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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [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: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Donato BB, Seadler BD, Mohammed BW, Zdanovec A, Ubert HA, Durham LA. Heartmate 3 Left Ventricular Assist Device Bend Relief Disconnection Causing Laceration of the Outflow Graft. ASAIO J 2024:00002480-990000000-00534. [PMID: 39083688 DOI: 10.1097/mat.0000000000002287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
As technology in mechanical circulatory support continues to advance, so does the utilization of durable left ventricular assist devices (LVADs). We present the first reported case of HeartMate 3 (HM3) LVAD bend relief disconnection causing laceration of the outflow graft. Our patient is a 34 year old male with end-stage heart failure status post-HM3 implantation with recent debridement of a driveline infection who presented with weakness and sanguineous drainage 5 days after an episode of heavy lifting associated with a palpable substernal pop. During the initial evaluation, he experienced sudden massive decompression of a left chest hematoma through a thoracotomy incision with exsanguinating hemorrhage and an abrupt drop in LVAD flow. An emergent anterolateral thoracotomy was performed where it was discovered that the bend relief was disconnected and had lacerated the outflow graft. The graft was repaired and the ring was removed using a diamond blade rotary saw. He was discharged home and made a full recovery. Mechanical device malfunction has been documented in several prior versions of durable LVADS. Although there have been reported cases in the Heartmate 2, this is the first reported case of a HM3 bend relief disconnection and resultant laceration of the outflow graft.
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Affiliation(s)
- Britton B Donato
- From the Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Benjamin D Seadler
- From the Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Buruj W Mohammed
- Medical College of Wisconsin Medical School, Milwaukee, Wisconsin
| | - Amber Zdanovec
- Division of Critical Care Anesthesia, Department of Anesthesia, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - H Adam Ubert
- From the Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- From the Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Shah P, Sayer G, Sinha SS, Kanwar MK, Cowger JA, Pagani FD, Nayak A, Mehra MR, Cleveland JC, Psotka MA, Singh R, Desai SS, Lu Q, Hu Y, Connolly A, Kormos RL, Uriel N. Dynamic Risk Estimation of Adverse Events in Ambulatory LVAD Patients: A MOMENTUM 3 Analysis. JACC. HEART FAILURE 2024:S2213-1779(24)00486-4. [PMID: 39066758 DOI: 10.1016/j.jchf.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/26/2024] [Accepted: 05/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Hemocompatibility-related adverse events affect patients after left ventricular assist device (LVAD) implantation but are hard to predict. OBJECTIVES Dynamic risk modeling with a multistate model can predict risk of gastrointestinal bleeding (GIB), stroke, or death in ambulatory patients. METHODS This was a secondary analysis of the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial. HeartMate 3 LVAD recipients who survived to hospital discharge and were followed for up to 2 years. A total of 145 variables were included in the multistate model with multivariate logistic regression. Model performance was assessed with the area under the curve in a holdout validation cohort. A risk stratification tool was created by dividing patients into categories of predicted risk using the final model variables and associated OR. RESULTS Among 2,056 LVAD patients, the median age was 59.4 years (20.4% women, 28.6% Black). At 2 years, the incidence of GIB, stroke, and death was 25.6%, 6.0%, and 12.3%, respectively. The multistate model included 39 total variables to predict risk of GIB (16 variables), stroke (10 variables), and death (19 variables). When ambulatory patients were classified according to their risk category, the 30-day observed event rate in the highest risk group for GIB, stroke, or death was 26.9%, 1.8%, and 4.8%, respectively. The multistate model predicted GIB, stroke, and death at any 30-day period with an area under the curve of 0.70, 0.69, and 0.86, respectively. CONCLUSIONS The multistate model informs 30-day risk in ambulatory LVAD recipients and allows recalculation of risk as new patient-specific data become available. The model allows for accurate risk stratification that predicts impending adverse events and may guide clinical decision making. (MOMENTUM 3 IDE Clinical Study Protocol; NCT02224755).
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Affiliation(s)
- Palak Shah
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Gabriel Sayer
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
| | | | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Aditi Nayak
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Ramesh Singh
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | | | | | | | | | | | - Nir Uriel
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
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Kostick-Quenet KM, Lang B, Dorfman N, Estep J, Mehra MR, Bhimaraj A, Civitello A, Jorde U, Trachtenberg B, Uriel N, Kaplan H, Gilmore-Szott E, Volk R, Kassi M, Blumenthal-Barby JS. Patients' and physicians' beliefs and attitudes towards integrating personalized risk estimates into patient education about left ventricular assist device therapy. PATIENT EDUCATION AND COUNSELING 2024; 122:108157. [PMID: 38290171 DOI: 10.1016/j.pec.2024.108157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/06/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Personalized risk (PR) estimates may enhance clinical decision making and risk communication by providing individualized estimates of patient outcomes. We explored stakeholder attitudes toward the utility, acceptability, usefulness and best-practices for integrating PR estimates into patient education and decision making about Left Ventricular Assist Device (LVAD). METHODS AND RESULTS As part of a 5-year multi-institutional AHRQ project, we conducted 40 interviews with stakeholders (physicians, nurse coordinators, patients, and caregivers), analyzed using Thematic Content Analysis. All stakeholder groups voiced positive views towards integrating PR in decision making. Patients, caregivers and coordinators emphasized that PR can help to better understand a patient's condition and risks, prepare mentally and logistically for likely outcomes, and meaningfully engage in decision making. Physicians felt it can improve their decision making by enhancing insight into outcomes, enhance tailored pre-emptive care, increase confidence in decisions, and reduce bias and subjectivity. All stakeholder groups also raised concerns about accuracy, representativeness and relevance of algorithms; predictive uncertainty; utility in relation to physician's expertise; potential negative reactions among patients; and overreliance. CONCLUSION Stakeholders are optimistic about integrating PR into clinical decision making, but acceptability depends on prospectively demonstrating accuracy, relevance and evidence that benefits of PR outweigh potential negative impacts on decision making quality.
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Affiliation(s)
| | - Benjamin Lang
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Dorfman
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | | | | | - Nir Uriel
- Columbia University Irving Medical Center, New York, NY, USA
| | - Holland Kaplan
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eleanor Gilmore-Szott
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Robert Volk
- University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Horie H, Isoyama T, Ishiyama K. Design of a hybrid left ventricular assist device with a new wireless charging system. Artif Organs 2024; 48:309-314. [PMID: 37877220 DOI: 10.1111/aor.14666] [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: 05/05/2023] [Revised: 09/07/2023] [Accepted: 10/06/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The objective of this study was to design a new wireless left ventricular assist device (LVAD) that can be charged without using a conventional transcutaneous energy transfer system (TETS). METHODS Our new wireless LVAD was a hybrid pump operating in two different modes: magnetic and electric modes. The pump was driven wirelessly by extracorporeal rotating magnets in magnetic mode, whereas it was driven by electricity provided by an intracorporeal battery in electric mode. A magnetic torque transmission system was introduced to wirelessly transmit torque to the pump impeller. The intracorporeal battery was charged in magnetic mode making use of electromagnetic coils as a generator, whereas the coils were used as a motor in electric mode. To demonstrate the feasibility of our system, we conducted a bench-top durability test for 1 week. RESULTS Our hybrid pump had shown sufficient pump performance as a LVAD, with a head pressure of approximately 80 mm Hg and a flow volume of 5.0 L/min, for 1 week. The intracorporeal battery was wirelessly charged enough to power electric mode for 2.5 h a day throughout the 1-week durability test. CONCLUSIONS Our hybrid wireless LVAD system demonstrated the possibility of a wireless LVAD and has the potential to reduce medical complications of LVAD therapy.
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Affiliation(s)
- Hideyuki Horie
- Biomedical Engineering, Tohoku University, Sendai, Japan
- Research Institute of Electrical Communication, Tohoku University, Sendai, Japan
| | - Takashi Isoyama
- Department of Clinical Engineering, Kyorin University, Tokyo, Japan
| | - Kazushi Ishiyama
- Research Institute of Electrical Communication, Tohoku University, Sendai, Japan
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [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: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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7
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Mano H, Tanaka Y, Orihara S, Moriya J. Application of sample size re-estimation in clinical trials: A systematic review. Contemp Clin Trials Commun 2023; 36:101210. [PMID: 37842317 PMCID: PMC10568275 DOI: 10.1016/j.conctc.2023.101210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/03/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Background Sample size re-estimation (SSR) is a method used to recalculate sample size during clinical trial conduct to address a lack of adequate information and can have a significant impact on study size, duration, resources, and cost. Few studies to date have summarized the conditions and circumstances under which SSR is applied. We therefore performed a systematic review of the literature related to SSR to better understand its application in clinical trial settings. Methods PubMed was used as the primary search source, supplemented with information from ClinicalTrials.gov where necessary details were lacking from PubMed. A systematic review was performed according to a pre-specified search strategy to identify clinical trials using SSR. Features of SSR, such as study phase and study start year, were summarized. Results In total, 253 publications met the pre-specified search criteria and 27 clinical trials were subsequently determined as relevant in SSR usage. Among trials where the study phase was provided, 2 (7.4%) trials were Phase I, 5 (18.5%) trials were Phase II, 11 (40.7%) trials were Phase III, and 2 (7.4%) trials were Phase IV. Conclusion Our results showed that SSR is also used in Phase I and II, which involve earlier decision making. We expect that SSR will continue to be used in early-phase trials where sufficient prior information may not be available. Furthermore, no major trends were observed in relation to therapy area or type of SSR, meaning that SSR may become a feasible and widely applied method in the future.
