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Preoperative vasodilator therapy harmful after LVAD implantation
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Preoperative phosphodiesterase-5 inhibitor therapy led to elevated rates of right HF after left ventricular assist device implantation, according to findings published in Circulation: Heart Failure.
Gaurav Gulati, MD, an MS student at the Cardiovascular Center at Tufts Medical Center, and colleagues investigated the association between preoperative use of phosphodiesterase-5 (PDE5) inhibitors, which are selective pulmonary vasodilators, and incidence of severe early right HF.
The researchers analyzed adult patients from the INTERMACS registry who received a continuous-flow LVAD after 2012.
The primary outcome was severe right HF incidence, a composite of death from right HF within 30 days, need for right ventricular assist device support within 30 days or inotrope use beyond 14 days.
Of the 11,544 patients with continuous LVAD flow, 10% received preoperative PDE5 inhibitors, Gulati and colleagues wrote.
Patients on PDE5 inhibitors had higher pulmonary artery systolic pressure (53.4 mm Hg vs. 49.5 mm Hg; P < .001) and pulmonary vascular resistance (2.6 Wood units [WU] vs. 2.3 WU; P <.001) compared with the control group, the researchers wrote.
Incidence of severe early right HF was higher in patients undergoing PDE5 inhibitor therapy compared with the control group before propensity matching (29.4% vs. 23.1%; unadjusted OR = 1.32; 95% CI, 1.17-1.5), Gulati and colleagues wrote. The association was similar after propensity matching (PDE5 group, 28.9%; control group, 23.7%; OR = 1.31; 95% CI, 1.09-1.57), driven by higher incidence of prolonged inotropic support.
Results were similar regardless of presence of markers of pulmonary vascular disease and RV dysfunction.
“We found no benefit of this therapy in patients receiving LVAD devices, including patients with pulmonary vascular disease or right ventricular dysfunction — the very patients who might be expected to benefit most,” Michael Kiernan, MD, MS, a cardiologist at Tufts Medical Center, assistant professor of medicine at Tufts University School of Medicine and a member of the research group, said in a press release. “Our findings should give pause to clinicians considering this therapy, and we would caution against routine use of these therapies prior to LVAD surgery.”
In a related editorial, Brian A. Houston, MD, an assistant professor of medicine and the director of mechanical circulatory support in the division of cardiology at the Medical University of South Carolina, wrote: “The call to action as presented by this study is increasingly pressing — if pulmonary arterial hypertension-specific therapy ... may be more effective for these patients. ... The currently enrolling SOPRANO study may shed light on the utility of endothelin receptor antagonist therapy post-LVAD, although doubtless questions will remain.” – by Earl Holland Jr.
Disclosures: Gulati and Houston report no relevant financial disclosures. Kiernan reports he received travel support from Abbott and consultant fees from Medtronic. Please see the study for all other authors’ relevant financial disclosures.
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