101
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Pinsino A, Castagna F, Zuver AM, Royzman EA, Nasiri M, Stöhr EJ, Cagliostro B, McDonnell B, Cockcroft JR, Garan AR, Topkara VK, Schulze PC, Takeda K, Takayama H, Naka Y, Demmer RT, Willey JZ, Yuzefpolskaya M, Colombo PC. Prognostic implications of serial outpatient blood pressure measurements in patients with an axial continuous-flow left ventricular assist device. J Heart Lung Transplant 2018; 38:396-405. [PMID: 30559034 DOI: 10.1016/j.healun.2018.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/06/2018] [Accepted: 11/09/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Elevated blood pressure (BP) has been linked to adverse events during left ventricular assist device support. In this study we investigated the association between outpatient BP and stroke or suspected pump thrombosis among HeartMate II (HMII) recipients. METHODS We retrospectively studied 220 HMII patients. Serial outpatient BP measurements were averaged. Patients were categorized by: (1) mean arterial pressure (MAP), high (>90 mm Hg) vs intermediate (80 mm Hg ≤ MAP ≤ 90 mm Hg) vs low (<80 mm Hg); (2) systolic BP (SBP), high (≥101 mm Hg, median) vs low; and (3) pulse pressure (PP), high (≥22 mm Hg, median) vs low. To assess visit-to-visit BP variability, patients were divided in quartiles of standard deviation of MAP and SBP. The primary end-point was the composite of stroke or suspected pump thrombosis. RESULTS The risk for the primary end-point was increased in the high MAP group (adjusted hazard ratio [HR] 2.75, 95% confidence interval [CI] 1.49 to 5.05, vs intermediate MAP; and 6.73, 1.9 to 23.9, vs low MAP). MAP had higher predictive value for the primary end-point compared with SBP (p = 0.05). Patients with high SBP had a higher rate of stroke (HR 2.8, 95% CI 1.09 to 7.17, vs low SBP). The combination of high SBP and low PP was associated with the highest risk for stroke. The lowest quartile of visit-to-visit MAP variability was associated with the highest risk for the primary end-point. CONCLUSIONS Elevated outpatient BP is associated with increased risk for stroke or suspected pump thrombosis in HMII recipients. Reduced PP and low visit-to-visit BP variability may confer additional risk.
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Affiliation(s)
- Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Francesco Castagna
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA; Department of Medicine, Yale New Haven Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Amelia M Zuver
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Eugene A Royzman
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Mojdeh Nasiri
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Eric J Stöhr
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA; Cardiff Metropolitan University, Cardiff, UK
| | - Barbara Cagliostro
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | | | - John R Cockcroft
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - A Reshad Garan
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - P Christian Schulze
- Department of Medicine I, Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Friedrich Schiller University Jena, University Hospital Jena, Jena, Germany
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Ryan T Demmer
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Joshua Z Willey
- Department of Neurology, Columbia University, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA.
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102
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Narang N, Raikhelkar J, Sayer G, Uriel N. Hemodynamic Pump-Patient Interactions and Left Ventricular Assist Device Imaging. Cardiol Clin 2018; 36:561-569. [PMID: 30297073 DOI: 10.1016/j.ccl.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Left ventricular assist devices (LVAD) provide a durable option for patients with advanced hear failure. Axial and centrifugal pump physiology differs with regard to the relationship between pump inflow-outflow cannula pressure differential and flow, which results in device behavior that can vary drastically under different loading conditions. Ramp studies can aid the clinician in choosing the optimal speed to adequately unload the left ventricle. Advances in 3-dimensional echocardiography enhance the understanding of chamber geometry for both types of LVADs. Novel outflow graft imaging techniques have been developed to better characterize aortic insufficiency, which may be underestimated with current standard methods.
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Affiliation(s)
- Nikhil Narang
- Section of Cardiology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Jayant Raikhelkar
- Section of Cardiology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Gabriel Sayer
- Section of Cardiology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Nir Uriel
- Section of Cardiology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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103
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Chen Z, Jena SK, Giridharan GA, Sobieski MA, Koenig SC, Slaughter MS, Griffith BP, Wu ZJ. Shear stress and blood trauma under constant and pulse-modulated speed CF-VAD operations: CFD analysis of the HVAD. Med Biol Eng Comput 2018; 57:807-818. [PMID: 30406881 DOI: 10.1007/s11517-018-1922-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
Modulation of pump speed has been proposed and implemented clinically to improve vascular pulsatility in continuous flow ventricular assist device patient. The flow dynamics of the HVAD with a promising asynchronous pump speed modulation and its potential risk for device-induced blood trauma was investigated numerically. The boundary conditions at the pump inlet and outlet were defined using the pressure waveforms adapted from the experimentally recorded ventricular and arterial pressure waveforms in a large animal ischemic heart failure (IHF) model supported by the HVAD operated at constant and modulated pump speeds. Shear stress fields and hemolysis indices were derived from the simulated flow fields. The overall features of the computationally generated flow waveforms at simulated constant and pulse-modulated speed operations matched with those of the experimentally recorded flow waveforms. The simulations showed that the shear stress field and hemolysis index vary throughout the cardiac cycle under the constant speed operation, and also as a function of modulation profile under modulated speed operation. The computational model did not demonstrate any differences in the time average hemolysis index between constant and modulated pump speed operations, thereby predicting pulse-modulated speed operation may help to restore vascular pulsatility without any further increased risk of blood trauma. Graphical abstract The streamline inside the HVAD pump and the wall shear stress distribution on the impeller surface at six discrete time instants over one cardiac cycle under constant speed operation (3000 rpm) (a) and under pulse-modulated speed operation (b). c Computationally predicted flow rate waveform under pulse-modulated speed operation. d Computationally predicted time-varying HI generated by the HVAD pump under the two operation modes constant speed (dash line) and pulse-modulated speed (solid line). These figures indicate that the pulse-modulated speed operation may help to restore vascular pulsatility without any further increased risk of blood trauma.
