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Mulzer J, Müller M, Schoenrath F, Falk V, Potapov E, Knierim J. Left Ventricular Assist Device Implantation in Cancer-Therapy-Related Heart Failure. Life (Basel) 2022; 12:life12101485. [PMID: 36294920 PMCID: PMC9605306 DOI: 10.3390/life12101485] [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: 05/31/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Cancer-therapy-related heart failure (CTrHF) due to cardiotoxic drugs or radiation is a growing cause of end-stage heart failure. Limited knowledge is available concerning the use of continuous-flow left-ventricular-assist devices (cfLVAD) in this setting. Methods: The files of all 1334 patients who underwent cfLVAD implantation between December 2008 and December 2020 were screened for the cause of heart failure. All patients with CTrHF were included in the analysis. Results: A total of 32 patients with a median age of 58 years (IQR: 46–65) were included in the study; 15 (47%) were male. The median time from the first diagnosis of heart failure (HF) to cfLVAD implantation was 6 months (IQR 2–24), and from cancer treatment to cfLVAD implantation 40 months (IQR 5–144). Malignancies comprised non-Hodgkin lymphoma (n = 12, 37%), breast cancer (n = 9, 28%), sarcoma (n = 5, 16%), leukemia (n = 5, 16%), and others (n = 1, 3%). In 24 patients, chemotherapy included anthracyclines (others n = 2, unknown n = 6). Chest radiation was performed in 13 patients (39%). Moreover, 71% were classified as INTERMACS profile 1 or 2. The 30-day survival rate after LVAD implantation was 88%. Rethoracotomy was necessary in nine (29%), and a temporary right ventricular assist device in seven (21%) patients. The median survival was 29 months. There was no significant difference in survival or right HF between patients with CTrHF and a matched control group. Conclusions: CfLVAD implantation is feasible in high-risk patients with CTrHF with or without prior chest radiation.
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Affiliation(s)
- Johanna Mulzer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
| | - Marcus Müller
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
| | - Felix Schoenrath
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
| | - Volkmar Falk
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Eidgenössiche Technische Hochschule Zürich, Department of Health Sciences and Technology, Translational Cardiovascular Technology, 8092 Zurich, Switzerland
| | - Evgenij Potapov
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
| | - Jan Knierim
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany
- Correspondence:
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George TJ, Schaffer JM, Harrington KB, Meidan TG, Michael DiMaio J, Kabra N, Rawitscher DA, Afzal A. Impact of preoperative Impella support on destination left ventricular assist device outcomes. J Card Surg 2022; 37:3576-3583. [PMID: 36124428 DOI: 10.1111/jocs.16942] [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: 03/16/2022] [Revised: 08/06/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although left ventricular assist device (LVAD) implantation is associated with improved heart failure survival, the impact of pre-implantation Impella support on outcomes is unknown. We undertook this study to evaluate the impact of preoperative Impella support on LVAD outcomes. METHODS We conducted a retrospective review of all Heartmate 3 LVAD implants. Primary stratification was by the need for preoperative Impella support with the 5.0/5.5 device. Longitudinal survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models were developed to evaluate mortality. Secondary outcomes included changes in laboratory values during Impella support. RESULTS From 2017 to 2021, 87 patients underwent LVAD implantation. Sixteen were supported with a single inotrope, 36 with dual inotropes, 27 with Impella, and 3 with extracorporeal membrane oxygenation (ECMO). When stratified by the need for Impella, there was no difference in survival at 30-days (98.3 [88.2-99.8]% vs. 96.3 [76.5-99.5]%, p = .59), 1-year (91.0 [79.8-96.2] vs. 74.9 [51.7-88.2], p = .10), or at 2 years (87.9 [74.3-94.5] vs. 74.9 [51.7-88.2], p = .15). On multivariable modeling, the need for preoperative Impella was not associated with an increased hazard of 1-year (1.24 [0.23-6.73], p = .81) or 2-year mortality (1.05 [0.21-5.19], p = .95). After 7 (5-10) days of Impella support, recipient creatinine (p < .01), creatinine clearance (p = .02), and total bilirubin (p = .053) improved and lactic acidosis resolved (p < .01). CONCLUSIONS Preoperative Impella support is not associated with increased short or long-term mortality but is associated with improved renal and hepatic function as well as total body perfusion before LVAD implantation.
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Affiliation(s)
- Timothy J George
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - Justin M Schaffer
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - Katherine B Harrington
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - Talia G Meidan
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - John Michael DiMaio
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - Nitin Kabra
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - David A Rawitscher
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | - Aasim Afzal
- Department of Advanced Heart Failure and MCS, Baylor Scott & White The Heart Hospital, Plano, Texas, USA
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203
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Pourriahi M, Dimitri DS, Kumar P, Cheng R. Advanced Heart Failure Therapies: Specific Considerations for Cardio-Oncology Patients. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00967-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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204
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Numan L, Moazeni M, Oerlemans MI, Aarts E, Van Der Kaaij NP, Asselbergs FW, Van Laake LW. Data-driven monitoring in patients on left ventricular assist device support. Expert Rev Med Devices 2022; 19:677-685. [DOI: 10.1080/17434440.2022.2132147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lieke Numan
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Mehran Moazeni
- Department of Methodology and Statistics, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Marish I.F.J. Oerlemans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Emmeke Aarts
- Department of Methodology and Statistics, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Niels P. Van Der Kaaij
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Folkert W. Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, Gower Street, WC1E 6BT, London, UK
- Health Data Research UK and Institute of Health Informatics, University College London, Gower Street, WC1E 6BT, London, UK
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, the Netherlands
| | - Linda W. Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, Gower Street WC1E 6BT, London, UK
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Minol JP, Dalyanoglu H, Yilmaz E, Dalyanoglu I, Immohr MB, Korbmacher B, Aissa J, Boeken U, Akhyari P, Lichtenberg A, Sugimura Y. Impact of psoas muscle evaluation on clinical outcomes in patients undergoing left ventricular assist device implantation. J Cardiovasc Med (Hagerstown) 2022; 23:608-614. [PMID: 35994709 DOI: 10.2459/jcm.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The measurement of muscle mass reflects the physical components of frailty, which might affect postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to investigate the relationship between preoperative skeletal muscle evaluation and clinical outcomes in patients undergoing LVAD implantation. METHODS From January 2010 to December 2017, a total of 63 patients were enrolled in this single-centre study. A retrospective analysis of preoperative abdominal computed tomography (CT) for psoas muscle index (PSMI) and Hounsfield-Units of the Psoas Muscle (PSHU) at the level of the mid-L4 vertebra was performed. RESULTS Sixty-three patients (male; n = 49, 78%), with a mean age of 58.0 ± 11.8 years, were treated with LVAD due to dilated (32%) or ischemic cardiomyopathy (68%). Among them, 43 patients (68.3%) were categorized in the Interagency Registry for Mechanically Assisted Circulatory Support profile I. The survival rate was 73.0% at 30 days and 44.4% at 1 year. Receiver-operating characteristic (ROC) curve analyses revealed that PSMI was a significant numeric predictor of 1-year mortality (P = 0.04). In contrast, PSHU displayed a significant predictive potential for pericardial effusion (P = 0.03) and respiratory insufficiency (P = 0.01). In addition, comparative ROC curve analysis revealed no significant difference in the predictive potential of PSMI and PSHU. CONCLUSION Preoperative PSMI might be a predictor of 1-year mortality in patients undergoing LVAD implantation. In contrast, the PSHU seemed to potentially assume postoperative adverse events in this study. Thus, the evaluation of the preoperative psoas muscle using CT appears to be promising.
