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Beese S, Avşar TS, Price M, Quinn D, Lim HS, Dretzke J, Ogwulu CO, Barton P, Jackson L, Moore D. Clinical and cost-effectiveness of left ventricular assist devices as destination therapy for advanced heart failure: systematic review and economic evaluation. Health Technol Assess 2024; 28:1-237. [PMID: 39189844 PMCID: PMC11367304 DOI: 10.3310/mlfa4009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
Background Selected patients with advanced heart failure ineligible for heart transplantation could benefit from left ventricular assist device therapy as 'destination therapy'. There is evidence of the efficacy of destination therapy; however, it is not currently commissioned within the United Kingdom National Health Service due to the lack of economic evidence. Objective What is the clinical and cost-effectiveness of a left ventricular assist device compared to medical management for patients with advanced heart failure ineligible for heart transplantation (destination therapy)? Methods A systematic review of evidence on the clinical and cost-effectiveness of left ventricular assist devices as destination therapy was undertaken including, where feasible, a network meta-analysis to provide an indirect estimate of the relative effectiveness of currently available left ventricular assist devices compared to medical management. For the systematic reviews, data sources searched (up to 11 January 2022) were Cochrane CENTRAL, MEDLINE and EMBASE via Ovid for primary studies, and Epistemonikos and Cochrane Database of Systematic Reviews for relevant systematic reviews. Trial registers were also searched, along with data and reports from intervention-specific registries. Economic studies were identified in EconLit, CEA registry and the NHS Economic Evaluation Database (NHS EED). The searches were supplemented by checking reference lists of included studies. An economic model (Markov) was developed to estimate the cost-effectiveness of left ventricular assist devices compared to medical management from the United Kingdom National Health Service/personal social service perspective. Deterministic and probabilistic sensitivity analyses were conducted to explore uncertainties. Where possible, all analyses focused on the only currently available left ventricular assist device (HeartMate 3TM, Abbott, Chicago, IL, USA) in the United Kingdom. Results The clinical effectiveness review included 134 studies (240 articles). There were no studies directly comparing HeartMate 3 and medical management (a randomised trial is ongoing). The currently available left ventricular assist device improves patient survival and reduces stroke rates and complications compared to earlier devices and relative to medical management. For example, survival at 24 months is 77% with the HeartMate 3 device compared to 59% with the HeartMate II (MOMENTUM 3 trial). An indirect comparison demonstrated a reduction in mortality compared to medical management [relative risk of death 0.25 (95% confidence interval 0.13 to 0.47); 24 months; this study]. The cost-effectiveness review included 5 cost analyses and 14 economic evaluations covering different generations of devices and with different perspectives. The reported incremental costs per quality-adjusted life-year gained compared to medical management were lower for later generations of devices [as low as £46,207 (2019 prices; United Kingdom perspective; time horizon at least 5 years)]. The economic evaluation used different approaches to obtain the relative effects of current left ventricular assist devices compared to medical management from the United Kingdom National Health Service/personal social service perspective. All gave similar incremental cost-effectiveness ratios of £53,496-58,244 per quality-adjusted life-year gained - lifetime horizon. Model outputs were sensitive to parameter estimates relating to medical management. The findings did not materially differ on exploratory subgroup analyses based on the severity of heart failure. Limitations There was no direct evidence comparing the clinical effectiveness of HeartMate 3 to medical management. Indirect comparisons made were based on limited data from heterogeneous studies regarding the severity of heart failure (Interagency Registry for Mechanically Assisted Circulatory Support score distribution) and possible for survival only. Furthermore, the cost of medical management of advanced heart failure in the United Kingdom is not clear. Conclusions Using cost-effectiveness criteria applied in the United Kingdom, left ventricular assist devices compared to medical management for patients with advanced heart failure ineligible for heart transplant may not be cost-effective. When available, data from the ongoing evaluation of HeartMate 3 compared to medical management can be used to update cost-effectiveness estimates. An audit of the costs of medical management in the United Kingdom is required to further decrease uncertainty in the economic evaluation. Study registration This study is registered as PROSPERO CRD42020158987. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128996) and is published in full in Health Technology Assessment; Vol. 28, No. 38. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sophie Beese
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tuba S Avşar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Institute of Epidemiology and Health, University College London, London, UK
| | - Malcolm Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Quinn
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hoong S Lim
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Janine Dretzke
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chidubem O Ogwulu
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Pelham Barton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Louise Jackson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Hwang B, Doyle M, Williams ML, Joshi Y, Iyer A, Watson A, Jansz P, Hayward C. Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis. Artif Organs 2024. [PMID: 38989991 DOI: 10.1111/aor.14819] [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: 12/10/2023] [Revised: 05/25/2024] [Accepted: 06/21/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. METHODS A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. RESULTS Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). CONCLUSIONS Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.
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Affiliation(s)
- Bridget Hwang
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Mathew Doyle
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Yashutosh Joshi
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Arjun Iyer
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Alasdair Watson
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Chris Hayward
- Department of Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
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Beneyto M, Martins R, Galand V, Kindo M, Schneider C, Sebestyen A, Boignard A, Sebbag L, Pozzi M, Genet T, Bourguignon T, Martin AC, Achouh P, Vanhuyse F, Blang H, David CH, Michel M, Anselme F, Litzler PY, Jungling M, Vincentelli A, Eschalier R, D'Ostrevy N, Nataf P, Para M, Garnier F, Rajinthan P, Porterie J, Faure M, Picard F, Gaudard P, Rouvière P, Babatasi G, Blanchart K, Gariboldi V, Porto A, Flecher E, Delmas C. Right Ventriculoarterial Coupling Surrogates and Long-Term Survival in LVAD Recipients: Results of the ASSIST-ICD Multicentric Registry. J Card Fail 2024:S1071-9164(24)00195-7. [PMID: 38851449 DOI: 10.1016/j.cardfail.2024.05.007] [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: 11/30/2023] [Revised: 04/09/2024] [Accepted: 05/10/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Prediction of outcomes remains an unmet need in candidates for LVADs. The development of right-heart failure portends an excess in mortality rates, but imaging parameters of right ventricular systolic function have failed to demonstrate a prognostic role. By integrating pulmonary pressure, right ventriculoarterial coupling could fill this gap. METHODS The ASSIST-ICD registry was used to test right ventriculoarterial coupling as a surrogate parameter at implantation for the prediction of all-cause mortality. RESULTS The ratio of the tricuspid annular-plane systolic excursion over the estimated systolic pulmonary pressure (TAPSE/sPAP) was not associated with long-term survival in univariate analysis (P = 0.89), nor was the pulmonary artery pulsatility index (PAPi) (P = 0.13). Conversely, the ratio of the right atrial pressure over the pulmonary capillary wedge pressure (RAP/PCWP) was associated with all-cause mortality (P < 0.01). After taking tricuspid regurgitation severity, LVAD indication, LVAD model, age, blood urea nitrogen levels, and pulmonary vascular resistance into account, RAP/PCWP remained associated with survival (HR 1.35 [1.10 - 1.65]; P < 0.01). CONCLUSION Among pre-implant RVAC surrogates, only RAP/PCWP was associated with long-term all-cause mortality in LVAD recipients. This association was independent of established risk factors.