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Affiliation(s)
- Zengsheng Chen
- Artificial Organs Laboratory, Department of Surgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF 434A, Baltimore, MD, 21201, USA
| | - Sofen K Jena
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA
| | - Guruprasad A Giridharan
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA.,Department of Bioengineering, Speed School of Engineering, University of Louisville, Louisville, KY, 40292, USA
| | - Michael A Sobieski
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA
| | - Steven C Koenig
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA.,Department of Bioengineering, Speed School of Engineering, University of Louisville, Louisville, KY, 40292, USA
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA
| | - Bartley P Griffith
- Artificial Organs Laboratory, Department of Surgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF 434A, Baltimore, MD, 21201, USA
| | - Zhongjun J Wu
- Artificial Organs Laboratory, Department of Surgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF 434A, Baltimore, MD, 21201, USA. .,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, 20742, USA.
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104
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105
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106
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Selmi M, Chiu WC, Chivukula VK, Melisurgo G, Beckman JA, Mahr C, Aliseda A, Votta E, Redaelli A, Slepian MJ, Bluestein D, Pappalardo F, Consolo F. Blood damage in Left Ventricular Assist Devices: Pump thrombosis or system thrombosis? Int J Artif Organs 2018; 42:113-124. [PMID: 30354870 DOI: 10.1177/0391398818806162] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Despite significant technical advancements in the design and manufacture of Left Ventricular Assist Devices, post-implant thrombotic and thromboembolic complications continue to affect long-term outcomes. Previous efforts, aimed at optimizing pump design as a means of reducing supraphysiologic shear stresses generated within the pump and associated prothrombotic shear-mediated platelet injury, have only partially altered the device hemocompatibility. Methods: We examined hemodynamic mechanisms that synergize with hypershear within the pump to contribute to the thrombogenic potential of the overall Left Ventricular Assist Device system. Results: Numerical simulations of blood flow in differing regions of the Left Ventricular Assist Device system, that is the diseased native left ventricle, the pump inflow cannula, the impeller, the outflow graft and the anastomosed downstream aorta, reveal that prothrombotic hemodynamic conditions might occur at these specific sites. Furthermore, we show that beyond hypershear, additional hemodynamic abnormalities exist within the pump, which may elicit platelet activation, such as recirculation zones and stagnant platelet trajectories. We also provide evidences that particular Left Ventricular Assist Device implantation configurations and specific post-implant patient management strategies, such as those allowing aortic valve opening, are more hemodynamically favorable and reduce the thrombotic risk. Conclusion: We extend the perspective of pump thrombosis secondary to the supraphysiologic shear stress environment of the pump to one of Left Ventricular Assist Device system thrombosis, raising the importance of comprehensive characterization of the different prothrombotic risk factors of the total system as the target to achieve enhanced hemocompatibility and improved clinical outcomes.
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Affiliation(s)
- Matteo Selmi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
- Department of Surgery, Division of Cardiac Surgery, Università di Verona, Verona, Italy
| | - Wei-Che Chiu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | | | - Giulio Melisurgo
- Anesthesia and Cardiothoracic Intensive Care, San Raffaele Scientific Institute, Milano, Italy
| | | | - Claudius Mahr
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA
| | - Emiliano Votta
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Marvin J Slepian
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
- Departments of Medicine and Biomedical Engineering, The University of Arizona, Tucson, AZ, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Federico Pappalardo
- Anesthesia and Cardiothoracic Intensive Care, San Raffaele Scientific Institute, Milano, Italy
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Filippo Consolo
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
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107
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Graefe R, Beyel C, Henseler A, Körfer R, Steinseifer U, Tenderich G. The Effect of LVAD Pressure Sensitivity on the Assisted Circulation Under Consideration of a Mitral Insufficiency: An In Vitro Study. Artif Organs 2018; 42:E304-E314. [DOI: 10.1111/aor.13279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 01/28/2023]
Affiliation(s)
| | | | | | - Reiner Körfer
- ReinVAD GmbH; Aachen Germany
- Department for the Surgical Therapy of End-stage Heart Failure and Mechanical Circulatory Support; Heart- and Vascular Center Duisburg; Duisburg Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering; Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University; Aachen Germany
| | - Gero Tenderich
- Department for the Surgical Therapy of End-stage Heart Failure and Mechanical Circulatory Support; Heart- and Vascular Center Duisburg; Duisburg Germany
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108
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Nelson JA, Mauermann WJ, Barbara DW. Left Ventricular Assist Devices and Noncardiac Surgery. Adv Anesth 2018; 36:99-123. [PMID: 30414644 DOI: 10.1016/j.aan.2018.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- James A Nelson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Barbara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA.
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109
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Determinants of Improvement in Cardiopulmonary Exercise Testing After Left Ventricular Assist Device Implantation. ASAIO J 2018; 64:610-615. [DOI: 10.1097/mat.0000000000000693] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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110
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111
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Device Management and Flow Optimization on Left Ventricular Assist Device Support. Crit Care Clin 2018; 34:453-463. [DOI: 10.1016/j.ccc.2018.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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112
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Management of Arrhythmias and Cardiac Implantable Electronic Devices in Patients With Left Ventricular Assist Devices. JACC Clin Electrophysiol 2018; 4:847-859. [DOI: 10.1016/j.jacep.2018.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 11/21/2022]
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113
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Wave Intensity Analysis of Right Ventricular Function during Pulsed Operation of Rotary Left Ventricular Assist Devices. ASAIO J 2018; 65:465-472. [PMID: 29863635 DOI: 10.1097/mat.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Changing the speed of left ventricular assist devices (LVADs) cyclically may be useful to restore aortic pulsatility; however, the effects of this pulsation on right ventricular (RV) function are unknown. This study investigates the effects of direct ventricular interaction by quantifying the amount of wave energy created by RV contraction when axial and centrifugal LVADs are used to assist the left ventricle. In 4 anesthetized pigs, pressure and flow were measured in the main pulmonary artery and wave intensity analysis was used to identify and quantify the energy of waves created by the RV. The axial pump depressed the intensity of waves created by RV contraction compared with the centrifugal pump. In both pump designs, there were only minor and variable differences between the continuous and pulsed operation on RV function. The axial pump causes the RV to contract with less energy compared with a centrifugal design. Diminishing the ability of the RV to produce less energy translates to less pressure and flow produced, which may lead to LVAD-induced RV failure. The effects of pulsed LVAD operation on the RV appear to be minimal during acute observation of healthy hearts. Further study is necessary to uncover the effects of other modes of speed modulation with healthy and unhealthy hearts to determine if pulsed operation will benefit patients by reducing LVAD complications.
