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John R, Kanwar MK, Cleveland JC, Uriel N, Naka Y, Salerno C, Horstmanshof D, Hall SA, Cowger JA, Heatley G, Somo SI, Mehra MR. Concurrent valvular procedures during left ventricular assist device implantation and outcomes: A comprehensive analysis of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 trial portfolio. J Thorac Cardiovasc Surg 2023; 166:1684-1694.e18. [PMID: 35643769 DOI: 10.1016/j.jtcvs.2022.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Correction of valvular disease is often undertaken during left ventricular assist device (LVAD) implantation with uncertain benefit. We analyzed clinical outcomes with HeartMate 3 (HM3; Abbott) LVAD implantation in those with various concurrent valve procedures (HM3+VP) with those with an isolated LVAD implant (HM3 alone). METHODS The study included 2200 patients with HM3 implanted within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial portfolio who underwent 820 concurrent procedures among which 466 (21.8%) were HM3+VP. VPs included 101 aortic, 61 mitral, 163 tricuspid; 85 patients had multiple VPs. Perioperative complications, major adverse events, and survival were analyzed. RESULTS Patients who underwent HM3+VP had higher-acuity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (1-2: 41% vs 31%) compared with no VPs (P < .05). The cardiopulmonary bypass time (124 vs 76 minutes; P < .0001) and hospital length of stay (20 vs 18 days; P < .0001) were longer in HM3+VP. A higher incidence of stroke (4.9% vs 2.4%), bleeding (33.9% vs 23.8%), and right heart failure (41.5% vs 29.6%) was noted in HM3+VP at 0 to 30 days (P < .01), with no difference in 30-day mortality (3.9% vs 3.3%) or 2-year survival (81.7% vs 80.8%). Analysis of individual VP showed no differences in survival compared to HM3 alone. No differences were noted among patients with either significant mitral (moderate or worse) or tricuspid (moderate or worse) regurgitation with or without corrective surgery. CONCLUSIONS Concurrent VPs, commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, with no effect on short- and long-term survival. There is sufficient equipoise to consider a randomized trial on the benefit of commonly performed VPs (such as mitral or tricuspid regurgitation correction), during LVAD implantation.
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Affiliation(s)
- Ranjit John
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minn
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pa
| | - Joseph C Cleveland
- Surgery-Cardiothoracic, University of Colorado School of Medicine, Aurora, Colo
| | - Nir Uriel
- Advanced Heart Failure and Cardiac Transplantation, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY
| | - Yoshifumi Naka
- Cardiac Surgery, Weill Cornell Medical College, New York, NY
| | | | | | - Shelley A Hall
- Transplant Cardiology and Mechanical Support/Heart Failure, Baylor University Medical Center, Dallas, Tex
| | - Jennifer A Cowger
- Mechanical Circulatory Support Team, Henry Ford Health System, Detroit, Mich
| | | | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
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2
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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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3
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Tanveer Ud Din M, Minhas AMK, Muslim MO, Wazir MHK, Dani SS, Goel SS, Alam M, Sá MP, Seese L, Hirji S. Outcomes of MitraClip and Surgical Mitral Valve Repair in Patients With Left Ventricular Assist Device. Am J Cardiol 2022; 173:143-145. [PMID: 35437161 DOI: 10.1016/j.amjcard.2022.03.012] [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: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Mian Tanveer Ud Din
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | | | | | | | - Sourbha S Dani
- Division of Cardiology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Mahboob Alam
- Michael E. DeBakey Veterans Affair Medical Center; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Laura Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sameer Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Riebandt J, Schaefer A, Wiedemann D, Schlöglhofer T, Laufer G, Sandner S, Zimpfer D. Concomitant cardiac surgery procedures during left ventricular assist device implantation: single-centre experience. Ann Cardiothorac Surg 2021; 10:248-254. [PMID: 33842219 DOI: 10.21037/acs-2020-cfmcs-30] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Additional cardiac pathologies including tricuspid or mitral valve regurgitation are common in left ventricular assist device (LVAD) recipients and whether to address them remains controversial. We present our institutional outcomes of concomitant cardiac procedures, other than temporary right ventricular (RV) support, at the time of LVAD implantation. Methods From 03/2006 to 06/2020, 352 adult patients {median age 60 [interquartile range (IQR): 52-66] years; INTERMACS level 1 29%; INTERMACS level 2 17%; INTERMACS level 3 23%, INTERMACS level 4-6 31%; male 86%} underwent continuous-flow LVAD [Medtronic HVAD® (HVAD) 50%; Abbott HeartMate IITM (HMII) 17%; Abbott HeartMate 3TM (HM3) 33%] implantation. Concomitant valvular procedures were performed in 86 patients (24%) and the majority of patients received the LVAD as bridge to candidacy (BTC) for transplant (74%). Primary study endpoints were short- and mid-term mortality, as well as need for temporary RV support. Results Tricuspid valve annuloplasty was the most frequent concomitant procedure (77%), followed by aortic valve replacements (AVRs) or Park's stitch (33%). Temporary RV support was common in the study cohort (35%) using either extracorporeal life support (ECLS, 37%) or a temporary RV assist device (RVAD, 63%). A less invasive (LIS) implantation technique was pursued in 12%. Thirty-day mortality was comparable between those with and without concomitant surgery (4% vs. 6%, P=0.426). In-hospital mortality was significantly higher for additional interventions (22% vs. 14%, P=0.05), whereas one-year survival was similar (71% vs. 79%, P=0.106). Conclusions Concomitant cardiac procedures, especially tricuspid and aortic valve surgery, are frequent but are associated with a higher perioperative morbidity and mortality.