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Affiliation(s)
- Maxime Beneyto
- Cardiology Department, Toulouse University Hospital, Toulouse, France.
| | - Raphaël Martins
- Cardiology Department, Rennes University Hospital, Rennes, France
| | - Vincent Galand
- Cardiology Department, Rennes University Hospital, Rennes, France
| | - Michel Kindo
- Strasbourg University Hospital, Strasbourg, France
| | | | | | | | | | | | | | | | | | | | | | - Hugues Blang
- Nancy University Hospital, Villeneuve les Nancy, France
| | | | - Magali Michel
- Institut du Thorax, Nantes University Hospital, Nantes, France
| | | | | | | | | | | | | | | | - Marylou Para
- Bichat University Hospital, AP-HP, Paris, France
| | - Fabien Garnier
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | | | - Jean Porterie
- Cardiovascular Surgery department, Toulouse University Hospital, Toulouse, France
| | - Maxime Faure
- Cardiology department, Bordeaux University Hospital, Pessac, France
| | - François Picard
- Cardiology department, Bordeaux University Hospital, Pessac, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERN, CNRS, Montpellier, France
| | - Philippe Rouvière
- Department of Cardiac Surgery, CHU Montpellier, University of Montpellier, Montpellier, France
| | | | | | - Vlad Gariboldi
- Cardiac Surgery Department, La Timone University Hospital, AP-HM, Marseille, France
| | - Alizée Porto
- Cardiac Surgery Department, La Timone University Hospital, AP-HM, Marseille, France
| | - Erwan Flecher
- Cardiac Surgery Department, Rennes University Hospital, Rennes, France
| | - Clement Delmas
- Cardiology Department, Toulouse University Hospital, Toulouse, France; REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
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Cutrone M, Cotter S, Swaminathan M, McCartney S. Intraoperative Echocardiography: Guide to Decision-Making. Curr Cardiol Rep 2024; 26:581-591. [PMID: 38573554 DOI: 10.1007/s11886-024-02054-1] [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] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW This review aims to provide a concise overview of key recommendations, with a specific focus on common challenges faced by intraoperative echocardiographers when dealing with frequently encountered valvular pathologies and mechanical circulatory support. It offers valuable insights for medical practitioners in this field. RECENT FINDINGS The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.
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Affiliation(s)
- Michael Cutrone
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, HAFS 5670, Durham, NC, 27710, USA.
| | - Sarah Cotter
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, HAFS 5670, Durham, NC, 27710, USA
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, HAFS 5670, Durham, NC, 27710, USA
| | - Sharon McCartney
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, HAFS 5670, Durham, NC, 27710, USA
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Silvestry SC. Commentary: Tricuspid repair and left ventricular assist device: A new baseline. J Thorac Cardiovasc Surg 2024; 167:1821-1822. [PMID: 36535819 DOI: 10.1016/j.jtcvs.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022]
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Luo Y, Leng J, Shi R, Jiang Y, Chen D, Wu Q, Tie H. Concomitant tricuspid valve surgery in patients undergoing left ventricular assist device: a systematic review and meta-analysis. Int J Surg 2024; 110:3039-3049. [PMID: 38348836 DOI: 10.1097/js9.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION This study aims to investigate the effect of concomitant tricuspid valve surgery (TVS) during left ventricular assist device (LVAD) implantation due to the controversy over the clinical outcomes of concomitant TVS in patients undergoing LVAD. METHODS A systematic literature search was performed in PubMed and EMbase from the inception to 1 August 2023. Studies comparing outcomes in adult patients undergoing concomitant TVS during LVAD implantation (TVS group) and those who did not (no-TVS group) were included. The primary outcomes were right heart failure (RHF), right ventricular assist device (RVAD) implantation, and early mortality. All meta-analyses were performed using random-effects models, and a two-tailed P <0.05 was considered significant. RESULTS Twenty-one studies were included, and 16 of them were involved in the meta-analysis, with 660 patients in the TVS group and 1291 in the no-TVS group. Patients in the TVS group suffered from increased risks of RHF [risk ratios (RR)=1.31, 95% CI: 1.01-1.70, P =0.04; I2 =38%, pH =0.13), RVAD implantation (RR=1.56, 95% CI: 1.16-2.11, P =0.003; I2 =0%, pH =0.74), and early mortality (RR=1.61, 95% CI: 1.07-2.42, P =0.02; I2 =0%, pH =0.75). Besides, the increased risk of RHF holds true in patients with moderate to severe tricuspid regurgitation (RR=1.36, 95% CI: 1.04-1.78, P =0.02). TVS was associated with a prolonged cardiopulmonary bypass time. No significant differences in acute kidney injury, reoperation requirement, hospital length of stay, or ICU stay were observed. CONCLUSIONS Concomitant TVS failed to show benefits in patients undergoing LVAD, and it was associated with increased risks of RHF, RVAD implantation, and early mortality.
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Affiliation(s)
- Yuxiang Luo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jiajie Leng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Rui Shi
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yingjiu Jiang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qingchen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
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Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, Green CL, Gross R, Bryner BS, Schroder JN, Daneshmand MA, Russell SD, DeVore AD, Patel CB, Katz JN, Milano CA, Bishawi M. Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial. J Thorac Cardiovasc Surg 2024; 167:1810-1820.e2. [PMID: 36639288 PMCID: PMC10185708 DOI: 10.1016/j.jtcvs.2022.10.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. METHODS Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. RESULTS This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. CONCLUSIONS The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.
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Affiliation(s)
| | - Yuting Chiang
- Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Ryan Gross
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | | | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center
| | | | - Jason N Katz
- Division of Cardiology, Duke University Medical Center
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center.
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Mitra A, Castleberry A, Urban M, Siddique A. Does concomitant tricuspid valve intervention at the time of left ventricular assist device placement for patients with significant tricuspid regurgitation lead to improved outcomes compared to isolated left ventricular assist device placement? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae005. [PMID: 38216526 PMCID: PMC10850842 DOI: 10.1093/icvts/ivae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with advanced heart failure (HF) and moderate to severe functional tricuspid regurgitation (TR) undergoing left ventricular assist device (LVAD) placement is concomitant tricuspid valve intervention (TVI) superior for the clinical outcomes of survival, right ventricular failure, rehospitalizations for HF, functional status, and quality of life?' Altogether, 56 papers were found using the reported search, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Our search found no significant clinical benefit for concomitant TVI at the time of LVAD placement. We conclude that patient with moderate-to-severe TR should not routinely undergo concomitant TVI with LVAD placement.
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Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony Castleberry
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marian Urban
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aleem Siddique
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [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: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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11
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Siems C, Aggarwal R, Shaffer A, John R. Right heart failure after left ventricular assist device implantation: a persistent problem. Indian J Thorac Cardiovasc Surg 2023; 39:161-169. [PMID: 37525713 PMCID: PMC10387018 DOI: 10.1007/s12055-023-01481-z] [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: 08/14/2022] [Revised: 12/09/2022] [Accepted: 01/17/2023] [Indexed: 02/24/2023] Open
Abstract
Left ventricular assist device (LVAD) is an option for bridge-to-transplant or destination therapy for patients with end-stage heart failure. Right heart failure (RHF) remains a complication after LVAD implantation that portends high morbidity and mortality, despite advances in LVAD technology. Definitions of RHF vary, but generally include the need for inotropic or pulmonary vasodilator support, or potential right ventricular (RV) mechanical circulatory support. This review covers the complex pathophysiology of RHF related to underlying myocardial dysfunction, interventricular dependence, and RV afterload, as well as treatment strategies to curtail this challenging problem.
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Affiliation(s)
- Chesney Siems
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
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12
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Mitra A, Siddique A. Tricuspid regurgitation in the setting of LVAD support. Front Cardiovasc Med 2023; 10:1090150. [PMID: 37304950 PMCID: PMC10250620 DOI: 10.3389/fcvm.2023.1090150] [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: 11/05/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Tricuspid valve regurgitation (TR) is a common complication of end-stage heart failure. Increased pulmonary venous pressures caused by left ventricular (LV) dysfunction can result in a progressive dilation of the right ventricle and tricuspid valve annulus, resulting in functional TR. Here, we review what is known about TR in the setting of severe LV dysfunction necessitating long-term mechanical support with left ventricular assist devices (LVADs), including the occurrence of significant TR, its pathophysiology, and natural history. We examine the impact of uncorrected TR on LVAD outcomes and the impact of tricuspid valve interventions at the time of LVAD placement, revealing that TR frequently improves after LVAD placement with or without concomitant tricuspid valve intervention such that the benefit of concomitant intervention remains controversial. We summarize the current evidence on which to base medical decisions and provide recommendations for future directions of study to address outstanding questions in the field.
