Perue, Radha Kanneganti

Abstract Background In light of the updated lowered threshold for diagnosing pulmonary hypertension (PH), the reversibility of precapillary PH with left ventricular assist device (LVAD) and the associated post heart transplantation (HT) outcomes remain unclear. Purpose and methods Using data from the United Network for Organ Sharing database, we aimed to investigate predictors of persistent precapillary PH in HT recipients bridged with LVAD, and examine the interrelated post-HT survival, using the updated pulmonary vascular resistance (PVR) cutoff of >2 WU for precapillary PH. Results Among 2169 HT recipients bridged with LVAD, 1299 had PVR>2 at baseline; 551 (42.4%) of whom normalized their PVR≤2 and 748 (57.6%) remained with elevated PVR>2 after LVAD implantation. Female sex (adjusted odds ratio [aOR] 2.22, 95% confidence interval [CI]:1.61-3.07, p<0.001) and inotropes-treatment at-listing (aOR 1.31, 95% CI: 1.03-1.66, p=0.028) were associated with persistently elevated PVR post LVAD. Conversely, longer duration of LVAD support (aOR 0.74, 95% CI: 0.65-.84, p<0.001) and use of HeartMate 2 (aOR 0.74, CI: 0.59-0. 93, p=0.011) were protective against persistently elevated PVR post-LVAD. Persistently elevated PVR >2 post-LVAD was associated with increased risk of death compared to those who normalized their PVR (adjusted hazard ratio [aHR] 1.26, 95% CI: 1.01-1.57, p=0.037). However, normalized PVR post-LVAD group had comparable survival to those with PVR≤2 at baseline (aHR 0.76, 95% CI: 0.57-1.02, p=0.07). Conclusions Many HT recipients bridged with LVAD remain with PVR>2 post-LVAD implantation, which is associated with increased risk of death post-HT compared to patients with normalized PVR post-LVAD.

Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.