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Affiliation(s)
- Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Anne Schaefer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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5
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Coyan GN, Pierce BR, Rhinehart ZJ, Ruppert KM, Katz W, Kilic A, Kormos RL, Sciortino CM. Impact of Pre-Existing Mitral Regurgitation Following Left Ventricular Assist Device Implant. Semin Thorac Cardiovasc Surg 2021; 33:988-995. [PMID: 33444766 DOI: 10.1053/j.semtcvs.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Optimal management of significant mitral regurgitation (SMR) during left ventricular assist device (LVAD) placement remains uncertain. This study evaluates the effect of untreated preop SMR on outcomes following LVAD implant. METHODS Adults undergoing primary LVAD placement from April 2004 to May 2017 were included. Most recent preop transthoracic echocardiogram (TTE) was used to divide patients into an SMR group with moderate or greater regurgitation, and a group without SMR. Patients underwent LVAD implant without correction of SMR. Primary endpoint was 3-year postoperative survival, with secondary endpoints of length of stay (LOS), resolution of SMR following LVAD on postdischarge (30 day) TTE, and 1-year TTE. RESULTS LVAD placement was performed in 270 patients, 172 (63.7%) without SMR and 98 (36.3%) with SMR. There were no differences in comorbidities including diabetes, hypertension, and renal disease. Preop ejection fraction was similar, but a higher pulmonary vascular resistance was recorded in the SMR group (3.6 vs 3.0 Wood Units, P = 0.048). There was no difference in 3-year mortality between the 2 cohorts (log-rank P = 0.0.803). The SMR group had decreased LOS (median 19.5 vs 22 days, P = 0.009). Of the 98 SMR patients, 91 (92.9%) had resolution of SMR to less than moderate at 30 days. At 1 year, 15% of those with preoperative SMR had recurrent SMR. CONCLUSIONS Patients undergoing LVAD placement with preop SMR experience no differences in mortality, and a majority experience resolution of MR after implant. Longer-term SMR recurrence and need for mitral intervention with LVAD implant warrant further investigation.
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Affiliation(s)
- Garrett N Coyan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian R Pierce
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zachary J Rhinehart
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kristen M Ruppert
- Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Katz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher M Sciortino
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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6
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Gulati G, Ruthazer R, Denofrio D, Vest AR, Kent D, Kiernan MS. Understanding Longitudinal Changes in Pulmonary Vascular Resistance After Left Ventricular Assist Device Implantation. J Card Fail 2021; 27:552-559. [PMID: 33450411 DOI: 10.1016/j.cardfail.2021.01.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) is common in patients with advanced heart failure. PVR generally improves after left ventricular assist device (LVAD) implantation, but the rate of decrease has not been quantified and the patient characteristics most strongly associated with this improvement are unknown. METHODS AND RESULTS We analyzed 1581 patients from the Interagency Registry for Mechanically Assisted Circulatory Support registry who received a primary continuous-flow LVAD, had a baseline PVR of ≥3 Wood units (WU), and had PVR measured at least once postoperatively. Multivariable linear mixed effects modeling was used to evaluate independent associations between postoperative PVR and patient characteristics. PVR decreased by 1.53 WU (95% confidence interval [CI] 1.27-1.79 WU) per month in the first 3 months postoperatively, and by 0.066 WU (95% CI 0.060-0.070 WU) per month thereafter. Severe mitral regurgitation at any time during follow-up was associated with a 1.29 WU (95% CI 1.05-1.52 WU) higher PVR relative to absence of mitral regurgitation at that time. In a cross-sectional analysis, 15%-25% of patients had persistently elevated PVR of ≥3 WU at any given time within 36 months after LVAD implantation. CONCLUSION The PVR tends to decrease rapidly early after implantation, and only more gradually thereafter. Residual mitral regurgitation may be an important contributor to elevated postoperative PVR. Future research is needed to understand the implications of elevated PVR after LVAD implantation and the optimal strategies for prevention and treatment.
