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Rohde S, Miera O, Sliwka J, Sandica E, Amodeo A, Veen K, de By TMMH, Bogers AJJC, Schweiger M. Durable left ventricular assist device explantation following recovery in paediatric patients: Determinants and outcome after explantation. Eur J Cardiothorac Surg 2024; 65:ezae126. [PMID: 38613845 DOI: 10.1093/ejcts/ezae126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/31/2024] [Accepted: 04/11/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES Myocardial recovery in children supported by a durable left ventricular assist device is a rare, but highly desirable outcome because it could potentially eliminate the need for a cardiac transplant and the lifelong need for immunosuppressant therapy and the risk of complications. However, experience with this specific outcome is extremely limited. METHODS All patients < 19 years old supported by a durable left ventricular assist device from the European Registry for Patients with Mechanical Circulatory Support database were included. Participating centres were approached for additional follow-up data after explantation. Associated factors for explantation due to myocardial recovery were explored using Cox proportional hazard models. RESULTS The incidence of recovery in children supported by a durable left ventricular assist device was 11.7% (52/445; median duration of support, 122.0 days). Multivariable analyses showed body surface area (hazard ratio 0.229; confidence interval 0.093-0.565; P = 0.001) and a primary diagnosis of myocarditis (hazard ratio 4.597; confidence interval 2.545-8.303; P < 0.001) to be associated with recovery. Left ventricular end-diastolic diameter in children with myocarditis was not associated with recovery. Follow-up after recovery was obtained for 46 patients (88.5%). Sustained myocardial recovery was reported in 33/46 (71.7%) at the end of the follow-up period (28/33; >2 year). Transplants were performed in 6/46 (11.4%) (in 5 after a ventricular assist device was reimplanted). Death occurred in 7/46 (15.2%). CONCLUSIONS Myocardial recovery occurs in a substantial portion of paediatric patients supported with durable left ventricular assist devices, and sustainable recovery is seen in around three-quarters of them. Even children with severely dilated ventricles due to myocarditis can show recovery. Clinicians should be attentive to (developing) myocardial recovery. These results can be used to develop internationally approved paediatric weaning guidelines.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum der Charité, Berlin, Germany
| | - Joanna Sliwka
- Department of Cardiac Surgery, Transplantology and Vascular Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Eugen Sandica
- Clinic for Pediatric Cardiac Surgery and Congenital Heart Defects, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Antonio Amodeo
- Heart Failure, Transplant and MCS Unit, Bambino Gesù Children Hospital & Research Institute, Rome, Italy, Catholic University of Sacred Heart, Department of Cardiac Surgery, Rome, Italy
| | - Kevin Veen
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children's Hospital Zurich, Pediatric Heart Centre, Department for congenital heart surgery, Zurich, Switzerland
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Giridharan GA, Berg IC, Ismail E, Nguyen KT, Hecking J, Kirklin JK, Cheng X, Sethu P. Loss of pulsatility with continuous-flow left ventricular assist devices and the significance of the arterial endothelium in von-Willebrand factor production and degradation. Artif Organs 2023; 47:640-648. [PMID: 36404709 PMCID: PMC10065921 DOI: 10.1111/aor.14456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/06/2022] [Accepted: 11/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients on continuous flow ventricular assist devices (CF-VADs) are at high risk for the development of Acquired von-Willebrand Syndrome (AVWS) and non-surgical bleeding. von Willebrand Factor (vWF) plays an essential role in maintaining hemostasis via platelet binding to the damaged endothelium to facilitate coagulation. In CF-VAD patients, degradation of vWF into low MW multimers that are inefficient in facilitating coagulation occurs and has been primarily attributed to the supraphysiological shear stress associated with the CF-VAD impeller. METHODS In this review, we evaluate information from the literature regarding the unraveling behavior of surface-immobilized vWF under pulsatile and continuous flow pertaining to: (A) the process of arterial endothelial vWF production and release into circulation, (B) the critical shear stress required to unravel surface bound versus soluble vWF which leads to degradation, and (C) the role of pulsatility in on the production and degradation of vWF. RESULTS AND CONCLUSION Taken together, these data suggests that the loss of pulsatility and its impact on arterial endothelial cells plays an important role in the production, release, unraveling, and proteolytic degradation of vWF into low MW multimers, contributing to the development of AVWS. Restoration of pulsatility can potentially mitigate this issue by preventing AVWS and minimizing the risk of non-surgical bleeding.
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Affiliation(s)
- Guruprasad A. Giridharan
- Department of Bioengineering, J. B. Speed School of Engineering, University of Louisville, Louisville, KY 40292
| | - Ian C. Berg
- Division of Cardiovascular Disease, Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
- Department of Biomedical Engineering, School of Engineering and Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
| | - Esraa Ismail
- Department of Bioengineering, Lehigh University, Bethlehem, PA, 18018
| | - Khanh T. Nguyen
- Division of Cardiovascular Disease, Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
- Department of Biomedical Engineering, School of Engineering and Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
| | - Jana Hecking
- Division of Cardiovascular Disease, Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
- Department of Biomedical Engineering, School of Engineering and Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
| | - James K. Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
| | - Xuanhong Cheng
- Department of Materials Science and Engineering, Lehigh University, Bethlehem, PA, 18018
- Department of Bioengineering, Lehigh University, Bethlehem, PA, 18018
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
- Department of Biomedical Engineering, School of Engineering and Heersink School of Medicine, University of Alabama at Birmingham, AL 35294
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Jedrzejewska A, Braczko A, Kawecka A, Hellmann M, Siondalski P, Slominska E, Kutryb-Zajac B, Yacoub MH, Smolenski RT. Novel Targets for a Combination of Mechanical Unloading with Pharmacotherapy in Advanced Heart Failure. Int J Mol Sci 2022; 23:ijms23179886. [PMID: 36077285 PMCID: PMC9456495 DOI: 10.3390/ijms23179886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 12/19/2022] Open
Abstract
LVAD therapy is an effective rescue in acute and especially chronic cardiac failure. In several scenarios, it provides a platform for regeneration and sustained myocardial recovery. While unloading seems to be a key element, pharmacotherapy may provide powerful tools to enhance effective cardiac regeneration. The synergy between LVAD support and medical agents may ensure satisfying outcomes on cardiomyocyte recovery followed by improved quality and quantity of patient life. This review summarizes the previous and contemporary strategies for combining LVAD with pharmacotherapy and proposes new therapeutic targets. Regulation of metabolic pathways, enhancing mitochondrial biogenesis and function, immunomodulating treatment, and stem-cell therapies represent therapeutic areas that require further experimental and clinical studies on their effectiveness in combination with mechanical unloading.
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Affiliation(s)
- Agata Jedrzejewska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Alicja Braczko
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Ada Kawecka
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Marcin Hellmann
- Department of Cardiac Diagnostics, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland
| | - Piotr Siondalski
- Department of Cardiac Surgery, Medical University of Gdansk, Debinki 7 Street, 80-211 Gdansk, Poland
| | - Ewa Slominska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Barbara Kutryb-Zajac
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
| | - Magdi H. Yacoub
- Heart Science Centre, Imperial College of London at Harefield Hospital, Harefield UB9 6JH, UK
| | - Ryszard T. Smolenski
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
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Wang Y, Nguyen KT, Ismail E, Donoghue L, Giridharan GA, Sethu P, Cheng X. Effect of pulsatility on shear-induced extensional behavior of Von Willebrand factor. Artif Organs 2022; 46:887-898. [PMID: 34866200 PMCID: PMC9791949 DOI: 10.1111/aor.14133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with continuous flow ventricular assist devices (CF-VADs) are at high risk for non-surgical bleeding, speculated to associate with the loss of pulsatility following CF-VAD placement. It has been hypothesized that continuous shear stress causes elongation and increased enzymatic degradation of von Willebrand Factor (vWF), a key player in thrombus formation at sites of vascular damage. However, the role of loss of pulsatility on the unravelling behavior of vWF has not been widely explored. METHODS vWF molecules were immobilized on the surface of microfluidic devices and subjected to various pulsatile flow profiles, including continuous flow and pulsatile flow of different magnitudes, dQ/dt (i.e., first derivative of flow rate) of pulsatility and pulse frequencies to mimic in vivo shear flow environments with and without CF-VAD support. VWF elongation was observed using total internal reflection fluorescence (TIRF) microscopy. Besides, the vWF level is measured from the patients' blood sample before and after CF-VAD implantation from a clinical perspective. To our knowledge, this work is the first in providing direct, visual observation of single vWF molecule extension under controlled-pulsatile shear flow. RESULTS Unravelling of vWF (total sample size n ~ 200 molecules) is significantly reduced under pulsatile flow (p < 0.01) compared to continuous flow. An increase in the magnitude of pulsatility further reduces unravelling lengths, while lower frequency of pulsatility (20 vs. 60 pulses per min) does not have a major effect on the maximum or minimum unravelling lengths. Evaluation of CF-VAD patient blood samples (n = 13) demonstrates that vWF levels decreased by ~40% following CF-VAD placement (p < 0.01), which correlates to single-molecule observations from a clinical point of view. CONCLUSIONS Pulsatile flow reduces unfolding of vWF compared to continuous flow and a lower pulse frequency of 20 pulses/minute yielded comparable vWF unfolding to 60 pulses/minute. These findings could shed light on non-surgical bleeding associated with the loss of pulsatility following CF-VAD placement.
