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James L, Smith DE. Supporting the "forgotten" ventricle: The evolution of percutaneous RVADs. Front Cardiovasc Med 2023; 9:1008499. [PMID: 36684567 PMCID: PMC9845717 DOI: 10.3389/fcvm.2022.1008499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/30/2022] [Indexed: 01/06/2023] Open
Abstract
Right heart failure (RHF) can occur as the result of an acute or chronic disease process and is a challenging clinical condition for surgeons and interventionalists to treat. RHF occurs in approximately 0.1% of patients after cardiac surgery, in 2-3% of patients following heart transplantation, and in up to 42% of patients after LVAD implantation. Regardless of the cause, RHF portends high morbidity and mortality and is associated with longer hospital stays and higher healthcare costs. The mainstays of traditional therapy for severe RHF have included pharmacological support, such as inotropes and vasopressors, and surgical right ventricular (RV) assist devices. However, in recent years catheter-based mechanical circulatory support (MCS) strategies have offered novel solutions for addressing RHF without the morbidity of open surgery. This manuscript will review the pathophysiology of RHF, including the molecular underpinnings, gross structural mechanisms, and hemodynamic consequences. The evolution of techniques for supporting the right ventricle will be explored, with a focus on various institutional experiences with percutaneous ventricular assist devices.
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2
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Prognostic value of TAPSE/PASP ratio in right ventricular failure after left ventricular assist device implantation: Experience from a tertiary center. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:334-343. [PMID: 36303699 PMCID: PMC9580292 DOI: 10.5606/tgkdc.dergisi.2022.23218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/11/2022] [Indexed: 12/02/2022]
Abstract
Background
In this study, we aimed to investigate the prognostic value of the tricuspid annular plane systolic excursion (TAPSE)/ pulmonary arterial systolic pressure (PASP) ratio in right ventricular failure patients undergoing left ventricular assist device implantation.
Methods
Between February 2013 and February 2020, a total of 75 heart failure patients (65 males, 10 females; median age: 54 years; range, 21 to 66 years) were retrospectively analyzed. The prognostic value of TAPSE/PASP ratio was assessed using the multivariate Cox regression models and confirmed using the Kaplan-Meier analyses.
Results
Forty-one (55.4%) patients had an ischemic heart failure etiology. The indication for assist device implantation was bridge to transplant in 64 (85.3%) patients. The overall survival rates at one, three, and five years following left ventricular assist device implantation were 82.7%, 68%, and 49.3%, respectively. Right ventricular failure was observed in 24 (32%) patients during follow-up. In the multivariate analysis, TAPSE/PASP was found to be independently associated with postoperative right ventricular failure (HR: 1.63; 95% CI: 1.49-2.23). A TAPSE/PASP of 0.34 mm/mmHg was found to be the most accurate predictor value, with lower ratios correlating with right ventricular failure. The Kaplan-Meier analysis showed a better overall survival using a TAPSE/PASP ≥ of 0.34 mm/mmHg (p<0.001).
Conclusion
A lower TAPSE/PASP ratio, particularly lower values than 0.34 mm/mmHg, strongly predicts right ventricular failure after left ventricular assist device implantation in patients with advanced heart failure.
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3
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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4
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DeFilippis EM, Topkara VK, Kirtane AJ, Takeda K, Naka Y, Garan AR. Mechanical Circulatory Support for Right Ventricular Failure. Card Fail Rev 2022; 8:e14. [PMID: 35516793 PMCID: PMC9062706 DOI: 10.15420/cfr.2021.11] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
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5
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Attinger-Toller A, Bossard M, Cioffi GM, Tersalvi G, Madanchi M, Bloch A, Kobza R, Cuculi F. Ventricular Unloading Using the Impella TM Device in Cardiogenic Shock. Front Cardiovasc Med 2022; 9:856870. [PMID: 35402561 PMCID: PMC8984099 DOI: 10.3389/fcvm.2022.856870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.
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Affiliation(s)
- Adrian Attinger-Toller
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland,*Correspondence: Adrian Attinger-Toller
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Gregorio Tersalvi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
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6
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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7
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Varma PK, Srimurugan B, Jose RL, Krishna N, Valooran GJ, Jayant A. Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure). Indian J Thorac Cardiovasc Surg 2021; 38:157-166. [PMID: 34751203 PMCID: PMC8566189 DOI: 10.1007/s12055-021-01226-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/01/2021] [Accepted: 06/13/2021] [Indexed: 12/01/2022] Open
Abstract
The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings-increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.