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Affiliation(s)
- Jan-Philipp Minol
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Esma Yilmaz
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Ismail Dalyanoglu
- cand. med. Medical Faculty of the Semmelweiss University, Budapest, Hungary
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Bernhard Korbmacher
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Joel Aissa
- Institute of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Yukiharu Sugimura
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
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206
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Inyom C, Haese T, Schoenrath F, Potapov E, Knierim J. Lived experiences of patients implanted with left ventricular assist devices. Heart Lung 2022; 55:155-161. [PMID: 35605356 DOI: 10.1016/j.hrtlng.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Besides survival, improvement in quality of life (QoL) is a major aim of left ventricular assist device (LVAD) implantation. QoL assessment tools in current use are effective in the gathering of standardized metrics but are limited in their ability to elucidate everyday lived patient experiences that also affect overall patient wellbeing. OBJECTIVE To describe and understand the lived experiences of patients undergoing long-term circulatory support with LVAD. METHODS A phenomenological approach was used. Purposive sampling of consecutive willing inpatients and outpatients living with an LVAD for longer than 6 months was conducted until theme saturation. There were a total of 21 patients interviewed and this was then recorded and transcribed. RESULTS A total of eight themes emerged from the data. Overall, the patients' quality of life was affected by: (1) whether they had experienced improvements or setbacks in their recent health condition, (2) experiencing burdens from their device such as weight and handling, (3) limitations in their physical ability such as participating in sports, their inability to work; or reduced sleep, (4) reduced social interactions; (5) reduction in sexual activity and performance; (6) experiencing emotional and psychological problems and experiencing anxiety. Patients highlighted the value of obtaining (7) support from family and friends. The interviews also revealed that some patients experienced the feeling of (8) optimism and obtaining "a second chance" at life. CONCLUSIONS LVAD patients have unique concerns and lived experiences. Some themes emerging from this interview series such as having to give up work, having reduced social contact, reduced sexual activity and emotional problems, family support structures demand careful attention during the pre-implantation counselling and post implantation ongoing care. These aspects also deserve more attention in quality of life studies among LVAD patients. Patients with recent improvements in health reported a more positive outlook. Overall the majority of patients reported feeling that they obtained a second chance at life.
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Affiliation(s)
- Charity Inyom
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin: Deutsches Herzzentrum Berlin, Berlin, Germany.
| | - Thomas Haese
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin: Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin: Deutsches Herzzentrum Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin: Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin: Deutsches Herzzentrum Berlin, Berlin, Germany
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Reza N, Edwards JJ, Katcoff H, Mondal A, Griffis H, Rossano JW, Lin KY, Holzhauser HL, Wald JW, Owens AT, Cappola TP, Birati EY, Edelson JB. Sex Differences in Left Ventricular Assist Device-related Emergency Department Encounters in the United States. J Card Fail 2022; 28:1445-1455. [PMID: 35644307 PMCID: PMC10066657 DOI: 10.1016/j.cardfail.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a paucity of data regarding sex differences in the profiles and outcomes of ambulatory patients on left ventricular assist device (LVAD) support who present to the emergency department (ED). METHODS AND RESULTS We performed a retrospective analysis of 57,200 LVAD-related ED patient encounters from the 2010 to 2018 Nationwide Emergency Department Sample. International Classification of Diseases Clinical Modification, Ninth Revision and Tenth Revision, codes identified patients aged 18 years or older with LVADs and associated primary and comorbidity diagnoses. Clinical characteristics and outcomes were stratified by sex and compared. Multivariable logistic regression was used to evaluate predictors of hospital admission and death. Female patient encounters comprised 27.2% of ED visits and occurred at younger ages and more frequently with obesity and depression (all P < .01). There were no sex differences in presentation for device complication, stroke, infection, or heart failure (all P > .05); however, female patient encounters were more often respiratory- and genitourinary or gynecological related (both P < .01). After adjustment for age group, diabetes, depression, and hypertension, male patient encounters had a 38% increased odds of hospital admission (95% confidence interval 1.20-1.58), but there was no sex difference in the adjusted odds of death (odds ratio 1.11, 95% confidence interval 0.86-1.45). CONCLUSIONS Patient encounters of females on LVAD support have significantly different comorbidities and outcomes compared with males. Further inquiry into these sex differences is imperative to improve long-term outcomes.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jonathan J Edwards
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Antara Mondal
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather Griffis
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Y Lin
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - H Luise Holzhauser
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anjali T Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas P Cappola
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, and Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Jonathan B Edelson
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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208
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Stencel J, Rajapreyar I, Samson R, Le Jemtel T. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 2022; 19:364-374. [PMID: 36045314 DOI: 10.1007/s11897-022-00573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE REVIEW Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.
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Affiliation(s)
- Jason Stencel
- Tulane University School of Medicine, New Orleans, LA, USA.
| | | | - Rohan Samson
- Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA
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209
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Wu P. Recent advances in the application of computational fluid dynamics in the development of rotary blood pumps. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2022. [DOI: 10.1016/j.medntd.2022.100177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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210
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Iskandar R, Federici C, Berns C, Blankart CR. An approach to quantify parameter uncertainty in early assessment of novel health technologies. HEALTH ECONOMICS 2022; 31 Suppl 1:116-134. [PMID: 35581685 DOI: 10.1002/hec.4525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/17/2022] [Accepted: 04/05/2022] [Indexed: 06/15/2023]
Abstract
Health economic modeling of novel technology at the early stages of a product lifecycle has been used to identify technologies that are likely to be cost-effective. Such early assessments are challenging due to the potentially limited amount of data. Modelers typically conduct uncertainty analyses to evaluate their effect on decision-relevant outcomes. Current approaches, however, are limited in their scope of application and imposes an unverifiable assumption, that is, uncertainty can be precisely represented by a probability distribution. In the absence of reliable data, an approach that uses the fewest number of assumptions is desirable. This study introduces a generalized approach for quantifying parameter uncertainty, that is, probability bound analysis (PBA), that does not require a precise specification of a probability distribution in the context of early-stage health economic modeling. We introduce the concept of a probability box (p-box) as a measure of uncertainty without necessitating a precise probability distribution. We provide formulas for a p-box given data on summary statistics of a parameter. We describe an approach to propagate p-boxes into a model and provide step-by-step guidance on how to implement PBA. We conduct a case and examine the differences between the status-quo and PBA approaches and their potential implications on decision-making.
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Affiliation(s)
- Rowan Iskandar
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, & Practice, Brown University, Providence, Rhode Island, USA
- Center of Excellence in Decision-Analytic Modeling and Health Economics Research, Sitem-insel, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carlo Federici
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | - Cassandra Berns
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, & Practice, Brown University, Providence, Rhode Island, USA
- Center of Excellence in Decision-Analytic Modeling and Health Economics Research, Sitem-insel, Bern, Switzerland
| | - Carl Rudolf Blankart
- Center of Excellence in Decision-Analytic Modeling and Health Economics Research, Sitem-insel, Bern, Switzerland
- KPM Center for Public Management, University of Bern, Bern, Switzerland
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211
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Kim KD, Funk RJ, Hou H, Airhart A, Nassar K, Pagani FD, Zhang M, Chandanabhumma PP, Aaronson KD, Chenoweth CE, Hider A, Cabrera L, Likosky DS. Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset. Circ Cardiovasc Qual Outcomes 2022; 15:e008592. [PMID: 36065815 PMCID: PMC9489640 DOI: 10.1161/circoutcomes.121.008592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). CONCLUSIONS Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.
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Affiliation(s)
- K. Dennie Kim
- Strategy, Ethics, and Entrepreneurship, Darden School of Business, University of Virginia, Charlottesville, VA
| | - Russell J. Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Khalil Nassar
- University Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - P. Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- University of Michigan Medical School, Ann Arbor, MI
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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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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Ruge M, Kochar K, Ullah W, Hajduczok A, Tchantchaleishvili V, Rame JE, Alvarez R, Brailovsky Y, Rajapreyar I. Impact of Ventricular Arrhythmia on LVAD Implantation Admission Outcomes. Artif Organs 2022; 46:2478-2485. [PMID: 35943857 DOI: 10.1111/aor.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/13/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ventricular arrhythmias (VAs) are common after left ventricular assist device (LVAD) implantation though data are mixed on whether these events have an impact on mortality. METHODS The National Inpatient Sample (NIS) database from 2002 - 2019 was queried for LVAD implantation admissions. Secondary ICD codes were analyzed to assess for the occurrence of VAs during this admission. Propensity score matching (PSM) was used to control for confounding variables between those with versus without VAs. RESULTS The NIS database from 2002 - 2019 contained 43,936 admissions with LVAD implantation. VAs occurred in 19,985 (45.4%) patients. After PSM, the study cohort consisted of 39,989 patients, 19,985 (50.0%) of which had a secondary diagnosis of VA during the admission. When compared to those without VA, those with VA were at no higher risk for in-hospital mortality (adjusted odds ratio 1.011, 99.9% CI 0.956 - 1.069, p = 0.699). Those with a VA were at higher risk for cardiogenic shock and requiring mechanical ventilation, tracheostomy, and percutaneous endoscopic gastrostomy placement. Patients with a VA were also at lower risk for device thrombosis. Conversely, the VA group was at no higher risk for stroke. In comparing trends from 2002 to 2019, the incidence of VAs has increased, while the mortality rate of those with and without VAs has decreased during this same period. CONCLUSION In this retrospective study of the NIS database, VAs were common (45.4%) during the LVAD implantation admission. However, the occurrence of VAs during the implantation admission did not alter in-hospital mortality. More longitudinal studies are required to assess the long-term impact of VAs on mortality. In comparing trends from 2002 - 2019, the incidence of VAs has increased, while the mortality rate of those with and without VAs has decreased.
