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Michelly Gonçalves Brandão S, Belletti Mutt Urasaki M, Machado Pires Lemos D, Neres Matos L, Takahashi M, Cristina Nogueira P, Lucia Conceição de Gouveia Santos V. Risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation: A scoping review. Intensive Crit Care Nurs 2024; 84:103726. [PMID: 38852239 DOI: 10.1016/j.iccn.2024.103726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Evidence on infection risk factors is scarce, and precise localization of the site of infection and its treatment remain clinically challenging. OBJECTIVES This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation. DESIGN This is a scoping review, registered in the Open Science Framework under DOI10.17605/OSF.IO/Q76B3(https://osf.io/q76b3/). METHOD This is a scoping review limited to the period between 2015 and 2022.The results of this scoping review are discussed and presented separately in 3 articles. This second paper synthesizes research evidence on the risk factors, diagnostic methods and treatment of infection in adult patients undergoing left ventricular assist device implantation. RESULTS The initial searches identified 771 studies. Sixty-nine patients met the eligibility criteria and were included in the scoping review. Forty-three articles addressing the risk factors, diagnosis and treatment of infection were included to answer the questions of this review. CONCLUSION Obesity has been shown to be the most common risk factor for the described process of infection by left ventricular assist devices.18F-fluorodeoxyglucose positron emission tomography showed high sensitivity in detecting cardiac device infection, and labeled leukocyte or gallium citrate-67 scintigraphy showed high specificity for left ventricular assist device infections; therefore, it can help differentiate infection from inflammation, particularly in patients with equivocal fluorodeoxyglucose positron emission tomography. Also, this review brings and discusses the limitations and strengths of diagnostic tests, the knowledge regarding the risk factors for left ventricular assist device infection, the therapeutic heterogeneity, the methodological issues of the studies, and the vast opportunity for future research on left ventricular assist device. IMPLICATIONS FOR CLINICAL PRACTICE Ventricular assist device professionals should evaluate risk factors prior to device implantation and periodically.18F-fluorodeoxyglucose positron emission tomography should be considered as diagnostic tool in detecting superficial and deep driveline infections. Early treatment, including chronic suppressive therapy and serial surgical debridement, combined with driveline exteriorization and delayed driveline relocation may constitute a potential therapeutic strategy for deep driveline infections.
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Affiliation(s)
- Sara Michelly Gonçalves Brandão
- Instituto do Coracao (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | | | | | | | | | - Paula Cristina Nogueira
- Medical-Surgical Department of the School of Nursing, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Maeda S, Toda K, Shimamura K, Nakamoto K, Igeta M, Sakata Y, Sawa Y, Miyagawa S. Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation. J Artif Organs 2024; 27:222-229. [PMID: 37468735 PMCID: PMC11345319 DOI: 10.1007/s10047-023-01411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16 months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2 years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00-1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00-1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.
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Affiliation(s)
- Shusaku Maeda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:2080-2088. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [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: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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4
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Tsuji M, Kurihara T, Isotani Y, Bujo C, Ishida J, Amiya E, Hatano M, Shimada A, Imai H, Kimura M, Shimada S, Ando M, Ono M, Komuro I. Right Heart Reserve Function Assessed With Fluid Loading Predicts Late Right Heart Failure After Left Ventricular Assist Device Implantation. Can J Cardiol 2024; 40:1745-1754. [PMID: 38402951 DOI: 10.1016/j.cjca.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND A left ventricular assist device (LVAD) is an effective therapeutic option for advanced heart failure. Late right heart failure (LRHF) is a complication after LVAD implantation that is associated with increasing morbidity and mortality; however, the assessment of right heart function, including right heart reserve function after LVAD implantation, has not been established. We focused on a fluid-loading test with right heart catheterization to evaluate right heart preload reserve function and investigate its impact on LRHF. METHODS Patients aged > 18 years who received a continuous-flow LVAD between November 2007 and December 2022 at our institution, and underwent right heart catheterization with saline loading (10 mL/kg for 15 minutes) 1 month after LVAD implantation, were included. RESULTS Overall, 31 cases of LRHF or death (right heart failure [RHF] group) occurred in 149 patients. In the RHF vs the non-RHF groups, the pulmonary artery pulsatility index (PAPi) at rest (1.8 ± 0.89 vs 2.5 ± 1.4, P = 0.02) and the right ventricular stroke work index (RVSWi) change ratio with saline loading (0.96 ± 0.32 vs 1.1 ± 0.20, P = 0.03) were significantly different. The PAPi at rest and the RVSWi change ratio with saline loading were identified as postoperative risks for LRHF and death. The cohort was divided into 3 groups based on whether the PAPi at rest and the RVSWi change ratio were low. The event-free curve differed significantly among the 3 groups (P < 0.001). CONCLUSIONS Hemodynamic assessment with saline loading can evaluate the right ventricular preload reserve function of patients with an LVAD. A low RVSWi change with saline loading was a risk factor for LRHF following LVAD implantation.
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Affiliation(s)
- Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
| | - Takahiro Kurihara
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Advanced Medical Center for Heart Failure, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Asako Shimada
- Department of Organ Transplantation, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroko Imai
- Department of Organ Transplantation, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Frontier Cardiovascular Science, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; International University of Health and Welfare, Tokyo, Japan
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5
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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024:S1053-2498(24)01679-6. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Matsushita H, Saku K, Nishikawa T, Unoki T, Yokota S, Sato K, Morita H, Yoshida Y, Fukumitsu M, Uemura K, Kawada T, Kikuchi A, Yamaura K. Impact of right ventricular and pulmonary vascular characteristics on Impella hemodynamic support in biventricular heart failure: A simulation study. J Cardiol 2024:S0914-5087(24)00145-X. [PMID: 39097144 DOI: 10.1016/j.jjcc.2024.07.008] [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] [Received: 04/12/2024] [Revised: 07/23/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Impella (Abiomed, Danvers, MA, USA) is a percutaneous ventricular assist device commonly used in cardiogenic shock, providing robust hemodynamic support, improving the systemic circulation, and relieving pulmonary congestion. Maintaining adequate left ventricular (LV) filling is essential for optimal hemodynamic support by Impella. This study aimed to investigate the impact of pulmonary vascular resistance (PVR) and right ventricular (RV) function on Impella-supported hemodynamics in severe biventricular failure using cardiovascular simulation. METHODS We used Simulink® (Mathworks, Inc., Natick, MA, USA) for the simulation, incorporating pump performance of Impella CP determined using a mock circulatory loop. Both systemic and pulmonary circulation were modeled using a 5-element resistance-capacitance network. The four cardiac chambers were represented by time-varying elastance with unidirectional valves. In the scenario of severe LV dysfunction (LV end-systolic elastance set at a low level of 0.4 mmHg/mL), we compared the changes in right (RAP) and left atrial pressures (LAP), total systemic flow, and pressure-volume loop relationship at varying degrees of RV function, PVR, and Impella flow rate. RESULTS The simulation results showed that under low PVR conditions, an increase in Impella flow rate slightly reduced RAP and LAP and increased total systemic flow, regardless of RV function. Under moderate RV dysfunction and high PVR conditions, an increase in Impella flow rate elevated RAP and excessively reduced LAP to induce LV suction, which limited the increase in total systemic flow. CONCLUSIONS PVR is the primary determinant of stable and effective Impella hemodynamic support in patients with severe biventricular failure.
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Affiliation(s)
- Hiroki Matsushita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan.
| | - Takuya Nishikawa
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Shohei Yokota
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Kei Sato
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Hidetaka Morita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Yuki Yoshida
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Masafumi Fukumitsu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan; NTTR-NCVC Bio Digital Twin Center, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Atsushi Kikuchi
- Department of Cardiology, Osaka General Medical Center, Suita, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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7
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Akamkam A, Galand V, Jungling M, Delmas C, Dambrin C, Pernot M, Kindo M, Gaudard P, Rouviere P, Senage T, Chavanon O, Para M, Gariboldi V, Pozzi M, Litzler P, Babatasi G, Bouchot O, Radu C, Bourguignon T, D'Ostrevy N, Abi Akar R, Vanhuyse F, Gaillard M, Chatelier G, Fels A, Flecher E, Guihaire J. Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device. ESC Heart Fail 2024; 11:2100-2112. [PMID: 38581135 PMCID: PMC11287349 DOI: 10.1002/ehf2.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024] Open
Abstract
AIMS Right ventricular failure after left ventricular assist device (LVAD) implantation is a major concern that remains challenging to predict. We sought to investigate the relationship between preoperative pulmonary artery pulsatility index (PAPi) and mortality after LVAD implantation. METHODS AND RESULTS A retrospective analysis of the ASSIST-ICD multicentre registry allowed the assessment of PAPi before LVAD according to the formula [(systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure]. The primary endpoint was survival at 3 months, according to the threshold value of PAPi determined by the receiver operating characteristic (ROC) curve. A multivariate analysis including demographic, echographic, haemodynamic, and biological variables was performed to identify predictive factors for 2 year mortality. One hundred seventeen patients were included from 2007 to 2021. The mean age was 58.45 years (±13.16), with 15.4% of women (sex ratio 5.5). A total of 53.4% were implanted as bridge to transplant and 43.1% as destination therapy. Post-operative right ventricular failure was observed in 57 patients (48.7%), with no significant difference between survivors and non-survivors at 1 month (odds ratio 1.59, P = 0.30). The median PAPi for the whole study population was 2.83 [interquartile range 1.63-4.69]. The threshold value of PAPi determined by the ROC curve was 2.84. Patients with PAPi ≥ 2.84 had a higher survival rate at 3 months [PAPi < 2.84: 58.1% [46.3-72.8%] vs. PAPi ≥ 2.84: 89.1% [81.1-97.7%], hazard ratio (HR) 0.08 [0.02-0.28], P < 0.01], with no significant difference after 3 months (HR 0.67 [0.17-2.67], P = 0.57). Other predictors of 2 year mortality were systemic hypertension (HR 4.22 [1.49-11.97], P < 0.01) and diabetes mellitus (HR 4.90 [1.83-13.14], P < 0.01). LVAD implantation as bridge to transplant (HR 0.18 [0.04-0.74], P = 0.02) and heart transplantation (HR 0.02 [0.00-0.18], P < 0.01) were associated with a higher survival rate at 2 years. CONCLUSIONS Preoperative PAPi < 2.84 was associated with a higher risk of early mortality after LVAD implantation without impacting 2 year outcomes among survivors.
