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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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Attard J, Sneiders D, Laing R, Boteon Y, Mergental H, Isaac J, Mirza DF, Afford S, Hartog H, Neil DAH, Perera MTPR. The effect of end-ischaemic normothermic machine perfusion on donor hepatic artery endothelial integrity. Langenbecks Arch Surg 2022; 407:717-726. [PMID: 34999966 DOI: 10.1007/s00423-021-02394-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ex vivo normothermic machine liver perfusion (NMLP) involves artificial cannulation of vessels and generation of flow pressures. This could lead to shear stress-induced endothelial damage, predisposing to vascular complications, or improved preservation of donor artery quality. This study aims to assess the spatial donor hepatic artery (HA) endothelial quality downstream of the cannulation site after end-ischaemic NMLP. METHODS Remnant HA segments from the coeliac trunk up to the gastroduodenal artery branching were obtained after NMLP (n = 15) and after static cold storage (SCS) preservation (n = 15). Specimens were fixed in 10% neutral buffered formalin and sectioned at pre-determined anatomical sites downstream of the coeliac trunk. CD31 immunohistostaining was used to assess endothelial integrity by a 5-point ordinal scale (grade 0: intact endothelial lining, grade 5: complete denudation). Endothelial integrity after SCS was used as a control for the state of the endothelium at commencement of NMP. RESULTS In the SCS specimens, regardless of the anatomical site, near complete endothelial denudation was present throughout the HA (median scores 4.5-5). After NMLP, significantly less endothelial loss in the distal HA was present compared to SCS grafts (NMLP vs. SCS: median grade 3 vs. 4.5; p = 0.042). In NMLP specimens, near complete endothelial denudation was present at the cannulation site in all cases (median grade: 5), with significantly less loss of the endothelial lining the further from the cannulation site (proximal vs. distal, median grade 5 vs. 3; p = 0.005). CONCLUSION Loss of endothelial lining throughout the HA after SCS and at the cannulation site after NMLP suggests extensive damage related to surgical handling and preservation injury. Gradual improved endothelial lining along more distal sites of the HA after NMLP indicates potential for re-endothelialisation. The regenerative effect of NMLP on artery quality seems to occur to a greater extent further from the cannulation site. Therefore, arterial cannulation for machine perfusion of liver grafts should ideally be as proximal as possible on the coeliac trunk or aortic patch, while the site of anastomosis should preferentially be attempted distal on the common HA.
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Affiliation(s)
- J Attard
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Sneiders
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - R Laing
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Y Boteon
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Afford
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - H Hartog
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D A H Neil
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M T P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Pathophysiology of heart failure and an overview of therapies. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cortese F, Ciccone MM, Gesualdo M, Iacoviello M, Frigerio M, Cipriani M, Giannattasio C, Maloberti A, Giordano P. Continuous flow left ventricular assist devices do not worsen endothelial function in subjects with chronic heart failure: a pilot study. ESC Heart Fail 2021; 8:3587-3593. [PMID: 34331419 PMCID: PMC8497342 DOI: 10.1002/ehf2.13484] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS To evaluate endothelial function in subjects with left ventricular assist devices (LVADs), comparing them with subjects with chronic heart failure with reduced ejection fraction on the list for heart transplant (HT) and with HT patients with a normal systolic cardiac function to identify any differences. METHODS We enrolled 28 subjects with LVAD, 55 subjects with HT, and 42 subjects with heart failure on the transplant list. The subjects underwent a general physical examination, assessment of laboratory blood parameters, and assessment of endothelial function through flow-mediated dilation (FMD) of brachial artery. RESULTS The three groups were homogeneous as regards age, gender, smoke abuse, C-reactive protein (CRP) and FMD parameters (P = ns). In LVAD group percentage of FMD change showed an inverse correlation with CRP (rho: -0.5, P: 0.003), a well-known marker of inflammation and tissue damage. CONCLUSIONS Continuous flow related to LVAD seems to not worsen endothelial function. Endothelial function was not affected by cardiovascular risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, and tobacco habit), by the functional status expressed by New York Heart Association class, by the left ventricular systolic function and by the presence or absence of ischaemic heart disease in all the populations analysed. CRP was the only factor able to influence percentage of FMD change in patient with LVAD, reinforcing the hypothesis that inflammation is the main determinant of endothelial function.
