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Loardi CM, Zanobini M, Ricciardi G, Vermes E. Current and future options for adult biventricular assistance: a review of literature. Front Cardiovasc Med 2023; 10:1234516. [PMID: 38028456 PMCID: PMC10657899 DOI: 10.3389/fcvm.2023.1234516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
In cardiogenic shock various short-term mechanical assistances may be employed, including an Extra Corporeal Membrane Oxygenator and other non-dischargeable devices. Once hemodynamic stabilization is achieved and the patient evolves towards a persisting biventricular dysfunction or an underlying long-standing end-stage disease is present, aside from Orthotopic Heart Transplantation, a limited number of long-term therapeutic options may be offered. So far, only the Syncardia Total Artificial Heart and the Berlin Heart EXCOR (which is not approved for adult use in the United States unlike in Europe) are available for extensive implantation. In addition to this, the strategy providing two continuous-flow Left Ventricular Assist Devices is still off-label despite its widespread use. Nevertheless, every solution ensures at best a 70% survival rate (reflecting both the severity of the condition and the limits of mechanical support) with patients suffering from heavy complications and a poor quality of life. The aim of the present paper is to summarize the features, implantation techniques, and results of current devices used for adult Biventricular Mechanical Circulatory Support, as well as a glance to future options.
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Affiliation(s)
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
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Kremer J, El-Dor A, Rivinius R, Schlegel P, Sommer W, Warnecke G, Karck M, Ruhparwar A, Meyer AL. Wound Infections in Adult Patients after Berlin Heart ® EXCOR Biventricular Assist Device Implantation. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101550. [PMID: 36294985 PMCID: PMC9604684 DOI: 10.3390/life12101550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/11/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022]
Abstract
Simple Summary Our study shows that the Berlin Heart® EXCOR as a biventricular assist device in adult patients is an effective strategy in heart failure medicine. Our results may increase the use of the EXCOR with acceptable clinical outcomes despite long support times. With ongoing research to implement the EXCOR as a permanent right ventricular assist device, our results highlight possible arising complications. Abstract The Berlin Heart® EXCOR is a paracorporeal, pulsatile ventricular assist device used in patients of all age groups. However, adolescent and adult patients on EXCOR support are scarcely explored. Herein, we present a detailed description of infectious complications in this patient cohort. From 2006 to 2020, 58 patients received a biventricular assist device (BiVAD) at our institution and were included in this study. Postoperative infections were assessed after BiVAD implantation and subsequent heart transplantation (HTx). A Berlin Heart® EXCOR BiVAD was implanted as a bridge to transplantation in 58 patients (12–64 years). Most patients were INTERMACS I, and their median age was 49 years. Wound infections (WI) specific to the ventricular assist device (VAD) occurred in 31 (53.4%) patients with a mean time of 113 ± 155 days after BiVAD implantation. HTx was performed in 30 (51.7%) patients and thereof 10 (33.3%) patients developed at least one WI post-HTx. The mean time of WI after HTx was 17 ± 14 days. In four cases, WIs were caused by the same pathogen as before HTx. According to our institutional BiVAD wound classification, the mean wound score was 3. The VAD-specific wound infections were manageable and did not increase mortality nor precluded HTx in Berlin Heart® EXCOR patients. No specific risk factors for VAD-specific wound infections could be identified.