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Affiliation(s)
- Ali Akamkam
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
| | - Vincent Galand
- Department of CardiologyUniversity of Rennes, CHU RennesRennesFrance
| | - Marie Jungling
- Department of Cardiac SurgeryLille University Hospital, Heart‐Lung InstituteLilleFrance
| | - Clément Delmas
- Department of CardiologyUniversity Hospital of ToulouseToulouseFrance
| | - Camille Dambrin
- Department of Cardiovascular SurgeryUniversity Hospital of ToulouseToulouseFrance
| | - Mathieu Pernot
- Haut‐Lévêque Cardiological HospitalBordeaux II UniversityBordeauxFrance
| | - Michel Kindo
- Department of Cardiovascular SurgeryUniversity Hospitals of StrasbourgStrasbourgFrance
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, PhyMedExpUniversity of Montpellier, INSERM, CNRS, CHU MontpellierMontpellierFrance
| | - Philippe Rouviere
- Department of Cardiac SurgeryUniversity of Montpellier, CHU MontpellierMontpellierFrance
| | - Thomas Senage
- Department of Cardiology and Heart Transplantation UnitCHU NantesNantesFrance
| | - Olivier Chavanon
- Department of Cardiology and Cardiovascular SurgeryCHU MichallonGrenobleFrance
| | - Marylou Para
- Department of Cardiology and Cardiac SurgeryBichat‐Claude Bernard HospitalParisFrance
| | - Vlad Gariboldi
- Department of Cardiac SurgeryLa Timone HospitalMarseilleFrance
| | - Matteo Pozzi
- Department of Cardiac Surgery‘Louis Pradel’ Cardiologic HospitalLyonFrance
| | - Pierre‐Yves Litzler
- Department of Cardiology and Cardiovascular SurgeryHospital Charles NicolleRouenFrance
| | - Gerard Babatasi
- Department of Cardiology and Cardiac SurgeryUniversity of Caen and University Hospital of CaenCaenFrance
| | - Olivier Bouchot
- Department of Cardiology and Cardiac SurgeryUniversity Hospital François MitterrandDijonFrance
| | - Costin Radu
- Department of Cardiology and Cardiac SurgeryAP‐HP CHU Henri MondorCréteilFrance
| | | | - Nicolas D'Ostrevy
- Department of Cardiac Surgery and CardiologyCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Ramzi Abi Akar
- Department of Cardiovascular SurgeryEuropean Georges Pompidou HospitalParisFrance
| | - Fabrice Vanhuyse
- Department of Cardiology and Cardiac SurgeryCHU de Nancy, Hôpitaux de BraboisNancyFrance
| | - Maïra Gaillard
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
| | - Gilles Chatelier
- Department of Clinical ResearchHôpital Paris Saint‐Joseph, Groupe Hospitalier Paris Saint JosephParisFrance
| | - Audrey Fels
- Department of Clinical ResearchHôpital Paris Saint‐Joseph, Groupe Hospitalier Paris Saint JosephParisFrance
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular SurgeryUniversity of Rennes, CHU RennesRennesFrance
| | - Julien Guihaire
- Department of Cardiovascular SurgeryMarie Lannelongue Hospital, Groupe Hospitalier Paris Saint JosephLe Plessis‐RobinsonFrance
- School of MedicineUniversity of Paris SaclayLe Kremlin‐BicêtreFrance
- Inserm U999, Marie Lannelongue HospitalLe Plessis‐RobinsonFrance
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8
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Oren D, Oh KT, Fried JA, Clerkin KJ, Raikhelkar JK, Topkara VK, Kaku Y, Takeda K, Naka Y, Burkhoff D, Latif F, Majure D, Colombo PC, Yuzefpolskaya M, Sayer GT, Uriel N. Hemodynamic Optimization by Invasive Ramp Test in Patients Supported With HeartMate 3 Left Ventricular Assist Device. ASAIO J 2024; 70:641-650. [PMID: 38373176 DOI: 10.1097/mat.0000000000002167] [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: 02/21/2024] Open
Abstract
In patients supported by the HeartMate 3 left ventricular assist device (HM3 LVAD), pump speed adjustments may improve hemodynamics. We investigated the hemodynamic implications of speed adjustments in HM3 recipients undergoing hemodynamic ramp tests. Clinically stable HM3 recipients who underwent routine invasive hemodynamic ramp tests between 2015 and 2022 at our center were included. Filling pressure optimization, defined as central venous pressure (CVP) <12 mm Hg and pulmonary capillary wedge pressure (PCWP) <18 mm Hg, was assessed at baseline and final pump speeds. Patients with optimized pressures were compared to nonoptimized patients. Overall 60 HM3 recipients with a median age of 62 years (56, 71) and time from LVAD implantation of 187 days (124, 476) were included. Optimized filling pressures were found in 35 patients (58%) at baseline speed. Speed was adjusted in 84% of the nonoptimized patients. Consequently, 39 patients (65%) had optimized pressures at final speed. There were no significant differences in hemodynamic findings between baseline and final speeds ( p > 0.05 for all). Six and 12 month readmission-free rates were higher in optimized compared with nonoptimized patients ( p = 0.03 for both), predominantly due to lower cardiac readmission-free rates ( p = 0.052). In stable outpatients supported with HM3 who underwent routine ramp tests, optimized hemodynamics were achieved in only 2 of 3 of the patients. Patients with optimized pressures had lower all-cause readmission rates, primarily driven by fewer cardiac-related hospitalizations.
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Affiliation(s)
- Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sharon Slomovich
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Andrea Fernandez-Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kyung T Oh
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - David Majure
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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9
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Meng F, Zhu Y, Yang M. Hemodynamic effects of pulsatile frequency of right ventricular assist device (RVAD) on pulmonary perfusion: a simulation study. Med Biol Eng Comput 2024:10.1007/s11517-024-03174-0. [PMID: 39048840 DOI: 10.1007/s11517-024-03174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
Right ventricular assist devices (RVADs) have been extensively used to provide hemodynamic support for patients with end-stage right heart (RV) failure. However, conventional in-parallel RVADs can lead to an elevation of pulmonary artery (PA) pressure, consequently increasing the right ventricular (RV) afterload, which is unfavorable for the relaxation of cardiac muscles and reduction of valve complications. The aim of this study is to investigate the hemodynamic effects of the pulsatile frequency of the RVAD on pulmonary artery. Firstly, a mathematical model incorporating heart, systemic circulation, pulmonary circulation, and RVAD is developed to simulate the cardiovascular system. Subsequently, the frequency characteristics of the pulmonary circulation system are analyzed, and the calculated results demonstrate that the pulsatile frequency of the RVAD has a substantive impact on the pulmonary artery pressure. Finally, to verify the analysis results, the hemodynamic effects of the pulsatile frequency of the RVAD on pulmonary artery are compared under diffident support modes. It is found that the pulmonary artery pressure decreases by approximately 6% when the pulsatile frequency changes from 1 to 3 Hz. The increased pulsatile frequency of RA-PA support mode may facilitate the opening of the pulmonary valve, while the RV-PA support mode can more effectively reduce the load of RV. This work provides a useful method to decrease the pulmonary artery pressure during the RVAD supports and may be beneficial for improving myocardial function in patients with end-stage right heart failure, especially those with pulmonary hypertension.
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Affiliation(s)
- Fan Meng
- Department of Instrument Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanfei Zhu
- Department of Instrument Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.
| | - Ming Yang
- Department of Instrument Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.
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10
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Carnicelli AP, Diepen SV, Gage A, Berhnardt AM, Houston BA, Siuba MT, Kataria R, Beavers CJ, John KJ, Meyns B, Kapur N, Tedford RJ, Kanwar M. Pragmatic Approach to Temporary Mechanical Circulatory Support in Acute Right Ventricular Failure. J Heart Lung Transplant 2024:S1053-2498(24)01740-6. [PMID: 39059594 DOI: 10.1016/j.healun.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Acute right ventricular failure (RVF) is prevalent in multiple disease states and is associated with poor clinical outcomes. Right-sided temporary mechanical circulatory support (tMCS) devices are used to unload RV congestion and increase cardiac output in cardiogenic shock (CS) with hemodynamically significant RVF. Several RV-tMCS device platforms are available; however consensus is lacking on patient selection, timing of escalation to RV-tMCS, device management, and device weaning. The purposes of this review are to 1) describe the current state of tMCS device therapies for acute RVF with CS, 2) discuss principles of escalation to RV-tMCS device therapy, 3) examine important aspects of clinical management for patients supported by RV-tMCS devices including volume management, anticoagulation, and positive pressure ventilation, and 4) provide a framework for RV-tMCS weaning.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ann Gage
- Department of Cardiology, Centennial Medical Center, Nashville, TN, USA
| | - Alexander M Berhnardt
- Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Matt T Siuba
- Department of Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rachna Kataria
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, RI, USA
| | - Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kevin J John
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Bart Meyns
- Department of Cardiothoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Navin Kapur
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
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11
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Zhang H, Lian H, Zhang Q, Zhao H, Wang X. Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients? Ann Intensive Care 2024; 14:114. [PMID: 39031301 PMCID: PMC11264666 DOI: 10.1186/s13613-024-01352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 07/09/2024] [Indexed: 07/22/2024] Open
Abstract
OBJECTIVE To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation. METHODS This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D). RESULTS A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%). CONCLUSIONS CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.