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114
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Schmidt T, Bjarnason-Wehrens B, Schulte-Eistrup S, Reiss N. Effects of pump speed changes on exercise capacity in patients supported with a left ventricular assist device-an overview. J Thorac Dis 2018; 10:S1802-S1810. [PMID: 30034856 DOI: 10.21037/jtd.2018.01.114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The implantation of left ventricular assist devices (LVAD) has been established as a successful treatment for terminal heart failure (HF) for many years. Patient benefits include significantly improved survival, as well as improved quality of life. However, peak exercise capacity following LVAD implantation remains considerably restricted. This could be due to the predominate use of continuous-flow pumps, which operate at a fixed rotational speed and do not adapt to exercise conditions. Therefore, current research is focused on whether, and to what extent, adaptations in pump speed can influence and improve patient exercise capacity. We performed a systematic PubMed literature search on this topic, and found 11 relevant studies with 161 patients. Exercise time, peak work load, total cardiac output (TCO), peak oxygen consumption (peak VO2) and, if available, values at the anaerobic threshold (AT) were all taken into consideration. Possible complications were documented. This paper aims to compare the results from these studies in order to discuss the effects of pump speed adaptations on exercise capacity.
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Affiliation(s)
- Thomas Schmidt
- Schüchtermann-Klinik Bad Rothenfelde, Bad Rothenfelde, Germany.,Institute for Cardiology and Sports Medicine, German Sports University Cologne, Cologne, Germany
| | - Birna Bjarnason-Wehrens
- Institute for Cardiology and Sports Medicine, German Sports University Cologne, Cologne, Germany
| | | | - Nils Reiss
- Schüchtermann-Klinik Bad Rothenfelde, Bad Rothenfelde, Germany
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115
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Desai SR, Hwang NC. Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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116
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Anjum A, Kurihara C, Critsinelis A, Kawabori M, Sugiura T, Civitello AB, Etheridge WB, Delgado RM, Simpson L, George JK, Nair AP, Frazier OH, Morgan JA. Acute kidney injury after implantation of a left ventricular assist device: a comparison of axial-flow (HeartMate II) and centrifugal-flow (HeartWare HVAD) devices. J Artif Organs 2018; 21:285-292. [DOI: 10.1007/s10047-018-1047-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/08/2018] [Indexed: 12/17/2022]
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117
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Eifert S. [Percutaneous and surgical options for mechanical circulatory support in treatment of terminal heart failure]. Anaesthesist 2018; 67:321-325. [PMID: 29736554 DOI: 10.1007/s00101-018-0444-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Eifert
- Herzchirurgische Klinik und Poliklinik, Transplantationszentrum, Klinikum Großhadern, LMU München, Marchioninistr. 15, 81377, München, Deutschland.
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118
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HVAD Flow Waveform Morphologies: Theoretical Foundation and Implications for Clinical Practice. ASAIO J 2018; 63:526-535. [PMID: 28323662 PMCID: PMC5585123 DOI: 10.1097/mat.0000000000000557] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Continuous-flow ventricular assist device (cfVAD) performance and patient hemodynamic conditions are intimately interrelated and dynamic, changing frequently with alterations in physiologic conditions, particularly pre- and afterloading conditions. The Heartware cfVAD (HVAD) provides a unique feature among currently approved VADs of providing an estimated instantaneous flow waveform, the characteristics of which can provide significant insights into patient and device properties. Despite being readily available, HVAD waveforms are poorly understood, underutilized, and insufficiently leveraged, even by clinicians who regularly manage HVAD patients. The purpose of this review is to provide the theoretical foundation for understanding the determinants of HVAD waveform characteristics and to provide practical examples illustrating how to interpret and integrate changes of HVAD waveforms into clinical practice. Heartware cfVAD waveforms should be considered a complimentary tool for the optimization of medical therapies and device speed in HVAD patients.