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Affiliation(s)
- Francesca Cortese
- Department of Cardiology, Cardiology Unit, Giovanni Paolo II Hospital, viale salerno, Policoro, Matera, Italy.,Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Bari, Italy
| | | | - Massimo Iacoviello
- Unit of Cardiology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Frigerio
- De Gasperis Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, Milan, Italy
| | - Manlio Cipriani
- De Gasperis Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, Milan, Italy
| | | | | | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, Pediatric Section, University "A. Moro" of Bari, Bari, Italy
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Cornwell WK, Tarumi T, Lawley J, Ambardekar AV. Rebuttal from William K. Cornwell III, Takashi Tarumi, Justin Lawley and Amrut V. Ambardekar. J Physiol 2018; 597:363-364. [PMID: 30560588 DOI: 10.1113/jp277244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Takashi Tarumi
- Human Informatics Research Institute, National Institute of Advanced Industrial Science and Technology, Tsukuba, Ibaraki, Japan
| | - Justin Lawley
- Department of Sports Science, Division of Physiology, University of Innsbruck, Innsbruck, Austria
| | - Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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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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A Comparative Study of Single and Dual Perfusion During End-ischemic Subnormothermic Liver Machine Preservation. Transplant Direct 2018; 4:e400. [PMID: 30534591 PMCID: PMC6233661 DOI: 10.1097/txd.0000000000000840] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
Background It remains controversial if arterial perfusion in addition to portal vein perfusion during machine preservation improves liver graft quality. Comparative studies using both techniques are lacking. We studied the impact of using single or dual machine perfusion of donation after circulatory death rat livers. In addition, we analyzed the effect of pulsatile versus continuous arterial flow. Methods Donation after circulatory death rat livers (n = 18) were preserved by 6 hours cold storage, followed by 1 hour subnormothermic machine perfusion (20°C, pressure of 40/5 mm Hg) and 2 hours ex vivo warm reperfusion (37°C, pressure of 80/11 mm Hg, 9% whole blood). Machine preservation was either through single portal vein perfusion (SP), dual pulsatile (DPP), or dual continuous perfusion (DCP) of the portal vein and hepatic artery. Hydrodynamics, liver function tests, histopathology, and expression of endothelial specific genes were assessed during 2 hours warm reperfusion. Results At the end of reperfusion, arterial flow in DPP livers tended to be higher compared to DCP and SP grafts. However, this difference was not significant nor was better flow associated with better outcome. No differences in bile production or alanine aminotransferase levels were observed. SP livers had significantly lower lactate compared to DCP, but not DPP livers. Levels of Caspase-3 and tumor necrosis factor-α were similar between the groups. Expression of endothelial genes Krüppel-like-factor 2 and endothelial nitric oxide synthase tended to be higher in dual perfused livers, but no histological evidence of better preservation of the biliary endothelium or vasculature of the hepatic artery was observed. Conclusions This study shows comparable outcomes after using a dual or single perfusion approach during end-ischemic subnormothermic liver machine preservation.
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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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Miyamoto T, Karimov JH, Fukamachi K. Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology. Expert Rev Med Devices 2018; 15:171-182. [DOI: 10.1080/17434440.2018.1437346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
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Successful Liver Transplantation From a Donor With a Continuous-Flow Left Ventricular Assist Device for 9 Months. Transplant Proc 2017; 49:2406-2408. [DOI: 10.1016/j.transproceed.2017.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 07/04/2017] [Accepted: 09/01/2017] [Indexed: 01/10/2023]
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Naito N, Nishimura T, Iizuka K, Takewa Y, Umeki A, Ando M, Ono M, Tatsumi E. Rotational speed modulation used with continuous-flow left ventricular assist device provides good pulsatility†. Interact Cardiovasc Thorac Surg 2017; 26:119-123. [DOI: 10.1093/icvts/ivx236] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/18/2017] [Indexed: 11/12/2022] Open
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Abstract
Heart failure (HF) is a systemic illness with grave implications for bodily functions. The brain, among other vital organs, often suffers insults as a result of HF, and both anatomic and functional brain abnormalities were found in the HF population. This injury was demonstrated across a wide range of clinical conditions and cardiac functions and was shown to affect patients' outcomes. Although reduced cardiac output and high burden of cardiovascular risk factors are the prevailing explanations for these findings, there are data showing the involvement of neurohormonal, nutritional, and inflammatory mechanisms in this complex process. Here, the authors review the suggested pathophysiology behind brain injury in HF, describe its effect on patients' outcomes, offer a diagnostic approach, and discuss possible therapeutic options.
