1
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Akbar AF, Rokui S, Zhou AL, Kilic A, King E, Cho SM. Incidence and Risk Factors for Stroke After Combined Heart-Kidney and Heart-Liver Transplantation. Clin Transplant 2024; 38:e15369. [PMID: 39031709 PMCID: PMC11262467 DOI: 10.1111/ctr.15369] [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: 03/21/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant. METHODS The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT. RESULTS Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p = 0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank) < 0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank) < 0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor. CONCLUSIONS Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT).
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Affiliation(s)
- Armaan F. Akbar
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sorush Rokui
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Division of Cardiac Surgery, University of British Columbia, Vancouver, Canada
| | - Alice L. Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ahmet Kilic
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Elizabeth King
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
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2
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Burma JS, Roy MA, Kennedy CM, Labrecque L, Brassard P, Smirl JD. A systematic review, meta-analysis, and meta-regression amalgamating the driven approaches used to quantify dynamic cerebral autoregulation. J Cereb Blood Flow Metab 2024:271678X241235878. [PMID: 38635887 DOI: 10.1177/0271678x241235878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Numerous driven techniques have been utilized to assess dynamic cerebral autoregulation (dCA) in healthy and clinical populations. The current review aimed to amalgamate this literature and provide recommendations to create greater standardization for future research. The PubMed database was searched with inclusion criteria consisting of original research articles using driven dCA assessments in humans. Risk of bias were completed using Scottish Intercollegiate Guidelines Network and Methodological Index for Non-Randomized Studies. Meta-analyses were conducted for coherence, phase, and gain metrics at 0.05 and 0.10 Hz using deep-breathing, oscillatory lower body negative pressure (OLBNP), sit-to-stand maneuvers, and squat-stand maneuvers. A total of 113 studies were included, with 40 of these incorporating clinical populations. A total of 4126 participants were identified, with younger adults (18-40 years) being the most studied population. The most common techniques were squat-stands (n = 43), deep-breathing (n = 25), OLBNP (n = 20), and sit-to-stands (n = 16). Pooled coherence point estimates were: OLBNP 0.70 (95%CI:0.59-0.82), sit-to-stands 0.87 (95%CI:0.79-0.95), and squat-stands 0.98 (95%CI:0.98-0.99) at 0.05 Hz; and deep-breathing 0.90 (95%CI:0.81-0.99); OLBNP 0.67 (95%CI:0.44-0.90); and squat-stands 0.99 (95%CI:0.99-0.99) at 0.10 Hz. This review summarizes clinical findings, discusses the pros/cons of the 11 unique driven techniques included, and provides recommendations for future investigations into the unique physiological intricacies of dCA.
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Affiliation(s)
- Joel S Burma
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Marc-Antoine Roy
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Courtney M Kennedy
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Lawrence Labrecque
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jonathan D Smirl
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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3
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Park MS, Kim EJ. A Correlative Relationship Between Heart Failure and Cognitive Impairment: A Narrative Review. J Korean Med Sci 2023; 38:e334. [PMID: 37821090 PMCID: PMC10562184 DOI: 10.3346/jkms.2023.38.e334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023] Open
Abstract
Heart failure (HF) is a chronic condition affecting millions of people worldwide. While the cardinal manifestations of HF are related to the cardiovascular system, it has become progressively evident that mild cognitive impairment (MCI) is also a significant complication of the disease. In fact, a significant number of patients with HF may experience MCI, which can manifest as deficits in attention, memory, executive function, and processing speed. The mechanisms responsible for cognitive dysfunction in HF are intricate and multifactorial. Possible factors contributing to this condition include decreased cerebral blood flow, thrombogenicity associated with HF, systemic inflammatory conditions, and proteotoxicity. MCI in HF has significant clinical implications, as it is linked to poorer quality of life, increased morbidity and mortality, and higher healthcare costs. Additionally, MCI can disrupt self-care behaviors, adherence to medication, and decision-making abilities, all of which are crucial for effectively managing HF. However, there is currently no gold standard diagnostic tool and follow-up strategy for MCI in HF patients. There is limited knowledge on the prevention and treatment of MCI. In conclusion, MCI is a common and clinically important complication of HF. Considering the substantial influence of MCI on patient outcomes, it is imperative for healthcare providers to be cognizant of this issue and integrate cognitive screening and management strategies into the care of HF patients.
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Affiliation(s)
- Myung Soo Park
- Department of Medicine, Korea University Graduate School, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Eung Ju Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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4
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Stöhr EJ, Ji R, Mondellini G, Braghieri L, Akiyama K, Castagna F, Pinsino A, Cockcroft JR, Silverman RH, Trocio S, Zatvarska O, Konofagou E, Apostolakis I, Topkara VK, Takayama H, Takeda K, Naka Y, Uriel N, Yuzefpolskaya M, Willey JZ, McDonnell BJ, Colombo PC. Pulsatility and flow patterns across macro- and microcirculatory arteries of continuous-flow left ventricular assist device patients. J Heart Lung Transplant 2023; 42:1223-1232. [PMID: 37098374 PMCID: PMC11078160 DOI: 10.1016/j.healun.2023.04.002] [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: 05/10/2022] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known. METHODS The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41. RESULTS In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r2 = 0.51, p < 0.0001; HM3 "continuous-flow," r2 = 0.32, p = 0.0009; HM3 "artificial pulse," r2 = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients. CONCLUSIONS The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs.
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Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, New York; Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Francesco Castagna
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiology Division, Montefiore Medical Center, New York, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald H Silverman
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York
| | - Samuel Trocio
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Oksana Zatvarska
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Iason Apostolakis
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koji Takeda
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Yoshifumi Naka
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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5
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Shariff M, Dobariya A, Albaghdadi O, Awkal J, Moussa H, Reyes G, Syed M, Hart R, Longfellow C, Douglass D, El Ahmadieh TY, Good LB, Jakkamsetti V, Kathote G, Angulo G, Ma Q, Brown R, Dunbar M, Shelton JM, Evers BM, Patnaik S, Hoffmann U, Hackmann AE, Mickey B, Peltz M, Jessen ME, Pascual JM. Maintenance of pig brain function under extracorporeal pulsatile circulatory control (EPCC). Sci Rep 2023; 13:13942. [PMID: 37626089 PMCID: PMC10457326 DOI: 10.1038/s41598-023-39344-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Selective vascular access to the brain is desirable in metabolic tracer, pharmacological and other studies aimed to characterize neural properties in isolation from somatic influences from chest, abdomen or limbs. However, current methods for artificial control of cerebral circulation can abolish pulsatility-dependent vascular signaling or neural network phenomena such as the electrocorticogram even while preserving individual neuronal activity. Thus, we set out to mechanically render cerebral hemodynamics fully regulable to replicate or modify native pig brain perfusion. To this end, blood flow to the head was surgically separated from the systemic circulation and full extracorporeal pulsatile circulatory control (EPCC) was delivered via a modified aorta or brachiocephalic artery. This control relied on a computerized algorithm that maintained, for several hours, blood pressure, flow and pulsatility at near-native values individually measured before EPCC. Continuous electrocorticography and brain depth electrode recordings were used to evaluate brain activity relative to the standard offered by awake human electrocorticography. Under EPCC, this activity remained unaltered or minimally perturbed compared to the native circulation state, as did cerebral oxygenation, pressure, temperature and microscopic structure. Thus, our approach enables the study of neural activity and its circulatory manipulation in independence of most of the rest of the organism.
