Impact of diastolic pulmonary gradient and pulmonary vascular remodeling on survival after left ventricular assist device implantation and heart transplantation

The Egyptian Heart Journal Pub Date : 2023-12-20 DOI:10.1186/s43044-023-00428-4

Mohamed Laimoud, Emad Hakami, Mary Jane Maghirang, Tahir Mohamed

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Abstract

The left ventricular assist devices (LVADs) are increasingly used for advanced heart failure as a bridge to heart transplantation or as a destination therapy. The aim of this study was to investigate the changes of diastolic pulmonary gradient (DPG), pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) after LVAD implantation and their impact on survival after LVAD and heart transplantation. A total of 73 patients who underwent LVAD (HeartMate III) implantation between 2016 and 2022 were retrospectively studied. According to pre-LVAD catheterization, 49 (67.1%) patients had DPG < 7 mmHg and 24 (32.9%) patients had DPG ≥ 7 mmHg. The patients with a pre-VAD DPG ≥ 7 mmHg had higher frequencies of right ventricular (RV) failure (p < 0.001), RVAD insertion (p < 0.001), need for renal replacement therapy (p = 0.002), total mortality (p = 0.036) and on-VAD mortality (p = 0.04) with a longer ICU stay (p = 0.001) compared to the patients with DPG < 7 mmHg. During the follow-up period of 38 (12–60) months, 24 (32.9%) patients died. Pre-LVAD DPG ≥ 7 mmHg (adjusted HR 1.83, 95% CI 1.21–6.341, p = 0.039) and post-LVAD DPG ≥ 7 mmHg (adjusted HR 3.824, 95% CI 1.482–14.648, p = 0.002) were associated with increased risks of mortality. Neither pre-LVAD TPG ≥ 12 (p = 0.505) nor post-LVAD TPG ≥ 12 mmHg (p = 0.122) was associated with an increased risk of death. Pre-LVAD PVR ≥ 3 WU had a statistically insignificant risk of mortality (HR 2.35, 95% CI 0.803–6.848, p = 0.119) while post-LVAD PVR ≥ 3 WU had an increased risk of death (adjusted HR 2.37, 95% CI 1.241–7.254, p = 0.038). For post-transplantation mortality, post-LVAD DPG ≥ 7 mmHg (p = 0.55), post-LVAD TPG ≥ 12 mmHg (p = 0.85) and PVR ≥ 3 WU (p = 0.54) did not have statistically increased risks. The logistic multivariable regression showed that post-LVAD PVR ≥ 3 WU (p = 0.013), post-LVAD DPG ≥ 7 mmHg (p = 0.026) and RVF (p = 0.018) were the predictors of mortality after LVAD implantation. Pre-LVAD DPG ≥ 7 mmHg (p < 0.001) and pre-LVAD PVR ≥ 3 WU (p = 0.036) were the predictors of RVF after LVAD implantation. Persistently high DPG was associated with right ventricular failure and mortality after LVAD implantation rather than after heart transplantation. DPG is a better predictor of pulmonary vascular remodeling compared to TPG and PVR. Further larger prospective studies are required in this field due to the growing numbers of patients with advanced heart failure, as possible candidates for LVAD implantation, and limitations of heart transplantation.

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舒张期肺梯度和肺血管重塑对左心室辅助装置植入术和心脏移植术后存活率的影响

左心室辅助装置（LVAD）越来越多地用于晚期心力衰竭患者，作为心脏移植的桥梁或目的疗法。本研究旨在探讨植入 LVAD 后舒张肺阶差（DPG）、肺血管阻力（PVR）和跨肺阶差（TPG）的变化及其对 LVAD 和心脏移植后存活率的影响。研究人员对2016年至2022年期间接受LVAD（HeartMate III）植入术的73名患者进行了回顾性研究。根据LVAD植入前的导管检查结果，49例（67.1%）患者的DPG＜7 mmHg，24例（32.9%）患者的DPG≥7 mmHg。与 DPG < 7 mmHg 的患者相比，VAD 术前 DPG ≥ 7 mmHg 的患者发生右心室（RV）衰竭（p < 0.001）、插入 RVAD（p < 0.001）、需要肾脏替代疗法（p = 0.002）、总死亡率（p = 0.036）和 VAD 术中死亡率（p = 0.04）的频率更高，入住 ICU 的时间更长（p = 0.001）。在 38（12-60）个月的随访期间，24（32.9%）名患者死亡。LVAD 前 DPG ≥ 7 mmHg（调整后 HR 1.83，95% CI 1.21-6.341，p = 0.039）和 LVAD 后 DPG ≥ 7 mmHg（调整后 HR 3.824，95% CI 1.482-14.648，p = 0.002）与死亡风险增加有关。LVAD前TPG≥12（p = 0.505）或LVAD后TPG≥12 mmHg（p = 0.122）均与死亡风险增加无关。LVAD 前 PVR ≥ 3 WU 的死亡风险在统计学上不显著（HR 2.35，95% CI 0.803-6.848，p = 0.119），而 LVAD 后 PVR ≥ 3 WU 的死亡风险增加（调整后 HR 2.37，95% CI 1.241-7.254，p = 0.038）。就移植后死亡率而言，LVAD 术后 DPG ≥ 7 mmHg（p = 0.55）、LVAD 术后 TPG ≥ 12 mmHg（p = 0.85）和 PVR ≥ 3 WU（p = 0.54）在统计学上没有增加风险。逻辑多变量回归显示，LVAD 术后 PVR ≥ 3 WU（p = 0.013）、LVAD 术后 DPG ≥ 7 mmHg（p = 0.026）和 RVF（p = 0.018）是 LVAD 植入术后死亡率的预测因素。LVAD 植入前 DPG ≥ 7 mmHg (p < 0.001) 和 LVAD 植入前 PVR ≥ 3 WU (p = 0.036) 是 LVAD 植入后 RVF 的预测因素。持续高 DPG 与 LVAD 植入术后右心室功能衰竭和死亡率相关，而与心脏移植术后相关。与 TPG 和 PVR 相比，DPG 更能预测肺血管重塑。由于晚期心力衰竭患者越来越多，可能成为 LVAD 植入术的候选者，以及心脏移植术的局限性，该领域需要进一步开展更大规模的前瞻性研究。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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The Egyptian Heart Journal

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