1
|
Estep JD, Nicoara A, Cavalcante J, Chang SM, Cole SP, Cowger J, Daneshmand MA, Hoit BD, Kapur NK, Kruse E, Mackensen GB, Murthy VL, Stainback RF, Xu B. Recommendations for Multimodality Imaging of Patients With Left Ventricular Assist Devices and Temporary Mechanical Support: Updated Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:820-871. [PMID: 39237244 DOI: 10.1016/j.echo.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Affiliation(s)
| | | | - Joao Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | | | | | - Brian D Hoit
- Case Western Reserve University, Cleveland, Ohio
| | | | - Eric Kruse
- University of Chicago, Chicago, Illinois
| | | | | | | | - Bo Xu
- Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
2
|
Zijderhand CF, Peek JJ, Sjatskig J, Manintveld OC, Bekkers JA, Bogers AJJC, Caliskan K. Influence of the Outflow Graft Angular Position on the Outcomes in Patients With a Left Ventricular Assist Device. ASAIO J 2024:00002480-990000000-00464. [PMID: 38595102 DOI: 10.1097/mat.0000000000002189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
This study aimed to explore the potential impact of the angular position of the outflow graft on thromboembolic events and aortic valve regurgitation in people with a left ventricular assist device (LVAD). We analyzed contrast computed tomography (CT) data of patients with LVAD implantation between 2016 and 2021. Three-dimensional reconstructions of the outflow graft and aortic arch were performed to calculate the horizontal (azimuth) angle and vertical (polar) angle, as well as the relative distance between the outflow graft, aortic valve, and brachiocephalic artery. Among 59 patients (median age 57, 68% male), a vertical angle ≥107° correlated significantly with increased cerebrovascular accidents (hazard ratio [HR]: 5.8, 95% confidence interval [CI]: 1.3-26.3, p = 0.022) and gastrointestinal bleeding (HR: 3.4, 95% CI: 1.0-11.2, p = 0.049) during a median 25 month follow-up. No significant differences were found between the vertical angle and aortic valve regurgitation or survival. The horizontal angle and relative distance did not show differences regarding clinical adverse events. This study emphasizes the importance of the LVAD outflow graft angular position to prevent life-threatening thromboembolic events. This study suggests the need for prospective research to further validate these findings.
Collapse
Affiliation(s)
- Casper F Zijderhand
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jette J Peek
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jelena Sjatskig
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Thoraxcenter, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jos A Bekkers
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- From the Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
3
|
Gu Z, Ong CW, Mi Y, Seetharaman A, Ling RR, Ramanathan K, Leo HL. The Impact of Left Ventricular Assist Device Outflow Graft Positioning on Aortic Hemodynamics: Improving Flow Dynamics to Mitigate Aortic Insufficiency. Biomimetics (Basel) 2023; 8:465. [PMID: 37887596 PMCID: PMC10604423 DOI: 10.3390/biomimetics8060465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/27/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
Heart failure is a global health concern with significant implications for healthcare systems. Left ventricular assist devices (LVADs) provide mechanical support for patients with severe heart failure. However, the placement of the LVAD outflow graft within the aorta has substantial implications for hemodynamics and can lead to aortic insufficiency during long-term support. This study employs computational fluid dynamics (CFD) simulations to investigate the impact of different LVAD outflow graft locations on aortic hemodynamics. The introduction of valve morphology within the aorta geometry allows for a more detailed analysis of hemodynamics at the aortic root. The results demonstrate that the formation of vortex rings and subsequent vortices during the high-velocity jet flow from the graft interacted with the aortic wall. Time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI) indicate that modification of the outflow graft location changes mechanical states within the aortic wall and aortic valve. Among the studied geometric factors, both the height and inclination angle of the LVAD outflow graft are important in controlling retrograde flow to the aortic root, while the azimuthal angle primarily determines the rotational direction of blood flow in the aortic arch. Thus, precise positioning of the LVAD outflow graft emerges as a critical factor in optimizing patient outcomes by improving the hemodynamic environment.