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Patel AC, Dodson RB, Cornwell WK, Hunter KS, Cleveland JC, Brieke A, Lindenfeld J, Ambardekar AV. Dynamic Changes in Aortic Vascular Stiffness in Patients Bridged to Transplant With Continuous-Flow Left Ventricular Assist Devices. JACC-HEART FAILURE 2017; 5:449-459. [PMID: 28285118 DOI: 10.1016/j.jchf.2016.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/30/2016] [Accepted: 12/15/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to measure aortic vascular stiffness from orthotopic heart transplant (OHT) patients exposed to varying types of flow as a result of the presence or absence of left ventricular assist device (LVAD) support pre-OHT. BACKGROUND The effects of continuous-flow LVADs (CF-LVADs) on vascular properties are unknown, but may contribute to the pathophysiology of CF-LVAD complications such as stroke, hypertension, and bleeding. METHODS Echocardiograms were reviewed from 172 OHT patients immediately before LVAD and at 3 time points post-OHT: baseline, 6 months, and 1 year. For each study, pulse pressure and aortic end-systolic and end-diastolic dimensions were used to calculate aortic strain, distensibility, and stiffness index. Patients were categorized into 3 groups based on the presence or absence of a LVAD and a pulse pre-OHT: No LVAD (n = 111), LVAD No Pulse (n = 30), and LVAD With Pulse (n = 31). RESULTS The aortic stiffness index among LVAD No Pulse patients increased from 2.8 ± 1.1 pre-CF-LVAD to 10.9 ± 4.7 immediately post-OHT (p < 0.001). This aortic stiffness index was also significantly higher compared with No LVAD (3.4 ± 1.1; p < 0.001) and LVAD With Pulse (3.7 ± 1.4; p < 0.001) immediately post-OHT with attenuation of these differences by 1 year post-OHT. Similar findings were noted for the other indices of aortic stiffness. CONCLUSIONS Aortic stiffness is markedly increased immediately post-OHT among patients bridged with CF-LVADs, with attenuation of this increased stiffness over the first year after transplant. These results suggest that aortic vascular properties are dynamic and may be influenced by alterations in flow pulsatility. As more patients are supported with CF-LVADs and as newer pump technology attempts to modulate pulsatility, further research examining the role of alterations in flow patterns on vascular function and the potential resultant systemic sequelae are needed.
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Affiliation(s)
- Amit C Patel
- Division of Cardiology, University of Colorado, Aurora, Colorado
| | - R Blair Dodson
- Department of Bioengineering, University of Colorado, Aurora, Colorado; Division of Pediatric Surgery, University of Colorado, Aurora, Colorado
| | | | - Kendall S Hunter
- Department of Bioengineering, University of Colorado, Aurora, Colorado; Department of Pediatrics, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Andreas Brieke
- Division of Cardiology, University of Colorado, Aurora, Colorado
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Yoshioka D, Takayama H, Colombo PC, Yuzefpolskaya M, Garan AR, Topkara VK, Han J, Kurlansky P, Naka Y, Takeda K. Changes in End-Organ Function in Patients With Prolonged Continuous-Flow Left Ventricular Assist Device Support. Ann Thorac Surg 2017; 103:717-724. [DOI: 10.1016/j.athoracsur.2016.12.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/03/2016] [Accepted: 12/08/2016] [Indexed: 11/29/2022]
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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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Mirasol RV, Tholany JJ, Reddy H, Fyfe-Kirschner BS, Cheng CL, Moubarak IF, Nosher JL. Gastrointestinal bleeding in a patient with a continuous-flow biventricular assist device. World J Radiol 2016; 8:428-433. [PMID: 27158430 PMCID: PMC4840201 DOI: 10.4329/wjr.v8.i4.428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/01/2016] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
The association between continuous-flow left ventricular assist devices (CF-LVADs) and gastrointestinal (GI) bleeding from angiodysplasia is well recognized. However, the association between continuous-flow biventricular assist devices (CF-BIVADs) and bleeding angiodysplasia is less understood. We report a case of GI bleeding from a patient with a CF-BIVAD. The location of GI bleeding was identified by nuclear red blood cell bleeding scan. The vascular malformation leading to the bleed was identified and localized on angiography and then by pathology. The intensity of bleeding, reflected by number of units of packed red blood cells needed for normalization of hemoglobin, as well as the time to onset of bleeding after transplantation, are similar to that seen in the literature for CF-LVADs and pulsatile BIVADs. While angiography only detected a dilated late draining vein, pathology demonstrated the presence of both arterial and venous dilation in the submucosa, vascular abnormalities characteristic of a late arteriovenous malformation.