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Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery,University of Nebraska Medical Center, Omaha, NE, United States
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13
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Dagher O, Santaló-Corcoy M, Perrin N, Dorval JF, Duggal N, Modine T, Ducharme A, Lamarche Y, Noly PE, Asgar A, Ben Ali W. Transcatheter valvular therapies in patients with left ventricular assist devices. Front Cardiovasc Med 2023; 10:1071805. [PMID: 36993995 PMCID: PMC10040555 DOI: 10.3389/fcvm.2023.1071805] [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: 10/16/2022] [Accepted: 02/21/2023] [Indexed: 03/14/2023] Open
Abstract
Aortic, mitral and tricuspid valve regurgitation are commonly encountered in patients with continuous-flow left ventricular assist devices (CF-LVADs). These valvular heart conditions either develop prior to CF-LVAD implantation or are induced by the pump itself. They can all have significant detrimental effects on patients' survival and quality of life. With the improved durability of CF-LVADs and the overall rise in their volume of implants, an increasing number of patients will likely require a valvular heart intervention at some point during CF-LVAD therapy. However, these patients are often considered poor reoperative candidates. In this context, percutaneous approaches have emerged as an attractive "off-label" option for this patient population. Recent data show promising results, with high device success rates and rapid symptomatic improvements. However, the occurrence of distinct complications such as device migration, valve thrombosis or hemolysis remain of concern. In this review, we will present the pathophysiology of valvular heart disease in the setting of CF-LVAD support to help us understand the underlying rationale of these potential complications. We will then outline the current recommendations for the management of valvular heart disease in patients with CF-LVAD and discuss their limitations. Lastly, we will summarize the evidence related to transcatheter heart valve interventions in this patient population.
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Affiliation(s)
- Olina Dagher
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Departmentof Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Marcel Santaló-Corcoy
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
| | - Nils Perrin
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-François Dorval
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
| | - Neal Duggal
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI, United States
| | - Thomas Modine
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévêque, CHU Bordeaux, Bordeaux, France
| | - Anique Ducharme
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
| | | | - Anita Asgar
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
| | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
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14
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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.
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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
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15
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Chaudhry S, DeVore AD, Vidula H, Nassif M, Mudy K, Birati EY, Gong T, Atluri P, Pham D, Sun B, Bansal A, Najjar SS. Left Ventricular Assist Devices: A Primer For the General Cardiologist. J Am Heart Assoc 2022; 11:e027251. [PMID: 36515226 PMCID: PMC9798797 DOI: 10.1161/jaha.122.027251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Durable implantable left ventricular assist devices (LVADs) have been shown to improve survival and quality of life for patients with stage D heart failure. Even though LVADs remain underused overall, the number of patients with heart failure supported with LVADs is steadily increasing. Therefore, general cardiologists will increasingly encounter these patients. In this review, we provide an overview of the field of durable LVADs. We discuss which patients should be referred for consideration of advanced heart failure therapies. We summarize the basic principles of LVAD care, including medical and surgical considerations. We also discuss the common complications associated with LVAD therapy, including bleeding, infections, thrombotic issues, and neurologic events. Our goal is to provide a primer for the general cardiologist in the recognition of patients who could benefit from LVADs and in the principles of managing patients with LVAD. Our hope is to "demystify" LVADs for the general cardiologist.
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Affiliation(s)
- Sunit‐Preet Chaudhry
- Division of CardiologyAscension St. Vincent Heart CenterIndianapolisIN,Ascension St. Vincent Cardiovascular Research InstituteIndianapolisIN
| | - Adam D. DeVore
- Department of Medicine and Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Himabindu Vidula
- Division of Heart Failure and TransplantUniversity of Rochester School of Medicine and DentistryRochesterNY
| | - Michael Nassif
- Division of Heart failure and TransplantSaint Luke’s Mid America Heart InstituteKansas CityMO
| | - Karol Mudy
- Division of Cardiothoracic SurgeryMinneapolis Heart InstituteMinneapolisMN
| | - Edo Y. Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and SurgeryPadeh‐Poriya Medical Center, Bar Ilan UniversityPoriyaIsrael
| | - Timothy Gong
- Center for Advanced Heart and Lung DiseaseBaylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical CenterDallasTX
| | - Pavan Atluri
- Division of Cardiovascular SurgeryUniversity of PennsylvaniaPhiladelphiaPA
| | - Duc Pham
- Center for Advanced Heart FailureBluhm Cardiovascular Institute, Northwestern University, Feinberg School of MedicineChicagoIL
| | - Benjamin Sun
- Division of Cardiothoracic Surgery, Abbott Northwestern HospitalMinneapolisMN
| | - Aditya Bansal
- Division of Cardiothoracic Surgery, Department of SurgeryOchsner Clinic FoundationNew OrleansLA
| | - Samer S. Najjar
- Division of Cardiology, MedStar Heart and Vascular InstituteMedstar Medical GroupBaltimoreMD
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16
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Hoopes C. Tricuspid surgery at the time of LVAD implant: A critique. Front Cardiovasc Med 2022; 9:1056414. [PMID: 36479565 PMCID: PMC9720263 DOI: 10.3389/fcvm.2022.1056414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/01/2022] [Indexed: 09/26/2023] Open
Abstract
Tricuspid regurgitation (TR) is a common finding in patients with end stage heart failure referred for implantation of left ventricular assist devices. While functional TR frequently resolves after left ventricular unloading, patients with residual and progressive TR demonstrate increased rates of RV dysfunction and poor survival. Criteria for intervention on the tricuspid valve have focused on the degree of tricuspid annular dilatation and the severity of tricuspid regurgitant volume. The surgical decision making regarding intervention on the tricuspid valve remains obscure and historical cohort data cannot distinguish cause from effect.
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Affiliation(s)
- Charles Hoopes
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
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17
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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18
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Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
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Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
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19
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Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
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Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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20
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Loforte A. Tricuspid valve repair and mechanical right ventricular support in rescue left ventricular assist device implantations: Still a relevant issue. J Card Surg 2022; 37:1118-1120. [DOI: 10.1111/jocs.16275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna Bologna Italy
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21
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Zubarevich A, Szczechowicz M, Arjomandi Rad A, Osswald A, Papathanasiou M, Luedike P, Koch A, Pizanis N, Kamler M, Schmack B, Ruhparwar A, Weymann A. Impact of severe mitral regurgitation on postoperative outcome after durable left-ventricular assist device implantation. Artif Organs 2021; 46:953-963. [PMID: 34931335 DOI: 10.1111/aor.14154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/08/2021] [Accepted: 11/29/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. METHODS From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n = 109) presented with MR 0-I°, and Group B presented with MR II-III° (n = 137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm2 ). RESULTS Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p < 0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p < 0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5-year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p = 0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p = 0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. CONCLUSION MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of developing postoperative major adverse events. Addressing the MR might be considered for these patients.
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Affiliation(s)
- Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Marcin Szczechowicz
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arian Arjomandi Rad
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Anja Osswald
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Peter Luedike
- Department of Cardiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Achim Koch
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
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22
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Ruiz-Cano MJ, Ramazyan L, Schramm R, Lauenroth V, Paluszkiewicz L, Rojas S, Gummert J, Morshuis M. Clinical implications of late-onset right ventricular failure after implantation of a continuous-flow left ventricular assist device as bridge to transplantation. Eur J Cardiothorac Surg 2021; 60:177-185. [PMID: 33783490 DOI: 10.1093/ejcts/ezab114] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The development of late-onset right ventricular failure (LoRVF) that occurs months after a continuous-flow left ventricular assist device (LVAD) is implanted is a clinical problem that warrants investigation. Our goal was to study the incidence, clinical manifestations and prognosis of LoRVF in a population of patients who received an LVAD as bridge to transplantation. METHODS Data were analysed from 97 consecutive patients who received an LVAD as bridge to transplantation and underwent a right heart catheterization at least 3 months after receiving an LVAD implantation. LoRVF was defined if both haemodynamic criteria of a central venous pressure >16 mmHg and a cardiac index <2.3 l/min/m2 were present. Clinical and echocardiographic variables, hospitalizations for heart failure and survival were compared between patients with and without LoRVF. RESULTS LoRVF was diagnosed in 13% of patients after a median time of 11 months. Patients with LoRVF presented preoperative worse right ventricular (RV) dilatation and severe tricuspid regurgitation. LORVF was also associated with postoperative RV dilatation, moderate to severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. LoRVF resulted in increased brain natriuretic peptide levels and the need for diuretics, lower haemoglobin levels and a higher rate of atrial fibrillation and gastrointestinal bleeding. The rate of hospitalizations for heart failure in patients with LoRVF was 46%, and 15% required an urgent transplantation due to refractory RV failure. LoRVF decreased global survival and survival free from hospitalizations for heart failure (P < 0.0001). CONCLUSIONS LoRVF after the implantation of an LVAD as bridge to transplantation is associated with higher morbidity and lower survival. The results suggest that the routine use of a right heart catheterization and transthoracic echocardiography may contribute to an early diagnosis before further severe complications due to refractory RV failure might occur. ID NUMBER OF THE IRB APPROVAL AZ-2019-521 on 10 July 2019.
