Post-LVAD diuretic trajectories and predictors of diuretic resistance

Renal dysfunction and diuretic resistance may persist or develop after left ventricular assist device (LVAD) implantation despite restoration of cardiac output (CO). This study aimed to characterize post-LVAD diuretic trajectories and identify hemodynamic predictors of diuretic resistance or diuretic de-escalation in patients receiving ≤ 160 mg versus > 160 mg of furosemide prior to implantation. In this retrospective, single-center observational study, 39 patients with advanced heart failure (79.5% male; median age 58 [53; 64] years) who underwent implantation of a HeartMate 3 LVAD as a bridge to transplantation between December 2017 and March 2024 were included. Pre-implant clinical, laboratory, echocardiographic, and invasive hemodynamic parameters were analysed according to baseline diuretic dose and subsequent changes in diuretic requirements following LVAD implantation. Patients receiving > 160 mg/day of furosemide (31%) had significantly higher right atrial pressure (p = 0.006), higher mean pulmonary artery pressure (p = 0.028), and lower pulmonary artery pulsatility index (PAPi; p = 0.004) compared with those receiving ≤ 160 mg/day. Among low-dose patients, 33% developed post-LVAD diuretic resistance, associated with lower PAPi and higher CO. In multivariate analysis, lower PAPi independently predicted diuretic resistance (OR 0.82, 95% CI 0.69–0.98; p = 0.027), while higher CO was also associated with increased risk (OR 3.09, 95% CI 1.25–7.59; p = 0.014). PAPi demonstrated significant inverse discrimination for diuretic resistance (AUC 0.26; p = 0.005). Kaplan-Meier analysis showed reduced event-free survival in patients with PAPi ≤ 1.85 (log-rank p = 0.022). Despite normalization of CO after LVAD implantation, diuretic resistance may persist or emerge in the setting of right ventricular – pulmonary uncoupling. Low pre-implant PAPi and venous congestion appear central to impaired renal response, highlighting the importance of comprehensive right-sided hemodynamic assessment during LVAD candidate evaluation.