Optimal hemodynamics reduce HF readmissions in LVAD patients

Optimizing hemodynamics for heart failure (HF) patients with continuous-flow left ventricular assist devices (LVADs) significantly reduces the rate of those patients’ hospital readmissions, according to a study published Feb. 1 in Circulation: Heart Failure.

LVADs have improved survival rates in patients with end-stage HF, Teruhiko Imamura, MD, PhD, of the University of Chicago Medical Center, and colleagues wrote, but LVAD patients also tend to see high rehospitalization rates as a result of myriad comorbidities. Recent studies have suggested a hemodynamic ramp test, used to enhance device performance, could hold value for optimizing LVAD speed, potentially reducing hospitalizations.

Imamura and co-authors enrolled 88 LVAD outpatients for their study, which involved each individual undergoing an invasive hemodynamic ramp test and being followed up with for at least a year. LVAD speed was optimized with the ramp test, targeting a central venous pressure (CVP) of less than 12 mmHg, a pulmonary capillary wedge pressure (PCWP) of less than 18 mm Hg and a cardiac index of greater than 2.2 L/min/m2.

All patients underwent ramp testing approximately 236 days after LVAD implantation, and the authors said 61 percent showed optimized hemodynamics after speed adjustment. One-year survival after the study was comparable between optimized and non-optimized patients—89 percent versus 88 percent, respectively—but the total hospital readmission rate was lower in the optimized group, at 1.15 events per year versus 2.86 events per year in the non-optimized group.

“The most frequent causes of readmission in our cohort were HF, in line with previous reports,” Imamura et al. wrote. “LVAD therapy aims to overcome HF by decreasing left ventricular end-diastolic pressure and increasing cardiac output. Thus, the persistence of HF symptoms can have two sources: inadequate device optimization and persistent right ventricular (RV) failure.”

The authors said RV failure can’t always be addressed with speed optimization alone, but their study revealed that a significant percentage of cases of persistent HF might have something to do with inadequate LVAD speed settings, suggesting optimization might mitigate persistent HF and prevent rehospitalizations. In their research, optimized patients saw an HF readmission rate of 0.08 events per year compared to non-optimized patients’ rate of 0.71 events per year.

“We found that the optimized hemodynamics was associated with lower readmission rate, largely because of reduced heart failure readmission in patients with an LVAD,” Imamura and co-authors said. “The findings suggest to clinicians a routine hemodynamic and echocardiographic ramp test after LVAD implantation to assess hemodynamic status and adjust device speed setting.”