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Bravo CA, Navarro AG, Dhaliwal KK, Khorsandi M, Keenan JE, Mudigonda P, O'Brien KD, Mahr C. Right heart failure after left ventricular assist device: From mechanisms to treatments. Front Cardiovasc Med 2022; 9:1023549. [PMID: 36337897 PMCID: PMC9626829 DOI: 10.3389/fcvm.2022.1023549] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/22/2022] [Indexed: 07/21/2023] Open
Abstract
Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5-44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.
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Affiliation(s)
- Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Andrew G. Navarro
- School of Medicine, University of Washington, Seattle, WA, United States
| | - Karanpreet K. Dhaliwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Parvathi Mudigonda
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Kevin D. O'Brien
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
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Duque ER, Alvarez P, Yang Y, Khalid M, Kshetri R, Doulamis IP, Panos A, Briasoulis A. Impact of Pre-Operative Right Ventricular Response to Hemodynamic Optimization on Outcomes in Patients with LVADs. J Clin Med 2022; 11:jcm11206111. [PMID: 36294432 PMCID: PMC9605231 DOI: 10.3390/jcm11206111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ±12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14−16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24−13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6−25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation.
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Affiliation(s)
- Ernesto Ruiz Duque
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Yingchi Yang
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Muhammad Khalid
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Rupesh Kshetri
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Ilias P. Doulamis
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Anthony Panos
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +319-678-8418; Fax: +319-353-6343
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Nair N. Use of machine learning techniques to identify risk factors for RV failure in LVAD patients. Front Cardiovasc Med 2022; 9:848789. [PMID: 36186964 PMCID: PMC9515379 DOI: 10.3389/fcvm.2022.848789] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
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Gautam N, Ghanta SN, Clausen A, Saluja P, Sivakumar K, Dhar G, Chang Q, DeMazumder D, Rabbat MG, Greene SJ, Fudim M, Al'Aref SJ. Contemporary Applications of Machine Learning for Device Therapy in Heart Failure. JACC. HEART FAILURE 2022; 10:603-622. [PMID: 36049812 DOI: 10.1016/j.jchf.2022.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
Despite a better understanding of the underlying pathogenesis of heart failure (HF), pharmacotherapy, surgical, and percutaneous interventions do not prevent disease progression in all patients, and a significant proportion of patients end up requiring advanced therapies. Machine learning (ML) is gaining wider acceptance in cardiovascular medicine because of its ability to incorporate large, complex, and multidimensional data and to potentially facilitate the creation of predictive models not constrained by many of the limitations of traditional statistical approaches. With the coexistence of "big data" and novel advanced analytic techniques using ML, there is ever-increasing research into applying ML in the context of HF with the goal of improving patient outcomes. Through this review, the authors describe the basics of ML and summarize the existing published reports regarding contemporary applications of ML in device therapy for HF while highlighting the limitations to widespread implementation and its future promises.
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Affiliation(s)
- Nitesh Gautam
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sai Nikhila Ghanta
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Alex Clausen
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Prachi Saluja
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kalai Sivakumar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gaurav Dhar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Qi Chang
- Department of Computer Science, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| | | | - Mark G Rabbat
- Department of Cardiology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Stephen J Greene
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Marat Fudim
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Subhi J Al'Aref
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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Jedrzejewska A, Braczko A, Kawecka A, Hellmann M, Siondalski P, Slominska E, Kutryb-Zajac B, Yacoub MH, Smolenski RT. Novel Targets for a Combination of Mechanical Unloading with Pharmacotherapy in Advanced Heart Failure. Int J Mol Sci 2022; 23:ijms23179886. [PMID: 36077285 PMCID: PMC9456495 DOI: 10.3390/ijms23179886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 12/19/2022] Open
Abstract
LVAD therapy is an effective rescue in acute and especially chronic cardiac failure. In several scenarios, it provides a platform for regeneration and sustained myocardial recovery. While unloading seems to be a key element, pharmacotherapy may provide powerful tools to enhance effective cardiac regeneration. The synergy between LVAD support and medical agents may ensure satisfying outcomes on cardiomyocyte recovery followed by improved quality and quantity of patient life. This review summarizes the previous and contemporary strategies for combining LVAD with pharmacotherapy and proposes new therapeutic targets. Regulation of metabolic pathways, enhancing mitochondrial biogenesis and function, immunomodulating treatment, and stem-cell therapies represent therapeutic areas that require further experimental and clinical studies on their effectiveness in combination with mechanical unloading.