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Affiliation(s)
- Max Ruge
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kirpal Kochar
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Waqas Ullah
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Hajduczok
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - J Eduardo Rame
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rene Alvarez
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Gobbo S, Favro F, Bullo V, Cugusi L, Blasio AD, Bortoletto A, Bocalini DS, Gasperetti A, Ermolao A, Bergamin M. Muscle strength, aerobic capacity, and exercise tolerance are impaired in left ventricular assist devices recipients: A pilot study. Front Physiol 2022; 13:967817. [PMID: 36003641 PMCID: PMC9393221 DOI: 10.3389/fphys.2022.967817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/12/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Left ventricular assist devices (LVAD) are increasingly being used as a therapy for advanced heart failure, both as a bridge to heart transplant and, given the rapid advances in the LVAD’s functionality and safety, and constant lack in availability of donor organs, as long-term destination therapy. With the diffusion of such therapy, it is crucial to assess patients’ muscle strength, aerobic capacity and exercise tolerance, to improve their functional capacity. Methods: 38 LVAD recipients (33 men and five women) were included. Exercise testing including a maximal cardiopulmonary exercise test (CPET), handgrip, isometric and isokinetic strength testing of knee and ankle flexion/extension, and Romberg balance test in three conditions (eyes open, eyes closed, double task). Given the small and heterogeneous final sample size, a mostly descriptive statistical approach was chosen. Results: 12 participants were classified as “Obese” (BMI>29.9). The most common comorbidities were type II diabetes and chronic kidney disease. Only 12 participants were able to successfully complete all the assessments. CPET and isokinetic strength trials were the least tolerated tests, and the handgrip test the best tolerated. Mean VO2 peak was 12.38 ± 3.43 ml/kg/min, with 15 participants below 50% of predicted VO2 max, of which 6 below 30% VO2max. Mean handgrip strength was 30.05 ± 10.61 Kg; 25 participants were below the 25° percentile of their population’s normative reference values for handgrip strength, 10 of which were below the 5° percentile. Issues with the management of the external pack of the LVAD and its influence on the test limited the validity of the balance tests data, therefore, no solid conclusions could be drawn from them. VO2 peak did not correlate with handgrip strength or with any of the lower limb strength measures. Conclusion: LVAD recipients show greatly reduced functional capacity and tolerance to exercise and exercise testing, with low overall strength levels. As strength variables appear to be independent from VO2 peak, different lower limbs strength tests should be explored to find a tolerable alternative in this population, which is subjected to muscle wasting due to old age, reduced tissue perfusion, side effects from the pharmacological therapies, and prolonged periods of bedrest.
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Affiliation(s)
- Stefano Gobbo
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Valentina Bullo
- Department of Medicine, University of Padova, Padova, Italy
- *Correspondence: Valentina Bullo,
| | - Lucia Cugusi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Andrea Di Blasio
- Department of Medicine and Sciences of Aging, G. D’Annunzio University of Chieti-Pescara, Chieti, Pescara, Italy
| | | | - Danilo Sales Bocalini
- Laboratorio de Fisiologia e Bioquimica Experimental, Centro de Educacao Fisica e Deportos, Universidade Federal do Espirito Santo (UFES), Vitoria, Brazil
| | - Andrea Gasperetti
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
| | - Andrea Ermolao
- Sports and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
| | - Marco Bergamin
- Department of Medicine, University of Padova, Padova, Italy
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Cai J, Xia W, Greenberg P, Okwuosa I, Setoguchi S, Akhabue E. Relation of Sociodemographic Factors With Primary Cause of Hospitalization Among Patients With Left Ventricular Assist Devices (from the National Inpatient Sample 2012 to 2017). Am J Cardiol 2022; 180:81-90. [DOI: 10.1016/j.amjcard.2022.06.047] [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: 03/29/2022] [Revised: 04/14/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
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Gómez-Bueno M, Pérez de la Sota E, Forteza Gil A, Ortiz-Berbel D, Castrodeza J, García-Cosío Carmena MD, Barge-Caballero E, Rangel Sousa D, Díaz Molina B, Manrique Antón R, Almenar-Bonet L, Uribarri González A, Barrio-Rodríguez A, Castel Lavilla MÁ, López-López L, Dobarro Pérez D, Pastor Pérez F, Burgos-Palacios V, Álvarez-García J, Garrido-Jiménez JM, González-Fernández Ó, Codina P, López-Granados A, Grau-Sepulveda A, González-Costello J. Asistencia ventricular de larga duración en España (2007-2020). I informe del registro REGALAD. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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217
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Chikwe J. Editor's Choice: Papers That May Change Your Practice. Ann Thorac Surg 2022; 114:359-363. [PMID: 35878951 DOI: 10.1016/j.athoracsur.2022.06.013] [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: 06/27/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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218
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Angleitner P, Kaider A, De By TMMH, Dimitrov K, Schlöglhofer T, Tops LF, Fiane AE, Rábago G, Laufer G, Zimpfer D. Obesity and outcomes after left ventricular assist device implantation-insights from the EUROMACS registry. Eur J Cardiothorac Surg 2022; 62:6650624. [PMID: 35894678 DOI: 10.1093/ejcts/ezac401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/07/2022] [Accepted: 07/25/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective was to analyze associations between obesity and outcomes after left ventricular assist device implantation. METHODS A retrospective analysis of the EUROMACS Registry was performed. Adult patients undergoing primary implantation of a continuous-flow left ventricular assist device between 2006 and 2019 were included (Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). Patients were classified in 4 different groups according to body mass index at the time of surgery (body mass index < 20 kg/m2: n = 254; 20-24.9 kg/m2: n = 1281; 25-29.9 kg/m2: n = 1238; ≥ 30 kg/m2: n = 691). RESULTS The study cohort was comprised of 3464 patients. Multivariable Cox proportional cause-specific hazards regression analysis demonstrated that obesity (body mass index ≥ 30 kg/m2) was independently associated with significantly increased risk of mortality (body mass index "≥ 30" vs "20-24.9" kg/m2: hazard ratio 1.36, 95% confidence interval 1.18 to 1.57, overall p < 0.001). Moreover, obesity was associated with significantly increased risk of infection and driveline infection. The probability to undergo heart transplantation was significantly decreased in obese patients (body mass index "≥ 30" vs "20-24.9" kg/m2: hazard ratio 0.59, 95% confidence interval 0.48 to 0.74, overall p < 0.001). CONCLUSIONS Obesity at the time of left ventricular assist device implantation is associated with significantly higher mortality and increased risk of infection as well as driveline infection. The probability to undergo heart transplantation is significantly decreased. These aspects should be considered when devising a treatment strategy before surgery.
