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Kaya E, Kocabaş U, Şimşek E, Nalbantgil S, Engin Ç, Özbaran M, Akilli A. Effect of Aortic Valve Opening Pattern on Endothelial Function After Continuous-Flow Left Ventricular Assist Device Implantation. ASAIO J 2023; 69:e429-e436. [PMID: 37773149 DOI: 10.1097/mat.0000000000002025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023] Open
Abstract
This study aimed to evaluate the effects of aortic valve opening patterns on endothelial functions in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) implantation. This study included 43 patients who underwent CF-LVAD implantation and 35 patients with heart failure reduced ejection fraction (HFrEF; control group). The CF-LVAD group was divided into three subgroups based on aortic valve opening patterns: open with each beat, intermittently opening, and not opening groups. Flow-mediated dilatation (FMD) and pulsatility index (PI) were compared before and 3 months after CF-LVAD implantation. Cardiopulmonary exercise test (CPET) and 6 minute walk test (6-MWT) scores were measured at baseline and follow-up in the CF-LVAD group. The mean FMD and PI of patients in the CF-LVAD group reduced 3 months after implantation. Patients with intermittently opening and not opening aortic valves had worse endothelial function at follow-up. Before and 3 months after implantation FMD% did not significantly differ in patients whose aortic valves were open with each beat (4.72 ± 1.06% vs. 4.67 ± 1.16%, p = 0.135). Pulsatility index changes paralleled FMD changes. Cardiopulmonary exercise test and 6-MWT scores improved after implantation but without significant differences between subgroups. Maintaining normal aortic valve function after CF-LVAD implantation may reduce endothelial dysfunction; however, larger studies are needed for long-term clinical effects.
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Affiliation(s)
- Ersin Kaya
- From the Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Umut Kocabaş
- Department of Cardiology, Baskent University, Izmir, Turkey
| | - Evrim Şimşek
- From the Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sanem Nalbantgil
- From the Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Çağatay Engin
- Department of Cardiovascular Surgery, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Azem Akilli
- From the Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
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Schaffer C, Gunga Z, Guillier D, Raffoul W, Kirsch M, di Summa PG. Pressure sore incidence and treatment in left ventricular assist device (LVAD)-equipped patients: Insights from a prospective series. J Plast Reconstr Aesthet Surg 2023; 77:388-396. [PMID: 36628855 DOI: 10.1016/j.bjps.2022.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/07/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION A left ventricular assistance device (LVAD) is indicated in patients with end-stage heart failure. Due to the non-physiologic blood flow, a LVAD may favor pressure sores with a devastating risk of infection. This work shows the prevalence and treatment of pressure sores in LVAD patients, to optimize their management. MATERIAL AND METHODS We retrospectively investigated all LVAD implantations at the Lausanne University Hospital (CHUV) from 2015 to 2019. We detected patients who developed a pressure sore and evaluated the timeline, management, and outcomes. RESULTS Forty-two patients benefited from LVAD, among whom 5 (12%) developed a stage III/IV pressure sore, within a mean time of 25 days. Due to their poor overall condition, 4/5 patients were treated surgically and 1/5 conservatively. Half of the patients treated with surgery had major complications requiring reoperation. After flap coverage, the mean time to healing for patients was 6 weeks. DISCUSSION The rapid development of deep pressure sores seen in 12% of patients may be a manifestation of the maladaptive blood flow induced by LVADs, combined with their bedridden condition. Initial signs of pressure sores should be considered seriously, as they are rapidly evolving and needing an aggressive surgical treatment whenever possible (80%). Complication rate was similar compared to standard pressure sore flap treatment. All patients benefiting from flap surgery achieved effective coverage after a mean follow-up of 24 months. No patient developed a LVAD infection. CONCLUSION Surgery must be considered early in this population to prevent potential device infection.
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Affiliation(s)
- Clara Schaffer
- Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, Lausanne 1006, Switzerland
| | - Ziyad Gunga
- Cardiac Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Guillier
- Plastic and Reconstructive Surgery, Dijon University Hospital (CHU Dijon), Dijon, France
| | - Wassim Raffoul
- Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, Lausanne 1006, Switzerland
| | - Matthias Kirsch
- Cardiac Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Pietro G di Summa
- Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, Lausanne 1006, Switzerland.
