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Antiplatelet and Anticoagulant Strategies Following Left Ventricular Assist Device (LVAD) Explantation or Decommissioning: A Scoping Review of the Literature. Heart Lung Circ 2021; 30:1525-1532. [PMID: 33933364 DOI: 10.1016/j.hlc.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/04/2021] [Indexed: 11/23/2022]
Abstract
Mechanical circulatory support using left ventricular assist devices (LVADs) has transformed management of patients with end-stage heart failure with more patients on LVAD therapy surviving long enough to necessitate either device explantation or decommissioning. Usually, there is foreign material retained following these procedures that requires maintaining antiplatelet and/or anticoagulant therapy. However, there is no consensus on optimal management of antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning. We conducted a scoping review of antiplatelet and anticoagulation strategies, searching EMBASE, PubMed and CENTRAL. A total of 15 case reports and series encompassing 38 patient cases were found that met inclusion criteria. There was a heterogeneity of LVAD types and techniques used for explantation and decommissioning. Most reports identified in our review maintained patients on a vitamin K antagonist for at least 3 months post-explantation or decommissioning with or without concomitant antiplatelet therapy with low-dose aspirin. However, there was no single agreed-upon optimal strategy for antiplatelet and anticoagulant use post-procedure. Factors such as the degree of foreign material retained following device explantation or decommissioning and whether there is another indication for anticoagulation or antiplatelet use must be considered. A lack of overall consensus indicates that more studies are needed in this area to establish definitive guidelines around antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning.
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Paul G, Rezaienia A, Avital E, Korakianitis T. Machinability and Optimization of Shrouded Centrifugal Impellers for Implantable Blood Pumps. J Med Device 2017. [DOI: 10.1115/1.4036287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This paper describes the use of analytical methods to determine machinable centrifugal impeller geometries and the use of computational fluid dynamics (CFD) for predicting the impeller performance. An analytical scheme is described to determine the machinable geometries for a shrouded centrifugal impeller with blades composed of equiangular spirals. The scheme is used to determine the maximum machinable blade angles for impellers with three to nine blades in a case study. Computational fluid dynamics is then used to analyze all the machinable geometries and determine the optimal blade number and angle based on measures of efficiency and rotor speed. The effect of tip width on rotor speed and efficiency is also examined. It is found that, for our case study, a six- or seven-bladed impeller with a low blade angle provides maximum efficiency and minimum rotor speed.
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Affiliation(s)
- Gordon Paul
- School of Engineering and Materials Science, Queen Mary University of London, London E1 4NS, UK
| | - Amin Rezaienia
- School of Engineering and Materials Science, Queen Mary University of London, London E1 4NS, UK
| | - Eldad Avital
- School of Engineering and Materials Science, Queen Mary University of London, London E1 4NS, UK
| | - Theodosios Korakianitis
- Professor Parks College of Engineering, Aviation and Technology, Saint Louis University, St. Louis, MO 63103 e-mail:
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Sunagawa G, Byram N, Karimov JH, Horvath DJ, Moazami N, Starling RC, Fukamachi K. The Contribution to Hemodynamics Even at Very Low Pump Speeds in the HVAD. Ann Thorac Surg 2016; 101:2260-4. [PMID: 26912300 DOI: 10.1016/j.athoracsur.2015.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/25/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We recently reported using bench testing that the Thoratec HeartMate II at 6,000 rpm contributed to hemodynamics when the heart had not recovered well, making weaning assessment questionable. In this bench study, we characterized hemodynamics and pump flow of the HeartWare HVAD at 1,800 rpm, the lowest speed commonly used to assess clinical recovery. METHODS The HVAD was operated in a mock loop at 1,800, 2,400, and 3,000 rpm. We acquired pressure-flow curves in each steady state. In pulsatile mode with the pneumatic ventricle (heart simulator) activated, pump flow, total flow, and aortic pressure (AoP) data were obtained under conditions simulating normal heart function or heart failure. RESULTS A large regurgitant flow during diastole was confirmed during normal heart function at 1,800 rpm support; however, the net flow was zero, and there was no difference in mean AoP between 1,800 rpm support and no HVAD support. In contrast, in the heart failure condition, HVAD flow at 1,800 rpm significantly contributed to mean AoP and total flow, because there was less regurgitant flow. CONCLUSIONS Similar to the results for the HeartMate II at 6,000 rpm, we found that the net pump flow generated by the HeartWare HVAD at 1,800 rpm depends on the degree of residual left ventricular (LV) function. In the setting of improved LV function, at 1,800 rpm we noted a large regurgitant flow. Although this "marker" can serve as a useful indicator for recovery, assessing recovery at this speed is flawed unless measures are taken to prevent regurgitant flow.