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Affiliation(s)
- Philipp Angleitner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
| | | | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Norway
| | - Gregorio Rábago
- Department of Cardiac Surgery, University of Navarra, Pamplona, Spain
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Mihalj M, Heinisch PP, Schober P, Wieser M, Martinelli M, de By TMMH, Schefold JC, Luedi MM, Kadner A, Carrel T, Mohacsi P, Hunziker L, Reineke D. Third-generation continuous-flow left ventricular assist devices: a comparative outcome analysis by device type. ESC Heart Fail 2022; 9:3469-3482. [PMID: 35880515 DOI: 10.1002/ehf2.13794] [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: 07/15/2021] [Revised: 10/17/2021] [Accepted: 12/16/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS Continuous-flow left ventricular assist devices (CF-LVADs) have become a standard of care in end-stage heart failure. Limited data exist comparing outcomes of HeartMate3 (HM3) and HeartWare HVAD (HW). We aimed to compare midterm outcomes of these devices. METHODS AND RESULTS Investigator-initiated retrospective-observational comparative analysis of all patients who underwent primary LVAD implantation of either HM3 or HW at our centre between January 2010 and December 2020. Data were derived from a prospective registry. Primary endpoints were all-cause mortality and heart transplantation. Secondary endpoints included device-related major adverse cardiac and cerebrovascular events, which included major bleeding, major neurological dysfunction (defined as persisting neurological impairment for ≥24 h), device-related major infection (excluding driveline infections), major device malfunctions leading to re-intervention or partial device exchange (pump failure, outflow-graft twist or failure, controller failure, battery failure, patient cable failure, but excluding pump thrombosis), and pump thrombosis. Further secondary endpoints included right heart failure, gastrointestinal bleeding, driveline infections, and surgical re-interventions. The secondary outcomes were analysed not only for the first event but also for recurrent events. The analysis included competing risks analysis and recurrent event regression analysis, with adjustment for confounders age, gender, body mass index (BMI), and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Out of 106 primary CF-LVAD implantations, 36 (34%) received HM3 and 70 (66%) received HW. Median follow-up was 1.48 years [interquartile range 0.67, 2.41]. HM3 was more often implanted in men (91.7% vs. 72.9%, P = 0.024); patients were older (median 61 years [54, 66.5] vs. 52.5 years [43, 60], P < 0.001), had a higher BMI (median 26.7 kg/m2 [23.4, 29.0] vs. 24.3 kg/m2 [20.7, 27.4], P = 0.013), had more comorbidities, and were more likely targeted for destination therapy (36.1% vs. 14.3%, P = 0.010). Death occurred in 33.3% of HM3 patients, compared with 22.9% of HW patients, P = 0.247 (probability of survival at 4 years, 54.7% vs. 74.1%, P = 0.296). After adjustment for confounders, we observed a significant six-fold risk increase in device malfunctions for HW [hazard ratio (HR) 6.49, 95% confidence interval (CI) [1.89, 22.32], P = 0.003], but no significant differences in pump thrombosis (P = 0.173) or overall survival (P = 0.801). CONCLUSIONS Comparing midterm outcomes between HM3 and HW for LVAD support from a prospective registry, HW patients had a significantly higher risk of device malfunctions. No significant differences were evident between devices in overall survival and in respect to most outcomes.
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Affiliation(s)
- Maks Mihalj
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Monika Wieser
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michele Martinelli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Theo M M H de By
- EUROMACS, European Association for Cardio-Thoracic Surgery (EACTS), Windsor, UK
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paul Mohacsi
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
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220
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Cleveland JC. LVAD in a nontransplant center: A good destination. J Card Surg 2022; 37:3199. [DOI: 10.1111/jocs.16787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph C. Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery University of Colorado Anschutz Medical Center Aurora Colorado USA
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221
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George TJ, Aldrich A, Smith RL, Ryan WH, DiMaio JM, Kabra N, Afzal A, Rawitscher DA. Development of a non‐transplant left ventricular assist device program. J Card Surg 2022; 37:3188-3198. [DOI: 10.1111/jocs.16790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Timothy J. George
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Allison Aldrich
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Robert L. Smith
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - William H. Ryan
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - J. Michael DiMaio
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Nitin Kabra
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Aasim Afzal
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - David A. Rawitscher
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
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Boudreaux JC, Urban M, Castleberry AW, Um JY, Moulton MJ, Siddique A. In a large-volume multidisciplinary setting individual surgeon volume does not impact LVAD outcomes. J Card Surg 2022; 37:3290-3299. [PMID: 35864745 PMCID: PMC9542019 DOI: 10.1111/jocs.16783] [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: 05/18/2022] [Revised: 06/18/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
Background In complex operations surgeon volume may impact outcomes. We sought to understand if individual surgeon volume affects left ventricular assist device (LVAD) outcomes. Methods We reviewed primary LVAD implants at an experienced ventricular assist devices (VAD)/transplant center between 2013 and 2019. Cases were dichotomized into a high‐volume group (surgeons averaging 11 or more LVAD cases per year), and a low‐volume group (10 or less per year). Propensity score matching was performed. Survival to discharge, 1‐year survival, and incidence of major adverse events were compared between the low‐ and high‐volume groups. Predictors of survival were identified with multivariate analysis. Results There were 315 patients who met inclusion criteria‐45 in the low‐volume group, 270 in the high‐volume group. There was no difference in survival to hospital discharge between the low (91.9%) and high (83.3%) volume matched groups (p = .22). Survival at 1‐year was also similar (85.4% vs. 80.6%, p = .55). There was no difference in the incidence of major adverse events between the groups. Predictors of mortality in the first year included: age (hazards ratio [HR]: 1.061, p < .001), prior sternotomy (HR: 1.991, p = .01), increasing international normalized ratio (HR: 4.748, p < .001), increasing AST (HR: 1.001, p < .001), increasing bilirubin (HR: 1.081, p = .01), and preoperative mechanical ventilation (HR: 2.662, p = .005). Individual surgeon volume was not an independent predictor of discharge or 1‐year survival. Conclusion There was no difference in survival or adverse events between high and low volume surgeons suggesting that, in an experienced multidisciplinary setting, low‐volume VAD surgeons can achieve similar outcomes to their high‐volume colleagues.
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Affiliation(s)
- Joel C Boudreaux
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marian Urban
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - John Y Um
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael J Moulton
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleem Siddique
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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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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Doulamis IP, Inampudi C, Kourek C, Mandarada T, Kuno T, Asleh R, Briasoulis A. Characteristics and Outcomes of Left Ventricular Assist Device Recipients Transplanted Before and After the New Donor Heart Allocation System. Artif Organs 2022; 46:2460-2468. [PMID: 35841284 DOI: 10.1111/aor.14363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/11/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Concerns about the impact of the new donor heart allocation system on post-transplant outcomes have emerged after its implementation. We sought to evaluate the characteristics and outcomes of left ventricular assist device (LVAD) recipients transplanted before and after the implantation of the new policy on October 18, 2018. METHODS Data on bridge to transplantation adult LVAD patients January 2015 and October 2021, with durable LVAD as a (BTT), was queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were 30-day all-cause mortality, 30-day fatal graft failure, 1-year all-cause mortality, treated acute rejection at one year and renal replacement therapy (RRT) for acute renal failure. RESULTS In our study, 7096 patients met the inclusion criteria including 2,435 in the new allocation system. The transplanted patients in the new allocation system era had older donor age, longer ischemic time and higher proportion of newer generation LVADs. Adjusted 30-day all-cause mortality was significantly lower for LVAD recipients in the new allocation system era (2.5% vs 3.6%; sub-hazard ratio [SHR] 0.36, 95% Confidence intervals [CI] 0.27-0.48, p<0.001) without differences in the risk of fatal graft failure and one-year mortality (7.8% vs 9.6%). Significantly lower adjusted 30-day mortality with HVAD and HM3 devices than HM2 in the new allocation system era was found, without differences in one-year mortality. Acute allograft rejection requiring treatment was significantly lower (Odds Ratio 0.78, 95% CI 0.65-0.94, p=0.01) whereas a trend towards higher risk of renal failure requiring RRT was identified. CONCLUSIONS Despite changing donor characteristics and longer ischemic times, post-transplant outcomes in LVAD recipients have not worsened with the implementation of the new allocation system and this finding is related to the use of newer generation continuous flow LVADs.