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Affiliation(s)
- Jamila Kremer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-566272
| | - Abbas El-Dor
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Schlegel
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Arjang Ruhparwar
- Clinic of Thoracic and Cardiovascular Surgery, Essen University Hospital, 45147 Essen, Germany
| | - Anna L. Meyer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
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Michel S, Buchholz S, Buech J, Veit T, Fabry T, Abicht J, Thierfelder N, Mueller C, Rosenthal LL, Pabst von Ohain J, Haas N, Hörer J, Hagl C. Bridging patients in cardiogenic shock with a paracorporeal pulsatile biventricular assist device to heart transplantation-a single-centre experience. Eur J Cardiothorac Surg 2022; 61:942-949. [PMID: 35020902 DOI: 10.1093/ejcts/ezab547] [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: 05/24/2021] [Revised: 09/06/2021] [Accepted: 11/14/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We evaluated the outcome of patients in cardiogenic shock receiving a paracorporeal pulsatile biventricular assist device as a bridge to transplantation. METHODS We performed a retrospective single-centre analysis of all patients who received a Berlin Heart Excor® at our institution between 2004 and 2019. RESULTS A total of 97 patients (90 adults, 7 paediatric) were analysed. Eighty-four patients were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 (80 adults, 4 paediatric). Diagnoses were dilated cardiomyopathy (n = 41), ischaemic cardiomyopathy (n = 17) or myocardial infarction (n = 4), myocarditis (n = 15), restrictive cardiomyopathy (n = 2), graft failure after heart transplant (n = 7), postcardiotomy heart failure (n = 5), postpartum cardiomyopathy (n = 3), congenital heart disease (n = 1), valvular cardiomyopathy (n = 1) and toxic cardiomyopathy (n = 1). All patients were in biventricular heart failure and had secondary organ dysfunction. The mean duration of support was 63 days (0-487 days). There was a significant decrease in creatinine values after assist device implantation (from 1.83 ± 0.79 to 1.12 ± 0.67 mg/dl, P = 0.001) as well as a decrease in bilirubin values (from 3.94 ± 4.58 to 2.65 ± 3.61 mg/dl, P = 0.084). Cerebral stroke occurred in 16 patients, bleeding in 15 and infection in 13 patients. Forty-eight patients died on support, while 49 patients could be successfully bridged to transplantation. Thirty-day survival and 1-year survival were 70.1% and 41.2%, respectively. CONCLUSIONS A pulsatile biventricular assist device is a reasonable therapeutic option in cardiogenic shock, when immediate high cardiac output is necessary to rescue the already impaired kidney and liver function of the patient.
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Affiliation(s)
- Sebastian Michel
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany.,Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | | | - Joscha Buech
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Tobias Veit
- Department of Pulmonology, Ludwig Maximilian University Munich, Munich, Germany
| | - Thomas Fabry
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Jan Abicht
- Department of Anesthesiology, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaus Thierfelder
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph Mueller
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Laura Lily Rosenthal
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Jelena Pabst von Ohain
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaus Haas
- Department of Pediatric Cardiology, Ludwig Maximilian University Munich, Munich, Germany
| | - Jürgen Hörer
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany.,Munich Heart Alliance, German Centre for Cardiovascular Research, Germany
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Kremer J, El-Dor A, Sommer W, Tochtermann U, Warnecke G, Karck M, Ruhparwar A, Meyer AL. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6582577. [PMID: 35532167 PMCID: PMC9419688 DOI: 10.1093/icvts/ivac107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamila Kremer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
- Corresponding author. Department of Cardiothoracic Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany. Tel: +49-6221-5634944; e-mail: (J. Kremer)
| | - Abbas El-Dor
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Clinic of Thoracic and Cardiovascular Surgery, Essen University Hospital, Essen, Germany
| | - Anna Lassia Meyer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Chaidaroglou A, Armenis I, Gkouziouta A, Bonios MJ, Kogerakis N, Fragoulis S, Leontiadis E, Zarkalis D, Stavridis G, Kaklamanis L, Adamopoulos S, Degiannis D. The effect of paracorporeal pulsatile biventricular assist devices on allosensitization in adults: A comparison with left ventricular assist devices. Transpl Immunol 2021; 69:101477. [PMID: 34600071 DOI: 10.1016/j.trim.2021.101477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/19/2022]
Abstract
Ventricular assist devices (VADs) have been associated with the development of anti-HLA antibodies ('allosensitization'), but data on devices providing biventricular support in adults are limited. We sought to characterize differences in anti-HLA antibody formation in adult patients receiving left- (LVAD) versus biventricular- (BiVAD) assist devices as bridge to transplantation (BTT) by retrospectively reviewing the records of adult patients who have undergone VAD implantation at our institution. We assessed 82 patients supported with a pulsatile-flow paracorporeal BiVAD and compared them with 40 patients receiving LVAD till 2018. Forty-eight (58.5%) of the BiVAD and 23 (57.5%) of the LVAD patients were eventually transplanted (p = 0.91) with an average time to transplantation 559 and 598 days, respectively (p = 0.73). Evidence of sensitization pre-VAD was found in 11.0% of the BiVAD patients and 15.0% of the LVAD ones (p = 0.53); these percentages rose to 43.9% (p < 0.001) and 40.0% (p = 0.01), respectively. The post-VAD sensitization status was not significantly different between the BiVAD and the LVAD group (p = 0.68). De novo sensitization was comparable between the two groups (p = 0.55). Post-transplantation outcomes regarding rejections and cardiac allograft vasculopathy were also similar. Conclusively, BiVAD- and LVAD- induced allosensitization do not appear to differ significantly.