Collapse
Affiliation(s)
- Zhuohan Gu
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
| | - Chi Wei Ong
- School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore 639798, Singapore
| | - Yongzhen Mi
- Institute of High Performance Computing (IHPC), Agency for Science, Technology and Research (A*STAR), Singapore 138632, Singapore;
| | - Ashwin Seetharaman
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore (K.R.)
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore (K.R.)
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, National Univeristy Health System, Singapore 119228, Singapore
| | - Hwa Liang Leo
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
| |
Collapse
|
4
|
Shields A, Setlur Nagesh SV, Rajagopal K, Bednarek DR, Rudin S, Chivukula VK. Application of 1,000 fps High-Speed Angiography to In-Vitro Hemodynamic Evaluation of Left Ventricular Assist Device Outflow Graft Configurations. ASAIO J 2023; 69:756-765. [PMID: 37140988 PMCID: PMC10524133 DOI: 10.1097/mat.0000000000001948] [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] [Indexed: 05/05/2023] Open
Abstract
Left ventricular assist device (LVAD)-induced hemodynamics are characterized by fast-moving flow with large variations in velocity, making quantitative assessments difficult with existing imaging methods. This study demonstrates the ability of 1,000 fps high-speed angiography (HSA) to quantify the effect of the surgical implantation angle of a LVAD outflow graft on the hemodynamics within the ascending aorta in vitro . High-speed angiography was performed on patient-derived, three-dimensional-printed optically opaque aortic models using a nonsoluble contrast media, ethiodol, as a flow tracer. Outflow graft configuration angles of 45° and 90° with respect to the central aortic axis were considered. Projected velocity distributions were calculated from the high-speed experimental sequences using two methods: a physics-based optical flow algorithm and tracking of radio-opaque particles. Particle trajectories were also used to evaluate accumulated shear stress. Results were then compared with computational fluid dynamics (CFD) simulations to confirm the results of the high-speed imaging method. Flow patterns derived from HSA coincided with the impingement regions and recirculation zones formed in the aortic root as seen in the CFD for both graft configurations. Compared with the 45° graft, the 90° configuration resulted in 81% higher two-dimensional-projected velocities (over 100 cm/s) along the contralateral wall of the aorta. Both graft configurations suggest elevated accumulated shear stresses along individual trajectories. Compared with CFD simulations, HSA successfully characterized the fast-moving flow and hemodynamics in each LVAD graft configuration in vitro , demonstrating the potential utility of this technology as a quantitative imaging modality.
Collapse
Affiliation(s)
- Allison Shields
- Medical Physics Program, University at Buffalo, Buffalo,
New York, USA
- Canon Stroke and Vascular Research Center, University at
Buffalo, Buffalo, New York, USA
| | - Swetadri Vasan Setlur Nagesh
- Medical Physics Program, University at Buffalo, Buffalo,
New York, USA
- Canon Stroke and Vascular Research Center, University at
Buffalo, Buffalo, New York, USA
| | - Keshava Rajagopal
- Division of Cardiac Surgery, Department of Surgery, Sidney
Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania,
USA
| | - Daniel R. Bednarek
- Medical Physics Program, University at Buffalo, Buffalo,
New York, USA
- Canon Stroke and Vascular Research Center, University at
Buffalo, Buffalo, New York, USA
| | - Stephen Rudin
- Medical Physics Program, University at Buffalo, Buffalo,
New York, USA
- Canon Stroke and Vascular Research Center, University at
Buffalo, Buffalo, New York, USA
| | - Venkat Keshav Chivukula
- Department of Biomedical Engineering, Florida Institute of
Technology, Melbourne, Florida, USA
| |
Collapse
|
5
|
Toda K, Bernhardt AM, Mehra MR. Mechanical circulatory support for adults in Japan: A 10-year perspective. Artif Organs 2023. [PMID: 37140177 DOI: 10.1111/aor.14536] [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: 07/29/2022] [Revised: 02/06/2023] [Accepted: 04/06/2023] [Indexed: 05/05/2023]
Abstract
Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.
