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Purpose The complex anatomy and different contraction patterns of the different right ventricular (RV) wall segments has made it challenging to predict acute RV failure (ARVF) in patients receiving a left ventricular assist device (LVAD). We sought to improve the prediction of ARVF after LVAD by performing a comprehensive 18-segment strain (e) analysis of the RV. Methods Prospectively enrolled LVAD recipients had a right heart catheterization and echocardiogram prior to implant. From RV-focused views (Figure 1A), 18-segment e was performed and indexed to pulmonary arterial elastance (Ea [PV]). ARVF was defined as need for RVAD, inotropes for >14 days or pulmonary vasodilator for >48 hours post-LVAD. Logistic regression was used to identify associations between specific parameters and ARVF. Results ARVF occurred in 15 of 30 patients enrolled. Lower pulmonary artery pulsatility index (PAPi), TAPSE and basal free wall (FW) (basal anterior, lateral and posterior FW) segmental e/Ea (PV) were significantly associated with ARVF. Indexed basal FW segmental strain provided incremental predictive value over PAPi and TAPSE (Figure 1B). Conclusion Prediction of ARVF in LVAD candidates can be improved by adding comprehensive RV segmental strain analysis to traditional echocardiographic and hemodynamics parameters.

Purpose Diabetes mellitus (DM) is prevalent among advanced heart failure (HF) patients, however its effect on the potential of left ventricular assist device (LVAD)-mediated cardiac recovery has not been described. Methods Consecutive advanced chronic HF patients (N=425) requiring durable continuous-flow LVAD were prospectively evaluated. After excluding patients with acute HF etiologies or post-LVAD follow up Results Baseline characteristics of the 2 groups are shown in the Table. Cardiac functional and structural improvement, as evidenced by relative LVEF and LVEDD changes, was more prominent in non-DM compared to DM patients, and in well- compared to not well-controlled DM patients (Figure). Overall, DM patients were less likely to experience cardiac recovery (8.4% vs 17.5%; p=0.032), while on LVAD support. This remained significant in a multivariate logistic regression after controlling for potential confounders. Conclusion The presence of DM, and notably not well-controlled DM, appears to negatively affect the potential for LVAD-induced myocardial recovery. Further research is needed to investigate the dynamic cardiac metabolism in HF with DM.

Purpose LVAD therapy has been primarily studied in patients with elevated pulmonary capillary wedge pressure (PCW) and low cardiac index (CI), “cold and wet”. In daily practice, LVADs are often also offered to patients with low PCW and low CI, “cold and dry”. The efficacy of LVAD therapy in this population is not well studied. Methods Patients implanted with LVAD with a baseline CI 18mmHg) or “dry” (PCW Results Serial invasive hemodynamics data was available for 92 pts (cold-dry group, n=34 and cold-wet group, n=58) (Table). Diuretic and vasodilator use pre-LVAD was comparable in both groups. Cold-dry patients had no change in CVP or PCW with a smaller increase in CI after LVAD. Adjusted 3-year mortality was higher for cold-dry patients (Figure). Age (HR=1.09, 95%CI 1.02-1.2; p=006) and cold-dry profile (HR=5.4, 95%CI 1.4-21; p=0.016) were identified as independent predictors of mortality. Conclusion “Cold and dry” patients with advanced heart failure may not derive equal benefit from LVAD therapy as those who are “cold and wet”. This observation warrants further investigation.

Purpose Predicting cardiac structural and functional improvement in advanced heart failure (HF) patients before durable left ventricular assist device (LVAD) implantation remains challenging. Identifying clinical predictors could improve patient selection and impact clinical management. Methods Advanced chronic HF patients (N=652) supported with continuous-flow LVADs were evaluated. After excluding patients with acute HF etiologies or without adequate post-LVAD follow up ( Results In total, 10% of the LVAD patients were R. Univariate analysis showed that R were younger, had shorter HF symptoms duration, less need for diuretics and their LV were less dilated pre-LVAD. Further, R had higher acuity disease as evidenced by the higher vasoactive agents need, higher BNP and higher incidence of abnormal liver enzymes. The multivariate Cox regression (AUC=0.74; p Conclusion Younger patients with less LV dilation and shorter duration of HF are more likely to improve their cardiac function during LVAD support. Whether these characteristics also predict sustainability of improved cardiac function after LVAD weaning warrants further investigation.

Purpose Despite several models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support, poor performance when externally validated has limited their widespread use. We sought to derive a predictive model for RVF after LVAD implantation, and ascertain its performance in an independent cohort. Methods End-stage heart failure (HF) patients requiring continuous-flow LVAD were prospectively enrolled at one US program (n=477, derivation cohort), with two other US medical centers forming the validation cohort (n=321). The primary outcome was RVF incidence, defined as the need for right ventricular assist device or inotropes for >14 days. Multivariable logistic regression in the derivation set yielded a RVF predictive model, which was subsequently applied to the validation cohort, and a risk score was ultimately developed. Results Derivation cohort included patients less likely to be African-Americans (7% vs 37%; p Conclusion We propose a novel scoring system to predict post-LVAD RVF, achieving high discriminative performance in distinct, heterogeneous LVAD cohorts.