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Affiliation(s)
- Yi Wang
- Department of Materials Science and Engineering, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Khanh T. Nguyen
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,Department of Biomedical Engineering, School of Engineering and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Esraa Ismail
- Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Leslie Donoghue
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,Department of Biomedical Engineering, School of Engineering and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guruprasad A. Giridharan
- Department of Bioengineering, J. B. Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,Department of Biomedical Engineering, School of Engineering and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Xuanhong Cheng
- Department of Materials Science and Engineering, Lehigh University, Bethlehem, Pennsylvania, USA,Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania, USA
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Nguyen KT, Donoghue L, Giridharan GA, Naber JP, Vincent D, Fukamachi K, Kotru A, Sethu P. Acute Response of Human Aortic Endothelial Cells to Loss of Pulsatility as Seen during Cardiopulmonary Bypass. Cells Tissues Organs 2021; 211:324-334. [PMID: 33631743 DOI: 10.1159/000512558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022] Open
Abstract
Cardiopulmonary bypass (CPB) results in short-term (3-5 h) exposure to flow with diminished pulsatility often referred to as "continuous flow". It is unclear if short-term exposure to continuous flow influences endothelial function, particularly, changes in levels of pro-inflammatory and pro-angiogenic cytokines. In this study, we used the endothelial cell culture model (ECCM) to evaluate if short-term (≤5 h) reduction in pulsatility alters levels of pro-inflammatory/pro-angiogenic cytokine levels. Human aortic endothelial cells (HAECs) cultured within the ECCM provide a simple model to evaluate endothelial cell function in the absence of confounding factors. HAECs were maintained under normal pulsatile flow for 24 h and then subjected to continuous flow (diminished pulsatile pressure and flow) as observed during CPB for 5 h. The ECCM replicated pulsatility and flow morphologies associated with normal hemodynamic status and CPB as seen with clinically used roller pumps. Levels of angiopoietin-2 (ANG-2), vascular endothelial growth factor-A (VEGF-A), and hepatocyte growth factor were lower in the continuous flow group in comparison to the pulsatile flow group whereas the levels of endothelin-1 (ET-1), granulocyte colony stimulating factor, interleukin-8 (IL-8) and placental growth factor were higher in the continuous flow group in comparison to the pulsatile flow group. Immunolabelling of HAECs subjected to continuous flow showed a decrease in expression of ANG-2 and VEGF-A surface receptors, tyrosine protein kinase-2 and Fms-related receptor tyrosine kinase-1, respectively. Given that the 5 h exposure to continuous flow is insufficient for transcriptional regulation, it is likely that pro-inflammatory/pro-angiogenic signaling observed was due to signaling molecules stored in Weible-Palade bodies (ET-1, IL-8, ANG-2) and via HAEC binding/uptake of soluble factors in media. These results suggest that even short-term exposure to continuous flow can potentially activate pro-inflammatory/pro-angiogenic signaling in cultured HAECs and pulsatile flow may be a successful strategy in reducing the undesirable sequalae following continuous flow CPB.
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Affiliation(s)
- Khanh T Nguyen
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leslie Donoghue
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guruprasad A Giridharan
- Department of Bioengineering, J. B. Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | | | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arushi Kotru
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA,
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Antonides CFJ, Schoenrath F, de By TMMH, Muslem R, Veen K, Yalcin YC, Netuka I, Gummert J, Potapov EV, Meyns B, Özbaran M, Schibilsky D, Caliskan K. Outcomes of patients after successful left ventricular assist device explantation: a EUROMACS study. ESC Heart Fail 2020; 7:1085-1094. [PMID: 32196996 PMCID: PMC7261531 DOI: 10.1002/ehf2.12629] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/03/2020] [Accepted: 01/09/2020] [Indexed: 11/11/2022] Open
Abstract
AIMS Sufficient myocardial recovery with the subsequent explantation of a left ventricular assist device (LVAD) occurs in approximately 1-2% of the cases. However, follow-up data about this condition are scarcely available in the literature. This study aimed to report the long-term outcomes and clinical management following LVAD explantation. METHODS AND RESULTS An analysis of the European Registry for Patients with Mechanical Circulatory Support was performed to identify all adult patients with myocardial recovery and successful explantation. Pre-implant characteristics were retrieved and compared with the non-recovery patients. The follow-up data after explantation were collected via a questionnaire. A Kaplan-Meier analysis for freedom of the composite endpoint of death, heart transplantation, LVAD reimplantion, or heart failure (HF) relapse was conducted. A total of 45 (1.4%) cases with myocardial recovery resulting in successful LVAD explantation were identified. Compared with those who did not experience myocardial recovery, the explanted patients were younger (44 vs. 56 years, P < 0.001), had a shorter duration of cardiac disease (P < 0.001), and were less likely to have ischaemic cardiomyopathy (9% vs. 41.8%, P < 0.001). Follow-up after explantation could be acquired in 28 (62%) cases. The median age at LVAD implantation was 43 years (inter-quartile range: 29-52), and 23 (82%) were male. Baseline left ventricular ejection fraction was 18% (inter-quartile range: 10-20%), and 60.7% of the patients had Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 or 2. Aetiologies of HF were dilated cardiomyopathy in 36%, myocarditis in 32%, and ischaemic in 14% of the patients, and 18% had miscellaneous aetiologies. The devices implanted were HeartMate II in 14 (50%), HVAD in 11 (39%), HeartMate 3 in 2 (7%), and 1 unknown with a median duration of support of 410 days (range: 59-1286). The median follow-up after explantation was 26 months (range 0.3-73 months), and 82% of the patients were in New York Heart Association Class I or II. Beta-blockers were prescribed to 85%, angiotensin-converting enzyme inhibitors to 71%, and loop diuretics to 50% of the patients, respectively. Freedom from the composite endpoint was 100% after 30 days and 88% after 2 years. CONCLUSIONS The survival after LVAD explantation is excellent without the need for heart transplantation or LVAD reimplantation. Only a minority of the patients suffer from a relapse of significant HF.
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Affiliation(s)
- Christiaan F J Antonides
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Theo M M H de By
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,EUROMACS, EACTS, Windsor, UK
| | - Rahatullah Muslem
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kevin Veen
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yunus C Yalcin
- Thoraxcenter, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Thoraxcenter, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege Üniversitesi Tıp Fakültesi, Izmir, Turkey
| | - David Schibilsky
- Department of Cardiovascular Surgery, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Freiburg, Germany
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Bastos MB, van Wiechen MP, Van Mieghem NM. PulseCath iVAC2L: next-generation pulsatile mechanical circulatory support. Future Cardiol 2020; 16:103-112. [PMID: 31934785 DOI: 10.2217/fca-2019-0060] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Contemporary state of the art percutaneous coronary intervention techniques offer treatment strategies and solutions to an increasing number of patients with heart failure and complex coronary artery disease. Percutaneous mechanical circulatory support is intended to alleviate the mechanical and energetic workload imposed to a failing ventricle by reducing left ventricle pressures and volumes and potentially also increasing coronary blood flow. The PulseCath iVAC2L is a transaortic left ventricular assist device that applies a pneumatic driving system to produce pulsatile forward flow. Herein, the essential aspects regarding iVAC2L are discussed with focus on its mechanisms of action and the available clinical experience.