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Affiliation(s)
- Gaurav Gulati
- Cardiovascular Center, Tufts Medical Center; Predictive Analytics and Comparative Effectiveness Center.
| | - Robin Ruthazer
- Clinical and Translational Sciences Institute, Tufts Medical Center, Boston, Massachusetts
| | | | | | - David Kent
- Predictive Analytics and Comparative Effectiveness Center
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7
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Kreusser MM, Hamed S, Weber A, Schmack B, Volz MJ, Geis NA, Grossekettler L, Pleger ST, Ruhparwar A, Katus HA, Raake PW. MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure. ESC Heart Fail 2020; 7:3891-3900. [PMID: 33107214 PMCID: PMC7754960 DOI: 10.1002/ehf2.12982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
Aims Mitral valve regurgitation (MR) is common in patients with advanced heart failure (HF). Percutaneous mitral valve repair (PMVR) via MitraClip (MC) has emerged as a feasible treatment strategy for these high‐risk patients. However, as HF often further progresses, there is a frequent need for left ventricular assist device (LVAD) implantation in these patients. We aimed to investigate whether prior MC implantation affects the subsequent LVAD implantation and outcome. Methods and results Thirty‐seven patients with advanced HF and significant MR who underwent LVAD implantation were retrospectively analysed. Follow‐up data were collected at 1 year after LVAD implantation. Primary endpoint was all‐cause mortality. Secondary endpoint included peri‐operative parameters and clinical development depicted as New York Heart Association (NYHA) class and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Seventeen patients initially received a MC device (MC group), resulting in a significant reduction in MR grade. After MC, NYHA class and INTERMACS level further worsened, leading to subsequent LVAD implantation after a median time of 475 days in the MC group. At LVAD implantation, overall characteristics were comparable with those of the patients undergoing LVAD implantation without prior MC placement (no‐MC group). Procedural data revealed a higher incidence of right ventricular (RV) failure needing mechanical RV assistance and a longer need for nitric oxide ventilation in the MC group after LVAD implantation. One‐year survival was slightly better in the no‐MC group compared with the MC group [41% (n = 7/17) vs. 65% (n = 13/20); P = 0.15], albeit event‐free survival was comparable between both groups, MC and no‐MC. Conclusions LVAD implantation after MC is feasible and safe. However, in patients with advanced HF and severe MR, PMVR may only delay a needed LVAD implantation and thereby lead to poorer peri‐operative RV function and impaired outcome. Arguably, these patients might benefit from the timely management of advanced HF by the means of early LVAD implantation or heart transplantation.
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Affiliation(s)
- Michael M Kreusser
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Sonja Hamed
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Andreas Weber
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany.,Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Martin J Volz
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Nicolas A Geis
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Leonie Grossekettler
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Sven T Pleger
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany.,Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Hugo A Katus
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
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8
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Briasoulis A, Yokoyama Y, Kuno T, Ueyama H, Shetty S, Alvarez P, Malik AΗ. In-Hospital Outcomes of Left Ventricular Assist Device Implantation and Concomitant Valvular Surgery. Am J Cardiol 2020; 132:87-92. [PMID: 32753267 DOI: 10.1016/j.amjcard.2020.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
Valvular heart disease is common among left ventricular assist device (LVAD) recipients. However, its management at the time of LVAD implantation remains controversial. Patients who underwent LVAD implantation and concomitant aortic (AVR), mitral (MVR), or tricuspid valve (TVR) repair or replacement from 2010 to 2017 were identified using the national inpatient sample. End points were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via ICD-9 and ICD-10 coding and analysis was performed via mixed effect models. A total of 25,171 weighted adults underwent LVAD implantation without valvular surgery, 1,329 had isolated TVR, 1,021 AVR, 377 MVR, and 615 had combined valvular surgery (411 had TVR + AVR, 115 TVR + MVR, 62 AVR + MVR, 25 AVR + MVR + TVR). During the study period, rates of AVR decreased and combined valvular surgeries increased. Patients who underwent TVR or combined valvular surgery had overall higher burden of co-morbidities than LVAD recipients with or without other valvular procedures. Postoperative bleeding was higher with AVR whereas acute kidney injury requiring dialysis was higher with TVR or combined valvular surgery. In-hospital mortality was higher with AVR, MVR, or combined surgery without differences in the rates of stroke. Length of stay did not differ significantly among groups but cost of hospitalization and nonroutine discharge rates were higher for cases of TVR and combined surgery. Approximately 1 in 9 LVAD recipients underwent concomitant valvular surgery and TVR was the most frequently performed procedure. In-hospital mortality and cost were lower among those who did not undergo valvular surgery.