Purpose Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a serious complication with poor prognosis. Improved selection of patients with greater risk of developing the condition is crucial, considering the growing need for destination therapy patients. However, predicting RVF remains a vexing clinical problem. Methods From 2008 to 2019, 478 consecutive chronic heart failure (HF) patients supported with continuous-flow LVADs were prospectively evaluated. RVF was defined by the need for intravenous inotropes for >14 days and/or right ventricular assist device implantation. Data was analyzed based on the presence or absence of RVF in the early post-operative period and their baseline clinical, hemodynamic, imaging and laboratory data were compared. Multivariable logistic regression was used to develop a clinical model for RVF prediction. Results Overall, 77 (16.1%) patients developed RVF. Univariate analysis showed that the RVF was associated with higher acuity disease before LVAD implantation reflected by low INTERMACS profile, high vasoactive medication requirement, presence of IABP support, hyponatremia, thrombocytopenia, low serum albumin, and renal dysfunction. Additionally, RVF was associated with increased heart rate, right atrial (RA) and right atrial to wedge pressure (RA/PCWP) ratio, along with decreased systolic pulmonary artery pressure (PAP), right ventricular stroke work index (RVSWi) and pulmonary artery pulsatility index (PAPi), at baseline. Interestingly, patients who developed RVF had decreased left ventricular end-diastolic diameter at baseline, when compared to the no RVF group. The multivariate model (AUC=0.77; p Conclusion Our model seems capable of distinguishing patients prone to develop RVF post-LVAD implantation. The identified pre-LVAD predictors include markers of globally advanced HF syndrome and higher acuity as well as markers specific to severity of RVF.

Purpose Although left ventricular (LV) reverse remodeling has been described in patients with left ventricular assist devices (LVADs), little is known about left atrial (LA) structural and functional changes. Methods Echocardiographic parameters were obtained at pre-LVAD implant and following 1, 3, and 6 months of LVAD support. Favorable LV structural and functional response following LVAD support (i.e. Responders) was defined using previously published criteria. Structural and functional indices specific to LA such as LA volume index (LAVI) and LA total emptying fraction (LATEF) were compared in eighteen Responders versus twenty Non-Responders. Statistical comparison of quantitative data was performed using 2-tailed Wilcoxon signed-rank test for paired samples and categorical data were compared using Fisher's exact test. Results The magnitude and time course of functional changes as reflected by the LVEF and LATEF in Responders and Non-Responders are depicted in Figure 1A and 1B. LA remodeling structural changes over time in Responders and Non-Responders are depicted in Figure 1C. Conclusion Patients experiencing post-LVAD favorable LV functional response had significantly better LA remodeling structural and functional indices before LVAD implantation and further improved those early after the initiation of LV mechanical support. LA reverse remodeling studies with longer follow-up and correlation with post LVAD-weaning patient outcomes are warranted.

Purpose Occasionally new onset cardiomyopathy patients (pts) present late, in such advanced disease stage that they cannot tolerate heart failure (HF) drug therapy. We investigated the cardiac recovery (CR) potential following a combination of left ventricular assist device (LVAD) and guideline-directed HF drug therapy in this medication-naive population. Methods Chronic advanced HF pts requiring durable continuous-flow LVAD were prospectively evaluated. Pts with acute HF (myocarditis etc) or post LVAD follow up Results Univariate analysis showed that “med-naive” pts were younger, more likely to be on intravenous vasoactive agents, temporary MCS and with lower INTERMACS profile before LVAD implantation. Interestingly, no differences were seen in HF symptoms duration or other comorbidities. Baseline and follow up hemodynamics were similar in both groups, besides higher right atrial pressure pre-LVAD in the “meds-naive” group (16 vs 11 mmHg; p=0.04). Baseline echocardiographic (including LV dilation) and biochemical parameters revealed no differences between the groups, besides lower LVEF and higher BNP in the “meds-naive” group (14 vs 19 %; p=0.03 and 2352 vs 1270; p=0.03, respectively). CR rates were significantly higher on “meds-naive” versus “meds-failed” group (50.0 vs 13.8 %; p=0.005). Despite higher cardiac recovery rates in the “meds-naive” group the time course and magnitude of the favorable functional and structural response was similar among the CR responders of each of the 2 groups. Conclusion Young pts with new onset dilated cardiomyopathy sometimes present late, with advanced disease stage, unable to tolerate HF medications and requiring durable LVAD support. This patient population appears to have a potential for CR up to 50% and this could be factored in decisions surrounding their long-term therapeutic options.