Development of a Novel Echocardiography Ramp Test for Speed Optimization and Diagnosis of Device Thrombosis in Continuous-Flow Left Ventricular Assist Devices

• Published in: Journal of the American College of Cardiology Vol. 60; no. 18; pp. 1764 - 1775
• Main Authors: Uriel, Nir, MD, Morrison, Kerry A., BA, Garan, Arthur R., MD, Kato, Tomoko S., MD, Yuzefpolskaya, Melana, MD, Latif, Farhana, MD, Restaino, Susan W., MD, Mancini, Donna M., MD, Flannery, Margaret, NP, Takayama, Hiroo, MD, John, Ranjit, MD, Colombo, Paolo C., MD, Naka, Yoshifumi, MD, PhD, Jorde, Ulrich P., MD
• Format: Journal Article
• Language: English
• Published: New York Elsevier Inc 30-10-2012; Elsevier Limited
• Subjects: Blood clots; Cardiology; Cardiovascular; Dehydrogenases; device thrombosis; Heart failure; Internal Medicine; LVAD; LVEDD; Optimization; ramp test; Roads & highways; Thrombosis; Transplants & implants; United States > US; aortic valve; pulsatility index; CF-LVAD; MR; mitral regurgitation; AI; lactate dehydrogenase; ramp test; aortic insufficiency; LVEDD; LVAD; left ventricular end-diastolic dimension; LDH; AV; PI; left ventricular assist device; continuous-flow left ventricular assist device; device thrombosis
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2012.07.052

Objectives This study sought to develop a novel approach to optimizing continuous-flow left ventricular assist device (CF-LVAD) function and diagnosing device malfunctions. Background In CF-LVAD patients, the dynamic interaction of device speed, left and right ventricular decompression, and valve function can be assessed during an echocardiography-monitored speed ramp test. Methods We devised a unique ramp test protocol to be routinely used at the time of discharge for speed optimization and/or if device malfunction was suspected. The patient's left ventricular end-diastolic dimension, frequency of aortic valve opening, valvular insufficiency, blood pressure, and CF-LVAD parameters were recorded in increments of 400 rpm from 8,000 rpm to 12,000 rpm. The results of the speed designations were plotted, and linear function slopes for left ventricular end-diastolic dimension, pulsatility index, and power were calculated. Results Fifty-two ramp tests for 39 patients were prospectively collected and analyzed. Twenty-eight ramp tests were performed for speed optimization, and speed was changed in 17 (61%) with a mean absolute value adjustment of 424 ± 211 rpm. Seventeen patients had ramp tests performed for suspected device thrombosis, and 10 tests were suspicious for device thrombosis; these patients were then treated with intensified anticoagulation and/or device exchange/emergent transplantation. Device thrombosis was confirmed in 8 of 10 cases at the time of emergent device exchange or transplantation. All patients with device thrombosis, but none of the remaining patients had a left ventricular end-diastolic dimension slope >−0.16. Conclusions Ramp tests facilitate optimal speed changes and device malfunction detection and may be used to monitor the effects of therapeutic interventions and need for surgical intervention in CF-LVAD patients.