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Affiliation(s)
- Antigoni Chaidaroglou
- Department of Molecular Immunopathology and Histocompatibility, Onassis Cardiac Surgery Center, Greece
| | - Iakovos Armenis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece.
| | - Angeliki Gkouziouta
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Michael J Bonios
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Nektarios Kogerakis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Socrates Fragoulis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Evangelos Leontiadis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Dimitrios Zarkalis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Georgios Stavridis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | | | - Stamatis Adamopoulos
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Dimitrios Degiannis
- Department of Molecular Immunopathology and Histocompatibility, Onassis Cardiac Surgery Center, Greece
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Schmack B, Weymann A, Lüdike P, Rassaf T, Ruhparwar A. The role of mechanical circulatory support in COVID 19 patients. J Card Surg 2020; 36:1597-1599. [PMID: 33331048 DOI: 10.1111/jocs.15239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Peter Lüdike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Rivinius R, Kaya Z, Schramm R, Boeken U, Provaznik Z, Heim C, Knosalla C, Schoenrath F, Rieth A, Berchtold-Herz M, Barten MJ, Rauschning D, Mücke VT, Heyl S, Pistulli R, Grinninger C, Hagl C, Gummert JF, Warnecke G, Schulze PC, Katus HA, Kreusser MM, Raake PW. COVID-19 among heart transplant recipients in Germany: a multicenter survey. Clin Res Cardiol 2020; 109:1531-1539. [PMID: 32783099 PMCID: PMC7418884 DOI: 10.1007/s00392-020-01722-w] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 01/08/2023]
Abstract
Aims Heart transplantation may represent a particular risk factor for severe coronavirus infectious disease 2019 (COVID-19) due to chronic immunosuppression and frequent comorbidities. We conducted a nation-wide survey of all heart transplant centers in Germany presenting the clinical characteristics of heart transplant recipients with COVID-19 during the first months of the pandemic in Germany. Methods and results A multicenter survey of all heart transplant centers in Germany evaluating the current status of COVID-19 among adult heart transplant recipients was performed. A total of 21 heart transplant patients with COVID-19 was reported to the transplant centers during the first months of the pandemic in Germany. Mean patient age was 58.6 ± 12.3 years and 81.0% were male. Comorbidities included arterial hypertension (71.4%), dyslipidemia (71.4%), diabetes mellitus (33.3%), chronic kidney failure requiring dialysis (28.6%) and chronic-obstructive lung disease/asthma (19.0%). Most patients received an immunosuppressive drug regimen consisting of a calcineurin inhibitor (71.4%), mycophenolate mofetil (85.7%) and steroids (71.4%). Eight of 21 patients (38.1%) displayed a severe course needing invasive mechanical ventilation. Those patients showed a high mortality (87.5%) which was associated with right ventricular dysfunction (62.5% vs. 7.7%; p = 0.014), arrhythmias (50.0% vs. none; p = 0.012), and thromboembolic events (50.0% vs. none; p = 0.012). Elevated high-sensitivity cardiac troponin T- and N-terminal prohormone of brain natriuretic peptide were significantly associated with the severe form of COVID-19 (p = 0.017 and p < 0.001, respectively). Conclusion Severe course of COVID-19 was frequent in heart transplanted patients. High mortality was associated with right ventricular dysfunction, arrhythmias, thromboembolic events, and markedly elevated cardiac biomarkers.