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Affiliation(s)
- Muhammed Shariff
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Aksharkumar Dobariya
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Obada Albaghdadi
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Jacob Awkal
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Hadi Moussa
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Gabriel Reyes
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Mansur Syed
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Robert Hart
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Cameron Longfellow
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Debra Douglass
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, 92354, USA
| | - Levi B Good
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Vikram Jakkamsetti
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Gauri Kathote
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Gus Angulo
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Qian Ma
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Ronnie Brown
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Misha Dunbar
- Animal Resource Center, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - John M Shelton
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Bret M Evers
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Sourav Patnaik
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ulrike Hoffmann
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Amy E Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Heart and Vascular Center Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Bruce Mickey
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Juan M Pascual
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA.
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Eugene McDermott Center for Human Growth and Development/Center for Human Genetics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
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6
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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7
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Neurologic Complications in Patients With Left Ventricular Assist Devices. Can J Cardiol 2023; 39:210-221. [PMID: 36400374 PMCID: PMC9905352 DOI: 10.1016/j.cjca.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.
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8
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [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: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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9
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Huang J, McDonnell BJ, Lawley JS, Byrd J, Stöhr EJ, Cornwell WK. Impact of Mechanical Circulatory Support on Exercise Capacity in Patients With Advanced Heart Failure. Exerc Sport Sci Rev 2022; 50:222-229. [PMID: 36095073 PMCID: PMC9475848 DOI: 10.1249/jes.0000000000000303] [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] [Indexed: 11/21/2022]
Abstract
Approximately 6 million individuals have heart failure in the United States alone and 15 million in Europe. Left ventricular assist devices (LVAD) improve survival in these patients, but functional capacity may not fully improve. This article examines the hypothesis that patients supported by LVAD experience persistent reductions in functional capacity and explores mechanisms accounting for abnormalities in exercise tolerance.
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Affiliation(s)
- Janice Huang
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Barry J. McDonnell
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff UK
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck Austria
| | - Jessica Byrd
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Eric J. Stöhr
- Faculty of Philosophical Sciences, Institute of Sport Science, Leibniz University Hannover, Hannover, Germany
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - William K. Cornwell
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
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10
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Adji A, Shehab S, Jain P, Robson D, Jansz P, Hayward CS. Arterial Compliance and Continuous-Flow Left Ventricular Assist Device Pump Function. ASAIO J 2022; 68:925-931. [PMID: 35544445 DOI: 10.1097/mat.0000000000001768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Durable continuous-flow left ventricular assist devices (cfLVADs) demonstrate superior survival, cardiac functional status, and overall quality of life compared to medical therapy alone in advanced heart failure. Previous studies have not considered the impact arterial compliance may have on pump performance or developed arterial pressure. This study assessed the impact of alterations in arterial compliance, preload, and afterload on continuous-flow pump function and measured hemodynamics using an in-vitro pulsatile mock circulatory loop. Decreased arterial compliance was associated with a significant increase in arterial pressure pulsatility which was not evident in the flow pulsatility, as displayed in pump flow waveforms. There were marked changes in the pump flow waveforms due to the significant alteration in the aortoventricular gradient during diastole according to the changes in compliance. This study demonstrates that changes in systemic blood pressure, afterload, and left ventricular contractility each significantly affects the flow waveform. The association of hypertension with lower aortic compliance results in markedly decreased diastolic flow rates which may be important in contributing to a greater risk of adverse events under cfLVAD support.
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Affiliation(s)
- Audrey Adji
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Sajad Shehab
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Desiree Robson
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Paul Jansz
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Christopher S Hayward
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
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11
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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Implications of Causes of Intracranial Hemorrhage During Left Ventricular Assist Device Support. Neurocrit Care 2022; 37:267-272. [PMID: 35411541 DOI: 10.1007/s12028-022-01494-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a frequent complication in patients with an implanted left ventricular assist device (LVAD) for advanced heart failure. Bloodstream infection is known to be associated with ICH in patients with LVAD, but its effects on ICH-associated mortality are unknown. We compared characteristics and mortality of infection-associated, traumatic, and spontaneous hemorrhages. METHODS Patients in an LVAD registry at a tertiary care center were reviewed for this cohort study. ICH included intraparenchymal hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage. Hemorrhages were categorized into infectious, traumatic, and spontaneous by the presence or absence of concurrent device-associated infection or antecedent trauma. RESULTS Of 683 patients with an LVAD, 73 experienced ICH (10.7%). Intraparenchymal hemorrhage was the most prevalent (72%), followed by subarachnoid hemorrhage (27%) and subdural hemorrhage (23%), with multiple concurrent hemorrhage subtypes in 16 patients (22%). Median time from implantation to ICH was shorter in spontaneous ICH than in infection-associated ICH (100 days vs. 252 days, p = 0.048). The prevalence of the different subtypes of ICH were similar between spontaneous and infection-associated ICH, and no differences were seen in mortality between the different causes of ICH. CONCLUSIONS Although spontaneous ICH occurred earlier after LVAD implantation than infection-associated ICH, no difference in mortality was seen between the different causes of ICH.