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Alexy T, Detterich J, Connes P, Toth K, Nader E, Kenyeres P, Arriola-Montenegro J, Ulker P, Simmonds MJ. Physical Properties of Blood and their Relationship to Clinical Conditions. Front Physiol 2022; 13:906768. [PMID: 35874542 PMCID: PMC9298661 DOI: 10.3389/fphys.2022.906768] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/14/2022] [Indexed: 02/03/2023] Open
Abstract
It has been long known that blood health heavily influences optimal physiological function. Abnormalities affecting the physical properties of blood have been implicated in the pathogenesis of various disorders, although the exact mechanistic links between hemorheology and clinical disease manifestations remain poorly understood. Often overlooked in current medical practice, perhaps due to the promises offered in the molecular and genetic era, the physical properties of blood which remain a valuable and definitive indicator of circulatory health and disease. Bridging this gap, the current manuscript provides an introduction to hemorheology. It reviews the properties that dictate bulk and microcirculatory flow by systematically dissecting the biomechanics that determine the non-Newtonian behavior of blood. Specifically, the impact of hematocrit, the mechanical properties and tendency of red blood cells to aggregate, and various plasma factors on blood viscosity will be examined. Subsequently, the manner in which the physical properties of blood influence hemodynamics in health and disease is discussed. Special attention is given to disorders such as sickle cell disease, emphasizing the clinical impact of severely abnormal blood rheology. This review expands into concepts that are highly topical; the relation between mechanical stress and intracellular homeostasis is examined through a contemporary cell-signaling lens. Indeed, accumulating evidence demonstrates that nitric oxide is not only transported by erythrocytes, but is locally produced by mechanically-sensitive enzymes, which appears to have intracellular and potentially extracellular effects. Finally, given the importance of shear forces in the developing field of mechanical circulatory support, we review the role of blood rheology in temporary and durable mechanical circulatory support devices, an increasingly utilized method of life support. This review thus provides a comprehensive overview for interested trainees, scientists, and clinicians.
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Affiliation(s)
- Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, United States
| | - Jon Detterich
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Philippe Connes
- Laboratory LIBM EA7424, Vascular Biology and Red Blood Cell Team, University of Lyon, Lyon, France
| | - Kalman Toth
- First Department of Medicine, Division of Cardiology, Medical School, University of Pecs, Pecs, Hungary
| | - Elie Nader
- Laboratory LIBM EA7424, Vascular Biology and Red Blood Cell Team, University of Lyon, Lyon, France
| | - Peter Kenyeres
- First Department of Medicine, Division of Cardiology, Medical School, University of Pecs, Pecs, Hungary
| | - Jose Arriola-Montenegro
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, United States
| | - Pinar Ulker
- Department of Physiology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Michael J Simmonds
- Biorheology Research Laboratory, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
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Cortese F, Ciccone MM, Gesualdo M, Iacoviello M, Frigerio M, Cipriani M, Giannattasio C, Maloberti A, Giordano P. Continuous flow left ventricular assist devices do not worsen endothelial function in subjects with chronic heart failure: a pilot study. ESC Heart Fail 2021; 8:3587-3593. [PMID: 34331419 PMCID: PMC8497342 DOI: 10.1002/ehf2.13484] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS To evaluate endothelial function in subjects with left ventricular assist devices (LVADs), comparing them with subjects with chronic heart failure with reduced ejection fraction on the list for heart transplant (HT) and with HT patients with a normal systolic cardiac function to identify any differences. METHODS We enrolled 28 subjects with LVAD, 55 subjects with HT, and 42 subjects with heart failure on the transplant list. The subjects underwent a general physical examination, assessment of laboratory blood parameters, and assessment of endothelial function through flow-mediated dilation (FMD) of brachial artery. RESULTS The three groups were homogeneous as regards age, gender, smoke abuse, C-reactive protein (CRP) and FMD parameters (P = ns). In LVAD group percentage of FMD change showed an inverse correlation with CRP (rho: -0.5, P: 0.003), a well-known marker of inflammation and tissue damage. CONCLUSIONS Continuous flow related to LVAD seems to not worsen endothelial function. Endothelial function was not affected by cardiovascular risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, and tobacco habit), by the functional status expressed by New York Heart Association class, by the left ventricular systolic function and by the presence or absence of ischaemic heart disease in all the populations analysed. CRP was the only factor able to influence percentage of FMD change in patient with LVAD, reinforcing the hypothesis that inflammation is the main determinant of endothelial function.
