Adverse neurologic events in patients bridged with long-term mechanical circulatory support: A device-specific comparative analysis

Neurologic Complications in Patients With Left Ventricular Assist Devices

Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.

Left Ventricular Assist Devices: A Primer For the General Cardiologist

Durable implantable left ventricular assist devices (LVADs) have been shown to improve survival and quality of life for patients with stage D heart failure. Even though LVADs remain underused overall, the number of patients with heart failure supported with LVADs is steadily increasing. Therefore, general cardiologists will increasingly encounter these patients. In this review, we provide an overview of the field of durable LVADs. We discuss which patients should be referred for consideration of advanced heart failure therapies. We summarize the basic principles of LVAD care, including medical and surgical considerations. We also discuss the common complications associated with LVAD therapy, including bleeding, infections, thrombotic issues, and neurologic events. Our goal is to provide a primer for the general cardiologist in the recognition of patients who could benefit from LVADs and in the principles of managing patients with LVAD. Our hope is to "demystify" LVADs for the general cardiologist.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke

The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.

Delineating Pathways to Death by Multisystem Organ Failure in Patients With a Left Ventricular Assist Device

BACKGROUND

This study delineates the sequences of adverse events (AEs) preceding mortality attributed to multisystem organ failure (MSOF) in patients with a left ventricular assist device (LVAD).

METHODS

We analyzed 3765 AEs after 536 LVAD implants recorded in The Society of Thoracic Surgeons Intermacs data registry between 2006 and 2015 that resulted in MSOF death. Hierarchical clustering identified and visualized quantitatively unique clusters of patients with similar AE profiles. Markov modeling was used to illustrate the AE sequences that led to MSOF death within the clusters. Cox proportional hazard models determined the risk-adjusted, preimplant predictors of MSOF.

RESULTS

We identified 2 distinct MSOF clusters based on their proportion of AE types and survival time. The early-death cluster (418 patients, 2304 AEs) had a median survival of 1 month (interquartile range, 3-6 months), whereas the late-death cluster (118 patients, 1,461 AEs) had a median survival of 11 months (interquartile range, 6-22 months). The predominant AE sequences in the early-death and late-death clusters were renal failure, to respiratory failure, to death (62%) and bleeding, to infection, to respiratory failure, to death (45%), respectively. Significant risk-adjusted preimplant predictors of MSOF included line sepsis (hazard ratio [HR] 3.0; 95% confidence interval [CI], 1.1-8.2), extracorporeal membrane oxygenation (HR, 2.2; 95% CI, 1.2-3.9), and dialysis or ultrafiltration (HR, 2.1; 95% CI, 1.5-3.0).

CONCLUSIONS

This analysis identified 2 AE clusters and the predominant sequences that result in MSOF-associated mortality. MSOF develops in 1 cluster of patients after chronic bleeding and repeated infections but has prolonged survival, while another group dies early after renal and respiratory complications.

Motor outcome, executive functioning, and health-related quality of life of children, adolescents, and young adults after ventricular assist device and heart transplantation

OBJECTIVE

The aim of the current study is to measure long-term executive function, motor outcome, and QoL in children, adolescents, and young adults after VAD and Htx.

METHODS

Patients were examined during routine follow-up. Investigation tools were used as follows: Examination for MND of motor outcomes, Epitrack^® for attention and executive functioning, and Kidscreen-52 and EQ-5D-5L questionnaires for QoL. Additional data were retrospectively obtained by an analysis of patient medical records.

RESULTS

Out of 145 heart transplant recipients at the department of pediatric cardiology of the University Hospital Munich, 39 were implanted with a VAD between 1992 and 2016. Seventeen (43.6%) patients died before or after Htx; 22 (56.4%) patients were included in our study. Mean age at transplant was 9.52 years (range: 0.58-24.39 years, median 9), and the mean follow-up time after Htx was 6.18 years (range: 0.05-14.60 years, median 5.82). MND examination could be performed in 13 patients (normal MND: n = 11, simple MND: n = 1, complex MND: n = 1). Executive functioning was tested in 15 patients. Two (13.3%) patients had good results, six (40%) average results, three (20%) borderline results, and four (26.7%) impaired results. QoL (Kidscreen n = 7, EQ-5D-5L n = 8) was similar to a healthy German population.

CONCLUSION

Motor outcome, executive functioning and QoL in survivors of VAD bridging therapy and Htx can be good, though underlying diseases and therapies are associated with a high risk of cerebral ischemic or hemorrhagic complications.

Do patients with the centrifugal flow HeartMate 3 or HeartWare left ventricular assist device have better outcomes compared to those with axial flow HeartMate II?

A best evidence topic was written according to a structured protocol. The question addressed was ‘Do patients with centrifugal flow HeartMate 3 (HM3) or HeartWare left ventricular assist device (HVAD) have better outcomes compared to those with the axial flow HeartMate II (HMII)?’ Altogether 1791 papers were found using the reported search, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In publications reporting on MOMENTUM 3 randomized control trial (RCT), HM3 had better outcomes compared to HMII with a lower rate of pump thrombosis (1.1% vs 15.7%), stroke events (10.1% vs 19.2%) and ischaemic stroke (6.3% vs 13.4%) at 2-year follow-up. Markers of quality of life and functional capacity were comparable between the 2 devices at 6 months. In publications reporting on ENDURANCE RCTs, compared to HMII, patients with HVAD had poorer outcomes with an increased rate of sepsis (23.6% vs 15.4%), stroke (29.7% vs 12.1%) and right heart failure (38.5% vs 26.8%) postoperatively. Outcomes were improved for the HVAD group in a more recent RCT where strict blood pressure control was instigated postoperatively. Outcomes from retrospective studies comparing HMII with HVAD varied, with some publications reporting higher rates of right ventricular assist device use (29% vs 15%), gastrointestinal bleeding (30% vs 0%), cerebrovascular accident (44% vs 10%), transient ischaemic attack (5% vs 2%) and higher cumulative risk of infection and haemorrhagic cerebrovascular accident with HVAD. This is not consistent across these studies, and 9 studies including a systematic review reported no difference in any outcomes. In conclusion, patients with centrifugal flow HM3 have better outcomes than those with axial flow HMII. Although there is some variability in outcomes in retrospective studies, patients with centrifugal flow HeartWare HVAD have similar outcomes to those with axial flow HMII when strict blood pressure control is instigated postoperatively. By inference, centrifugal flow HM3 would appear to be the superior device, although all conclusions are based on 1 large (industry-sponsored) RCT.