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Affiliation(s)
- Hirotaka Mano
- Biostatistics Group, Biometrics Department, Development Unit, R&D Division, Kyowa Kirin Co., Ltd., Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Yuji Tanaka
- Biostatistics Group, Biometrics Department, Development Unit, R&D Division, Kyowa Kirin Co., Ltd., Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Shunichiro Orihara
- Biostatistics Group, Biometrics Department, Development Unit, R&D Division, Kyowa Kirin Co., Ltd., Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Junji Moriya
- Biostatistics Group, Biometrics Department, Development Unit, R&D Division, Kyowa Kirin Co., Ltd., Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
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Zhang J, Saju C. A systematic review of randomised controlled trials with adaptive and traditional group sequential designs - applications in cardiovascular clinical trials. BMC Med Res Methodol 2023; 23:200. [PMID: 37679710 PMCID: PMC10483862 DOI: 10.1186/s12874-023-02024-1] [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: 01/25/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Trial design plays a key role in clinical trials. Traditional group sequential design has been used in cardiovascular clinical trials over decades as the trials can potentially be stopped early, therefore, it can reduce pre-planned sample size and trial resources. In contrast, trials with adoptive designs provide greater flexibility and are more efficient due to the ability to modify trial design according to the interim analysis results. In this systematic review, we aim to explore characteristics of adaptive and traditional group sequential trials in practice and to gain an understanding how these trial designs are currently being reported in cardiology. METHODS PubMed, Embase and Cochrane Central Register of Controlled Trials database were searched from January 1980 to June 2022. Randomised controlled phase 2/3 trials with either adaptive or traditional group sequential design in patients with cardiovascular disease were included. Descriptive statistics were used to present the collected data. RESULTS Of 456 articles found in the initial search, 56 were identified including 43 (76.8%) trials with traditional group sequential design and 13 (23.2%) with adaptive. Most trials were large, multicentre, led by the USA (50%) and Europe (28.6%), and were funded by companies (78.6%). For trials with group sequential design, frequency of interim analyses was determined mainly by the number of events (47%). 67% of the trials stopped early, in which 14 (32.6%) were due to efficacy, and 5 (11.6%) for futility. The commonly used stopping rule to terminate trials was O'Brien- Fleming-type alpha spending function (10 (23.3%)). For trials with adaptive designs, 54% of the trials stopped early, in which 4 (30.8%) were due to futility, and 2 (15.4%) for efficacy. Sample size re-estimation was commonly used (8 (61.5%)). In 69% of the trials, simulation including Bayesian approach was used to define the statistical stopping rules. The adaptive designs have been increasingly used (from 0 to 1999 to 38.6% after 2015 amongst adaptive trials). 25% of the trials reported "adaptive" in abstract or title of the studies. CONCLUSIONS The application of adaptive trials is increasingly popular in cardiovascular clinical trials. The reporting of adaptive design needs improving.
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Affiliation(s)
- Jufen Zhang
- School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, U.K..
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, U.K..
| | - Christy Saju
- School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, U.K
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Nayak A, Hall SA, Uriel N, Goldstein DJ, Cleveland JC, Cowger JA, Salerno CT, Naka Y, Horstmanshof D, Crandall D, Wang A, Mehra MR. Predictors of 5-Year Mortality in Patients Managed With a Magnetically Levitated Left Ventricular Assist Device. J Am Coll Cardiol 2023; 82:771-781. [PMID: 37612008 DOI: 10.1016/j.jacc.2023.05.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND In advanced heart failure patients implanted with a fully magnetically levitated HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD), it is unknown how preimplant factors and postimplant index hospitalization events influence 5-year mortality in those able to be discharged. OBJECTIVES The goal was to identify risk predictors of mortality through 5 years among HM3 LVAD recipients conditional on discharge from index hospitalization in the MOMENTUM 3 pivotal trial. METHODS This analysis evaluated 485 of 515 (94%) patients discharged after implantation of the HM3 LVAD. Preimplant (baseline), implant surgery, and index hospitalization characteristics were analyzed individually, and as multivariable predictors for mortality risk through 5 years. RESULTS Cumulative 5-year mortality in the cohort (median age: 62 years, 80% male, 65% White, 61% destination therapy due to transplant ineligibility) was 38%. Two preimplant characteristics (elevated blood urea nitrogen and prior coronary artery bypass graft or valve procedure) and 3 postimplant characteristics (hemocompatibility-related adverse events, ventricular arrhythmias, and estimated glomerular filtration rate <60 mL/min/1.73 m2 at discharge) were predictors of 5-year mortality. In 171 of 485 patients (35.3%) without any risk predictors, 5-year mortality was reduced to 22.6% (95% CI: 15.4%-32.7%). Even among those with 1 or more predictors, mortality was <50% at 5 years (45.7% [95% CI: 39.0%-52.8%]). CONCLUSIONS Long-term survival in successfully discharged HM3 LVAD recipients is largely influenced by clinical events experienced during the index surgical hospitalization in tandem with baseline factors, with mortality of <50% at 5 years. In patients without identified predictors of risk, long-term 5-year mortality is low and rivals that achieved with heart transplantation, even though most were implanted with destination therapy intent. (MOMENTUM 3 IDE Clinical Study Protocol, NCT02224755; MOMENTUM 3 Pivotal Cohort Extended Follow-up PAS, NCT03982979).
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Affiliation(s)
- Aditi Nayak
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | | | | | | | | | | | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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10
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Schweiger M, Hussein H, de By TMMH, Zimpfer D, Sliwka J, Davies B, Miera O, Meyns B. Use of Intracorporeal Durable LVAD Support in Children Using HVAD or HeartMate 3-A EUROMACS Analysis. J Cardiovasc Dev Dis 2023; 10:351. [PMID: 37623364 PMCID: PMC10455245 DOI: 10.3390/jcdd10080351] [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: 07/08/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Purpose: The withdrawal of HVAD in 2021 created a concern for the pediatric population. The alternative implantable centrifugal blood pump HeartMate 3 has since been used more frequently in children. This paper analyses the outcome of children on LVAD support provided with an HVAD or HM3. Methods: A retrospective analysis of the EUROMACS database on children supported with VAD < 19 years of age from 1 January 2009 to 1 December 2021 was conducted. All patients with an LVAD and either an HVAD or HM3 were included. Patients with missing data on VAD status and/or missing baseline and/or follow up information were excluded. Kaplan-Meier survival analysis was performed to evaluate survival differences. Analyses were performed using Fisher's exact test. Results: The study included 150 implantations in 142 patients with 128 implants using an HVAD compared to 28 implants using an HM3. Nine patients (6%) needed temporary right ventricular mechanical support, which was significantly higher in the HM3 group, with 25% (p: 0.01). Patients in the HVAD group were significantly younger (12.7 vs. 14.5 years, p: 0.01), weighed less (45.7 vs. 60 kg, p: <0.000) and had lower BSA values (1.3 vs. 1.6 m2, p: <0.000). Median support time was 204 days. Overall, 98 patients (69%) were discharged and sent home, while 87% were discharged in group HM3 (p: ns). A total of 123 children (86%) survived to transplantation, recovery or are ongoing, without differences between groups. In the HVAD group, 10 patients (8%) died while on support, whereas in 12% of HM3 patients died (p: 0.7). Conclusions: Survival in children implanted with an HM3 was excellent. Almost 90% were discharged and sent home on the device.
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Affiliation(s)
- Martin Schweiger
- Department of Congenital Cardiovascular Surgery, Pediatric Heart Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Hina Hussein
- Quality and Outcomes Research Unit, University Hospital Birmingham, Birmingham B15 2TH, UK;
| | | | - Daniel Zimpfer
- Department for Heart Surgery, Medical University Graz, Graz A-8010, Austria
| | - Joanna Sliwka
- Department of Cardiac Surgery, Transplantology and Vascular Surgery, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Ben Davies
- Royal Children’s Hospital, Melbourne 3052, Australia;
| | - Oliver Miera
- Department of Congenital Heart Diseases—Pediatric Cardiology, Deutsches Herzzentrum der Charité, 13353 Berlin, Germany;
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium;
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11
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Meissner F, Eichelkraut D, Schimmel M, Maier S, Vestner H, Schoen M, Czerny M, Bothe W. Impact of an Accessory for Left Ventricular Assist Devices on Device Flow and Pressure Head In Vitro. Bioengineering (Basel) 2023; 10:bioengineering10040486. [PMID: 37106673 PMCID: PMC10135582 DOI: 10.3390/bioengineering10040486] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
A novel accessory directing the blood from the outflow of a left ventricular assist device (LVAD) back through the left ventricular apex and across the aortic valve allows LVAD implantation via the left ventricular apex solely but may affect the LVAD performance. We quantified the effect of the accessory on LVAD flow and pressure head in vitro. In a mock circulatory loop, a centrifugal-flow LVAD (HeartMate 3, Abbott, Abbott Park, IL, USA) with (Accessory) and without the accessory (Control) was compared under physiological conditions using a water/glycerol solution as a blood substitute. The pump was operated at 4000, 5200, and 6400 rpm and 5 different resistance levels. Flow, inlet, and outlet pressure were measured, and pressure head was calculated. Compared to the Control, flow and pressure head in the Accessory group were reduced by an overall average of 0.26 L/min and 9.9 mmHg (all speeds and resistance levels). The highest decline in flow and pressure head occurred at the lowest resistance levels. In conclusion, the accessory leads to a reduction of LVAD flow and pressure head that is enhanced by decreases in resistance. Future developments in the LVAD accessory's design may reduce these effects and allow unimpaired LVAD performance and minimally invasive device implantation.