Collapse
Affiliation(s)
- Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Si MS, Sood V, Biniwale R, Peng D. Considerations of valvular heart disease in children with ventricular assist devices. Front Cardiovasc Med 2023; 10:1056663. [PMID: 37034354 PMCID: PMC10075362 DOI: 10.3389/fcvm.2023.1056663] [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: 09/29/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Ventricular assist devices have become a valuable tool in the treatment of heart failure in children. The use of ventricular assist devices has decreased mortality in children with end-stage heart failure awaiting transplant. It is not uncommon for children with end-stage heart failure associated with cardiomyopathy or congenital heart disease to have significant systemic semilunar and atrioventricular valve regurgitation, which can impact the efficiency and efficacy of hemodynamic support provided by a ventricular assist device. Therefore, implanting clinicians should carefully assess for valve abnormalities that may need repair and impact device selection and cannulation strategy to effectively support this diverse population. The purpose of this review is to provide an overview of this important and relevant topic and to discuss strategies for managing these patients.
Collapse
Affiliation(s)
- Ming-Sing Si
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
- Correspondence: Ming-Sing Si
| | - Vikram Sood
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
| | - Reshma Biniwale
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
| | - David Peng
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, Mattel Children’s Hospital, Los Angeles, CA, United States
| |
Collapse
|
7
|
Acharya D, Kazui T, Al Rameni D, Acharya T, Betterton E, Juneman E, Loyaga-Rendon R, Lotun K, Shetty R, Chatterjee A. Aortic valve disorders and left ventricular assist devices. Front Cardiovasc Med 2023; 10:1098348. [PMID: 36910539 PMCID: PMC9996073 DOI: 10.3389/fcvm.2023.1098348] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/02/2023] [Indexed: 02/25/2023] Open
Abstract
Aortic valve disorders are important considerations in advanced heart failure patients being evaluated for left ventricular assist devices (LVAD) and those on LVAD support. Aortic insufficiency (AI) can be present prior to LVAD implantation or develop de novo during LVAD support. It is usually a progressive disorder and can lead to impaired LVAD effectiveness and heart failure symptoms. Severe AI is associated with worsening hemodynamics, increased hospitalizations, and decreased survival in LVAD patients. Diagnosis is made with echocardiographic, device assessment, and/or catheterization studies. Standard echocardiographic criteria for AI are insufficient for accurate diagnosis of AI severity. Management of pre-existing AI includes aortic repair or replacement at the time of LVAD implant. Management of de novo AI on LVAD support is challenging with increased risks of repeat surgical intervention, and percutaneous techniques including transcatheter aortic valve replacement are assuming greater importance. In this manuscript, we provide a comprehensive approach to contemporary diagnosis and management of aortic valve disorders in the setting of LVAD therapy.
Collapse
Affiliation(s)
- Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, United States
| | - Toshinobu Kazui
- Division of Cardiovascular Surgery, University of Arizona, Tucson, AZ, United States
| | - Dina Al Rameni
- Division of Cardiovascular Surgery, University of Arizona, Tucson, AZ, United States
| | - Tushar Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, United States
| | - Edward Betterton
- Artificial Heart Program, University of Arizona, Tucson, AZ, United States
| | - Elizabeth Juneman
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, United States
| | | | - Kapildeo Lotun
- Division of Cardiology, Carondelet Medical Center, Tucson, AZ, United States
| | - Ranjith Shetty
- Division of Cardiology, Carondelet Medical Center, Tucson, AZ, United States
| | - Arka Chatterjee
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, United States
| |
Collapse
|
8
|
Gasparovic H, Jakus N, Brugts JJ, Pouleur AC, Timmermans P, Rubiś P, Gaizauskas E, Van Craenenbroeck EM, Barge-Caballero E, Grundmann S, Paolillo S, D'Amario D, Braun OÖ, Meyns B, Droogne W, Wierzbicki K, Holcman K, Planinc I, Lovric D, Flammer AJ, Petricevic M, Biocina B, Lund LH, Milicic D, Ruschitzka F, Cikes M. Impact of progressive aortic regurgitation on outcomes after left ventricular assist device implantation. Heart Vessels 2022; 37:1985-1994. [PMID: 35737119 DOI: 10.1007/s00380-022-02111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/25/2022] [Indexed: 11/26/2022]
Abstract