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Affiliation(s)
- Maria J Ruiz-Cano
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Lylit Ramazyan
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Renné Schramm
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Volker Lauenroth
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Lech Paluszkiewicz
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Sebastian Rojas
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Jan Gummert
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
| | - Michiel Morshuis
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, NRW, Ruhr-University Bochum, Germany
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Natural History and Prognosis of Patients with Unrepaired Tricuspid Regurgitation Undergoing Implantation of Left Ventricular Assist Device. ASAIO J 2021; 68:508-515. [PMID: 34261877 DOI: 10.1097/mat.0000000000001521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We aimed to describe the natural history of left ventricular assist device (LVAD)-supported patients with preimplantation significant tricuspid regurgitation (TR) in a single-center retrospective analysis of LVAD-implanted patients (2008-2019). TR severity was assessed semiqualitatively using color-Doppler flow: insignificant TR (iTR) was defined as none/mild TR and significant TR (sTR) as ≥moderate TR. Included were 121 LVAD-supported patients of which 53% (n = 64) demonstrated sTR preimplantation. Among patients with pre-LVAD implantation sTR and available echocardiographic data, 55% (n = 26) ameliorated their TR severity grade to iTR during the first-year postsurgery and 55% (n = 17) had iTR at 2-year follow-up. On univariate analysis, predictors for TR severity improvement post-LVAD implantation were preimplant lack of atrial fibrillation, reduced inferior vena cavae diameter, and elevated pulmonary vascular resistance. In patients who failed to improve their TR severity grade, we observed a deterioration in right ventricular (RV) function (pulmonary artery pressure index 2.0 [1.7, 2.9], a decline in RV work index 242 [150, 471] mm Hg·L/m2) and higher loop-diuretics dose requirement. At a median of 21 (IQR 8, 40) months follow-up, clinical LVAD-related complications, heart failure-hospitalizations, and overall survival were similar among patients who improved versus failed to improve their TR severity-grade post-LVAD implantation. In conclusion, LVAD implantation is accompanied by a reduction in TR severity in approximately 50% of patients. In patients who failed to improve their TR severity grade, progressive RV dysfunction was observed. Overall, an isolated LVAD implantation in patients with sTR does not adversely affect survival.
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Veen KM, Mokhles MM, Soliman O, de By TMMH, Mohacsi P, Schoenrath F, Paluszkiewicz L, Netuka I, Bogers AJJC, Takkenberg JJM, Caliskan K. Clinical impact and 'natural' course of uncorrected tricuspid regurgitation after implantation of a left ventricular assist device: an analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). Eur J Cardiothorac Surg 2021; 59:207-216. [PMID: 33038216 PMCID: PMC7781523 DOI: 10.1093/ejcts/ezaa294] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/15/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES ![]()
Data on the impact and course of uncorrected tricuspid regurgitation (TR) during left ventricular assist device (LVAD) implantation are scarce and inconsistent. This study explores the clinical impact and natural course of uncorrected TR in patients after LVAD implantation.
METHODS The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients with LVAD implants without concomitant tricuspid valve surgery. A mediation model was developed to assess the association of TR with 30-day mortality via other risk factors. Generalized mixed models were used to model the course of post-LVAD TR. Joint models were used to perform sensitivity analyses. RESULTS A total of 2496 procedures were included (median age: 56 years; men: 83%). TR was not directly associated with higher 30-day mortality, but mediation analyses suggested an indirect association via preoperative elevated right atrial pressure and creatinine (P = 0.035) and bilirubin (P = 0.027) levels. Post-LVAD TR was also associated with increased late mortality [hazard ratio 1.16 (1.06–1.3); P = 0.001]. On average, uncorrected TR diminished after LVAD implantation. The probability of having moderate-to-severe TR immediately after an implant in patients with none-to-mild TR pre-LVAD was 10%; in patients with moderate-to-severe TR pre-LVAD, it was 35% and continued to decrease in patients with moderate-to-severe TR pre-LVAD, regardless of pre-LVAD right ventricular failure or pulmonary hypertension. CONCLUSIONS Uncorrected TR pre-LVAD and post-LVAD is associated with increased early and late mortality. Nevertheless, on average, TR diminishes progressively without intervention after an LVAD implant. Therefore, these data suggest that patient selection for concomitant tricuspid valve surgery should not be based solely on TR grade.
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Affiliation(s)
- Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Osama Soliman
- Department of Cardiology, Erasmus MC, Rotterdam, Netherlands
| | | | - Paul Mohacsi
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Lech Paluszkiewicz
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Department of Cardiothoracic Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, Rotterdam, Netherlands
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25
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Mulzer J, Krastev H, Hoermandinger C, Meyer A, Haese T, Stein J, Müller M, Schoenrath F, Knosalla C, Starck C, Falk V, Potapov E, Knierim J. Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices. Ann Cardiothorac Surg 2021; 10:364-374. [PMID: 34159117 DOI: 10.21037/acs-2020-cfmcs-fs-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tricuspid regurgitation (TR) after left ventricular assist device (LVAD) implantation is associated with a poor prognosis. This study evaluates the development of TR and right ventricular (RV) performance after LVAD implantation. Methods Retrospective analysis of patients who underwent LVAD implantation between March 2018 and June 2019. Patients who underwent concomitant tricuspid valve surgery and patients with congenital heart disease were excluded. Results A total of 155 patients underwent LVAD implantation. Fourteen patients were excluded. Of the remaining patients, thirty-one died during the first six months, six were lost to follow-up and two underwent transplantation. 102 patients presented at 6.3 months (5.8 to 7.0). Patients were supported with HeartWare HVAD (74%) or HeartMate 3 (26%). 50.4% were rated as INTERMACS profile 1 or 2. At six months, systolic pulmonary artery pressure dropped from 36 to 21 mmHg (P<0.001). Tricuspid annular plane systolic excursion decreased from 17.3 to 14.3 mm (P<0.001), RV fractional area change did not change (P=0.839). Twenty-two patients (22%) presented with moderate-to-severe or severe (ms-s) TR pre-operatively. Of these, eighteen (81%) showed improvement to ≤ moderate TR. At follow-up twelve patients presented with ms-s TR. Of these, only four patients (33%) had been diagnosed with ms-s TR pre-operatively. There were no differences in pre-operative echocardiographic or clinical parameters between the twelve patients with ms-s late TR and the other ninety patients in the cohort. Conclusions TR can show an impressive improvement with LVAD support. Longitudinal RV function decreases; this appears to be compensated by transverse shortening. Late TR can develop independently from pre-operative parameters including TR.