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Affiliation(s)
- Florian Meissner
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Derya Eichelkraut
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Marius Schimmel
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Heiko Vestner
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Manuela Schoen
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Wolfgang Bothe
- Department of Cardiovascular Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
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Milam AJ, Ramakrishna H. Predicting Survival After HeartMate 3 Left Ventricular Assist Device Implantation-Progress Continues. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00250-1. [PMID: 37149472 DOI: 10.1053/j.jvca.2023.04.015] [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: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Adam J Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
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The Impact of MOMENTUM 3 Trial Eligibility on Left Ventricular Assist Device Outcomes: A Real-World Experience. J Surg Res 2023; 287:40-46. [PMID: 36868122 DOI: 10.1016/j.jss.2023.01.015] [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: 09/20/2022] [Revised: 01/01/2023] [Accepted: 01/28/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION Although the landmark MOMENTUM 3 trial was associated with excellent short-term left ventricular assist device (LVAD) outcomes, many end-stage heart failure patients would not have met the trial eligibility criteria. Moreover, the outcomes of trial ineligible patients are poorly characterized. Therefore, we undertook this study to compare MOMENTUM 3 eligible and ineligible patients. METHODS We conducted a retrospective review of all primary LVAD implants from 2017 to 2022. Primary stratification was according to MOMENTUM 3 inclusion and exclusion criteria. Primary outcome was survival. Secondary outcomes included complications and length of stay. Multivariable Cox proportional hazards regression models were constructed to further characterize outcomes. RESULTS From 2017 to 2022, 96 patients underwent primary LVAD implantation. Thirty-seven (38.54%) patients were trial eligible while 59 (61.46%) were ineligible. When stratified by trial eligibility, patients who were trial eligible had higher 1-year (80.15% versus 94.52%, P = 0.04) and 2-year survival (70.17% versus 94.52%, P = 0.02). Multivariable analysis showed that trial eligibility was protective of mortality at both 1 y (HR: 0.19 [0.04-0.99], P = 0.049) and 2 y (HR: 0.17 [0.03-0.81], P = 0.03). Although the groups had similar rates of bleeding, stroke, and right ventricular failure, trial ineligibility was associated with a longer periprocedural length of stay. CONCLUSIONS In conclusion, the majority of contemporary LVAD patients would not have been eligible for the MOMENTUM 3 trial. Ineligible patients have decreased but acceptable short-term survival. Our findings suggest that a simply reductionist approach to short-term mortality may improve outcomes but fail to capture the majority of patients who could benefit from therapy.
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14
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Design of an Innovative Wireless Left Ventricular Assist Device Driven by either Extracorporeal Magnets or an Intracorporeal Battery Pack. ASAIO J 2023; 69:e73-e79. [PMID: 36716071 DOI: 10.1097/mat.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
This study aimed to design a new wireless left ventricular assist device (LVAD) that solved the driveline problem of current LVADs and the heat problem of the transcutaneous energy transfer system (TETS). Our new wireless LVAD consisted of two blood pumps capable of driving using extracorporeal magnets and an intracorporeal battery pack. When one pump was driven, the other pump was stopped. The battery pack was wirelessly and slowly charged using TETS with low-power transmission, whereas the magnetic pump was driven wirelessly by extracorporeal magnets. We demonstrated the feasibility of our system in a bench-top durability test for 7 days. The distance between the extracorporeal magnets and the magnetic pump was 27.5 mm. Our LVAD system had steadily provided sufficient pressure and flow volume (approximately 108 mmHg and 5.0 L/min, respectively) to the test loop for 7 days. Although loss of synchronism occurred once during the test, it recovered within a few minutes. The results demonstrate the feasibility of the proposed wireless LVAD system. Further technical improvements are required in our system, such as downsizing the electric devices inside the body, to conduct an in vivo test for the next step.
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15
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Uriel N, Milano C, Agarwal R, Lee S, Cleveland J, Goldstein D, Wang A, Crandall D, Mehra MR. Incidence and clinical correlates of de-novo aortic regurgitation with a fully magnetically levitated left ventricular assist device: a MOMENTUM 3 trial portfolio analysis. Eur J Heart Fail 2023; 25:286-294. [PMID: 36404406 DOI: 10.1002/ejhf.2746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS We assessed the incidence, predictors and clinical correlates of de-novo aortic regurgitation (AR), which physiologically reduces left ventricular assist device (LVAD) effectiveness due to recirculation syndrome, in the MOMENTUM 3 trial portfolio of the fully magnetically levitated HeartMate 3 (HM3) pump using the randomized pivotal trial (PT) and post-trial continued access protocol (CAP). METHODS AND RESULTS De-novo aortic regurgitation incidence at 2 years was analysed in the randomized PT and validated in the first 1000 implanted patients of the CAP. Patients with concomitant/prior aortic valve surgery or without baseline or post-implant echocardiograms were excluded from this analysis. AR severity was assessed qualitatively by site-adjudicated echocardiograms (significant AR was defined as moderate or severe grade on echocardiogram). Of 1028 patients enrolled in the PT, 918 were eligible for inclusion in this analysis (HM3, n = 465; HMII, n = 453). At 2 years of LVAD support, freedom from significant AR was greater in the HM3 (92%) than HMII (82%) (hazard ratio 0.45, 95% confidence interval 0.27-0.75, p < 0.01). Of 907 HM3 patients analysed from the first 1000 implanted CAP patients, the rate of freedom from significant AR was 90%, consistent with the PT (p = 0.3). In the combined HM3 group (n = 1372), multivariable Cox modelling identified increasing age and female sex as significant predictors. Survival free of urgent transplant or AR corrective procedure was similar between HM3 patients with and without significant de-novo AR. CONCLUSIONS The development of moderate or severe grade de-novo AR is reduced with the fully magnetically levitated HM3 LVAD compared to the axial-flow HMII pump. The occurrence of significant de-novo AR with the HM3 pump is not associated with a worse outcome at 2 years of follow-up.
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Affiliation(s)
- Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richa Agarwal
- Section of Advanced Heart Failure and Cardiac Transplantation, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Sangjin Lee
- Division of Medicine, Advanced Heart Failure and Transplantation, Spectrum Health Meijer Heart & Vascular Institute, Grand Rapids, MI, USA
| | - Joseph Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Daniel Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Einstein Center for Heart and Vascular Care, Bronx, NY, USA
| | - AiJia Wang
- Clinical Biostatistics - Heart Failure, Abbott, Burlington, MA, USA
| | - Daniel Crandall
- Global Clinical Affairs - Heart Failure, Abbott, Pleasanton, CA, USA
| | - Mandeep R Mehra
- Heart and Vascular Center, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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16
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Current status of adult cardiac surgery-part 2. Curr Probl Surg 2023; 60:101245. [PMID: 36642488 DOI: 10.1016/j.cpsurg.2022.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/13/2022] [Indexed: 12/13/2022]
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17
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Hirschhorn M, Catucci N, Day SW, Stevens RM, Tchantchaleishvili V, Throckmorton AL. Channel impeller design for centrifugal blood pump in hybrid pediatric total artificial heart: Modeling, magnet integration, and hydraulic experiments. Artif Organs 2022; 47:680-694. [PMID: 36524792 DOI: 10.1111/aor.14480] [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: 07/22/2022] [Revised: 10/10/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this research is to address ongoing device shortfalls for pediatric patients by developing a novel pediatric hybrid total artificial heart (TAH). The valveless magnetically-levitated MCS device (Dragon Heart) has only two moving parts, integrates an axial and centrifugal blood pump into a single device, and will occupy a compact footprint within the chest for the pediatric patient population. METHODS Prior work on the Dragon Heart focused on the development of pump designs to achieve hemodynamic requirements. The impeller of these pumps was shaft-driven and thus could not be integrated for testing. The presented research leverages an existing magnetically levitated axial flow pump and focuses on centrifugal pump development. Using the axial pump diameter as a geometric constraint, a shaftless, magnetically supported centrifugal pump was designed for placement circumferentially around the axial pump domain. The new design process included the computational analysis of more than 50 potential centrifugal impeller geometries. The resulting centrifugal pump designs were prototyped and tested for levitation and no-load rotation, followed by in vitro testing using a blood analog. To meet physiologic demands, target performance goals were pressure rises exceeding 90 mm Hg for flow rates of 1-5 L/min with operating speeds of less than 5000 RPM. RESULTS Three puck-shaped, channel impellers for the centrifugal blood pump were selected based on achieving performance and space requirements for magnetic integration. A quasi-steady flow analysis revealed that the impeller rotational position led to a pulsatile component in the pressure generation. After prototyping, the centrifugal prototypes (3, 4, and 5 channeled designs) demonstrated levitation and no-load rotation. Hydraulic experiments established pressure generation capabilities beyond target requirements. The pressure-flow performance of the prototypes followed expected trends with a dependence on rotational speed. Pulsatile blood flow was observed without pump-speed modulation due to rotating channel passage frequency. CONCLUSION The results are promising in the advancement of this pediatric TAH. The channeled impeller design creates pressure-flow curves that are decoupled from the flow rate, a benefit that could reduce the required controller inputs and improve treatment of hypertensive patients.
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Affiliation(s)
- Matthew Hirschhorn
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Nicholas Catucci
- Drexel Machine Shop, Office of Research and Innovation, Drexel University, Philadelphia, Pennsylvania, USA
| | - Steven W Day
- Department of Biomedical Engineering, Kate Gleason College of Engineering, Rochester Institute of Technology, Rochester, New York, USA
| | - Randy M Stevens
- Pediatrics, College of Medicine, St. Christopher's Hospital for Children, Drexel University, Philadelphia, Pennsylvania, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amy L Throckmorton
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
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Bjelic M, Wood KL, Simon BV, Vidula H, Cheyne C, Chase K, Wu IY, Alexis JD, McNitt S, Goldenberg I, Gosev I. Left atrial appendage exclusion with less invasive left ventricular assist device implantation. J Card Surg 2022; 37:4967-4974. [PMID: 36378835 DOI: 10.1111/jocs.17200] [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: 09/13/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The objective of this single-center, pilot, prospective, and historical control study is to evaluate safety and feasibility outcomes associated with left atrial appendage exclusion (LAAE) concomitant with left ventricular assist device (LVAD) implantation via less invasive surgery (LIS) as a stroke prevention strategy. METHODS A predefined number of 30 eligible subjects scheduled for LIS LVAD with LAAE were enrolled in the prospective arm between January 2020 and February 2021. Eligible retrospective LIS LVAD patients without LAAE were propensity-matched in a 1:1 ratio with the prospective arm subjects. The primary study objectives were to evaluate the safety, feasibility, and efficacy of the LAAE concomitant with LIS LVAD. RESULTS Preoperative characteristics of patients in the Non-LAAE and LAAE groups were similar. LAAE was successfully excluded in all prospective patients (100%). Primary safety endpoints of chest tube output within the first 24 postoperative hours, Reoperation for bleeding within 48 h, and index hospitalization mortality demonstrated comparable safety of LAAE versus Non-LAAE with LIS LVAD. Cox proportional hazard regression demonstrated that LAAE with LIS LVAD was associated with 37% and 49% reduction in the risk of stroke and disabling stroke, respectively (p > .05). CONCLUSION Results from our pilot study demonstrated the safety and feasibility of LAAE concomitant with LIS LVAD as a stroke prevention strategy. This is the first prospective study describing LAAE performed concomitantly to less invasive LVAD implantation. The efficacy of LAAE in long-term stroke prevention needs to be confirmed in future prospective randomized clinical trials.