Aortic regurgitation (AR) following continuous flow left ventricular assist device implantation (cf-LVAD) may adversely impact outcomes. We aimed to assess the incidence and impact of progressive AR after cf-LVAD on prognosis, biomarkers, functional capacity and echocardiographic findings. In an analysis of the PCHF-VAD database encompassing 12 European heart failure centers, patients were dichotomized according to the progression of AR following LVAD implantation. Patients with de-novo AR or AR progression (AR_1) were compared to patients without worsening AR (AR_0). Among 396 patients (mean age 53 ± 12 years, 82% male), 153 (39%) experienced progression of AR over a median of 1.4 years on LVAD support. Before LVAD implantation, AR_1 patients were less frequently diabetic, had lower body mass indices and higher baseline NT-proBNP values. Progressive AR did not adversely impact mortality (26% in both groups, HR 0.91 [95% CI 0.61-1.36]; P = 0.65). No intergroup variability was observed in NT-proBNP values and 6-minute walk test results at index hospitalization discharge and at 6-month follow-up. However, AR_1 patients were more likely to remain in NYHA class III and had worse right ventricular function at 6-month follow-up. Lack of aortic valve opening was related to de-novo or worsening AR (P < 0.001), irrespective of systolic blood pressure (P = 0.67). Patients commonly experience de-novo or worsening AR when exposed to continuous flow of contemporary LVADs. While reducing effective forward flow, worsening AR did not influence survival. However, less complete functional recovery and worse RV performance among AR_1 patients were observed. Lack of aortic valve opening was associated with progressive AR.
Collapse
Affiliation(s)
- Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia.
| | - Nina Jakus
- Department of Cardiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Jasper J Brugts
- Division of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - 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
| | | | | | - Sebastian Grundmann
- Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - 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 Cardiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Daniel Lovric
- Department of Cardiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Andreas J Flammer
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Mate Petricevic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Davor Milicic
- Department of Cardiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Maja Cikes
- Department of Cardiology, University Hospital Center Zagreb, Zagreb, Croatia
| |
Collapse
|
9
|
Yu XY, Shi JW, Zang YR, Zhang JM, Liu ZG. Factors influencing the functional status of aortic valve in ovine models supported by continuous-flow left ventricular assist device. Artif Organs 2022; 46:1334-1345. [PMID: 35167127 PMCID: PMC9310577 DOI: 10.1111/aor.14207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Objectives An acute animal experiment was performed to observe factors influencing the functional status of the aortic valve functional status after continuous‐flow left ventricular assist device (CF‐LVAD) implantation in an ovine model, and a physiologic predictive model was established. Methods A CF‐LVAD model was established in Small Tail Han sheep. The initial heart rate (HR) was set to 60 beats/min, and grouping was performed at an interval of 20 beats/min. In all groups, the pump speed was started from 2000 rpm and was gradually increased by 50–100 rpm. A multi‐channel physiological recorder recorded the HR, aortic pressure, central venous pressure, and left ventricular systolic pressure (LVSP). A double‐channel ultrasonic flowmeter was used to obtain real‐time artificial vascular blood flow (ABF). A color Doppler ultrasound device was applied to assess the aortic valve functional status. Multivariate dichotomous logistic regression was used to screen significant variables for predicting the functional status of the aortic valve. Results Observational studies showed that ABF and the risk of aortic valve closure (AVC) were positively correlated with pump speed at the same HR. Meanwhile, the mean arterial pressure (MAP) was unaltered or slightly increased with increased pump speed. When the pump speed was constant, an increase in HR was associated with a decrease in the size of the aortic valve opening. This phenomenon was accompanied by an initial transient increase in the ABF and MAP, which subsequently decreased. Statistical analysis showed that the AVC was associated with increased pump speed (OR = 1.02, 95% CI = 1.01–1.04, p = 0.001), decreased LVSP (OR = 0.95, 95% CI = 0.91–0.98, p = 0.003), and decreased pulse pressure (OR = 0.82, 95% CI = 0.68–0.96, p = 0.026). ABF or MAP was negatively associated with the risk of AVC (OR < 1). The prediction model of AVC after CF‐LVAD implantation exhibited good differentiation (AUC = 0.973, 95% CI = 0.978–0.995) and calibration performance (Hosmer–Lemeshow χ2 = 9.834, p = 0.277 > 0.05). Conclusions The pump speed, LVSP, ABF, MAP, and pulse pressure are significant predictors of the risk of AVC. Predictive models built from these predictors yielded good performance in differentiating aortic valve opening and closure after CF‐LVAD implantation.