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Affiliation(s)
- Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - René Schramm
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Zdenek Provaznik
- Department of Cardiovascular Surgery, Regensburg University Hospital, Regensburg, Germany
| | - Christian Heim
- Department of Cardiovascular Surgery, Erlangen University Hospital, Erlangen, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Andreas Rieth
- Department of Cardiology, Kerckhoff Hospital, Bad Nauheim, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart and Vascular Center, Hamburg, Germany
| | - Dominic Rauschning
- Department of Internal Medicine, Bundeswehr Central Hospital, Koblenz, Germany
| | - Victoria T Mücke
- Department of Internal Medicine I, Frankfurt University Hospital, Frankfurt, Germany
| | - Stephan Heyl
- Department of Internal Medicine III, Frankfurt University Hospital, Frankfurt, Germany
| | - Rudin Pistulli
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, Münster University Hospital, Münster, Germany
| | - Carola Grinninger
- Department of Cardiac Surgery, Munich University Hospital, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Munich University Hospital, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich, Germany
| | - Jan F Gummert
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Gregor Warnecke
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - P Christian Schulze
- Department of Cardiology, Angiology and Pneumology, Jena University Hospital, Jena, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
- German Center for Infection Research (DZIF), Partner Site Heidelberg, Heidelberg, Germany.
| | - Philip W Raake
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
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Welches ventrikuläre Assistenzsystem für welchen Patienten? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00375-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Bartfay SE, Dellgren G, Hallhagen S, Wåhlander H, Dahlberg P, Redfors B, Ekelund J, Karason K. Durable circulatory support with a paracorporeal device as an option for pediatric and adult heart failure patients. J Thorac Cardiovasc Surg 2020; 161:1453-1464.e4. [PMID: 32653285 DOI: 10.1016/j.jtcvs.2020.04.163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Not all patients in need of durable mechanical circulatory support are suitable for a continuous-flow left ventricular assist device. We describe patient populations who were treated with the paracorporeal EXCOR, including children with small body sizes, adolescents with complex congenital heart diseases, and adults with biventricular failure. METHODS Information on clinical data, echocardiography, invasive hemodynamic measurements, and surgical procedures were collected retrospectively. Differences between various groups were compared. RESULTS Between 2008 and 2018, a total of 50 patients (21 children and 29 adults) received an EXCOR as bridge to heart transplantation or myocardial recovery. The majority of patients had heart failure compatible with Interagency Registry for Mechanically Assisted Circulatory Support profile 1. At year 5, the overall survival probability for children was 90%, and for adults 75% (P = .3). After we pooled data from children and adults, the survival probability between patients supported by a biventricular assist device was similar to those treated with a left ventricular assist device/ right ventricular assist device (94% vs 75%, respectively, P = .2). Patients with dilated cardiomyopathy had a trend toward better survival than those with other heart failure etiologies (92% vs 70%, P = .05) and a greater survival free from stroke (92% vs 64%, P = .01). Pump house exchange was performed in nine patients due to chamber thrombosis (n = 7) and partial membrane rupture (n = 2). There were 14 cases of stroke in eleven patients. CONCLUSIONS Despite severe illness, patient survival on EXCOR was high, and the long-term overall survival probability following heart transplantation and recovery was advantageous. Treatment safety was satisfactory, although still hampered by thromboembolism, mechanical problems, and infections.