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Affiliation(s)
- Milica Bjelic
- Department of Surgery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine L Wood
- Department of Surgery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bartholomew V Simon
- Department of Surgery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Himabindu Vidula
- Department of Medicine, Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Christina Cheyne
- Department of Medicine, Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Karin Chase
- Department of Surgery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Isaac Y Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeffrey D Alexis
- Department of Medicine, Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, New York, USA
| | - Igor Gosev
- Department of Surgery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York, USA
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19
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Mehra MR, Goldstein DJ, Cleveland JC, Cowger JA, Hall S, Salerno CT, Naka Y, Horstmanshof D, Chuang J, Wang A, Uriel N. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA 2022; 328:1233-1242. [PMID: 36074476 PMCID: PMC9459909 DOI: 10.1001/jama.2022.16197] [Citation(s) in RCA: 166] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Although durable left ventricular assist device (LVAD) therapy has emerged as an important treatment option for patients with advanced heart failure refractory to pharmacological support, outcomes, including survival, beyond 2 years remain poorly characterized. OBJECTIVE To report the composite end point of survival to transplant, recovery, or LVAD support free of debilitating stroke (Modified Rankin Scale score >3) or reoperation to replace the pump 5 years after the implant in participants who received the fully magnetically levitated centrifugal-flow HeartMate 3 or axial-flow HeartMate II LVAD in the MOMENTUM 3 randomized trial and were still receiving LVAD therapy at the 2-year follow-up. DESIGN, SETTING, AND PARTICIPANTS This observational study was a 5-year follow-up of the MOMENTUM 3 trial, conducted in 69 US centers, that demonstrated superiority of the centrifugal-flow LVAD to the axial-flow pump with respect to survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump at 2 years. A total of 295 patients were enrolled between June 2019 to April 2021 in the extended-phase study, with 5-year follow-up completed in September 2021. EXPOSURES Of 1020 patients in the investigational device exemption per-protocol population, 536 were still receiving LVAD support at 2 years, of whom 289 received the centrifugal-flow pump and 247 received the axial-flow pump. MAIN OUTCOMES AND MEASURES There were 10 end points evaluated at 5 years in the per-protocol population, including a composite of survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump between the centrifugal-flow and axial-flow pump groups and overall survival between the 2 groups. RESULTS A total of 477 patients (295 enrolled and 182 provided limited data) of 536 patients still receiving LVAD support at 2 years contributed to the extended-phase analysis (median age, 62 y; 86 [18%] women). The 5-year Kaplan-Meier estimate of survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump in the centrifugal-flow vs axial-flow group was 54.0% vs 29.7% (hazard ratio, 0.55 [95% CI, 0.45-0.67]; P < .001). Overall Kaplan-Meier survival was 58.4% in the centrifugal-flow group vs 43.7% in the axial-flow group (hazard ratio, 0.72 [95% CI, 0.58-0.89]; P = .003). Serious adverse events of stroke, bleeding, and pump thrombosis were less frequent in the centrifugal-flow pump group. CONCLUSIONS AND RELEVANCE In this observational follow-up study of patients from the MOMENTUM 3 randomized trial, per-protocol analyses found that receipt of a fully magnetically levitated centrifugal-flow LVAD vs axial-flow LVAD was associated with a better composite outcome and higher likelihood of overall survival at 5 years. These findings support the use of the fully magnetically levitated LVAD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02224755 and NCT03982979.
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Affiliation(s)
| | | | | | | | | | | | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Medical College, New York, New York
| | | | | | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, New York
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20
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George TJ, Aldrich A, Smith RL, Ryan WH, DiMaio JM, Kabra N, Afzal A, Rawitscher DA. Development of a non‐transplant left ventricular assist device program. J Card Surg 2022; 37:3188-3198. [DOI: 10.1111/jocs.16790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Timothy J. George
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Allison Aldrich
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Robert L. Smith
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - William H. Ryan
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - J. Michael DiMaio
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Nitin Kabra
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Aasim Afzal
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - David A. Rawitscher
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
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21
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Comparison of the Hemocompatibility of an Axial and a Centrifugal Left Ventricular Assist Device in an In Vitro Test Circuit. J Clin Med 2022; 11:jcm11123431. [PMID: 35743501 PMCID: PMC9225365 DOI: 10.3390/jcm11123431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hemocompatibility of left ventricular assist devices is essential for preventing adverse events. In this study, we compared the hemocompatibility of an axial-flow (Sputnik) to a centrifugal-flow (HeartMate 3) pump. METHODS Both pumps were integrated into identical in vitro test circuits, each filled with 75 mL heparinized human blood of the same donor. During each experiment (n = 7), the pumps were operated with equal flow for six hours. Blood sampling and analysis were performed on a regular schedule. The analytes were indicators of hemolysis, coagulation activation, platelet count and activation, as well as extracellular vesicles. RESULTS Sputnik induced higher hemolysis compared to the HeartMate 3 after 360 min. Furthermore, platelet activation was higher for Sputnik after 120 min onward. In the HeartMate 3 circuit, the platelet count was reduced within the first hour. Furthermore, Sputnik triggered a more pronounced increase in extracellular vesicles, a potential trigger for adverse events in left ventricular assist device application. Activation of coagulation showed a time-dependent increase, with no differences between both groups. CONCLUSIONS This experimental study confirms the hypothesis that axial-flow pumps may induce stronger hemolysis compared to centrifugal pumps, coming along with larger amounts of circulating extracellular vesicles and a stronger PLT activation.
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22
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Fang P, Du J, Boraschi A, Bozzi S, Redaelli A, Schmid Daners M, Kurtcuoglu V, Consolo F, de Zélicourt D. Insights Into the Low Rate of In-Pump Thrombosis With the HeartMate 3: Does the Artificial Pulse Improve Washout? Front Cardiovasc Med 2022; 9:775780. [PMID: 35360020 PMCID: PMC8962620 DOI: 10.3389/fcvm.2022.775780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/02/2022] [Indexed: 01/14/2023] Open
Abstract
While earlier studies reported no relevant effect of the HeartMate 3 (HM3) artificial pulse (AP) on bulk pump washout, its effect on regions with prolonged residence times remains unexplored. Using numerical simulations, we compared pump washout in the HM3 with and without AP with a focus on the clearance of the last 5% of the pump volume. Results were examined in terms of flush-volume (Vf, number of times the pump was flushed with new blood) to probe the effect of the AP independent of changing flow rate. Irrespective of the flow condition, the HM3 washout scaled linearly with flush volume up to 70% washout and slowed down for the last 30%. Flush volumes needed to washout 95% of the pump were comparable with and without the AP (1.3–1.4 Vf), while 99% washout required 2.1–2.2 Vf with the AP vs. 2.5 Vf without the AP. The AP enhanced washout of the bend relief and near-wall regions. It also transiently shifted or eliminated stagnation regions and led to rapid wall shear stress fluctuations below the rotor and in the secondary flow path. Our results suggest potential benefits of the AP for clearance of fluid regions that might elicit in-pump thrombosis and provide possible mechanistic rationale behind clinical data showing very low rate of in-pump thrombosis with the HM3. Further optimization of the AP sequence is warranted to balance washout efficacy while limiting blood damage.
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Affiliation(s)
- Peng Fang
- School of Mechanical Engineering and Automation, Harbin Institute of Technology, Shenzhen, Shenzhen, China
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Jianjun Du
- School of Mechanical Engineering and Automation, Harbin Institute of Technology, Shenzhen, Shenzhen, China
| | - Andrea Boraschi
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Silvia Bozzi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Marianne Schmid Daners
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Filippo Consolo
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
- Università Vita Salute San Raffaele, Milano, Italy
| | - Diane de Zélicourt
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- *Correspondence: Diane de Zélicourt
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23
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Yang M, Houck KL, Dong X, Hernandez M, Wang Y, Nathan SS, Wu X, Afshar-Kharghan V, Fu X, Cruz MA, Zhang J, Nascimbene A, Dong JF. Hyperadhesive von Willebrand Factor Promotes Extracellular Vesicle-Induced Angiogenesis: Implication for LVAD-Induced Bleeding. JACC Basic Transl Sci 2022; 7:247-261. [PMID: 35411318 PMCID: PMC8993768 DOI: 10.1016/j.jacbts.2021.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/22/2022]
Abstract
VWF in patients on LVAD supports was hyperadhesive, activated platelets, and generated platelet-derived extracellular vesicles. Extracellular vesicles from LVAD patients and those from shear-activated platelets promoted aberrant angiogenesis in a VWF-dependent manner. The activated VWF exposed the A1 domain through the synergistic actions of oxidative stress and HSS generated in LVAD-driven circulation.
Bleeding associated with left ventricular assist device (LVAD) implantation has been attributed to the loss of large von Willebrand factor (VWF) multimers to excessive cleavage by ADAMTS-13, but this mechanism is not fully supported by the current evidence. We analyzed VWF reactivity in longitudinal samples from LVAD patients and studied normal VWF and platelets exposed to high shear stress to show that VWF became hyperadhesive in LVAD patients to induce platelet microvesiculation. Platelet microvesicles activated endothelial cells, induced vascular permeability, and promoted angiogenesis in a VWF-dependent manner. Our findings suggest that LVAD-driven high shear stress primarily activates VWF, rather than inducing cleavage in the majority of patients.