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119
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Dalia AA, Cronin B, Stone ME, Turner K, Hargrave J, Vidal Melo MF, Essandoh M. Anesthetic Management of Patients With Continuous-Flow Left Ventricular Assist Devices Undergoing Noncardiac Surgery: An Update for Anesthesiologists. J Cardiothorac Vasc Anesth 2018; 32:1001-1012. [DOI: 10.1053/j.jvca.2017.11.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Indexed: 12/16/2022]
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120
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Granegger M, Schweiger M, Schmid Daners M, Meboldt M, Hübler M. Cavopulmonary mechanical circulatory support in Fontan patients and the need for physiologic control: A computational study with a closed-loop exercise model. Int J Artif Organs 2018. [DOI: 10.1177/0391398818762359] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Rotary blood pumps are a promising treatment approach for patients with a total cavopulmonary connection and a failing cardiovascular system. The aim of this study was to investigate the hemodynamic effects of cavopulmonary support using a numerical model with closed-loop baroreflex and exercise mechanisms. Methods: A numerical model of the univentricular cardiovascular system was developed, mimicking the hemodynamics during rest and exercise. Rotary blood pumps with different hydraulic pump characteristics (flat vs steep pressure-flow relationships) were investigated in the cavopulmonary position. Furthermore, two support modes—a constant speed setting and a physiologically controlled speed—were examined. Results: Hemodynamics without rotary blood pumps were achieved with less than 10% deviation from reported values during rest and exercise. Rotary blood pumps at constant speed improve the hemodynamics at rest, however, they constitute a hydraulic resistance during light (steep characteristics) or moderate (flat characteristics) exercise. In contrast, physiologic control increases cardiac output (moderate exercise: 8.2 vs 7.4 L/min) and reduces sympathetic activation (heart rate at moderate exercise: 111 vs 123 bpm). Conclusion: In this simulation study, the necessity of an automatically controlled rotary blood pump in the cavopulmonary position was shown. A pump at constant speed might constitute an additional resistance to venous return during physical activity. Therefore, a physiologic control algorithm based on the pressure difference between the caval veins and the atrial pressure is proposed to improve hemodynamics, especially during physical activity.
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Affiliation(s)
- Marcus Granegger
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Mirko Meboldt
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
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121
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Telyshev D, Denisov M, Pugovkin A, Selishchev S, Nesterenko I. The Progress in the Novel Pediatric Rotary Blood Pump Sputnik Development. Artif Organs 2018; 42:432-443. [DOI: 10.1111/aor.13109] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/23/2017] [Accepted: 12/12/2017] [Indexed: 01/29/2023]
Affiliation(s)
- Dmitry Telyshev
- National Research University of Electronic Technology, Biomedical Systems Department; Zelenograd, Moscow Russia
| | - Maxim Denisov
- National Research University of Electronic Technology, Biomedical Systems Department; Zelenograd, Moscow Russia
| | - Alexander Pugovkin
- National Research University of Electronic Technology, Biomedical Systems Department; Zelenograd, Moscow Russia
| | - Sergey Selishchev
- National Research University of Electronic Technology, Biomedical Systems Department; Zelenograd, Moscow Russia
| | - Igor Nesterenko
- National Research University of Electronic Technology, Biomedical Systems Department; Zelenograd, Moscow Russia
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122
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Unrecognized Left Heart Failure in LVAD Recipients: The Role of Routine Invasive Hemodynamic Testing. ASAIO J 2018; 64:183-190. [DOI: 10.1097/mat.0000000000000617] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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123
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Kawabori M, Kurihara C, Sugiura T, Cohn WE, Civitello AB, Frazier OH, Morgan JA. Continuous-Flow Left Ventricular Assist Device Implantation in Patients With a Small Left Ventricle. Ann Thorac Surg 2018; 105:799-806. [DOI: 10.1016/j.athoracsur.2017.09.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/07/2017] [Accepted: 09/22/2017] [Indexed: 11/26/2022]
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Chung BB, Sayer G, Uriel N. Mechanical circulatory support devices: methods to optimize hemodynamics during use. Expert Rev Med Devices 2018; 14:343-353. [PMID: 28448170 DOI: 10.1080/17434440.2017.1324292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Mechanical circulatory support (MCS) is an increasingly utilized mode of therapy in the management of advanced heart failure, both as bridge to heart transplantation and destination therapy. As MCS becomes more prevalent, it is ever more important to understand the complex hemodynamics of these devices, as well as the strategies for hemodynamic optimization. Areas covered: This review provides an overview of hemodynamics in the normal human heart and the failing heart. We discuss the various short-term mechanical circulatory support devices and their hemodynamic consequences. We will then discuss the differences between left ventricular assist devices, and the impact of these differences on hemodynamics. We will describe the strategies for hemodynamic optimization using echocardiographic and invasive ramp studies. Finally, we will discuss the impact of speed changes with exercise and discuss future directions for advancements in MCS therapies. Expert commentary: We advocate for a deeper understanding of the hemodynamics underpinning MCS devices. We also recommend the more widespread use of ramp studies for speed optimization, which have been well validated across a number of different left ventricular assist device types.
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Affiliation(s)
- Ben Bow Chung
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Gabriel Sayer
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Nir Uriel
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
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125
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Thamsen B, Plamondon M, Granegger M, Schmid Daners M, Kaufmann R, Neels A, Meboldt M. Investigation of the Axial Gap Clearance in a Hydrodynamic-Passive Magnetically Levitated Rotary Blood Pump Using X-Ray Radiography. Artif Organs 2018; 42:510-515. [DOI: 10.1111/aor.13074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Bente Thamsen
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
| | - Mathieu Plamondon
- Empa, Swiss Federal Laboratories for Material Science and Technology, Center for X-ray Analytics; Dübendorf Switzerland
| | - Marcus Granegger
- Pediatric Heart Center; University Children's Hospital, University of Zurich; Zurich Switzerland
| | - Marianne Schmid Daners
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
| | - Rolf Kaufmann
- Empa, Swiss Federal Laboratories for Material Science and Technology, Center for X-ray Analytics; Dübendorf Switzerland
| | - Antonia Neels
- Empa, Swiss Federal Laboratories for Material Science and Technology, Center for X-ray Analytics; Dübendorf Switzerland
| | - Mirko Meboldt
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
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126
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Clinical Implications of Physiologic Flow Adjustment in Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2018; 63:241-250. [PMID: 28459742 DOI: 10.1097/mat.0000000000000477] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank-Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs.