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Affiliation(s)
- Agata Jedrzejewska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Alicja Braczko
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Ada Kawecka
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Marcin Hellmann
- Department of Cardiac Diagnostics, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland
| | - Piotr Siondalski
- Department of Cardiac Surgery, Medical University of Gdansk, Debinki 7 Street, 80-211 Gdansk, Poland
| | - Ewa Slominska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Barbara Kutryb-Zajac
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
| | - Magdi H. Yacoub
- Heart Science Centre, Imperial College of London at Harefield Hospital, Harefield UB9 6JH, UK
| | - Ryszard T. Smolenski
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
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A Holistic View of Advanced Heart Failure. Life (Basel) 2022; 12:life12091298. [PMID: 36143336 PMCID: PMC9501910 DOI: 10.3390/life12091298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023] Open
Abstract
Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.
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Abbasi MA, Stoller DA, Lyden E, Lowes BD, Zolty R, Lundgren SW. Impact of digoxin utilization on clinical outcomes following left ventricular assist device implantation. Int J Artif Organs 2022; 45:919-926. [PMID: 35945816 DOI: 10.1177/03913988221112684] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We aimed to assess the impact of digoxin use following left ventricular assist device (LVAD) implantation on clinical outcomes. METHODS Patients implanted with continuous flow LVADs at a single academic medical center and survived to initial hospital discharge were included in the analysis (n = 346). Clinical events were captured at a maximum of 2 years of follow up. Digoxin use was defined as 30-day continuous use post-LVAD. Negative binomial regression and Kaplan-Meier method were used to assess the association between digoxin use and clinical outcomes. RESULTS Mean age of the cohort was 56 years (±13) and 23% (79/346) were female sex. Digoxin was used in 144 patients (41.6%) for a median of 268 days (IQR 154, 616). Digoxin use was associated with a significant reduction in cumulative incidence of gastrointestinal bleeding (GIB) (15% vs 26%, p = 0.004). After adjusting for age, hypertension, post-operative hemoglobin, RDW, potassium, and GFR, and use of angiotensin receptor/neprilysin inhibitor, there remained a significant 47% reduction in GIB incidence in patients treated with digoxin. There was no significant difference in cumulative incidence in right ventricular failure (RVF) between the two groups. There was no difference in overall 2-year survival between groups. CONCLUSIONS Digoxin use was associated with reduction in GIB events, but not in RVF or mortality. Further studies are needed to confirm these findings and to investigate optimal timing and patient population.
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Affiliation(s)
- Muhannad Aboud Abbasi
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Douglas A Stoller
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Lyden
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Brian D Lowes
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ronald Zolty
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott W Lundgren
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Orozco-Hernandez EJ, Kurt DeLay T, Hoopes CW, Gongora E, Pamboukian S, Xie R, Davies JE, Vardas PN. Preoperative hemodynamics as predictors of right heart failure post-left ventricular assist device. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Mechanical circulatory support has garnered significant popularity as both a bridge to transplant as well as a destination therapy for patients with end-stage heart failure. Right heart failure (RHF) is a devastating complication after LVAD placement and is very unpredictable. Assisted circulation of the left ventricle (LV) with an LVAD device could unmask an underlying RHF. However, otherwise healthy right ventricles (RVs) can develop RHF after LVAD placement as well due to poor adaptation to new filling pressures and altered hemodynamics. It has been proposed that preoperative volumetric measurements in the pulmonary and systemic vasculature may serve as indicators for a risk of RHF after LVAD implantation. The aim of this study is to examine a potential relationship of preoperative hemodynamic values such as pulmonary artery pulsatility index (PAPi) and the ratio of central venous pressure to pulmonary wedge pressure (CVP/PWP) as preoperative predictors for RHF post LVAD placement.
Methods
We retrospectively reviewed patients undergoing initially planned isolated LVAD implantation with or without concomitant procedures in our institution from January 1, 2017 to June 12, 2020. Data were gathered from hemodynamic records, echocardiographic interpretations, and clinical notes. Patients who had RHF after LVAD implantation but without hemodynamic data available within 14 days from the operation were excluded. Univariable analysis was performed.
Results
Of the 114 patients who received planned isolated LVAD surgery, 70 (61.4%) experienced RHF within the first 7 days postoperatively. PAPi did not correlate significantly with RHF vs non-RHF among LVAD recipients (3.1 ± 2.1 vs. 3.8 ± 3.4 P = 0.21). Pre-op CVP/PWP did not differ significantly between RHF and non-RHF patients (0.4 ± 0.2 vs. 0.5 ± 0.8 P = 0.28). There was a nonsignificant correlation between elevated pre-op PWP and those with RHF vs those without, OR = 1.05 (95% CI: 1.00, 1.10). Pre-op systolic pulmonary artery pressure (SysPAP) was elevated in patients with post-LVAD RHF compared to those without (51.3 ± 12.3 vs. 47.2 ± 13.0, P = 0.09).