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Affiliation(s)
- Marcelo B Bastos
- Department of Interventional Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maarten P van Wiechen
- Department of Interventional Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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9
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Poglajen G, Gregoric ID, Radovancevic R, Vrtovec B. Stem Cell and Left Ventricular Assist Device Combination Therapy. Circ Heart Fail 2019; 12:e005454. [PMID: 30759999 DOI: 10.1161/circheartfailure.118.005454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ventricular assist device (VAD) technology has evolved significantly over the past decades and currently represents one of the most important treatment strategies for patients with advanced chronic heart failure. There is increasing evidence that in selected patients undergoing long-term VAD support, improvement of myocardial structure and function may occur. However, there seems to be a significant discrepancy between structural and functional recovery of the failing myocardium, as only a small fraction of VAD-supported patients demonstrate reverse structural remodeling and eventually reach clinically significant and stable, functional improvement. More recently, cell therapy has gained a growing interest in the heart failure community because of its potential to augment reverse remodeling of the failing myocardium. Although theoretically the combination of long-term VAD support and cell therapy may offer significant advantages over using these therapeutic modalities separately, it remains largely unexplored. This review aims to summarize the current state of the art of the effects of VAD support and cell therapy on the reverse remodeling of the failing myocardium and to discuss the rationale for using a combined treatment strategy to further promote myocardial recovery in patients with advanced chronic heart failure.
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Affiliation(s)
- Gregor Poglajen
- Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Slovenia (G.P., B.V.).,Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston (G.P., I.D.G., R.R.)
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston (G.P., I.D.G., R.R.)
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston (G.P., I.D.G., R.R.)
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Slovenia (G.P., B.V.)
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10
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Dandel M, Hetzer R. Recovery of failing hearts by mechanical unloading: Pathophysiologic insights and clinical relevance. Am Heart J 2018; 206:30-50. [PMID: 30300847 DOI: 10.1016/j.ahj.2018.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 09/08/2018] [Indexed: 12/23/2022]
Abstract
By reduction of ventricular wall-tension and improving the blood supply to vital organs, ventricular assist devices (VADs) can eliminate the major pathophysiological stimuli for cardiac remodeling and even induce reverse remodeling occasionally accompanied by clinically relevant reversal of cardiac structural and functional alterations allowing VAD explantation, even if the underlying cause for the heart failure (HF) was dilated cardiomyopathy. Accordingly, a tempting potential indication for VADs in the future might be their elective implantation as a therapeutic strategy to promote cardiac recovery in earlier stages of HF, when the reversibility of morphological and functional alterations is higher. However, the low probability of clinically relevant cardiac improvement after VAD implantation and the lack of criteria which can predict recovery already before VAD implantation do not allow so far VAD implantations primarily designed as a bridge to cardiac recovery. The few investigations regarding myocardial reverse remodeling at cellular and sub-cellular level in recovered patients who underwent VAD explantation, the differences in HF etiology and pre-implant duration of HF in recovered patients and also the differences in medical therapy used by different institutions during VAD support make it currently impossible to understand sufficiently all the biological processes and mechanisms involved in cardiac improvement which allows even VAD explantation in some patients. This article aims to provide an overview of the existing knowledge about VAD-promoted cardiac improvement focusing on the importance of bench-to-bedside research which is mandatory for attaining the future goal to use long-term VADs also as therapy-devices for reversal of chronic HF.
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11
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Saito T, Miyagawa S, Toda K, Yoshikawa Y, Fukushima S, Saito S, Yoshioka D, Sakata Y, Daimon T, Sawa Y. Effect of Continuous‐Flow Mechanical Circulatory Support on Microvasculature Remodeling in the Failing Heart. Artif Organs 2018; 43:350-362. [DOI: 10.1111/aor.13348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/06/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Tetsuya Saito
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Shunsuke Saito
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Yasushi Sakata
- Department of Cardiology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Takashi Daimon
- Department of Biostatistics Hyogo College of Medicine Nishinomiya Hyogo Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita Osaka Japan
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Haglund TA, Rajasekaran NS, Smood B, Giridharan GA, Hoopes CW, Holman WL, Mauchley DC, Prabhu SD, Pamboukian SV, Tallaj JA, Rajapreyar IN, Kirklin JK, Sethu P. Evaluation of flow-modulation approaches in ventricular assist devices using an in-vitro endothelial cell culture model. J Heart Lung Transplant 2018; 38:456-465. [PMID: 30503074 DOI: 10.1016/j.healun.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/11/2018] [Accepted: 10/24/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Continuous-flow ventricular assist devices (CF-VADs) produce non-physiologic flow with diminished pulsatility, which is a major risk factor for development of adverse events, including gastrointestinal (GI) bleeding and arteriovenous malformations (AVMs). Introduction of artificial pulsatility by modulating CF-VAD flow has been suggested as a potential solution. However, the levels of pulsatility and frequency of CF-VAD modulation necessary to prevent adverse events are currently unknown and need to be evaluated. METHODS The purpose of this study was to use human aortic endothelial cells (HAECs) cultured within an endothelial cell culture model (ECCM) to: (i) identify and validate biomarkers to determine the effects of pulsatility; and (ii) conclude whether introduction of artificial pulsatility using flow-modulation approaches can mitigate changes in endothelial cells seen with diminished pulsatile flow. Nuclear factor erythroid 2-related factor 2 (Nrf-2)-regulated anti-oxidant genes and proteins and the endothelial nitric oxide synthase/endothelin-1 (eNOS/ET-1) signaling pathway are known to be differentially regulated in response to changes in pulsatility. RESULTS Comparison of HAECs cultured within the ECCM (normal pulsatile vs CF-VAD) with aortic wall samples from patients (normal pulsatile [n = 5] vs CF-VADs [n = 5]) confirmed that both the Nrf-2-activated anti-oxidant response and eNOS/ET-1 signaling pathways were differentially regulated in response to diminished pulsatility. Evaluation of 2 specific CF-VAD flow-modulation protocols to introduce artificial pulsatility, synchronous (SYN, 80 cycles/min, pulse pressure 20 mm Hg) and asynchronous (ASYN, 40 cycles/min, pulse pressure 45 mm Hg), suggested that both increased expression of Nrf-2-regulated anti-oxidant genes and proteins along with changes in levels of eNOS and ET-1 can potentially be minimized with ASYN and, to a lesser extent, with SYN. CONCLUSIONS HAECs cultured within the ECCM can be used as an accurate model of large vessels in patients to identify biomarkers and select appropriate flow-modulation protocols. Pressure amplitude may have a greater effect in normalizing anti-oxidant response compared with frequency of modulation.
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Affiliation(s)
- Thomas A Haglund
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Namakkal S Rajasekaran
- Division of Molecular and Cellular Pathology, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA; School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Smood
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guruprasad A Giridharan
- Department of Bioengineering, Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William L Holman
- Department of Bioengineering, Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | - David C Mauchley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sumanth D Prabhu
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose A Tallaj
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Indranee N Rajapreyar
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James K Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Purohit SN, Cornwell WK, Pal JD, Lindenfeld J, Ambardekar AV. Living Without a Pulse: The Vascular Implications of Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2018; 11:e004670. [PMID: 29903893 PMCID: PMC6007027 DOI: 10.1161/circheartfailure.117.004670] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pulsatility seems to have a teleological role because evolutionary hierarchy favors higher ordered animals with more complex, multichamber circulatory systems that generate higher pulse pressure compared with lower ordered animals. Yet despite years of such natural selection, the modern generation of continuous-flow left ventricular assist devices (CF-LVADs) that have been increasingly used for the last decade have created a unique physiology characterized by a nonpulsatile, nonlaminar blood flow profile with the absence of the usual large elastic artery Windkessel effect during diastole. Although outcomes and durability have improved with CF-LVADs, patients supported with CF-LVADs have a high rate of complications that were not as frequently observed with older pulsatile devices, including gastrointestinal bleeding from arteriovenous malformations, pump thrombosis, and stroke. Given the apparent fundamental biological role of the pulse, the purpose of this review is to describe the normal physiology of ventricular-arterial coupling from pulsatile flow, the effects of heart failure on this physiology and the vasculature, and to examine the effects of nonpulsatile blood flow on the vascular system and potential role in complications seen with CF-LVAD therapy. Understanding these concomitant vascular changes with CF-LVADs may be a key step in improving patient outcomes as modulation of pulsatility and flow characteristics may serve as a novel, yet simple, therapy for reducing complications.