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127
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Quantitative Assessment of Inflow Malposition in Two Continuous-Flow Left Ventricular Assist Devices. Ann Thorac Surg 2018; 105:1377-1383. [PMID: 29305851 DOI: 10.1016/j.athoracsur.2017.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/20/2017] [Accepted: 12/05/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND We previously investigated preoperative variables associated with qualitative inflow cannula malposition in the HeartMate II (Thoratec-Abbott, Abbott Park, IL) continuous-flow left ventricular assist device. In this report, we assess inflow cannula malposition quantitatively in recipients of both the HeartMate II and the HeartWare (Medtronic-HeartWare, Minneapolis, MN) and examine its association with device thrombosis. METHODS Malposition was quantified based on angular deviation from a hypothetic ideal inflow cannula position in two orthogonal computed tomography imaging planes. Ideal position lies on a line from the apex to the center of the mitral valve. Positive anterior plane angulation indicates deviation toward the superior free wall; negative, toward the inferior wall. Positive lateral plane angulation indicates deviation toward the septum; negative, toward the lateral wall. Device thrombosis was assessed based on clinical criteria. RESULTS Fifty-four HeartMate II patients and 68 HeartWare patients were analyzed. Inflow cannula deviation was significantly higher for HeartMate II than for HeartWare (anterior plane angle 36.7 ± 16.8 versus -18.7 ± 11.6 degrees, p < 0.001; lateral plane angle 23.7 ± 20.1 versus 0.2 ± 15.0 degrees, p < 0.001. Pump thrombosis occurred in 31% of HeartMate II patients and 2.9% of HeartWare patients (p < 0.001). In a multivariate model, HeartMate II and increasing inflow cannula deviation toward the septum were associated with higher thrombosis risk (odds ratio 1.35 per 10-degree increase). CONCLUSIONS We found distinct device-dependent differences in inflow cannula positioning and thrombosis, with HeartWare showing both less malposition and less thrombosis. Malposition toward the ventricular septum may contribute to pump thrombosis through a vicious cycle of suction events, low flow, and speed reduction.
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128
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Li Z, Nguyen BL, Cheng YC, Xue J, MacLaren G, Yap CH. Durable, flexible, superhydrophobic and blood-repelling surfaces for use in medical blood pumps. J Mater Chem B 2018; 6:6225-6233. [DOI: 10.1039/c8tb01547c] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A new sand-casting method for fabricating superhydrophobic materials gives highly durable, flexible, and blood-repelling surfaces useful for cardiovascular medical devices.
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Affiliation(s)
- Zhe Li
- Department of Biomedical Engineering, National University of Singapore
- Singapore
| | - Ba Loc Nguyen
- Department of Biomedical Engineering, National University of Singapore
- Singapore
| | - Yi Chih Cheng
- Department of Biomedical Engineering, National University of Singapore
- Singapore
| | - Junmin Xue
- Department of Material Science and Engineering, National University of Singapore
- Singapore
| | - Graeme MacLaren
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore
- Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre
- Singapore
| | - Choon Hwai Yap
- Department of Biomedical Engineering, National University of Singapore
- Singapore
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129
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Shida S, Masuzawa T, Osa M, Sato R. Effects of Eccentric Impeller Position on Radial Passive Stability in a Magnetically Levitated Centrifugal Blood Pump with a Double Volute. ADVANCED BIOMEDICAL ENGINEERING 2018. [DOI: 10.14326/abe.7.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Shuya Shida
- Graduate School of Science and Engineering, Ibaraki University
| | - Toru Masuzawa
- Department of Mechanical Engineering, Ibaraki University
| | - Masahiro Osa
- Department of Mechanical Engineering, Ibaraki University
| | - Ryota Sato
- Graduate School of Science and Engineering, Ibaraki University
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Sadasivan C, Lieber BB, Woo HH. Physical Simulators and Replicators in Endovascular Neurosurgery Training. COMPREHENSIVE HEALTHCARE SIMULATION: NEUROSURGERY 2018. [DOI: 10.1007/978-3-319-75583-0_3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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131
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Ozgök A, Demir ZA, Sert G, Sert D, Gölbaşı Z, Kervan U. Intraoperative left atrium inversion after implantation of HeartMate III ventricular assist device. Acta Chir Belg 2017. [PMID: 28651485 DOI: 10.1080/00015458.2017.1341146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We report here a case of left atrium inversion after implanting HeartMate III LVAD, which is known to be the first in literature. LVAD can be functional only if there is adequate inflow to the device. Parameters and filling of left ventricle can be assessed by TEE. In our case, initial examination with TEE showed thrombus like images. HeartMate III has a reliable algorithm that automatically reduces pump speed if 'suction effect' is detected. HeartMate III demonstrates clean flow properties and good surface wash. Despite these positive features of the HeartMate III, left atrium inversion can still be seen with it, so users should be alert in this regard.