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Affiliation(s)
- Johanna Mulzer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Hristo Krastev
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | - Alexander Meyer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | | | - Marcus Müller
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Felix Schoenrath
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Starck
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Volkmar Falk
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Eidgenössiche Technische Hochschule Zürich, Department of Health Sciences and Technology, Translational Cardiovascular Technology, Zurich, Switzerland
| | - Evgenij Potapov
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Jan Knierim
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
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26
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Nayak A, Hu Y, Ko YA, Steinberg R, Das S, Mehta A, Liu C, Pennington J, Xie R, Kirklin JK, Kormos RL, Cowger J, Simon MA, Morris AA. Creation and Validation of a Novel Sex-Specific Mortality Risk Score in LVAD Recipients. J Am Heart Assoc 2021; 10:e020019. [PMID: 33764158 PMCID: PMC8174331 DOI: 10.1161/jaha.120.020019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Prior studies have shown that women have worse 3‐month survival after receiving a left ventricular assist device compared with men. Currently used prognostic scores, including the Heartmate II Risk Score, do not account for the increased residual risk in women. We used the IMACS (International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support) registry to create and validate a sex‐specific risk score for early mortality in left ventricular assist device recipients. Methods and Results Adult patients with a continuous‐flow LVAD from the IMACS registry were randomly divided into a derivation cohort (DC; n=9113; 21% female) and a validation cohort (VC; n=6074; 21% female). The IMACS Risk Score was developed in the DC to predict 3‐month mortality, from preoperative candidate predictors selected using the Akaike information criterion, or significant sex × variable interaction. In the DC, age, cardiogenic shock at implantation, body mass index, blood urea nitrogen, bilirubin, hemoglobin, albumin, platelet count, left ventricular end‐diastolic diameter, tricuspid regurgitation, dialysis, and major infection before implantation were retained as significant predictors of 3‐month mortality. There was significant ischemic heart failure × sex and platelet count × sex interaction. For each quartile increase in IMACS risk score, men (odds ratio [OR], 1.86; 95% CI, 1.74–2.00; P<0.0001), and women (OR, 1.93; 95% CI, 1.47–2.59; P<0.0001) had higher odds of 3‐month mortality. The IMACS risk score represented a significant improvement over Heartmate II Risk Score (IMACS risk score area under the receiver operating characteristic curve: men: DC, 0.71; 95% CI, 0.69–0.73; VC, 0.69; 95% CI, 0.66–0.72; women: DC, 0.73; 95% CI, 0.70–0.77; VC, 0.71 [95% CI, 0.66–0.76; P<0.01 for improvement in receiver operating characteristic) and provided excellent risk calibration in both sexes. Removal of sex‐specific interaction terms resulted in significant loss of model fit. Conclusions A sex‐specific risk score provides excellent risk prediction in LVAD recipients.
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Affiliation(s)
- Aditi Nayak
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Yi-An Ko
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA.,Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Rebecca Steinberg
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Subrat Das
- Icahn School of Medicine at Mount Sinai New York City NY
| | - Anurag Mehta
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Chang Liu
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA.,Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - John Pennington
- Department of Surgery University of Alabama at Birmingham AL
| | - Rongbing Xie
- Department of Surgery University of Alabama at Birmingham AL
| | - James K Kirklin
- Department of Surgery University of Alabama at Birmingham AL
| | - Robert L Kormos
- Department of Cardiothoracic Surgery University of Pittsburgh PA
| | - Jennifer Cowger
- Division of Cardiovascular Medicine Department of Medicine Henry Ford Hospital Detroit MI.,Department of Internal Medicine Wayne State University Detroit MI
| | - Marc A Simon
- Departments of Medicine (Division of Cardiology) and Bioengineering Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute McGowan Institute for Regenerative MedicineClinical and Translational Science InstituteUniversity of Pittsburgh PA.,Heart and Vascular Institute University of Pittsburgh Medical Center (UPMC) Pittsburgh PA
| | - Alanna A Morris
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
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27
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Gomez Hamacher CJ, Torregroza C, Sadat N, Scheiber D, von der Beek JC, Westenfeld R, Knorr IJ, Sager M, Lichtenberg A, Saeed D. Impact of tricuspid valve insufficiency on the performance of left ventricular assist devices. JTCVS OPEN 2020; 4:16-23. [PMID: 36004302 PMCID: PMC9390470 DOI: 10.1016/j.xjon.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/18/2020] [Indexed: 12/02/2022]
Abstract
Objective To evaluate the impact of severe tricuspid valve insufficiency (TVI) at the time of left ventricular assist device (LVAD) implantation on the hemodynamic and LVAD parameters in an acute ovine model. Methods Stable heart failure (HF) was induced in 10 ovines through the application of 3 ± 1 coronary ligations. Once stable HF was obtained (after 15 ± 5 days), the animals were supported with an LVAD. Hemodynamic data and pump parameters were obtained and compared in 2 settings; first with LVAD in place after weaning from the cardiopulmonary bypass machine (no TVI condition) and second following the induction of severe TVI through resection of the tricuspid valve (TVI condition). Results There were no statistically significant differences in the hemodynamic and pump parameters between TVI condition and no TVI conditions except for lower cardiac output in the TVI condition (2 [1.38-2.8] L/min vs 3.2 [1.55-3.7] L/min, P = .027) and the expected greater central venous pressure in the TVI condition (26 [24-31] mm Hg vs 15 [13-25] mm Hg, P = .020). A median pump flow of 2.8 (2.45-3.75) L/min versus 2.9 (2.75-3.8) L/min in the TVI condition and no TVI condition was documented (P = .160). Conclusions Results from this acute animal study suggest that severe TVI in HF with preserved right ventricular function does not have significant impact on the LVAD pump parameters. The observed reduction in cardiac output may warrant further investigations, especially under loading conditions.
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Vierecke J, Gahl B, de By TMMH, Antretter H, Beyersdorf F, Caliskan K, Krachak V, Loforte A, Potapov E, Schoenrath F, Stockman B, Vanderheyden M, Meyns B, Gummert J, Mohacsi P. Results of primary biventricular support: an analysis of data from the EUROMACS registry. Eur J Cardiothorac Surg 2020; 56:1037-1045. [PMID: 31369075 DOI: 10.1093/ejcts/ezz173] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 05/01/2019] [Accepted: 05/05/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The purpose of this study was to describe pre- and postoperative data from the EUROMACS registry with regard to indications, for and survival and complication rates of patients with primary continuous flow and pulsatile biventricular long-term assist devices (BiVADs) versus total artificial hearts (TAHs) or left ventricular assist devices (LVADs) + short-term right ventricular assist device (RVAD) implants. METHODS We investigated patients who received implants between 1 January 2011 and 21 October 2017. Clinical baseline information about comorbidities, laboratory results, medical and device therapies and echocardiographic, haemodynamic and right ventricle (RV) parameters were evaluated along with the rates of deaths and complications. RESULTS A total of 413 of 3282 patients (12.5%) needed a biventricular pump. We investigated 37 long-term BiVADs, 342 LVAD + short-term RVAD implants and 34 TAHs. Minor differences were found in the baseline characteristics of our population, which had an overall high morbidity profile. The 1-year survival rate was 55% for patients with a continuous flow BiVAD; 52% for patients with an LVAD + short-term RVAD; 37% for patients with pulsatile BiVADs; and 36% for patients with a TAH. No statistical difference was observed among the groups. Over 50% of patients with BiVAD support were classified as INTERMACS profiles 1 and 2. The percent of patients with ambulatory heart failure (INTERMACS 4‒7) undergoing BiVAD implants was modest at <15%. No patients with a pulsatile BiVAD (n = 15) or a TAH (n = 34) were implanted as destination therapy, but 27% of the patients with continuous flow BiVADs (n = 6) and 23% of the patients with LVAD + short-term RVAD (n = 342) were implanted as 'destination'. The adverse events profile remained high, with no significant difference among pump types. The right ventricular stroke work index and right heart failure scores indicated poor RV function in all groups. After 3 months of LVAD + short-term RVAD support, 46.7% still required ongoing support, and only 18.5% were weaned from RVAD support; 33.1% died. CONCLUSIONS The mortality rate after BiVAD support was high. Survival rates and adverse events were statistically not different among the investigated groups. In the future, composite study end points examining quality of life and adverse events beyond survival may help in shared decision-making prior to general mechanical circulatory support, particularly in patients with BiVAD implants.
