A Multi-Institutional Retrospective Cohort Study of the Pulmonary Artery Pulsatility Index's Ability to Predict post-LVAD Implant Right Ventricular Failure and 1-Year Mortality

摘要

IntroductionThe pulmonary artery pulsatility index (PAPi) is an emerging hemodynamic marker correlated with severe post-LVAD RVF in single-center cohort studies. We set out to examine if this is generalizable in a multi-institutional analysis. HypothesisThe preoperative PAPi correlates with RVF as defined by new INTERMACS criteria (INTERMACS-RVF), severe RVF, and death at 1-year. MethodsWe performed a dual-center retrospective study of 404 patients from Ohio and New York who received a continuous-flow durable LVAD and had a pre-operative PAPi measurement. The PAPi was defined as:[(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD placement during implant admission, and death from RVF during implant admission. A multivariate analysis of predictors of post-LVAD severe RVF was conducted. A survival analysis was performed to examine pre-operative PAPi as a predictor of 1-year mortality. ResultsIn our cohort of 404 patients, 84 (21%) had severe RVF. Multivariable logistic regression for severe RVF (controlling for age, INTERMACS level, creatinine, and gender) showed that creatinine > 1.5 (OR 2.24, p=0.002, 95% CI [1.43-4.42]) and total bilirubin > 2.5 (OR 2.87, p=0.004, 95% CI [1.39-5.93]) significantly increased the odds of severe RVF, and a PAPi < 1 (OR 1.93, p=0.071, 95% CI [0.95-3.94]) was nearly significant. The multivariable model for INTERMACS-RVF (controlling for age, INTERMACS level, creatinine, and gender) found that a PAPi < 1 (OR 2.2, p=0.018, 95% CI [1.15-4.24]) doubled the odds of RVF. The ROC curves for PAPi < 1 and severe RVF (c-statistic=0.69, ) and INTERMACS-RVF (c-statistic=0.63) were similar. With respect to survival, the final multivariable model (controlling for age, gender, and ethnicity) showed a PAPi < 1 was nearly a significant independent predictor of 1-year mortality (HR 1.76, p=0.054, 95% CI [0.99-3.13]). ConclusionPAPi < 1 significantly increases the odds of INTERMACS-RVF and was associated with severe RVF. To our knowledge, this is the first time that the PAPi has been validated in a multi-institutional retrospective LVAD cohort study and shown to predict death at 1-year.