Conclusion
Preoperative hemodynamic variables such as PAPi or CVP/PWP did not show a significant correlation predicting RHF post LVAD implantation. Acute RHF post LVAD implantation remains a complex medical entity. Several studies have devised multivariable risk scores; however, their performance has been limited. Despite the widespread use of preoperative hemodynamics measurements as risk scores, our study suggests these scores are not as accurate as their use would suggest, particularly among especially morbid patient populations. More prospective studies are needed to accurately demonstrate how preoperative hemodynamics could predict and help prevent this catastrophic complication.
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Bjelic M, Vidula H, Wu IY, McNitt S, Barrus B, Cheyne C, Chase K, Zottola Z, Alexis JD, Goldenberg I, Gosev I. Impact of surgical approach for left ventricular assist device implantation on postoperative invasive hemodynamics and right ventricular failure. J Card Surg 2022; 37:3072-3081. [PMID: 35842802 DOI: 10.1111/jocs.16766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/06/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Right ventricular failure (RVF) remains one of the major causes of morbidity and mortality after left ventricular assist device (LVAD) implantation. We sought to compare immediate postoperative invasive hemodynamics and the risk of RVF following two different surgical approaches: less invasive surgery (LIS) versus full sternotomy (FS). METHODS The study population comprised all 231 patients who underwent implantation of a HeartMate 3 (Abbott) LVAD at our institution from 2015 to 2020, utilizing an LIS (n = 161; 70%) versus FS (n = 70; 30%) surgical approach. Outcomes included postoperative invasive hemodynamic parameters, vasoactive-inotropic score (VIS), RVF during index hospitalization, and 6-month mortality. RESULTS Baseline clinical characteristics of the two groups were similar. Multivariate analysis showed that LIS, compared with FS, was associated with the improved cardiac index (CI) at the sixth postoperative hour (p = .036) and similar CI at 24 h, maintained by lower VIS at both timepoints (p = .002). The LIS versus FS approach was also associated with a three-fold lower incidence of in-hospital severe RVF (8.7% vs. 28.6%, p < .001) and need for RVAD support (5.0% vs. 17.1%, p = .003), and with 68% reduction in the risk of 6-month mortality after LVAD implantation (Hazard ratio, 0.32; CI, 0.13-0.78; p = .012). CONCLUSION Our findings suggest that LIS, compared with FS, is associated with a more favorable hemodynamic profile, as indicated by similar hemodynamic parameters maintained by lower vasoactive-inotropic support during the acute postoperative period. These findings were followed by a reduction in the risk of severe RVF and 6-month mortality in the LIS group.
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Affiliation(s)
- Milica Bjelic
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Himabindu Vidula
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Isaac Y Wu
- Department of Anesthesiology, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Bryan Barrus
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Christina Cheyne
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Karin Chase
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Zachary Zottola
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Jeffrey D Alexis
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
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Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
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Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Usman AA, Spelde AE, Weiss S, Augoustides JG, Vernick W, Gutsche J. The Evolution of Percutaneous Right Ventricular Support and Development of a Right Ventricular Mechanical Support team lead by Cardiac Anesthesiologists. J Cardiothorac Vasc Anesth 2022; 36:3722-3724. [DOI: 10.1053/j.jvca.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
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Bleiweis MS, Stukov Y, Philip J, Peek GJ, Pitkin AD, Sullivan KJ, Neal D, Jacobs JP. Analysis of 82 Children Supported with Pulsatile Paracorporeal Ventricular Assist Device: Comparison of Patients with Biventricular versus Univentricular Circulation. Semin Thorac Cardiovasc Surg 2022; 35:367-376. [DOI: 10.1053/j.semtcvs.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/11/2022]
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Hall SA, Copeland H, Alam A, Joseph SM. The “Right” Definition for Post–Left Ventricular Assist Device Right Heart Failure: The More We Learn, the Less We Know. Front Cardiovasc Med 2022; 9:893327. [PMID: 35557521 PMCID: PMC9087190 DOI: 10.3389/fcvm.2022.893327] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Right heart failure is a major cause of morbidity and mortality following left ventricular assist device implantation. Over the past few decades, the definition proposed by the Interagency Registry of Mechanical Circulatory Support and Society of Thoracic Surgeons has continually evolved to better identify this complex pathology. We propose that the latest definition proposed by the Mechanical Circulatory Support Academic Research Consortium in 2020 will increase our recognition and understanding of this complex disease phenomenon.
