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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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  • Artificial Heart (Clinical)
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Abstract

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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Acknowledgements

Dr. Grinstein is a consultant for Medtronic and speakers bureau for Abbott. Dr. Sheikh receives institutional research support from Abbott. Dr. Najjar receives research support and is a consultant for Abbott. All other authors have no relevant disclosures. No funding was received for this work.

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Authors and Affiliations

  1. University of Chicago, Chicago, IL, USA

    Jonathan Grinstein & Sara Kalantari

  2. MedStar Washington Hospital Center, Washington, DC, USA

    Yazan Sawalha, Diego A. Medvedofsky, Mark Hofmeyer, Maria Rodrigo, Ajay Kadakkal, Christopher Barnett, Raja Zaghol, Ezequiel J. Molina, Farooq H. Sheikh & Samer S. Najjar

  3. University of Toronto, Toronto, ON, Canada

    Sarah Ahmad

  4. Georgetown School of Medicine, Washington, DC, USA

    Ish Talati

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  1. Jonathan Grinstein
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Correspondence to Jonathan Grinstein.

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Conflict of interest

Grinstein—Consultant for Medtronic and Speakers Bureau for Abbott; Sawalha, Medvedofsky, Ahmad, Hofmeyer, Rodrigo, Kadakkal, Barnett, Kalantari, Talati, Zaghol and Molina—none; Sheikh—institutional research support from Abbott; Najjar—research support and consultant for Abbott.

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Grinstein, J., Sawalha, Y., Medvedofsky, D.A. et al. VE/VCO2 slope predicts RV dysfunction and mortality after left ventricular assist device: a fresh look at cardiopulmonary stress testing for prognostication. J Artif Organs 24, 425–432 (2021). https://doi.org/10.1007/s10047-021-01261-9

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  • DOI: https://doi.org/10.1007/s10047-021-01261-9

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