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Key Words
- ADAMTS-13:Ag, ADAMTS-13 antigen
- AVS, aortic vascular segment
- EC, endothelial cell
- EV, extracellular vesicle
- EVFP, extracellular vesicle–free plasma
- GI, gastrointestinal
- GOF, gain of function
- GP, glycoprotein
- GPM, growth factor-poor medium
- GRM, growth factor-rich medium
- HSS, high shear stress
- LVAD, left ventricular assist device
- PS, phosphatidylserine
- SIPA, shear-induced platelet aggregation
- ULVWF, ultra-large von Willebrand factor
- VEGF, vascular endothelial growth factor
- VWF, von Willebrand factor
- VWF:Ag, von Willebrand factor antigen
- VWF:CB, von Willebrand factor binding to collagen
- VWF:pp, von Willebrand factor propeptide
- aVWS, acquired von Willebrand syndrome
- angiogenesis
- extracellular vesicles
- left ventricular assist devices
- pEV, extracellular vesicle from von Willebrand factor-activated platelets
- platelets
- shear stress
- von Willebrand factor
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Affiliation(s)
- Mengchen Yang
- Bloodworks Research Institute, Seattle, Washington, USA.,Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
| | - Katie L Houck
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Xinlong Dong
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Maria Hernandez
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Yi Wang
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Sriram S Nathan
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Xiaoping Wu
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Department of Pulmonary Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Xiaoyun Fu
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Miguel A Cruz
- Cardiovascular Research Section, Department of Medicine, Baylor College of Medicine.,Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Angelo Nascimbene
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington, USA.,Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Park Y, Kim D, Yang JH, Cho YH, Choi JO, Jeon ES. Clinical outcome in patients with end-stage heart failure who underwent continuous-flow left ventricular assist devices in a single center. Korean J Intern Med 2022; 37:340-349. [PMID: 34871480 PMCID: PMC8925944 DOI: 10.3904/kjim.2021.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The continuous flow left ventricular assist device (cf-LVAD) has improved the survival of chronic end-stage heart failure (HF) patients. Here we describe our clinical experience of the initial 50 LVAD patients from a single center. METHODS A total of 50 patients underwent LVAD implantation as bridge to transplantation (BTT; n = 28, 56%), bridge to candidacy (BTC; n = 2, 4%), or as destination therapy (DT; n = 20, 40%) from 2012 to 2019. Pre-implant characteristics and clinical outcomes were compared between BTT/BTC and DT. RESULTS The median age of patients was 67 years (range, 59 to 73). Men were more likely to receive LVAD (76% vs. 24%) than women. DT patients were older, had smaller body surface area, and worse laboratory profiles than BTT/BTC patients. There was no in-hospital mortality. During an average of 14 months (range, 8 to 23), the all-cause mortality was 22%. The first-year survival was 86 and 90% in BTT/BTC and DT groups, respectively. Hemorrhagic stroke was the most common cause (27%) of death. In the BTT/BTC group, 22 patients successfully underwent heart transplantation during median duration of 10 months (range, 7 to 14). The most common post-LVAD complication during the first year of LVAD implantation was major bleeding (44%). A significant proportion (76%) of patients experienced rehospitalization with gastrointestinal bleeding as the most common cause. CONCLUSION We describe short-term clinical outcome of LVAD patients from a single center for the first time in Korea. With the newer generation LVAD and a dedicated team approach, improved clinical outcomes of LVAD for end-stage HF are expected.
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Affiliation(s)
- Yoonjee Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
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25
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Petersen E. Development of Mechanical Circulatory Support Devices: 55 Years and Counting. AACN Adv Crit Care 2021; 32:424-433. [PMID: 34879140 DOI: 10.4037/aacnacc2021811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Heart failure is a leading cause of morbidity and mortality in the United States. Treatment of this condition increasingly involves mechanical circulatory support devices. Even with optimal medical therapy and use of simple cardiac devices, heart failure often leads to reduced quality of life and a shortened life span, prompting exploration of more advanced treatment approaches. Left ventricular assist devices constitute an effective alternative to cardiac transplantation. These devices are not without complications, however, and their use requires careful cooperative management by the patient's cardiology team and primary care provider. Left ventricular assist devices have undergone many technological advancements since they were first introduced, and they will continue to evolve. This article reviews the history of different types of left ventricular assist devices, appropriate patient selection, and common complications in order to increase health professionals' familiarity with these treatment options.
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Affiliation(s)
- Emalie Petersen
- Emalie Petersen is Mechanical Circulatory Support Nurse Practitioner and Coordinator, Bryan Heart Institute, 1600 South 48th St, Suite 600, Lincoln, NE 68506
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26
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Dabbagh SR, Alseed MM, Saadat M, Sitti M, Tasoglu S. Biomedical Applications of Magnetic Levitation. ADVANCED NANOBIOMED RESEARCH 2021. [DOI: 10.1002/anbr.202100103] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sajjad Rahmani Dabbagh
- Department of Mechanical Engineering Koç University Sariyer Istanbul Turkey 34450
- Koç University Arçelik Research Center for Creative Industries (KUAR) Koç University Sariyer Istanbul Turkey 34450
| | - M. Munzer Alseed
- Institute of Biomedical Engineering Boğaziçi University Çengelköy Istanbul Turkey 34684
| | - Milad Saadat
- Department of Mechanical Engineering Koç University Sariyer Istanbul Turkey 34450
| | - Metin Sitti
- Department of Mechanical Engineering Koç University Sariyer Istanbul Turkey 34450
- School of Medicine Koç University Istanbul 34450 Turkey
- Physical Intelligence Department Max Planck Institute for Intelligent Systems 70569 Stuttgart Germany
| | - Savas Tasoglu
- Department of Mechanical Engineering Koç University Sariyer Istanbul Turkey 34450
- Koç University Arçelik Research Center for Creative Industries (KUAR) Koç University Sariyer Istanbul Turkey 34450
- Institute of Biomedical Engineering Boğaziçi University Çengelköy Istanbul Turkey 34684
- Physical Intelligence Department Max Planck Institute for Intelligent Systems 70569 Stuttgart Germany
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Sheikh FH, Ravichandran AK, Goldstein DJ, Agarwal R, Ransom J, Bansal A, Kim G, Cleveland JC, Uriel N, Sheridan BC, Chomsky D, Patel SR, Dirckx N, Franke A, Mehra MR. Impact of Race on Clinical Outcomes After Implantation With a Fully Magnetically Levitated Left Ventricular Assist Device: An Analysis From the MOMENTUM 3 Trial. Circ Heart Fail 2021; 14:e008360. [PMID: 34525837 DOI: 10.1161/circheartfailure.120.008360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure disproportionately affects Black patients. Whether differences among race influence outcomes in advanced heart failure with use of a fully magnetically levitated continuous-flow left ventricular assist device remains uncertain. METHODS We included 515 IDE (Investigational Device Exemption) clinical trial patients and 500 Continued Access Protocol patients implanted with the HeartMate 3 left ventricular assist device in the MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3). Outcomes were compared between Black and White left ventricular assist device recipients for the primary end point of survival free of disabling stroke or reoperation to replace or remove a malfunctioning device at 2 years, overall survival, adverse events, 6-minute walk distance, and quality of life scores. RESULTS Of 1015 HeartMate 3 patients, 675 were self-identified as White and 285 as Black individuals. The Black patient cohort was younger, more obese and with a history of hypertension, and more nonischemic cause of heart failure, relative to the White patient group. Black and White patients did not experience a difference in the primary end point (81.1% versus 77.9%; hazard ratio, 1.08 [95% CI, 0.76-1.54], P=0.6568). Black patients were at higher risk of adverse events (calculated as events per 100 patient-years), including bleeding (75.4 versus 63.5; P<0.0001), stroke (9.5 versus 7.2; P=0.0183), and hypertension (10.1 versus 3.2; P<0.0001). The 6-minute walk distance was not different at baseline and 6 months between the groups, however, the absolute change from baseline was greater for White patients (median: +183.0 [interquartile range, 42.0-335.3] versus +163.8 [interquartile range, 42.3-315.0] meters, P=0.01). The absolute quality of life measurement (EuroQoL group, 5-dimension, 5-level instrument visual analog scale) at baseline and 6 months was better in the Black patient group, but relative improvement from baseline to 6 months was greater in White patients (median: +20.0 [interquartile range, 5.0-40.0] versus +25.0 [interquartile range, 10.0-45.0]; P=0.0298). CONCLUSIONS Although the survival free of disabling stroke or reoperation to replace/remove a malfunctioning device at 2 years with the HM 3 left ventricular assist device did not differ by race, Black HeartMate 3 patients experienced a higher morbidity burden and smaller gains in functional capacity and quality of life when compared with White patients. These findings require efforts designed to better understand and overcome these gaps through systematic identification and tackling of putative factors. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02224755 and NCT02892955.
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Affiliation(s)
- Farooq H Sheikh
- Medstar Heart and Vascular Institute, Washington, DC (F.H.S.)
| | | | | | | | - John Ransom
- Baptist Health, Heart and Transplant Institute, Little Rock, AR (J.R.)
| | | | - Gene Kim
- University of Chicago Medical Center, IL (G.K.)
| | | | - Nir Uriel
- New York Presbyterian and Columbia University (N.U.)
| | | | | | | | - Nick Dirckx
- Global Biometrics, Abbott, Plymouth, MN (N.D.)
| | - Abi Franke
- Global Clinical Affairs - Heart Failure, Abbott, Sylmar, CA (A.F.)
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA (M.R.M.)
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Kervan U, Kocabeyoglu SS, Emre Sert D, Karahan M, Temizhan A, Demirkan B, Akin Y, Beyazal OF, Akdi M, Catav Z. Midterm Results of Minimally Invasive Left Thoracotomy Fully Magnetically Levitated Left Ventricular Assist Device Implantation. ASAIO J 2021; 67:1006-1011. [PMID: 33528161 DOI: 10.1097/mat.0000000000001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study is to compare outcomes of the patients who underwent HeartMate3 (HM3) implantation with conventional sternotomy (CS) and minimally invasive thoracotomy technique (MILT). From June 2013 to April 2019, 50 patients who underwent isolated HM3 implantation were included. Patients were divided into two groups according to the operative technique; of 50 patients, 28 were implanted with CS and 22 with MILT. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit stay, time on mechanical ventilation, and postoperative right ventricular failure. Primary outcomes were early mortality and occurrence of adverse events. Patients characteristics were similar; preoperative central venous pressure (CVP) and the ratio of CVP to pulmonary capillary wedge pressure (CVP/PCWP) were significantly higher in the MILT group versus the CS group (p < 0.05). Intensive care unit stay was significantly shorter in the MILT group (p < 0.05). Incidence of bleeding requiring exploratory sternotomy and postoperative drainage on the first postoperative day were statistically higher in the CS group (p < 0.05). Right ventricular failure was higher in the CS group but was not statistically significant (p = 0.4). There was no significant difference in long-term adverse events. The Kaplan-Meier survival analysis showed no difference between the groups (p = 0.66). The HM3 assist system can be successfully implanted with the MILT technique, which has proved to be safe and reproducible and yields good clinical outcomes.