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Affiliation(s)
- Gengo Sunagawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Byram
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - David J Horvath
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nader Moazami
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C Starling
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
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4
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Current status of third-generation implantable left ventricular assist devices in Japan, Duraheart and HeartWare. Surg Today 2014; 45:672-81. [DOI: 10.1007/s00595-014-0957-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 05/12/2014] [Indexed: 10/24/2022]
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Topkara VK, O'Neill JK, Carlisle A, Novak E, Silvestry SC, Ewald GA. HeartWare and HeartMate II left ventricular assist devices as bridge to transplantation: a comparative analysis. Ann Thorac Surg 2013; 97:506-12. [PMID: 24140211 DOI: 10.1016/j.athoracsur.2013.08.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this study is to comparatively analyze outcomes of heart transplant patients bridged to transplantation with HeartWare (HW-VAD) versus HeartMate II (HMII-VAD) left ventricular assist devices. METHODS The United Network for Organ Sharing Database was reviewed to identify first-time heart transplant recipients who were bridged to transplantation with either HW-VAD (n=141) or HMII-VAD (n=1824) from January 2009 through July 2012. RESULTS Recipients of HW-VAD had a higher proportion of female patients (27.0% versus 18.9%; p=0.019), a lower body surface area (2.01±0.25 m2 versus 2.06±0.25 m2; p=0.035), and a trend toward a higher peak percentage of panel reactive antibody against human leukocyte class I antigens (40.4%±32.8% versus 33.0%±30.4%; p=0.070). Pretransplantation recipient cardiac index (2.33±0.66 L⋅min(-1)⋅m(-2) versus 2.33±0.68 L⋅min(-1)⋅m(-2)), serum creatinine (1.21±0.43 mg/dL versus 1.26±0.57 mg/dL), and total bilirubin (1.34±3.45 mg/dL versus 1.06±1.84 mg/dL) were comparable between the two groups (p>0.05 for all comparisons). After transplantation, there were no significant differences in freedom from rejection or freedom from cardiac allograft vasculopathy. Posttransplant graft survival rates were similar between the HW-VAD group and the HMII-VAD group at 1, 2, and 3 years (88.4% versus 87.8%, 79.9% versus 83.8%, and 77.4% versus 79.9%, respectively; p=0.843). CONCLUSIONS These findings suggest similar hemodynamic unloading, pretransplant end-organ function, and posttransplant outcomes in patients bridged to transplantation with both the HW-VAD and HMII-VAD.
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Affiliation(s)
- Veli K Topkara
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri.
| | - James K O'Neill
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Adam Carlisle
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Eric Novak
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Scott C Silvestry
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory A Ewald
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
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Balkanay M, Fedakar A, Alsalehi S, Rabus MB. Implantation of a left ventricular assist device with mini-pericardiotomy technique. Prog Transplant 2013; 23:75-7. [PMID: 23448825 DOI: 10.7182/pit2012686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The left ventricular assist device may be a lifesaving therapy for a patient awaiting a heart transplant. The most common complications of this device are mediastinal bleeding, infections, embolic events, right-sided heart failure, and mediastinal adhesions. We are reporting a patient who had a Levitronix left ventricular assist device implanted with mini-pericardiotomy technique for bridging to heart transplant.
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Affiliation(s)
- Mehmet Balkanay
- Kartal Kosuyolu Education and Research Hospital, İstanbul, Turkey
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Miller LW, Guglin M. Patient selection for ventricular assist devices: a moving target. J Am Coll Cardiol 2013; 61:1209-21. [PMID: 23290542 DOI: 10.1016/j.jacc.2012.08.1029] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 08/29/2012] [Accepted: 08/30/2012] [Indexed: 02/09/2023]
Abstract
The number of patients with advanced heart failure that has become unresponsive to conventional medical therapy is increasing rapidly. One of the most promising new alternatives to heart transplantation is use of ventricular assist devices (VADs). To date, there are no guidelines for appropriate selection for use of these devices that are approved by national societies in the field. This review addresses all of the general criteria for clinicians to keep in mind regarding when to refer a patient for evaluation and the specific issues addressed in patient selection. The field of mechanical circulatory support has advanced significantly over the past 10 years, resulting in rapid expansion of patients with advanced heart failure who can benefit from implantable devices. With progress of technology, limitations associated with age, body size, and comorbidities gradually become less prohibitive. The continuing simplification of design along with continued reduction in size of the devices, plus eventual elimination of the external drive line will make the use of VADs a superior option to heart transplant and even to medical management in many patients. We anticipate that the patient selection process outlined in the present review will continue to shift toward less advanced cases of heart failure.
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Affiliation(s)
- Leslie W Miller
- Department of Cardiovascular Sciences, University of South Florida, Tampa, FL 33606, USA.
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Third-generation continuous flow left ventricular assist devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 5:250-8. [PMID: 22437454 DOI: 10.1097/imi.0b013e3181ee77a1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tremendous advances have been made in the treatment of end-stage heart failure patients with left ventricular assist devices (LVADs). An important factor playing a role in the improved clinical outcomes is the development of continuous flow, rotary LVADs. New technology using magnetic levitation and hydrodynamic suspension to eliminate contact bearings offers the potential of more durable and efficacious mechanical circulatory blood pumps. Clinical trials evaluating these novel "third-generation" LVADs are in progress.