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Affiliation(s)
- Ayşegül Ozgök
- Department of Anesthesiology, Türkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Z. Asli Demir
- Department of Anesthesiology, Türkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Gökçe Sert
- Department of Anesthesiology, Türkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Doğan Sert
- Cardiac Surgery, Turkey Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Zehra Gölbaşı
- Cardiology, Turkey Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Umit Kervan
- Cardiac Surgery, Turkey Yuksek Ihtisas Hospital, Ankara, Turkey
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132
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Maltais S, Anwer LA, Haglund NA, Cowger J, Shah P, Aaronson KD, Pagani FD, Dunlay SM, Singh R, Salerno CT, Stulak JM. Temporal Differences in Outcomes During Long-Term Mechanical Circulatory Support. J Card Fail 2017; 23:852-858. [DOI: 10.1016/j.cardfail.2017.07.403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/30/2017] [Accepted: 07/25/2017] [Indexed: 11/25/2022]
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Kuchibhotla S, Esposito ML, Breton C, Pedicini R, Mullin A, O'Kelly R, Anderson M, Morris DL, Batsides G, Ramzy D, Grise M, Pham DT, Kapur NK. Acute Biventricular Mechanical Circulatory Support for Cardiogenic Shock. J Am Heart Assoc 2017; 6:e006670. [PMID: 29054842 PMCID: PMC5721869 DOI: 10.1161/jaha.117.006670] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/01/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Biventricular failure is associated with high in-hospital mortality. Limited data regarding the efficacy of biventricular Impella axial flow catheters (BiPella) support for biventricular failure exist. The aim of this study was to explore the clinical utility of percutaneously delivered BiPella as a novel acute mechanical support strategy for patients with cardiogenic shock complicated by biventricular failure. METHODS AND RESULTS We retrospectively analyzed data from 20 patients receiving BiPella for biventricular failure from 5 tertiary-care hospitals in the United States. Left ventricular support was achieved with an Impella 5.0 (n=8), Impella CP (n=11), or Impella 2.5 (n=1). All patients received the Impella RP for right ventricular (RV) support. BiPella use was recorded in the setting of acute myocardial infarction (n=11), advanced heart failure (n=7), and myocarditis (n=2). Mean flows achieved were 3.4±1.2 and 3.5±0.5 for left ventricular and RV devices, respectively. Total in-hospital mortality was 50%. No intraprocedural mortality was observed. Major complications included limb ischemia (n=1), hemolysis (n=6), and Thrombolysis in Myocardial Infarction major bleeding (n=7). Compared with nonsurvivors, survivors were younger, had a lower number of inotropes or vasopressors used before BiPella, and were more likely to have both devices implanted simultaneously during the same procedure. Compared with nonsurvivors, survivors had lower pulmonary artery pressures and RV stroke work index before BiPella. Indices of RV afterload were quantified for 14 subjects. Among these patients, nonsurvivors had higher pulmonary vascular resistance (6.8; 95% confidence interval [95% CI], 5.5-8.1 versus 1.9; 95% CI, 0.8-3.0; P<0.01), effective pulmonary artery elastance (1129; 95% CI, 876-1383 versus 458; 95% CI, 263-653; P<0.01), and lower pulmonary artery compliance (1.5; 95% CI, 0.9-2.1 versus 2.7; 95% CI, 1.8-3.6; P<0.05). CONCLUSIONS This is the largest, retrospective analysis of BiPella for cardiogenic shock. BiPella is feasible, reduces cardiac filling pressures and improves cardiac output across a range of causes for cardiogenic shock. Simultaneous left ventricular and RV device implantation and lower RV afterload may be associated with better outcomes with BiPella. Future prospective studies of BiPella for cardiogenic shock are required.
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MESH Headings
- Adult
- Aged
- Disease Progression
- Feasibility Studies
- Female
- Heart Failure/diagnosis
- Heart Failure/mortality
- Heart Failure/physiopathology
- Heart Failure/therapy
- Heart-Assist Devices
- Hemodynamics
- Hospital Mortality
- Humans
- Male
- Middle Aged
- Prosthesis Design
- Recovery of Function
- Retrospective Studies
- Risk Factors
- Shock, Cardiogenic/diagnosis
- Shock, Cardiogenic/mortality
- Shock, Cardiogenic/physiopathology
- Shock, Cardiogenic/therapy
- Tertiary Care Centers
- Time Factors
- Treatment Outcome
- United States
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/mortality
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/therapy
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/mortality
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/therapy
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- Sudeep Kuchibhotla
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Michele L Esposito
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Catalina Breton
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Robert Pedicini
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Andrew Mullin
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Ryan O'Kelly
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | | | | | | | - Danny Ramzy
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Duc Thinh Pham
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Navin K Kapur
- Acute Mechanical Circulatory Support Working Group, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
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Abstract
An increasing number of end-stage heart failure patients are now implanted with continuous-flow left ventricular assist devices (CF-LVADs). Although this therapeutic approach is associated with improved clinical outcomes, continuous flow physiology reduces arterial pulse pressure and pulsatility to an extent that is unique to this population. Recent data suggest that high blood pressure (BP) contributes to life-threatening complications such as pump thrombosis and stroke of CF-LVAD patients. However, limited understanding of the distinct hemodynamics of these pumps makes measurement and, consequently, medical management of BP quite challenging. Here, we review the evolution of LVAD design, the impact of CF-LVAD flow, and "artificial pulse" technology on hemodynamics and BP measurement, as well as suggest new approaches for the assessment and interpretation of the unique physiology of modern LVADs.
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135
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Hosseinipour M, Gupta R, Bonnell M, Elahinia M. Rotary mechanical circulatory support systems. J Rehabil Assist Technol Eng 2017; 4:2055668317725994. [PMID: 31186935 PMCID: PMC6453075 DOI: 10.1177/2055668317725994] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 07/20/2017] [Indexed: 12/25/2022] Open
Abstract
A detailed survey of the current trends and recent advances in rotary mechanical
circulatory support systems is presented in this paper. Rather than clinical reports, the
focus is on technological aspects of these rehabilitating devices as a reference for
engineers and biomedical researchers. Existing trends in flow regimes, flow control, and
bearing mechanisms are summarized. System specifications and applications of the most
prominent continuous-flow ventricular assistive devices are provided. Based on the flow
regime, pumps are categorized as axial flow, centrifugal flow, and mixed flow. Unique
characteristics of each system are unveiled through an examination of the structure,
bearing mechanism, impeller design, flow rate, and biocompatibility. A discussion on the
current limitations is provided to invite more studies and further improvements.