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Affiliation(s)
- Hongmin Zhang
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
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12
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Das BB. Unlocking the Potential: Angiotensin Receptor Neprilysin and Sodium Glucose Co-Transporter 2 Inhibitors for Right Ventricle Dysfunction in Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1112. [PMID: 39064541 PMCID: PMC11279219 DOI: 10.3390/medicina60071112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
This review article examines the mechanism of action of Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) and Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2is) in managing chronic right ventricular (RV) dysfunction. Despite advancements in heart failure (HF) treatment, RV dysfunction remains a significant contributor to morbidity and mortality. This article explores the The article explores the impact of ARNIs and SGLT2is on RV function based on clinical and preclinical evidence, and the potential benefits of combined therapy. It highlights the need for further research to optimize patient outcomes and suggests that RV function should be considered in future clinical trials as part of risk stratification for HF therapies. This review underscores the importance of the early initiation of ARNIs and SGLT2is as per guideline-directed medical therapy for eligible HFrEF and HFpEF patients to improve co-existing RV dysfunction.
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Affiliation(s)
- Bibhuti B Das
- Heart Failure and Transplant Program, Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
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13
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Crespo-Diaz R, Mudy K, Khan N, Samara M, Eckman PM, Sun B, Hryniewicz K. Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival. ASAIO J 2024; 70:570-577. [PMID: 38373178 DOI: 10.1097/mat.0000000000002160] [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: 02/21/2024] Open
Abstract
Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 ( p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.
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Affiliation(s)
- Ruben Crespo-Diaz
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Karol Mudy
- Department of Cardiothoracic Surgery, Baptist Health, Little Rock, Arkansas
| | - Nadeem Khan
- Department of Cardiovascular Diseases, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Michael Samara
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Peter M Eckman
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Benjamin Sun
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Katarzyna Hryniewicz
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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14
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Tang PC, Millar J, Noly PE, Sicim H, Likosky DS, Zhang M, Pagani FD. Preoperative passive venous pressure-driven cardiac function determines left ventricular assist device outcomes. J Thorac Cardiovasc Surg 2024; 168:133-144.e5. [PMID: 37495169 PMCID: PMC10805966 DOI: 10.1016/j.jtcvs.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/22/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Right heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether the magnitude of this "passive cardiac output" can predict LVAD outcomes. METHODS This was a retrospective review of 383 patients who received a continuous-flow LVAD at the University of Michigan between 2012 and 2021. Pre-LVAD cardiac output driven by venous pressure was determined by dividing right atrial pressure by mean pulmonary artery pressure, multiplied by total cardiac output. Normalization to body surface area led to the passive cardiac index (PasCI). The Youden J statistic was used to identify the PasCI threshold, which predicted LVAD death by 2 years. RESULTS Increased preoperative PasCI was associated with reduced survival (hazard ratio [HR], 2.27; P < .01), and increased risk of right ventricular failure (RVF) (HR, 3.46; P = .04). Youden analysis showed that a preoperative PasCI ≥0.5 (n = 226) predicted LVAD death (P = .10). Patients with PasCI ≥0.5 had poorer survival (P = .02), with a trend toward more heart failure readmission days (mean, 45.09 ± 67.64 vs 35.13 ± 45.02 days; P = .084) and increased gastrointestinal bleeding (29.2% vs 20.4%; P = .052). Additionally, of the 97 patients who experienced readmissions for heart failure, those with pre-LVAD implantation PasCI ≥0.5 were more likely to have more than 1 readmission (P = .05). CONCLUSIONS Although right heart output can be augmented by raising venous pressure, this negatively impacts end-organ function and increases heart failure readmission days. Patients with a pre-LVAD PasCI ≥0.5 have worse post-LVAD survival and increased RVF. Using the PasCI metric in isolation or incorporated into a predictive model may improve the management of LVAD candidates with RV dysfunction.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Jessica Millar
- Department of Surgery, University of Michigan Ann Arbor, Mich
| | | | - Hüseyin Sicim
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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15
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Heerdt PM, Kheyfets VO, Oakland HT, Joseph P, Singh I. Right Ventricular Pressure Waveform Analysis-Clinical Relevance and Future Directions. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00395-1. [PMID: 39025682 DOI: 10.1053/j.jvca.2024.06.022] [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] [Received: 05/11/2024] [Revised: 06/02/2024] [Accepted: 06/15/2024] [Indexed: 07/20/2024]
Abstract
Continuous measurement of pressure in the right atrium and pulmonary artery has commonly been used to monitor right ventricular function in critically ill and surgical patients. This approach is largely based upon the assumption that right atrial and pulmonary arterial pressures provide accurate surrogates for diastolic filling and peak right ventricular pressures, respectively. However, due to both technical and physiologic factors, this assumption is not always true. Accordingly, recent studies have begun to emphasize the potential clinical value of also measuring right ventricular pressure at the bedside. This has highlighted both past and emerging research demonstrating the utility of analyzing not only the amplitude of right ventricular pressure but also the shape of the pressure waveform. This brief review summarizes data demonstrating that combining conventional measurements of right ventricular pressure with variables derived from waveform shape allows for more comprehensive and ideally continuous bedside assessment of right ventricular function, particularly when combined with stroke volume measurement or 3D echocardiography, and discusses the potential use of right ventricular pressure analysis in computational models for evaluating cardiac function.
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Affiliation(s)
- Paul M Heerdt
- Department of Anesthesiology, Applied Hemodynamics, Yale School of Medicine, New Haven, CT.
| | - Vitaly O Kheyfets
- Department of Pediatrics-Critical Care Medicine, University of Colorado - Anschutz Medical Campus, Denver, CO
| | - Hannah T Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
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16
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Adamopoulos S, Bonios M, Ben Gal T, Gustafsson F, Abdelhamid M, Adamo M, Bayes-Genis A, Böhm M, Chioncel O, Cohen-Solal A, Damman K, Di Nora C, Hashmani S, Hill L, Jaarsma T, Jankowska E, Lopatin Y, Masetti M, Mehra MR, Milicic D, Moura B, Mullens W, Nalbantgil S, Panagiotou C, Piepoli M, Rakisheva A, Ristic A, Rivinius R, Savarese G, Thum T, Tocchetti CG, Tops LF, Van Laake LW, Volterrani M, Seferovic P, Coats A, Metra M, Rosano G. Right heart failure with left ventricular assist devices: Preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2024. [PMID: 38853659 DOI: 10.1002/ejhf.3323] [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] [Received: 12/21/2023] [Revised: 05/11/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024] Open
Abstract
Right heart failure (RHF) following implantation of a left ventricular assist device (LVAD) is a common and potentially serious condition with a wide spectrum of clinical presentations with an unfavourable effect on patient outcomes. Clinical scores that predict the occurrence of right ventricular (RV) failure have included multiple clinical, biochemical, imaging and haemodynamic parameters. However, unless the right ventricle is overtly dysfunctional with end-organ involvement, prediction of RHF post-LVAD implantation is, in most cases, difficult and inaccurate. For these reasons optimization of RV function in every patient is a reasonable practice aiming at preparing the right ventricle for a new and challenging haemodynamic environment after LVAD implantation. To this end, the institution of diuretics, inotropes and even temporary mechanical circulatory support may improve RV function, thereby preparing it for a better adaptation post-LVAD implantation. Furthermore, meticulous management of patients during the perioperative and immediate postoperative period should facilitate identification of RV failure refractory to medication. When RHF occurs late during chronic LVAD support, this is associated with worse long-term outcomes. Careful monitoring of RV function and characterization of the origination deficit should therefore continue throughout the patient's entire follow-up. Despite the useful information provided by the echocardiogram with respect to RV function, right heart catheterization frequently offers additional support for the assessment and optimization of RV function in LVAD-supported patients. In any patient candidate for LVAD therapy, evaluation and treatment of RV function and failure should be assessed in a multidimensional and multidisciplinary manner.
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Affiliation(s)
- Stamatis Adamopoulos
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Michael Bonios
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Magdy Abdelhamid
- Faculty of Medicine, Department of Cardiology, Cairo University, Giza, Egypt
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Bayes-Genis
- Heart Failure and Cardiac Regeneration Research Program, Health Sciences Research Institute Germans Trias i Pujol, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- Cardiology Service, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Michael Böhm
- Clinic for Internal Medicine III (Cardiology, Intensive Care Medicine and Angiology), Saarland University Medical Center, Homburg, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | | | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands
| | - Concetta Di Nora
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Shahrukh Hashmani
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden
| | - Ewa Jankowska
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russian Federation
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Sanem Nalbantgil
- Cardiology Department, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Chrysoula Panagiotou
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Massimo Piepoli
- IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Rasmus Rivinius
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Heidelberg, Germany
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) and Rebirth Center for Translational Regenerative Therapies, Hannover Medical School, Hannover, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Serbia Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- St. George's Hospitals NHS Trust University of London, London, UK
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17
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Chen X, Zhang P, Lou J, Zhao R, Zhang S, Xie M, Lv Q. Application of an echocardiographic index to characterize right ventricular-pulmonary arterial coupling in heart failure. ESC Heart Fail 2024; 11:1290-1304. [PMID: 38229524 PMCID: PMC11098638 DOI: 10.1002/ehf2.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
Heart failure (HF), with its high morbidity and mortality, remains a global public health issue. Right ventricular (RV) dysfunction is a sign of deterioration in the natural history of HF, and a thorough evaluation of the relationship between RV contractility and its afterload through RV-pulmonary arterial (RV-PA) coupling can aid in accurately assessing overall RV function. The ratio of RV end-systolic elastance (Ees) to pulmonary arterial elastance (Ea) invasively measured by right heart catheterization served as the gold standard for evaluating RV-PA coupling. An echocardiographic index termed tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) has been shown to correlate well with Ees/Ea. TAPSE/PASP is recognized as a non-invasive surrogate of RV-PA coupling and has been extensively studied in patients with HF. This review briefly describes the methods of assessing RV-PA coupling, mainly discussing echocardiography, summarizes the clinical utility of TAPSE/PASP in patients with different HF types, and provides an overview of the available literature.