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Affiliation(s)
- Praveen Kerala Varma
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Balaji Srimurugan
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Reshmi Liza Jose
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
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8
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Lo Coco V, De Piero ME, Massimi G, Chiarini G, Raffa GM, Kowalewski M, Maessen J, Lorusso R. Right ventricular failure after left ventricular assist device implantation: a review of the literature. J Thorac Dis 2021; 13:1256-1269. [PMID: 33717597 PMCID: PMC7947472 DOI: 10.21037/jtd-20-2228] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation remains a major complication which may significantly impair patient outcome. The genesis of RVF is, however, multifactorial, and the mechanisms underlying such a condition have not been fully elucidated, making its prevention challenging and the course not always predictable. Although preoperative risks factors can be associated with RV impairment, the physiologic changes after the LV support, can still hamper the function of the RV. Current medical treatment options are limited and sometimes, patients with a severe post-LVAD RVF may be unresponsive to pharmacological therapy and require more aggressive treatment, such as temporary RV support. We retrieved 11 publications which we assessed and divided in groups based on the RV support [extracorporeal membrane oxygenation (ECMO), right ventricular assist device (RVAD), TandemHeart with ProtekDuo cannula]. The current review comprehensively summarizes the main studies of the literature with particular attention to the RV physiology and its changes after the LVAD implantation, the predictors and prognostic score as well as the different modalities of temporary mechanical cardio-circulatory support, and its effects on patient prognosis for RVF in such a setting. In addition, it provides a decision making of the pre-, intra and post-operative management in high- and moderate- risk patients.
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Affiliation(s)
- Valeria Lo Coco
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Maria Elena De Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Anesthesia/Intensive Care, San Giovanni, Turin, Italy
| | - Giulio Massimi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Cardiac Surgery, Circolo Hospital, University of Insurbia, Varese, Italy
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Division of Anesthesiology, Intensive Care and Emergency medicine, Spedali Civili University, Brescia, Italy
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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9
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Deng L, Xia Q, Chi C, Hu G. Awake veno-arterial extracorporeal membrane oxygenation in patients with perioperative period acute heart failure in cardiac surgery. J Thorac Dis 2020; 12:2179-2187. [PMID: 32642123 PMCID: PMC7330313 DOI: 10.21037/jtd.2020.04.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective extracorporeal life support technology that has been applied to treat cardiorespiratory failure patients. Some medical centers have started using ECMO on awake, non-intubated, spontaneously breathing patients, as this strategy offers several benefits over mechanical ventilation. However, most awake-ECMO methods focus on venovenous ECMO, and few cases of awake veno-arterial ECMO (V-A ECMO) have been reported, especially in perioperative acute heart failure. Therefore, our study aimed to examine awake—V-A ECMO cases that were not given continuous sedation or invasive mechanical ventilation (IMV) during perioperative heart failure. Method In total, 40 ECMO patients from December 2013 to November 2019 were divided into 2 groups (the awake-ECMO group and the asleep-ECMO group) according to the ventilation use. The demographics, patient outcomes, and ECMO parameters were collected and retrospectively analyzed. Results We identified 12 cases of awake ECMO without continuous ventilation, and 28 cases of simultaneous IMV and ECMO (asleep ECMO). Awake-ECMO patients showed fewer complications and better outcomes compared to ventilation patients. All patients in the awake group were successfully weaned off ECMO, while only 5 (18%) patients were weaned off ECMO in the asleep group. Furthermore, 9 (75%) patients survived until discharge in the awake group vs. 3 (11%) in the asleep group; 3 patients died of septic shock after weaning in the awake group, while 25 patients died of septic shock, hemodynamic disorder, bleeding, cerebral hemorrhage, etc., in the asleep group. These complications, including bleeding, pneumonia, hemolysis, and abdominal distension, etc., occurred less frequently in the asleep group compared to the awake group (P<0.05). Conclusions Awake V-A ECMO is an effective, feasible, and safe strategy in patients with perioperatively acute heart failure and can be applied as a bridge to cardiac function recovery or transplantation.
