Christine Sailer1, Hannah Edelmann2, Cullen Buchanan3, Pedro Giro3, Matthew Babcock4, Christine Swanson5, Melanie Spotts6, Margaret Schulte6, Ashley Pratt-Cordova6, Greg Coe1, Mark Beindorff1, Robert L Page7, Amrut V Ambardekar1, Jay D Pal8, Wendy Kohrt4,6, Eugene Wolfel1, Justin S Lawley9, Takashi Tarumi10, William K Cornwell1,6. 1. Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora. 2. University of Colorado-Denver (H.E.). 3. Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora. 4. Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora. 5. Department of Medicine-Endocrinology, Metabolism and Diabetes (C.S.), University of Colorado Anschutz Medical Campus, Aurora. 6. Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora. 7. Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Services, Aurora (R.L.P.). 8. Department of Cardiothoracic Surgery (J.D.P.), University of Colorado Anschutz Medical Campus, Aurora. 9. Department of Sport Science, University of Innsbruck, Austria (J.S.L.). 10. Human Informatics Interaction Research Institute, National Institute of Advanced Industrial Science and Technology, Ibaraki prefecture, Japan (T.T.).
Abstract
BACKGROUND: Continuous-flow (CF) left ventricular assist devices (LVADs) improve outcomes for patients with advanced heart failure (HF). However, the lack of a physiological pulse predisposes to side-effects including uncontrolled blood pressure (BP), and there are little data regarding the impact of CF-LVADs on BP regulation. METHODS: Twelve patients (10 males, 60±11 years) with advanced heart failure completed hemodynamic assessment 2.7±4.1 months before, and 4.3±1.3 months following CF-LVAD implantation. Heart rate and systolic BP via arterial catheterization were monitored during Valsalva maneuver, spontaneous breathing, and a 0.05 Hz repetitive squat-stand maneuver to characterize cardiac baroreceptor sensitivity. Plasma norepinephrine levels were assessed during head-up tilt at supine, 30o and 60o. Heart rate and BP were monitored during cardiopulmonary exercise testing. RESULTS: Cardiac baroreceptor sensitivity, determined by Valsalva as well as Fourier transformation and transfer function gain of Heart rate and systolic BP during spontaneous breathing and squat-stand maneuver, was impaired before and following LVAD implantation. Norepinephrine levels were markedly elevated pre-LVAD and improved-but remained elevated post-LVAD (supine norepinephrine pre-LVAD versus post-LVAD: 654±437 versus 323±164 pg/mL). BP increased during cardiopulmonary exercise testing post-LVAD, but the magnitude of change was modest and comparable to the changes observed during the pre-LVAD cardiopulmonary exercise testing. CONCLUSIONS: Among patients with advanced heart failure with reduced ejection fraction, CF-LVAD implantation is associated with modest improvements in autonomic tone, but persistent reductions in cardiac baroreceptor sensitivity. Exercise-induced increases in BP are blunted. These findings shed new light on mechanisms for adverse events such as stroke, and persistent reductions in functional capacity, among patients supported by CF-LVADs. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078972.
BACKGROUND: Continuous-flow (CF) left ventricular assist devices (LVADs) improve outcomes for patients with advanced heart failure (HF). However, the lack of a physiological pulse predisposes to side-effects including uncontrolled blood pressure (BP), and there are little data regarding the impact of CF-LVADs on BP regulation. METHODS: Twelve patients (10 males, 60±11 years) with advanced heart failure completed hemodynamic assessment 2.7±4.1 months before, and 4.3±1.3 months following CF-LVAD implantation. Heart rate and systolic BP via arterial catheterization were monitored during Valsalva maneuver, spontaneous breathing, and a 0.05 Hz repetitive squat-stand maneuver to characterize cardiac baroreceptor sensitivity. Plasma norepinephrine levels were assessed during head-up tilt at supine, 30o and 60o. Heart rate and BP were monitored during cardiopulmonary exercise testing. RESULTS: Cardiac baroreceptor sensitivity, determined by Valsalva as well as Fourier transformation and transfer function gain of Heart rate and systolic BP during spontaneous breathing and squat-stand maneuver, was impaired before and following LVAD implantation. Norepinephrine levels were markedly elevated pre-LVAD and improved-but remained elevated post-LVAD (supine norepinephrine pre-LVAD versus post-LVAD: 654±437 versus 323±164 pg/mL). BP increased during cardiopulmonary exercise testing post-LVAD, but the magnitude of change was modest and comparable to the changes observed during the pre-LVAD cardiopulmonary exercise testing. CONCLUSIONS: Among patients with advanced heart failure with reduced ejection fraction, CF-LVAD implantation is associated with modest improvements in autonomic tone, but persistent reductions in cardiac baroreceptor sensitivity. Exercise-induced increases in BP are blunted. These findings shed new light on mechanisms for adverse events such as stroke, and persistent reductions in functional capacity, among patients supported by CF-LVADs. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078972.
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