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Affiliation(s)
- Juliane Vierecke
- Department of Cardiovascular Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Division of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Herwig Antretter
- Universitätsklinik für Herzchirurgie, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Friedhelm Beyersdorf
- Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany.,Medical Faculty of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC Rotterdam, Rotterdam, Netherlands
| | | | - Antonio Loforte
- Department of Cardiovascular Surgery, S. Orsola-Malpighi, University Hospital Bologna, Bologna, Italy
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany
| | - Bernard Stockman
- Department of Cardiology, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | | | - Bart Meyns
- Department of Cardiovascular Surgery, UZ Gasthuisberg, Leuven, Belgium
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, University Hospital of the Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Paul Mohacsi
- Department of Cardiovascular Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
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Combined Left Ventricular Assist Device and Coronary Artery Bypass Grafting Surgery: Should We Bypass the Bypass? ASAIO J 2020; 66:32-37. [PMID: 31294723 DOI: 10.1097/mat.0000000000000956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular assist devices (LVADs) have become a mainstay of therapy for advanced heart failure. Although selected patients undergo concomitant coronary artery bypass grafting (CABG) at the time of LVAD implantation, the detailed implication of this combined surgical approach is not yet well studied. In this study, all ischemic cardiomyopathy patients who underwent concomitant CABG during LVAD implantation between 2010 and 2016 were enrolled. A control group matching for age, gender, and device type, were selected. Of 79 LVAD patients finally included, 28 patients underwent concomitant CABG (CABG group); whereas 51 did not (non-CABG group). There was no difference in the baseline characteristics between groups. There was a trend toward longer cardiopulmonary bypass time in the CABG group (169 vs. 147 min; p = 0.09). One month survival in the CABG group was significantly lower than the non-CABG group (75.0% vs. 94.1%; p = 0.014). No difference in the occurrence of ventricular arrhythmias was detected between the groups, nor was there a difference in the incidence or severity of right ventricular failure. Concomitant CABG surgery during LVAD implantation may carry significant perioperative mortality, and addition of CABG to LVAD surgery may be performed only in strictly selected cases.
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Hulde N, Koster A, von Dossow V. Perioperative management of patients with undergoing durable mechanical circulatory support. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:830. [PMID: 32793675 PMCID: PMC7396234 DOI: 10.21037/atm-20-2527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Durable mechanical circulatory support (MCS) devices revolutionized the treatment options for patients with end-stage heart failure (HF). Implantation of durable mechanical support has become an integral treatment modality in end-stage HF patients and it is associated with improved quality of life and survival. There is no doubt that this needs an interdisciplinary and interprofessional approach of cardiac surgeons, cardiologists, cardiac anesthesiologists, perfusionists, intensivists, psychologists, assist device coordinators as well as physiotherapists and intensive care. Implantation of durable MCS is a challenging procedure for the anesthesiologist due to the patient’s characteristics and comorbid diseases. It demands comprehensive training, high vigilance and quick response during the acute hemodynamic changes occurring during the surgery. Preoperative risk stratification is of major importance to guide perioperative medical treatment strategies. Most of these patients have several comorbidities and multiple medications. Therefore, to anticipate postoperative end-organ dysfunction such as cognitive dysfunction, pulmonary or renal failure, an interdisciplinary approach is necessary to optimize patient’s prior surgery. Transthoracic and transesophageal echocardiography (TTE and TEE), both play an invaluable role in diagnosing the cause and guiding the management in different unstable clinical situations. Especially prevention of postoperative right HF with subsequent necessity of temporary MCS is important as it is associated with higher mortality. The aim of this review is to provide an overview about the current concepts of perioperative management for durable MCS. A multimodal standard operating procedure supports early recovery after surgery and intensive care stay. Standardized perioperative care helps to ensure optimal medical treatment. This review focusses on several major skills of perioperative management of these high-risk surgical patients.
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Affiliation(s)
- Nikolai Hulde
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
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31
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Ruiz‐Cano MJ, Morshuis M, Koster A, Lauenroth V, Prashovikj E, Gummert J, Paluszkiewicz L. Risk factors of early right ventricular failure in patients undergoing LVAD implantation with intermediate Intermacs profile for advanced heart failure. J Card Surg 2020; 35:1832-1839. [DOI: 10.1111/jocs.14696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Maria J. Ruiz‐Cano
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Michiel Morshuis
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Andreas Koster
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Volker Lauenroth
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Emir Prashovikj
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Jan Gummert
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
| | - Lech Paluszkiewicz
- Thorax and Cardiovascular Surgery, Heart and Diabetes Center Ruhr‐University Bochum Bad Oeynhausen Germany
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Ramsdell GC, Nelson JA, Pislaru SV, Ramakrishna H. Tricuspid Regurgitation in Congestive Heart Failure: Management Strategies and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2020; 35:1205-1214. [PMID: 32622710 DOI: 10.1053/j.jvca.2020.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/11/2022]
Abstract
Tricuspid regurgitation is a notable aspect of congestive heart failure and is linked with worse outcomes if untreated. Functional tricuspid regurgitation commonly is seen in patients with heart failure, particularly in patients presenting for surgical management, such as those for mechanical cardiac assist device implantation. This review aims to study the published data related to the surgical management of tricuspid regurgitation in the cardiac surgical population comprehensively.
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Affiliation(s)
- Geoffrey C Ramsdell
- Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020; 33:692-734. [PMID: 32503709 DOI: 10.1016/j.echo.2020.03.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
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Affiliation(s)
| | | | - Niv Ad
- White Oak Medical Center and University of Maryland, Silver Spring, Maryland
| | - Alan Finley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Bradley Taylor
- University of Maryland Medical Center, Baltimore, Maryland
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Mullan C, Caraballo C, Ravindra NG, Miller PE, Mori M, McCullough M, Clarke JRD, Anwer M, Velazquez EJ, Geirsson A, Desai NR, Ahmad T. Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation. J Heart Lung Transplant 2020; 39:926-933. [PMID: 32593561 DOI: 10.1016/j.healun.2020.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/29/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in patients with end-stage heart failure receiving left ventricular assist devices (LVADs), but the benefit of concomitant tricuspid valve procedures (TVPs) remains uncertain. This study examined the impact of TVP at the time of LVAD implantation on clinical outcomes and quality of life (QOL) metrics. METHODS We included adult patients in the Interagency Registry for Mechanical Circulatory Support database with various degrees of TR who received continuous-flow LVADs from 2008 to 2017. Patients undergoing concomitant TVP were compared with those without the intervention in a stratified analysis. Descriptive analyses, survival analyses, and Andersen‒Gill hazard models were used as appropriate to examine associations with clinical and patient-centered QOL outcomes. RESULTS Our analysis included 8,263 (53.1%) mild, 4,252 (33.3%) moderate, and 2,100 (13.5%) severe TR cases. TVP rate increased with severity: 8.6% of mild, 18.0% of moderate, and 43.9% of severe cases. TVP was not associated with survival benefit in cases of mild (adjusted hazard ratio [aHR]: 0.97, 95% CI: 0.79-1.19, p = 0.75), moderate (aHR: 1.03, 95% CI: 0.88-1.20, p = 0.72), or severe (aHR: 1.20, 95% CI: 0.98-1.48, p = 0.08) TR. For patients with combined moderate or severe TR, TVP was associated with increased mortality (log-rank p < 0.01, aHR: 1.13, 95% CI: 1.00-1.27, p = 0.04). After adjusting for TR severity, TVP was associated with increased risk of bleeding, arrhythmia, and stroke (p < 0.01 each) and no improvements in QOL (p > 0.05). CONCLUSIONS TVP at the time of LVAD implantation was not associated with either improved survival or QOL, and there were associations with increased risk of adverse events among patients with moderate and severe TR.
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Affiliation(s)
- Clancy Mullan
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Neal G Ravindra
- Cardiovascular Research Center and Department of Computer Science, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Yale National Clinician Scholars Program, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Megan McCullough
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - John-Ross D Clarke
- Department of Internal Medicine (Bridgeport Hospital), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Nihar R Desai
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Tariq Ahmad
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut.
