Postoperative Day 1 Mean Arterial Pressure and 30-Day Mortality or Day 7 Renal Replacement Therapy After Ventricular Assist Device Implantation

Abstract

Background The association between mean arterial pressure (MAP) early after ventricular assist device (VAD) implantation and short-term outcomes remains incompletely characterized. Our primary objective was to examine the association of postoperative day (POD) 1 MAP with death within 30 days or renal replacement therapy (RRT) on POD 7, accounting for initial support. Secondary exploratory objectives concerned other hemodynamic markers and subsequent renal and hepatic laboratory outcomes. Methods This single-center exploratory retrospective cohort included patients aged 18 years or older at an eligible index procedure between July 1, 2019, and March 31, 2025. Groups A-D represented initial VAD support strategies at the index procedure: (A) HeartMate 3 (Abbott Medical, Pleasanton, CA; HM3) alone; (B) HM3 with right ventricular assist device (RVAD) support; (C) extracorporeal left ventricular assist device (LVAD) alone; and (D) extracorporeal LVAD with RVAD support. Later support changes did not alter group assignment. The exposure was the median invasive MAP on POD 1. The composite outcome was death within 30 days or RRT on POD 7. Firth logistic regression included initial strategy and MAP centered within strategy. Seven hemodynamic markers were examined with Holm adjustment. Results The cohort comprised 156 patients (A, 92; B, five; C, 31; D, 28). The outcome was ascertainable in 146 patients, including 22 (15.1%) with events. Each 5-mmHg higher MAP was associated with lower odds of the outcome (odds ratio (OR), 0.217; 95% confidence interval (CI), 0.082-0.501; P < 0.001; Holm-adjusted P < 0.001). Mean perfusion pressure (MPP) was also associated with the outcome (OR per 5 mmHg, 0.412; 95% CI, 0.213-0.729). In a joint model, MAP remained associated (OR, 0.235; 95% CI, 0.085-0.553), whereas right atrial pressure did not. Sensitivity analyses showed the same direction of association. MAP was not clearly associated with subsequent creatinine or bilirubin summaries. Conclusions Lower invasive MAP on POD 1 was associated with early death or RRT on POD 7 after accounting for initial VAD support. These exploratory findings support further evaluation of MAP as an early risk marker; the effects and targets of interventions to increase MAP require further study.