Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy
Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy
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新型左心导管插入斜坡方案可指导接受左心室辅助装置治疗的患者血流动力学优化
DOI：
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发表时间：
2019
期刊：
影响因子：
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通讯作者：
A. Behfar
中科院分区：
文献类型：
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作者：
A. Rosenbaum;R. Frantz;S. Kushwaha;J. Stulak;S. Maltais;A. Behfar
背景 对使用连续流左心室辅助装置 (cfLVAD) 的患者进行左心室 (LV) 血流动力学评估的情况很少。在斜坡研究期间深入了解左心参数的动态变化可以改善左心室辅助装置的优化并评估病理学。方法和结果 为了补充右心导管插入术，开发了一种对 cfLVAD 患者进行左心导管插入术的新技术。植入 cfLVAD 的患者接受了血流动力学斜坡左心导管插入术和右心导管插入术以及经胸超声心动图检查。连续测量主动脉压和左心室压力以及右心房、肺动脉和肺毛细血管楔压。建立了一种新的指标，即经主动脉梯度（TAG）。 38 名患有 cfLVAD 的患者在装置植入后平均 446 天（四分位数范围，183-742）进行了评估。在进行左心导管检查以优化血流动力学期间，左心室舒张末压和肺毛细血管楔压的下降与 TAG 的升高相关。确定了 TAG 的一个范围（20-40 mm Hg），以提供最佳的血流动力学卸载水平。病理状态偏离了对斜坡的正常反应。左心室辅助装置血栓形成与速度斜坡期间 TAG 无法增加有关。尽管随着左心室辅助装置速度的增加，肺毛细血管楔压随之降低，但显着的主动脉瓣关闭不全与左心室舒张末压显着增加有关。结论 将左心导管插入术纳入典型的右心导管插入术 LV 辅助装置斜坡方案为优化不同临床情况下的 cfLVAD 速度提供了独特的见解。 TAG 是一种新颖的索引，它被定义为优化卸载提供了额外的分辨率。
Background Left ventricular (LV) hemodynamic assessment has been sparsely performed in patients supported on continuous‐flow LV assist devices (cfLVADs). Insight into dynamic changes of left heart parameters during ramp studies may improve LV assist device optimization and evaluate pathology. Methods and Results To complement right heart catheterization, a novel technique for left heart catheterization in patients with a cfLVAD was developed. Patients implanted with cfLVADs underwent hemodynamic ramp left heart catheterization and right heart catheterization with transthoracic echocardiography. Continuous aortic and LV pressures were measured along with right atrial, pulmonary artery, and pulmonary capillary wedge pressures. A novel index, the transaortic gradient (TAG) was established. Thirty eight patients with cfLVADs were evaluated at a median of 446 days (interquartile range, 183–742) after device implant. During left heart catheterization performed for hemodynamic optimization, drop‐in LV end‐diastolic pressure and pulmonary capillary wedge pressure were associated with a rise in TAG. A range was identified for TAG (20–40 mm Hg) as providing the most optimal level of hemodynamic offloading. Pathologic states deviated from normal responses to ramp. LV assist device thrombosis was associated with an inability to increase in TAG during speed ramp. Significant aortic insufficiency was associated with a marked increase in LV end‐diastolic pressure despite a concomitant decrease in pulmonary capillary wedge pressure with increasing LV assist device speeds. Conclusions Inclusion of left heart catheterization to a typical right heart catheterization LV assist device ramp protocol imparted unique insights to optimize cfLVAD speeds in different clinical scenarios. A novel index, the TAG was defined and provided additional resolution to optimized offloading.