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Affiliation(s)
- Shelley A. Hall
- Baylor University Medical Center, Dallas, TX, United States
- Texas A&M University College of Medicine, Dallas, TX, United States
- *Correspondence: Shelley A. Hall
| | - Hannah Copeland
- Lutheran Hospital, Indiana University Fort Wayne, Fort Wayne, IN, United States
| | - Amit Alam
- Baylor University Medical Center, Dallas, TX, United States
- Texas A&M University College of Medicine, Dallas, TX, United States
| | - Susan M. Joseph
- University of Maryland Medical Center, Baltimore, MD, United States
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De Lazzari B, Iacovoni A, Capoccia M, Papa S, Badagliacca R, Filomena D, De Lazzari C. Ventricular and Atrial Pressure—Volume Loops: Analysis of the Effects Induced by Right Centrifugal Pump Assistance. Bioengineering (Basel) 2022; 9:bioengineering9050181. [PMID: 35621459 PMCID: PMC9137510 DOI: 10.3390/bioengineering9050181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/06/2022] [Accepted: 04/17/2022] [Indexed: 11/16/2022] Open
Abstract
The main indications for right ventricular assist device (RVAD) support are right heart failure after implantation of a left ventricular assist device (LVAD) or early graft failure following heart transplantation. We sought to study the effects induced by different RVAD connections when right ventricular elastance (EesRIGHT) was modified using numerical simulations based on atrial and ventricular pressure–volume analysis. We considered the effects induced by continuous-flow RVAD support on left/right ventricular/atrial loops when EesRIGHT changed from 0.3 to 0.8 mmHg/mL during in-series or parallel pump connection. Pump rotational speed was also addressed. Parallel RVAD support at 4000 rpm with EesRIGHT = 0.3 mmHg/mL generated percentage changes up to 60% for left ventricular pressure–volume area and external work; up to 20% for left ventricular ESV and up to 25% for left ventricular EDV; up to 50% change in left atrial pressure-volume area (PVLAL-A) and only a 3% change in right atrial pressure–volume area (PVLAR-A). Percentage variation was lower when EesRIGHT = 0.8 mmHg/mL. Early recognition of right ventricular failure followed by aggressive treatment is desirable, so as to achieve a more favourable outcome. RVAD support remains an option for advanced right ventricular failure, although the onset of major adverse events may preclude its use.
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Affiliation(s)
- Beatrice De Lazzari
- Department of Human Movement and Sport Sciences, “Foro Italico” 4th University of Rome, 00135 Rome, Italy;
| | - Attilio Iacovoni
- Department of Cardiology, ASST-Papa Giovanni XIII Hospital, 24127 Bergamo, Italy;
| | - Massimo Capoccia
- Department of Cardiac Surgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK
- Correspondence:
| | - Silvia Papa
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy; (S.P.); (R.B.); (D.F.)
| | - Roberto Badagliacca
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy; (S.P.); (R.B.); (D.F.)
| | - Domenico Filomena
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy; (S.P.); (R.B.); (D.F.)
| | - Claudio De Lazzari
- National Research Council, Institute of Clinical Physiology (IFC-CNR), 00185 Rome, Italy;
- Faculty of Medicine, Teaching University Geomedi, Tbilisi 0114, Georgia
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65
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Varshney AS, DeFilippis EM, Cowger JA, Netuka I, Pinney SP, Givertz MM. Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1092-1107. [PMID: 35300822 DOI: 10.1016/j.jacc.2022.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 12/27/2022]
Abstract
As the prevalence of advanced heart failure continues to rise, treatment strategies for select patients include heart transplantation or durable left ventricular assist device (LVAD) support, both of which improve quality of life and extend survival. Recently, the HeartMate 3 has been incorporated into clinical practice, the United Network for Organ Sharing donor heart allocation system was revised, and the management of LVAD-related complications has evolved. Contemporary LVAD recipients have greater preoperative illness severity, but survival is higher and adverse event rates are lower compared with prior eras. This is driven by advances in device design, patient selection, surgical techniques, and long-term management. However, bleeding, infection, neurologic events, and right ventricular failure continue to limit broader implementation of LVAD support. Ongoing efforts to optimize management of patients implanted with current devices and parallel development of next-generation devices are likely to further improve outcomes for patients with advanced heart failure.