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Affiliation(s)
- Milad Hosseinipour
- Dynamic and Smart Systems Laboratory, The University of Toledo, Toledo, OH, USA.,Department of Mechanical Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Rajesh Gupta
- Cardiovascular Medicine Division, The University of Toledo Medical Center, Toledo, OH, USA
| | - Mark Bonnell
- Cardiothoracic Surgery Division, The University of Toledo Medical Center, Toledo, OH, USA
| | - Mohammad Elahinia
- Dynamic and Smart Systems Laboratory, The University of Toledo, Toledo, OH, USA
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136
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Platts DG, Bartnikowski N, Gregory SD, Scalia GM, Fraser JF. Contrast Microsphere Destruction by a Continuous Flow Ventricular Assist Device: An In Vitro Evaluation Using a Mock Circulation Loop. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4907898. [PMID: 28884121 PMCID: PMC5572588 DOI: 10.1155/2017/4907898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/22/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Transthoracic echocardiography (TTE) is fundamental in managing patients supported with ventricular assist devices (VAD). However imaging can be difficult in these patients. Contrast improves image quality but they are hydrodynamically fragile agents. The aim was to assess contrast concentration following passage through a VAD utilising a mock circulation loop (MCL). METHODS Heartware continuous flow (CF) VAD was incorporated into a MCL. Definity® contrast was infused into the MCL with imaging before and after CF-VAD. 5 mm2 regions of interest were used to obtain signal intensity (decibels), as a surrogate of contrast concentration. RESULTS Four pump speeds revealed significant reduction in contrast signal intensity after CF-VAD compared to before CF-VAD (all p < 0.0001). Combined pre- and postpump data at all speeds showed a 22.2% absolute reduction in contrast signal intensity across the CF-VAD (14.8 ± 0.8 dB prepump versus 11.6 ± 1.4 dB postpump; p < 0.0001). Mean signal intensity reduction at each speed showed an inverse relationship between speed and relative reduction in signal intensity. CONCLUSION Contrast microsphere transit through a CF-VAD within a MCL resulted in significant reduction in signal intensity, consistent with destruction within the pump. This was evident at all CF-VAD pump speeds but relative signal drop was inversely proportional to pump speed.
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Affiliation(s)
- David G. Platts
- Department of Echocardiography, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Nicole Bartnikowski
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Shaun D. Gregory
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering, Griffith University, Brisbane, QLD, Australia
| | - Gregory M. Scalia
- Department of Echocardiography, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Heart Care Partners, Wesley Hospital, Brisbane, QLD, Australia
| | - John F. Fraser
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
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Kapur NK, Davila CD. Timing, timing, timing: the emerging concept of the ‘door to support’ time for cardiogenic shock. Eur Heart J 2017; 38:3532-3534. [DOI: 10.1093/eurheartj/ehx406] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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139
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Shah P, Birk S, Maltais S, Stulak J, Elmi A, Pagani FD, Cowger JA. Left ventricular assist device outcomes based on flow configuration and pre-operative left ventricular dimension: An Interagency Registry for Mechanically Assisted Circulatory Support Analysis. J Heart Lung Transplant 2017; 36:640-649. [DOI: 10.1016/j.healun.2016.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/30/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022] Open
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Left Ventricular Assist Devices: Challenges Toward Sustaining Long-Term Patient Care. Ann Biomed Eng 2017; 45:1836-1851. [DOI: 10.1007/s10439-017-1858-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/22/2017] [Indexed: 11/25/2022]
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141
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Stulak JM, Abou El Ela A, Pagani FD. Implantation of a Durable Left Ventricular Assist Device: How I Teach It. Ann Thorac Surg 2017; 103:1687-1692. [PMID: 28528026 DOI: 10.1016/j.athoracsur.2017.03.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/12/2017] [Indexed: 11/25/2022]
Affiliation(s)
- John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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142
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Esposito ML, Kapur NK. Acute mechanical circulatory support for cardiogenic shock: the "door to support" time. F1000Res 2017; 6:737. [PMID: 28580136 PMCID: PMC5443341 DOI: 10.12688/f1000research.11150.1] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2017] [Indexed: 12/17/2022] Open
Abstract
Cardiogenic shock (CS) remains a major cause of in-hospital mortality in the setting of acute myocardial infarction. CS begins as a hemodynamic problem with impaired cardiac output leading to reduced systemic perfusion, increased residual volume within the left and right ventricles, and increased cardiac filling pressures. A critical step towards the development of future algorithms is a clear understanding of the treatment objectives for CS. In this review, we introduce the "door to support" time as an emerging target of therapy to improve outcomes associated with CS, define four key treatment objectives in the management of CS, discuss the importance of early hemodynamic assessment and appropriate selection of acute mechanical circulatory support (AMCS) devices for CS, and introduce a classification scheme that identifies subtypes of CS based on cardiac filling pressures.
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Affiliation(s)
- Michele L Esposito
- The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, 02339, USA
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, 02339, USA
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143
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Abstract
In the setting of mechanical circulatory support devices, including ventricular assist devices, extracorporeal membrane oxygenation, intraaortic balloon pumps, and the total artificial heart, the spectral Doppler waveform is significantly altered, reflecting systemic hemodynamic changes. As the prevalence of these devices increases, a better understanding of both the devices themselves and their associated Doppler ultrasound findings is necessary for accurate image interpretation. This article reviews the clinical indications, pathophysiology, and sonographic findings of these devices, with emphasis on the variation in arterial Doppler waveforms that can be seen with normal function, as well as the major complications.
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144
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Amat-Santos IJ, Varela-Falcón LH, Abraham WT. Terapias percutáneas en el tratamiento de la insuficiencia cardiaca aguda y crónica: presente y futuro. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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146
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Medvedev AL, Karimov JH, Kuban BD, Horvath DJ, Moazami N, Fukamachi K. Unlocking the box: basic requirements for an ideal ventricular assist device controller. Expert Rev Med Devices 2017; 14:393-400. [PMID: 28395539 DOI: 10.1080/17434440.2017.1318059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A modern ventricular assist device (VAD) system comprises an implantable rotary blood pump and external components located outside the patient's body: a wearable controller connected to the pump via a percutaneous cable, wearable rechargeable batteries, battery charger, alternating- and direct-current power supplies, and a hospital device to control and monitor the system. If the blood pump is the 'heart' of a VAD system, the controller is its 'brain.' The controller drives the pump's electrical motor; varies the pump speed or flow based on user commands or feedback signals; collects, processes, and stores data; performs self-diagnostics; transmits to and receives data from other system components, i.e., hospital monitor and batteries; and provides various types of user interface - audible, visual, and tactile. Areas covered: Here we describe the essential functions and basic design of the VAD external controller and give our views on the future of this technology. Expert commentary: Controllers for VAD systems are crucial to their successful operation. The current clinically available system comprises an external power supply and patient-friendly controller unit. Future controller solutions may enable remote hospital monitoring, more intuitive system interface, and the potential to use a single controller to automatically control a biventricular assist device configuration.
