Pulmonary Vascular Reverse Remodeling in Combined Post and Pre Capillary Pulmonary Hypertension Occurs Over Time after Left Ventricular Assist Device Implantation

• Published in: The Journal of heart and lung transplantation Vol. 40; no. 4; pp. S97 - S98
• Main Authors: Anegawa, E., Seguchi, O., Iwasaki, Y., Komeyama, S., Yoshitake, K., Sujino, Y., Yagi, N., Mochizuki, H., Kuroda, K., Nakajima, S., Watanabe, T., Yanase, M., Fukushima, S., Fujita, T., Fukushima, N.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01-04-2021
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2021.01.323

Left ventricular assist device (LVAD) has been reported to improve pulmonary hypertension (PH) due to left heart disease (PH-LHD). However, prevalence of combined post- and pre-capillary PH (Cpc-PH) in patients with PH-LHD and the impact of LVAD implantation on Cpc-PH has not been fully elucidated. This study aimed to investigate hemodynamic changes following LVAD implantation in patients with PH-LHD to assess pulmonary vascular reverse remodeling.
Eighty-nine patients with advanced heart failure complicated by PH-LHD undergoing LVAD implantation who received serial right heart catheterizations at least 3 time points (before, early after, and 1-year after implantation) were retrospectively reviewed. Patients were divided into 2 groups as Cpc-PH group (n=50): pulmonary vascular resistance (PVR) > 3 Wood unit (WU) or diastolic pulmonary pressure gradient (DPG) ≥ 7 mmHg, and isolated post-capillary PH (Ipc-PH) group (n=39).
Values of brain natriuretic peptide and transaminase in Cpc-PH group were higher than those in Ipc-PH group. Cpc-PH patients were consisted of 41 with PVR > 3 WU, 8 with PVR > 3 WU and DPG ≥ 7 mmHg, and 1 with DPG ≥ 7 mmHg preoperatively. Median values of PVR in both groups significantly decreased early after LVAD implantation [from 4.1 to 2.7 WU (p < 0.05) in Cpc-PH group; from 2.0 to 1.7 WU (p < 0.05) in Icp-PH group]. However, 15 patients were still found to be PVR > 3 WU (n=14) or DPG ≥ 7 mmHg (n=1) at that point. Among these 15 patients, 4 patients still remained on their PVR > 3 WU (n=3) or DPG ≥ 7 mmHg (n=1) even 1-year after LVAD implantation. PVR and DPG in these 4 patients turned to normal values at 3-year after implantation.
Over half of patients with PH-LHD were complicated by Cpc-PH in our study cohort. LVAD implantation readily improved hemodynamics regardless of complication of Cpc-PH, whereas 15 patients were still found to be PVR > 3 WU or DPG ≥ 7 mmHg which should be considered as persistent Cpc-PH. We speculate that most of Cpc-PH in patients with PH-LHD might be caused by alteration of vascular tone which will be promptly relieved by substantial left ventricular unload, however a certain number of patients with Cpc-PH might develop structural remodeling of pulmonary vasculature which requires months or years to achieve pulmonary vascular reverse remodeling.