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Sidhu K, Lam PH, Mehra MR. Evolving trends in mechanical circulatory support: Clinical development of a fully magnetically levitated durable ventricular assist device. Trends Cardiovasc Med 2020; 30:223-229. [DOI: 10.1016/j.tcm.2019.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/17/2022]
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Roberts WC, Ather N, Guileyardo JM. Examining Hearts Containing Left Ventricular Assist Devices at Necropsy. Am J Cardiol 2020; 125:244-250. [PMID: 31753314 DOI: 10.1016/j.amjcard.2019.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
There are no publications describing hearts at necropsy containing left ventricular assist devices (LVADs). The purpose was to study the relation of the LVAD cannula to the left ventricular (LV) cavity and wall. We studied the hearts at necropsy of 15 adults who had an LVAD inserted from 4 to 1,423 days (median 60) earlier. In 13 patients, the cannula had been inserted at an angle to the major longitudinal axis of the LV chamber, and in 11 patients, the orifice margin of the cannulas contacted the LV mural endocardium. In 3 patients, the LVAD cannula was inserted into the posterior wall, and, in another into the anterior wall. In the remaining 11 patients, the cannula had been inserted into the LV apex. Despite the insertion of the cannulas into the LV apex, the direction of the insertion was not into the longitudinal axis of the LV cavity in 9 patients. These unusual insertions in some patients may have altered flow into the orifice of the cannula; in others, based on their long postoperative survival, physiologic consequences were almost certainly absent. The presence of considerable quantities of subepicardial adipose tissue and pericardial adhesions from previous cardiac procedures (mainly coronary bypass) potentially interfered with achieving proper alignment of the LVAD cannula during its insertion. Misalignment of the cannulas of the LVAD in the LV cavity appears to be rather frequent.
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Barac YD, Nicoara A, Bishawi M, Schroder JN, Daneshmand MA, Hashmi NK, Velazquez E, Rogers JG, Patel CB, Milano CA. Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. JACC-HEART FAILURE 2019; 8:141-150. [PMID: 31838034 DOI: 10.1016/j.jchf.2019.08.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/03/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BACKGROUND Surgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. METHODS A retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors' institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. RESULTS A total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). CONCLUSIONS Failure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nazish K Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Eric Velazquez
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
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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.
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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.
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Fiedler AG, Hermsen JL, Smith JW, Dhingra R. Long-term discontinuation of warfarin in a patient with HeartMate 3 left ventricular assist device without complication. J Card Surg 2019; 35:447-449. [PMID: 31730719 DOI: 10.1111/jocs.14352] [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] [Indexed: 11/27/2022]
Abstract
A 38-year-old woman with peripartum cardiomyopathy underwent placement of a HeartMate 3 (HM3) left ventricular assist device (LVAD). Postoperatively, she refused warfarin therapy and was maintained on aspirin monotherapy for 19 months. She did not experience thrombotic or thromboembolic complications associated with lack of oral vitamin K antagonist anticoagulation. Our patient represents the longest reported duration of a patient with HM3 LVAD maintained without warfarin without evidence of thrombotic or thromboembolic events.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisconsin
| | - Joshua L Hermsen
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisconsin
| | - Jason W Smith
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisconsin
| | - Ravi Dhingra
- Division of Cardiology, University of Wisconsin, Madison, Wisconsin
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Critsinelis A, Kurihara C, Kawabori M, Sugiura T, Loor G, Frazier OH, Morgan J. Outcomes in patients who underwent a concomitant tricuspid valve procedure during left ventricular assist device implantation. J Card Surg 2019; 34:1458-1464. [PMID: 31730728 DOI: 10.1111/jocs.14304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Study findings have been inconsistent regarding whether a concomitant tricuspid valve replacement or repair performed concurrently with continuous-flow left ventricular assist device (CF-LVAD) implantation has additive clinical benefit in patients with severe tricuspid valve regurgitation (TR). AIM OF STUDY To determine the effect of performing a concomitant tricuspid valve procedure (TVP) at the time of CF-LVAD implantation on patient outcomes. METHODS We retrospectively reviewed our single-institution experience in 526 patients who underwent primary implantation of a CF-LVAD between November 2003 and March 2016. We identified 59 (11.2%) patients who had severe TR at the time of implantation and analyzed the effect of performing a concomitant TVP at the time of CF-LVAD implantation on the rate of survival, incidence of postoperative right heart failure (RHF), recurrence of TR, and incidence of 30-day readmission. RESULTS We did not observe a significant difference in the overall survival rate (P = .51), incidence of postoperative RHF (P = .26), or recurrence of TR (P = .73) between patients with severe TR who underwent a TVP and those who did not at the time of CF-LVAD implantation. However, the incidence of 30-day readmission was significantly lower in patients who underwent a TVP than in those who did not (P = .002). CONCLUSIONS Performing a concomitant TVP at the time of CF-LVAD implantation did not improve patient outcomes but reduced the incidence of 30-day readmission.
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Affiliation(s)
- Andre Critsinelis
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Chitaru Kurihara
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Masashi Kawabori
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Tadahisa Sugiura
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - O H Frazier
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Jeffrey Morgan
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
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Imamura T, Narang N, Nnanabu J, Rodgers D, Raikhelkar J, Kalantari S, Smith B, Nguyen A, Chung B, Ota T, Song T, Jeevanandam V, Kim G, Sayer G, Uriel N. Hemodynamics of concomitant tricuspid valve procedures at LVAD implantation. J Card Surg 2019; 34:1511-1518. [PMID: 31693250 DOI: 10.1111/jocs.14275] [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] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in patients receiving left ventricular assist device (LVAD) implantation. The current literature is conflicting regarding the effects of concomitant tricuspid valve repair (TVR) at LVAD implantation. We investigated the hemodynamic effects of concomitant TVR at LVAD implantation. METHODS Consecutive clinically stable LVAD outpatients who underwent hemodynamic ramp testings were enrolled in this study, and they were stratified by concomitant TVR. Results of hemodynamic ramp tests were compared between the TVR group and the non-TVR group. RESULTS Among 65 LVAD patients undergoing ramp tests, 34 patients had received TVR, and 31 had not. There were no significant differences in baseline characteristics between two groups except for higher degree of TR and lower pulmonary artery pulsatility index in the TVR group (P < .05 for both). Following LVAD implantation, the degree of TR improved significantly in the TVR group down to the comparable level with the non-TVR group. During ramp tests, the TVR group had steeper cardiac index slope (0.14 ± 0.12 vs 0.07 ± 0.07 L/min/m2 /step, P = .002) and higher cardiac index at set LVAD speed (2.99 ± 0.84 vs 2.52 ± 0.42 L/min/m2 , P = .007). CONCLUSIONS Concomitant TVR improves cardiac output and its response to LVAD speed change following LVAD implantation. Longitudinal clinical implications of such hemodynamic changes are unknown.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jerry Nnanabu
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Veen KM, Caliskan K, de By TMMH, Mokhles MM, Soliman OI, Mohacsi P, Schoenrath F, Gummert J, Paluszkiewicz L, Netuka I, Loforte A, Pya Y, Takkenberg JJM, Bogers AJJC. Outcomes after tricuspid valve surgery concomitant with left ventricular assist device implantation in the EUROMACS registry: a propensity score matched analysis. Eur J Cardiothorac Surg 2019; 56:1081-1089. [DOI: 10.1093/ejcts/ezz208] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Tricuspid regurgitation (TR) is common in patients receiving a left ventricular assist device (LVAD). Controversy exists as to whether concomitant tricuspid valve surgery (TVS) is beneficial in currently treated patients. Therefore, our goal was to investigate the effect of TVS concomitant with a LVAD implant.
METHODS
The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients. Matched patients with and without concomitant TVS were compared using a propensity score matching strategy.
RESULTS
In total, 3323 patients underwent LVAD implantation of which 299 (9%) had TVS. After matching, 258 patients without TVS were matched to 258 patients with TVS. In the matched population, hospital deaths, days on inotropic support, temporary right ventricular assist device implants and hospital stay were comparable, whereas stay in the intensive care unit was higher in the TVS cohort (11 vs 15 days; P = 0.026). Late deaths (P = 0.17), cumulative incidence of unexpected hospital readmission (P = 0.15) and right heart failure (P = 0.55) were comparable between patients with and without concomitant TVS. In the matched population, probability of moderate-to-severe TR immediately after surgery was lower in patients with concomitant TVS compared to patients without TVS (33% vs 70%; P = 0.001). Nevertheless, the probability of moderate-to-severe TR decreased more quickly in patients without TVS (P = 0.030), resulting in comparable probabilities of moderate-to-severe TR within 1.5 years of follow-up.