Collapse
Affiliation(s)
- Xin-Yi Yu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, China
| | - Jian-Wei Shi
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, China
| | - Yi-Rui Zang
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, China
| | - Jie-Min Zhang
- Laboratory Animal Center, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, China
| | - Zhi-Gang Liu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, China
| |
Collapse
|
10
|
Kohno H, Matsumiya G, Sawa Y, Fukushima N, Saiki Y, Shiose A, Ono M. Can the intermittent low-speed function of left ventricular assist device prevent aortic insufficiency? J Artif Organs 2021; 24:191-198. [PMID: 33420874 PMCID: PMC8154761 DOI: 10.1007/s10047-020-01234-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/02/2020] [Indexed: 11/25/2022]
Abstract
Aortic insufficiency (AI) is known to associate with a persistently closed aortic valve during continuous-flow ventricular assist device support. Some devices carry an intermittent low-speed (ILS) function, which facilitates aortic valve opening, but whether this function prevents AI is unknown. In this study, the Jarvik 2000 device, which is programmed to reduce the pump speed each minute for 8 s, was chosen to examine this potential effect. Prospectively collected data of 85 heart transplant-eligible Jarvik 2000 recipients who met the study criteria (no pre-existing AI and aortic valve surgery) were retrospectively analyzed for the incidence, correlating factors, and clinical outcomes of de novo AI. All data were provided by the Japanese Registry for Mechanically Assisted Circulatory Support. De novo AI occurred in 58 patients, 23 of whom developed at least moderate AI during a median support duration of 23.5 months. Freedom from moderate or greater AI was 84.4%, 66.1% and 60.2% at 1, 2 and 3 years, respectively. Multivariate analyses revealed that progressive AI was correlated with decreased pulse pressure after implantation (hazard ratio 1.060, 95% confidence interval 1.001–1.127, p = 0.045). No correlation was found for mortality or other adverse events, including stroke, bleeding, infection, pump failure, hemolysis, and readmission. The benefit of the Jarvik 2000′s current ILS mode against AI appears to be minimal. However, in this limited cohort where all recipients underwent implantation as a bridge to transplantation, the impact of de novo progressive AI on other clinical adversities was also minimal.
Collapse
Affiliation(s)
- Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
11
|
Gao B, Zhang Q. Biomechanical effects of the working modes of LVADs on the aortic valve: A primary numerical study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 193:105512. [PMID: 32344270 DOI: 10.1016/j.cmpb.2020.105512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/08/2020] [Accepted: 04/15/2020] [Indexed: 06/11/2023]
Abstract
Aortic valve diseases caused by the support from left ventricular assist devices (LVADs) have attracted increasing attention due to the wide application of the LVADs. However, the biomechanical effects of the working modes of LVADs on the aortic valve are still poorly understood. Hence, in this study, these biomechanical effects are investigated using a novel fluid-structure interaction method, which combines the lattice Boltzmann and the finite element methods. On the basis of the clinical practice, three working modes of LVADs, namely, the constant flow, co-pulse, and counter pulse modes, are chosen. Results demonstrate that the working mode of LVADs is an important factor as it can change the biomechanical states of the aortic valve and the hemodynamic environment in the aortic root directly. Compared with the constant flow mode, the two other working modes can provide better biomechanical effects on the aortic valve. However, the advantages of the co-pulse and the counter pulse modes on the aortic valve are not the same. The LVADs in the co-pulse mode can remarkable reduce the pressure load of the leaflets during the diastolic phase (maximum stress: co-pulse mode, 0.85 MPa; constant flow mode, 1.23 MPa; counter pulse mode, 1.50 MPa). By contrast, the LVADs in the counter pulse mode can achieve the highest effective orifice area of the aortic valve (co-pulse mode: 0.12 cm2, constant flow mode: 0.17 cm2, counter pulse mode: 0.25 cm2). In sum, the co-pulse mode is suitable for patients with certain cardiac function, because this mode keeps the valve open intermittently and reduces the pressure load on the aortic leaflets during the diastolic phase to prevent valve remodeling. By contrast, the counter pulse mode is suitable for patients with severely impaired cardiac function, because this mode keeps the valve open as much as possible and provides high blood perfusion.