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9
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Abstract
PURPOSE OF REVIEW Atrial arrhythmias commonly occur in patients with advanced heart failure with reduced ejection fraction (HFrEF) who require left ventricular assist devices (LVADs) implantation. This review summarizes the current literature regarding the incidence, prevalence, and predictors of atrial arrhythmias in LVAD patients and its impact on the clinical outcomes. Moreover, we review the mechanisms and management strategies of atrial arrhythmias in this population. RECENT FINDINGS Atrial arrhythmias including atrial fibrillation, atrial flutter, and atrial tachycardia are highly prevalent in patients with advanced HFrEF before or after the LVAD implantation. Atrial arrhythmias have a significant impact on overall clinical outcome including survival, heart failure hospitalization, quality of life, thromboembolic events and resource utilization. Atrial fibrillation and other atrial arrhythmias frequently coexist in this population. In patients with atrial arrhythmias and LVAD, anticoagulation and cardiovascular implantable electronic devices should be closely monitored and managed to prevent thromboembolic events or inappropriate shocks. Rhythm and rate control strategies are comparable regarding overall clinical outcomes in this population. LVADs induce favorable atrial remodeling in patients with HFrEF. SUMMARY Atrial arrhythmias are highly common in LVAD patients and have significant impact on overall clinical outcomes. Further studies are needed to determine optimal management and prevention of atrial arrhythmias in LVAD population.
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10
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Kawabori M, Kurihara C, Critsinelis A, Chou BPH, Zhang Q, Kaku Y, Civitello AB, Morgan JA. Effect of cardiac arrest with aortic cross-clamping during left ventricular assist device implantation. Interact Cardiovasc Thorac Surg 2019; 30:47-53. [DOI: 10.1093/icvts/ivz223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 08/02/2019] [Accepted: 08/16/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Some patients who undergo continuous-flow left ventricular assist device (CF-LVAD) implantation require concomitant procedures that can be performed with or without cardiac arrest under aortic cross-clamping (AXC). Procedures normally performed with cardiac arrest are sometimes avoided or performed without cardiac arrest because it may be detrimental to right heart function. However, the effects of cardiac arrest on patients with advanced heart failure necessitating CF-LVAD support have not been thoroughly studied. We examined our single-centre experience to determine whether cardiac arrest during CF-LVAD implantation was associated with worse patient outcomes.
METHODS
From November 2003 to March 2016, a total of 526 patients with chronic end-stage heart failure underwent primary CF-LVAD implantation. Preoperative demographics, postoperative complications and mortality rates were compared between patients who required cardiac arrest with AXC (n = 50) and those who did not (n = 476).
RESULTS
The most frequently performed procedure requiring AXC was aortic valve closure (n = 23, 26.1%). Although the AXC group had longer cardiopulmonary bypass times (P < 0.01), long-term (5-year) survival was similar in AXC and non-AXC patients (P = 0.13). Also, postoperative right heart failure (P = 0.15) and neurological dysfunction (P = 0.89) rates were not significantly different between the 2 groups. Cox proportional hazards analysis showed that cardiac arrest with AXC was not an independent predictor of mortality (hazard ratio, 0.89; P = 0.73).
CONCLUSIONS
Cardiac arrest with AXC during CF-LVAD implantation did not negatively affect long-term survival or the incidence of right ventricular failure or stroke. These findings should be considered in deciding surgical strategies. Additional investigation may be warranted to further understand the effects of cardiac arrest during LVAD implantation.
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Affiliation(s)
- Masashi Kawabori
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Chitaru Kurihara
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
- Department of Cardiothoracic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Andre Critsinelis
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Brendan Pen-Haw Chou
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Qianzi Zhang
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Yuji Kaku
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Andrew B Civitello
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Jeffrey A Morgan
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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11
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Bechtel JFM. Commentary: When suction alone is not enough. J Thorac Cardiovasc Surg 2019; 159:906-907. [PMID: 31128905 DOI: 10.1016/j.jtcvs.2019.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- J F Matthias Bechtel
- Department for Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany.
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