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Affiliation(s)
- Francesca Cortese
- Department of Cardiology, Cardiology Unit, Giovanni Paolo II Hospital, viale salerno, Policoro, Matera, Italy.,Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Bari, Italy
| | | | - Massimo Iacoviello
- Unit of Cardiology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, Milan, Italy
| | - Manlio Cipriani
- De Gasperis Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, Milan, Italy
| | | | | | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, Pediatric Section, University "A. Moro" of Bari, Bari, Italy
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Ivak P, Netuka I, Tucanova Z, Wohlfahrt P, Konarik M, Szarszoi O, Novakova S, Kubanek M, Lanska V, Pitha J. The Effect of Artificial Pulsatility on the Peripheral Vasculature in Patients with A Continuous-Flow Ventricular Assist Device. Can J Cardiol 2021; 37:1578-1585. [PMID: 34090978 DOI: 10.1016/j.cjca.2021.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Implantation of left ventricular assist systems (LVASs) has become the standard of care for advanced heart failure (HF). The absence of pulsatility in previous devices contributes to vascular and endothelial dysfunction, related to atherosclerotic or vascular complications. We hypothesized that the artificial pulsatility provided by the HeartMate 3 (HM3) LVAS would exert a favorable effect on the vasculature. METHODS In 32 patients implanted with HM3 (5 females; mean age 55±13.6 years), the reactive hyperemia index (RHI) and peripheral augmentation index (AI), markers of endothelial function and arterial stiffness, were measured with an Endo-PAT2000 prior to and in the 3rd and 6th months after implantation. RHI and AI data from 30 HeartMate II (HM II) recipients in the 3rd and 6th months after implantation, from 15 advanced HF patients without LVASs, and from 13 healthy volunteers were also analyzed. RESULTS In HM3 recipients, the mean RHI significantly decreased at 3rd and 6th months after implantation. The RHI was substantially lower at baseline than that of healthy or HF reference group. Increasing AI values, indicating worsening arterial stiffness, were also observed. Similar trends were observed in HM II recipients between the 3rd and 6th months, but with higher absolute values of RHI and AI. CONCLUSIONS We detected impaired vascular function in HM3 patients and provided additional evidence on the negative effect of low pulsatility on vascular function after LVAS implantation. The results suggest that the artificial pulsatility of the HM3 does not avert the progression of endothelial dysfunction.
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Affiliation(s)
- Peter Ivak
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic; Second Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Second Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Tucanova
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Peter Wohlfahrt
- Laboratory for Atherosclerosis Research, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Miroslav Konarik
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Szarszoi
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Sarka Novakova
- Laboratory for Atherosclerosis Research, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milos Kubanek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Vera Lanska
- Medical Statistics Unit, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Pitha
- Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Lilliu M, Onorati F, Luciani GB, Faggian G. The determinants of functional capacity in left ventricular assist device patients: many actors with not well defined roles. J Cardiovasc Med (Hagerstown) 2020; 21:472-480. [DOI: 10.2459/jcm.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gross C, Moscato F, Schlöglhofer T, Maw M, Meyns B, Marko C, Wiedemann D, Zimpfer D, Schima H, Fresiello L. LVAD speed increase during exercise, which patients would benefit the most? A simulation study. Artif Organs 2019; 44:239-247. [DOI: 10.1111/aor.13569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/03/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Christoph Gross
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
| | - Thomas Schlöglhofer
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Martin Maw
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Bart Meyns
- Department of Cardiac Surgery Katholieke Universiteit Leuven Leuven Belgium
| | | | - Dominik Wiedemann
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Daniel Zimpfer
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig‐Boltzmann‐Cluster for Cardiovascular Research Vienna Austria
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Libera Fresiello
- Department of Cardiac Surgery Katholieke Universiteit Leuven Leuven Belgium
- Institute of Clinical Physiology National Research Council Pisa Italy
