VE/VCO2 slope predicts RV dysfunction and mortality after left ventricular assist device: a fresh look at cardiopulmonary stress testing for prognostication.

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Citation: Journal of Artificial Organs. 24(4):425-432, 2021 Dec.PMID: 33792816Institution: MedStar Heart & Vascular Institute | MedStar Washington Hospital CenterDepartment: Internal Medicine Residency | Medicine/General Internal MedicineForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Heart Failure | *Heart-Assist Devices | *Ventricular Dysfunction, Right | Exercise Test | Heart Failure/di [Diagnosis] | Humans | Oxygen Consumption | PrognosisYear: 2021ISSN:
  • 1434-7229
Name of journal: Journal of artificial organs : the official journal of the Japanese Society for Artificial OrgansAbstract: Preoperative cardiopulmonary exercise testing (CPET) is well validated for prognostication before advanced surgical heart failure therapies, but its role in prognostication after LVAD surgery has never been studied. VE/VCO2 slope is an important component of CPET which has direct pathophysiologic links to right ventricular (RV) performance. We hypothesized that VE/VCO2 slope would prognosticate RV dysfunction after LVAD. All CPET studies from a single institution were collected between September 2009 and February 2019. Patients who ultimately underwent LVAD implantation were selectively analyzed. Peak VO2 and VE/VCO2 slope were measured for all patients. We evaluated their association with hemodynamic, echocardiographic and clinical markers of RV dysfunction as well mortality. Patients were stratified into those with a ventilatory class of III or greater. (VE/VCO2 slope of >= 36, n = 43) and those with a VE/VCO2 slope < 36 (n = 27). We compared the mortality between the 2 groups, as well as the hemodynamic, echocardiographic and clinical markers of RV dysfunction. 570 patients underwent CPET testing. 145 patients were ultimately referred to the advanced heart failure program and 70 patients later received LVAD implantation. Patients with VE/VCO2 slope of >= 36 had higher mortality (30.2% vs. 7.4%, p = 0.02) than patients with VE/VCO2 slope < 36 (n = 27). They also had a higher incidence of clinically important RVF (Acute severe 9.3% vs. 0%, Severe 32.6% vs 25.9%, p = 0.03). Patients with a VE/VCO2 slope >= 36 had a higher CVP than those with a lower VE/VCO2 slope (11.2 +/- 6.1 vs. 6.0 +/- 4.8 mmHg, p = 0.007), and were more likely to have a RA/PCWP >= 0.63 (65% vs. 19%, p = 0.008) and a PAPI <= 2 (57% vs. 13%, p = 0.008). In contrast, peak VO2 < 12 ml/kg/min was not associated with postoperative RV dysfunction or mortality. Elevated preoperative VE/VCO2 slope is a predictor of postoperative mortality, and is associated with postoperative clinical and hemodynamic markers of impaired RV performance.All authors: Ahmad S, Barnett C, Grinstein J, Hofmeyer M, Kadakkal A, Kalantari S, Medvedofsky DA, Molina EJ, Najjar SS, Rodrigo M, Sawalha Y, Sheikh FH, Talati I, Zaghol ROriginally published: Journal of Artificial Organs. 2021 Apr 01Fiscal year: FY2022Fiscal year of original publication: FY2021Digital Object Identifier: Date added to catalog: 2021-06-07
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Journal Article MedStar Authors Catalog Article 33792816 Available 33792816

Preoperative cardiopulmonary exercise testing (CPET) is well validated for prognostication before advanced surgical heart failure therapies, but its role in prognostication after LVAD surgery has never been studied. VE/VCO2 slope is an important component of CPET which has direct pathophysiologic links to right ventricular (RV) performance. We hypothesized that VE/VCO2 slope would prognosticate RV dysfunction after LVAD. All CPET studies from a single institution were collected between September 2009 and February 2019. Patients who ultimately underwent LVAD implantation were selectively analyzed. Peak VO2 and VE/VCO2 slope were measured for all patients. We evaluated their association with hemodynamic, echocardiographic and clinical markers of RV dysfunction as well mortality. Patients were stratified into those with a ventilatory class of III or greater. (VE/VCO2 slope of >= 36, n = 43) and those with a VE/VCO2 slope < 36 (n = 27). We compared the mortality between the 2 groups, as well as the hemodynamic, echocardiographic and clinical markers of RV dysfunction. 570 patients underwent CPET testing. 145 patients were ultimately referred to the advanced heart failure program and 70 patients later received LVAD implantation. Patients with VE/VCO2 slope of >= 36 had higher mortality (30.2% vs. 7.4%, p = 0.02) than patients with VE/VCO2 slope < 36 (n = 27). They also had a higher incidence of clinically important RVF (Acute severe 9.3% vs. 0%, Severe 32.6% vs 25.9%, p = 0.03). Patients with a VE/VCO2 slope >= 36 had a higher CVP than those with a lower VE/VCO2 slope (11.2 +/- 6.1 vs. 6.0 +/- 4.8 mmHg, p = 0.007), and were more likely to have a RA/PCWP >= 0.63 (65% vs. 19%, p = 0.008) and a PAPI <= 2 (57% vs. 13%, p = 0.008). In contrast, peak VO2 < 12 ml/kg/min was not associated with postoperative RV dysfunction or mortality. Elevated preoperative VE/VCO2 slope is a predictor of postoperative mortality, and is associated with postoperative clinical and hemodynamic markers of impaired RV performance.

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