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Affiliation(s)
- Xin Chen
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Peige Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Jie Lou
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Ruohan Zhao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Siyi Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
- Shenzhen Huazhong University of Science and Technology Research InstituteShenzhenChina
- Tongji Medical College and Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhanChina
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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18
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Akbar AF, Zhou AL, Wang A, Feng ASN, Rizaldi AA, Ruck JM, Kilic A. Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation. J Cardiovasc Dev Dis 2024; 11:119. [PMID: 38667737 PMCID: PMC11050210 DOI: 10.3390/jcdd11040119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7107, Baltimore, MD 21287, USA; (A.F.A.); (A.L.Z.); (A.W.); (A.S.N.F.); (A.A.R.); (J.M.R.)
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19
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Chamogeorgakis T, Toumpoulis I, Bonios MJ, Lanfear D, Williams C, Koliopoulou A, Cowger J. Treatment Strategies and Outcomes of Right Ventricular Failure Post Left Ventricular Assist Device Implantation: An INTERMACS Analysis. ASAIO J 2024; 70:264-271. [PMID: 38029763 DOI: 10.1097/mat.0000000000002105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Right heart failure (RHF) management after left ventricular assist device (LVAD) implantation includes inotropes, right ventricular mechanical support, and heart transplantation. The purpose of this study is to compare different RHF treatment strategies in patients with a magnetically levitated centrifugal LVAD. A total of 6,632 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) patients from 2013 to 2020 were included. Of which, 769 (69.6%) patients (group 1) were supported with inotropes (≥14 days post-LVAD implantation), 233 (21.1%) patients (group 2) were supported with temporary right ventricular assist device (RVAD) that was implanted during LVAD implant, 77 (7.0%) patients (group 3) with durable centrifugal RVAD implanted during the LVAD implant, and 26 (2.4%) patients (group 4) were supported with RVAD (temporary or permanent), which was implanted at a later stage. Groups 1 and 4 had higher survival rates in comparison with group 2 (hazard ratio [HR] = 0.513, 95% confidence intervals [CIs] = 0.402-0.655, p < 0.001, versus group 1) and group 3 (HR = 0.461, 95% CIs = 0.320-0.666, p < 0.001, versus group 1). Patients in group 3 showed higher heart transplantation rates at 12 and 36 months as compared with group 1 (40.4% and 46.6% vs. 21.9% and 37.4%, respectively), group 2 (40.4% and 46.6% vs. 25.8% and 39.3%, respectively), and group 4 (40.4% and 46.6% vs. 3.8% and 12.0%, respectively). Severe RHF post-LVAD is associated with poor survival. Patients with LVAD who during the perioperative period are in need of right ventricular temporary or durable mechanical circulatory support constitute a group at particular risk. Improvement of devices tailored for right ventricular support is mandatory for further evolution of the field.
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Affiliation(s)
- Themistokles Chamogeorgakis
- From the Henry Ford, Transplant Institute, Detroit, Michigan
- 2nd Cardiac Surgery Department, Onassis Cardiac Surgery Centre, Athens, Greece
| | | | - Michael J Bonios
- 2nd Cardiac Surgery Department, Onassis Cardiac Surgery Centre, Athens, Greece
| | - David Lanfear
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Celeste Williams
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | | | - Jennifer Cowger
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
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20
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Hayashi H, Kirschner M, Vinogradsky A, Ning Y, Kurlansky P, Yuzefpolskaya M, Colombo PC, Sayer GT, Uriel N, Naka Y, Takeda K. Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients. J Heart Lung Transplant 2024; 43:642-651. [PMID: 38070663 DOI: 10.1016/j.healun.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND The physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. METHODS We retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and RV end-diastolic area (RVEDA) were measured on preoperative and predischarge transthoracic echocardiography. The nonadapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. RESULTS There were 82 patients (44%) who had a nonadapted and 106 patients (56%) who had an adapted RV. Preoperatively, the nonadapted group had smaller RVEDD (46 vs 49 mm, p < 0.001) and RVEDA (27 vs 31 cm2, p < 0.001). At discharge, the nonadapted group had larger RVEDD (51 vs 43 mm, p < 0.001) and RVEDA (33 vs 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs 91%, p = 0.006) and freedom from composite outcome (58% vs 85%, p < 0.001) in the nonadapted group. A multivariable Cox proportional hazards model showed that nonadaption (hazard ratio [HR] 3.09, 95% confidence interval [CI] 1.29-7.40, p = 0.01) and age (HR 3.73, 95% CI 1.42-9.77, p = 0.007) were independent predictors of composite outcome. CONCLUSIONS Acute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.
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Affiliation(s)
- Hideyuki Hayashi
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York.
| | - Michael Kirschner
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Alice Vinogradsky
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Paul Kurlansky
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Gabriel T Sayer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York; Department of Surgery, Division of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
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21
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Min JJ, Cho YH, Lee SM, Lee JH. Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices. Korean J Anesthesiol 2024; 77:175-184. [PMID: 36912004 PMCID: PMC10982535 DOI: 10.4097/kja.23169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023] Open
Abstract
With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.
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Affiliation(s)
- Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic & Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangmin M. Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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22
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Antonopoulos M, Bonios MJ, Dimopoulos S, Leontiadis E, Gouziouta A, Kogerakis N, Koliopoulou A, Elaiopoulos D, Vlahodimitris I, Chronaki M, Chamogeorgakis T, Drakos SG, Adamopoulos S. Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices. J Cardiovasc Dev Dis 2024; 11:61. [PMID: 38392275 PMCID: PMC10888700 DOI: 10.3390/jcdd11020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
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Affiliation(s)
- Michael Antonopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Michael J Bonios
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Evangelos Leontiadis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Aggeliki Gouziouta
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Nektarios Kogerakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ioannis Vlahodimitris
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Maria Chronaki
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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23
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Balcioglu O, Ozgocmen C, Ozsahin DU, Yagdi T. The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review. Diagnostics (Basel) 2024; 14:380. [PMID: 38396419 PMCID: PMC10888030 DOI: 10.3390/diagnostics14040380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.
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Affiliation(s)
- Ozlem Balcioglu
- Department of Cardiovascular Surgery, Faculty of Medicine, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Cemre Ozgocmen
- Department of Biomedical Engineering, Faculty of Engineering, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Dilber Uzun Ozsahin
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Faculty of Medicine, Ege University, Izmir 35100, Turkey
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24
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Tu J, Xu L, Li F, Dong N. Developments and Challenges in Durable Ventricular Assist Device Technology: A Comprehensive Review with a Focus on Advancements in China. J Cardiovasc Dev Dis 2024; 11:29. [PMID: 38248899 PMCID: PMC10817065 DOI: 10.3390/jcdd11010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Heart transplantation is currently the most effective treatment for end-stage heart failure; however, the shortage in donor hearts constrains the undertaking of transplantation. Mechanical circulatory support (MCS) technology has made rapid progress in recent years, providing diverse therapeutic options and alleviating the dilemma of donor heart shortage. The ventricular assist device (VAD), as an important category of MCS, demonstrates promising applications in bridging heart transplantation, destination therapy, and bridge-to-decision. VADs can be categorized as durable VADs (dVADs) and temporary VADs (tVADs), according to the duration of assistance. With the technological advancement and clinical application experience accumulated, VADs have been developed in biocompatible, lightweight, bionic, and intelligent ways. In this review, we summarize the development history of VADs, focusing on the mechanism and application status of dVADs in detail, and further discuss the research progress and use of VADs in China.
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Affiliation(s)
- Jingrong Tu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan 430022, China; (J.T.); (L.X.)
| | - Li Xu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan 430022, China; (J.T.); (L.X.)
| | - Fei Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan 430022, China; (J.T.); (L.X.)
- Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, 528 Shahebei Rd, Kunming 650500, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan 430022, China; (J.T.); (L.X.)
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25
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Moeller CM, Valledor AF, Oren D, Rubinstein G, Sayer GT, Uriel N. Evolution of Mechanical Circulatory Support for advanced heart failure. Prog Cardiovasc Dis 2024; 82:135-146. [PMID: 38242192 DOI: 10.1016/j.pcad.2024.01.018] [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: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/21/2024]
Abstract
This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.
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Affiliation(s)
- Cathrine M Moeller
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Andrea Fernandez Valledor
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Daniel Oren
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Gal Rubinstein
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA.
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26
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Landra F, Sciaccaluga C, Pastore MC, Gallone G, Barilli M, Fusi C, Focardi M, Cavigli L, D'Ascenzi F, Natali BM, Bernazzali S, Maccherini M, Valente S, Cameli M, Mandoli GE. Right ventricular myocardial work for the prediction of early right heart failure and long-term mortality after left ventricular assist device implant. Eur Heart J Cardiovasc Imaging 2023; 25:105-115. [PMID: 37542478 DOI: 10.1093/ehjci/jead193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 08/07/2023] Open
Abstract
AIMS Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant. METHODS AND RESULTS Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033). CONCLUSION RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.
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Affiliation(s)
- Federico Landra
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Carlotta Sciaccaluga
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Maria Concetta Pastore
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cittá della Salute e della Scienza, Turin, Italy
| | - Maria Barilli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Chiara Fusi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Marta Focardi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Luna Cavigli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Benedetta Maria Natali
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, Siena, Italy
| | | | - Serafina Valente
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Giulia Elena Mandoli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
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Kakuda N, Amiya E, Hatano M, Ishida J, Tsuji M, Bujo C, Yagi H, Fujita K, Ishii S, Isotani Y, Kurihara T, Numata G, Gyoten T, Shimada S, Ando M, Ono M, Komuro I. Effect of renal function under left ventricular assist device support on the cardiac function and clinical events after heart transplantation. Clin Transplant 2023; 37:e15107. [PMID: 37615650 DOI: 10.1111/ctr.15107] [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: 05/31/2023] [Revised: 07/21/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
AIM We investigated the effects of pre-transplantation renal dysfunction under left ventricular assisted device (LVAD) support on post-transplantation cardiac function, and patient prognosis after heart transplantation (HTx). METHOD All patients who were bridged by LVAD and underwent HTx at our hospital between 2007 and 2022 were included in this study. Patients were classified into two groups based on estimated glomerular filtration rate (eGFR) before HTx: renal dysfunction (RD) group (eGFR < 60 mL/min/1.73 m2 ) and non-renal dysfunction (NRD) group. RESULT A total of 132 patients were analyzed, of whom 48 were classified into the RD group and 84 into the NRD group (RD group, 47.9 ± 10.1 years; NRD group, 38.4 ± 11.9 years, p < .0001). Under LVAD support before HTx, the RD group tended to have a history of right ventricular failure (RD group, nine (19%); NRD group, seven (8%); p = .098). After HTx, the echocardiographic parameters did not differ between the two groups in the long term. Furthermore, more concise hemodynamic parameters, exemplified by right heart catheterization, were not significantly different between the two groups. Regarding graft rejection, no significant differences were found in acute cellular rejection and cardiac allograft vasculopathy following HTx. In contrast, patients with RD before HTx had significantly increased mortality in the chronic phase after HTx and initiation of maintenance dialysis, without any overt changes in cardiac function. CONCLUSION Pre-transplantation renal dysfunction under LVAD support significantly affected clinical course after HTx without any overt changes in graft cardiac function.