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Severin R, Sabbahi A, Ozemek C, Phillips S, Arena R. Approaches to improving exercise capacity in patients with left ventricular assist devices: an area requiring further investigation. Expert Rev Med Devices 2019; 16:787-798. [PMID: 31453716 DOI: 10.1080/17434440.2019.1660643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Introduction: Left ventricular assist device (LVAD) implantation has become a well-established treatment option for patients with end stage heart failure (HF) who are refractory to medical therapy. While LVADs implantation does effectively improve hemodynamic performance many patients still possess peripheral pathological adaptations often present in end-stage HF. Therefore, increased attention has been placed on investigating the effects of exercise training for patients with LVADs to improve clinical outcomes. However, the available evidence on exercise training for patients with LVADs is limited. Areas covered: The purpose of this narrative review is to summarize: 1) The evolution of LVAD technology and usage; 2) The physiological responses to exercise in patients with LVADs; 3) The available evidence regarding exercise training; 4) Potential strategies to implement exercise training programs for this patient population. Expert opinion: The available evidence for exercise training to improve physical function and clinical outcomes for patients with LVADs is promising but limited. Future research is needed to further elucidate the ideal exercise training parameters, method of delivery for exercise training, and unique barriers and facilitators to exercise training for patients receiving LVAD implantation.
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Affiliation(s)
- Richard Severin
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Ahmad Sabbahi
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Cemal Ozemek
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Shane Phillips
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Ross Arena
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
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Significant impact of left ventricular assist device models on the value of flow-mediated dilation: effects of LVAD on endothelial function. Heart Vessels 2019; 35:207-213. [DOI: 10.1007/s00380-019-01474-2] [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: 04/04/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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10
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Miyamoto T, Karimov JH, Fukamachi K. Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology. Expert Rev Med Devices 2018; 15:171-182. [DOI: 10.1080/17434440.2018.1437346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
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Abstract
PURPOSE OF REVIEW The majority of patients currently implanted with left ventricular assist devices have the expectation of support for more than 2 years. As a result, survival alone is no longer a sufficient distinctive for this technology, and there have been many studies within the last few years examining functional capacity and exercise outcomes. RECENT FINDINGS Despite strong evidence for functional class improvements and increases in simple measures of walking distance, there remains incomplete normalization of exercise capacity, even in the presence of markedly improved resting hemodynamics. Reasons for this remain unclear. Despite current pumps being run at a fixed speed, it is widely recognized that pump outputs significantly increase with exercise. The mechanism of this increase involves the interaction between preload, afterload, and the intrinsic pump function curves. The role of the residual heart function is also important in determining total cardiac output, as well as whether the aortic valve opens with exercise. Interactions with the vasculature, with skeletal muscle blood flow and the state of the autonomic nervous system are also likely to be important contributors to exercise performance. SUMMARY Further studies examining optimization of pump function with active pump speed modulation and options for optimization of the overall patient condition are likely to be needed to allow left ventricular assist devices to be used with the hope of full functional physiological recovery.
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The response of the microcirculation to mechanical support of the heart in critical illness. Best Pract Res Clin Anaesthesiol 2016; 30:511-522. [PMID: 27931654 DOI: 10.1016/j.bpa.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Critical illness associated with cardiac pump failure results in reduced tissue perfusion in all organs and occurs in various conditions such as sepsis, cardiogenic shock, and heart failure. Mechanical circulatory support (MCS) devices can be used to maintain organ perfusion in patients with cardiogenic shock and decompensated chronic heart failure. However, correction of global hemodynamic parameters by MCS does not always cause a parallel improvement in microcirculatory perfusion and oxygenation of the organ systems, a condition referred to as a loss of hemodynamic coherence between macro- and microcirculation (MC). In this paper, we review the literature describing hemodynamic coherence or loss occurring during MCS of the heart. By using Embase, Medline Cochrane, Web of Science, and Google Scholar, we analyzed the literature on the response of MC and macrocirculation to MCS of the heart in critical illness. The characteristics of patients, MCS devices, and micro- and macrocirculatory parameters were very heterogenic. Short-term MCS studies (78%) described the effects of intra-aortic balloon pumps (IABPs) on the MC and macrocirculation. Improvement in MC, observed by handheld microscopy (orthogonal polarization spectral (OPS), sidestream dark-field (SDF), and Cytocam IDF imaging) in line with restored macrocirculation was found in 44% and 40% of the studies of short- and long-term MCS, respectively. In only 6 of 14 studies, hemodynamic coherence was described. It is concluded that more studies using direct visualization of the MC in short- and long-term MCS by handheld microscopy are needed, preferably randomized controlled studies, to identify the presence and clinical significance of hemodynamic coherence. It is anticipated that these further studies can enable to better identify patients who will benefit from treatment by mechanical heart support to ensure adequate organ perfusion.