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Affiliation(s)
- Li Deng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Qingping Xia
- Department of Medical Research Center, Mudanjiang Medical University, Mudanjiang 157011, China
| | - Chao Chi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang Hu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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10
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Lorusso R, Raffa GM, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Kowalewski M, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, D'Alessandro DA, Boeken U, Whitman GJR. Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients. J Heart Lung Transplant 2019; 38:1125-1143. [PMID: 31522913 PMCID: PMC8152367 DOI: 10.1016/j.healun.2019.08.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 07/21/2019] [Accepted: 08/05/2019] [Indexed: 01/25/2023] Open
Abstract
Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Daniel Brodie
- Center for Acute Respiratory Care, Columbia University college of Physicians & Surgeon/New Yor Presbyterian Hospital, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University, Singapore, Singapore
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Heidi Dalton
- I.N.O.V.A. Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Centre, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn J R Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
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11
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Nowroozpoor A, Malekmohammad M, Seyyedi SR, Hashemian SM. Pulmonary Hypertension in Intensive Care Units: An Updated Review. TANAFFOS 2019; 18:180-207. [PMID: 32411259 PMCID: PMC7210574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension (PH) is a condition associated with high morbidity and mortality. Patients with PH who require critical care usually have severe right ventricular (RV) dysfunction. Although different groups of PH have different etiologies, pulmonary vascular dysfunction is common in these groups. PH can lead to increased pulmonary artery pressure, which can ultimately cause RV failure. Clinicians should be familiar with the presentations of this disease and diagnostic tools. The contributing factors, if present (e.g., sepsis), and coexisting conditions (e.g., arrhythmias) should be identified and addressed accordingly. The preload should be optimized by fluid administration, diuretics, and dialysis, if necessary. On the other hand, the RV afterload should be reduced to improve the RV function with pulmonary vasodilators, such as prostacyclins, inhaled nitric oxide, and phosphodiesterase type 5 inhibitors, especially in group 1 PH. Inotropes are also used to improve RV contractility, and if inadequate, use of ventricular assist devices and extracorporeal life support should be considered in suitable candidates. Moreover, vasopressors should be used to maintain systemic blood pressure, albeit cautiously, as they increase the RV afterload. Measures should be also taken to ensure adequate oxygenation. However, mechanical ventilation is avoided in RV failure. In this study, we reviewed the pathophysiology, manifestations, diagnosis, monitoring, and management strategies of PH, especially in intensive care units.
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Affiliation(s)
- Armin Nowroozpoor
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Malekmohammad
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Reza Seyyedi
- Lung Transplantation Research Center, Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammadreza Hashemian
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran,,Correspondence to: Hashemian SMR, Address: Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran Email address:
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12
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Han J, Trumble DR. Cardiac Assist Devices: Early Concepts, Current Technologies, and Future Innovations. Bioengineering (Basel) 2019; 6:bioengineering6010018. [PMID: 30781387 PMCID: PMC6466092 DOI: 10.3390/bioengineering6010018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 01/31/2023] Open
Abstract
Congestive heart failure (CHF) is a debilitating condition that afflicts tens of millions of people worldwide and is responsible for more deaths each year than all cancers combined. Because donor hearts for transplantation are in short supply, a safe and durable means of mechanical circulatory support could extend the lives and reduce the suffering of millions. But while the profusion of blood pumps available to clinicians in 2019 tend to work extremely well in the short term (hours to weeks/months), every long-term cardiac assist device on the market today is limited by the same two problems: infections caused by percutaneous drivelines and thrombotic events associated with the use of blood-contacting surfaces. A fundamental change in device design is needed to address both these problems and ultimately make a device that can support the heart indefinitely. Toward that end, several groups are currently developing devices without blood-contacting surfaces and/or extracorporeal power sources with the aim of providing a safe, tether-free means to support the failing heart over extended periods of time.
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Affiliation(s)
- Jooli Han
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA.
| | - Dennis R Trumble
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA.
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Dandel M, Hetzer R. Temporary assist device support for the right ventricle: pre-implant and post-implant challenges. Heart Fail Rev 2019; 23:157-171. [PMID: 29453695 DOI: 10.1007/s10741-018-9678-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Severe right ventricular (RV) failure is more likely reversible than similar magnitudes of left ventricular (LV) failure and, because reversal of both adaptive remodeling and impaired contractility require most often only short periods of support, the use of temporary RV assist devices (t-RVADs) can be a life-saving therapy option for many patients. Although increased experience with t-RVADs and progresses made in the development of safer devices with lower risk for complications has improved both recovery rate of RV function and patient survival, the mortality of t-RVAD recipients can still be high but it depends mainly on the primary cause of RV failure (RVF), the severity of end-organ dysfunction, and the timing of RVAD implantation, and much less on adverse events and complications related to RVAD implantation, support, or removal. Reduced survival of RVAD recipients should therefore not discourage appropriate application of RVADs because their underuse further reduces the chances for RV recovery and patient survival. The article reviews and discusses the challenges related to the pre-implant and post-implant decision-making processes aiming to get best possible therapeutic results. Special attention is focused on pre-implant RV assessment and prediction of RV improvement during mechanical unloading, patient selection for t-RVAD therapy, assessment of unloading-promoted RV recovery, and prediction of its stability after RVAD removal. Particular consideration is also given to prediction of RVF after LVAD implantation which is usually hampered by the complex interactions between the different risk factors related indirectly or directly to the RV potential for reverse remodeling and functional recovery.