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Affiliation(s)
- Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Hallhagen
- Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Wåhlander
- Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Dahlberg
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Redfors
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Ekelund
- Centre of Registers Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Gummert JF, Haverich A, Schmitto JD, Potapov E, Schramm R, Falk V. Permanent Implantable Cardiac Support Systems. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:843-848. [PMID: 31931951 DOI: 10.3238/arztebl.2019.0843] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/11/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nearly 1000 permanent ventricular assist devices (VADs) are implanted in patients with severe congestive heart failure in Germany each year. VADs are miniaturized centrifugal pumps that generate continuous blood flow; they are powered and controlled through a cable that passes through the skin. Para- corporeal systems are only rarely implanted, usually in children. METHODS In this selective review of the literature, including guidelines and registry data, we discuss the indications, therapeutic effects, and complications of permanently implantable cardiac support systems. RESULTS The optimal time for VAD implantation cannot be precisely defined. A comparative assessment of the various available systems is not possible, as no randomized trials have been performed on this topic. Registry data indicate that 69% to 81% of patients survive one year after VAD implantation, which is signifi- cantly better than the natural course of (conservatively treated) severe congestive heart failure. The distance patients are able to walk is 129 to 220 m longer at six months, depending on the system implanted. Scores on the EQ-5D health status questionnaire are 28 to 37 points better at six months. The potential severe compli- cations include infection, right-heart failure, hemorrhage, pump thrombosis, stroke, and death. CONCLUSION A VAD system can be implanted as an alternative to cardiac transplan- tation or as a bridging treatment until the patient can be listed for transplantation and receive the transplant. Because of the organ s , only a minority of VAD patients ever receive a transplant.
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Affiliation(s)
- Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany; Department of Cardiovascular Surgery, Charité, Universitätsmedizin Berlin; German Center of Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung) - DZHK, Partner Site Berlin; Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany; Department of Thoracic and Cardiovascular Surgery, German Heart Center, Berlin, Germany
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Expanding Use of New Technology Creates New Challenges in Preventing and Managing Infections: a Review of Diagnostic and Management Considerations for Infections Among Patients with Long-Term Invasive Devices for Advanced Heart Failure. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 237] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Hamed S, Schmack B, Mueller F, Ehlermann P, Hittmann D, Ruhparwar A, Katus HA, Raake PW, Kreusser MM. Implementation of an intensified outpatient follow-up protocol improves outcomes in patients with ventricular assist devices. Clin Res Cardiol 2019; 108:1197-1207. [DOI: 10.1007/s00392-019-01451-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
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14
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Sponga S, Benedetti G, Livi U. Short-term mechanical circulatory support as bridge to heart transplantation: paracorporeal ventricular assist device as alternative to extracorporeal life support. Ann Cardiothorac Surg 2019; 8:143-150. [PMID: 30854324 DOI: 10.21037/acs.2019.01.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal life support (ECLS) is generally considered to be the treatment of choice for bridging to heart transplantation (HTx) patients with cardiogenic shock; however, alternative mechanical circulatory support (MCS) devices have been proposed with satisfactory results and, among those, paracorporeal systems have demonstrated to be safe and effective. This technology has been used for decades as bridge to transplant, especially in patients with advanced right ventricular dysfunction or evidence of multiorgan failure (MOF), which could be difficult to manage with an isolated left ventricular support. Paracorporeal systems are defined by having the pump located outside of the body, with inflow and outflow cannulas that traverse the skin connecting the pump with the heart and great vessels. They can be utilised in a uni- or bi-ventricular configuration and can provide pulsatile or continuous flow, depending on the device technology (pneumatic vs. centrifugal). In particular, pneumatic devices allow for patient mobilization and hospital discharge, improving rehabilitation and organ recovery while bridging to transplant. In our institution at the University Hospital of Udine, 34 pneumatic paracorporeal ventricular assist devices (VADs) have been implanted since 1998: in most cases (32 pts), as biventricular support for patients in INTERMACS class I-II. After a median support time of 34 (range, 0-385) days, with 19 patients (56%) supported for more than 1 month, 23 patients (68%) underwent HTx and 3 (9%) were successfully weaned to hospital discharge, resulting in an overall combined 76% survival to HTx or weaning. After transplant, the survival rate was similar to the one of the patients not bridged with MCS. In conclusion, pneumatic VADs can effectively assist patients with severe biventricular failure, especially those with contraindications to ECLS or expected long waiting times for HTx. Moreover, they can potentially result in hospital discharge, optimal organ and patient recovery and donor-recipient matching, resulting in a satisfactory transplant outcome.
