Comparison of continuous-flow ventricular assist device therapy with intensive medical therapy in fixed pulmonary hypertension secondary to advanced left heart failure

Abstract

Aims: Both ventricular assist device (VAD) and pulmonary vasodilator therapy have been shown in uncontrolled studies to improve pulmonary hypertension secondary to advanced left heart failure (Group 2 PH). This study aimed to compare haemodynamic benefits and survival in patients with fixed Group 2 PH treated with continuous-flow VAD to intensive medical therapy.

Methods and results: Ninety-five patients listed for heart transplantation with sequential right heart catheters were studied, 24 patients having fixed Group 2 PH (as defined by cardiac index < 2.8 L/min/m² , pulmonary capillary wedge pressure > 15 mmHg, and transpulmonary gradient ≥ 15 mmHg or pulmonary vascular resistance > 3.0 WU, unresponsive to vasodilator challenge). Ten patients received VAD therapy, and 14 patients received standard heart failure therapy with or without sildenafil, nitrates, or endothelin receptor antagonists. At repeat right heart catheterization, patients treated with VAD therapy demonstrated significant improvement in both transpulmonary gradient (19 vs. 12 mmHg, P = 0.046) and pulmonary vascular resistance (6.5 vs. 2.9 WU, P = 0.003) compared with baseline, while those treated with medical therapy did not (20.9 vs. 20.3 mmHg and 6.5 vs. 6.4 WU, P = NS for both). Patients who received VAD therapy were significantly more likely to achieve normalized transpulmonary gradient (8/10 vs. 4/14, P = 0.013) and were more likely to be listed for orthotopic heart transplantation (7/10 vs. 4/14, P < 0.05). There were no significant differences between groups in terms of all-cause mortality.

Conclusions: Continuous-flow VAD therapy more effectively reverses fixed Group 2 PH compared with medical therapy alone and may allow a higher rate of listing for orthotopic heart transplantation.

Keywords: Heart transplantation; Hemodynamics; LVAD; Pulmonary hypertension.

Figure 1

Study outline. Group 2 PH, pulmonary hypertension secondary to left heart failure; PH, pulmonary hypertension; VAD, ventricular assist device.

Figure 2

Comparison of mean pulmonary arterial pressure (mPAP), mean pulmonary capillary wedge pressure (mPCWP), cardiac index, transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR) at baseline and follow‐up, stratified by therapy. Values are displayed as the mean and upper 95% confidence limit. *P < 0.05 vs. baseline; **P < 0.01 vs. baseline; ***P < 0.01 vs. ventricular assist device (VAD) therapy.

Figure 3

Kaplan–Meier curve showing survival following initial right heart catheterization. Patients were censored at the study end date or last visit if lost to follow‐up. Differences between groups were calculated using log‐rank test. HR, hazard ratio; VAD, ventricular assist device.