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Affiliation(s)
- Umit Kervan
- From the Department of Cardiovascular Surgery
| | | | | | | | - Ahmet Temizhan
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Burcu Demirkan
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Yesim Akin
- Department of Cardiology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | | | | | - Zeki Catav
- From the Department of Cardiovascular Surgery
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29
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Mehra MR, Cleveland JC, Uriel N, Cowger JA, Hall S, Horstmanshof D, Naka Y, Salerno CT, Chuang J, Williams C, Goldstein DJ. Primary results of long-term outcomes in the MOMENTUM 3 pivotal trial and continued access protocol study phase: a study of 2200 HeartMate 3 left ventricular assist device implants. Eur J Heart Fail 2021; 23:1392-1400. [PMID: 33932272 PMCID: PMC8453814 DOI: 10.1002/ejhf.2211] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 01/02/2023] Open
Abstract
AIM The MOMENTUM 3 pivotal trial established superiority of the HeartMate 3 (HM3) left ventricular assist device (LVAD), a fully magnetically levitated centrifugal-flow pump, over the HeartMate II axial-flow pump. We now evaluate HM3 LVAD outcomes in a single-arm prospective continuous access protocol (CAP) post-pivotal trial study. METHODS AND RESULTS We enrolled 2200 HM3 implanted patients (515 pivotal trial and 1685 CAP patients) and compared outcomes including survival free of disabling stroke or reoperation to replace or remove a malfunctioning device (primary composite endpoint), overall survival and major adverse events at 2 years. The 2-year primary endpoint [76.7% vs. 74.8%; adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.71-1.08, P = 0.21] and overall survival (81.2% vs. 79.0%) were similar among CAP and pivotal cohorts despite sicker patients (more intra-aortic balloon pump use and INTERMACS profile 1) in CAP who were more often intended for destination therapy. Survival was similar between the CAP and pivotal trial in transplant ineligible patients (79.1% vs. 76.7%; adjusted HR 0.89, 95% CI 0.68-1.16, P = 0.38). In a pooled analysis, the 2-year primary endpoint was similar between INTERMACS profiles 1-2 ('unstable' advanced heart failure), profile 3 ('stable' on inotropic therapy), and profiles 4-7 ('stable' ambulatory advanced heart failure) (75.7% vs. 77.6% vs. 72.9%, respectively). The net burden of adverse events was lower in CAP (adjusted rate ratio 0.93, 95% CI 0.88-0.98, P = 0.006), with consequent decrease in hospitalization. CONCLUSIONS The primary results of accumulating HM3 LVAD experience suggest a lower adverse event burden and similar survival compared to the pivotal MOMENTUM 3 trial.
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Affiliation(s)
- Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | | | - Shelley Hall
- Baylor University Medical Center, Dallas, TX, USA
| | | | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | | | | | | | - Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, NY, USA
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30
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Li M, Chen Y, Slepian MJ, Howard J, Thomas S, Barth EJ. Design, Modeling, and Experimental Characterization of A Valveless Pulsatile Flow Mechanical Circulatory Support Device. J Med Device 2021. [DOI: 10.1115/1.4049560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Mechanical circulatory support (MCS) devices, i.e., ventricular assist devices (VADs) and total artificial hearts (TAHs), while effective and vital in restoring hemodynamics in patients with circulatory compromise in advanced heart failure, remain limited by significant adverse thrombotic, embolic and bleeding events. Many of these complications relate to chronic exposure, via these devices, to nonpulsatile flow and the high shear stress created by current methods of blood propulsion or use of prosthetic valves. Here we propose a novel noncompressing single sliding vane MCS device to: 1) dramatically reduce pump operating speed thus potentially lowering the shear stress imparted to blood; 2) eliminate utilization of prosthetic valves thus diminishing potential shear stress generations; 3) allow direct flow rate control to generate physically desired blood flow rate include pulsatile flow; and 4) achieve compactness to fit into the majority of patients. The fundamental working principle and governing design equations are introduced first with multiple design and performance objectives presented. A first prototype was fabricated and experimental tests were conducted to validate the model with a 93.10% match between theoretical and experimental flow rate results. After model validation, the proposed MCS was tested to illustrate the ability of pulsatile flow generation. Finally, it was compared with some representative MCS pumps to discuss its potential of improving current MCS design. The presented work offers a novel MCS design and paves the way for next steps in device hemocompatibility testing.
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Affiliation(s)
- Mengtang Li
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Ye Chen
- Department of Mechanical Engineering, Santa Clara University, Santa Clara, CA 95053
| | - Marvin J. Slepian
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ 85724; Department of Medicine, University of Arizona, Tucson, AZ 85724; Sarver Heart Center, University of Arizona, Tucson, AZ 85724
| | - Joseph Howard
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Seth Thomas
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Eric J. Barth
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235
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31
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Goldstein DJ, Naka Y, Horstmanshof D, Ravichandran AK, Schroder J, Ransom J, Itoh A, Uriel N, Cleveland JC, Raval NY, Cogswell R, Suarez EE, Lowes BD, Kim G, Bonde P, Sheikh FH, Sood P, Farrar DJ, Mehra MR. Association of Clinical Outcomes With Left Ventricular Assist Device Use by Bridge to Transplant or Destination Therapy Intent: The Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) Randomized Clinical Trial. JAMA Cardiol 2021; 5:411-419. [PMID: 31939996 PMCID: PMC6990746 DOI: 10.1001/jamacardio.2019.5323] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Question In patients with advanced heart failure, do outcomes with left ventricular assist device implantation differ by the initial intended goal of therapy as a bridge to transplant or destination therapy? Findings In this randomized clinical trial, the composite end point of survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years was significantly better with the magnetically levitated centrifugal-flow HeartMate 3 than the mechanical-bearing axial-flow HeartMate II, irrespective of preimplant therapeutic intent. Event-free survival was not different between patients in the bridge to transplant or destination therapy groups treated with the HeartMate 3 pump. Meaning Per this randomized clinical trial, use of categorizations based on current or future transplant eligibility should be abandoned in favor of a single treatment indication for use of left ventricular assist devices. Importance Left ventricular assist devices (LVADs) are well established in the treatment of advanced heart failure, but it is unclear whether outcomes are different based on the intended goal of therapy in patients who are eligible vs ineligible for heart transplant. Objective To determine whether clinical outcomes in the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) trial differed by preoperative categories of bridge to transplant (BTT) or bridge to transplant candidacy (BTC) vs destination therapy (DT). Design, Setting, and Participants This study was a prespecified secondary analysis of the MOMENTUM 3 trial, a multicenter randomized clinical trial comparing the magnetically levitated centrifugal-flow HeartMate 3 (HM3) LVAD to the axial-flow HeartMate II (HMII) pump. It was conducted in 69 centers with expertise in managing patients with advanced heart failure in the United States. Patients with advanced heart failure were randomized to an LVAD, irrespective of the intended goal of therapy (BTT/BTC or DT). Main Outcomes and Measures The primary end point was survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years. Secondary end points included adverse events, functional status, and quality of life. Results Of the 1020 patients with implants (515 with HM3 devices [50.5%] and 505 with HMII devices [49.5%]), 396 (38.8%) were in the BTT/BTC group (mean [SD] age, 55 [12] years; 310 men [78.3%]) and 624 (61.2%) in the DT group (mean [SD] age, 63 [12] years; 513 men [82.2%]). Of the patients initially deemed as transplant ineligible, 84 of 624 patients (13.5%) underwent heart transplant within 2 years of LVAD implant. In the primary end point analysis, HM3 use was superior to HMII use in patients in the BTT/BTC group (76.8% vs 67.3% for survival free of disabling stroke and reoperation; hazard ratio, 0.62 [95% CI, 0.40-0.94]; log-rank P = .02) and patients in the DT group (73.2% vs 58.7%; hazard ratio, 0.61 [95% CI, 0.46-0.81]; log-rank P < .001). For patients in both BTT/BTC and DT groups, there were not significantly different reductions in rates of pump thrombosis, stroke, and gastrointestinal bleeding with HM3 use relative to HMII use. Improvements in quality of life and functional capacity for either pump were not significantly different regardless of preimplant strategy. Conclusions and Relevance In this trial, the superior treatment effect of HM3 over HMII was similar for patients in the BTT/BTC or DT groups. It is possible that use of arbitrary categorizations based on current or future transplant eligibility should be clinically abandoned in favor of a single preimplant strategy: to extend the survival and improve the quality of life of patients with medically refractory heart failure. Trial Registration ClinicalTrials.gov identifier: NCT02224755
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Affiliation(s)
- Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | | | | | - John Ransom
- Baptist Health Medical Center, Little Rock, Arkansas
| | - Akinobu Itoh
- Washington University School of Medicine, St Louis, Missouri
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | - Nirav Y Raval
- Advent Health Transplant Institute, Orlando, Florida
| | | | | | | | - Gene Kim
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois.,University of Chicago Medical Center, Chicago, Illinois
| | | | | | | | | | - Mandeep R Mehra
- Heart and Vascular Center, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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32
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Wayne SL, Zimmet AD. Surgical Management of Heart Failure. Curr Cardiol Rev 2021; 17:e160721192831. [PMID: 33855948 PMCID: PMC8950451 DOI: 10.2174/1573403x17666210414094452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022] Open
Abstract
Optimal management of heart failure is collaborative, with the involvement of specialist heart failure physicians, nurses, interventionalists, and surgeons. In addition to medical optimisation and cardiac resynchronisation therapy, surgery plays a valuable role in many patients. We herein study the evidence and the role of surgical intervention in functional mitral regurgitation, coronary revascularisation in ischaemic cardiomyopathy, and surgical ventricular reconstruction. Additionally, we describe techniques of temporary and durable mechanical circulatory support, with their relative advantages and disadvantages, and applications. Finally, we describe the history and nomenclature around heart transplants, their indications, techniques, present-day outcomes, complications, and new developments in the field.