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Affiliation(s)
- Sandro Sponga
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | - Ugolino Livi
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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15
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Gomes B, Bekeredjian R, Leuschner F, Ehlermann P, Schmack B, Ruhparwar A, Raake PW, Katus HA, Kreusser MM. Transfemoral aortic valve replacement for severe aortic valve regurgitation in a patient with a pulsatile-flow biventricular assist device. ESC Heart Fail 2018; 6:217-221. [PMID: 30479049 PMCID: PMC6351890 DOI: 10.1002/ehf2.12384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/19/2018] [Accepted: 10/23/2018] [Indexed: 12/21/2022] Open
Abstract
Severe aortic regurgitation (AR) is a rare but significant complication of ventricular assist device therapy. Experience with transcatheter aortic valve replacement (TAVR) in this setting of patients is very limited, while the scarcely reported cases exclusively refer to TAVR under continuous‐flow left ventricular assist devices. Here, we present the first successful TAVR while running a pulsatile‐flow biventricular assist device (PF‐BiVAD). Clinical data were collected based on the patient's electronic medical records after the patient's consent was obtained. We describe the case of a 57‐year‐old man in whom a PF‐BiVAD (EXCOR, Berlin Heart, Berlin, Germany) had been initially inserted after fulminant myocarditis with subsequent severe dilated cardiomyopathy as bridge‐to‐transplantation therapy. Over the following 2 years, the patient developed severe de novo AR under PF‐BiVAD therapy. This, along with progressive cardiac decompensation, led to the decision for TAVR by our heart team as a minimal invasive approach for severe AR. TAVR using two Edwards SAPIEN 3 bioprostheses as a valve‐in‐valve procedure resulted in a significant reduction of AR from severe to mild, with trace paravalvular leakage and without significant pressure gradients. The patient underwent total orthotopic heart transplantation afterwards. This is the first report of successful TAVR in a patient with severe de novo AR while running a PF‐BiVAD.
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Affiliation(s)
- Bruna Gomes
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Raffi Bekeredjian
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Florian Leuschner
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany.,Department of Internal Medicine, Kurpfalzkrankenhaus, Heidelberg, Germany
| | - Bastian Schmack
- Department of Internal Medicine, Kurpfalzkrankenhaus, Heidelberg, Germany
| | - Arjang Ruhparwar
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany.,Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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Long-term effects of device-guided slow breathing in stable heart failure patients with reduced ejection fraction. Clin Res Cardiol 2018; 108:48-60. [PMID: 29943271 PMCID: PMC6333716 DOI: 10.1007/s00392-018-1310-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/19/2018] [Indexed: 12/13/2022]
Abstract
Background Slow breathing (SLOWB) alleviates symptoms of chronic heart failure (HF) but its long-term effects are unknown. We examined the acute and long-term impact of device-guided breathing on hemodynamics and prognostic parameters in HF patients with reduced ejection fraction (HFrEF). Methods and results Twenty-one patients with HFrEF (23.9 ± 5.8%, SD ± mean) on optimal medical therapy underwent blood pressure (BP), heart rate (HR), HR variability, 6-min walk test (6MWT), cardiopulmonary exercise testing (CPET), and echocardiography measurements before and 3 months after SLOWB home training (30 min daily). After 3 months, all patients were assigned to continue SLOWB (Group 1) or no-SLOWB (Group 2). All tests were repeated after 6 months. Acute SLOWB (18 ± 5 vs 8 ± 2 breaths/min, P < 0.001) had no influence on BP and HR but improved saturation (97 ± 2 vs 98 ± 2%, P = 0.01). Long-term SLOWB reduced office systolic BP (P < 0.001) but not central or ambulatory systolic BP. SLOWB reduced SDNN/RMSSD ratio (P < 0.05) after 3 months. One-way repeated measures of ANOVA revealed a significant increase in 6MWT and peak RER (respiratory exchange ratio) from baseline to 6-month follow-up in group 1 (P < 0.05) but not group 2 (P = 0.85 for 6MWT, P = 0.69 for RER). No significant changes in echocardiography were noted at follow-up. No HF worsening, rehospitalisation or death occurred in group 1 out to 6-month follow-up. Two hospitalizations for HF decompensation and two deaths ensued in group 2 between 3- and 6-month follow-up. Conclusions SLOWB training improves cardiorespiratory capacity and appears to slow the progression of HFrEF. Further long-term outcome studies are required to confirm the benefits of paced breathing in HFrEF.
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