Pre-implant right heart catheterization and liver biomarkers in left ventricular assist device candidates

Background Left ventricular assist device (LVAD) therapy is an established treatment for patients with advanced heart failure (HF). Nevertheless, early postoperative complications remain significant. Enhancing pre-implant risk stratification requires a deeper understanding of the systemic consequences of end-stage HF among LVAD candidates. While renal function in this population is relatively well characterized, knowledge regarding the importance of hepatic parameters remains limited.1 Purpose We (1) evaluated associations between pre-implant right heart catheterization (RHC) parameters and liver biomarkers, (2) characterized 1-year post-implant liver biomarker trajectories, and (3) assessed the prognostic value of liver and hemodynamic markers for early postoperative adverse events. Methods We conducted a retrospective single-center cohort study (2016–2025) of recipients of a fully magnetically levitated continuous-flow LVAD with a pre-implant RHC. Associations between RHC measures and liver biomarkers were assessed using adjusted regression with standardized exposures and outcomes. One-year post-implant liver trajectories were modeled using mixed-effects models. We stratified trajectories by baseline right atrial pressure (RAP) to test whether baseline RAP modified post-implant liver biomarker trajectories, given prior associations between elevated right-sided filling pressure and end-organ abnormalities (including hepatic and renal dysfunction) in HF.2,3 Prognostic value for the 30-day composite endpoint (all-cause death, right HF or acute kidney injury requiring renal replacement therapy) was evaluated using bias-reduced multivariable logistic regression. Results A total of 113 patients were included (78% male; median age 60 years). Seven RHC–liver biomarker associations remained significant after false discovery rate (FDR) correction (Figure 1). The strongest was bilirubin with RAP (standardized β=0.54, representing SD change in bilirubin per 1-SD increase in RAP; FDR-adjusted p<0.001). Other FDR-significant associations included bilirubin with RAP/PCWP (β=0.40), AST with RAP (β=0.43) and PCWP (β=0.37) and inversely with CPO (β=−0.29), and GGT with RAP (β=0.33) and RAP/PCWP (β=0.27). During follow-up, elevated baseline RAP (≥12 mmHg) was associated with less favorable recovery of bilirubin and albumin (Figure 2), whereas other liver biomarkers followed largely similar trajectories regardless of RAP. Higher bilirubin (adjusted odds ratio [aOR] 1.06; p=0.016) and higher RAP (aOR 1.13; p=0.006) were independently associated with the 30-day primary endpoint. Conclusion In continuous-flow LVAD candidates, RAP as a marker of venous congestion showed the most consistent associations with liver biomarker levels, with the clearest signal observed for bilirubin. Higher RAP was associated with poorer recovery of bilirubin and albumin during LVAD support and a higher risk of early postoperative adverse events.Figure 1.Pre-implant RHC-liver associationsFigure 2.Bilirubin/albumin trajectories