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Grosman-Rimon L, Billia F, Fuks A, Jacobs I, A McDonald M, Cherney DZ, Rao V. New therapy, new challenges: The effects of long-term continuous flow left ventricular assist device on inflammation. Int J Cardiol 2016; 215:424-30. [PMID: 27131263 DOI: 10.1016/j.ijcard.2016.04.133] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
Surgically implanted continuous flow left ventricular assist devices (CF-LVADs) are currently used in patients with end-stage heart failure (HF). However, CF-LVAD therapy introduces a new set of complications and adverse events in these patients. Major adverse events with the CF-LVAD include right heart failure, vascular dysfunction, stroke, hepatic failure, and multi-organ failure, complications that may have inflammation as a common etiology. Our aim was to review the current evidence showing a relationship between these adverse events and elevated levels of inflammatory biomarkers in CF-LVAD recipients.
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Affiliation(s)
- Liza Grosman-Rimon
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Avi Fuks
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Ira Jacobs
- Faculty of Kinesiology and Physical Education, University of Toronto, Canada
| | - Michael A McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - David Z Cherney
- Division of Nephrology, University Health Network, University of Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
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15
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Witman MAH, Garten RS, Gifford JR, Groot HJ, Trinity JD, Stehlik J, Nativi JN, Selzman CH, Drakos SG, Richardson RS. Further Peripheral Vascular Dysfunction in Heart Failure Patients With a Continuous-Flow Left Ventricular Assist Device: The Role of Pulsatility. JACC-HEART FAILURE 2015; 3:703-11. [PMID: 26277768 DOI: 10.1016/j.jchf.2015.04.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/07/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Using flow-mediated vasodilation (FMD) and reactive hyperemia (RH), this study aimed to provide greater insight into left ventricular assist device (LVAD)-induced changes in peripheral vascular function. BACKGROUND Peripheral endothelial function is recognized to be impaired in patients with heart failure with reduced ejection fraction (HFrEF), but the peripheral vascular effects of continuous-flow LVAD implantation, now used as either a bridge to transplantation or as a destination therapy, remain unclear. METHODS Sixty-eight subjects (13 New York Heart Association [NYHA] functional class II HFrEF patients, 19 NYHA functional class III/IV HFrEF patients, 20 NYHA functional class III/IV HFrEF patients post-LVAD implantation, and 16 healthy age-matched control subjects) underwent FMD and RH testing in the brachial artery with blood flow velocity, artery diameters, and pulsatility index (PI) assessed by ultrasound Doppler. RESULTS PI was significantly lower in the LVAD group (2.0 ± 0.4) compared with both the HFrEF II (8.6 ± 0.8) and HFrEF III/IV (8.1 ± 0.9) patients, who, in turn, had significantly lower PI than the control subjects (12.8 ± 0.9). Likewise, LVAD %FMD/shear rate (0.09 ± 0.01 %Δ/s(-1)) was significantly reduced compared with all other groups (control subjects, 0.24 ± 0.03; HFrEF II, 0.17 ± 0.02; and HFrEF III/IV, 0.13 ± 0.02 %Δ/s(-1)), and %FMD/shear rate significantly correlated with PI (r = 0.45). RH was unremarkable across groups. CONCLUSIONS Although central hemodynamics are improved in patients with HFrEF by a continuous-flow LVAD, peripheral vascular function is further compromised, which is likely due, at least in part, to the reduction in pulsatility that is a characteristic of such a mechanical assist device.
