Echocardiographic Ramp Test for Continuous-Flow Left Ventricular Assist Devices: Do Loading Conditions Matter?

Sirtaz Adatya, Christopher T. Holley, Samit S. Roy, Hirad Yarmohammadi, Amy Feng, Peter Eckman, Monica Colvin-Adams, Ranjit John, Carolina Masri

Research output: Contribution to journalArticlepeer-review

15 Scopus citations

Abstract

Objectives: This study investigated whether continuous AI and/or elevated mean arterial pressure (MAP) were associated with false positive results for flow obstruction in echocardiographic ramp speed tests in patients with a continuous-flow left ventricular assist device. Background: Failure to reduce the left ventricular end-diastolic diameter (LVEDD) with increasing device speeds in a ramp test is predictive of pump obstruction. Aortic insufficiency (AI) or increased MAP can diminish the ability to unload the left ventricle. Methods: LVEDD was plotted against device speed, and a linear function slope was calculated. A flat LVEDD slope (≥-0.16) was considered abnormal (suggestive of obstruction). Ramp test results were compared in patients with or without either AI or increased MAP at baseline speed, and receiver-operator characteristic (ROC) curves were constructed for predictors of device obstruction. Device thrombosis was confirmed by direct visualization of clot at explantation or on inspection by the manufacturer. Results: Of 78 ramp tests (55 patients), 36 were abnormal (18 true positive, 18 false positive), and 42 were normal (37true negative, 5 false negative). In patients with AI, LVEDD slope was -0.14 ± 0.17, which was consistent with device obstruction (vs. -0.25 ± 0.11 in patients without AI; p< 0.001), despite no difference in mean lactate dehydrogenase concentration between the 2 groups (1,301 ± 1,651 U/l vs. 1,354 ± 1,365 U/l; p = 0.91). Area under the ROC curve (AUC) for LVEDD slope was 0.76and improved to 0.88 after removal of patients with AI from the study. LVEDD slope in patients with MAP ≥85mmHg was similar to that for device obstruction (-0.18 ± 0.07) and was abnormal in 6 of the 12 ramp tests performed. Combining LVEDD slope with lactate dehydrogenase concentration increased the AUC to 0.96 as an indicator of device obstruction. Conclusions: Abnormal loading conditions due to AI or elevated MAP may result in false positive ramp tests.

Original languageEnglish (US)
Pages (from-to)291-299
Number of pages9
JournalJACC: Heart Failure
Volume3
Issue number4
DOIs
StatePublished - Apr 1 2015

Keywords

  • AI
  • AUC
  • Aortic insufficiency
  • CF
  • Continuous-flow left ventricular assist device
  • Echocardiographic ramp test
  • Heartfailure
  • Hemodynamics
  • LDH
  • LVAD
  • LVEDD
  • MAP
  • Mean arterial pressure thrombosis
  • PI
  • ROC

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