Kirklin; David Naftel; Robert L Kormos; Jeffrey J Teuteberg; David DeNofrio

doi:10.1161/CIRCHEARTFAILURE.117.003863

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support

Circ Heart Fail. 2017 Oct;10(10):e003863. doi: 10.1161/CIRCHEARTFAILURE.117.003863.

Authors

Michael S Kiernan¹, E Wilson Grandin², Marshall Brinkley Jr², Navin K Kapur², Duc Thinh Pham², Robin Ruthazer², J Eduardo Rame², Pavan Atluri², Edo Y Birati², Guilherme H Oliveira², Francis D Pagani², James K Kirklin², David Naftel², Robert L Kormos², Jeffrey J Teuteberg², David DeNofrio²

Affiliations

¹ From the Cardiovascular Center, Tufts Medical Center, Boston, MA (M.S.K., N.K.K., D.D.); Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA (E.W.G.); Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN (M.B.); Division of Cardiothoracic Surgery, Northwestern Memorial Hospital, Chicago, IL (D.T.P.); Clinical and Translational Science Institute, Tufts University, Boston, MA (R.R.); Heart and Vascular Institute, University of Pennsylvania, Philadelphia (J.E.R., E.Y.B.); Division of Cardiology, University Hospitals, Cleveland, OH (P.A., G.H.O.); Division of Cardiothoracic Surgery, University of Michigan School of Medicine, Ann Arbor (F.D.P.); Division of Cardiothoracic Surgery, University of Alabama Birmingham School of Medicine (J.K.K.); University of Alabama Birmingham School of Public Health (D.N.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (R.L.K., J.J.T.). mkiernan@tuftsmedicalcenter.org.
² From the Cardiovascular Center, Tufts Medical Center, Boston, MA (M.S.K., N.K.K., D.D.); Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA (E.W.G.); Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN (M.B.); Division of Cardiothoracic Surgery, Northwestern Memorial Hospital, Chicago, IL (D.T.P.); Clinical and Translational Science Institute, Tufts University, Boston, MA (R.R.); Heart and Vascular Institute, University of Pennsylvania, Philadelphia (J.E.R., E.Y.B.); Division of Cardiology, University Hospitals, Cleveland, OH (P.A., G.H.O.); Division of Cardiothoracic Surgery, University of Michigan School of Medicine, Ann Arbor (F.D.P.); Division of Cardiothoracic Surgery, University of Alabama Birmingham School of Medicine (J.K.K.); University of Alabama Birmingham School of Public Health (D.N.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (R.L.K., J.J.T.).

PMID: 29021348
PMCID: PMC5717751
DOI: 10.1161/CIRCHEARTFAILURE.117.003863

Abstract

Background: To investigate preimplant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (LVAD) surgery.

Methods and results: Patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent primary continuous-flow-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined end point of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9976 patients undergoing continuous-flow-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Preimplant characteristics associated with RVAD use included interagency registry for mechanically assisted circulatory support patient profiles 1 and 2, the need for preoperative extracorporeal membrane oxygenation or renal replacement therapy, severe preimplant tricuspid regurgitation, history of cardiac surgery, and concomitant procedures other than tricuspid valve repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (area under the curve, 0.78) and the combined end point of RVAD or death within 14 days (area under the curve, 0.73). Compared with patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9%, respectively (P<0.0001 for both).

Conclusions: The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction, and profiles of hemodynamic instability.

Keywords: atrial pressure; blood pressure; heart; humans; risk factors.

MeSH terms

Adult
Aged
Cardiac Surgical Procedures / adverse effects*
Extracorporeal Membrane Oxygenation / methods
Female
Heart Failure / epidemiology*
Heart Failure / physiopathology
Heart-Assist Devices / adverse effects*
Humans
Incidence
Male
Middle Aged
Prostheses and Implants
Registries
Risk Factors
Time Factors
Treatment Outcome
Ventricular Dysfunction, Left / epidemiology*
Ventricular Dysfunction, Left / physiopathology
Ventricular Dysfunction, Right / epidemiology*
Ventricular Dysfunction, Right / physiopathology
Young Adult

Abstract

MeSH terms

Grants and funding