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Affiliation(s)
- Melissa A H Witman
- Geriatric Research, Education, and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, Utah; Department of Internal Medicine, Division of Geriatrics, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Ryan S Garten
- Geriatric Research, Education, and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, Utah; Department of Internal Medicine, Division of Geriatrics, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jayson R Gifford
- Department of Exercise and Sport Science, University of Utah, Salt Lake City, Utah
| | - H Jonathan Groot
- Department of Exercise and Sport Science, University of Utah, Salt Lake City, Utah
| | - Joel D Trinity
- Geriatric Research, Education, and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, Utah; Department of Internal Medicine, Division of Geriatrics, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Department of Internal Medicine, Division of Cardiovascular Medicine, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jose N Nativi
- Department of Internal Medicine, Division of Cardiovascular Medicine, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Craig H Selzman
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stavros G Drakos
- Department of Internal Medicine, Division of Cardiovascular Medicine, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Russell S Richardson
- Geriatric Research, Education, and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, Utah; Department of Internal Medicine, Division of Geriatrics, George E. Whalen VA Medical Center and University of Utah Medical Center, University of Utah School of Medicine, Salt Lake City, Utah; Department of Exercise and Sport Science, University of Utah, Salt Lake City, Utah
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16
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Exercise physiology, testing, and training in patients supported by a left ventricular assist device. J Heart Lung Transplant 2015; 34:1005-16. [DOI: 10.1016/j.healun.2014.12.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 01/14/2023] Open
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Hasin T, Matsuzawa Y, Guddeti RR, Aoki T, Kwon TG, Schettle S, Lennon RJ, Chokka RG, Lerman A, Kushwaha SS. Attenuation in peripheral endothelial function after continuous flow left ventricular assist device therapy is associated with cardiovascular adverse events. Circ J 2015; 79:770-7. [PMID: 25739569 DOI: 10.1253/circj.cj-14-1079] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with heart failure (HF) have abnormal endothelial function. Although use of a continuous flow left ventricular assist device (CF-LVAD) results in significant hemodynamic improvement, the effects on systemic endothelial function are unclear. METHODS AND RESULTS Eighteen HF patients with CF-LVAD implantation were included in this prospective observational study. We measured reactive hyperemia index (RHI) before and after CF-LVAD implantation to evaluate sequential changes in endothelial function. Patients were followed clinically for the occurrence of adverse cardiovascular events, a composite of death, thrombosis, bleeding, HF, renal failure, and arrhythmia. Preoperative RHI was 1.77±0.39. Early in the postoperative period (7-14 days after operation) RHI significantly decreased to 1.19±0.31 (P<0.001, compared with preoperative RHI). At first and second follow-up (4-6 weeks and 3-7 months after operation) RHI remained lower at 1.48±0.50 (P=0.030) and 1.26±0.37 (P=0.002), respectively, compared with preoperative RHI. The decrease in early postoperative RHI relative to preoperative RHI was significantly associated with adverse cardiovascular events after CF-LVAD (age-adjusted risk ratio for 0.25 decrease in RHI, 1.35; 95% confidence interval: 1.13-1.62, P=0.001). CONCLUSIONS Peripheral endothelial function had a significant and persistent decline up to 5 months following implantation of CF-LVAD, and this decline was associated with adverse cardiovascular events. These findings may provide insight into some of the vascular complications following CF-LVAD in HF patients.