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9
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Inappropriate implantable cardioverter-defibrillator therapy due to electromagnetic interference in patient with a HeartWare HVAD left ventricular assist device. Heart Rhythm 2011; 8:778-80. [DOI: 10.1016/j.hrthm.2010.11.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 11/11/2010] [Indexed: 11/19/2022]
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Krabatsch T, Schweiger M, Stepanenko A, Kukucka M, Vierecke J, Lehmkuhl HB, Huebler M, Hennig E, Potapov E, Hetzer R. Mechanical Circulatory Support—Results, Developments and Trends. J Cardiovasc Transl Res 2011; 4:332-9. [PMID: 21394530 DOI: 10.1007/s12265-011-9268-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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The role of echocardiography and other imaging modalities in patients with left ventricular assist devices. JACC Cardiovasc Imaging 2011; 3:1049-64. [PMID: 20947051 DOI: 10.1016/j.jcmg.2010.07.012] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 07/08/2010] [Accepted: 07/20/2010] [Indexed: 12/14/2022]
Abstract
Recent advances in the field of left ventricular device support have led to an increased use of left ventricular assist devices (LVADs) in patients with end stage heart disease. The primary imaging modality to monitor patients with LVADs has been echocardiography. The purpose of this review is to highlight the clinical role of echo and other noninvasive imaging modalities in the assessment of cardiac structure and function in patients with pulsatile and continuous flow LVADs. In addition, we discuss the role of imaging with emphasis on echo to detect LVAD dysfunction and device related complications.
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Affiliation(s)
- Deborah J Kozik
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
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13
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Nguyen DQ, Thourani VH. Third-Generation Continuous Flow Left Ventricular Assist Devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Duc Q. Nguyen
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Vinod H. Thourani
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
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Holman WL, Pamboukian SV, McGiffin DC, Tallaj JA, Cadeiras M, Kirklin JK. Device Related Infections: Are We Making Progress? J Card Surg 2010; 25:478-83. [DOI: 10.1111/j.1540-8191.2010.01034.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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15
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Alba AC, Delgado DH. The future is here: ventricular assist devices for the failing heart. Expert Rev Cardiovasc Ther 2009; 7:1067-77. [PMID: 19764860 DOI: 10.1586/erc.09.86] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mechanical circulatory support is an important adjunct to the management of patients with advanced heart failure. Technological advances in this area have improved overall survival and decreased the incidence of complications. In addition, they have expanded the population suitable for this therapy. The challenge for clinicians is to translate the clinical evidence into the selection of the most appropriate device that will benefit an individual patient. This paper will review ventricular assist devices currently available and their clinical indications.
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Affiliation(s)
- Ana C Alba
- Heart Failure and Transplantation, University Health Network, NCSB 11C-1201, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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Fukamachi K, Horvath DJ, Massiello AL, Fumoto H, Horai T, Rao S, Golding LAR. An innovative, sensorless, pulsatile, continuous-flow total artificial heart: device design and initial in vitro study. J Heart Lung Transplant 2009; 29:13-20. [PMID: 19782599 DOI: 10.1016/j.healun.2009.05.034] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 05/27/2009] [Accepted: 05/27/2009] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We are developing a very small, innovative, continuous-flow total artificial heart (CFTAH) that passively self-balances left and right pump flows and atrial pressures without sensors. This report details the CFTAH design concept and our initial in vitro data. METHODS System performance of the CFTAH was evaluated using a mock circulatory loop to determine the range of systemic and pulmonary vascular resistance (SVR and PVR) levels over which the design goal of a maximum absolute atrial pressure difference of 10 mm Hg is achieved for a steady-state flow condition. Pump speed was then modulated at 2,600 +/- 900 rpm to induce flow and arterial pressure pulsation to evaluate the effects of speed pulsations on the system performance. An automatic control mode was also evaluated. RESULTS Using only passive self-regulation, pump flows were balanced and absolute atrial pressure differences were maintained at <10 mm Hg over a range of SVR (750 to 2,750 dyne.sec.cm(-5)) and PVR (135 to 600 dyne.sec.cm(-5)) values far exceeding normal levels. The magnitude of induced speed pulsatility affected relative left/right performance, allowing for an additional active control to improve balanced flow and pressure. The automatic control mode adjusted pump speed to achieve targeted pump flows based on sensorless calculations of SVR and CFTAH flow. CONCLUSIONS The initial in vitro testing of the CFTAH with a single, valveless, continuous-flow pump demonstrated its passive self-regulation of flows and atrial pressures and a new automatic control mode.
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Affiliation(s)
- Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Someya T, Kobayashi M, Waguri S, Ushiyama T, Nagaoka E, Hijikata W, Shinshi T, Arai H, Takatani S. Development of a Disposable Maglev Centrifugal Blood Pump Intended for One-Month Support in Bridge-to-Bridge Applications: In Vitro and Initial In Vivo Evaluation. Artif Organs 2009; 33:704-13. [DOI: 10.1111/j.1525-1594.2009.00900.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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