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Affiliation(s)
- Anubodh S Varshney
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | | | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic. https://twitter.com/netuka_ivan
| | - Sean P Pinney
- University of Chicago Medicine, Chicago, Illinois, USA. https://twitter.com/spinneymd
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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66
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Schlöglhofer T, Wittmann F, Paus R, Riebandt J, Schaefer AK, Angleitner P, Granegger M, Aigner P, Wiedemann D, Laufer G, Schima H, Zimpfer D. When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation. Life (Basel) 2022; 12:life12030459. [PMID: 35330210 PMCID: PMC8952681 DOI: 10.3390/life12030459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 01/24/2023] Open
Abstract
Right heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation. The aim of this study was to analyze the incidence, risk factors, and biomarkers for late RHF including the possible superiority of the device and implantation method. This retrospective, single-center study included patients who underwent LVAD implantation between 2014 and 2018. Primary outcome was freedom from RHF over one-year after LVAD implantation; secondary outcomes included pre- and postoperative risk factors and biomarkers for RHF. Of the 145 consecutive patients (HeartMate 3/HVAD: n = 70/75; female: 13.8%), thirty-one patients (21.4%) suffered RHF after a mean LVAD support of median (IQR) 105 (118) days. LVAD implantation method (less invasive: 46.7% vs. 35.1%, p = 0.29) did not differ significantly in patients with or without RHF, whereas the incidence of RHF was lower in HeartMate 3 vs. HVAD patients (12.9% vs. 29.3%, p = 0.016). Multivariate Cox proportional hazard analysis identified HVAD (HR 4.61, 95% CI 1.12–18.98; p = 0.03), early post-op heart rate (HR 0.96, 95% CI 0.93–0.99; p = 0.02), and central venous pressure (CVP) (HR 1.21, 95% CI 1.05–1.39; p = 0.01) as independent risk factors for RHF, but no association of RHF with increased all-cause mortality (HR 1.00, 95% CI 0.99–1.01; p = 0.50) was found. To conclude, HVAD use, lower heart rate, and higher CVP early post-op were independent risk factors for RHF following LVAD implantation.
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Affiliation(s)
- Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
- Ludwig Boltzmann Institute for Cardiovascular Research, 1020 Vienna, Austria;
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence:
| | - Franziska Wittmann
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Robert Paus
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Anne-Kristin Schaefer
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Philipp Angleitner
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Marcus Granegger
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Philipp Aigner
- Ludwig Boltzmann Institute for Cardiovascular Research, 1020 Vienna, Austria;
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
| | - Heinrich Schima
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
- Ludwig Boltzmann Institute for Cardiovascular Research, 1020 Vienna, Austria;
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (F.W.); (R.P.); (J.R.); (A.-K.S.); (P.A.); (M.G.); (D.W.); (G.L.); (H.S.); (D.Z.)
- Ludwig Boltzmann Institute for Cardiovascular Research, 1020 Vienna, Austria;
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Montisci A, Sala S, Maj G, Cattaneo S, Pappalardo F. Comprehensive evaluation of Impella RP ® in right ventricular failure. Future Cardiol 2022; 18:285-298. [PMID: 35187952 DOI: 10.2217/fca-2021-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Right ventricular failure has a high morbidity and mortality in patients suffering from advanced heart failure, pulmonary hypertension, acute myocardial infarction after cardiac surgery and in left ventricular assist device patients. The Impella RP® catheter is a mechanical circulatory device, positioned from a venous femoral percutaneous access and passing through the tricuspid and pulmonary valves, reaches the pulmonary artery. Impella RP (Abiomed Inc., MA, USA) acts as a direct right ventricle bypass and it provides a flow up to 4.4 liters per minute, unloading the right ventricle. The main contraindications are: thrombi in the vena cava, right atrium and ventricle and pulmonary artery; mechanical tricuspid or pulmonary prostheses. In this review, the principles of operations, clinical applications and results of Impella RP are summarized and evaluated.