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Affiliation(s)
- Suneet N Purohit
- Division of Cardiology, Department of Medicine (S.N.P., W.K.C, A.V.A.)
| | | | - Jay D Pal
- Division of Cardiothoracic Surgery, Department of Surgery (J.D.P.)
| | - JoAnn Lindenfeld
- University of Colorado, Aurora. Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
| | - Amrut V Ambardekar
- Division of Cardiology, Department of Medicine (S.N.P., W.K.C, A.V.A.)
- Consortium for Fibrosis Research and Translation (A.V.A.)
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15
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Favorable Effects on Pulmonary Vascular Hemodynamics with Continuous-Flow Left Ventricular Assist Devices Are Sustained 5 Years After Heart Transplantation. ASAIO J 2018; 64:38-42. [PMID: 28661912 DOI: 10.1097/mat.0000000000000614] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It is unclear whether pulmonary hemodynamics improvement with left ventricle unloading with left ventricular assist devices (LVADs) is sustained long term after heart transplant (HT). We sought to assess the effects on pulmonary vascular hemodynamics during continuous-flow (CF-LVAD) and pulsatile flow (PF-LVAD) support up to 5 years after HT. Invasive hemodynamics were evaluated before LVAD, before HT, and at 3 months, 1, and 3-5 years posttransplant. Thirty-eight patients were included in the study and divided into two groups according to the type of LVAD support. The two groups were well matched in age and gender. Mean pulmonary artery pressure (PAPm) and systolic PAP (PAPs) improved significantly in the PF-LVAD group (40 ± 10.6 to 19.8 ± 4.4 mm Hg and 62.7 ± 14.9 to 31.8 ± 5.9 mm Hg, respectively) and in the CF-LVAD group (37.4 ± 11.6 to 22.4 ± 7.7 mm Hg and 53.7 ± 18.0 to 34.6 ± 11.8 mm Hg, respectively). Reductions in PAPm and PAPs were more pronounced in PF-LVAD group than in CF-LVAD group (p = 0.005 and p = 0.03, respectively). After HT, the improvement in PAPm and PAPs was sustained after 3-5 years in patients who received PF-LVAD (22.6 ± 6.5 and 32.2 ± 9.2 mm Hg, respectively) and in patients who received CF-LVAD (22.2 ± 8.4 and 33.8 ± 9.6 mm Hg, respectively). In conclusion, long-term LVAD support resulted in significant improvement in PAPm and PAPs regardless of the pump generation. The improvement in hemodynamics observed during LVAD support was sustained 3-5 years posttransplant.
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16
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Hamilton DJ. Metabolic Recovery of the Failing Heart: Emerging Therapeutic Options. Methodist Debakey Cardiovasc J 2017; 13:25-28. [PMID: 28413579 DOI: 10.14797/mdcj-13-1-25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Heart failure has mortality rates that parallel those of breast cancer. Current management strategies include neurohormonal blockade, rate control measures, natriuretic peptide preservation, implantation of mechanical assist devices, and heart transplantation. Despite these strategies, however, the failing myocardium remains energy depleted. New strategies to promote metabolic recovery are being developed to potentially augment current treatment guidelines. For example, an unexpected finding of our own studies showed that mechanical unloading with assist devices in advanced-stage heart failure restored metabolic flux. Unfortunately, at that point it is too late for myocardial recovery. Traditional metabolic therapies addressing hyperglycemia have had limited long-term outcome benefit. Now, new therapeutic options are emerging based on increased understanding of the molecular mechanisms underlying energy depletion. Metabolic cardiac imaging combined with laboratory diagnostics could guide the design of individual therapeutic strategies. To date, agents that show benefit in select individuals include mimetics that stimulate glucagon-like peptide-1, inhibitors of sodium-glucose cotransporter receptors, drugs that limit fatty acid oxidation, and hormonal therapy in select individuals. This review will summarize mechanisms and investigations related to these metabolic approaches to heart failure.
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Affiliation(s)
- Dale J Hamilton
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
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Farris SD, Don C, Helterline D, Costa C, Plummer T, Steffes S, Mahr C, Mokadam NA, Stempien-Otero A. Cell-Specific Pathways Supporting Persistent Fibrosis in Heart Failure. J Am Coll Cardiol 2017; 70:344-354. [PMID: 28705316 DOI: 10.1016/j.jacc.2017.05.040] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/11/2017] [Accepted: 05/16/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Only limited data exist describing the histologic and noncardiomyocyte function of human myocardium in end-stage heart failure (HF). OBJECTIVES The authors sought to determine changes in noncardiomyocyte cellular activity in patients with end-stage HF after left ventricular assist device (LVAD)-induced remodeling to identify mechanisms impeding recovery. METHODS Myocardium was obtained from subjects undergoing LVAD placement and/or heart transplantation. Detailed histological analyses were performed, and, when feasible, mononuclear cells were isolated from fresh, dissociated myocardium for quantitative reverse transcription polymerase chain reaction studies. Echocardiographic and catheterization data were obtained during routine care. RESULTS Sixty-six subjects were enrolled; 54 underwent 8.0 ± 1.2 months of LVAD unloading. Despite effective hemodynamic unloading and remodeling, there were no differences after LVAD use in capillary density (0.78 ± 0.1% vs. 0.9 ± 0.1% capillary area; n = 42 and 28, respectively; p = 0.40), cardiac fibrosis (25.7 ± 2.4% vs. 27.9 ± 2.4% fibrosis area; n = 44 and 31, respectively; p = 0.50), or macrophage density (80.7 ± 10.4 macrophages/mm2 vs. 108.6 ± 15 macrophages/mm2; n = 33 and 28, respectively; p = 0.1). Despite no change in fibrosis or myofibroblast density (p = 0.40), there was a 16.7-fold decrease (p < 0.01) in fibroblast-specific collagen expression. Furthermore, there was a shift away from pro-fibrotic/alternative pro-fibrotic macrophage signaling after LVAD use. CONCLUSIONS Despite robust cardiac unloading, capillary density and fibrosis are unchanged compared with loaded hearts. Fibroblast-specific collagen expression was decreased and might be due to decreased stretch and/or altered macrophage polarization. Dysfunctional myocardium may persist, in part, from ongoing inflammation and poor extracellular matrix remodeling. Understanding these changes could lead to improved therapies for HF.
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Affiliation(s)
- Stephen D Farris
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Creighton Don
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Deri Helterline
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Christopher Costa
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Tabitha Plummer
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Susanne Steffes
- University of Washington, School of Nursing, Seattle, Washington
| | - Claudius Mahr
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington
| | - Nahush A Mokadam
- University of Washington, Department of Cardiothoracic Surgery, Seattle, Washington
| | - April Stempien-Otero
- University of Washington, Department of Medicine, Division of Cardiology, Seattle, Washington.