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13
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Yang M, Sun D, Wang Y, Yan M, Zheng J, Ren J. Cognitive Impairment in Heart Failure: Landscape, Challenges, and Future Directions. Front Cardiovasc Med 2022; 8:831734. [PMID: 35198608 PMCID: PMC8858826 DOI: 10.3389/fcvm.2021.831734] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 12/20/2022] Open
Abstract
Heart failure (HF) is a major global healthcare problem accounting for substantial deterioration of prognosis. As a complex clinical syndrome, HF often coexists with multi-comorbidities of which cognitive impairment (CI) is particularly important. CI is increasing in prevalence among patients with HF and is present in around 40%, even up to 60%, of elderly patients with HF. As a potent and independent prognostic factor, CI significantly increases the hospitalization and mortality and decreases quality of life in patients with HF. There has been a growing awareness of the complex bidirectional interaction between HF and CI as it shares a number of common pathophysiological pathways including reduced cerebral blood flow, inflammation, and neurohumoral activations. Research that focus on the precise mechanism for CI in HF is still ever insufficient. As the tremendous adverse consequences of CI in HF, effective early diagnosis of CI in HF and interventions for these patients may halt disease progression and improve prognosis. The current clinical guidelines in HF have begun to emphasize the importance of CI. However, nearly half of CI in HF is underdiagnosed, and few recommendations are available to guide clinicians about how to approach CI in patients with HF. This review aims to synthesize knowledge about the link between HF and cognitive dysfunction, issues pertaining to screening, diagnosis and management of CI in patients with HF, and emerging therapies for prevention. Based on data from current studies, critical gaps in knowledge of CI in HF are identified, and future research directions to guide the field forward are proposed.
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Affiliation(s)
- Mengxi Yang
- Heart Failure Center, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Di Sun
- Heart Failure Center, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yu Wang
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Mengwen Yan
- Heart Failure Center, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingang Zheng
- Heart Failure Center, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingyi Ren
- Heart Failure Center, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- Vascular Health Research Center of Peking University Health Science Center, Beijing, China
- *Correspondence: Jingyi Ren
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14
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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15
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Konarik M, Sramko M, Dorazilova Z, Blah M, Netuka I, Ivak P, Maly J, Szarszoi O. Effects of Acute Pump Speed Changes on Cerebral Hemodynamics in Patients With an Implantable Continuous-Flow Left Ventricular Assist Devices. Physiol Res 2021; 70:831-839. [PMID: 34717062 DOI: 10.33549/physiolres.934738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mechanical circulatory support (MCS) with an implantable left ventricular assist device (LVAD) is an established therapeutic option for advanced heart failure. Most of the currently used LVADs generate a continuous stream of blood that decreases arterial pulse pressure. This study investigated whether a change of the pulse pressure during different pump speed settings would affect cerebral autoregulation and thereby affect cerebral blood flow (CBF). The study included 21 haemodynamically stable outpatients with a continuous-flow LVAD (HeartMate II, Abbott, USA) implanted a median of 6 months before the study (interquartile range 3 to 14 months). Arterial blood pressure (measured by finger plethysmography) was recorded simultaneously with CBF (measured by transcranial Doppler ultrasound) during baseline pump speed (8900 rpm [IQR 8800; 9200]) and during minimum and maximum tolerated pump speeds (8000 rpm [IQR 8000; 8200] and 9800 rpm [IQR 9800; 10 000]). An increase in LVAD pump speed by 800 rpm [IQR 800; 1000] from the baseline lead to a significant decrease in arterial pulse pressure and cerebral blood flow pulsatility (relative change -24% and -32%, both p < 0.01), but it did not affect mean arterial pressure and mean CBF velocity (relative change 1% and -1.7%, p = 0.1 and 0.7). In stable patients with a continuous-flow LVAD, changes of pump speed settings within a clinically used range did not impair static cerebral autoregulation and cerebral blood flow.
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Affiliation(s)
- M Konarik
- Dept. of Cardiac Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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16
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Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 295] [Impact Index Per Article: 98.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
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Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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17
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Ovsenik A, Podbregar M, Fabjan A. Cerebral blood flow impairment and cognitive decline in heart failure. Brain Behav 2021; 11:e02176. [PMID: 33991075 PMCID: PMC8213942 DOI: 10.1002/brb3.2176] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/31/2021] [Accepted: 04/16/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Cognitive decline is an important contributor to disability in patients with chronic heart failure, affecting 25%-50% of patients. The aim of this review is to stress the importance of understanding pathophysiological mechanisms of heart failure involved in cognitive decline. METHODS An extensive PubMed search was conducted for the literature on the basic mechanisms of cerebral blood flow regulation, the effect of cardiac dysfunction on cerebral blood flow, and possible mechanisms underlying the association between cardiac dysfunction and cognitive decline. RESULTS Published literature supports the thesis that cardiac dysfunction leads to cerebral blood flow impairment and predisposes to cognitive decline. One of the postulated mechanisms underlying cognitive decline in chronic heart failure is chronic regional hypoperfusion of critical brain areas. Cognitive function may be further compromised by microvascular damage due to cardiovascular risk factors. Furthermore, it is implied that cerebral blood flow assessment could enable early recognition of patients at risk and help guide appropriate therapeutic strategies. CONCLUSION Interdisciplinary knowledge in the fields of neurology and cardiology is essential to clarify heart and brain interconnections in chronic heart failure. Understanding and identifying the basic neuropathophysiological changes in chronic heart failure could help with developing methods for early recognition of patients at risk, followed by institution of therapeutic actions to prevent or decrease cognitive decline.