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Affiliation(s)
- Michael Dandel
- DZHK (German Centre for Heart and Circulatory Research), Partner site Berlin, Berlin, Germany. .,Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Roland Hetzer
- Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Cardio Centrum Berlin, Berlin, Germany
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Comparison of Percutaneous and Surgical Right Ventricular Assist Device Support After Durable Left Ventricular Assist Device Insertion. J Card Fail 2018; 25:105-113. [PMID: 30582967 DOI: 10.1016/j.cardfail.2018.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 12/13/2018] [Accepted: 12/20/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Early right ventricular (RV) failure after left ventricular assist device (LVAD) implantation increases morbidity and mortality. Percutaneous right ventricular assist device (pRVAD) support is an alternative to more invasive surgical RVAD (sRVAD). METHODS AND RESULTS We retrospectively reviewed patients receiving isolated pRVAD or sRVAD after durable LVAD at our center in the years 2007-2018. Hemodynamic parameters before and after implantation and survival outcomes were compared among groups. Nineteen patients received pRVAD and 21 sRVAD. Hemodynamic parameters improved immediately with the use of pRVAD; central venous pressure decreased (from 15.9 ± 2.4 to 12.3 ± 3.2 mm Hg; P<.001) and cardiac index increased (from 2.4 ± 0.5 to 3.5 ± 0.8 L·min-1·m-2; P<.001). These were sustained after device removal and were similar to those with the use of sRVAD. Patients with pRVAD required fewer blood transfusions and mechanically ventilated days than those with sRVAD. Among survivors, intensive care unit and hospital days were fewer with the use of pRVAD: 21 (16-27) versus 34 (27-46) ICU days (P = .01); 43.5 (30-66) versus 91 (62-111) hospital days (P = .03). There was no significant difference in 30-day mortality with the use of pRVAD compared with sRVAD (21.1% vs 42.9%; P = .14), but there was a trend toward a higher rate of discharge free from hemodialysis (73.7% vs 47.6%; P = .09). CONCLUSIONS Novel pRVAD systems for RV failure provide hemodynamic benefits similar to sRVAD, are associated with less morbidity, and should be considered as an alternative to sRVAD.
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Coz Yataco A, Aguinaga Meza M, Buch KP, Disselkamp MA. Hospital and intensive care unit management of decompensated pulmonary hypertension and right ventricular failure. Heart Fail Rev 2018; 21:323-46. [PMID: 26486799 PMCID: PMC7102249 DOI: 10.1007/s10741-015-9514-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension and concomitant right ventricular failure present a diagnostic and therapeutic challenge in the intensive care unit and have been associated with a high mortality. Significant co-morbidities and hemodynamic instability are often present, and routine critical care unit resuscitation may worsen hemodynamics and limit the chances of survival in patients with an already underlying poor prognosis. Right ventricular failure results from structural or functional processes that limit the right ventricle’s ability to maintain adequate cardiac output. It is commonly seen as the result of left heart failure, acute pulmonary embolism, progression or decompensation of pulmonary hypertension, sepsis, acute lung injury, or in the perioperative setting. Prompt recognition of the underlying cause and institution of treatment with a thorough understanding of the elements necessary to optimize preload, cardiac contractility, enhance systemic arterial perfusion, and reduce right ventricular afterload are of paramount importance. Moreover, the emergence of previously uncommon entities in patients with pulmonary hypertension (pregnancy, sepsis, liver disease, etc.) and the availability of modern devices to provide support pose additional challenges that must be addressed with an in-depth knowledge of this disease.
