Hemodynamic and physiologic changes during support with an implantable left ventricular assist device Patrick M. McCarthy, MD (by invitation), Robert.

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Hemodynamic and physiologic changes during support with an implantable left ventricular assist device Patrick M. McCarthy, MD (by invitation), Robert M. Savage, MD (by invitation), Charles D. Fraser, MD (by invitation), Rita Vargo, RN, MSN (by invitation), Karen B. James, MD (by invitation), Marlene Goormastic, MPH (by invitation), Robert E. Hobbs, MD (by invitation) The Journal of Thoracic and Cardiovascular Surgery Volume 109, Issue 3, Pages 409-418 (March 1995) DOI: 10.1016/S0022-5223(95)70271-7 Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 1 The cardiac index (CI) before LVAD insertion (pre-implant) was low (1.7 ± 0.3 L/min per square meter) in these patients with cardiogenic shock. In the operating room during LVAD support (post-implant), the cardiac index rose to 3.1 L/min per square meter and stayed at approximately this level at 24 hours and for the duration of support until the time of device explantation and transplantation (pre-explant). The left atrial pressure (LAP) dropped from 23 mm Hg to 10 mm Hg with the initiation of LVAD pumping and stayed low at 24 hours and pre-explant. Right atrial pressure (RAP) dropped gradually from a mean of 20 mm Hg down to 12 mm Hg before device explantation and transplantation. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 1 The cardiac index (CI) before LVAD insertion (pre-implant) was low (1.7 ± 0.3 L/min per square meter) in these patients with cardiogenic shock. In the operating room during LVAD support (post-implant), the cardiac index rose to 3.1 L/min per square meter and stayed at approximately this level at 24 hours and for the duration of support until the time of device explantation and transplantation (pre-explant). The left atrial pressure (LAP) dropped from 23 mm Hg to 10 mm Hg with the initiation of LVAD pumping and stayed low at 24 hours and pre-explant. Right atrial pressure (RAP) dropped gradually from a mean of 20 mm Hg down to 12 mm Hg before device explantation and transplantation. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 2 Pulmonary artery (PA) pressures were elevated in these patients with severe congestive heart failure. The pressures dropped immediately after the start of LVAD pumping and showed a further decrease by the time of device explantation. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 3 The transpulmonary gradient (mean PA pressure minus mean LA pressure) rose after insertion of the device (p = 0.046). This was thought to be due to the effects of cardiopulmonary bypass and blood product administration. The transpulmonary gradient gradually decreased after this as the patient recovered from the operation (24 hours) and was not significantly different from baseline at the time of device explantation. TPG, Transpulmonary gradient; PA, pulmonary artery; LA, left atrium; N.S., Not significant. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 4 The right heart was markedly dilated in these patients, decreased with the initiation of LVAD support, and decreased further by the time of device explantation. Changes were seen in both the right ventricular end-diastolic volume (RVEDV) and end-systolic volume (RVESV), and the difference between the two represents right ventricular stroke volume. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 5 Measures of liver function such as total bilirubin and aspartate aminotransferase (AST) levels were elevated at baseline. Both bilirubin and aspartate aminotransferase returned to normal levels in patients who were survivors and were underwent transplantation. There was an increase, especially notable in the total bilirubin levels, in patients who died. There was no significant difference at baseline between patients who were survivors and those who were nonsurvivors. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 5 Measures of liver function such as total bilirubin and aspartate aminotransferase (AST) levels were elevated at baseline. Both bilirubin and aspartate aminotransferase returned to normal levels in patients who were survivors and were underwent transplantation. There was an increase, especially notable in the total bilirubin levels, in patients who died. There was no significant difference at baseline between patients who were survivors and those who were nonsurvivors. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 6 Measures of renal function, blood urea nitrogen (BUN) and serum creatinine (Scr), were generally elevated before device insertion. The levels for the patients who died were significantly higher for both blood urea nitrogen (p = 0.01) and serum creatinine (p = 0.02). For patients who survived and underwent transplantation, blood urea nitrogen and creatinine generally returned to normal. Inasmuch as three survivors were removed from long-term dialysis with the recovery of renal function, a slight increase in blood urea nitrogen and serum creatinine were seen late. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 6 Measures of renal function, blood urea nitrogen (BUN) and serum creatinine (Scr), were generally elevated before device insertion. The levels for the patients who died were significantly higher for both blood urea nitrogen (p = 0.01) and serum creatinine (p = 0.02). For patients who survived and underwent transplantation, blood urea nitrogen and creatinine generally returned to normal. Inasmuch as three survivors were removed from long-term dialysis with the recovery of renal function, a slight increase in blood urea nitrogen and serum creatinine were seen late. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 7 Treadmill distance during daily exercise indicated the steadily improving physical condition of patients receiving long-term support. Shortly after patients left the intensive care unit, levels of activity were low, but they steadily increased as the patients returned to better physical condition before transplantation. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 409-418DOI: (10.1016/S0022-5223(95)70271-7) Copyright © 1995 Mosby, Inc. Terms and Conditions