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Capoccia M. Mechanical Circulatory Support for Advanced Heart Failure: Are We about to Witness a New "Gold Standard"? J Cardiovasc Dev Dis 2016; 3:E35. [PMID: 29367578 PMCID: PMC5715724 DOI: 10.3390/jcdd3040035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/03/2016] [Accepted: 12/06/2016] [Indexed: 01/08/2023] Open
Abstract
The impact of left ventricular assist devices (LVADs) for the treatment of advanced heart failure has played a significant role as a bridge to transplant and more recently as a long-term solution for non-eligible candidates. Continuous flow left ventricular assist devices (CF-LVADs), based on axial and centrifugal design, are currently the most popular devices in view of their smaller size, increased reliability and higher durability compared to pulsatile flow left ventricular assist devices (PF-LVADs). The trend towards their use is increasing. Therefore, it has become mandatory to understand the physics and the mathematics behind their mode of operation for appropriate device selection and simulation set up. For this purpose, this review covers some of these aspects. Although very successful and technologically advanced, they have been associated with complications such as pump thrombosis, haemolysis, aortic regurgitation, gastro-intestinal bleeding and arterio-venous malformations. There is perception that the reduced arterial pulsatility may be responsible for these complications. A flow modulation control approach is currently being investigated in order to generate pulsatility in rotary blood pumps. Thrombus formation remains the most feared complication that can affect clinical outcome. The development of a preoperative strategy aimed at the reduction of complications and patient-device suitability may be appropriate. Patient-specific modelling based on 3D reconstruction from CT-scan combined with computational fluid dynamic studies is an attractive solution in order to identify potential areas of stagnation or challenging anatomy that could be addressed to achieve the desired outcome. The HeartMate II (axial) and the HeartWare HVAD (centrifugal) rotary blood pumps have been now used worldwide with proven outcome. The HeartMate III (centrifugal) is now emerging as the new promising device with encouraging preliminary results. There are now enough pumps on the market: it is time to focus on the complications in order to achieve the full potential and selling-point of this type of technology for the treatment of the increasing heart failure patient population.
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Affiliation(s)
- Massimo Capoccia
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow G81 4DY, UK.
- Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK.
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19
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Hickey KT, Garan H, Mancini DM, Colombo PC, Naka Y, Sciacca RR, Abrams MP, Solove M, Zeoli N, Flannery M, Garan AR, Biviano AB. Atrial Fibrillation in Patients With Left Ventricular Assist Devices. JACC Clin Electrophysiol 2016; 2:793-798. [DOI: 10.1016/j.jacep.2016.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/24/2016] [Accepted: 03/10/2016] [Indexed: 11/27/2022]
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20
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Healy AH, McKellar SH, Drakos SG, Koliopoulou A, Stehlik J, Selzman CH. Physiologic effects of continuous-flow left ventricular assist devices. J Surg Res 2016; 202:363-71. [PMID: 27229111 PMCID: PMC4886545 DOI: 10.1016/j.jss.2016.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/10/2016] [Accepted: 01/12/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Within the past 10 years, continuous-flow left ventricular assist devices (LVADs) have replaced pulsatile-flow LVADs as the standard of care for both destination therapy and bridging patients to heart transplantation. Despite the rapid clinical adoption of continuous-flow LVADs, an understanding of the effects of continuous-flow physiology, as opposed to more natural pulsatile-flow physiology, is still evolving. MATERIALS AND METHODS A thorough review of the relevant scientific literature regarding the physiological and clinical effects of continuous-flow physiology was performed. These effects were analyzed on an organ system basis and include an evaluation of the cardiovascular, respiratory, hematologic, gastrointestinal, renal, hepatic, neurologic, immunologic, and endocrine systems. RESULTS Continuous-flow physiology is, generally speaking, well tolerated over the long term. However, several changes are manifest at the organ system level. Although many of these changes are without appreciable clinical significance, other changes, such as an increased rate of gastrointestinal bleeding, appear to be associated with continuous-flow physiology. CONCLUSIONS Continuous-flow LVADs confer a significant advantage over their pulsatile-flow counterparts with regard to size and durability. From a physiological standpoint, continuous-flow physiology has limited clinical effects at the organ system level. Although improved over previous generations, challenges with this technology remain. Approaching these problems with a combination of clinical and engineering solutions may be needed to achieve continued progression in the field of durable mechanical circulatory support.
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Affiliation(s)
- Aaron H. Healy
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
| | - Stephen H. McKellar
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
| | - Stavros G. Drakos
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
| | - Antigoni Koliopoulou
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
| | - Josef Stehlik
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
| | - Craig H. Selzman
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, Utah, United States of America
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22
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Grosman-Rimon L, Billia F, Fuks A, Jacobs I, A McDonald M, Cherney DZ, Rao V. New therapy, new challenges: The effects of long-term continuous flow left ventricular assist device on inflammation. Int J Cardiol 2016; 215:424-30. [PMID: 27131263 DOI: 10.1016/j.ijcard.2016.04.133] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
Surgically implanted continuous flow left ventricular assist devices (CF-LVADs) are currently used in patients with end-stage heart failure (HF). However, CF-LVAD therapy introduces a new set of complications and adverse events in these patients. Major adverse events with the CF-LVAD include right heart failure, vascular dysfunction, stroke, hepatic failure, and multi-organ failure, complications that may have inflammation as a common etiology. Our aim was to review the current evidence showing a relationship between these adverse events and elevated levels of inflammatory biomarkers in CF-LVAD recipients.
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Affiliation(s)
- Liza Grosman-Rimon
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Avi Fuks
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Ira Jacobs
- Faculty of Kinesiology and Physical Education, University of Toronto, Canada
| | - Michael A McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - David Z Cherney
- Division of Nephrology, University Health Network, University of Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
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Drakos SG, Mehra MR. Clinical myocardial recovery during long-term mechanical support in advanced heart failure: Insights into moving the field forward. J Heart Lung Transplant 2016; 35:413-20. [DOI: 10.1016/j.healun.2016.01.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/21/2015] [Accepted: 01/10/2016] [Indexed: 01/04/2023] Open
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Building a bridge to recovery: the pathophysiology of LVAD-induced reverse modeling in heart failure. Surg Today 2015; 46:149-54. [PMID: 25840890 DOI: 10.1007/s00595-015-1149-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/20/2015] [Indexed: 10/23/2022]
Abstract
Heart failure mainly caused by ischemic or dilated cardiomyopathy is a life-threatening disorder worldwide. The previous work in cardiac surgery has led to many excellent surgical techniques for treating cardiac diseases, and these procedures are now able to prolong the human lifespan. However, surgical treatment for end-stage heart failure has been under-explored, although left ventricular assist device (LVAD) implantation and heart transplantation are options to treat the condition. LVAD can provide powerful circulatory support for end-stage heart failure patients and improve the survival and quality of life after implantation compared with the existing medical counterparts. Moreover, LVADs play a crucial role in the "bridge to transplantation", "bridge to recovery" and recently have served as "destination therapy". The structural and molecular changes that improve the cardiac function after LVAD implantation are called "reverse remodeling", which means that patients who have received a LVAD can be weaned from the LVAD with restoration of their cardiac function. This strategy is a desirable alternative to heart transplantation in terms of both the patient quality of life and due to the organ shortage. The mechanism of this bridge to recovery is interesting, and is different from other treatments for heart failure. Bridge to recovery therapy is one of the options in regenerative therapy which only a surgeon can provide. In this review, we pathophysiologically analyze the reverse remodeling phenomenon induced by LVAD and comment about the clinical evidence with regard to its impact on the bridge to recovery.