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Affiliation(s)
- Ana Ovsenik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matej Podbregar
- Faculty of Medicine, Department for Internal Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Intensive care, General Hospital Celje, Celje, Slovenia
| | - Andrej Fabjan
- Faculty of Medicine, Institute for Physiology, University of Ljubljana, Ljubljana, Slovenia.,Department of Vascular Neurology and Intensive Care, Neurological Clinic, University Medical Centre Ljubljana, Ljubljana, Slovenia
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18
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Stöhr EJ, Ji R, Akiyama K, Mondellini G, Braghieri L, Pinsino A, Cockcroft JR, Yuzefpolskaya M, Amlani A, Topkara VK, Takayama H, Naka Y, Uriel N, Takeda K, Colombo PC, McDonnell BJ, Willey JZ. Cerebral vasoreactivity in HeartMate 3 patients. J Heart Lung Transplant 2021; 40:786-793. [PMID: 34134913 DOI: 10.1016/j.healun.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND While rates of stroke have declined with the HeartMate3 (HM3) continuous- flow (CF) left ventricular assist device (LVAD), the impact of non-pulsatile flow and artificial pulse physiology on cerebrovascular function is not known. We hypothesized that improved hemodynamics and artificial pulse physiology of HM3 patients would augment cerebrovascular metabolic reactivity (CVR) compared with HeartMate II (HMII) CF-LVAD and heart failure (HF) patients. METHODS Mean, peak systolic and diastolic flow velocities (MFV, PSV, MinFV, respectively) and cerebral pulsatility index were determined in the middle cerebral artery (MCA) before and after a 30 sec breath-hold challenge in 90 participants: 24 healthy controls; 30 HF, 15 HMII, and 21 HM3 patients. RESULTS In HM3 patients, breath-holding increased MFV (Δ8 ± 10 cm/sec, p < .0001 vs baseline) to levels similar to HF patients (Δ9 ± 8 cm/sec, p > .05), higher than HMII patients (Δ2 ± 8 cm/sec, p < .01) but lower than healthy controls (Δ13 ± 7 cm/sec, p < .05). CF-LVAD altered the proportion of systolic and diastolic flow responses as reflected by a differential cerebral pulsatility index (p = .03). Baseline MFV was not related to CVR (r2 = 0.0008, p = .81). However, CF-LVAD pump speed was strongly inversely associated with CVR in HM II (r2 = 0.51, p = .003) but not HM3 patients (r2 = 0.01, p = .65). CONCLUSIONS Compared with HMII, HM3 patients have a significantly improved CVR. However, CVR remains lower in HM3 and HF patients than in healthy controls, therefore suggesting that changes in cerebral hemodynamics are not reversed by CF-LVAD therapy. Further research on the mechanisms and the long-term impact of altered cerebral hemodynamics in this unique patient population are warranted.
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Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York; Department of Anesthesia, Yodogawa Christian Hospital, Osaka City, Osaka, Japan
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Amrin Amlani
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Hiroo Takayama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Yoshifumi Naka
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koji Takeda
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York
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19
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Cho SM, Tahsili-Fahadan P, Kilic A, Choi CW, Starling RC, Uchino K. A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke. Semin Neurol 2021; 41:411-421. [PMID: 33851393 DOI: 10.1055/s-0041-1726328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.
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Affiliation(s)
- Sung-Min Cho
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pouya Tahsili-Fahadan
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, Inova Fairfax Medical Campus, Falls Church, Virginia.,Neuroscience Research, Neuroscience and Spine Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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20
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Sailer C, Edelmann H, Buchanan C, Giro P, Babcock M, Swanson C, Spotts M, Schulte M, Pratt-Cordova A, Coe G, Beindorff M, Page RL, Ambardekar AV, Pal JD, Kohrt W, Wolfel E, Lawley JS, Tarumi T, Cornwell WK. Impairments in Blood Pressure Regulation and Cardiac Baroreceptor Sensitivity Among Patients With Heart Failure Supported With Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2021; 14:e007448. [PMID: 33464953 DOI: 10.1161/circheartfailure.120.007448] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous-flow (CF) left ventricular assist devices (LVADs) improve outcomes for patients with advanced heart failure (HF). However, the lack of a physiological pulse predisposes to side-effects including uncontrolled blood pressure (BP), and there are little data regarding the impact of CF-LVADs on BP regulation. METHODS Twelve patients (10 males, 60±11 years) with advanced heart failure completed hemodynamic assessment 2.7±4.1 months before, and 4.3±1.3 months following CF-LVAD implantation. Heart rate and systolic BP via arterial catheterization were monitored during Valsalva maneuver, spontaneous breathing, and a 0.05 Hz repetitive squat-stand maneuver to characterize cardiac baroreceptor sensitivity. Plasma norepinephrine levels were assessed during head-up tilt at supine, 30o and 60o. Heart rate and BP were monitored during cardiopulmonary exercise testing. RESULTS Cardiac baroreceptor sensitivity, determined by Valsalva as well as Fourier transformation and transfer function gain of Heart rate and systolic BP during spontaneous breathing and squat-stand maneuver, was impaired before and following LVAD implantation. Norepinephrine levels were markedly elevated pre-LVAD and improved-but remained elevated post-LVAD (supine norepinephrine pre-LVAD versus post-LVAD: 654±437 versus 323±164 pg/mL). BP increased during cardiopulmonary exercise testing post-LVAD, but the magnitude of change was modest and comparable to the changes observed during the pre-LVAD cardiopulmonary exercise testing. CONCLUSIONS Among patients with advanced heart failure with reduced ejection fraction, CF-LVAD implantation is associated with modest improvements in autonomic tone, but persistent reductions in cardiac baroreceptor sensitivity. Exercise-induced increases in BP are blunted. These findings shed new light on mechanisms for adverse events such as stroke, and persistent reductions in functional capacity, among patients supported by CF-LVADs. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078972.
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Affiliation(s)
- Christine Sailer
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | | | - Cullen Buchanan
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Pedro Giro
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Matthew Babcock
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora
| | - Christine Swanson
- Department of Medicine-Endocrinology, Metabolism and Diabetes (C.S.), University of Colorado Anschutz Medical Campus, Aurora
| | - Melanie Spotts
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret Schulte
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Ashley Pratt-Cordova
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Greg Coe
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Mark Beindorff
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Services, Aurora (R.L.P.)
| | - Amrut V Ambardekar
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jay D Pal
- Department of Cardiothoracic Surgery (J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| | - Wendy Kohrt
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Eugene Wolfel
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Justin S Lawley
- Department of Sport Science, University of Innsbruck, Austria (J.S.L.)
| | - Takashi Tarumi
- Human Informatics Interaction Research Institute, National Institute of Advanced Industrial Science and Technology, Ibaraki prefecture, Japan (T.T.)
| | - William K Cornwell
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
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21
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Longitudinal Effects of Left Ventricular Assist Device Implantation on Global and Domain-Specific Cognitive Function. J Cardiovasc Nurs 2020; 37:31-40. [PMID: 33755380 DOI: 10.1097/jcn.0000000000000709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are a common treatment of advanced heart failure, but cognitive dysfunction, which is common in heart failure, could limit the ability to perform postimplantation LVAD care. Implantation of an LVAD has been associated with improved cerebral perfusion and may improve cognitive function post implantation. OBJECTIVE The aim of this study was to quantify longitudinal change in cognitive function after LVAD implantation. METHODS A secondary analysis of data on 101 adults was completed to evaluate cognitive function before implantation and again at 1, 3, and 6 months post implantation of an LVAD. Latent growth curve modeling was conducted to characterize change over time. Serial versions of the Montreal Cognitive Assessment were used to measure overall (total) cognitive function and function in 6 cognitive domains. RESULT There was moderate, nonlinear improvement from preimplantation to 6 months post implantation in Montreal Cognitive Assessment total score (Hedges' g = 0.50) and in short-term memory (Hedges' g = 0.64). There also were small, nonlinear improvements in visuospatial ability, executive function, and attention from preimplantation to 6 months post implantation (Hedges' g = 0.20-0.28). The greatest improvements were observed in the first 3 months after implantation and were followed by smaller, sustained improvements or no additional significant change. CONCLUSIONS Implantation of an LVAD is associated with significant, nonlinear improvement in short-term memory and global cognitive function, with the most significant improvements occurring in the first 3 months after implantation. Clinicians should anticipate improvements in cognitive function after LVAD implantation and modify postimplantation education to maximize effectiveness of LVAD self-care.