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Affiliation(s)
- Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Advanced Medical Center for Heart Failure, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kanna Fujita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Satoshi Ishii
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Takahiro Kurihara
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Genri Numata
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Takayuki Gyoten
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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28
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Thut TLZ, Petrou A, Meboldt M, Daners MS, Wilhelm MJ. The impact of right ventricular hemodynamics on the performance of a left ventricular assist device in a numerical simulation model. BIOMED ENG-BIOMED TE 2023; 68:503-510. [PMID: 37099745 DOI: 10.1515/bmt-2020-0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/03/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Left ventricular assist devices (LVADs) have been established as alternative to heart transplantation for patients with end-stage heart failure refractory to medical therapy. Right heart failure (RHF) after LVAD implantation is associated with inferior outcome. Its preoperative anticipation may influence the selection between a pure left ventricular and a biventricular device type and, thus, improve outcomes. Reliable algorithms to predict RHF are missing. METHODS A numerical model was used for simulation of a cardiovascular circulation. The LVAD was placed as parallel circuit between left ventricle and aorta. In contrast to other studies, the dynamic hydraulic behavior of a pulsatile LVAD was replaced by that of a continuous LVAD. A variety of hemodynamic states was tested mimicking different right heart conditions. Adjustable parameters included heart rate (HR), pulmonary vascular resistance (PVR), tricuspid regurgitation (TR), right ventricular contractility (RVC) and pump speed. Outcome parameters comprised central venous pressure (CVP), mean pulmonary artery pressure (mPAP), cardiac output (CO) and occurrence of suction. RESULTS Alteration of HR, PVR, TR, RVC and pump speed resulted in diverse effects on CO, CVP and mPAP, resulting in improvement, impairment or no change of the circulation, depending on the degree of alteration. CONCLUSIONS The numerical simulation model allows prediction of circulatory changes and LVAD behaviour following variation of hemodynamic parameters. Such a prediction may be of particular advantage to anticipate RHF after LVAD implantation. It may help preoperatively to choose the appropriate strategy of only left ventricular or both left and right ventricular support.
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Affiliation(s)
- Titus L Z Thut
- Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Anastasios Petrou
- Product Development Group Zurich, Department for Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Mirko Meboldt
- Product Development Group Zurich, Department for Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- Product Development Group Zurich, Department for Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
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29
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Schurr JW, Sigal I, Usman A, Patel P, Lefebvre B, Kurcik K, Atluri P, Acker M, Bermudez C, Rame JE, Hanff T, Cevasco M, Wald J. Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study. ASAIO J 2023; 69:907-914. [PMID: 37578995 DOI: 10.1097/mat.0000000000002010] [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: 08/16/2023] Open
Abstract
Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.
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Affiliation(s)
- James W Schurr
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Sigal
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prakash Patel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy Kurcik
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Hyland PM, Fleming LM. Right-Sided Cardiac Failure After Destination-Therapy-Left Ventricular Assist Device: Where Do We Go from Here? Am J Cardiol 2023:S0002-9149(23)00471-X. [PMID: 37468397 DOI: 10.1016/j.amjcard.2023.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/24/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Patrick M Hyland
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lisa M Fleming
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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31
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Powell TR. Early Intraoperative Detection and Management of Right Ventricular Failure After Left Ventricular Assist Device Implantation. Tex Heart Inst J 2023; 50:e238169. [PMID: 37450655 PMCID: PMC10660638 DOI: 10.14503/thij-23-8169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Thomas R Powell
- Department of Anesthesiology, Division of Cardiovascular Anesthesia and Critical Care Medicine, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Anesthesiology, The Texas Heart Institute, Houston, Texas
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32
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George TJ, Sheasby J, Milligan G, Kabra N, Dimaio JM, Rawitscher DA, Afzal A. Managing Right Ventricular Failure After Left Ventricular Assist Device Implant at a Destination Therapy Center. Am J Cardiol 2023; 201:1-7. [PMID: 37348151 DOI: 10.1016/j.amjcard.2023.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/20/2023] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
Although left ventricular assist device (LVAD) implant is associated with an increased survival in patients with end-stage heart failure, severe right ventricular failure requiring a right ventricular assist device (RVAD) placement is associated with increased short-term morbidity and mortality. Patients not eligible for transplant have limited options, which may impact decision-making and outcomes at nontransplant centers. We conducted a retrospective review of all LVAD implants at our nontransplant center. Primary stratification was by the need for a postoperative RVAD implant. The primary outcome was survival. The Cox proportional hazards regression modeling was used to further evaluate mortality. From 2017 to 2022, 128 patients underwent a primary LVAD implant and 24 (18.75%) required a perioperative RVAD placement. RVAD implant was associated with increased operative mortality (1.92% vs 33.33%, p <0.01) and decreased 1-year (91.29% vs 60.60%, p <0.01) and 2-year survival (84.05% vs 36.36%, p <0.01). However, in patients who survived their index hospitalization, 1-year (93.00% vs 91.67%, p = 0.78) and 2-year (86.16% vs 55.00%, p = 0.10) mortality were similar. On multivariable analysis, the need for a RVAD was associated with an increased hazard of 1-year (5.60 [1.96 to 16.01], p <0.01) and 2-year (5.17 [2.01 to 13.28], p <0.01) mortality. In conclusion, our series from a nontransplant center suggests that patients who survive the implant have acceptable short-term survival, even if they do not have a transplant option; thus, carefully selected patients with biventricular failure may benefit from an LVAD implant, even if an RVAD is needed.
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Affiliation(s)
| | | | - Greg Milligan
- Baylor Scott and White, The Heart Hospital, Plano, Texas
| | - Nitin Kabra
- Baylor Scott and White, The Heart Hospital, Plano, Texas
| | | | | | - Aasim Afzal
- Baylor Scott and White, The Heart Hospital, Plano, Texas
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33
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Satish M, Anyanwu A, Moss N, Lala A, Itagaki S, Roldan J, Mancini D. HeartMate-3 Ventricular Assist Devices Versus the Total Artificial Heart for Biventricular Support: A Single-Center Series. ASAIO J 2023; 69:544-551. [PMID: 36867839 DOI: 10.1097/mat.0000000000001900] [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: 03/05/2023] Open
Abstract
INTRODUCTION The SynCardia total artificial heart (TAH) is the only device approved for biventricular support. Continuous flow ventricular assist devices (VAD) in a biventricular configuration (BiVAD) have been used with variable results. The purpose of this report was to examine differences in patient characteristics and outcomes between two HeartMate-3 (HM-3) VADs in comparison with TAH support. METHODS All patients who received durable biventricular mechanical support from November 2018 to May 2022 at The Mount Sinai Hospital (New York) were considered. Baseline clinical, echocardiographic, hemodynamic, and outcome data were extracted. Primary outcomes were postoperative survival and successful bridge-to-transplant (BTT). RESULTS A total of 16 patients received durable biventricular mechanical support during the study period, of which 6 (38%) patients received two HM-3 VAD pumps as BiVAD support and 10 (62%) patients received a TAH. Overall, TAH patients had a lower median lactate ( p < 0.05) at baseline compared to those on HM-3 BiVAD support yet had higher operative morbidity, lower 6-month survival ( p < 0.05), and a higher rate of renal failure (80 vs . 17%; p = 0.03). However, survival declined to the same rate at 1 year (50%) and was largely because of extracardiac adverse events related to underlying comorbidities (particularly, renal failure and diabetes, p < 0.05). Successful BTT was achieved in 3 out of 6 HM-3 BiVAD patients and in 5 out of 10 TAH patients. CONCLUSION In our single center experience, similar outcomes were observed among patients BTT with HM-3 BiVAD compared to those BTT on TAH support despite lower Interagency Registry for Mechanically Assisted Circulatory Support level.
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Affiliation(s)
- Mohan Satish
- From the Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai
| | - Anelechi Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai
| | - Noah Moss
- From the Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai
| | - Anuradha Lala
- From the Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai
| | - Shinobu Itagaki
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai
| | - Julie Roldan
- From the Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai
| | - Donna Mancini
- From the Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai
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Pienta MJ, Noly PE, Janda AM, Tang PC, Bitar A, Mathis MR, Aaronson KD, Pagani FD, Likosky DS. Rescuing the right ventricle: A conceptual framework to target new interventions for patients receiving a durable left ventricular assist device. J Thorac Cardiovasc Surg 2023; 165:2126-2131. [PMID: 35527048 PMCID: PMC11170340 DOI: 10.1016/j.jtcvs.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Despite significant advances in durable LVAD technology, right heart failure remains a morbid and fatal condition that is difficult to predict, prevent, and successfully treat.