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Imamura T, Kinugawa K, Nitta D, Hatano M, Kinoshita O, Nawata K, Ono M. Advantage of Pulsatility in Left Ventricular Reverse Remodeling and Aortic Insufficiency Prevention During Left Ventricular Assist Device Treatment. Circ J 2015; 79:1994-9. [DOI: 10.1253/circj.cj-15-0419] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Koichiro Kinugawa
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Daisuke Nitta
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Kan Nawata
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
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Cheng A, Williamitis CA, Slaughter MS. Comparison of continuous-flow and pulsatile-flow left ventricular assist devices: is there an advantage to pulsatility? Ann Cardiothorac Surg 2014; 3:573-81. [PMID: 25512897 DOI: 10.3978/j.issn.2225-319x.2014.08.24] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/23/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (CFVAD) are currently the most widely used type of mechanical circulatory support as bridge-to-transplant and destination therapy for end-stage congestive heart failure (HF). Compared to the first generation pulsatile-flow left ventricular assist devices (PFVADs), CFVADs have demonstrated improved reliability and durability. However, CFVADs have also been associated with certain complications thought to be linked with decreased arterial pulsatility. Previous studies comparing CFVADs and PFVADs have presented conflicting results. It is important to understand the outcome differences between CFVAD and PFVAD in order to further advance the current VAD technology. METHODS In this review, we compared the outcomes of CFVADs and PFVADs and examined the need for arterial pulsatility for the future generation of mechanical circulatory support. RESULTS CVADs offer advantages of smaller size, increased reliability and durability, and subsequent improvements in survival. However, with the increasing duration of long-term support, it appears that CFVADs may have specific complications and a lower rate of left ventricular recovery associated with diminished pulsatility, increased pressure gradients on the aortic valve and decreased compliance in smaller arterial vessels. PFVAD support or pulsatility control algorithms in CFVADs could be beneficial and potentially necessary for long term support. CONCLUSIONS Given the relative advantages and disadvantages of CFVADs and PFVADs, the ultimate solution may lie in incorporating pulsatility into current and emerging CFVADs whilst retaining their existing benefits. Future studies examining physiologic responses, end-organ function and LV remodeling at varying degrees of pulsatility and device support levels are needed.
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Affiliation(s)
- Allen Cheng
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky 40202, USA
| | - Christine A Williamitis
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky 40202, USA
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky 40202, USA
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Abstract
The extracellular matrix (ECM) is a living network of proteins that maintains the structural integrity of the myocardium and allows the transmission of electrical and mechanical forces between the myocytes for systole and diastole. During ventricular remodeling, as a result of iterations in the hemodynamic workload, collagen, the main component of the ECM, increases and occupies the areas between the myocytes and the vessels. The resultant fibrosis (reparative fibrosis) is initially a compensatory mechanism and may progress adversely influencing tissue stiffness and ventricular function. Replacement fibrosis appears at sites of previous cardiomyocyte necrosis to preserve the structural integrity of the myocardium, but with the subsequent formation of scar tissue and widespread distribution, it has adverse functional consequences. Continued accumulation of collagen impairs diastolic function and compromises systolic mechanics. Nevertheless, the development of fibrosis is a dynamic process wherein myofibroblasts, the principal cellular elements of fibrosis, are not only metabolically active and capable of the production and upregulation of cytokines but also have contractile properties. During the process of reverse remodeling with left ventricular assist device unloading, cellular, structural, and functional improvements are observed in terminal heart failure patients. With the advent of anti-fibrotic pharmacologic therapies, cellular therapy, and ventricular support devices, fibrosis has become an important therapeutic target in heart failure patients. Herein, we review the current concepts of fibrosis as a main component of ventricular remodeling in heart failure patients. Our aim is to integrate the histopathologic process of fibrosis with the neurohormonal, cytochemical, and molecular changes that lead to ventricular remodeling and its physiologic consequences in patients. The concept of fibrosis as living scar allows us to envision targeting this scar as a means of improving ventricular function in heart failure patients.
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Affiliation(s)
- Ana Maria Segura
- Department of Cardiovascular Pathology Research, Texas Heart Institute at St. Luke's Episcopal Hospital, MC 1-283, PO Box 20345, Houston, TX, 77225-0345, USA,
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Bennett MK, Sweet WE, Baicker-McKee S, Looney E, Karohl K, Mountis M, Tang WHW, Starling RC, Moravec CS. S100A1 in human heart failure: lack of recovery following left ventricular assist device support. Circ Heart Fail 2014; 7:612-8. [PMID: 24842913 PMCID: PMC4102621 DOI: 10.1161/circheartfailure.113.000849] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We hypothesized that S100A1 is regulated during human hypertrophy and heart failure and that it may be implicated in remodeling after left ventricular assist device. S100A1 is decreased in animal and human heart failure, and restoration produces functional recovery in animal models and in failing human myocytes. With the potential for gene therapy, it is important to carefully explore human cardiac S100A1 regulation and its role in remodeling. METHODS AND RESULTS We measured S100A1, the sarcoplasmic endoplasmic reticulum Ca(2+)ATPase, phospholamban, and ryanodine receptor proteins, as well as β-adrenergic receptor density in nonfailing, hypertrophied (left ventricular hypertrophy), failing, and failing left ventricular assist device-supported hearts. We determined functional consequences of protein alterations in isolated contracting muscles from the same hearts. S100A1, sarcoplasmic endoplasmic reticulum Ca(2+)ATPase and phospholamban were normal in left ventricular hypertrophy, but decreased in failing hearts, while ryanodine receptor was unchanged in either group. Baseline muscle contraction was not altered in left ventricular hypertrophy or failing hearts. β-Adrenergic receptor and inotropic response were decreased in failing hearts. In failing left ventricular assist device-supported hearts, S100A1 and sarcoplasmic endoplasmic reticulum Ca(2+)ATPase showed no recovery, while phospholamban, β-adrenergic receptor, and the inotropic response fully recovered. CONCLUSIONS S100A1 and sarcoplasmic endoplasmic reticulum Ca(2+)ATPase, both key Ca(2+)-regulatory proteins, are decreased in human heart failure, and these changes are not reversed after left ventricular assist device. The clinical significance of these findings for cardiac recovery remains to be addressed.
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Affiliation(s)
- Mosi K Bennett
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Wendy E Sweet
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Sara Baicker-McKee
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Elizabeth Looney
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Kristen Karohl
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Maria Mountis
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - W H Wilson Tang
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Randall C Starling
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Christine S Moravec
- From the Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, OH.
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Improving Arterial Pulsatility by Feedback Control of a Continuous Flow Left Ventricular Assist Device via in Silico Modeling. Int J Artif Organs 2014; 37:773-85. [DOI: 10.5301/ijao.5000328] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2014] [Indexed: 11/20/2022]
Abstract
Purpose Continuous flow left ventricular assist devices (CF-LVADs) generally operate at a constant speed, which causes a decrease in pulse pressure and pulsatility in the arteries and allegedly may lead to late complications such as aortic insufficiency and gastrointestinal bleeding. The purpose of this study is to increase the arterial pulse pressure and pulsatility while obtaining more physiological hemodynamic signals, by controlling the CF-LVAD flow rate. Methods A lumped parameter model was used to simulate the cardiovascular system including the heart chambers, heart valves, systemic and pulmonary arteries and veins. A baroreflex model was used to regulate the heart rate and a model of the Micromed DeBakey CF-LVAD (Micromed Technology, Houston, TX, USA) to simulate the pump dynamics at different operating speeds. A model simulating the flow rate through the aortic valve served as reference model. CF-LVAD operating speed was regulated by applying proportional-integral (PI) control to the pump flow rate. For comparison, the CF-LVAD was also operated at a constant speed, equaling the mean CF-LVAD speed as applied in pulsatile mode. Results In different operating modes, at the same mean operating speeds, mean pump output, mean arterial pressure, end-systolic and end-diastolic volume and heart rate were the same over the cardiac cycle. However, the arterial pulse pressure and index of pulsatility increased by 50% in the pulsatile CF-LVAD support mode with respect to constant speed pump support. Conclusions This study shows the possibility of obtaining more physiological pulsatile hemodynamics in the arteries by applying output-driven varying speed control to a CF-LVAD.