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Affiliation(s)
- Tal Hasin
- Division of Cardiovascular Disease, Mayo College of Medicine
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Hasin T, Jaarsma T, Murninkas D, Setareh-Shenas S, Yaari V, Bar-Yosef S, Medalion B, Gerber Y, Ben-Gal T. Sexual function in patients supported with left ventricular assist device and with heart transplant. ESC Heart Fail 2014; 1:103-109. [PMID: 28834629 DOI: 10.1002/ehf2.12014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 09/27/2014] [Accepted: 10/20/2014] [Indexed: 11/12/2022] Open
Abstract
AIMS Sexual dysfunction is common among patients with heart failure (HF) and considered an important hamper to quality of life. While implantation of left ventricular assist device (LVAD) may prolong and improve life in advanced HF, limited data are available on its impact on sexual function. The aim of this study is to evaluate sexual function in LVAD patients and compare this with patients after heart transplantation (HTx). METHODS AND RESULTS Sexual activity and satisfaction of stable patients with durable LVAD or after HTx were evaluated using a validated questionnaire and visual analogue scale from 0 to 10. Data were collected from 31 patients (mean age 59 ± 12 years, 87% male), 17 after HTx and 14 with LVAD. Pleasure or satisfaction with sex was significantly higher in HTx patients (P = 0.0005). In total, 29% LVAD patients and 71% HTx patients reported content with sexual activity. Recalled satisfaction with sex life pre-operation was comparable between the groups. During support, satisfaction with sex life using visual analogue scale was 7.6 ± 3.1 for HTx versus 3.9 ± 4.0 for LVAD patients (P = 0.017). In total, 11 LVAD patients (79%) reported specific problems in sexual function including erectile dysfunction or vaginal dryness (8, 57%); problems with the LVAD, cable, or batteries (5, 36%); problems with orgasm (4,29%); and other problems such as fear of injury, feeling depressed, partner issues, self-image, and pain (1, 7% each). CONCLUSION Sexual dysfunction occurs in patients with LVAD support and may be more prominent than after HTx. Problems limiting sexual function related to physiological, psychological, and equipment merit consideration during follow-up.
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Affiliation(s)
- Tal Hasin
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tiny Jaarsma
- Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - Daniel Murninkas
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
| | | | - Victoria Yaari
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
| | - Simona Bar-Yosef
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
| | - Benjamin Medalion
- Department of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Gerber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tuvia Ben-Gal
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Systolic blood pressure on discharge after left ventricular assist device insertion is associated with subsequent stroke. J Heart Lung Transplant 2014; 34:503-8. [PMID: 25540881 DOI: 10.1016/j.healun.2014.09.042] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/18/2014] [Accepted: 09/30/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Stroke is a significant complication in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) and hypertension is a significant risk factor for stroke, but the association between blood pressure and stroke in LVAD patients is not well characterized. METHODS We identified 275 consecutive patients who survived implant hospitalization between January 2005 and April 2013. Patients were grouped according to systolic blood pressure (SBP) as above a median and below a median of 100 mm Hg by their averaged systolic blood pressure during the 48 hours before discharge from implantation hospitalization. The groups were compared for the primary outcome of time to stroke. RESULTS The above-median SBP group had mean SBP of 110 mm Hg and the below-median SBP group had mean SBP of 95 mm Hg. There were no significant between-group differences in body mass index, smoking, vascular disease, hypertension, atrial fibrillation, or prior stroke. During a mean follow-up of 16 months, stroke occurred in 16% of the above-median SBP group vs in 7% of the below-median SBP group (hazard ratio, 2.38; 95% confidence interval, 1.11-5.11), with a similar proportion of hemorrhagic and ischemic strokes in each group. In Cox proportional hazard models adjusting for age, diabetes, or prior stroke, the hazard ratio remained statistically significant. SBP as a continuous variable predictor of stroke had an area under the curve of 0.64 in a receiver operating characteristic curve analysis. CONCLUSIONS In this large, CF-LVAD cohort, elevated SBP was independently associated with a greater risk of subsequent stroke. These results identify management of hypertension as a potential modifiable risk factor for reducing the incidence of stroke in patients supported by CF-LVAD.
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Holley CT, Harvey L, John R. Left ventricular assist devices as a bridge to cardiac transplantation. J Thorac Dis 2014; 6:1110-9. [PMID: 25132978 DOI: 10.3978/j.issn.2072-1439.2014.06.46] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 06/30/2014] [Indexed: 11/14/2022]
Abstract
Heart failure remains a significant cause of morbidity and mortality, affecting over five million patients in the United States. Continuous-flow left ventricular assist devices (LVAD) have become the standard of care for patients with end stage heart failure. This review highlights the current state of LVAD as a bridge to transplant (BTT) in patients requiring mechanical circulatory support (MCS).