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Affiliation(s)
- Michael J Pienta
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Pierre-Emmanuel Noly
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Allison M Janda
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Mich
| | - Paul C Tang
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Abbas Bitar
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Francis D Pagani
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Donald S Likosky
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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35
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Bonios MJ, Armenis I, Kogerakis N, Thodou A, Fragoulis S, Georgiadou P, Leontiadis E, Chamogeorgakis T, Drakos SG, Adamopoulos S. Prospective Phenotyping of Right Ventricle Function Following Intra-Aortic Balloon Pump Counterpulsation in Left Ventricular Assist Device Candidates: Outcomes and Predictors of Response. ASAIO J 2023; 69:e215-e222. [PMID: 37000672 DOI: 10.1097/mat.0000000000001927] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Intra-aortic balloon pump (IABP) may be applied to optimize advanced heart failure (AHF) patients and improve right ventricular (RV) function before left ventricular assist device (LVAD) implantation. We aimed to evaluate the outcome of this intervention and define RV response predictors. Decompensated AHF patients, not eligible for LVAD because of poor RV function, who required IABP for stabilization were enrolled. Echocardiography and invasive hemodynamics were serially applied to determine fulfillment of prespecified "LVAD eligibility RV function" criteria (right atrium pressure [RA] <12 mm Hg, pulmonary artery pulsatility index [PAPi] >2.00, RA/pulmonary capillary wedge pressure [PCWP] <0.67, RV strain <-14.0%). Right ventricular-free wall tissue was harvested to assess interstitial fibrosis. Eighteen patients (12 male), aged 38 ± 14 years were supported with IABP for 55 ± 51 (3-180) days. In 11 (61.1%), RV improved and fulfilled the prespecified criteria, while seven (38.9%) showed no substantial improvement. Histopathology revealed an inverse correlation between RV interstitial fibrosis and functional benefit following IABP: interstitial fibrosis correlated with post-IABP RA ( r = 0.63, p = 0.037), RA/PCWP ( r = 0.87, p = 0.001), PAPi ( r = -0.83, p = 0.003). Conclusively, IABP improves RV function in certain AHF patients facilitating successful LVAD implantation. Right ventricular interstitial fibrosis quantification may be applied to predict response and guide preoperative patient selection and optimization. http://links.lww.com/ASAIO/A995.
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Affiliation(s)
- Michael J Bonios
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
- Division of Cardiovascular Medicine and Nora Eccles Treadwell Cardiovascular Research and Training Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | - Iakovos Armenis
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Nektarios Kogerakis
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Aspasia Thodou
- Division of Cardiovascular Medicine and Nora Eccles Treadwell Cardiovascular Research and Training Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | - Socrates Fragoulis
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Panagiota Georgiadou
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Evangelos Leontiadis
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Stavros G Drakos
- Division of Cardiovascular Medicine and Nora Eccles Treadwell Cardiovascular Research and Training Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stamatis Adamopoulos
- From the Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
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36
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Asakage A, Bækgaard J, Mebazaa A, Deniau B. Management of Acute Right Ventricular Failure. Curr Heart Fail Rep 2023; 20:218-229. [PMID: 37155123 DOI: 10.1007/s11897-023-00601-5] [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] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE OF REVIEW Acute right ventricular failure (RVF) is a frequent condition associated with high morbidity and mortality. This review aims to provide a current overview of the pathophysiology, presentation, and comprehensive management of acute RVF. RECENT FINDINGS Acute RVF is a common disease with a pathophysiology that is not completely understood. There is renewed interest in the right ventricle (RV). Some advances have been principally made in chronic right ventricular failure (e.g., pulmonary hypertension). Due to a lack of precise definition and diagnostic tools, acute RVF is poorly studied. Few advances have been made in this field. Acute RVF is a complex, frequent, and life-threatening condition with several etiologies. Transthoracic echocardiography (TTE) is the key diagnostic tool in search of the etiology. Management includes transfer to an expert center and admission to the intensive care unit (ICU) in most severe cases, etiological treatment, and general measures for RVF.
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Affiliation(s)
- Ayu Asakage
- UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), INSERM, Université de Paris Cité, Paris, France
| | - Josefine Bækgaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Alexandre Mebazaa
- UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), INSERM, Université de Paris Cité, Paris, France
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, Paris, France
| | - Benjamin Deniau
- UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), INSERM, Université de Paris Cité, Paris, France.
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France.
- Université de Paris Cité, Paris, France.
- FHU PROMICE, Paris, France.
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Fortuni F, Zilio F, Iannopollo G, Ciliberti G, Trambaiolo P, Ceriello L, Musella F, Scicchitano P, Albani S, Di Fusco SA, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. Management of temporary mechanical circulatory support devices in cath-lab and cardiac intensive care unit. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad011. [PMID: 39044800 PMCID: PMC11195697 DOI: 10.1093/ehjimp/qyad011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2024]
Abstract
Different temporary mechanical circulatory support (tMCS) devices are available and can be used to maintain end-organ perfusion while reducing cardiac work and myocardial oxygen demand. tMCS can provide support to the right ventricle, left ventricle, or both, and its use can be considered in emergency situations such as cardiogenic shock or in elective procedures such as high-risk percutaneous coronary intervention to prevent haemodynamic deterioration. Invasive and, most importantly, non-invasive haemodynamic parameters should be taken into account when choosing the type of tMCS device and its initiation and weaning timing, determining the need for a device upgrade, and screening for complications. In this context, ultrasound tools, specifically echocardiography, can provide important data. This review aims to provide a description of the different tMCS devices, the invasive and non-invasive tools and parameters to guide their management, and their advantages and drawbacks.
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Affiliation(s)
- Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, via Massimo Arcamone, CAP 06034, Foligno (PG), Italy
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2330RC Leiden, The Netherlands
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Gianmarco Iannopollo
- Department of Cardiology, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | | | - Laura Ceriello
- Cardiology Department, Ospedale Civile G. Mazzini, Teramo, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | | | - Stefano Albani
- Division of Cardiology, U. Parini Hospital, Aosta, Italy
- Department of Cardiology, Cardiovascular Institute Paris Sud, Massy, France
| | | | | | - Domenico Gabrielli
- Cardio-Toraco-Vascular Department, San Camillo-Forlanini Hospital, Rome, Italy
- Heart Care Foundation, Florence, Italy
| | - Fabrizio Oliva
- Cardiologia 1, A. De Gasperis Cardicocenter, ASST Niguarda, Milan, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, Rome, Italy
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38
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Bahl A, Qureshi B, Zhang K, Bravo C, Mahr C, Li S. Explainable Machine Learning Analysis of Right Heart Failure After Left Ventricular Assist Device Implantation. ASAIO J 2023; 69:417-423. [PMID: 36730914 DOI: 10.1097/mat.0000000000001843] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Right heart failure (RHF) remains a common and serious complication after durable left ventricular assist device (LVAD) implantation. We used explainable machine learning (ML) methods to derive novel insights into preimplant patient factors associated with RHF. Continuous-flow LVAD implantations from 2008 to 2017 in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) were included. A total of 186 preimplant patient factors were analyzed and the primary outcome was 30 days of severe RHF. A boosted decision tree ML algorithm and an explainable ML method were applied to identify the most important factors associated with RHF, nonlinear relationships and interactions, and risk inflection points. Out of 19,595 patients, 19.1% developed severe RHF at 30 days. Thirty top predictors of RHF were identified with the top five being INTERMACS profile, Model for End-stage Liver Disease score, the number of inotropic infusions, hemoglobin, and race. Many top factors exhibited nonlinear relationships with key risk inflection points such as INTERMACS profile between 2 and 3, right atrial pressure of 15 mmHg, pulmonary artery pressure index of 3, and prealbumin of 23 mg/dl. Finally, the most important variable interactions involved INTERMACS profile and the number of inotropes. These insights could help formulate patient optimization strategies prior to LVAD implantation.
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Affiliation(s)
- Arjun Bahl
- From the Department of Medicine, University of Washington, Seattle, Washington
| | - Binish Qureshi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Kevin Zhang
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Claudio Bravo
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Claudius Mahr
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Song Li
- Division of Cardiology, University of Washington, Seattle, Washington
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Inglis SS, Villavicencio MT, Spencer PJ, Schettle SD, Stulak JM, Clavell AL, Kushwaha SS, Behfar A, Rosenbaum AN. Interventricular-Septal Output While Supported on Left Ventricular Assist Device Therapy. ASAIO J 2023; 69:424-428. [PMID: 36730725 DOI: 10.1097/mat.0000000000001851] [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: 02/04/2023] Open
Abstract
The effects of left ventricular unloading on septal function in patients with left ventricular assist devices (LVADs) have not been well characterized in vivo. The purpose of this study was to evaluate the relationship between markers of septal function with echocardiography in relationship to RV dysfunction and late RV failure after LVAD implantation. A retrospective study was conducted of patients supported on centrifugal-flow LVADs implanted over a 10-year period. Echocardiographic data were collected pre-operatively and up to 2 years after implantation. Interventricular septum (IVS) measurements were taken at end-systole and end-diastole. Interventricular-septal output (ISO) was calculated using the formula: (IVSs-IVSd)×heart rate. A total of 110 patients were included. An immediate and sustained reduction in both lateral annulus systolic velocity (RVS') and TAPSE were observed after implant ( p < 0.0001). However, ISO gradually decreased over time ( p < 0.0001). While ISO was not predictive of late RV failure, a decrease in ISO by 25% or greater from pre-implant to hospital discharge was associated with late RV failure (OR 4.8; 95% CI, 1.4-16.5; p = 0.012) even after adjusting for relevant clinical variables ( p ≤ 0.01 for each model). RV function is known to be influenced by mechanical ventricular interdependence and we demonstrate that measurement of ISO may be a useful marker in assessing RV dysfunction and predicting RV failure in patients following LVAD implantation.