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Cordero-Reyes AM, Youker K, Estep JD, Torre-Amione G, Nagueh SF. Molecular and Cellular Correlates of Cardiac Function in End-Stage DCM. JACC Cardiovasc Imaging 2014; 7:441-52. [DOI: 10.1016/j.jcmg.2013.11.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/14/2013] [Accepted: 11/15/2013] [Indexed: 11/26/2022]
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Rosenbaum AN, John R, Liao KK, Adatya S, Colvin-Adams MM, Pritzker M, Eckman PM. Survival in elderly patients supported with continuous flow left ventricular assist device as bridge to transplantation or destination therapy. J Card Fail 2014; 20:161-7. [PMID: 24412524 DOI: 10.1016/j.cardfail.2013.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 12/11/2013] [Accepted: 12/18/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Published data on mechanical circulatory support for elderly patients in continuous flow devices are sparse and suggest relatively poor survival. This study investigated whether LVADs can be implanted in selected patients over the age of 65 years with acceptable survival compared with published outcomes. METHODS AND RESULTS A single-center retrospective analysis was conducted in 64 consecutive patients ≥65 years of age implanted with a continuous-flow left ventricular assist device (CF-LVAD) as either bridge to transplantation or destination therapy from August 2005 to January 2012. Baseline laboratory and hemodynamic characteristics and follow-up data were obtained. Median survival was 1,090 days. Survival was 85%, 74%, 55%, and 45% at 6 months and 1, 2, and 3 years, respectively. Our cohort had a baseline mean Seattle Heart Failure Model (SHFM) score of 2.6 ± 0.9. Observed survival was significantly better than SHFM-predicted medical survival. Stratification by age subsets, renal function, SHFM, implantation intention, or etiology did not reveal significant differences in survival. The most common cause of death was sepsis and nonlethalcomplication was bleeding. CONCLUSIONS Our experience with patients over the age of 65 receiving CF-LVADs suggests that this group demonstrates excellent survival. Further research is needed to discern the specific criteria for risk stratification for LVAD support in the elderly.
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Affiliation(s)
- Andrew N Rosenbaum
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kenneth K Liao
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Sirtaz Adatya
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Monica M Colvin-Adams
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Marc Pritzker
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Peter M Eckman
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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Imamura T, Kinugawa K, Hatano M, Fujino T, Muraoka H, Inaba T, Maki H, Kagami Y, Endo M, Kinoshita O, Nawata K, Kyo S, Ono M. Preoperative beta-blocker treatment is a key for deciding left ventricular assist device implantation strategy as a bridge to recovery. J Artif Organs 2013; 17:23-32. [PMID: 24337665 DOI: 10.1007/s10047-013-0748-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 11/24/2013] [Indexed: 11/29/2022]
Abstract
To date, there have been few reports demonstrating preoperative predictors for left ventricular reverse remodeling (LVRR) after LV assist device (LVAD) implantation, especially among patients with dilated cardiomyopathy (DCM). We retrospectively analyzed 60 patients with stage D heart failure due to DCM who had received LVAD treatment [pulsatile flow (PF) type, 26; continuous flow type, 34]. Data were evaluated at 6 months or just before explantation of the LVAD. We defined "LV reverse remodeling" (LVRR) by the achievement of an LV ejection fraction (LVEF) of ≥ 35 % after 6 months of LVAD support or explantation of LVAD within 6 months. LVRR occurred in 16 of our patients (26.7 %). Uni/multivariate logistic regression analyses for LVRR demonstrated that of the preoperative variables evaluated, PF LVAD usage and insufficient preoperative β-blocker treatment were independent predictors for LVRR. Patients who accomplished LVRR had a better clinical course, including lower levels of aortic valve insufficiency and lower levels of plasma B-type natriuretic peptide. Of the six patients (10.0 %) in whom LVADs were eventually explanted, all had an LVEF of ≥ 35 % before explantation or at 6 months. Based on these results, we conclude that DCM patients with insufficient preoperative β-blocker treatment have a chance to achieve LVRR under LVAD support as a bridge to recovery.
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Affiliation(s)
- Teruhiko Imamura
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan,
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Drakos SG, Wever-Pinzon O, Selzman CH, Gilbert EM, Alharethi R, Reid BB, Saidi A, Diakos NA, Stoker S, Davis ES, Movsesian M, Li DY, Stehlik J, Kfoury AG. Magnitude and time course of changes induced by continuous-flow left ventricular assist device unloading in chronic heart failure: insights into cardiac recovery. J Am Coll Cardiol 2013; 61:1985-94. [PMID: 23500219 DOI: 10.1016/j.jacc.2013.01.072] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 12/12/2012] [Accepted: 01/14/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to prospectively investigate the longitudinal effects of continuous-flow left ventricular assist device (LVAD) unloading on myocardial structure and systolic and diastolic function. BACKGROUND The magnitude, timeline, and sustainability of changes induced by continuous-flow LVAD on the structure and function of the failing human heart are unknown. METHODS Eighty consecutive patients with clinical characteristics consistent with chronic heart failure requiring implantation of a continuous-flow LVAD were prospectively enrolled. Serial echocardiograms (at 1, 2, 3, 4, 6, 9, and 12 months) and right heart catheterizations were performed after LVAD implant. Cardiac recovery was assessed on the basis of improvement in systolic and diastolic function indices on echocardiography that were sustained during LVAD turn-down studies. RESULTS After 6 months of LVAD unloading, 34% of patients had a relative LV ejection fraction increase above 50% and 19% of patients, both ischemic and nonischemic, achieved an LV ejection fraction ≥ 40%. LV systolic function improved as early as 30 days, the greatest degree of improvement was achieved by 6 months of mechanical unloading and persisted over the 1-year follow up. LV diastolic function parameters also improved as early as 30 days after LVAD unloading, and this improvement persisted over time. LV end-diastolic and end-systolic volumes decreased as early as 30 days after LVAD unloading (113 vs. 77 ml/m(2), p < 0.01, and 92 vs. 60 ml/m(2), p < 0.01, respectively). LV mass decreased as early as 30 days after LVAD unloading (114 vs. 95 g/m(2), p < 0.05) and continued to do so over the 1-year follow-up but did not reach values below the normal reference range, suggesting no atrophic remodeling after prolonged LVAD unloading. CONCLUSIONS Continuous-flow LVAD unloading induced in a subset of patients, both ischemic and nonischemic, early improvement in myocardial structure and systolic and diastolic function that was largely completed within 6 months, with no evidence of subsequent regression.
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Affiliation(s)
- Stavros G Drakos
- Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program, Divisions of Cardiology and Cardiothoracic Surgery, University of Utah Health Sciences Center, Intermountain Medical Center, Salt Lake City, Utah 84132, USA.
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Pulsatile vs. continuous flow in ventricular assist device therapy. Best Pract Res Clin Anaesthesiol 2013; 26:105-15. [PMID: 22910084 DOI: 10.1016/j.bpa.2012.03.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/14/2012] [Indexed: 12/15/2022]
Abstract
A left ventricular assist device (LVAD) is an important treatment option for a patient with end-stage heart failure. Both continuous and non-pulsatile devices are available, each with different effects on a patient's physiology. In general, these effects are not clinically significant with the exception of bleeding events which are more common with continuous-flow devices in some series. Both devices increase survival beyond medical management. Continuous-flow devices are smaller and are associated with less overall morbidity than pulsatile devices.
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Left Ventricular Reverse Remodeling With a Continuous Flow Left Ventricular Assist Device Measured by Left Ventricular End-Diastolic Dimensions and Severity of Mitral Regurgitation. ASAIO J 2012; 58:574-7. [DOI: 10.1097/mat.0b013e31826e4267] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cho H, Barth AS, Tomaselli GF. Basic science of cardiac resynchronization therapy: molecular and electrophysiological mechanisms. Circ Arrhythm Electrophysiol 2012; 5:594-603. [PMID: 22715238 DOI: 10.1161/circep.111.962746] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Hana Cho
- Department of Physiology, Sungkyunkwan University School of Medicine, Suwon, Korea.
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Drakos SG, Kfoury AG, Stehlik J, Selzman CH, Reid BB, Terrovitis JV, Nanas JN, Li DY. Bridge to recovery: understanding the disconnect between clinical and biological outcomes. Circulation 2012; 126:230-41. [PMID: 22777666 PMCID: PMC3714227 DOI: 10.1161/circulationaha.111.040261] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Stavros G Drakos
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA.