Mechanical circulatory support: 60 years of evolving knowledge

Since the 1950s when the first devices for mechanical circulatory support were developed, there has been an impressive evolution of their technology. The first pioneering pumps were used to rescue acute complications after cardiac surgery. Advances in technology, increased knowledge of flow dynamics, and a more appropriate selection of the patients who actually need this support have contributed to significantly improve the benefits of this therapy. Today, mechanical circulatory support is an essential tool for the treatment of advanced heart failure. This strategy is used either as a bridge to heart transplantation or as a destination therapy for patients who do not meet the transplant criteria. A third indication is the bridge to recovery option for those patients in whom the improvement in cardiac function may be so important that the pump can be removed and the transplantation circumvented. In addition, mechanical circulatory support has fostered marked improvements in several clinical aspects affecting both patient health and quality of life. Despite the improvements in the technology of the devices of the last generation, severe adverse effects are still the Achilles heel of mechanical circulatory support therapy. This review summarizes the history, the technology, the clinical outcomes, and the possible future directions of this therapy.

Prevention and Treatment of Thrombotic and Hemorrhagic Complications in Patients Supported by Continuous-Flow Left Ventricular Assist Devices

PURPOSE OF REVIEW

The purpose of this review is to describe the current knowledge in prevention and treatment of thrombotic (pump thrombosis and ischemic stroke) and bleeding (gastrointestinal and hemorrhagic stroke) complications in patients supported by continuous-flow left ventricular assist devices (CF-LVAD).

RECENT FINDINGS

Left ventricular assist devices (LVADs) are now widely used for the management of end-stage heart failure. Unfortunately, in spite of the indisputable positive impact LVADs have on patients, the frequency and severity of complications are limitations of this therapy. Stroke, pump thrombosis, and gastrointestinal bleeding are among the most serious and frequent complications in these patients. The balance between hemorrhagic and thrombotic complications in patients supported with CF-LVAD is difficult as most patients do not necessarily fit a "bleeder" or a "clotter" profile but rather move from one side to the other of the thrombotic/bleeding spectrum. Further research is necessary to better understand the risk factors and mechanisms involved in the development of these complications.

New role of ventricular assist devices as bridge to transplantation: European perspective

PURPOSE OF REVIEW

Progress of ventricular assist devices (VAD) technology led to improved survival and apparently low morbidity. However, from the European perspective, updated analysis of EUROMACS reveals a somewhat less impressive picture with respect to mortality and morbidity.

RECENT FINDINGS

We describe the great demand of cardiac allografts versus the lack of donors, which is larger in Europe than in the United States. Technical progress of VADs made it possible to work out a modern algorithm of bridge-to-transplant, which is tailored to the need of the particular patient. We analyze the burden of patients undergoing bridge-to-transplant therapy. They are condemned to an intermediate step, coupled with additional major surgery and potential adverse events during heart transplantation.

SUMMARY

Based on current registry data, we do have to question the increasingly popular opinion, that the concept of heart transplantation is futureless, which seems to be for someone who treats and compares both patients (VAD and heart transplantation) in daily practice, questionable. Up to now, left ventricular assist device therapy remains a bridge to a better future, which means a bridge to technical innovations or to overcome the dramatic lack of donors in Europe.

Clinical trial design and rationale of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) investigational device exemption clinical study protocol

The HeartMate 3 left ventricular assist system (LVAS; St. Jude Medical, Inc., formerly Thoratec Corporation, Pleasanton, CA) was recently introduced into clinical trials for durable circulatory support in patients with medically refractory advanced-stage heart failure. This centrifugal, fully magnetically levitated, continuous-flow pump is engineered with the intent to enhance hemocompatibility and reduce shear stress on blood elements, while also possessing intrinsic pulsatility. Although bridge-to-transplant (BTT) and destination therapy (DT) are established dichotomous indications for durable left ventricular assist device (LVAD) support, clinical practice has challenged the appropriateness of these designations. The introduction of novel LVAD technology allows for the development of clinical trial designs to keep pace with current practices. The prospective, randomized Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) clinical trial aims to evaluate the safety and effectiveness of the HeartMate 3 LVAS by demonstrating non-inferiority to the HeartMate II LVAS (also St. Jude Medical, Inc.). The innovative trial design includes patients enrolled under a single inclusion and exclusion criteria , regardless of the intended use of the device, with outcomes ascertained in the short term (ST, at 6 months) and long term (LT, at 2 years). This adaptive trial design includes a pre-specified safety phase (n = 30) analysis. The ST cohort includes the first 294 patients and the LT cohort includes the first 366 patients for evaluation of the composite primary end-point of survival to transplant, recovery or LVAD support free of debilitating stroke (modified Rankin score >3), or re-operation to replace the pump. As part of the adaptive design, an analysis by an independent statistician will determine whether sample size adjustment is required at pre-specified times during the study. A further 662 patients will be enrolled to reach a total of 1,028 patients for evaluation of the secondary end-point of pump replacement at 2 years.