Collapse
Affiliation(s)
- Bin Gao
- School of Life Science and Bioengineering, Beijing University of Technology, Beijing, 100124, PR China.
| | - Qi Zhang
- National Energy Conservation Center, Beijing, PR China
| |
Collapse
|
12
|
Noly PE, Pagani FD, Noiseux N, Stulak JM, Khalpey Z, Carrier M, Maltais S. Continuous-Flow Left Ventricular Assist Devices and Valvular Heart Disease: A Comprehensive Review. Can J Cardiol 2019; 36:244-260. [PMID: 32036866 DOI: 10.1016/j.cjca.2019.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/15/2022] Open
Abstract
Mechanical circulatory support with implantable durable continuous-flow left ventricular assist devices (CF-LVADs) represents an established surgical treatment option for patients with advanced heart failure refractory to guideline-directed medical therapy. CF-LVAD therapy has been demonstrated to offer significant survival, functional, and quality-of-life benefits. However, nearly one-half of patients with advanced heart failure undergoing implantation of a CF-LVAD have important valvular heart disease (VHD) present at the time of device implantation or develop VHD during support that can lead to worsening right or left ventricular dysfunction and result in development of recurrent heart failure, more frequent adverse events, and higher mortality. In this review, we summarize the recent evidence related to the pathophysiology and treatment of VHD in the setting of CF-LAVD support and include a review of the specific valve pathologies of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR). Recent data demonstrate an increasing appreciation and understanding of how VHD may adversely affect the hemodynamic benefits of CF-LVAD support. This is particularly relevant for MR, where increasing evidence now demonstrates that persistent MR after CF-LVAD implantation can contribute to worsening right heart failure and recurrent heart failure symptoms. Standard surgical interventions and novel percutaneous approaches for treatment of VHD in the setting of CF-LVAD support, such as transcatheter aortic valve replacement or transcatheter mitral valve repair, are available, and indications to intervene for VHD in the setting of CF-LVAD support continue to evolve.
Collapse
Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - John M Stulak
- Department of Cardiac Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Zain Khalpey
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Michel Carrier
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Simon Maltais
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| |
Collapse
|
13
|
Gao B, Zhang Q, Chang Y. Hemodynamic effects of support modes of LVADs on the aortic valve. Med Biol Eng Comput 2019; 57:2657-2671. [PMID: 31707689 DOI: 10.1007/s11517-019-02058-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 11/02/2019] [Indexed: 12/11/2022]
Abstract
As the alternative treatment for heart failure, left ventricular assist devices (LVADs) have been widely applied to clinical practice. However, the effects of the support modes of LVADs on the biomechanical states of the aortic valve are still poorly understood. Hence, the present study investigates such effects and proposes a novel fluid-structure interaction (FSI) approach that combines the lattice Boltzmann method (LBM) and finite element (FE) method. Two support modes of LVADs, namely constant speed mode and constant flow mode, which have been widely applied to clinical practice, are also designed. Results demonstrate that the support modes of LVADs could significantly affect the biomechanical states of the aortic valve and the blood flow pattern of the ascending aorta. Compared with those in the constant flow mode, the leaflets in the constant speed mode could achieve better dynamic performance and lower stress during the systolic phase. The max radial displacement of the leaflets in the constant speed mode is at 8 mm, whereas that in the constant flow mode is at 0.8 mm. Furthermore, the outflow of LVADs directly impacts the aortic surfaces of the leaflets during the diastolic phase by increasing the level of wall shear stress of the leaflets. The leaflets in the constant speed mode receive less impact than those in the constant flow mode. The condition with such minimal impact is conducive to maintaining the normal structure of leaflets and benefits the reduction of the risk of valvular diseases. In sum, the support modes of LVADs exert a crucial effect on the biomechanical environment of the aortic valve. The constant speed mode is better than the constant flow mode in terms of providing a good hemodynamic environment for the aortic valve.