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Affiliation(s)
- Andrea Montisci
- Cardiothoracic Department, Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia 25123, Italy
| | - Silvia Sala
- Postgraduate in Anesthesia & Intensive Care, University of Brescia, Brescia, Italy
| | - Giulia Maj
- Department of Anesthesia & Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
| | - Sergio Cattaneo
- Cardiothoracic Department, Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia 25123, Italy
| | - Federico Pappalardo
- Department of Anesthesia & Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
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68
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Transcriptomic Signatures of End-Stage Human Dilated Cardiomyopathy Hearts with and without Left Ventricular Assist Device Support. Int J Mol Sci 2022; 23:ijms23042050. [PMID: 35216165 PMCID: PMC8878549 DOI: 10.3390/ijms23042050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022] Open
Abstract
Left ventricular assist device (LVAD) use in patients with dilated cardiomyopathy (DCM) can lead to a differential response in the LV and right ventricle (RV), and RV failure remains the most common complication post-LVAD insertion. We assessed transcriptomic signatures in end-stage DCM, and evaluated changes in gene expression (mRNA) and regulation (microRNA/miRNA) following LVAD. LV and RV free-wall tissues were collected from end-stage DCM hearts with (n = 8) and without LVAD (n = 8). Non-failing control tissues were collected from donated hearts (n = 6). Gene expression (for mRNAs/miRNAs) was determined using microarrays. Our results demonstrate that immune response, oxygen homeostasis, and cellular physiological processes were the most enriched pathways among differentially expressed genes in both ventricles of end-stage DCM hearts. LV genes involved in circadian rhythm, muscle contraction, cellular hypertrophy, and extracellular matrix (ECM) remodelling were differentially expressed. In the RV, genes related to the apelin signalling pathway were affected. Following LVAD use, immune response genes improved in both ventricles; oxygen homeostasis and ECM remodelling genes improved in the LV and, four miRNAs normalized. We conclude that LVAD reduced the expression and induced additional transcriptomic changes of various mRNAs and miRNAs as an integral component of the reverse ventricular remodelling in a chamber-specific manner.
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69
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Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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70
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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71
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Akhmerov A, Ramzy D. Supporting the Right Heart - Do It Right and Do It Early. Ann Thorac Surg 2021; 114:491. [PMID: 34838738 DOI: 10.1016/j.athoracsur.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Akbarshakh Akhmerov
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Suite A3105 Los Angeles, CA, 90048
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Suite A3105 Los Angeles, CA, 90048.
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72
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Lorusso R, Ravaux JM, Mariani S. Left ventricular assist devices and right ventricular failure prediction: Quo Vadis? Interact Cardiovasc Thorac Surg 2021; 33:793-794. [PMID: 34405858 PMCID: PMC8557794 DOI: 10.1093/icvts/ivab208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Justine M Ravaux
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
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73
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Kumar S, Derbala MH, Nguyen DT, Ferrall J, Cefalu M, Rivas-Lasarte M, Rashid SMI, Joseph DT, Graviss EA, Goldstein D, Jorde UP, Bhimaraj A, Suarez EE, Smith SA, Sims DB, Guha A. A multi-institutional retrospective analysis on impact of RV acute mechanical support timing after LVAD implantation on 1-year mortality and predictors of RV acute mechanical support weaning. J Heart Lung Transplant 2021; 41:244-254. [PMID: 34802875 DOI: 10.1016/j.healun.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/31/2021] [Accepted: 10/08/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is little insight into which patients can be weaned off right ventricular (RV) acute mechanical circulatory support (AMCS) after left ventricular assist device (LVAD) implantation. We hypothesize that concomitant RV AMCS insertion instead of postoperative implantation will improve 1-year survival and increase the likelihood of RV AMCS weaning. METHODS A multicenter retrospective database of 826 consecutive patients who received a HeartMate II or HVAD between January 2007 and December 2016 was analyzed. We identified 91 patients who had early RV AMCS on index admission. Cox proportional-hazards model was constructed to identify predictors of 1-year mortality post-RV AMCS implantation and competing risk modeling identified RV AMCS weaning predictors. RESULTS There were 91 of 826 patients (11%) who required RV AMCS after CF-LVAD implantation with 51 (56%) receiving a concomitant RV AMCS and 40 (44%) implanted with a postoperative RV AMCS during their ICU stay; 48 (53%) patients were weaned from RV AMCS support. Concomitant RV AMCS with CF-LVAD insertion was associated with lower mortality (HR 0.45 [95% CI 0.26-0.80], p = 0.01) in multivariable model (which included age, BMI, angiotensin-converting enzyme inhibitor use, and heart transplantation as a time-varying covariate). In the multivariate competing risk analysis, a TPG < 12 (SHR 2.19 [95% CI 1.02-4.70], p = 0.04) and concomitant RV AMCS insertion (SHR 3.35 [95% CI 1.73-6.48], p < 0.001) were associated with a successful wean. CONCLUSIONS In patients with RVF after LVAD implantation, concomitant RV AMCS insertion at the time of LVAD was associated with improved 1-year survival and increased chances of RV support weaning compared to postoperative insertion.