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Affiliation(s)
- Stephanie L. Wayne
- CJOB Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Adam D. Zimmet
- CJOB Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Victoria, Australia
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33
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Köhne I. Kontinuierlich fördernde Blutpumpen für die Langzeitherzunterstützung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hanff TC, Birati EY. Left Ventricular Assist Device as Destination Therapy: a State of the Science and Art of Long-Term Mechanical Circulatory Support. Curr Heart Fail Rep 2020; 16:168-179. [PMID: 31631240 DOI: 10.1007/s11897-019-00438-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize and summarize recent developments in the care of patients with end-stage heart failure being managed with a left ventricular assist device (LVAD) as destination therapy. RECENT FINDINGS Although the survival of patients treated with LVAD continues to improve, the rates of LVAD-associated complication, such as right ventricular failure, bleeding complications, and major infection, remain high, and management of these patients remains challenging. The durability and hemocompatibility of LVAD support have greatly increased in recent years as a result of new technologies and novel management strategies. Challenges remain in the comprehensive care of patients with destination therapy LVADs, including management of comorbidities and optimizing patient function and quality of life.
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Affiliation(s)
- Thomas C Hanff
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Loring Z, Sen S, Black-Maier E, Atwater BD, Russell SD, DeVore AD, Piccini JP. Reducing ECG Artifact From Left Ventricular Assist Device Electromagnetic Interference. J Am Heart Assoc 2020; 9:e017563. [PMID: 32787630 PMCID: PMC7660795 DOI: 10.1161/jaha.120.017563] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Left ventricular assist devices (LVADs) generate electromagnetic interference that causes high-frequency noise artifacts on 12-lead ECGs. We describe the causes of this interference and potential solutions to aid ECG interpretation in patients with LVAD. Methods and Results Waveform data from ECGs performed before and after LVAD implantation were passed through a fast Fourier transform to identify LVAD-related changes in the spectral profile. ECGs recorded in 9 patients with HeartMate II, HeartMate 3, and HeartWare LVADs were analyzed to identify the LVAD model-specific spectral patterns. Waveform data were then passed through digital low-pass and bandstop filters and redisplayed to evaluate the effect of filtering on LVAD-related electromagnetic interference. The spectral profile of patients with HeartMate II and HeartMate 3 LVADs demonstrated a prominent signal at the device-specific frequency of impeller rotation. In patients with the HeartMate 3 LVAD, 2 additional peaks were observed at the frequencies equivalent to the LVAD's artificial pulsatility rotational speeds. Patients with HeartWare devices demonstrated a prominent signal peak at a frequency equal to double their LVAD's set rotational speed. Applying a low-pass filter to a value below the observed frequency peak from the LVAD significantly improved the waveform tracing and quality of the ECG. Applying a speed-specific bandstop filter to remove the observed LVAD frequency peak also improved the clarity of the ECG without compromising physiological high-frequency signal components. Conclusions LVADs create impeller rotational speed-specific electromagnetic interference that can be ameliorated by application of low-pass or bandstop filters to improve ECG clarity.
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Affiliation(s)
- Zak Loring
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University Medical Center Durham NC
| | - Sounok Sen
- Division of Cardiology Duke University Medical Center Durham NC
| | - Eric Black-Maier
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University Medical Center Durham NC
| | - Brett D Atwater
- Division of Cardiology Duke University Medical Center Durham NC
| | | | - Adam D DeVore
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University Medical Center Durham NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University Medical Center Durham NC
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Left ventricular assist systems and infection-related outcomes: A comprehensive analysis of the MOMENTUM 3 trial. J Heart Lung Transplant 2020; 39:774-781. [DOI: 10.1016/j.healun.2020.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022] Open
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Whitaker-Lea WA, Toms B, Toms JB, Shah KB, Quader M, Tang D, Kasirajan V, Rivet DJ, Reavey-Cantwell JF. Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review. World Neurosurg 2020; 139:e635-e642. [DOI: 10.1016/j.wneu.2020.04.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 01/11/2023]
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The adaptive designs CONSORT extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. Trials 2020; 21:528. [PMID: 32546273 PMCID: PMC7298968 DOI: 10.1186/s13063-020-04334-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits. In order to encourage its wide dissemination this article is freely accessible on the BMJ and Trials journal websites."To maximise the benefit to society, you need to not just do research but do it well" Douglas G Altman.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK.
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, Cardiff, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marc K Walton
- Janssen Pharmaceuticals, Titusville, New Jersey, USA
| | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The Adaptive designs CONSORT Extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. BMJ 2020; 369:m115. [PMID: 32554564 PMCID: PMC7298567 DOI: 10.1136/bmj.m115] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, UK
- Institute of Health and Society, Newcastle University, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, UK
- MRC Biostatistics Unit, University of Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Austria
| | | | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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Loebe M, Ghodsizad A. Commentary: The feng shui of LVAD implantation. J Thorac Cardiovasc Surg 2020; 162:1564-1566. [PMID: 32534752 DOI: 10.1016/j.jtcvs.2020.04.122] [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: 04/16/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Matthias Loebe
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, Miami, Fla.
| | - Ali Ghodsizad
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, Miami, Fla
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41
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Sidhu K, Lam PH, Mehra MR. Evolving trends in mechanical circulatory support: Clinical development of a fully magnetically levitated durable ventricular assist device. Trends Cardiovasc Med 2020; 30:223-229. [DOI: 10.1016/j.tcm.2019.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/17/2022]
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Loardi C, Zanobini M. Why do left ventricular assist device recipients remain heart failure patients? Letter regarding the article 'Effects of left ventricular assist device on cardiopulmonary exercise performance'. Eur J Heart Fail 2020; 22:1054-1055. [PMID: 32232891 DOI: 10.1002/ejhf.1807] [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: 03/03/2020] [Accepted: 03/06/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Claudia Loardi
- Department of Cardiac Surgery, Tours University Hospital, Tours, France
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy
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43
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Saeed O, Colombo PC, Mehra MR, Uriel N, Goldstein DJ, Cleveland J, Connors JM, Najjar SS, Mokadam NA, Bansal A, Crandall DL, Sood P, Jorde UP. Effect of aspirin dose on hemocompatibility-related outcomes with a magnetically levitated left ventricular assist device: An analysis from the MOMENTUM 3 study. J Heart Lung Transplant 2020; 39:518-525. [PMID: 32340871 DOI: 10.1016/j.healun.2020.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 02/29/2020] [Accepted: 03/01/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Aspirin (ASA) anti-platelet therapy is mandated with left ventricular assist devices (LVADs) to prevent hemocompatibility-related adverse events (HRAEs). However, the optimal dose of ASA with HeartMate 3 (HM3) LVAD is unknown. METHODS In an exploratory analysis of HM3-supported patients in the MOMENTUM 3 study (NCT02224755), 2 groups were analyzed: usual-dose (325 mg) and low-dose (81 mg) ASA with anti-coagulation targeted to an international normalized ratio of 2.0 to 3.0. Exclusion criteria included patients not receiving either ASA 81 mg or 325 mg, those with HRAEs ≤7 days after device implantation, and those receiving >1 anti-platelet agent. The primary end-point was survival free from HRAEs (non-surgical bleeding, pump thrombosis, stroke, and peripheral arterial thromboembolic events) at 2 years. RESULTS Overall, 321 HM3 patients (usual-dose: n = 141, low-dose: n = 180) were included in this analysis. Usual-dose group patients were younger (57 ± 13 vs 60 ± 12 years, p = 0.035) and less often assigned destination therapy (55% vs 67%, p = 0.029) than low-dose ASA. At 2 years, a similar proportion of patients in the usual- and low-dose groups (43.4% vs 45.3%, p = 0.94) met the primary end-point. There were no differences in survival free from hemorrhagic (usual-dose: 54.4% vs low-dose: 51.7%, p = 0.42) or thrombotic (usual-dose: 76.8% vs low-dose: 75.7%, p = 0.92) events. CONCLUSIONS Usual- and low-dose ASA revealed similar rates of bleeding and thrombotic events in HM3 LVAD-supported patients within the MOMENTUM 3 trial. Whether ASA therapy provides any meaningful therapeutic effect in patients treated by the HM3 LVAD remains to be determined.
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Affiliation(s)
- Omar Saeed
- Department of Medicine and Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Paolo C Colombo
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nir Uriel
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Daniel J Goldstein
- Department of Medicine and Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Joseph Cleveland
- Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Jean M Connors
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samer S Najjar
- Department of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
| | | | - Aditya Bansal
- Department of Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Daniel L Crandall
- Division of Cardiology Department of Medicine, Abbott, Chicago, Illinois
| | - Poornima Sood
- Division of Cardiology Department of Medicine, Abbott, Chicago, Illinois
| | - Ulrich P Jorde
- Department of Medicine and Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York.
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Schramm R, Zittermann A, Morshuis M, Schoenbrodt M, von Roessing E, von Dossow V, Koster A, Fox H, Hakim-Meibodi K, Gummert JF. Comparing short-term outcome after implantation of the HeartWare® HVAD® and the Abbott® HeartMate 3®. ESC Heart Fail 2020; 7:908-914. [PMID: 32190985 PMCID: PMC7261579 DOI: 10.1002/ehf2.12649] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 01/29/2020] [Indexed: 11/06/2022] Open
Abstract
AIMS Centrifugal continuous flow pumps are currently the state of the art in left ventricular assist device therapy. This study was conducted to compare the results after implantation of the HVAD® and the HeartMate 3®. METHODS AND RESULTS We retrospectively analysed preoperative and post-operative patient data of all 106 patients, who received a HeartMate 3 (HM3) at our centre between 2014 and 2018. A total of 392 patients receiving a sintered HVAD® served as controls. Patient matching was performed for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support level at the time of implant, perioperative right heart failure, and implantation strategy, that is, bridge to transplant or destination therapy, as well as preoperative renal function, that is, as indicated by serum creatinine levels. A total of 79 matched pairs could be identified. During a median follow-up of 15.3 months (range: 0-30 months), 23 (29.1%) and 19 (24.1%) patients died in the HVAD and HM3 groups, respectively, with a hazard ratio for mortality of 0.84 [95% confidence interval (CI): 0.46-1.54; P = 0.568]. Freedom from cerebrovascular events did not differ significantly between study groups, with a hazard ratio of 0.57 (95% CI: 0.23-1.45; P = 0.241). The risk of driveline infection was significantly lower in the HM3 (n = 33) than in the HVAD (n = 55) group (hazard ratio = 0.54; 95% CI: 0.35-0.84; P = 0.006). Eight HVAD, but no HM3, patients developed a pump thrombosis during follow-up (P = 0.148). CONCLUSIONS Performance of both currently used centrifugal left ventricular assist device systems is comparable in terms of short-term patient survival and freedom from cerebrovascular events. In our single-centre experience, HM3 patients less frequently develop driveline infections and no pump thrombosis, which requires further evaluation.