Collapse
Affiliation(s)
- Bin Gao
- School of Life Science and BioEngineering, Beijing University of Technology, Beijing, 100124, People's Republic of China.
| | - Qi Zhang
- School of Life Science and BioEngineering, Beijing University of Technology, Beijing, 100124, People's Republic of China
| | - Yu Chang
- School of Life Science and BioEngineering, Beijing University of Technology, Beijing, 100124, People's Republic of China
| |
Collapse
|
14
|
A Comprehensive Imaging Approach to Guide the Management of Patients with Continuous-Flow Left Ventricular Assist Devices. Cardiol Clin 2018; 36:583-597. [PMID: 30297075 DOI: 10.1016/j.ccl.2018.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent advances in mechanical circulatory support have allowed patients with end-stage heart failure to be successfully bridged to heart transplantation or live for many years on continuous-flow left ventricular assist devices (CF-LVADs) as destination therapy. As survival and quality of life continue to improve and the number of patients supported by CF-LVADs continues to grow, utilization of different imaging modalities in the care for these patients has become an integral part of many heart failure centers. We review currently available imaging modalities, with a focus on echocardiography, that aid to diagnose and manage common adverse events associated with CF-LVADs.
Collapse
|
15
|
Utility of Cardiac Computed Tomography in Patients with Left Ventricular Assist Devices. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9466-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
16
|
Iizuka K, Nishinaka T, Akiyama D, Sumikura H, Mizuno T, Tsukiya T, Takewa Y, Yamazaki K, Tatsumi E. The angle of the outflow graft to the aorta can affect recirculation due to aortic insufficiency under left ventricular assist device support. J Artif Organs 2018; 21:399-404. [PMID: 30039455 DOI: 10.1007/s10047-018-1064-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/17/2018] [Indexed: 11/24/2022]
Abstract
Aortic insufficiency (AI) is a crucial complication during continuous-flow left ventricular assist device (LVAD) support. Our previous clinical study suggested that a larger angle between the outflow graft and the aorta (O-A angle) could cause AI progression. This study examined the effect of the O-A angle on the hemodynamics of AI under LVAD support in an acute animal experimental model. An LVAD was installed in seven calves, with the inflow cannula inserted from the LV apex and with the outflow graft sutured at the ascending aorta. The AI model was made using a temporary inferior vena cava filter inserted from the LV apex and placed at the aortic valve. Cardiac dysfunction was induced by continuous beta-blocker infusion. Hemodynamic values and the myocardial oxygen extraction rate (O2ER) were evaluated at three O-A angles (45°, 90°, and 135°) over three levels of AI (none, Sellers I-II AI, and Sellers III-IV AI). The recirculation rate, defined as the percentage of regurgitation flow to LVAD output, was calculated. Systemic flow tended to decrease with a larger O-A angle. The recirculation rate was significantly increased with a larger O-A angle (22, 23, and 31% at 45°, 90°, and 135° in Sellers III-IV AI, respectively). Coronary artery flow was decreased at a larger O-A angle (86, 76 and 75 mL/min at 45°, 90°, and 135° in Sellers I-II AI, respectively, and 77, 67, and 56 mL/min at 45°, 90°, and 135° in Sellers III-IV AI, respectively). O2ER tended to increase with a larger O-A angle (40, 43, and 49% at 45°, 90°, and 135° in Sellers III-IV AI, respectively). A larger O-A angle can increase the recirculation due to AI and can be disadvantageous to LVAD-AI hemodynamics and myocardial oxygen metabolism.
Collapse
Affiliation(s)
- Kei Iizuka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan. .,Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
| | - Tomohiro Nishinaka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Daichi Akiyama
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Hirohito Sumikura
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Toshihide Mizuno
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Tomonori Tsukiya
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Yoshiaki Takewa
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Eisuke Tatsumi
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| |
Collapse
|