What is the target cardiac output and cardiac index after BRIO ventricular assist device implantation?

Target Cardiac Output and Cardiac Index After BRIO VAD Implantation

Hemodynamic Goals

The target cardiac index after BRIO ventricular assist device implantation should exceed 2.0 L/min/m², with an optimal goal of approximately 2.4 L/min/m² to ensure adequate systemic perfusion and end-organ function. 1

Specific Hemodynamic Targets

Cardiac Index Requirements

• Maintain cardiac index >2.0 L/min/m² as the minimum acceptable threshold for adequate circulatory support 2, 1
• Target an optimal cardiac index of approximately 2.4 L/min/m² for best outcomes 1
• Cardiac index <1.8 L/min/m² defines refractory cardiogenic shock and represents inadequate support 2

Supporting Hemodynamic Parameters

• Mean arterial pressure should be maintained >65 mmHg to ensure end-organ perfusion 1
• Central venous pressure should be optimized between 8-15 mmHg during the support phase 1
• Systolic blood pressure should remain >80 mmHg 2

Critical Monitoring Considerations

Early Post-Implantation Phase

• The immediate post-implantation increase in cardiac index is a key predictor of right ventricular function 3
• Patients who develop right ventricular failure demonstrate significantly smaller increases in cardiac index immediately after implantation (0.2 ± 0.5 L/min vs 0.96 ± 0.8 L/min in those without RV failure) 3
• Serial measurements of cardiac index should be performed to track hemodynamic improvement 1

Right Ventricular Considerations

• Right ventricular afterload sensitivity dramatically increases after LVAD implantation, making RV function the critical determinant of achieving target cardiac output 4
• Despite reducing RV load, LVAD implantation initially leads to worsened RV adaptation to afterload 4
• Monitor pulmonary artery diastolic pressure as a primary indicator of RV recovery 1

Blood Pressure Management

Afterload Optimization

• Titration of medical therapy to maintain mean arterial blood pressure in the normal range is imperative to optimize forward flow and prevent adverse events 2
• Hypertension after VAD implantation is common and increases afterload, which decreases pump flow and increases risk of neurological events 2
• Use neurohormone-modifying agents (ACE inhibitors, ARBs, beta-blockers, mineralocorticoid receptor antagonists) to decrease afterload and improve pump function 2

Metabolic and Perfusion Markers

End-Organ Function Assessment

• Evaluate lactate clearance regularly as an indicator of metabolic normalization and adequate tissue perfusion 1
• Perform daily liver function testing (transaminases) to assess hepatic recovery 1
• Monitor for signs of critical organ hypoperfusion, systemic acidosis, and increasing lactate levels 2

Common Pitfalls to Avoid

Inadequate Support Recognition

• Do not accept cardiac index <2.0 L/min/m² as adequate support, as this represents ongoing circulatory compromise 2, 1
• Failure to achieve target cardiac index despite maximal device settings may indicate need for additional mechanical support or intervention 2

Preload Management Errors

• Avoid volume overload, as excess fluid aggravates right ventricular failure and can prevent achievement of target cardiac output 1
• Conversely, excessive preload reduction can compromise pump filling and reduce cardiac output 2

Delayed Recognition of RV Failure

• Patients requiring increasing doses of inotropes to maintain target cardiac index despite adequate LVAD function likely have developing RV failure 2, 3
• Early RV failure manifests as inability to increase cardiac index appropriately despite device support 3

Device-Specific Monitoring

Continuous Assessment

• Abnormal hemodynamics are associated with increased risk of future adverse events including recurrent heart failure, gastrointestinal bleeding, stroke, and pump thrombosis 5
• Many patients appear clinically stable yet have abnormal hemodynamics that require correction 5
• Automatic and timely device speed adjustments considering hemodynamic status may improve outcomes 5