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22
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Pal JD, Cleveland J, Reece BT, Byrd J, Pierce CN, Brieke A, Cornwell WK. Cardiac Emergencies in Patients with Left Ventricular Assist Devices. Heart Fail Clin 2020; 16:295-303. [PMID: 32503753 DOI: 10.1016/j.hfc.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Continuous-flow left ventricular assist devices are frequently used for management of patients with advanced heart failure with reduced ejection fraction. Although technologic advancements have contributed to improved outcomes, several complications arise over time. These complications result from several factors, including medication effects, physiologic responses to chronic exposure to circulatory support that is minimally/entirely nonpulsatile, and dysfunction of the device itself. Clinical presentation can range from chronic and indolent to acute, life-threatening emergencies. Several areas of uncertainty exist regarding best practices for managing complications; however, growing awareness has led to development of new guidelines to reduce risk and improve outcomes.
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Affiliation(s)
- Jay D Pal
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - Joseph Cleveland
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - Brett T Reece
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - Jessica Byrd
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - Christopher N Pierce
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - Andreas Brieke
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA
| | - William K Cornwell
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B130, Office 7107, Aurora, CO 80045, USA.
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23
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Lescroart M, Hébert JL, Vincent F, Nguyen LS. Pulsatility in ventricular assistance devices: A translational review focused on applied haemodynamics. Arch Cardiovasc Dis 2020; 113:461-472. [DOI: 10.1016/j.acvd.2020.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 11/17/2022]
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24
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Buchanan C, Kanwar M, Cockcroft JR, McDonnell B, Stöhr EJ, Cornwell WK. Bionic women and men - Part 4: Cardiovascular, cerebrovascular and exercise responses among patients supported with left ventricular assist devices. Exp Physiol 2020; 105:763-766. [PMID: 32105385 DOI: 10.1113/ep088325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/26/2020] [Indexed: 01/08/2023]
Abstract
NEW FINDINGS LVAD patients are predisposed to hypertension which may increase the risk of stroke. Hypertension may result from markedly elevated levels of sympathetic nerve activity, which occurs through a baroreceptor-mediated pathway in response to chronic exposure to a non-physiologic (and reduced) pulse. Cerebral autoregulatory processes appear to be preserved in the absence of a physiologic pulse. Nevertheless, the rate of ischemic/embolic and hemorrhagic stroke is unacceptably high and is a major cause of morbidity and mortality in these patients. Despite normalization of a resting cardiac output, LVAD patients suffer from persistent, severe reductions in functional capacity. ABSTRACT Current generation left ventricular assist devices (LVADs) have led to significant improvements in survival compared to medical therapy alone, when used for management of patients with advanced heart failure. However, there are a number of side-effects associated with LVAD use, including hypertension, gastrointestinal bleeding, stroke, as well as persistent and severe limitations in functional capacity despite normalization of a resting cardiac output. These issues are, in large part, related to chronic exposure to a non-physiologic pulse, which contributes to a hyperadrenergic environment characterized by markedly elevated levels of sympathetic nerve activity through a baroreceptor-mediated pathway. In addition, these machines are unable to participate in, or contribute to, normal cardiovascular/autonomic reflexes that attempt to modulate flow through the body. Efforts to advance device technology and develop biologically sensitive devices may resolve these issues, and lead to further improvements in quality-of-life, functional capacity, and ultimately, survival, for the patients they support.
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Affiliation(s)
- Cullen Buchanan
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
| | - John R Cockcroft
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Barry McDonnell
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Eric J Stöhr
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK.,Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - William K Cornwell
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Cho SM, Kilic A, Dodd-O JM. Incomplete Cushing's reflex in extracorporeal membrane oxygenation. Int J Artif Organs 2019; 43:401-404. [PMID: 31856638 DOI: 10.1177/0391398819893701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a case of intracranial hypertension presenting with bradycardia as the only component of Cushing's triad in a patient on extracorporeal membrane oxygenation. A 41-year-old woman with recurrent driveline infections of HeartMate-II had sternotomy and debridement that was complicated by right ventricular failure requiring veno-arterial extracorporeal membrane oxygenation. Patient was comatose and acute onset of bradycardia occurred without any change in blood pressure or respiration. Computed tomography of brain demonstrated an uncal herniation from diffuse cerebral edema. Acute onset of bradycardia in comatose patients may be the sole component of Cushing's triad in laminar flow circulatory support.
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Affiliation(s)
- Sung-Min Cho
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey M Dodd-O
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Smith KJ, Moreno-Suarez I, Scheer A, Dembo L, Naylor LH, Maiorana AJ, Green DJ. Cerebral blood flow responses to exercise are enhanced in left ventricular assist device patients after an exercise rehabilitation program. J Appl Physiol (1985) 2019; 128:108-116. [PMID: 31774355 DOI: 10.1152/japplphysiol.00604.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cerebral blood flow during exercise is impaired in patients with heart failure implanted with left ventricular assist devices (LVADs). Our aim was to determine whether a 3-mo exercise training program could mitigate cerebrovascular dysfunction. Internal carotid artery (ICA) blood flow and intracranial middle (MCAv) and posterior cerebral (PCAv) artery velocities were measured continuously using Doppler ultrasound, alongside cardiorespiratory measures at rest and in response to an incremental cycle ergometer exercise protocol in 12 LVAD participants (5 female, 53.6 ± 11.8 yr; 84.2 ± 15.7 kg; 1.73 ± 0.08) pre- (PreTR) and post- (PostTR) completion of a 3-mo supervised exercise rehabilitation program. At rest, only PCAv was different PostTR (38.1 ± 10.4 cm/s) compared with PreTR (43.0 ± 10.8 cm/s; P < 0.05). PreTR, the reduction in PCAv observed from rest to exercise (5.2 ± 1.8%) was mitigated PostTR (P < 0.001). Similarly, exercise training enhanced ICA flow during submaximal exercise (~8.6 ± 13.7%), resulting in increased ICA flow PostTR compared with a reduced flow PreTR (P < 0.001). Although both end-tidal partial pressure of carbon dioxide and mean arterial pressure responses during incremental exercise were greater PostTR than PreTR, only the improved PETCO2 was related to the improved ICA flow (R2 = 0.14; P < 0.05). Our findings suggest that short-term exercise training improves cerebrovascular function during exercise in patients with LVADs. This finding should encourage future studies investigating long-term exercise training and cerebral and peripheral vascular adaptation.NEW & NOTEWORTHY Left ventricular assist devices, now used as destination therapy in end-stage heart failure, enable patients to undertake rehabilitative exercise training. We show, for the first time in humans, that training improves cerebrovascular function during exercise in patients with left ventricular assist devices. This finding may have implications for cerebrovascular health in patients with heart failure.