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Affiliation(s)
- Rene Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Michael Schoenbrodt
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Ellen von Roessing
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Cardiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Kavous Hakim-Meibodi
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Georgstr. 11, D-32503, Bad Oeynhausen, Germany
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Interpreting Neurologic Outcomes in a Changing Trial Design Landscape: An Analysis of HeartWare Left Ventricular Assist Device Using a Hybrid Intention to Treat Population. ASAIO J 2020; 65:293-296. [PMID: 30562168 PMCID: PMC6400392 DOI: 10.1097/mat.0000000000000931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Randomized controlled trials can provide optimal clinical evidence to assess the benefits of new devices, and it is these data that often shape device usage in real-world practice. However, individual clinical trial results sometimes appear discordant for the same device, and alternative devices are sometimes not employed in similar patient populations. To make sound evidence-based decisions, clinicians routinely rely on cross-trial comparisons from different trials of similar but not identical patient populations to assess competing technology when head-to-head randomized comparisons are unavailable.
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46
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Anderson AS. At Last, One Indication for Left Ventricular Assist Devices—A Bridge to a Better and Longer Life. JAMA Cardiol 2020; 5:251-252. [DOI: 10.1001/jamacardio.2019.5592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Allen S. Anderson
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
- Now with Division of Cardiology, Department of Medicine, Long School of Medicine, University of Texas, San Antonio
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Karason K, Lund LH, Dalén M, Björklund E, Grinnemo K, Braun O, Nilsson J, van der Wal H, Holm J, Hübbert L, Lindmark K, Szabo B, Holmberg E, Dellgren G. Randomized trial of a left ventricular assist device as destination therapy versus guideline-directed medical therapy in patients with advanced heart failure. Rationale and design of the SWEdish evaluation of left Ventricular Assist Device (SweVAD) trial. Eur J Heart Fail 2020; 22:739-750. [PMID: 32100946 DOI: 10.1002/ejhf.1773] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS Patients with advanced heart failure (AdHF) who are ineligible for heart transplantation (HTx) can become candidates for treatment with a left ventricular assist device (LVAD) in some countries, but not others. This reflects the lack of a systematic analysis of the usefulness of LVAD systems in this context, and of their benefits, limitations and cost-effectiveness. The SWEdish evaluation of left Ventricular Assist Device (SweVAD) study is a Phase IV, prospective, 1:1 randomized, non-blinded, multicentre trial that will examine the impact of assignment to mechanical circulatory support with guideline-directed LVAD destination therapy (GD-LVAD-DT) using the HeartMate 3 (HM3) continuous flow pump vs. guideline-directed medical therapy (GDMT) on survival in a population of AdHF patients ineligible for HTx. METHODS A total of 80 patients will be recruited to SweVAD at the seven university hospitals in Sweden. The study population will comprise patients with AdHF (New York Heart Association class IIIB-IV, INTERMACS profile 2-6) who display signs of poor prognosis despite GDMT and who are not considered eligible for HTx. Participants will be followed for 2 years or until death occurs. Other endpoints will be determined by blinded adjudication. Patients who remain on study-assigned interventions beyond 2 years will be asked to continue follow-up for outcomes and adverse events for up to 5 years. CONCLUSION The SweVAD study will compare survival, medium-term benefits, costs and potential hazards between GD-LVAD-DT and GDMT and will provide a valuable reference point to guide destination therapy strategies for patients with AdHF ineligible for HTx.
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Affiliation(s)
- Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars H Lund
- Departments of Cardiology and Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Dalén
- Departments of Cardiology and Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Björklund
- Departments of Cardiology and Cardiothoracic Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Karl Grinnemo
- Departments of Cardiology and Cardiothoracic Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Oscar Braun
- Departments of Cardiology and Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Johan Nilsson
- Departments of Cardiology and Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Henriette van der Wal
- Departments of Cardiology and Cardiothoracic Surgery, Linköping University Hospital, Linköping, Sweden
| | - Jonas Holm
- Departments of Cardiology and Cardiothoracic Surgery, Linköping University Hospital, Linköping, Sweden
| | - Laila Hübbert
- Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Krister Lindmark
- Department of Cardiology, Umeå University Hospital, Umeå, Sweden
| | - Barna Szabo
- Department of Cardiology, Örebro University Hospital, Örebro, Sweden
| | - Erik Holmberg
- Regional Cancer Centre West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Departments of Cardiothorax Surgery and Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
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Hijikata W, Maruyama T, Murashige T, Sakota D, Maruyama O. Detection of thrombosis in a magnetically levitated blood pump by vibrational excitation of the impeller. Artif Organs 2020; 44:594-603. [DOI: 10.1111/aor.13632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/28/2019] [Accepted: 01/03/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Wataru Hijikata
- School of Engineering Tokyo Institute of Technology Tokyo Japan
| | - Takuro Maruyama
- School of Engineering Tokyo Institute of Technology Tokyo Japan
| | | | - Daisuke Sakota
- National Institute of Advanced Industrial Science and Technology Tsukuba Japan
| | - Osamu Maruyama
- National Institute of Advanced Industrial Science and Technology Tsukuba Japan
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Akin S, Soliman O, de By TMMH, Muslem R, Tijssen JGP, Schoenrath F, Meyns B, Gummert JF, Mohacsi P, Caliskan K. Causes and predictors of early mortality in patients treated with left ventricular assist device implantation in the European Registry of Mechanical Circulatory Support (EUROMACS). Intensive Care Med 2020; 46:1349-1360. [PMID: 32016536 PMCID: PMC7334284 DOI: 10.1007/s00134-020-05939-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of the study was to analyze early mortality after continuous-flow left ventricular assist device (LVAD) implantation which remains high. METHODS We analyzed consecutive (n = 2689) patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) undergoing continuous-flow LVAD implantation. The primary outcome was early (< 90 days) mortality. Secondary outcomes were differential causes of early post-operative death following LVAD implantation. RESULTS Univariable and multivariable analysis as well as regression analysis were used to examine determinants and differential causes of early (< 90 days) mortality after LVAD implantation. During the first 90 days, 2160 (80%) patients were alive with ongoing LVAD support, 40(2%) patients underwent heart transplantation, and 487(18%) deceased. The main causes of early death were MOF (36%), sepsis (28%), cardiopulmonary failure (CPF; 10%), CVA (9%), and right-sided heart failure (RHF, 8%). Furthermore, MOF and sepsis are 70% of causes of death in the first week. Independent clinical predictors of early death were age, female sex, INTERMACS profile 1 to 3, and ECMO. Laboratory predictors included elevated serum creatinine, total bilirubin, lactate, and low hemoglobin. Furthermore, hemodynamic predictors included elevated RA-to-PCWP ratio, pulmonary vascular resistance, and low systemic vascular resistance. Longer total implantation time was also independent predictor of early mortality. A simple model of 12 variables predicts early mortality following LVAD implantation with a good discriminative power with area under the curve of 0.75. CONCLUSIONS In the EUROMACS registry, approximately one out of five patients die within 90 days after LVAD implantation. Early mortality is primarily dominated by multiorgan failure followed by sepsis. A simple model identifies important parameters which are associated with early mortality following LVAD implantation.
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Affiliation(s)
- Sakir Akin
- Thoraxcenter, Department of Cardiology, Erasmus MC University Medical Centre Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Osama Soliman
- Department of Cardiology, College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Saolta University Healthcare Group, Galway University Road, Galway, Ireland
| | | | - Rahatullah Muslem
- Thoraxcenter, Department of Cardiology, Erasmus MC University Medical Centre Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jan G P Tijssen
- Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands.,Cardialysis, Academic Research Organisation Rotterdam, Rotterdam, The Netherlands
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital Leuven, University of Leuven, Leuven, Belgium
| | - Jan F Gummert
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Paul Mohacsi
- Department of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus MC University Medical Centre Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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Lanfear AT, Hamandi M, Fan J, DiMaio JM, George TJ. Trends in HeartMate 3: What we know so far. J Card Surg 2019; 35:180-187. [PMID: 31692113 DOI: 10.1111/jocs.14319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The HeartMate 3 left ventricular assist device (LVAD) is a novel, intrapericardial, centrifugal-flow pump with a fully magnetically-levitated rotor designed to provide hemodynamic support in patients with end-stage heart failure. Unique aspects of this LVAD have allowed for improved hemocompatibility and the development of minimally-invasive implantation techniques. METHODS The PubMed, EMBASE, and Google Scholar databases were searched for publications relating to the HeartMate 3 device, with a focus on hemocompatibility related outcomes, anticoagulation management, and surgical techniques. RESULTS Nine articles analyzing hemocompatibility related outcomes from two clinical trials, two clinical studies, and one registry series were identified. CONCLUSION HeartMate 3 has reduced the rate of disabling stroke and pump thrombosis. However, despite increased hemocompatibility due to specialized design features, the residual risk of both surgical, and gastrointestinal bleeding remains a major adverse outcome. Different anticoagulation management and surgical techniques have been evaluated to address the remaining complications.
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Affiliation(s)
- Allison T Lanfear
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Mohanad Hamandi
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Joy Fan
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - J Michael DiMaio
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas.,Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Timothy J George
- Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
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