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Affiliation(s)
- Salil Kumar
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Mohamed H Derbala
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Joel Ferrall
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Cefalu
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mercedes Rivas-Lasarte
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Advanced Heart Failure and Heart Transplant Unit, Hospital Univesitario Puerta de Hierro, Madrid, Spain
| | - Syed Muhammad Ibrahim Rashid
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Denny T Joseph
- Department of Internal Medicine, Houston Methodist Hospital, Houston, Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Hospital, Houston, Texas; Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Daniel Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ulrich P Jorde
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Erik E Suarez
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Sakima A Smith
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daniel B Sims
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas.
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74
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Contemporary Mechanical Circulatory Support with Continuous Flow Biventricular Assist Devices: A Systematic Review. Cardiol Rev 2021; 30:197-205. [PMID: 34636808 DOI: 10.1097/crd.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the incidence of heart failure increases, so too has that of biventricular failure. While transplantation remains the gold standard therapy for end-stage heart failure, the limited organ supply has increased the need for durable mechanical circulatory support. We therefore sought to conduct a systematic review of continuous flow ventricular assist devices in a biventricular configuration (CF-BiVAD). An electronic search of PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases was performed using the keyword "BIVAD". Studies were reviewed to identify discrete variables, including implant indication, INTERMACs profile, timing of implant, mean age and BMI, and the anticoagulation/antiplatelet regimens employed post implant. Outcomes of interest included mortality and the incidence of thrombus, bleeding, infection, stroke and renal failure. A total of 25 studies met inclusion criteria. No single variable was consistently reported, with only four studies reporting all five adverse effects. INTERMACs profile at implant and anticoagulation/antiplatelet regimen were reported in less than 50% of studies. Of those reporting mortality, there was a wide range of follow-up, from less than six months to >10 years, and the survival rate was similarly widely variable. Additionally, more than 50% of studies failed to isolate CF-BiVAD from alternative means of biventricular support, such as temporary support platforms, TAH, and pulsatile VADs. Therefore high-quality quantitative analysis is not possible. In summary, CF-BiVAD literature has a very heterogenous reporting of data. Standard reporting criteria may allow for future analyses to determine which patient characteristics portend a favorable outcome with CF-BiVAD implantation.
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75
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Rivas-Lasarte M, Kumar S, Derbala MH, Ferrall J, Cefalu M, Rashid SMI, Joseph DT, Goldstein DJ, Jorde UP, Guha A, Bhimaraj A, Suarez EE, Smith SA, Sims DB. Prediction of right heart failure after left ventricular assist implantation: external validation of the EUROMACS right-sided heart failure risk score. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:723-732. [PMID: 34050652 DOI: 10.1093/ehjacc/zuab029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/21/2021] [Indexed: 11/13/2022]
Abstract
AIMS Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant remains a challenge. The EUROMACS right-sided heart failure (EUROMACS-RHF) risk score was proposed as a prediction tool for post-LVAD RHF but lacks from large external validation. The aim of our study was to externally validate the score. METHODS AND RESULTS From January 2007 to December 2017, 878 continuous-flow LVADs were implanted at three tertiary centres. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated its predictive performance for early RHF defined as either (i) need for short- or long-term right-sided circulatory support, (ii) continuous inotropic support for ≥14 days, or (iii) nitric oxide for ≥48 h post-operatively. Right heart failure occurred in 211 patients (32%). When compared with non-RHF patients, pre-operatively they had higher creatinine, bilirubin, right atrial pressure, and lower INTERMACS class (P < 0.05); length of stay and in-hospital mortality were higher. Area under the ROC curve for RHF prediction of the EUROMACS-RHF score was 0.64 [95% confidence interval (CI) 0.60-0.68]. Reclassification of patients with RHF was significantly better when applying the EUROMACS-RHF risk score on top of previous published scores. Patients in the high-risk category had significantly higher in-hospital and 2-year mortality [hazard ratio: 1.64 (95% CI 1.16-2.32) P = 0.005]. CONCLUSION In an external cohort, the EUROMACS-RHF had limited discrimination predicting RHF. The clinical utility of this score remains to be determined.