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Affiliation(s)
- Kurt J Smith
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia.,School of Kinesiology, Lakehead University, Thunder Bay, Canada
| | | | - Anna Scheer
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - Lawrence Dembo
- Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Australia
| | - Louise H Naylor
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia.,Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Australia
| | - Andrew J Maiorana
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia.,Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Australia
| | - Daniel J Green
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
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27
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Cornwell WK, Ambardekar AV, Tran T, Pal JD, Cava L, Lawley J, Tarumi T, Cornwell CL, Aaronson K. Stroke Incidence and Impact of Continuous-Flow Left Ventricular Assist Devices on Cerebrovascular Physiology. Stroke 2019; 50:542-548. [PMID: 30602359 DOI: 10.1161/strokeaha.118.022967] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- William K Cornwell
- From the Division of Cardiology, Department of Internal Medicine (W.K.C., A.V.A.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Amrut V Ambardekar
- From the Division of Cardiology, Department of Internal Medicine (W.K.C., A.V.A.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Tomio Tran
- Department of Internal Medicine (T. Tran), University of Colorado, Anschutz Medical Campus, Aurora
| | - Jay D Pal
- Division of Cardiothoracic Surgery, Department of Surgery (J.D.P.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Luis Cava
- Department of Neurosurgery (L.C.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Justin Lawley
- Division of Physiology, Department of Sports Science, University of Innsbruck, Austria (J.L.)
| | - Takashi Tarumi
- Human Informatics Research Institute, National Institute of Advanced Industrial Science and Technology, Tsukuba, Ibaraki, Japan (T. Tarumi)
| | | | - Keith Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (K.A.)
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28
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Cross TJ, Sajgalik P, Fabian V, Matera L, Kushwaha SS, Maltais S, Stulak JM, Schirger JA, Johnson BD. Non-invasive assessment of arterial pulsatility in patients with continuous-flow left ventricular assist devices. Int J Artif Organs 2019; 43:99-108. [PMID: 31411101 DOI: 10.1177/0391398819868236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Long-term use of continuous-flow left ventricular assist devices may have negative consequences for autonomic, cardiovascular and gastrointestinal function. It has thus been suggested that non-invasive monitoring of arterial pulsatility in patients with a left ventricular assist device is highly important for ensuring patient safety and longevity. We have developed a novel, semi-automated frequency-domain-based index of arterial pulsatility that is obtained during suprasystolic occlusions of the upper arm: the 'cuff pulsatility index'. PURPOSE The purpose of this study was to evaluate the relationship between the cuff pulsatility index and invasively determined arterial pulsatility in patients with a left ventricular assist device. METHODS Twenty-three patients with a left ventricular assist device with end-stage heart failure (six females: age = 65 ± 9 years; body mass index = 30.5 ± 3.7 kg m-2) were recruited for this study. Suprasystolic occlusions were performed on the upper arm of the patient's dominant side, from which the cuff pressure waveform was obtained. Arterial blood pressure was obtained from the radial artery on the contralateral arm. Measurements were obtained in triplicate. The relationship between the cuff pressure and arterial blood pressure waveforms was assessed in the frequency-domain using coherence analysis. A mixed-effects approach was used to assess the relationship between cuff pulsatility index and invasively determined arterial pulsatility (i.e. pulse pressure). RESULTS The cuff pressure and arterial blood pressure waveforms demonstrated a high coherence up to the fifth harmonic of the cardiac frequency (heart rate). The cuff pulsatility index accurately tracked changes in arterial pulse pressure within a given patient across repeated measurements. CONCLUSIONS The cuff pulsatility index shows promise as a non-invasive index for monitoring residual arterial pulsatility in patients with a left ventricular assist device across time.
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Affiliation(s)
- Troy J Cross
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Pavol Sajgalik
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Vratislav Fabian
- Department of Physics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Lukas Matera
- Department of Physics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Simon Maltais
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - John A Schirger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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29
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Symons JD, Deeter L, Deeter N, Bonn T, Cho JM, Ferrin P, McCreath L, Diakos NA, Taleb I, Alharethi R, McKellar S, Wever-Pinzon O, Navankasattusas S, Selzman CH, Fang JC, Drakos SG. Effect of Continuous-Flow Left Ventricular Assist Device Support on Coronary Artery Endothelial Function in Ischemic and Nonischemic Cardiomyopathy. Circ Heart Fail 2019; 12:e006085. [DOI: 10.1161/circheartfailure.119.006085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The coronary vasculature encounters a reduction in pulsatility after implementing durable continuous-flow left ventricular assist device (CF-LVAD) circulatory support. Evidence exists that appropriate pulsatility is required to maintain endothelial cell homeostasis. We hypothesized that coronary artery endothelial function would be impaired after CF-LVAD intervention.
Methods and Results:
Coronary arteries from patients with end-stage heart failure caused by ischemic cardiomyopathy (ICM; n=16) or non-ICM (n=22) cardiomyopathy were isolated from the left ventricular apical core, which was removed for the CF-LVAD implantation. In 11 of these patients, paired coronary arteries were obtained from an adjacent region of myocardium after the CF-LVAD intervention (n=6 ICM, 5 non-ICM). Vascular function was assessed ex vivo using isometric tension procedures in these patients and in 7 nonfailing donor controls. Maximal endothelium-dependent vasorelaxation to BK (bradykinin; 10
−
6
–10
−
10
M) was blunted (
P
<0.05) in arteries from patients with ICM compared with non-ICM and donor controls, whereas responses to sodium nitroprusside (10
−4
–10
−9
M) were similar among the groups. Contrary to our hypothesis, vasorelaxation responses to BK and sodium nitroprusside were similar before and 219±37 days after CF-LVAD support. Of these patients, an exploratory subgroup analysis revealed that BK-induced coronary artery vasorelaxation was greater (
P
<0.05) after (87±6%) versus before (54±14%) CF-LVAD intervention in ICM patients, whereas sodium nitroprusside–evoked responses were similar.