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Affiliation(s)
| | - Jamshid H Karimov
- b Department of Biomedical Engineering, Lerner Research Institute , Cleveland Clinic , Cleveland , OH , USA
| | - Barry D Kuban
- c Electronics Core, Medical Device Solutions, Lerner Research Institute , Cleveland Clinic , Cleveland , OH , USA
| | | | - Nader Moazami
- b Department of Biomedical Engineering, Lerner Research Institute , Cleveland Clinic , Cleveland , OH , USA.,e Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute , Cleveland Clinic , Cleveland , OH , USA
| | - Kiyotaka Fukamachi
- b Department of Biomedical Engineering, Lerner Research Institute , Cleveland Clinic , Cleveland , OH , USA
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Addetia K, Uriel N, Maffessanti F, Sayer G, Adatya S, Kim GH, Sarswat N, Fedson S, Medvedofsky D, Kruse E, Collins K, Rodgers D, Ota T, Jeevanandam V, Mor-Avi V, Burkhoff D, Lang RM. 3D Morphological Changes in LV and RV During LVAD Ramp Studies. JACC Cardiovasc Imaging 2017; 11:159-169. [PMID: 28412431 DOI: 10.1016/j.jcmg.2016.12.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/12/2016] [Accepted: 12/02/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the differential impact of the 2 most commonly available left ventricular assist device (LVAD) types on the right ventricle (RV) and left ventricle (LV) using 3-dimensional (3D) echocardiography-based analysis of ventricular morphology. BACKGROUND LVADs have emerged as common therapy for advanced heart failure. Recent data suggest that the heart responds differently to speed settings in the 2 main devices available (HeartMate II [HMII], St Jude Medical, Pleasanton, California, and HVAD, HeartWare International, Framingham, Massachusetts). The authors hypothesized that 3D echocardiographic assessment of LV and RV volumes and shape would help describe the differential impact of the 2 LVAD types on the heart. METHODS Simultaneous 3D echocardiography, ramp test, and right heart catheterization were performed in 31 patients with LVADs (19 with HMII and 12 with HVAD). Device speed was increased stepwise (8,000 to 12,000 for HMII and 2,300 to 3,200 revolutions per minute for HVAD). 3D echocardiographic full-volume LV and RV datasets were acquired, and endocardial surfaces were analyzed using custom software to calculate LV sphericity, conicity (perfect sphere/cone = 1) and RV septal and free-wall curvature (0 = flat; <0 = concave; >0 = convex). RESULTS For both devices, cardiac output increased and wedge pressure decreased with increasing speed. In HMII, LV volumes progressively decreased (meanΔ = 127 ml) as the LV became less spherical and more conical, whereas the RV volume initially remained stable, but subsequently increased at higher speeds (meanΔ = 60 ml). Findings for the HVAD were similar, but less pronounced (LV:meanΔ = 51 ml, RV:meanΔ = 22 ml), and the LV remained significantly more spherical even at high speeds. On average, in HMII patients, the RV septum became more convex (bulging into the LV) at the highest speeds whereas in HVAD patients, there was no discernable change in the RV septum. CONCLUSIONS The heart responds differently to pump speed changes with the 2 types of LVAD, as reflected by the volume and shape changes of both the LV and RV. Our study suggests that adding RV assessment to the clinical echo-ramp study may better optimize LVAD speed. Further study is needed to determine whether this would have an impact on patient outcomes.
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Affiliation(s)
- Karima Addetia
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Francesco Maffessanti
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Gabriel Sayer
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Sirtaz Adatya
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Gene H Kim
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Nitasha Sarswat
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Savitri Fedson
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Diego Medvedofsky
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Eric Kruse
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Keith Collins
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Takayoshi Ota
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Valluvan Jeevanandam
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Daniel Burkhoff
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois.
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New Innovations in Circulatory Support With Ventricular Assist Device and Extracorporeal Membrane Oxygenation Therapy. Anesth Analg 2017; 124:1071-1086. [DOI: 10.1213/ane.0000000000001629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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149
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Chaudhry SP, Stewart GC. New pharmacological and technological management strategies in heart failure. Vasc Health Risk Manag 2017; 13:111-121. [PMID: 28356751 PMCID: PMC5367380 DOI: 10.2147/vhrm.s106841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Heart failure is a complex clinical syndrome resulting from impairment of ventricular filling or ejection of blood associated with symptoms of dyspnea, fatigue, as well as peripheral and/or pulmonary edema. This syndrome is progressive and characterized by worsening quality of life despite escalating levels of care, affecting 5.7 million Americans with an annual cost of over ≥30 billion US dollars. Treatment for this syndrome has evolved over three distinct eras: the nonpharmacological era, the pharmacological era, and the device era, with the focus shifting from symptomatic relief to decreasing morbidity and mortality. Over the past 10 years, the field has undergone a renaissance, with the development of new pharmacologic, hemodynamic monitoring, and device therapies proven to improve outcomes in patients with heart failure. This article will review several recent innovations in the management of patients with heart failure.
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Affiliation(s)
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
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150
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Telyshev DV. Load Sensitivity of Rotary Blood Pumps under Static Pressure Conditions. BIOMEDICAL ENGINEERING 2017. [DOI: 10.1007/s10527-017-9670-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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