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Affiliation(s)
- Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Toshi Kuno
- Montefiore Medical Center, Division of Cardiology, Bronx, NY, USA
| | - Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Rochester, MN, USA
| | - Alexandros Briasoulis
- National Kapodistrian University of Athens, Greece.,Division of Cardiovascular Medicine, Section of Heart failure and Transplantation, University of Iowa, IA, USA
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225
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Magkoutas K, Arm P, Meboldt M, Schmid Daners M. Physiologic Data-Driven Iterative Learning Control for Left Ventricular Assist Devices. Front Cardiovasc Med 2022; 9:922387. [PMID: 35911509 PMCID: PMC9326058 DOI: 10.3389/fcvm.2022.922387] [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: 04/17/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
Continuous flow ventricular assist devices (cfVADs) constitute a viable and increasingly used therapy for end-stage heart failure patients. However, they are still operating at a fixed-speed mode that precludes physiological cfVAD response and it is often related to adverse events of cfVAD therapy. To ameliorate this, various physiological controllers have been proposed, however, the majority of these controllers do not account for the lack of pulsatility in the cfVAD operation, which is supposed to be beneficial for the physiological function of the cardiovascular system. In this study, we present a physiological data-driven iterative learning controller (PDD-ILC) that accurately tracks predefined pump flow trajectories, aiming to achieve physiological, pulsatile, and treatment-driven response of cfVADs. The controller has been extensively tested in an in-silico environment under various physiological conditions, and compared with a physiologic pump flow proportional-integral-derivative controller (PF-PIDC) developed in this study as well as the constant speed (CS) control that is the current state of the art in clinical practice. Additionally, two treatment objectives were investigated to achieve pulsatility maximization and left ventricular stroke work (LVSW) minimization by implementing copulsation and counterpulsation pump modes, respectively. Under all experimental conditions, the PDD-ILC as well as the PF-PIDC demonstrated highly accurate tracking of the reference pump flow trajectories, outperforming existing model-based iterative learning control approaches. Additionally, the developed controllers achieved the predefined treatment objectives and resulted in improved hemodynamics and preload sensitivities compared to the CS support.
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Affiliation(s)
| | | | | | - Marianne Schmid Daners
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
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226
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Färber G, Kirov H, Schwan I, Gräger S, Diab M, Tkebuchava S, Doenst T. Bend relief fenestration might prevent outflow graft obstruction in patients with left ventricular assist device. Interact Cardiovasc Thorac Surg 2022; 35:6596601. [PMID: 35642889 PMCID: PMC9373956 DOI: 10.1093/icvts/ivac149] [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: 02/21/2022] [Revised: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 01/09/2023] Open
Affiliation(s)
- Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Imke Schwan
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Stephanie Gräger
- Department of Radiology, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Sophie Tkebuchava
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University , Jena, Germany
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227
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Cascino TM, Somanchi S, Colvin M, Chung GS, Brescia AA, Pienta M, Thompson MP, Stewart JW, Sukul D, Watkins DC, Pagani FD, Likosky DS, Aaronson KD, McCullough JS. Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2223080. [PMID: 35895063 PMCID: PMC9331085 DOI: 10.1001/jamanetworkopen.2022.23080] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
Importance While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. Objectives To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role. Design, Setting, and Participants This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been admitted for heart failure from 2008 to 2014. Data were collected from July 2007 to December 2015 and analyzed from August 23, 2020, to May 15, 2022. Exposures Beneficiary race and sex. Main Outcomes and Measures The propensity for LVAD implantation was based on clinical risk factors from the 6 months preceding HF admission using XGBoost and the synthetic minority oversampling technique. Beneficiaries with a 5% or greater probability of receiving an LVAD were included. Logistic regression models were estimated to measure associations of race and sex with LVAD receipt adjusting for clinical characteristics and social determinants of health (eg, distance from LVAD center, Medicare low-income subsidy, neighborhood deprivation). Next, 1-year mortality after LVAD was examined. Results The analytic sample included 12 310 beneficiaries, of whom 22.9% (n = 2819) were Black and 23.7% (n = 2920) were women. In multivariable models, Black beneficiaries were 3.0% (0.2% to 5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (5.6% to 10.2%) less likely to receive LVAD than men. Individual poverty and worse neighborhood deprivation were associated with reduced use, 2.9% (0.4% to 5.3%) and 6.7% (2.9% to 10.5%), respectively, but these measures did little to explain observed disparities. The racial disparity was concentrated among patients with a low propensity score (propensity score <0.52). One-year survival by race and sex were similar on average, but Black patients with a low propensity score experienced improved survival (7.2% [95% CI, 0.9% to 13.5%]). Conclusions and Relevance In this cohort study of Medicare beneficiaries hospitalized for HF, disparities in LVAD use by race and sex existed and were not explained by clinical characteristics or social determinants of health. The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates. However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients. Inequity in LVAD access may have resulted from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Sriram Somanchi
- University of Notre Dame, Mendoza College of Business, Department of IT Analytics and Operations, Notre Dame, Indiana
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Grace S. Chung
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
| | | | - Michael Pienta
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | | | - James W. Stewart
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | - Devraj Sukul
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | | | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Jeffrey S. McCullough
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
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228
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Adji A, Shehab S, Jain P, Robson D, Jansz P, Hayward CS. Arterial Compliance and Continuous-Flow Left Ventricular Assist Device Pump Function. ASAIO J 2022; 68:925-931. [PMID: 35544445 DOI: 10.1097/mat.0000000000001768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Durable continuous-flow left ventricular assist devices (cfLVADs) demonstrate superior survival, cardiac functional status, and overall quality of life compared to medical therapy alone in advanced heart failure. Previous studies have not considered the impact arterial compliance may have on pump performance or developed arterial pressure. This study assessed the impact of alterations in arterial compliance, preload, and afterload on continuous-flow pump function and measured hemodynamics using an in-vitro pulsatile mock circulatory loop. Decreased arterial compliance was associated with a significant increase in arterial pressure pulsatility which was not evident in the flow pulsatility, as displayed in pump flow waveforms. There were marked changes in the pump flow waveforms due to the significant alteration in the aortoventricular gradient during diastole according to the changes in compliance. This study demonstrates that changes in systemic blood pressure, afterload, and left ventricular contractility each significantly affects the flow waveform. The association of hypertension with lower aortic compliance results in markedly decreased diastolic flow rates which may be important in contributing to a greater risk of adverse events under cfLVAD support.
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Affiliation(s)
- Audrey Adji
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Sajad Shehab
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Desiree Robson
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Paul Jansz
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Christopher S Hayward
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
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229
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Cogswell R, Rogers JG. Residual Heart Failure on Mechanically Assisted Circulation: A Call to Action. JACC. HEART FAILURE 2022; 10:482-484. [PMID: 35772858 DOI: 10.1016/j.jchf.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
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230
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LVAD as a Bridge to Remission from Advanced Heart Failure: Current Data and Opportunities for Improvement. J Clin Med 2022; 11:jcm11123542. [PMID: 35743611 PMCID: PMC9225013 DOI: 10.3390/jcm11123542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Left ventricular assist devices (LVADs) are an established treatment modality for advanced heart failure (HF). It has been shown that through volume and pressure unloading they can lead to significant functional and structural cardiac improvement, allowing LVAD support withdrawal in a subset of patients. In the first part of this review, we discuss the historical background, current evidence on the incidence and assessment of LVAD-mediated cardiac recovery, and out-comes including quality of life after LVAD support withdrawal. In the second part, we discuss current and future opportunities to promote LVAD-mediated reverse remodeling and improve our pathophysiological understanding of HF and recovery for the benefit of the greater HF population.
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231
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Lechiancole A, Loforte A, Scandroglio M, Comisso M, Iacovoni A, Maiani M, Gliozzi G, De Bonis M, Musumeci F, Terzi A, Pacini D, Livi U. Does the distance between residency and implanting center affect the outcome of patients supported by left ventricular assist devices? A multicenter Italian study on radial mechanically assisted circulatory support (MIRAMACS) analysis. Artif Organs 2022; 46:1932-1936. [PMID: 35718933 DOI: 10.1111/aor.14343] [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: 01/07/2022] [Revised: 02/16/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with LVAD require continuous monitoring and care, and since Implanting Centers (ICs) are more experienced in managing LVAD patients than other healthcare facilities, the distance between patient residency and IC could negatively affect the outcomes. METHODS Data of patients discharged after receiving an LVAD implantation between 2010 and 2021 collected from the MIRAMACS database were retrospectively analyzed. The population was divided into two groups: A (n = 175) and B (n = 141), according to the distance between patient residency and IC ≤ or >90 miles. The primary endpoint was freedom from Adverse Events (AEs), a composite outcome composed of death, cerebrovascular accident, hospital admission because of GI bleeding, infection, pump thrombosis, and right ventricular failure. Secondary endpoints were incidences of mortality and complications. All patients were followed-up regularly, according to participating center protocols. RESULTS Baseline clinical characteristics and indications for LVAD did not differ between the two groups. The mean duration of support was 25.5 ± 21 months for Group A and 25.7 ± 20 months for Group B (p = 0.79). At 3 years, freedom from AEs was similar between Group A and Group B (p = 0.36), and there were no differences in rates of mortality and LVAD-related complications. CONCLUSIONS Distance from the IC does not represent a barrier to successful outcomes as long as regular and continuous follow-up is provided.