Conclusions:
Coronary artery endothelial function is not impaired by durable CF-LVAD support and in ICM patients appears to be improved. Investigating coronary endothelial function using in vivo approaches in a larger patient population is warranted.
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Affiliation(s)
- J. David Symons
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes (J.D.S.), University of Utah, Salt Lake City
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
| | - Lance Deeter
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
| | - Nicholas Deeter
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
| | - Trevor Bonn
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
| | - Jae Min Cho
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
| | - Peter Ferrin
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
| | - Lauren McCreath
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
| | - Nikolaos A. Diakos
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
| | - Iosif Taleb
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - Rami Alharethi
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - Stephen McKellar
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - Omar Wever-Pinzon
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - Sutip Navankasattusas
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
| | - Craig H. Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - James C. Fang
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
| | - Stavros G. Drakos
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City (J.D.S., L.D., N.D., T.B., J.M.C., S.G.D.)
- Molecular Medicine Program (J.D.S., P.F., L.M., N.A.D., I.T., S.N., S.G.D.), University of Utah, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute (P.F., L.M., N.A.D., I.T., S.N., C.H.S., S.G.D.), University of Utah, Salt Lake City
- UTAH Cardiac Transplant Program, Intermountain Medical Center, Salt Lake VA Medical Center (I.T., R.A., S.M., O.W.-P., C.H.S., J.C.F., S.G.D.), University of Utah, Salt Lake City
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30
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Stöhr EJ, McDonnell BJ, Colombo PC, Willey JZ. Rebuttal from Eric J. Stöhr, Barry J. McDonnell, Paolo C. Colombo and Joshua Z. Willey. J Physiol 2019; 597:361-362. [PMID: 30560580 PMCID: PMC6332811 DOI: 10.1113/jp277243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Eric J. Stöhr
- Department of MedicineDivision of CardiologyColumbia University Irving Medical CenterNew YorkNY10032USA
- School of Sport & Health SciencesCardiff Metropolitan UniversityCardiffCF5 2YBUK
| | - Barry J. McDonnell
- School of Sport & Health SciencesCardiff Metropolitan UniversityCardiffCF5 2YBUK
| | - Paolo C. Colombo
- Department of MedicineDivision of CardiologyColumbia University Irving Medical CenterNew YorkNY10032USA
| | - Joshua Z. Willey
- Department of NeurologyNeurological Institute of New YorkColumbia University Irving Medical CenterNew YorkNY10032USA
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31
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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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Cornwell WK, Tarumi T, Lawley J, Ambardekar AV. CrossTalk opposing view: Blood flow pulsatility in left ventricular assist device patients is not essential to maintain normal brain physiology. J Physiol 2018; 597:357-359. [PMID: 30560586 DOI: 10.1113/jp276730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] 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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Stöhr EJ, McDonnell BJ, Colombo PC, Willey JZ. CrossTalk proposal: Blood flow pulsatility in left ventricular assist device patients is essential to maintain normal brain physiology. J Physiol 2018; 597:353-356. [PMID: 30560570 DOI: 10.1113/jp276729] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Eric J Stöhr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, 10032, USA.,School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Joshua Z Willey
- Department of Neurology, Neurological Institute of New York, Columbia University Irving Medical Center, New York, NY, 10032, USA
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Goodwin K, Kluis A, Alexy T, John R, Voeller R. Neurological complications associated with left ventricular assist device therapy. Expert Rev Cardiovasc Ther 2018; 16:909-917. [DOI: 10.1080/14779072.2018.1540300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Kevin Goodwin
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Austin Kluis
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Ranjit John
- Division of Cardiovascular Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Rochus Voeller
- Division of Cardiovascular Surgery, University of Minnesota, Minneapolis, MN, USA
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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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Does cognition improve following LVAD implantation? Gen Thorac Cardiovasc Surg 2018; 66:456-463. [PMID: 29796750 DOI: 10.1007/s11748-018-0947-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/18/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Studies of cognition after LVAD surgery have produced mixed results. To explore whether cognition would improve, decline, or remain stable after LVAD surgery, we examined cognition before and 1- and 3-months after LVAD surgery. Patients with post-surgical stroke were excluded. METHODS 28 subjects (mean age = 54.31 ± 12 years) comprised an observational case series from the DuraHeart LVAS device® trial. Cognitive testing was performed at baseline, 1-month, and 3-month post-surgery, and included tests of attention, memory, language, visualmotor speed (TMT) and visualconstruction. RESULTS No difference in cognition was found between baseline and 1-month exams (means z score improvement = 0.06, p = 0.43) but cognition improved significantly between baseline and 3-month exams (mean z score improvement = 0.34, p < 0.00001). Examination of individual test scores found, after correction for multiple comparisons, only the TMT variable was significantly different at the 3-month exam. CONCLUSIONS We found significantly improved cognition 3 months after LVAD surgery in a subset of patients without post-surgical stroke. The reasons for the lack of cognitive improvement at the 1-month post-surgical assessment may include ongoing medical and physiological disruptions in the immediate post-operative period. Further research into the sources of delayed improvement is warranted. Cognitive assessments performed immediately after surgery should be interpreted with caution because the results may not reflect longer term cognitive outcomes. LVAD patients may require additional support to successfully manage their health in the weeks immediately following surgery but assistance needs may decrease over time.
