Vasoactive Choices and Interpreting PAPI

CardioNerds (Dr. Hamza Patel, Dr. Jenna Skowronski, and Dr. Apoorva Gangavelli) discuss advanced heart failure and LVAD management with Dr. Mark Belkin, Advanced Heart Failure & Transplant Cardiologist, and Dr. Chris Salerno, Cardiothoracic Surgeon. They explore the nuances of right ventricular (RV) physiology, perioperative hemodynamic optimization, long-term complications, sensitization and transplant considerations, and the evolving role of GDMT in LVAD patients.  This episode highlights the delicate interplay between surgical and medical management in achieving optimal outcomes for patients living with durable mechanical circulatory support.Audio editing by CardioNerds Academy intern, student doctor, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

Pearls

1. “The right ventricle sets the stage.” — LVAD success hinges on RV performance; a struggling RV can turn a perfect LVAD surgery into a perfect storm. 

2. “Watch the ratios.” — A PAPi < 2 and RA:PCWP >0.6 signal high risk for RV failure post-implant; trends and response to optimization matter more than static numbers. 

3. “From hemocompatibility to hemodynamics.” — The LVAD field has moved from fighting pump thrombosis to mastering long-term RV failure and aortic insufficiency. 

4. “Not all antibodies are created equal.” — LVAD-related sensitization often resolves post-transplant, reminding clinicians to interpret PRA trends in context. 

5. “Recovery is possible.” — The RESTAGE-HF trial and emerging SGLT2 data hint at a new era: not just sustaining life with LVADs but restoring native heart function. 

Notes

Notes drafted by Dr. Hamza Patel.

1. Hemodynamic & Vasoactive Management of the RV 

• Use norepinephrine and vasopressin for pressor support; consider dobutamine as inotrope of choice. 

• Consider avoiding early milrinone due to hypotension and reduced coronary perfusion. 

• Use inhaled NO or epoprostenol selectively; institutional variation depends on cost and supply. 

• Key hemodynamic markers: 
  • PAPi = (PA systolic – PA diastolic) / RA pressure. 
  • PAPi < 2 → increased RV failure risk. 
  • RA:PCWP ratio ≈ 0.6 normal; ≈ 1 → severe RV dysfunction. 

• RV reserve—the ability to improve these indices with optimization—is a stronger predictor of outcomes than baseline numbers alone. 

• NOTE: there is no robust data to guide vasoactive medical decision-making and there is substantial institutional variability in practive. 

2. Long-Term LVAD Complications 

• MOMENTUM 3 trial: HeartMate 3 reduced pump thrombosis (10 → 1 %), stroke (14 → 5%), and GI bleed (77 → 43 %). 

• Persistent issues: driveline infections, RV failure, and aortic insufficiency. 

• Driveline care: silver sulfadiazine (Silvadene) cream linked to lower infection rates (Cowher & Kenmore 2025). 

• Field now focuses on hemodynamic-related adverse events—the next frontier in LVAD outcomes. 

• Innovation ahead: smaller drivelines and fully implantable LVADs to eliminate infection risk. 

3. Sensitization and Transplant Candidacy 

• LVADs may induce de novo HLA antibodies, complicating transplant matching. 

• These antibodies tend to be transient and less cytotoxic, often resolving post-transplant. 

• Sensitization degree varies by device and patient; management strategies are center-dependent. 

• The field is redefining which antibodies are truly LVAD-induced versus incidental. 

4. GDMT & Myocardial Recovery 

• GDMT data in LVAD patients limited—excluded from major HFrEF trials. 

• RESTAGE-HF: aggressive GDMT post-LVAD yielded 52% explant rate within 18 months. 

• SGLT2 inhibitors: emerging evidence of reverse remodeling and reduced LV size (Belkin et al., THT 2025). 

• GDMT promotes recovery but requires cautious titration to avoid hypotension and RV strain. 

5. Future of LVAD Therapy 

• The fully implantable LVAD remains the goal—wireless energy, no driveline, and fewer infections. 

• Short-term focus: device miniaturization, improved energy efficiency, and better hemocompatibility. 

• HeartMate 3 remains gold standard until next-generation systems mature. 

References

1. Mehra MR et al. NEJM 2018 — MOMENTUM 3 Final Report. 

2. Takeda K et al. JHLT 2020 — Predictors of RV Failure After LVAD. 

3. Imamura T et al. Circ Heart Fail 2017 — Hemodynamics and RV Adaptation Post-LVAD. 

4. RESTAGE-HF Trial, JHLT 2019. 

5. Cowher J, Kenmore C et al. 2025 — Driveline Care & Infection Outcomes. 

6. Belkin M et al. THT 2025 — SGLT2 Inhibition and Reverse Remodeling Post-LVAD.