Impact of left ventricular assist device implantation on right ventricular-pulmonary arterial coupling assessed by high-fidelity hemodynamics.

BACKGROUND: Postoperative right ventricular (RV) adaptation to left ventricular assist device (LVAD) implantation remains poorly characterized. RV-pulmonary artery (PA) coupling, defined as the ratio of end-systolic to arterial elastance (Ees/Ea), provides a framework to assess RV performance under altered loading conditions. This study examined intraoperative RV adaptations to LVAD implantation using RV conductance catheters and three-dimensional echocardiography. METHODS: In this prospective observational study, 39 patients undergoing LVAD implantation were enrolled. Pressure-volume loop, echocardiographic, and hemodynamic data were collected intraoperatively at two time points: (1) after induction of anesthesia and before skin incision, and (2) following chest closure. RV mechanics were analyzed by decomposing longitudinal, radial, and anteroposterior motion components. Patients were classified into subphenotypes based on directional changes in Ees and Ea. RESULTS: Following LVAD implantation, Ees decreased (1.09 ± 0.37 to 0.95 ± 0.34 mm Hg/ml; p=0.043), while Ea remained unchanged, resulting in reduced coupling (Ees/Ea: 1.07 ± 0.18 to 0.91 ± 0.18; p<0.001). RV ejection fraction and longitudinal/anteroposterior components declined, with a compensatory increase in radial contribution. Compared with adaptive responses, the maladaptive phenotype-characterized by ↓Ees and ↑Ea-was associated with more advanced heart failure, elevated right-sided filling pressures, impaired pulmonary vascular pulsatility, greater postoperative afterload increase, and higher rates of early right-heart failure and acute kidney injury. CONCLUSION: LVAD implantation was associated with reduced RV contractility and RV-PA coupling, but individual responses were heterogeneous. A maladaptive phenotype, suggestive of latent RV dysfunction, may be unmasked by hemodynamic shifts after LVAD implantation.

Duke Scholars

Author Alina Nicoara Anesthesiology, Cardiothoracic