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Saito T, Wassilew K, Gorodetski B, Stein J, Falk V, Krabatsch T, Potapov E. Aortic Valve Pathology in Patients Supported by Continuous-Flow Left Ventricular Assist Device. Circ J 2016; 80:1371-7. [PMID: 27151333 DOI: 10.1253/circj.cj-15-1188] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (CF-LVAD) may induce pathological changes to the aortic wall and aortic valve. We assessed histological changes in the relevant anatomic structures exposed to continuous flow over time and compared the histological results with clinical features in patients supported with CF-LVAD. METHODS AND RESULTS A retrospective histological analysis was performed of 38 explanted hearts supported with CF-LVAD from patients who received heart transplantation between July 2003 and February 2014. Sections of formalin-fixed paraffin-embedded tissue showing the continuity of aortic wall and left-sided valves were examined histologically. Thickness of aorta, aortic root and aortic valve as well as 3 layers of the aortic cusps were measured individually on Elastica van Gieson-stained slides using specific software. Clinical parameters concerning aortic valve dysfunction were evaluated and validated against the histology. The aortic valve spongiosa and fibrosa layers showed no significant differences in thickness with regard to support duration or occurrence of aortic insufficiency. Longer CF-LVAD support duration correlated with a thinner aortic valve ventricularis layer (rS=-0.496). CONCLUSIONS Long-term CF-LVAD support appears to cause involution of the ventricularis layer of the aortic valve cusp, consistent with more pronounced degenerative change with longer LVAD exposure, which may be explained by continuous coaptation of the cusps. (Circ J 2016; 80: 1371-1377).
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Affiliation(s)
- Tomohiro Saito
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin
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18
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Hetzer R, Kaufmann MEng F, Potapov E, Krabatsch T, Delmo Walter EM. Rotary Blood Pumps as Long-Term Mechanical Circulatory Support: A Review of a 15-Year Berlin Experience. Semin Thorac Cardiovasc Surg 2016; 28:12-23. [PMID: 27568128 DOI: 10.1053/j.semtcvs.2016.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
Abstract
This article reports our 15-year single-center experience with rotary blood pumps (RBPs) as long-term mechanical circulatory support (MCS) with emphasis on outcomes. For more than 15-year period, we have used various RBPs as bridge to transplantation or to myocardial recovery. Our group performed the first human implantation worldwide of RBCs, the MicroMed DeBakey ventricular assist device in November 1998 in a patient with end-stage heart failure who was supported for 47 days until his death. Based on this initial experience, we recognized the feasibility of providing long-term support and since then it has been our primary armamentarium in treating patients with heart failure. Between 1987 and September 2013, we have implanted 2208 ventricular assist devices ranging from pulsatile to continuous-flow systems, as short-term, long-term, or permanent support in patients with end-stage heart failure. In total, 1009 RBPs were implanted on 908 patients, and their outcomes are reported here. We have shared some milestones in MCS including the first implantation of Jarvik 2000 on the oldest patient (81-year old) in 2008 and the first worldwide implantation of a biventricular HeartWare. Over time, implantation techniques, anticoagulation, and postoperative care have been modified and individualized. A relevant aspect of our experience has been the incidence of pump thrombosis. This is particularly frustrating because the problem has occurred in the setting of full anticoagulation and antiplatelet therapy, guided by strict anticoagulation monitoring. It has become clear to us that the devices are still not perfect. Technical pump failures such as cable breaks also occur, prompting urgent pump exchange, and infection. A 15-year cumulative mortality rate is 46.9%. This report emphasizes that MCS with RBPs has evolved into a routine treatment in heart failure and is a highly feasible option for permanent therapy particularly for elderly patients.