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Affiliation(s)
- Angel Coz Yataco
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA.
| | - Melina Aguinaga Meza
- Department of Internal Medicine, Division of Cardiovascular Medicine - Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ketan P Buch
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
| | - Margaret A Disselkamp
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
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[Indications and strategies in mechanical circulatory support : Rise of the machines?]. Med Klin Intensivmed Notfmed 2017; 114:452-458. [PMID: 28871359 DOI: 10.1007/s00063-017-0336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Terminal heart failure is an emerging problem with a continuously growing number of diseased patients worldwide. Because of the limited number of donor hearts, mechanical circulatory support is increasingly becoming an integral part of surgical treatment for end-stage heart failure, especially in patients deemed for destination therapy. Accurate patient selection, appropriate indication, and the optimal implantation time point guarantee a good outcome for these patients. This review article gives a systematic overview of the possible indication settings and treatment strategies for various patient groups in need of mechanical circulatory support.
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Camboni D, Zerdzitzki M, Hirt S, Tandler R, Weyand M, Schmid C. Reduction of INCOR® driveline infection rate with silicone at the driveline exit site. Interact Cardiovasc Thorac Surg 2017; 24:222-228. [PMID: 27702831 DOI: 10.1093/icvts/ivw336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 08/04/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives A silicone interface at skin level of left ventricular assist device (LVAD) may reduce the risk of driveline (DL) exit site infections when compared with other materials (e.g. velour). The purpose of this study was to evaluate the rate of DL exit site infection according to the presence of silicone or velour at the exit site with the redesigned INCOR, facilitating the positioning of silicone at the exit site. Methods The rate of DL exit site infection and overall survival were compared between the two groups (silicone group, n = 16/velour group, n = 24) with 1-year follow-up postimplantation. Results Risk factors for infection were more prevalent in the silicone group (obesity P = 0.33, prevalence of renal dysfunction P = 0.007, higher CRP levels P = 0.001). During the observation period, 6 patients developed a DL infection (25%) in the velour group, whereas 1 patient developed a DL infection in (6%) in the silicone group (P = 0.19). The event-per-patient year (EPPY) rates were 0.34 and 0.10 for velour group and silicone group, respectively (P = 0.30). All DL infections could be treated successfully by the antibiotic treatment, surgical debridement and ultimately high urgency heart transplantation, resulting in no direct DL infection-related mortality in this cohort. One-year survival was similar in both the groups (silicone 69 vs 75% in the velour group; P = 0.67). Conclusions Fewer infections were observed at the exit site in case of a silicone-covered DL, without reaching statistical significance. More patients and longer observation periods are needed to demonstrate a statistical difference.
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Affiliation(s)
- Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthaeus Zerdzitzki
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Hirt
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - René Tandler
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Michael Weyand
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Jayaraman AL, Cormican D, Shah P, Ramakrishna H. Cannulation strategies in adult veno-arterial and veno-venous extracorporeal membrane oxygenation: Techniques, limitations, and special considerations. Ann Card Anaesth 2017; 20:S11-S18. [PMID: 28074818 PMCID: PMC5299823 DOI: 10.4103/0971-9784.197791] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) refers to specific mechanical devices used to temporarily support the failing heart and/or lung. Technological advances as well as growing collective knowledge and experience have resulted in increased ECMO use and improved outcomes. Veno-arterial (VA) ECMO is used in selected patients with various etiologies of cardiogenic shock and entails either central or peripheral cannulation. Central cannulation is frequently used in postcardiotomy cardiogenic shock and is associated with improved venous drainage and reduced concern for upper body hypoxemia as compared to peripheral cannulation. These concerns inherent to peripheral VA ECMO may be addressed through so-called triple cannulation approaches. Veno-venous (VV) ECMO is increasingly employed in selected patients with respiratory failure refractory to more conventional measures. Newer dual lumen VV ECMO cannulas may facilitate extubation and mobilization. In summary, the pathology being addressed impacts the ECMO approach that is deployed, and each ECMO implementation has distinct virtues and drawbacks. Understanding these considerations is crucial to safe and effective ECMO use.
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Affiliation(s)
- Arun L Jayaraman
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic; Department of Critical Care Medicine, Mayo Clinic, Arizona, USA
| | - Daniel Cormican
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Allegheny General Hospital, Pennsylvania, USA
| | - Pranav Shah
- Department of Anesthesiology, Virginia Commonwealth University, Virginia, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, USA
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Saxena P, Marasco SF. Tunneling a Pulmonary Artery Graft: A Simplified Way to Insert and Remove a Temporary Right Ventricular Assist Device. Tex Heart Inst J 2015; 42:540-2. [PMID: 26664306 DOI: 10.14503/thij-14-4855] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Right ventricular failure can occur early or late after left ventricular assist device implantation. Support with a right ventricular assist device is needed in patients whose right ventricular failure does not respond to conservative management. The use of a temporary right ventricular assist device can enable the recovery of right ventricular function and avoid the use of a more permanent biventricular assist device, which is associated with complications and higher costs. We present our technique of instituting temporary right ventricular assist device support in patients who have undergone left ventricular assist device implantation.