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Affiliation(s)
- Andrea Lechiancole
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, S. Maria della Misericordia University Hospital of Udine, Udine, Italy
| | - Antonio Loforte
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna, Bologna, Italy
| | - Mara Scandroglio
- Division of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Marina Comisso
- Cardiothoracic Department, San Camillo Forlanini Hospital, Rome, Italy
| | - Attilio Iacovoni
- Cardiothoracic Department, Papa Giovanni XXII Hospital of Bergamo, Bergamo, Italy
| | - Massimo Maiani
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, S. Maria della Misericordia University Hospital of Udine, Udine, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna, Bologna, Italy
| | - Michele De Bonis
- Division of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Amedeo Terzi
- Cardiothoracic Department, Papa Giovanni XXII Hospital of Bergamo, Bergamo, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna, Bologna, Italy
| | - Ugolino Livi
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, S. Maria della Misericordia University Hospital of Udine, Udine, Italy
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232
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Zhang X, Song YC, Yang DG, Liu HW, Liu SH, Li XB, Li JJ. The Effect of Vocal Intonation Therapy on Vocal Dysfunction in Patients With Cervical Spinal Cord Injury: A Randomized Control Trial. Front Neurosci 2022; 16:860127. [PMID: 35784833 PMCID: PMC9241375 DOI: 10.3389/fnins.2022.860127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
In this study, the vocal intonation therapy (VIT) was compared with the standard respiratory therapy for people suffering from respiratory dysfunction as a result of cervical spinal cord injury (CSCI) to observe its effect on vocal quality. Thirty patients with vocal dysfunction after CSCI with the injury time of more than 3 months were screened for inclusion in the trial, and 18 patients completed the 12-weeks, each participant had 60 sessions in total in the clinical trial. All patients were allocated to the intervention group or the control group. The intervention group received VIT training and the control group received respiratory phonation therapy. Both groups were trained by professional therapists, and the training time was 30 min/day, 5 days/week, for 60 sessions for each group in a total of 12 weeks. In the Baseline (T0), mid-intervention period (after 6 weeks, T1), and after intervention (after 12 weeks, T2), the vocal quality of the two groups of patients was tested with a computer-aided real-time audio analyzer 2.1.6 (Adobe Systems, United States) for Sing-SPL (p < 0.0001), Speech-SPL (p < 0.0001), SNL (p < 0.0001), and F0 (p < 0.0001) of the intervention group were significantly improved compared with the control group. In comparing the spectrometry analysis of vocal quality for the 2 groups of participants, there was a significant difference in the results of Sing-SPL and Speech-SPL acoustic analysis in the intervention group of patients at T2 (after 12 weeks) compared to the control group. Vocal intonation therapy—music therapy can improve the speech sound quality of cervical CSCI patients and provide CSCI patients with a practical, highly operable treatment that has both functional training effects and can bring a pleasant experience that can be promoted in the medical field. This study was approved by the Ethics Committee of China Rehabilitation Research Center (CRRC) (approval No. 2019-83-1) on May 20th, 2019. It was registered with the National Health Security Information Platform, medical research registration, and filing information system (Registration No. MR-11-21-011802) on January 28th, 2021.
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Affiliation(s)
- Xiaoying Zhang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - Yi-Chuan Song
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - De-Gang Yang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Hong-Wei Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Song-Huai Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - Xiao-Bing Li
- Laboratory of Music Artificial Intelligence, Central Conservatory of Music, Beijing, China
- *Correspondence: Xiao-Bing Li,
| | - Jian-Jun Li
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Jian-Jun Li,
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233
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Li T, Mariani S, Bounader K, Boethig D, Schöde A, Homann K, Hanke JS, Napp LC, Merzah AS, Dogan G, Haverich A, Schmitto JD. Is There a Sex Gap in Outcomes of Comparable Patients Supported with Left Ventricular Assist Devices? Artif Organs 2022; 46:2293-2303. [PMID: 35686944 DOI: 10.1111/aor.14333] [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] [Received: 11/20/2021] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Historically, females were described as suffering from worse outcomes after left ventricular assist device (LVAD) implantation. However, females' preoperative conditions are unique, making direct comparisons with males challenging. This study aimed to select through propensity score (PS) matching two preoperatively comparable populations of females and males and test if any real sex-related difference exists regarding survival and adverse events after LVAD implantation. METHODS This retrospective single-center observational study investigated patients who received LVAD implantation between 2010 and 2018. PS matching was applied to balance preoperative heterogeneity between males and females. Primary endpoint was survival at follow-up. Secondary endpoints included perioperative outcomes and LVAD-related adverse events. RESULTS 92 fully comparable females(n=46) and males(n=46) were selected after PS matching (median age:57 years, min-max:18-75). 26.1% of patients required preoperative mechanical circulatory support. Females needed more intraoperative fresh frozen plasma (p<0.001) and platelets transfusions (p=0.008) compared to males, but postoperative outcomes were comparable between groups. In-hospital, 1-year and 2-year survival were 78.3%, 69.6% and 65.2%, respectively, with no differences between groups. Survival probability remained comparable up to 8 years of follow-up(p=0.35). Overall, females showed a higher rate of strokes(p=0.039) compared to males in the follow-up time. CONCLUSIONS After reducing preoperative heterogeneity between females and males, survival after LVAD implantation does not differ based on sex. However, differences might exist in terms of higher transfusions and strokes in females. Reducing preoperative sex disparities and developing intraoperative and anticoagulation strategies which acknowledge sex-related variations might help abolishing differences in LVAD outcomes.
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Affiliation(s)
- Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastrichts, Netherlands
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexandra Schöde
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Katharina Homann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ali Saad Merzah
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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234
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Nayak A, Mehra MR. Global Challenges in Left Ventricular Assist Device Therapy: A Tale Across Two Continents. Eur J Heart Fail 2022; 24:1316-1318. [DOI: 10.1002/ejhf.2570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/04/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Mandeep R. Mehra
- Brigham and Women's Hospital and Harvard Medical School Boston MA
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235
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Hansen B, Singer Englar T, Cole R, Catarino P, Chang D, Czer L, Emerson D, Geft D, Kobashigawa J, Megna D, Ramzy D, Moriguchi J, Esmailian F, Kittleson M. Extracorporeal membrane oxygenation as a bridge to durable mechanical circulatory support or heart transplantation. Int J Artif Organs 2022; 45:604-614. [PMID: 35658592 DOI: 10.1177/03913988221103284] [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: 11/16/2022]
Abstract
BACKGROUND Patients with cardiogenic shock may require extracorporeal membrane oxygenation (ECMO) prior to durable mechanical circulatory support (dMCS) or heart transplantation (HTx). METHODS We investigated the clinical characteristics and outcomes of adult patients with ECMO support as bridge to dMCS or HTx between 1/1/13 and 12/31/20. RESULTS Of 57 patients who underwent bridging ECMO, 41 (72%) received dMCS (approximately half with biventricular support) and 16 (28%) underwent HTx, 13 (81%) after the 2018 UNOS allocation system change. ECMO → HTx patients had shorter ventilatory time (3.5 vs 7.5 days; p = 0.018), ICU stay (6 vs 18 days; p = 0.001), and less need for inpatient rehabilitation (18.8% vs 57.5%; p = 0.016). The 1-year survival post HTx was 81.3% in the ECMO → HTx group and 86.4% in the ECMO → dMCS group (p = 0.11). For those patients in the ECMO → dMCS group who did not undergo HTx, 1-year survival was significantly lower, 31.6% (p = 0.001). CONCLUSION Patients on ECMO who undergo HTx, with or without dMCS bridge, have acceptable post-HTx survival. These findings suggest that HTx from ECMO is a viable option for carefully selected patients deemed acceptable to proceed with definitive advanced therapies, especially in the era of the new UNOS allocation system.