CONCLUSIONS
In matched patients, TVS concomitant with LVAD implant does not seem to be associated with better clinical outcomes. Concomitant TVS reduced TR significantly early after LVAD implant; however, differences in probability of TR disappeared during the follow-up period.
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Affiliation(s)
- Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, Rotterdam, Netherlands
| | | | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Osama I Soliman
- Department of Cardiology, Erasmus MC, Rotterdam, Netherlands
| | - Paul Mohacsi
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Jan Gummert
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Lech Paluszkiewicz
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Department of Cardiothoracic Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Antonio Loforte
- Cardiac Surgery Unit, Policlinico di S. Orsola, Bologna, Italy
| | - Yuriy Pya
- National Research Cardiac Surgery Center, Astana, Kazakhstan
| | | | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
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Practical valvular issues in patients requiring ventricular assist devices. Curr Opin Cardiol 2019; 33:162-167. [PMID: 29334508 DOI: 10.1097/hco.0000000000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As ventricular assist device (VAD) therapy in patients with advanced heart failure continues to grow, experience with concomitant valvular diseases present either before or after VAD implantation continues to accrue. In this review, we discuss recent data and current practice as it pertains to the subject of concomitant valvular disease in patients requiring VADs. RECENT FINDINGS Persistent aortic valve closure has been identified as a potential contributor to aortic valve 'disuse atrophy' resulting in valve degeneration. Dilation of the aortic root may be predictive of future development of aortic insufficiency. Novel echocardiographic parameters to identify the severity of aortic insufficiency following VAD implantation may be useful for risk stratification. Concomitant repair of significant mitral regurgitation may confer benefit to pulmonary vascular resistance and right ventricular function; however, this remains controversial. Concomitant repair of significant tricuspid regurgitation has not demonstrated early postoperative benefit nor survival benefit. Atrial fibrillation has emerged as a risk factor that may predict accelerated progression of postoperative tricuspid regurgitation. SUMMARY Management of aortic insufficiency, mitral regurgitation or tricuspid regurgitation in patients requiring VADs continues to be the source of controversy. As experience accrues with varying strategies to prevent or manage these valvular lesions, our understanding of the impact of these strategies continues to evolve.
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Zhigalov K, Szczechowicz M, Mashhour A, Kadyraliev BK, Mkalaluh S, Easo J, Ennker J, Eichstaedt HC, Weymann A. Left ventricular assist device implantation with concomitant tricuspid valve repair: is there really a benefit? J Thorac Dis 2019; 11:S902-S912. [PMID: 31183169 DOI: 10.21037/jtd.2018.11.116] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The objectives of this study was to investigate if concomitant tricuspid valve repair in patients undergoing continuous flow left ventricular assist device (LVAD) implantation has an impact on the outcome regarding survival and adverse events. Methods Between June 2007 and February 2018, 124 consecutive patients received HeartMate II (HMII) [74 (59.7%)] HeartWare (HVAD) [16 (12.9%)], or HeartMate III (HM III) [34 (27.4%)] for end-stage heart failure. Mean age was 63.5±10.9 years. Two 18-patient groups were identified; with [tricuspid valve reconstruction (TVR)] group and without (non-TVR group) accompanying TVR. The primary endpoint was overall survival after device implantation. Secondary endpoints were adverse events during the follow-up period. Results Survival was not significantly different between the groups (P>0.05). In TVR group, there was a higher need for open chest after surgery and a prolonged inotrope use because of right heart failure (RHF), a higher incidence of acute kidney dysfunction requiring dialysis, as well as a higher need for packed red blood cells due to postoperative bleeding (P<0.05). Conclusions In this cohort of patients, LVAD implantation with a concurrent tricuspid valve repair appears to have a worse outcome regarding RHF, bleeding tendency and renal dysfunction (P<0.05). However, the survival was comparable in both TVR and Non-TVR groups (P>0.05).
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Affiliation(s)
- Konstantin Zhigalov
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Bakitbek K Kadyraliev
- Federal Center of Cardiovascular Surgery named after S.G. Sukhanov, Perm State Medical University, Perm, Russia
| | - Sabreen Mkalaluh
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Juergen Ennker
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Harald C Eichstaedt
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Okoh A, Yanagida R, Schultheis M, Chaudari S, Fugar S, Nnaoma C, Chan O, Zucker M, Karanam R, Russo M, Camacho M. Impact of Baseline Mitral Regurgitation on Postoperative Outcomes After Left Ventricular Assist Device Implantation as Destination Therapy. Transplant Proc 2019; 51:859-864. [DOI: 10.1016/j.transproceed.2019.01.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/08/2018] [Accepted: 01/17/2019] [Indexed: 01/07/2023]
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Bouchez S, Van Belleghem Y, De Somer F, De Pauw M, Stroobandt R, Wouters P. Haemodynamic management of patients with left ventricular assist devices using echocardiography: the essentials. Eur Heart J Cardiovasc Imaging 2019; 20:373-382. [DOI: 10.1093/ehjci/jez003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stefaan Bouchez
- Department of Anaesthesiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Yves Van Belleghem
- Department of Cardiac Surgery, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Roland Stroobandt
- Department of Cardiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Patrick Wouters
- Department of Anaesthesiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
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Veen KM, Muslem R, Soliman OI, Caliskan K, Kolff MEA, Dousma D, Manintveld OC, Birim O, Bogers AJJC, Takkenberg JJM. Left ventricular assist device implantation with and without concomitant tricuspid valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2018; 54:644-651. [DOI: 10.1093/ejcts/ezy150] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/18/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kevin M Veen
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Rahatullah Muslem
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Osama I Soliman
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Marit E A Kolff
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Dagmar Dousma
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Olivier C Manintveld
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ozcan Birim
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
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Malinowski M, Proudfoot AG, Langholz D, Eberhart L, Brown M, Schubert H, Wodarek J, Timek TA. Large animal model of functional tricuspid regurgitation in pacing induced end-stage heart failure. Interact Cardiovasc Thorac Surg 2017; 24:905-910. [PMID: 28329164 DOI: 10.1093/icvts/ivx012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/03/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Functional tricuspid regurgitation (FTR) is common in patients with advanced heart failure and frequently complicates left ventricular assist device implantation yet remains poorly understood. We set out to establish large animal model of FTR that could serve as a research platform to investigate the pathogenesis of FTR associated with end-stage heart failure. METHODS : Through right thoracotomy, ten adult sheep underwent implantation of pacemaker with epicardial LV lead, five sonomicrometry crystals on the right ventricle, and left and right ventricular telemetry pressure sensors during a beating heart off-pump procedure. After 5 ± 1 days of recovery, baseline haemodynamic, echocardiographic and sonomicrometry data were collected. Animals were paced thereafter at a rate of 220-240 beats/min until the development of heart failure and concomitant tricuspid regurgitation. RESULTS : Three animals died during early recovery period and one during the pacing phase. Six surviving animals were paced for a mean of 14 ± 5 days. Cardiac function was significantly depressed compared to baseline, with LV ejection fraction falling from 69 ± 2% to 22 ± 4% ( P < 0.001) and RV fractional area change from 52 ± 11% to 25 ± 9% ( P = 0.005). All animals developed significant enlargement of tricuspid annulus (from 29.5 ± 1.6 to 36.5 ± 4.5 mm; P = 0.01) and right ventricle (from 21.9 ± 0.2 to 30.3 ± 0.6 mm; P = 0.03). Sonomicrometry derived contractility of RV free wall was depressed and at least moderate tricuspid insufficiency developed in all animals. CONCLUSIONS : Biventricular dysfunction, tricuspid annular dilatation and significant FTR were observed in our model of ovine tachycardia induced cardiomyopathy. This animal model reflects the clinical situation of end-stage heart failure patients presenting for mechanical support.
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Affiliation(s)
- Marcin Malinowski
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA.,Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | | | - David Langholz
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Lenora Eberhart
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Michael Brown
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Hans Schubert
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Jeremy Wodarek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
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