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20
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Argiriou M, Kolokotron SM, Sakellaridis T, Argiriou O, Charitos C, Zarogoulidis P, Katsikogiannis N, Kougioumtzi I, Machairiotis N, Tsiouda T, Tsakiridis K, Zarogoulidis K. Right heart failure post left ventricular assist device implantation. J Thorac Dis 2014; 6 Suppl 1:S52-9. [PMID: 24672699 DOI: 10.3978/j.issn.2072-1439.2013.10.26] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 10/29/2013] [Indexed: 11/14/2022]
Abstract
Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation. The incidence of RHF complicates 20-50% (range, 9-44%) of cases and is a major factor of postoperative morbidity and mortality. Unfortunately, despite the fact that many risk factors contributing to the development of RHF after LVAD implantation have been identified, it seems to be extremely difficult to avoid them. Prevention of RHF consists of the management of the preload and the afterload of the right ventricle with optimum inotropic support. The administration of vasodilators designed to reduce pulmonary vascular resistance is standard practice in most centers. The surgical attempt of implantation of a right ventricular assist device does not always resolve the problem and is not available in all cardiac surgery centers.
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Affiliation(s)
- Mihalis Argiriou
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Styliani-Maria Kolokotron
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Timothy Sakellaridis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Orestis Argiriou
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Christos Charitos
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Ioanna Kougioumtzi
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Nikolaos Machairiotis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Theodora Tsiouda
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Kosmas Tsakiridis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Cardiac Surgery Department, Transplantation Unit, "Evangelismos" Hospital, Athens, Greece ; 2 University of Ioannina School of Medicine, Ioannina, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, Theageneio Anticancer Hospital, Thessaloniki, Greece ; 6 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece
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Noly PE, Kirsch M, Quessard A, Leger P, Pavie A, Amour J, Leprince P. Temporary right ventricular support following left ventricle assist device implantation: a comparison of two techniques. Interact Cardiovasc Thorac Surg 2014; 19:49-55. [DOI: 10.1093/icvts/ivu072] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lang SA, O'Neill B, Waterworth P, Bilal H. Can the temporary use of right ventricular assist devices bridge patients with acute right ventricular failure after cardiac surgery to recovery? Interact Cardiovasc Thorac Surg 2013; 18:499-510. [PMID: 24371221 DOI: 10.1093/icvts/ivt472] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Can the temporary use of right ventricular assist devices (RVADs) bridge patients to recovery who suffer acute right ventricular failure after cardiac surgery? More than 183 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Indications for surgical intervention included coronary artery bypass surgery, valve replacement, post-heart transplant and left ventricular assist device insertion. Significant reductions in central venous pressure (P = 0.005) and mean pulmonary artery pressures (P < 0.01) were reported during and after RVAD support. Furthermore, increases in right ventricular cardiac output (P < 0.05), right ventricular ejection fraction (P < 0.05), right ventricular stroke work (P < 0.05) and pulmonary artery oxygen saturations (P < 0.05) were also seen. Assessment by one study showed that on Day 7 after RVAD removal, the right ventricular ejection fraction had increased by up to 40%. Dynamic echocardiography studies performed before, during and after RVAD placement demonstrated that after RVAD implantation, right ventricular end-diastolic dimensions (P < 0.05) and right atrial dimensions decreased (P < 0.05) and right ventricular ejection fraction (P < 0.05) increased. Although several studies successfully weaned patients from an RVAD, there were several complications, including bleeding requiring surgical intervention. However, this may be reduced by using percutaneous implantation (bleeding incidence: 4 of 9 patients) rather than by a surgically implanted RVAD (bleeding incidence: 5 of 5 patients). However, mortality is higher in percutaneous RVAD patients rather than in surgical RVAD (80-44%) patients. Causes of death cited for patients on an RVAD included multiorgan failure, sepsis, thromboembolic events, reoccurring right heart failure and failure to wean due to persistent right ventricular failure. We conclude that RVADs have been successfully used to bridge patients to recovery after cardiac surgery; however, RVADs carry numerous risks and a high mortality rate.
