Clinical potential of hemodynamic ramp test by simultaneous echocardiography and right heart catheterization for aortic
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CASE REPORT Artificial Heart (Clinical)
Clinical potential of hemodynamic ramp test by simultaneous echocardiography and right heart catheterization for aortic insufficiency in a patient with continuous‑flow left ventricular assist device Yasumori Sujino1 · Kensuke Kuroda1 · Koichi Yoshitake1 · Nobuichiro Yagi1 · Eiji Anegawa1 · Hiroki Mochizuki1 · Keiichiro Iwasaki1 · Seiko Nakajima1 · Takuya Watanabe1 · Masanobu Yanase1 · Satsuki Fukushima2 · Tomoyuki Fujita2 · Junjiro Kobayashi2 · Norihide Fukushima1 Received: 2 April 2020 / Accepted: 18 August 2020 © The Author(s) 2020
Abstract Aortic insufficiency (AI) is an important adverse event in patients with continuous-flow (CF) left ventricular assist device (LVAD) support. AI is often progressive, resulting in elevated 2-year morbidity and mortality. The effectiveness of echocardiographic ramp studies in patients with AI has been unclear. Here, we describe a patient with a CF-LVAD implant who underwent aortic valve replacement (AVR), following assessment of AI using a hemodynamic ramp test with simultaneous echocardiography and right heart catheterization (RHC). The patient was a 21-year-old man with cardiogenic shock due to acute myocarditis, who underwent HeartWare CF-LVAD (HVAD) implantation. Heart failure persisted despite increased doses of diuretics and inotrope, as well as an increased HVAD pump rate. HVAD monitoring revealed a correlation between increased HVAD pump rate and flow at each speed step. A hemodynamic ramp test with simultaneous transthoracic echocardiography and RHC revealed a significant discrepancy between HVAD pump flow and cardiac output (CO) at each speed step; moreover, pulmonary capillary wedge pressure remained high. Therefore, the patient underwent AVR. Subsequently, his low CO symptoms disappeared and inotropes were successfully discontinued. A postoperative hemodynamic ramp test revealed that AVR had successfully closed the loop of blood flow and reduced the discrepancy between HVAD pump flow and CO, thereby increasing CO. The patient was then discharged uneventfully. In conclusion, a hemodynamic ramp test with simultaneous echocardiography and RHC was useful for the evaluation of the causal relationship between AI and low CO, and for selection of surgical treatment for AI in a patient with CF-LVAD. Keywords Heart-assist devices · Aortic valve replacement · Aortic valve insufficiency · Cardiac output · Pulmonary wedge pressure
Introduction
* Norihide Fukushima [email protected] 1
Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6‑1 Kishibe‑shinmachi, Suita, Osaka 564‑8564, Japan
Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6‑1 Kishibe‑Shinmachi, Suita 564‑8564, Osaka, Japan
2
Aortic insufficiency (AI) is an important adverse event in patients with continuous-flow (CF) left ventricular assist device (LVAD) support [1]. In such patients, survival is considerably worse when de novo AI develops during longterm LVAD [2]. This is presumed to be at least partia
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