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Affiliation(s)
| | | | - Robert Cole
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | - David Chang
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Dael Geft
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Danny Ramzy
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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Chikwe J. Editor’s Choice: Strengths, Challenges, and Opportunities. Ann Thorac Surg 2022; 113:1761-1766. [DOI: 10.1016/j.athoracsur.2022.04.028] [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: 04/25/2022] [Indexed: 11/01/2022]
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Pourtau L, Beneyto M, Porterie J, Roncalli J, Massot M, Biendel C, Fournier P, Itier R, Galinier M, Lairez O, Delmas C. Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients. ESC Heart Fail 2022; 9:1931-1941. [PMID: 35338605 PMCID: PMC9065835 DOI: 10.1002/ehf2.13899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Left ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge-to-transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients. METHODS AND RESULTS We conducted a retrospective, single-centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty-eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5-9.3, P < 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2-51.1, P < 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9-9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2-2.7, P < 0.01). Finally, only early bleedings (<9 months post-implantation) had an impact on mortality (HR 4.2, 95% CI 1.6-11.1, P < 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed. CONCLUSIONS Haemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.
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Affiliation(s)
- Laetitia Pourtau
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Maxime Beneyto
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Jean Porterie
- Department of Cardiovascular SurgeryRangueil University HospitalToulouseFrance
| | - Jerome Roncalli
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
| | - Montse Massot
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Caroline Biendel
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Pauline Fournier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Romain Itier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Michel Galinier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
| | - Olivier Lairez
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
- Department of Nuclear MedicineRangueil University HospitalToulouseFrance
| | - Clement Delmas
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
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Tam CW, Shen L, Zeidman AD, Srivastava A, Ivascu NS. Mechanical Circulatory Support: Primer for Consultant Specialists. Clin J Am Soc Nephrol 2022; 17:890-901. [PMID: 35595531 PMCID: PMC9269658 DOI: 10.2215/cjn.13341021] [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: 01/08/2023]
Abstract
Mechanical life support therapies exist in many forms to temporarily replace the function of vital organs. Generally speaking, these tools are supportive therapy to allow for organ recovery but, at times, require transition to long-term mechanical support. This review will examine nonrenal extracorporeal life support for cardiac and pulmonary support as well as other mechanical circulatory support options. This is intended as a general primer and overview to assist nephrologist consultants participating in the care of these critically ill patients who often experience acute renal injury as a result of cardiopulmonary shock and from their exposure to mechanical circulatory support.
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Affiliation(s)
- Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Liang Shen
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | | | - Ankur Srivastava
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Natalia S Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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Alam A, Jermyn R, Mastoris I, Steinkamp L, Bhimaraj A, Sauer AJ. Ambulatory factors influencing pulmonary artery pressure waveforms and implications for clinical practice. Heart Fail Rev 2022; 27:2083-2093. [PMID: 35587304 DOI: 10.1007/s10741-022-10249-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/04/2022]
Abstract
CardioMEMS, a remote pulmonary artery pressure monitoring system, provides waveform patterns for the ambulatory heart failure patient. These waveforms provide significant insights into patient volume and clinical management. We aim to provide a foundation for understanding the determinants of waveform characteristics and provide practical examples illustrating how to interpret and integrate common scenario waveforms into clinical decision-making. A total of three groups of relevant scenarios were included namely (a) location and activity at time of waveform transmission, (b) impact of contemporary interventions, and (c) arrhythmias. We illustrate that waveform analysis can be individualized to each patient's care strategy in the appropriate clinical context to help guide clinical decision-making.
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Affiliation(s)
- Amit Alam
- Department of Advanced Heart Failure, Baylor University Medical Center, Dallas, TX, USA. .,Texas A&M University College of Medicine, Dallas, TX, USA.
| | - Rita Jermyn
- St. Francis Hospital, Roslyn, Long Island, NY, USA
| | - Ioannis Mastoris
- Department of Cardiovascular Medicine, School of Medicine, University of Kansas, Kansas City, KS, USA
| | - Leslie Steinkamp
- Department of Cardiovascular Medicine, School of Medicine, University of Kansas, Kansas City, KS, USA
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, School of Medicine, University of Kansas, Kansas City, KS, USA
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Giménez-Milà M, Sandoval E, Farrero M. Let's Reduce Bleeding Complications in Patients With Left Ventricular Assist Device. J Cardiothorac Vasc Anesth 2022; 36:3435-3438. [PMID: 35691855 DOI: 10.1053/j.jvca.2022.04.041] [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: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Marc Giménez-Milà
- Department of Anesthesia and Intensive Care, Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain.
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Marta Farrero
- Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain; Department of Cardiology. Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain
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241
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Concept, Design, and Early Prototyping of a Low-Cost, Minimally Invasive, Fully Implantable Left Ventricular Assist Device. Bioengineering (Basel) 2022; 9:bioengineering9050201. [PMID: 35621479 PMCID: PMC9137825 DOI: 10.3390/bioengineering9050201] [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: 03/29/2022] [Revised: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 11/23/2022] Open
Abstract
Despite evidence associating the use of mechanical circulatory support (MCS) devices with increased survival and quality of life in patients with advanced heart failure (HF), significant complications and high costs limit their clinical use. We aimed to design an innovative MCS device to address three important needs: low cost, minimally invasive implantation techniques, and low risk of infection. We used mathematical modeling to calculate the pump characteristics to deliver variable flows at different pump diameters, turbomachinery design software CFturbo (2020 R2.4 CFturbo GmbH, Dresden, Germany) to create the conceptual design of the pump, computational fluid dynamics analysis with Solidworks Flow Simulation to in silico test pump performance, Solidworks (Dassault Systèmes SolidWorks Corporation, Waltham, MA, USA) to further refine the design, 3D printing with polycarbonate filament for the initial prototype, and a stereolithography printer (Form 2, Formlabs, Somerville, MA, USA) for the second variant materialization. We present the concept, design, and early prototyping of a low-cost, minimally invasive, fully implantable in a subcutaneous pocket MCS device for long-term use and partial support in patients with advanced HF which unloads the left heart into the arterial system containing a rim-driven, hubless axial-flow pump and the wireless transmission of energy. We describe a low-cost, fully implantable, low-invasive, wireless power transmission left ventricular assist device that has the potential to address patients with advanced HF with higher impact, especially in developing countries. In vitro testing will provide input for further optimization of the device before proceeding to a completely functional prototype that can be implanted in animals.
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242
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Jakus N, Brugts JJ, Claggett B, Timmermans P, Pouleur AC, Rubiś P, Van Craenenbroeck EM, Gaizauskas E, Barge-Caballero E, Paolillo S, Grundmann S, D'Amario D, Braun OÖ, Gkouziouta A, Meyns B, Droogne W, Wierzbicki K, Holcman K, Planinc I, Skoric B, Flammer AJ, Gasparovic H, Biocina B, Lund LH, Milicic D, Ruschitzka F, Cikes M. Improved survival of left ventricular assist device carriers in Europe according to implantation eras - results from the PCHF-VAD registry. Eur J Heart Fail 2022; 24:1305-1315. [PMID: 35508920 DOI: 10.1002/ejhf.2526] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIM Temporal changes in patient selection and major technological developments in have occurred in the field of LVADs, yet analyses depicting this trend are lacking for Europe. We describe the advances of European LVAD programmes from the PCHF-VAD registry across device implantation eras. METHODS Of 583 patients from 13 European centres in the registry, 556 patients (mean age 53 ± 12 years, 82% male) were eligible for this analysis. Patients were divided to eras (E) by date of LVAD implantation: E1 from December 2006 to and including December 2012 (6 years), E2 from January 2013 to January 2020 (7 years). RESULTS Patients implanted more recently were older with more comorbidities, but less acutely ill. Receiving an LVAD in E2 was associated with improved 1-year survival in adjusted analysis (HR 0.58 [0.35-0.98] p = 0.043). LVAD implantation in E2 was associated with a significantly lower chance of heart transplantation (adjusted HR 0.40 [0.23-0.67], p = 0.001), and lower risk of LVAD-related infections (adjusted HR 0.64, [0.43-0.95], p = 0.027), both in unadjusted and adjusted analyses. The adjusted risk of haemocompatibility-related events decreased (HR 0.60 [0.39-0.91], p = 0.016), while the heart failure-related events increased in E2 (HR 1.67 [1.02-2.75], p = 0.043). CONCLUSION In an analysis depicting the evolving landscape of cf-LVAD carriers in Europe over 13 years, a trend towards better survival is seen in the recent years, despite older recipients with more comorbidities, potentially attributable to increasing expertise of LVAD centres, improved patient selection and pump technology. However, a smaller chance of undergoing heart transplantation was noted in the second era, underscoring the relevance of improved outcomes on LVAD support.