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Cordero-Reyes AM, Youker K, Hamilton DJ, Torre-Amione G, Marian AJ, Nagueh SF. Molecular, cellular, and functional characterization of myocardial regions in hypertrophic cardiomyopathy. Circ Cardiovasc Imaging 2012; 5:419-22. [PMID: 22592011 DOI: 10.1161/circimaging.112.972802] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrea M Cordero-Reyes
- Methodist DeBakey Heart and Vascular Center, 6550 Fannin, SM-677, Houston, TX 77030, USA.
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Abstract
The use of left ventricular assist devices to induce substantial myocardial recovery with explantation of the device, bridge to recovery (BTR), is an exciting but currently grossly underused application. Recently acquired knowledge relating to BTR and its mechanisms offers unprecedented opportunities to streamline its use and unravel some of the secrets of heart failure with much wider implications. This article reviews the status, challenges, and future of cardiac recovery.
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Affiliation(s)
- Michael Ibrahim
- Heart Science Centre, Magdi Yacoub Institute, Harefield Hospital, London, UK
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Abstract
The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study shows that implanted ventricular assist devices improve survival time and quality of life when used as a permanent therapy in patients who do not qualify for heart transplant. The success of the pulsatile 70 cc stroke volume left ventricular assist device (LVAD) developed by Penn State has led to the development of a 50 cc stroke volume pump for use in patients with smaller chest cavities to benefit a larger patient population. The initial 50 cc pump shows regions of in vivo thrombus formation, which correlate to low wall shear rates within the device. In an in vitro evaluation of three new designs (V-2, V-3, and V-4) of the 50 cc LVAD, identical except for the location and orientation of their outlet ports, particle image velocimetry (PIV) is used to capture planar flow field data within the pumps. V-2 has an outlet port that is located parallel to the inlet. In V-3, the outlet port is rotated away from the inlet port, with the intention of minimizing the amount of fluid turning needed to exit the device. With V-4 the outlet port is moved to the center of the pump to prolong the desirable rotational flow. PIV data were taken at six planar locations within the pump. Although the modifications to the outlet port locations serve their intended purpose, they also introduce unwanted changes in the flow. Poorer wall washing and weaker rotational flow are observed with V-3 and V-4. Although the differences between the devices are subtle, the device that has the most desirable flow characteristics is V-2.
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The paradox of left ventricular assist device unloading and myocardial recovery in end-stage dilated cardiomyopathy: implications for heart failure in the elderly. Heart Fail Rev 2012; 17:615-33. [DOI: 10.1007/s10741-012-9300-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Healy AH, Mason NO, Hammond ME, Reid BB, Clayson SE, Drakos SG, Kfoury AG, Patel AN, Bull DA, Budge D, Alharethi RA, Bader FM, Gilbert EM, Stehlik J, Selzman CH. Allograft rejection in patients supported with continuous-flow left ventricular assist devices. Ann Thorac Surg 2011; 92:1601-7; discussion 1607. [PMID: 21944258 DOI: 10.1016/j.athoracsur.2011.05.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 05/23/2011] [Accepted: 05/27/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Both pulsatile-flow and continuous-flow left ventricular assist devices (LVADs) successfully provide patients a bridge to transplantation. Some data suggest that continuous-flow pumps increase the risk of allograft rejection, contributing to posttransplantation morbidity and mortality. We sought to analyze the relationship between LVAD flow characteristics and subsequent allograft rejection in bridge to transplant (BTT) patients. METHODS Patients with LVADs from the UTAH Transplant Affiliated Hospitals were retrospectively analyzed. Rejection was determined pathologically according to the International Society for Heart and Lung Transplantation revised cardiac allograft rejection scale. Multimodal statistical analyses were applied. RESULTS Of 1,076 patients who underwent transplantation over a 26-year period, 151 had LVADs. Of these, 111 (77 pulsatile flow, 34 continuous flow) patients had pathologic data available. There was no difference in overall rejection (grades 1R to 3R) between the pulsatile-flow LVAD and continuous-flow LVAD groups (2.00 ± 1.43 versus 1.50 ± 1.16 episodes/year; p = 0.076.) Patients with pulsatile-flow LVADs had more clinically relevant (grades 2R to 3R) rejection than did patients with continuous-flow LVADs (0.49 ± 0.72 versus 0.12 ± 0.33 episodes/year; p < 0.001). There was no survival difference at 1 year (p = 0.920) or 4 years (p = 0.721) after transplantation. CONCLUSIONS Patients with continuous-flow LVADs have similar overall rejection rates and a reduced rate of clinically relevant rejection compared with patients with pulsatile-flow LVADs during the first year after transplantation. Although there is theoretical concern that nonphysiologic, nonpulsatile flow could alter the neurohormonal profile of patients in heart failure, we are encouraged that the type of LVAD circulation does not influence posttransplantation allograft survival.
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Affiliation(s)
- Aaron H Healy
- UTAH (Utah Transplant Affiliated Hospitals) Cardiac Transplant Program, University of Utah, Salt Lake City, Utah 84132, USA
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Abstract
Left ventricular assist device (LVAD) support is an accepted treatment of patients with end-stage heart failure. The increased applicability and excellent results with LVADs have revolutionized the treatment options available for such patients. Success with LVADs as bridge-to-transplant therapy has led to their successful use as an alternate to a transplant (ie, as destination therapy [DT]). The use of these devices as DT represents a relatively newer but growing indication. Until recently, most patients who have undergone LVAD implantation have been supported by pulsatile devices. Newer continuous-flow (CF) pumps have resulted in superior outcomes, including significantly reduced complication rates with improved durability over first-generation pulsatile design pumps. However, as with all new technology, the newer LVADs have introduced management challenges that were either unimportant or absent with pulsatile LVADs. This article reviews the current state of left ventricular devices, focusing on the CF pumps that currently dominate the field, including clinical outcomes, the physiologic and pathologic effects that are associated with CF pumps, and their unique management issues and complications.
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Affiliation(s)
- Marco Caccamo
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
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Left ventricular assist device unloading effects on myocardial structure and function: current status of the field and call for action. Curr Opin Cardiol 2011; 26:245-55. [PMID: 21451407 DOI: 10.1097/hco.0b013e328345af13] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Myocardial remodeling driven by excess pressure and volume load is believed to be responsible for the vicious cycle of progressive myocardial dysfunction in chronic heart failure. Left ventricular assist devices (LVADs), by providing significant volume and pressure unloading, allow a reversal of stress-related compensatory responses of the overloaded myocardium. Herein, we summarize and integrate insights from studies which investigated how LVAD unloading influences the structure and function of the failing human heart. RECENT FINDINGS Recent investigations have described the impact of LVAD unloading on key structural features of cardiac remodeling - cardiomyocyte hypertrophy, fibrosis, microvasculature changes, adrenergic pathways and sympathetic innervation. The effects of LVAD unloading on myocardial function, electrophysiologic properties and arrhythmias have also been generating significant interest. We also review information describing the extent and sustainability of the LVAD-induced myocardial recovery, the important advances in understanding of the pathophysiology of heart failure derived from such studies, and the implications of these findings for the development of new therapeutic strategies. Special emphasis is given to the great variety of fundamental questions at the basic, translational and clinical levels that remain unanswered and to specific investigational strategies aimed at advancing the field. SUMMARY Structural and functional reverse remodeling associated with LVADs continues to inspire innovative research. The ultimate goal of these investigations is to achieve sustained recovery of the failing human heart.
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Hong KN, Iribarne A, Yang J, Ramlawi B, Takayama H, Naka Y, Russo MJ. Do Posttransplant Outcomes Differ in Heart Transplant Recipients Bridged With Continuous and Pulsatile Flow Left Ventricular Assist Devices? Ann Thorac Surg 2011; 91:1899-906. [DOI: 10.1016/j.athoracsur.2011.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/03/2011] [Accepted: 02/07/2011] [Indexed: 10/18/2022]
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Orrego CM, Nasir N, Oliveira GH, Flores-Arredondo JH, Cordero-Reyes AM, Loebe M, Youker KA, Torre-Amione G. Cellular Evidence of Reverse Cardiac Remodeling Induced by Cardiac Resynchronization Therapy. ACTA ACUST UNITED AC 2011; 17:140-6. [DOI: 10.1111/j.1751-7133.2011.00227.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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