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Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Friedrich Kaufmann MEng
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
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19
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Berthiaume J, Kirk J, Ranek M, Lyon R, Sheikh F, Jensen B, Hoit B, Butany J, Tolend M, Rao V, Willis M. Pathophysiology of Heart Failure and an Overview of Therapies. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00008-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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20
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Bhimaraj A, Uribe C, Suarez EE. Physiological impact of continuous flow on end-organ function: clinical implications in the current era of left ventricular assist devices. Methodist Debakey Cardiovasc J 2015; 11:12-7. [PMID: 25793024 DOI: 10.14797/mdcj-11-1-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The clinical era of continuous-flow left ventricular assist devices has debunked many myths about the dire need of a pulse for human existence. While this therapy has been documented to provide a clear survival benefit in end-stage heart failure patients, we are now faced with certain morbidity challenges that as of yet have no easy mechanistic physiological explanation. The effect of physiological changes on end-organ function in patients supported by continuous-flow ventricular assist devices may offer insight into some of these morbidities. We therefore present a review of current evidence documenting the impact of continuous flow on end-organ function.
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Affiliation(s)
- Arvind Bhimaraj
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Cesar Uribe
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Erick E Suarez
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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21
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Absence of structural lesions in human renal arcuate arteries after LVAD implantation: response to a letter regarding "left ventricular assist devices: a kidney's perspective". Heart Fail Rev 2015; 20:753-4. [PMID: 26395012 DOI: 10.1007/s10741-015-9507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Cooper TK. Letter to the Editor regarding the article "Left ventricular assist devices: a kidney's perspective". Heart Fail Rev 2015; 20:751-2. [PMID: 26387095 DOI: 10.1007/s10741-015-9504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy K Cooper
- Departments of Comparative Medicine and Pathology, Penn State Hershey Medical Center, Hershey, PA, USA.
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23
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Ambardekar AV, Hunter KS, Babu AN, Tuder RM, Dodson RB, Lindenfeld J. Changes in Aortic Wall Structure, Composition, and Stiffness With Continuous-Flow Left Ventricular Assist Devices: A Pilot Study. Circ Heart Fail 2015; 8:944-52. [PMID: 26136459 DOI: 10.1161/circheartfailure.114.001955] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 06/25/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effects of nonpulsatile flow on the aorta are unknown. Our aim was to examine the structure of the aorta from patients with continuous-flow left ventricular assist devices (LVADs) and directly measure aortic wall composition and stiffness. METHODS AND RESULTS Age-matched aortic wall samples were collected from consecutive patients with heart failure (HF) at the time of transplantation and compared with nonfailing donor hearts. An unbiased stereological approach was used to quantify aortic morphometry and composition, and biomechanical testing was performed to determine the stress-strain relationship of the vessel. Data were obtained from 4 patients without a left ventricular assist device (HF group: mean age, 58.3±8.0 years), 7 patients with a continuous-flow LVAD (HF+LVAD group: mean, 57.7±5.6 years), and 3 nonfailing donors (mean, 53.3±12.9 years). Compared with HF, the aortic walls from HF+LVAD had an increase in wall thickness, collagen, and smooth muscle content accompanied by a reduction in elastin and mucinous ground-substance content. Stress-strain curves from the aortas revealed increased vessel stiffness in HF+LVAD compared with HF and nonfailing. The physiological modulus of the aorta progressively stiffened from 74.3±5.5 kPa in the nonfailing to 134.4±35.0 kPa in the HF to 201.7±36.4kPa in the HF+LVAD groups (P<0.001). CONCLUSIONS Among continuous-flow LVAD patients without aortic valve opening, there are changes in the structure and composition of the aorta as well as an increase in aortic wall stiffness compared with age-matched HF patients and nonfailing donors. Further studies examining the role of nonpulsatile blood flow on aortic function and the potential resultant systemic sequelae are needed.