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Affiliation(s)
- Nina Jakus
- Department of Cardiovascular diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Anne-Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Brussels, Belgium.,Pôle de Recherche Cardiovasculaire (CARD) Institut de Recherche Expérimentale et Clinique (IREC) Université Catholique de Louvain, Louvain, Belgium
| | - Pawel Rubiś
- Department of Cardiac and Vascular Diseases Krakow, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | | | - Edvinas Gaizauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Sebastian Grundmann
- Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | | | - Oscar Ö Braun
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | | | - Bart Meyns
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Walter Droogne
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Katarzyna Holcman
- Department of Cardiac and Vascular Diseases Krakow, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Ivo Planinc
- Department of Cardiovascular diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Bosko Skoric
- Department of Cardiovascular diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Andreas J Flammer
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Davor Milicic
- Department of Cardiovascular diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Maja Cikes
- Department of Cardiovascular diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
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243
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Troutman GS, Genuardi MV. Left Ventricular Assist Devices: A Primer for the Non-Mechanical Circulatory Support Provider. J Clin Med 2022; 11:jcm11092575. [PMID: 35566701 PMCID: PMC9100630 DOI: 10.3390/jcm11092575] [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: 04/06/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 02/01/2023] Open
Abstract
Survival after implant of a left ventricular assist device (LVAD) continues to improve for patients with end-stage heart failure. Meanwhile, more patients are implanted with a destination therapy, rather than bridge-to-transplant, indication, meaning the population of patients living long-term on LVADs will continue to grow. Non-LVAD healthcare providers will encounter such patients in their scope of practice, and familiarity and comfort with the physiology and operation of these devices and common problems is essential. This review article describes the history, development, and operation of the modern LVAD. Common LVAD-related complications such as bleeding, infection, stroke, and right heart failure are reviewed and an approach to the patient with an LVAD is suggested. Nominal operating parameters and device response to various physiologic conditions, including hypo- and hypervolemia, hypertension, and device failure, are reviewed.
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Affiliation(s)
- Gregory S. Troutman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Michael V. Genuardi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: ; Tel.: +1-215-615-0800
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 623] [Impact Index Per Article: 311.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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245
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Bourque K, Fraser CE, Lorts A, Molina EJ, Kormos RL, Naka Y, Sheikh FH, Uriel NY, Morales DLS. Special Considerations for Durable Left Ventricular Assist Device Use in Small Patients. ASAIO J 2022; 68:619-622. [PMID: 35275881 DOI: 10.1097/mat.0000000000001716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | | | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ezequiel J Molina
- MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | | | - Yoshifumi Naka
- Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Farooq H Sheikh
- MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | - Nir Y Uriel
- Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
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246
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Ferreira SMA, Pêgo-Fernandes PM. Long-term mechanical assisted circulation devices. SAO PAULO MED J 2022; 140:329-330. [PMID: 35584526 PMCID: PMC9671251 DOI: 10.1590/1516-3180.2022.140303122021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Silvia Moreira Ayub Ferreira
- MD, PhD. Attending Physician, Division of Cardiology, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paulo Manuel Pêgo-Fernandes
- MD, PhD. Full Professor, Thoracic Surgery Program, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR. Director, Scientific Department, Associação Paulista de Medicina, São Paulo, SP, BR
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247
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Time Spent Engaging in Health Care Among Patients With Left Ventricular Assist Devices. JACC. HEART FAILURE 2022; 10:321-332. [PMID: 35483794 PMCID: PMC9908068 DOI: 10.1016/j.jchf.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This study aims to examine a novel patient-centered metric of time spent engaging in left ventricular assist device (LVAD)-related clinical care outside the home. BACKGROUND Although LVAD implantation can improve survival and functional capacity in patients with advanced heart failure, this may occur at the expense of significant time spent engaging in LVAD-related health care activities. METHODS The authors retrospectively assessed consecutive patients at a single center who received a continuous-flow LVAD between May 9, 2008, and December 31, 2019, and queried health care encounters after implantation, including all inpatient encounters and LVAD-related ambulatory encounters. Patient-level time metrics were determined, including the total number of days with any health care encounter, and the total estimated time spent receiving care. The primary outcome was the proportion (%) of days alive with an LVAD spent engaged in at least 1 health care encounter. The secondary outcome was the proportion (%) of total time alive with an LVAD spent receiving care. RESULTS Among 373 patients, the median number of days alive with LVAD was 390 (IQR: 158-840 days). Patients had a median number of 88 (IQR: 45-161) days with ≥1 health care encounter, accounting for 23.2% (IQR: 16.3%-32.4%) of their days alive with an LVAD. A median 6.0% (IQR: 2.1%-14.1%) and 15.0% (IQR: 10.7%-20.0%) of total days alive were spent in inpatient and ambulatory encounters, respectively. Patients spent a median of 592 (IQR: 197-1,257) hours receiving care, accounting for 5.6% (IQR: 2.2%-12.7%) of their total time alive with an LVAD. CONCLUSIONS LVAD patients spent more than 1 of every 5 days engaging in health care. Our findings may inform strategies to improve efficiency of postdischarge care delivery and expectations for post-treatment care.
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248
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Chikwe J. Editor's Choice: Strength in Numbers. Ann Thorac Surg 2022; 113:1401-1404. [PMID: 35459448 DOI: 10.1016/j.athoracsur.2022.03.007] [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: 03/15/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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249
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Pienta MJ, Wu X, Cascino TM, Brescia AA, Abou El Ela A, Zhang M, McCullough JS, Shore S, Aaronson KD, Thompson MP, Pagani FD, Likosky DS. Advancing Quality Metrics for Durable Left Ventricular Assist Device Implant: Analysis of the Society of Thoracic Surgeons Intermacs Database. Ann Thorac Surg 2022; 113:1544-1551. [PMID: 35176258 PMCID: PMC9035070 DOI: 10.1016/j.athoracsur.2022.01.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing left ventricular assist device (LVAD) implantation are at risk for death and postoperative adverse outcomes. Interhospital variability and concordance of quality metrics were assessed using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). METHODS A total of 22 173 patients underwent primary, durable LVAD implantation across 160 hospitals from 2012 to 2020, excluding hospitals performing <10 implant procedures. Observed and risk-adjusted operative mortality rates were calculated for each hospital. Outcomes included operative and 90-day mortality, a composite of adverse events (operative mortality, bleeding, stroke, device malfunction, renal dysfunction, respiratory failure), and secondarily failure to rescue. Rates are presented as median (interquartile range [IQR]). Hospital performance was evaluated using observed-to-expected (O/E) ratios for mortality and the composite outcome. RESULTS Interhospital variability existed in observed (median, 7.2% [IQR, 5.1%-9.6%]) mortality. The rates of adverse events varied across hospitals: major bleeding, 15.6% (IQR, 11.4%-22.4%); stroke, 3.1% (IQR, 1.6%-4.7%); device malfunction, 2.4% (IQR, 0.8%-3.7%); respiratory failure, 10.5% (IQR, 4.6%-15.7%); and renal dysfunction, 6.4% (IQR, 3.2%-9.6%). The O/E ratio for operative mortality varied from 0.0 to 6.1, whereas the O/E ratio for the composite outcome varied from 0.28 to 1.99. Hospital operative mortality O/E ratios were more closely correlated with the 90-day mortality O/E ratio (r = 0.74) than with the composite O/E ratio (r = 0.12). CONCLUSIONS This study reported substantial interhospital variability in performance for hospitals implanting durable LVADs. These findings support the need to (1) report hospital-level performance (mortality, composite) and (2) undertake benchmarking activities to reduce unwarranted variability in outcomes.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | | | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey S McCullough
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Supriya Shore
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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