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Hetzer R, Delmo Walter EM. Existing issues and valid concerns in continuous-flow ventricular assist devices. Expert Rev Med Devices 2017; 14:949-959. [DOI: 10.1080/17434440.2017.1409112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiac, Transplantation, Thoracic and Vascular Surgery, Hannover Medical School, Hannover, Germany
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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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Risk factors, mortality, and timing of ischemic and hemorrhagic stroke with left ventricular assist devices. J Heart Lung Transplant 2017; 36:673-683. [DOI: 10.1016/j.healun.2016.12.010] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/11/2016] [Accepted: 12/14/2016] [Indexed: 11/21/2022] Open
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Abstract
PURPOSE OF REVIEW The majority of patients currently implanted with left ventricular assist devices have the expectation of support for more than 2 years. As a result, survival alone is no longer a sufficient distinctive for this technology, and there have been many studies within the last few years examining functional capacity and exercise outcomes. RECENT FINDINGS Despite strong evidence for functional class improvements and increases in simple measures of walking distance, there remains incomplete normalization of exercise capacity, even in the presence of markedly improved resting hemodynamics. Reasons for this remain unclear. Despite current pumps being run at a fixed speed, it is widely recognized that pump outputs significantly increase with exercise. The mechanism of this increase involves the interaction between preload, afterload, and the intrinsic pump function curves. The role of the residual heart function is also important in determining total cardiac output, as well as whether the aortic valve opens with exercise. Interactions with the vasculature, with skeletal muscle blood flow and the state of the autonomic nervous system are also likely to be important contributors to exercise performance. SUMMARY Further studies examining optimization of pump function with active pump speed modulation and options for optimization of the overall patient condition are likely to be needed to allow left ventricular assist devices to be used with the hope of full functional physiological recovery.
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Debate: creating adequate pulse with a continuous flow ventricular assist device: can it be done and should it be done? Probably not, it may cause more problems than benefits! Curr Opin Cardiol 2017; 31:337-42. [PMID: 26998788 DOI: 10.1097/hco.0000000000000289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW The feasibility and benefits of creating adequate pulsatility with continuous flow left ventricular assist devices (LVADs) have long been debated. This review discusses recent technical and clinical findings to answer whether such intervention should be implemented in the standard patient management. RECENT FINDINGS Only a limited amount of pulsatility can be generated by periodic speed steps, both considerably smaller in flow increase and in pace rate than the natural circulation. Organ systems are not impeded in their normal function and even not in recovery by a continuous flow. Known problems such as gastrointestinal bleeding are not necessarily due to pulsatility per se, or not important for therapeutic progress, such as minor modifications of the arterial walls. SUMMARY The speculative benefits of augmented pulsatility with continuous flow LVADs could be overrated and are still incompletely evaluated. Potential risks that might arise from this strategy should be carefully weighed before implementing extensive pulsatility as standard patient management.
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Willey JZ, Boehme AK, Castagna F, Yuzefpolskaya M, Garan AR, Topkara V, Colombo PC. Hypertension and Stroke in Patients with Left Ventricular Assist Devices (LVADs). Curr Hypertens Rep 2016; 18:12. [PMID: 26781252 DOI: 10.1007/s11906-015-0618-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Stroke is one of the most dreaded complications of left ventricular assist device therapy in patients with end-stage congestive heart failure. There is strong evidence linking anticoagulation and infection with ischemic and hemorrhagic strokes, though recent data has emerged regarding the importance of elevated blood pressure. In the recently completed Heartware Ventricular Assist Device studies, a mean arterial pressure greater than 90 mmHg was associated with greater stroke risk, particularly the hemorrhagic subtype. In this review, we discuss recent evidence regarding deleterious effects of uncontrolled hypertension in patients with left ventricular devices, and propose measurement and management strategies.
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Affiliation(s)
- Joshua Z Willey
- Department of Neurology, Division of Stroke and Cerebrovascular Diseases, Columbia University, New York, NY, USA.
| | - Amelia K Boehme
- Department of Neurology, Division of Neurology Clinical Outcomes Research and Population Science, Columbia University, New York, NY, USA
| | - Francesco Castagna
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA
| | - A Reshad Garan
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA
| | - Veli Topkara
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA
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Abstract
Despite >100 clinical trials, only 2 new drugs had been approved by the US Food and Drug Administration for the treatment of chronic heart failure in more than a decade: the aldosterone antagonist eplerenone in 2003 and a fixed dose combination of hydralazine-isosorbide dinitrate in 2005. In contrast, 2015 has witnessed the Food and Drug Administration approval of 2 new drugs, both for the treatment of chronic heart failure with reduced ejection fraction: ivabradine and another combination drug, sacubitril/valsartan or LCZ696. Seemingly overnight, a range of therapeutic possibilities, evoking new physiological mechanisms, promise great hope for a disease that often carries a prognosis worse than many forms of cancer. Importantly, the newly available therapies represent a culmination of basic and translational research that actually spans many decades. This review will summarize newer drugs currently being used in the treatment of heart failure, as well as newer strategies increasingly explored for their utility during the stages of the heart failure syndrome.
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Affiliation(s)
- Anjali Tiku Owens
- From the Cardiovascular Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Susan C Brozena
- From the Cardiovascular Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mariell Jessup
- From the Cardiovascular Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.
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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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Date K, Nishimura T, Takewa Y, Kishimoto S, Arakawa M, Umeki A, Ando M, Mizuno T, Tsukiya T, Ono M, Tatsumi E. Shifting the pulsatility by increasing the change in rotational speed for a rotary LVAD using a native heart load control system. J Artif Organs 2016; 19:315-321. [DOI: 10.1007/s10047-016-0906-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 05/08/2016] [Indexed: 10/21/2022]
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Breathett K, Allen LA, Ambardekar AV. Patient-centered care for left ventricular assist device therapy: current challenges and future directions. Curr Opin Cardiol 2016; 31:313-20. [PMID: 26890085 PMCID: PMC4964268 DOI: 10.1097/hco.0000000000000279] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Discuss the current status and obstacles that need to be overcome in the future to provide patient-centered care with left ventricular assist device (LVAD) therapy. RECENT FINDINGS LVADs offer both longer survival and improvements in quality of life for carefully selected patients with inotrope-dependent heart failure. Yet, this technology does not come without significant risk of adverse effects and burdens. Recent observational data comparing LVAD with medical therapy in ambulatory, noninotrope-dependent patients with advanced heart failure suggest that survival may be similar and changes in quality of life may depend on baseline status. As both LVAD technology and medical therapy continue to evolve, there are many unanswered questions regarding the benefits, risks, and burdens of LVAD therapies in less severe heart failure populations. SUMMARY Further research is needed to ensure the optimal delivery of LVAD therapy, including improved patient selection, implantation timing, device type, and decision support. VIDEO ABSTRACT.
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Exercise Intolerance in Heart Failure: Did We Forget the Brain? Can J Cardiol 2016; 32:475-84. [DOI: 10.1016/j.cjca.2015.12.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 01/15/2023] Open
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50
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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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