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Affiliation(s)
- Sommer A Lang
- School of Medicine, University of Manchester, Manchester, UK
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Atluri P, Fairman AS, MacArthur JW, Goldstone AB, Cohen JE, Howard JL, Zalewski CM, Shudo Y, Woo YJ. Continuous flow left ventricular assist device implant significantly improves pulmonary hypertension, right ventricular contractility, and tricuspid valve competence. J Card Surg 2013; 28:770-5. [PMID: 24118109 DOI: 10.1111/jocs.12214] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous flow left ventricular assist devices (CF LVAD) are being implanted with increasing frequency for end-stage heart failure. At the time of LVAD implant, a large proportion of patients have pulmonary hypertension, right ventricular (RV) dysfunction, and tricuspid regurgitation (TR). RV dysfunction and TR can exacerbate renal dysfunction, hepatic dysfunction, coagulopathy, edema, and even prohibit isolated LVAD implant. Repairing TR mandates increased cardiopulmonary bypass time and bicaval cannulation, which should be reserved for the time of orthotopic heart transplantation. We hypothesized that CF LVAD implant would improve pulmonary artery pressures, enhance RV function, and minimize TR, obviating need for surgical tricuspid repair. METHODS One hundred fourteen continuous flow LVADs implanted from 2005 through 2011 at a single center, with medical management of functional TR, were retrospectively analyzed. Pulmonary artery pressures were measured immediately prior to and following LVAD implant. RV function and TR were graded according to standard echocardiographic criteria, prior to, immediately following, and long-term following LVAD. RESULTS There was a significant improvement in post-VAD mean pulmonary arterial pressures (26.6 ± 4.9 vs. 30.2 ± 7.4 mmHg, p = 0.008) with equivalent loading pressures (CVP = 12.0 ± 4.0 vs. 12.1 ± 5.1 p = NS). RV function significantly improved, as noted by right ventricular stroke work index (7.04 ± 2.60 vs. 6.05 ± 2.54, p = 0.02). There was an immediate improvement in TR grade and RV function following LVAD implant, which was sustained long term. CONCLUSION Continuous flow LVAD implant improves pulmonary hypertension, RV function, and tricuspid regurgitation. TR may be managed nonoperatively during CF LVAD implant.
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Affiliation(s)
- Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ventricular assist device implant in the elderly is associated with increased, but respectable risk: a multi-institutional study. Ann Thorac Surg 2013; 96:141-7. [PMID: 23731606 DOI: 10.1016/j.athoracsur.2013.04.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/02/2013] [Accepted: 04/05/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND There are an increasing number of elderly patients with end-stage heart failure. Destination mechanical circulatory support is often the only therapy available for these patients who are not transplant candidates. The outcomes after continuous flow left ventricular assist device (CF LVAD) implant in older patients remains unclear. We undertook this multi-institutional study to quantify short-term and midterm outcomes after CF LVAD implant in the elderly. METHODS We retrospectively analyzed all patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) national registry that underwent implant of a CF LVAD (June 2006 to April 2012). Patients were divided into 2 cohorts based upon age (<70 years [n = 4,439] and ≥ 70 years (n = 590]). Preoperative, intraoperative, and postoperative variables were analyzed. The primary endpoint, survival, was compared between cohorts. RESULTS Patients age 70 and older were more hemodynamically stable pre-VAD implant as evidenced by INTERMACS profile and inotrope dependence. Perioperative outcomes, including median bypass time (89 vs 89 minutes) and length of stay (0.657 vs 0.657 months) were similar between cohorts (p = not significant). Kaplan-Meier analysis revealed a significant difference in 2-year survival between patients aged 70 years or greater (63%) and less than 70 (71%, p < 0.001). Multivariable Cox proportional hazard analysis revealed age as an independent predictor of mortality during follow-up (p < 0.001). Nonetheless, midterm cumulative survival in the older cohort was still reasonable (63% at 2 years). CONCLUSIONS Multi-institutional analysis revealed advanced age as a predictor of increased mortality after CF LVAD implantation. Careful patient selection is critical in the elderly to optimize long-term outcomes after CF LVAD implantation.