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Affiliation(s)
- Amrut V Ambardekar
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.).
| | - Kendall S Hunter
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
| | - Ashok N Babu
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
| | - Rubin M Tuder
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
| | - R Blair Dodson
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
| | - JoAnn Lindenfeld
- From the Department of Medicine, Division of Cardiology (A.V.A.), Department of Bioengineering (K.S.H., R.B.D.), Department of Pediatrics, Division of Cardiology (K.S.H.), Department of Surgery, Division of Cardiothoracic Surgery (A.N.B.), Department of Medicine, Divisions of Pulmonary Sciences and Critical Care Medicine (R.M.T.), and Department of Surgery, Division of Pediatric Surgery (R.B.D.), University of Colorado, Aurora; and Vanderbilt Heart and Vascular Institute, Nashville, TN (J.L.)
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24
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Abstract
Continuous-flow left ventricular assist devices (LVAD) have become standard therapy option for patients with advanced heart failure. They offer several advantages over previously used pulsatile-flow LVADs, including improved durability, less surgical trauma, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients. However, mounting evidence shows unanticipated consequences of continuous-flow support, such as acquired aortic valve insufficiency and acquired von Willebrand syndrome. In this review article we discuss current evidence on differences between continuous and pulsatile mechanical circulatory support, with a focus on clinical implications and potential benefits of pulsatile flow.
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Affiliation(s)
- Davor Barić
- Davor Barić, Department of Cardiac Surgery and Transplantation, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia,
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25
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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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26
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Cornwell WK, Tarumi T, Aengevaeren VL, Ayers C, Divanji P, Fu Q, Palmer D, Drazner MH, Meyer DM, Bethea BT, Hastings JL, Fujimoto N, Shibata S, Zhang R, Markham DW, Levine BD. Effect of pulsatile and nonpulsatile flow on cerebral perfusion in patients with left ventricular assist devices. J Heart Lung Transplant 2014; 33:1295-303. [DOI: 10.1016/j.healun.2014.08.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/28/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022] Open
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27
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Moazami N, Dembitsky WP, Adamson R, Steffen RJ, Soltesz EG, Starling RC, Fukamachi K. Does pulsatility matter in the era of continuous-flow blood pumps? J Heart Lung Transplant 2014; 34:999-1004. [PMID: 25447568 DOI: 10.1016/j.healun.2014.09.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022] Open
Abstract
Despite significant improved survival with continuous flow left ventricular assist devices (LVADs), complications related to aortic valve insufficiency, gastrointestinal bleeding, stroke, pump thrombosis, and hemolysis have dampened the long term success of these pumps. Evolution has favored a pulsatile heart pump to be able to deliver the maximum flow at different levels of systemic vascular resistance, confer kinetic energy to the flow of blood past areas of stenosis and generate low shear stress on blood elements. In this perspective, we suggest that lack of pulsatility may be one factor that has limited the success of continuous flow LVADs and suggest that research needs to focus on methods to generate pulsatility either by the native heart or by various speed modulation algorithms.
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Affiliation(s)
- Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Walter P Dembitsky
- Department of Cardiac Surgery, Sharp Memorial Hospital, San Diego, California
| | - Robert Adamson
- Department of Cardiac Surgery, Sharp Memorial Hospital, San Diego, California
| | - Robert J Steffen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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28
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Westaby S. Rotary blood pumps as definitive treatment for severe heart failure. Future Cardiol 2013; 9:199-213. [DOI: 10.2217/fca.12.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Rotary blood pumps are increasingly recognized as mainstream therapy for severely symptomatic heart failure. Carefully targeted refinements in patient selection and postoperative care have substantially reduced the adverse event burden. These improvements translate into better survival and quality of life in comparison with medical management. Medium-term outcomes now compete favorably with cardiac transplantation, although evidence-based outcome data indicate that transplant and ‘lifetime’ left ventricular-assist device (LVAD) candidates are fundamentally different. Significant challenges remain in relation to neurological injury and right heart failure, which may continue to limit exercise capacity. In the meantime, both physician awareness and patient access to LVAD technology remain limited. The debate is rarely between cardiac transplant or lifetime LVAD. It should focus on the choice between pump versus palliative care for the thousands of patients of all age groups who are judged ineligible for transplantation. Comprehensive healthcare systems must consider contemporary evidence and provide the most symptomatic of heart failure patients with effective care. Cardiac resynchronization therapy is no longer the ceiling for this.
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Affiliation(s)
- Stephen Westaby
- Oxford University Hospitals Trust, John Radcliffe Hospital, Department of Cardiac Surgery, Oxford, OX3 9DU, UK
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