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Affiliation(s)
- Mercedes Rivas-Lasarte
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.,Advanced Heart Failure and Transplant Unit, Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Majadahonda, Madrid, Spain
| | - Salil Kumar
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.,Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Mohamed H Derbala
- Department of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joel Ferrall
- Department of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew Cefalu
- Department of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Syed Muhammad Ibrahim Rashid
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Denny T Joseph
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Erik E Suarez
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Sakima A Smith
- Department of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel B Sims
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
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76
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Brener MI, Hamid NB, Fried JA, Masoumi A, Raikhelkar J, Kanwar MK, Pahuja M, Mondellini GM, Braghieri L, Majure DT, Colombo PC, Yuzefpolskaya M, Sayer GT, Uriel N, Burkhoff D. Right Ventricular Pressure-Volume Analysis During Left Ventricular Assist Device Speed Optimization Studies: Insights Into Interventricular Interactions and Right Ventricular Failure. J Card Fail 2021; 27:991-1001. [PMID: 33989781 DOI: 10.1016/j.cardfail.2021.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interventricular interaction, which refers to the impact of left ventricular (LV) function on right ventricular (RV) function and vice versa, has been implicated in the pathogenesis of RV failure in LV assist device (LVAD) recipients. We sought to understand more about interventricular interaction by quantifying changes in the RV systolic and diastolic function with varying LVAD speeds. METHODS AND RESULTS Four patients (ages 22-69 years, 75% male, and 25% with ischemic cardiomyopathy) underwent a protocolized hemodynamic ramp test within 12 months of LVAD implantation where RV pressure-volume loops were recorded with a conductance catheter. The end-systolic PV relationship and end-diastolic PV relationship were compared using the V20 and V10 indices (volumes at which end-systolic PV relationship and end-diastolic PV relationship reach a pressure of 20 and 10 mm Hg, respectively). The ∆V20 and ∆V10 refer to the change in V20 and V10 from the minimum to maximum LVAD speeds. RV PV loops demonstrated variable changes in systolic and diastolic function with increasing LVAD speed. The end-systolic PV relationship changed in 1 patient (patient 2, ∆V20 = 23.5 mL), reflecting a decrease in systolic function with increased speed, and was unchanged in 3 patients (average ∆V20 = 7.4 mL). The end-diastolic PV relationship changed with increasing speed in 3 of 4 patients (average ∆V10 = 12.5 mL), indicating an increase in ventricular compliance, and remained unchanged in one participant (patient 1; ∆V10 = 4.0 mL). CONCLUSIONS Interventricular interaction can improve RV compliance and impair systolic function, but the overall effect on RV performance in this pilot investigation is heterogeneous. Further research is required to understand which patient characteristics and hemodynamic parameters influence the net impact of interventricular interaction.
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Affiliation(s)
- Michael I Brener
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York.
| | - Nadira B Hamid
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Justin A Fried
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Amirali Masoumi
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Manreet K Kanwar
- Cardiovascular Institute at Alleghany Health Network in Pittsburgh, Pennsylvania
| | - Mohit Pahuja
- Division of Cardiology, MedStar Georgetown University/Washington Hospital Center in Washington, DC
| | - Giulio M Mondellini
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Lorenzo Braghieri
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - David T Majure
- Division of Cardiology, Weill Cornell University-New York Presbyterian Hospital in New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Nir Uriel
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York; Cardiovascular Research Foundation in New York, New York
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77
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Malik A, Winchester ML, Gorman K, Parrott J, Parrish M. Left ventricular assist device in pregnancy: Case report and review of the literature. J Obstet Gynaecol Res 2021; 47:1589-1593. [PMID: 33565182 DOI: 10.1111/jog.14699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/11/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
Left ventricular assist devices have emerged as a safe and effective therapy for end-stage heart failure patients. However, little is known about the safety of these devices during pregnancy. We describe a 23-year-old woman who received a left ventricular device for nonischemic cardiomyopathy of uncertain origin. She became pregnant approximately 1 year later. With close monitoring of her hemodynamic parameters, she was able to achieve a gestational age of 34 weeks, at which time she delivered a healthy male infant by cesarean delivery. Pregnancies in women with left ventricular assist devices may be successful, but remain medically challenging and complex pregnancies. Close multidisciplinary involvement and frequent assessment of device parameters during pregnancy is warranted.
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Affiliation(s)
- Alexa Malik
- Kansas University School of Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Mae-Lan Winchester
- Division of Maternal-Fetal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Kelly Gorman
- Division of Maternal-Fetal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | | | - Marc Parrish
- Division of Maternal-Fetal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
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78
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Stawiarski K, Stulak JM, Ramakrishna H. HeartMate 3-Analysis of Recent Trial Data. J Cardiothorac Vasc Anesth 2020; 35:3105-3107. [PMID: 33446405 DOI: 10.1053/j.jvca.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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