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Affiliation(s)
- Sara S Inglis
- From the Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | | | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Alam A, Baran DA, Doshi H, Van Zyl J, Patlolla S, Salem M, Afzal A, Al-Saffar F, Hall SA. Safety and efficacy of ProtekDuo right ventricular assist device: A systemic review. Artif Organs 2023. [PMID: 37012224 DOI: 10.1111/aor.14525] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 01/04/2023] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Right ventricular failure is associated with increased morbidity and mortality. The ProtekDuo (Livanova, Uk) is a dual-lumen cannula that allows for percutaneous right ventricular support and may be connected to a centrifugal blood pump such as the TandemHeart or LifeSparc (Livanova, UK). This systematic review aims to evaluate the safety and efficacy of ProtekDuo right ventricular support and evaluate potential clinical variables that can influence outcomes. METHODS PubMed, MEDLINE, SCOPUS, EMBASE, and the Cochrane Library were systematically searched. Studies meeting inclusion criteria, where ProtekDuo was used as the right ventricular assist device with reported numerical death counts for mortality as outcome measures. The primary endpoints were in-hospital 30-day and 1-year mortality rates. Secondary endpoints included ICU length of stay, conversion rates to surgical RVADs, ProtekDuo wean rates, duration of use of ProtekDuo, and adverse event rates. RESULTS Of 49 studies reviewed, 7 met inclusion criteria with study periods between October 2014 and November 2019. ProtekDuo was utilized due to RV failure post-LVAD insertion in 64.8% (68/105) of patients. In-hospital mortality, 30-day mortality, and 1-year mortality ranged between 9%-46%, 15%-40%, and 19%-40%, respectively. Weaning from ProtekDuo and conversion to surgical RVAD ranged between 24%-91% and 11%-35%, respectively. The ICU stay average ranged from 15.8 to 36 days and ProtekDuo mean support duration ranged from 10.5 to 58 days. CONCLUSION The ProtekDuo cannula is increasingly utilized as a right ventricular support device. Despite the sparse retrospective data available with variable patient characteristics and study design, percutaneous RV mechanical support via ProtekDuo cannula is a safe and feasible option.
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Affiliation(s)
- Amit Alam
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
- Texas A&M University College of Medicine, Dallas, Texas, USA
| | - David A Baran
- Cleveland Clinic Heart, Vascular and Thoracic Institute, Weston, Florida, USA
| | - Harsh Doshi
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Johanna Van Zyl
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
| | - Srikant Patlolla
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
| | - Mahmoud Salem
- University of Pittsburg Medical Center, Harrisburg, Pennsylvania, USA
| | - Aasim Afzal
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
- Texas A&M University College of Medicine, Dallas, Texas, USA
| | - Farah Al-Saffar
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
- Texas A&M University College of Medicine, Dallas, Texas, USA
| | - Shelley A Hall
- Center for Advanced Heart Failure and Transplant Cardiology, Baylor University Medical Center, Texas, Dallas, USA
- Texas A&M University College of Medicine, Dallas, Texas, USA
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41
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Stevens E, Lampert BC, Whitson BA, Rush LJ, Mokadam NA, Barrett TA. Total artificial heart implantation: supportive care preparedness planning framework. BMJ Support Palliat Care 2023:spcare-2023-004210. [PMID: 36990682 DOI: 10.1136/spcare-2023-004210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/08/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The total artificial heart (TAH) is an implanted device approved as a modality to stabilize patients with severe biventricular heart failure or persistent ventricular arrhythmias for evaluation and bridge to transplantation. According to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), about 450 patients received a TAH between 2006 and 2018. Patients being evaluated for a TAH are often critically ill and a TAH offers the best chance at survival. Given the prognostic uncertainty of these patients, there is a crucial need for preparedness planning to help patients and their caregivers plan for living and supporting a loved one with a TAH. AIM To describe an approach to preparedness planning and highlight the importance of palliative care. METHODS We reviewed the current needs and approaches to preparedness planning for a TAH. We categorized our findings and suggest a guide to maximize conversations with patients and their decision makers. RESULTS We identified four critical areas to address: the decision maker, minimal acceptable outcome/maximal acceptable burden, living with the device, and dying with the device. We suggest using a framework of mental and physical outcomes and locations of care as a way to identify minimal acceptable outcome and maximal acceptable burden. CONCLUSION Decision making for a TAH is complex. There is an urgency and patients do not always have capacity. Identifying legal decision makers and social support is critical. The surrogate decision makers should be included in preparedness planning including discussions about end-of-life care and treatment discontinuation. Having palliative care as members of the interdisciplinary mechanical circulatory support team can assist in these preparedness conversations.
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Affiliation(s)
- Erin Stevens
- Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brent C Lampert
- Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Laura J Rush
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
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42
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Alkhunaizi FA, Azih NI, Read JM, Goldberg RL, Gulati AA, Scheel PJ, Muslem R, Gilotra NA, Sharma K, Kilic A, Houston BA, Tedford RJ, Hsu S. Characteristics and Predictors of Late Right Heart Failure After Left Ventricular Assist Device Implantation. ASAIO J 2023; 69:315-323. [PMID: 36191552 PMCID: PMC10901567 DOI: 10.1097/mat.0000000000001804] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Late right heart failure (LRHF) following left ventricular assist device (LVAD) implantation remains poorly characterized and challenging to predict. We performed a multicenter retrospective study of LRHF in 237 consecutive adult LVAD patients, in which LRHF was defined according to the 2020 Mechanical Circulatory Support Academic Research Consortium guidelines. Clinical and hemodynamic variables were assessed pre- and post-implant. Competing-risk regression and Kaplan-Meier survival analysis were used to assess outcomes. LRHF prediction was assessed using multivariable logistic and Cox proportional hazards regression. Among 237 LVAD patients, 45 (19%) developed LRHF at a median of 133 days post-LVAD. LRHF patients had more frequent heart failure hospitalizations ( p < 0.001) alongside other complications. LRHF patients did not experience reduced bridge-to-transplant rates but did suffer increased mortality (hazard ratio 1.95, 95% confidence interval [CI] 1.11-3.42; p = 0.02). Hemodynamically, LRHF patients demonstrated higher right atrial pressure, mean pulmonary arterial pressure, and pulmonary vascular resistance (PVR), but no difference in pulmonary arterial wedge pressure. History of early right heart failure, blood urea nitrogen (BUN) > 35 mg/dl at 1 month post-LVAD, and diuretic requirements at 1 month post-LVAD were each significant, independent predictors of LRHF in multivariable analysis. An LRHF prediction risk score incorporating these variables predicted LRHF with excellent discrimination (log-rank p < 0.0001). Overall, LRHF post-LVAD is more common than generally appreciated, with significant morbidity and mortality. Elevated PVR and precapillary pulmonary pressures may play a role. A risk score using early right heart failure, elevated BUN, and diuretic requirements 1 month post implant predicted the development of LRHF.
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Affiliation(s)
- Fatimah A Alkhunaizi
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Nnamdi I Azih
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jacob M Read
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Rachel L Goldberg
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Arune A Gulati
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul J Scheel
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Rahatullah Muslem
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nisha A Gilotra
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kavita Sharma
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Hsu
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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Pergola V, Tarzia V, Baroni G, Iliceto S, Gerosa G, Mele D. Utilization of an Ultrasound-Enhancing Agent Improves the Evaluation of the Right Ventricle in Patients With Left Ventricular Assist Device. J Am Soc Echocardiogr 2023; 36:337-339. [PMID: 36460213 DOI: 10.1016/j.echo.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Valeria Pergola
- Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Vincenzo Tarzia
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Giulia Baroni
- Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, University of Padua, Padua, Italy
| | - Donato Mele
- Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Takenaka S, Sato T, Nagai T, Omote K, Kobayashi Y, Kamiya K, Konishi T, Tada A, Mizuguchi Y, Takahashi Y, Naito S, Saiin K, Ishizaka S, Wakasa S, Anzai T. Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device. Am J Physiol Heart Circ Physiol 2023; 324:H355-H363. [PMID: 36705992 DOI: 10.1152/ajpheart.00626.2022] [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: 01/28/2023]
Abstract
Although measuring right ventricular (RV) function during exercise is more informative than assessing it at rest, the relationship between RV reserve function, exercise capacity, and health-related quality of life (HRQoL) in patients with left ventricular assist devices (LVAD) remains unresolved. We aimed to investigate whether RV reserve assessed by the change in RV stroke work index (RVSWI) during exercise is correlated with exercise capacity and HRQoL in patients with LVAD. We prospectively assessed 24 consecutive patients with LVAD who underwent invasive right heart catheterization in the supine position. Exercise capacity and HRQoL were assessed using the 6-min walk distance (6 MWD) and peak oxygen consumption (V̇o2) in cardiopulmonary exercise testing, and the EuroQol visual analog scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (change from rest to peak exercise). Patients with lower ΔRVSWI had significantly lower changes in cardiac index and absolute value of RV dP/dt than those with higher ΔRVSWI. The ΔRVSWI was positively correlated with 6 MWD (r = 0.59, P = 0.003) and peak V̇o2 (r = 0.56, P = 0.006). In addition, ΔRVSWI was positively correlated with the EQ-VAS (r = 0.44, P = 0.030). In contrast, there was no significant correlation between RVSWI at rest and 6 MWD (r = -0.34, P = 0.88), peak V̇o2 (r = 0.074, P = 0.74), or EQ-VAS (r = 0.127, P = 0.56). Our findings suggest that the assessment of RV reserve function is useful for risk stratification in patients with LVAD.NEW & NOTEWORTHY The change in right ventricular stroke work index (RVSWI) during exercise, not RVSWI at rest, was associated with exercise capacity and HRQoL. Our findings suggest that the assessment of change in RVSWI during exercise as a surrogate of RV reserve function may aid in risk stratification of patients with LVAD.