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Mishra V, Fiane AE, Geiran O, Sørensen G, Khushi I, Hagen TP. Hospital costs fell as numbers of LVADs were increasing: experiences from Oslo University Hospital. J Cardiothorac Surg 2012; 7:76. [PMID: 22925716 PMCID: PMC3515474 DOI: 10.1186/1749-8090-7-76] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 08/13/2012] [Indexed: 11/29/2022] Open
Abstract
Background The current study was undertaken to examine total hospital costs per patient of a consecutive implantation series of two 3rd generation Left Ventricle Assist Devices (LVAD). Further we analyzed if increased clinical experience would reduce total hospital costs and the gap between costs and the diagnosis related grouped (DRG)-reimbursement. Method Cost data of 20 LVAD implantations (VentrAssist™) from 2005-2009 (period 1) were analyzed together with costs from nine patients using another LVAD (HeartWare™) from 2009-June 2011 (period 2). For each patient, total costs were calculated for three phases - the pre-LVAD implantation phase, the LVAD implantation phase and the post LVAD implant phase. Patient specific costs were obtained prospectively from patient records and included personnel resources, medication, blood products, blood chemistry and microbiology, imaging and procedure costs including operating room costs. Overhead costs were registered retrospectively and allocated to the specific patient by predefined allocation keys. Finally, patient specific costs and overhead costs were aggregated into total hospital costs for each patient. All costs were calculated in 2011-prices. We used regression analyses to analyze cost variations over time and between the different devices. Results The average total hospital cost per patient for the pre-LVAD, LVAD and post-LVAD for period 1 was $ 585, 513 (range 132, 640- 1 247, 299), and the corresponding DRG- reimbursement (2009) was $ 143, 192 . The mean LOS was 54 days (range 12- 127). For period 2 the total hospital cost per patient was $ 413, 185 (range 314, 540- 622, 664) and the corresponding DRG- reimbursement (2010) was $ 136, 963. The mean LOS was 49 days (range 31- 93). The estimates from the regression analysis showed that the total hospital costs, excluding device costs, per patient were falling as the number of treated patients increased. The estimate from the trend variable was -14, 096 US$ (CI -3, 842 to -24, 349, p < 0.01). Conclusion There were significant reductions in total hospital costs per patient as the numbers of patients were increasing. This can possibly be explained by a learning effect including better logistics, selection and management of patients.
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Affiliation(s)
- Vinod Mishra
- Department of Finance and Resource Management Unit, Oslo University Hospital, Oslo, Norway.
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Atluri P, Ullery BW, MacArthur JW, Goldstone AB, Fairman AS, Hiesinger W, Acker MA, Woo YJ. Rapid onset of fulminant myocarditis portends a favourable prognosis and the ability to bridge mechanical circulatory support to recovery. Eur J Cardiothorac Surg 2012; 43:379-82. [DOI: 10.1093/ejcts/ezs242] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Haneya A, Philipp A, Puehler T, Ried M, Hilker M, Zink W, Hirt SW, Schmid C. Ventricular assist device implantation in patients on percutaneous extracorporeal life support without switching to conventional cardiopulmonary bypass system. Eur J Cardiothorac Surg 2012; 41:1366-70. [PMID: 22228845 DOI: 10.1093/ejcts/ezr203] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Ventricular assist device (VAD) implantation using cardiopulmonary bypass (CPB) is an established procedure. However, the well-described complications of CPB may exacerbate multiple organ failure and increase blood product transfusions especially in end-stage heart failure patients. METHODS We describe our successful experience in six consecutive patients with profound cardiogenic shock, who were provided on an emergency basis with a percutaneous extracorporeal life support (ECLS) system via the peripheral vessels. After stabilization, a VAD was implanted using ECLS without switching to a conventional CPB system to reduce its side effects. We compared the data with those of 11 patients in whom the VAD was placed with the aid of an additional CPB system. RESULTS The six patients demonstrated a shorter duration of operating room time compared with the patients requiring CPB for device placement. During and after surgery, blood loss and blood product transfusions were lower in these patients. The need for mechanical ventilation and inotropic support was shorter and the survival rate (100% at 30 days, 83.3% at 3 months and 83.3% at 6 months) was higher when compared with patients who were operated upon with CPB. Two patients were successfully bridged to transplantation. One patient died due to cerebral bleeding after 7 weeks. CONCLUSIONS Our experience suggests that VAD implantation using percutaneous ECLS without switching to conventional CPB is a safe alternative in the bridge to bridge concept, especially in high-risk patients with cardiogenic shock who would benefit from the avoidance of the adverse sequels associated with conventional CPB.
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Affiliation(s)
- Assad Haneya
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
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