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Affiliation(s)
| | - Laura Harvey
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
| | - Ranjit John
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
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Mitchell A, Guan W, Staggs R, Hamel A, Hozayen S, Adhikari N, Grindle S, Desir S, John R, Hall JL, Eckman P. Identification of differentially expressed transcripts and pathways in blood one week and six months following implant of left ventricular assist devices. PLoS One 2013; 8:e77951. [PMID: 24205042 PMCID: PMC3804545 DOI: 10.1371/journal.pone.0077951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 09/06/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Continuous-flow left ventricular assist devices (LVADs) are an established therapy for patients with end-stage heart failure. The short- and long-term impact of these devices on peripheral blood gene expression has not been characterized, and may provide insight into the molecular pathways mediated in response to left ventricular remodeling and an improvement in overall systemic circulation. We performed RNA sequencing to identify genes and pathways influenced by these devices. Methods RNA was extracted from blood of 9 heart failure patients (8 male) prior to LVAD implantation, and at 7 and 180 days postoperatively. Libraries were sequenced on an Illumina HiSeq2000 and sequences mapped to the human Ensembl GRCh37.67 genome assembly. Results A specific set of genes involved in regulating cellular immune response, antigen presentation, and T cell activation and survival were down-regulated 7 days after LVAD placement. 6 months following LVAD placement, the expression levels of these genes were significantly increased; yet importantly, remained significantly lower than age and sex-matched samples from healthy controls. Conclusions In summary, this genomic analysis identified a significant decrease in the expression of genes that promote a healthy immune response in patients with heart failure that was partially restored 6 months following LVAD implant.
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Affiliation(s)
- Adam Mitchell
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Weihua Guan
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Rodney Staggs
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Aimee Hamel
- Lillehei Clinical Research Unit, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Sameh Hozayen
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Neeta Adhikari
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Suzanne Grindle
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Snider Desir
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Ranjit John
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jennifer L. Hall
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- * E-mail: (JH); (PE)
| | - Peter Eckman
- Lillehei Heart Institute, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
- * E-mail: (JH); (PE)
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Postcardiac transplant survival in the current era in patients receiving continuous-flow left ventricular assist devices. J Thorac Cardiovasc Surg 2013; 145:575-81. [PMID: 23321132 DOI: 10.1016/j.jtcvs.2012.09.095] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/07/2012] [Accepted: 09/27/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Continuous-flow left ventricular assist devices have become the standard of care for patients with heart failure requiring mechanical circulatory support as a bridge to transplant. However, data on long-term post-transplant survival for these patients are limited. We evaluated the effect of continuous-flow left ventricular assist devices on postcardiac transplant survival in the current era. METHODS All patients who received a continuous-flow left ventricular assist device as a bridge to transplant at a single center from June 2005 to September 2011 were evaluated. RESULTS Of the 167 patients who received a continuous-flow left ventricular assist device as a bridge to transplant, 77 (46%) underwent cardiac transplantation, 27 died before transplantation (16%), and 63 (38%) remain listed for transplantation and continued with left ventricular assist device support. The mean age of the transplanted patients was 54.5 ± 11.9 years, 57% had an ischemic etiology, and 20% were women. The overall mean duration of left ventricular assist device support before transplantation was 310 ± 227 days (range, 67-1230 days). The mean duration of left ventricular assist device support did not change in patients who had received a left ventricular assist device in the early period of the study (2005-2008, n = 62) compared with those who had received a left ventricular assist device later (2009-2011, n = 78, 373 vs 392 days, P = NS). In addition, no difference was seen in survival between those patients supported with a left ventricular assist device for fewer than 180 days or longer than 180 days before transplantation (P = NS). The actuarial survival after transplantation at 30 days and 1, 3, and 5 years by Kaplan-Meier analysis was 98.7%, 93.0%, 91.1%, and 88.0%, respectively. CONCLUSIONS The short- and long-term post-transplant survival for patients bridged with a continuous-flow left ventricular assist device in the current era has been excellent. Furthermore, the duration of left ventricular assist device support did not affect post-transplant survival. The hemodynamic benefits of ventricular unloading with continuous-flow left ventricular assist devices, in addition to their durability and reduced patient morbidity, have contributed to improved post-transplant survival.
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