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Affiliation(s)
- Sakae Takenaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takao Konishi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Takahashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Seiichiro Naito
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kohei Saiin
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoru Wakasa
- Department of Cardiovascular Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Valente F, Stefanidis C, Vachiéry JL, Dewachter C, Engelman E, Vanden Eynden F, Roussoulières A. A novel metrics to predict right heart failure after left ventricular assist device implantation. J Artif Organs 2023; 26:24-35. [PMID: 35482120 DOI: 10.1007/s10047-022-01334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Right Heart Failure (RHF) is a severe complication that can occur after left ventricular assist device (LVAD) implantation, increasing early and late mortality. Although numerous RHF predictive scores have been developed, limited data exist on the external validation of these models. We therefore aimed at comparing existent risk score models and identifying predictors of severe RHF at our center. METHODS In this retrospective, single-center analysis, clinical, biological and functional data were collected in patients implanted with a LVAD between 2011 and 2020. Early severe RHF was defined as the use of inotropes for ≥ 14 days, nitric oxide use for ≥ 48 h or unplanned right-sided circulatory support. Risk models were evaluated for the primary outcome of RHF or RVAD implantation by means of logistic regression and receiver operating characteristic curves. RESULTS Among 92 patients implanted, 24 (26%) developed early severe RHF. The EUROMACS-RHF risk score performed the best in predicting RHF (C = 0.82-95% CI: 0.68-0.90), compared with the other scores (Michigan, CRITT). In addition, we developed a new model, based on four variables selected for the best reduced logistic model: the INTERMACS level, the number of inotropes used, the ratio of right atrial/pulmonary capillary wedge pressure and the ratio of right ventricle/left ventricle diameters by echocardiography. This model demonstrated significant discrimination of RHF (C = 0.9-95% CI: 0.76-0.96). CONCLUSION Amongst available risk scores, EUROMACS-RHF performs best to predict the occurrence of RHF after LVAD implantation. Our model's performance compares well to the EUROMACS-RHF score, adding a more objective parameter to RV function evaluation.
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Affiliation(s)
- Federica Valente
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium.
| | - Constantin Stefanidis
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Vachiéry
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Céline Dewachter
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | | | - Frédéric Vanden Eynden
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ana Roussoulières
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
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46
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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Edward J, Banchs J, Parker H, Cornwell W. Right ventricular function across the spectrum of health and disease. Heart 2023; 109:349-355. [PMID: 35641176 PMCID: PMC9985748 DOI: 10.1136/heartjnl-2021-320526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022] Open
Abstract
Knowledge of right ventricular (RV) structure and function has historically lagged behind that of the left ventricle (LV). However, advancements in invasive and non-invasive evaluations, combined with epidemiological analyses, have advanced the current understanding of RV (patho)physiology across the spectrum of health and disease, and reinforce the centrality of the RV in contributing to clinical outcomes. In the healthy heart, ventricular-arterial coupling is preserved during rest and in response to increased myocardial demand (eg, exercise) due to substantial RV contractile reserve. However, prolonged exposure to increased myocardial demand, such as endurance exercise, may precipitate RV dysfunction, suggesting that unlike the LV, the RV is unable to sustain high levels of contractility for extended periods of time. Emerging data increasingly indicate that both LV and RV function contribute to clinical heart failure. Reductions in quality-of-life, functional capacity and overall clinical outcomes are worsened among patients with heart failure when there is evidence of RV dysfunction. In addition, the RV is adversely impacted by pulmonary vascular disease, and among affected patients, overall RV function differs based on mechanisms of the underlying pulmonary hypertension, which may result from variations in sarcomere function within RV cardiomyocytes.
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Affiliation(s)
- Justin Edward
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jose Banchs
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hugh Parker
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - William Cornwell
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Arjomandi Rad A, Kapadia S, Zubarevich A, Nanchahal S, Van den Eynde J, Vardanyan R, Bareka M, Krasopoulos G, Quarto C, Ruhparwar A, Athanasiou T, Weymann A. Sex disparities in left ventricular assist device implantation outcomes: A systematic review and meta-analysis of over 50 000 patients. Artif Organs 2023; 47:273-289. [PMID: 36461903 DOI: 10.1111/aor.14469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) represent an important therapeutic option for patients progressing to end-stage heart failure. Women have been historically underrepresented in LVAD studies, and have been reported to have worse outcomes despite technological optimisation. We aimed to systematically explore the evidence on sex disparities in the use and outcomes of LVAD implantation. METHODS A systematic database search with meta-analysis was conducted of comparative original articles of men versus women undergoing LVAD implantation, in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to July 2022. Primary outcomes were stroke (haemorrhagic and ischaemic) and early/overall mortality. Secondary outcomes were LVAD thrombosis, right VAD implantation, major bleeding, kidney dysfunction, and device/driveline infection. RESULTS Our search yielded 137 relevant studies, including 22 meeting the inclusion criteria with a total of 53 227 patients (24.2% women). Overall mortality was higher in women (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.05-1.62, p = 0.02), as was overall stroke (OR 1.32, 95%CI 1.06-1.66, p = 0.01), including ischemic (OR 1.80, 95%CI 1.22-2.64, p = 0.003) and haemorrhagic (OR 1.72, 95%CI 1.09-2.70, p = 0.02). Women had more frequent right VAD implantation (OR 2.11, 95%CI 1.24-3.57, p = 0.006) and major bleeding (OR 1.40, 95%CI 1.06-1.85, p = 0.02). Kidney dysfunction, LVAD thrombosis, and device/driveline infections were comparable between sexes. CONCLUSIONS Our analysis suggests that women face a greater risk of adverse events and mortality post-LVAD implantation. Although the mechanisms remain unclear, the difference in outcomes is thought to be multifactorial. Further research, that includes comprehensive pre-operative characteristics and post-operative outcomes, is encouraged.
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Affiliation(s)
- Arian Arjomandi Rad
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Sharan Kapadia
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Sukanya Nanchahal
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | | | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Metaxia Bareka
- Department of Anaesthesiology, University of Laryssa, Laryssa, Greece
| | - George Krasopoulos
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospital NHS Trust, Oxford, UK
| | - Cesare Quarto
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Trust, London, UK
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
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Dogan G, Hanke JS, Alhumood K, Tarazi R, Riebandt J, Wiedemann D, Kneževič I, Haverich A, Zimpfer D, Schmitto JD. Three-month outcomes after the implantation of two HeartMate 3 devices in total artificial heart configuration. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:121-129. [PMID: 36763071 DOI: 10.23736/s0021-9509.22.12445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Total artificial heart (TAH) implantation is a rarely performed procedure. Contrarily, left ventricular assist device (VAD) implantation is rather common in many centers. As transplantation is quantitatively limited cardiac replacement with artificial hearts is a viable alternative in the treatment of severe biventricular heart failure. An alternative to TAH is the implantation of two VADs in a TAH configuration. We hereby present the first multi-center study on 3-months outcomes of patients treated by cardiectomy and placement of two HeartMate 3s in a TAH configuration. METHODS We retrospectively investigated a cohort of 15 patients that underwent HM3-TAH-implantation at three international institutions. Follow-up was 3 months after implantation. Baseline, intra- and postoperative parameters as well as survival data and adverse events were collected. RESULTS A total of 1089 days on HM3-TAH were observed. Thirty-day survival after HM3-TAH implantation was 53% (8/15) and three month survival was 40% (6/15). The longest duration on device was 274 days. Causes of death were multi-organ failure, sepsis, and neurological adverse events. No technical complications were documented. Two patients remained on the device. Four patients (26%) were successfully bridged to transplantation. CONCLUSIONS The implantation of two HeartMate 3s in a TAH configuration is a last resort and off-label concept in cases of extreme biventricular heart failure. In a diligently selected patient cohort, HM3-TAH implantation is a feasible method to increase the chance of survival in a severely ill patient cohort and successfully bridge patients to heart transplantation that would otherwise have died.
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Affiliation(s)
- Günes Dogan
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany -
| | - Khaldoon Alhumood
- Department of Cardiac Surgery, Salman Al Dabbous Cardiac Center, Kuwait City, Kuwait
| | - Riyad Tarazi
- Department of Cardiac Surgery, Salman Al Dabbous Cardiac Center, Kuwait City, Kuwait
| | - Julia Riebandt
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Ivan Kneževič
- Department of Cardiovascular Surgery, Ljubljana University Medical Center, Ljubljana, Slovenia
| | - Axel Haverich
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Daniel Zimpfer
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jan D Schmitto
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Sugimura Y, Kalampokas N, Arikan M, Rellecke P, Dalyanoglu H, Tudorache I, Westenfeld R, Boeken U, Lichtenberg A, Akhyari P, Aubin H. Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:6978238. [PMID: 36802258 PMCID: PMC9931070 DOI: 10.1093/icvts/ivac289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/12/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Perioperative mortality and complications still remain high after left ventricular assist device (LVAD) implantation, especially in highly compromised patient cohorts. Here, we evaluate the effects of preoperative Levosimendan therapy on peri- and postoperative outcomes after LVAD implantation. METHODS We retrospectively analysed 224 consecutive patients with LVAD implantation for end-stage heart failure between November 2010 and December 2019 in our centre with regard to short- and longer-term mortality as well as incidence of postoperative right ventricular failure (RV-F). Out of these, 117 (52.2%) received preoperative i.v. Levosimendan therapy within 7 days before LVAD implantation (Levo group). RESULTS In-hospital, 30-day and 5-year mortality was comparable (in-hospital mortality: 18.8% vs 23.4%, P = 0.40; 30-day mortality: 12.0% vs 14.0%, P = 0.65; Levo vs control group). However, in the multivariate analysis, preoperative Levosimendan therapy significantly reduced postoperative RV-F but increased postoperative vasoactive inotropic score ([RV-F: odds ratio 2.153, confidence interval 1.146-4.047, P = 0.017; vasoactive inotropic score 24 h post-surgery: odds ratio 1.023, confidence interval 1.008-1.038, P = 0.002). These results were further confirmed by 1:1 propensity score matching of 74 patients in each group. Especially in the subgroup of patients with normal preoperative RV function, the prevalence of postoperative RV-F was significantly lower in the Levo- group as compared to the control group (17.6% vs 31.1%, P = 0.03; respectively). CONCLUSIONS Preoperative Levosimendan therapy reduces the risk of postoperative RV-F, especially in patients with normal preoperative RV function without effects on mortality up to 5 years after LVAD implantation.
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Affiliation(s)
| | | | - Metin Arikan
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Phillip Rellecke
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Duesseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Payam Akhyari
- Corresponding author. Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany. Tel: +49-241-8012345; fax: +49-241-80-33-12345; e-mail: (P. Akhyari)
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
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