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Kherallah RY, Lamba HK, Civitello AB, Nair AP, Simpson L, Shafii AE, Loor G, George JK, Delgado RM, Liao KK, Stainback RF, Frazier OH, Koneru S. Effect of Preoperative Mitral Regurgitation on LVAD Outcomes in Patients with Elevated Pulmonary Vascular Resistance. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07581-1. [PMID: 39162770 DOI: 10.1007/s10557-024-07581-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE In patients with end-stage heart failure who undergo left ventricular assist device (LVAD) implantation, higher pulmonary vascular resistance (PVR) is associated with higher right heart failure rates and ineligibility for heart transplant. Concomitant mitral regurgitation (MR) could potentially worsen pulmonary hemodynamics and lead to worse outcomes; however, its effects in this patient population have not been specifically examined. METHODS Using an institutional database spanning November 2003 to August 2017, we retrospectively identified patients with elevated PVR who underwent LVAD implantation. Patients were stratified by concurrent MR: moderate/severe (PVR + MR) vs. mild/none (PVR - MR). Cumulative incidence functions and Fine-Gray competing risk regression were performed to assess the effect of MR on heart transplant rates and overall survival during index LVAD support. RESULTS Of 644 LVAD recipients, 232 (171 HeartMate II, 59 HeartWare, 2 HeartMate III) had baseline PVR > 3 Woods units; of these, 124 (53%) were INTERMACS 1-2, and 133 (57%) had moderate/severe MR (≥ 3 +). Patients with PVR + MR had larger a baseline left ventricular end-diastolic diameter than patients with PVR - MR (87.9 ± 38.2 mm vs. 75.9 ± 38.0 mm; P = 0.02). Median clinical follow-up was 18.8 months (interquartile range: 4.7-36.4 months). Moderate/severe MR was associated with lower mortality rates during index LVAD support (adjusted hazard ratio 0.64, 95% CI 0.41-0.98; P = 0.045) and higher heart transplant rates (adjusted odds ratio 2.86, 95% CI 1.31-6.25; P = 0.009). No differences in stroke, gastrointestinal bleeding, or right heart failure rates were observed. CONCLUSIONS Among LVAD recipients with elevated preoperative PVR, those with moderate/severe MR had better overall survival and higher transplant rates than those with mild/no MR. These hypothesis-generating findings could be explained by incremental LVAD benefits resulting from reduction of MR and better LV unloading in a subset of patients with larger ventricles at baseline. In patients with preoperative elevated PVR, MR severity may be a prognostic sign that can inform patient selection for end-stage heart failure therapy.
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Affiliation(s)
- Riyad Yazan Kherallah
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Harveen K Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Andrew B Civitello
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Ajith P Nair
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Leo Simpson
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Alexis E Shafii
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Joggy K George
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Reynolds M Delgado
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Kenneth K Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Raymond F Stainback
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - O H Frazier
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Srikanth Koneru
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
- Department of Cardiology, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA.
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2
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Arjomandi Rad A, Fleet B, Zubarevich A, Nanchahal S, Naruka V, Subbiah Ponniah H, Vardanyan R, Sardari Nia P, Loubani M, Moorjani N, Schmack B, Punjabi PP, Schmitto J, Ruhparwar A, Weymann A. Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta-analysis. Artif Organs 2024; 48:16-27. [PMID: 37822301 DOI: 10.1111/aor.14659] [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: 06/16/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The management of concomitant valvular lesions in patients undergoing left ventricular assist device (LVAD) implantation remains a topic of debate. This systematic review and meta-analysis aimed to evaluate the existing evidence on postoperative outcomes following LVAD implantation, with and without concomitant MV surgery. METHODS A systematic database search was conducted as per PRISMA guidelines, of original articles comparing LVAD alone to LVAD plus concomitant MV surgery up to February 2023. The primary outcomes assessed were overall mortality and early mortality, while secondary outcomes included stroke, need for right ventricular assist device (RVAD) implantation, postoperative mitral valve regurgitation, major bleeding, and renal dysfunction. RESULTS The meta-analysis included 10 studies comprising 32 184 patients. It revealed that concomitant MV surgery during LVAD implantation did not significantly affect overall mortality (OR:0.83; 95% CI: 0.53 to 1.29; p = 0.40), early mortality (OR:1.17; 95% CI: 0.63 to 2.17; p = 0.63), stroke, need for RVAD implantation, postoperative mitral valve regurgitation, major bleeding, or renal dysfunction. These findings suggest that concomitant MV surgery appears not to confer additional benefits in terms of these clinical outcomes. CONCLUSION Based on the available evidence, concomitant MV surgery during LVAD implantation does not appear to have a significant impact on postoperative outcomes. However, decision-making regarding MV surgery should be individualized, considering patient-specific factors and characteristics. Further research with prospective studies focusing on specific patient populations and newer LVAD devices is warranted to provide more robust evidence and guide clinical practice in the management of valvular lesions in LVAD recipients.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ben Fleet
- School of Medicine, Lancaster University, Lancaster, UK
| | - Alina Zubarevich
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sukanya Nanchahal
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Vinci Naruka
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Robert Vardanyan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth NHS Trust, Cambridge, UK
| | - Bastian Schmack
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Prakash P Punjabi
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jan Schmitto
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Weymann
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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John R, Kanwar MK, Cleveland JC, Uriel N, Naka Y, Salerno C, Horstmanshof D, Hall SA, Cowger JA, Heatley G, Somo SI, Mehra MR. Concurrent valvular procedures during left ventricular assist device implantation and outcomes: A comprehensive analysis of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 trial portfolio. J Thorac Cardiovasc Surg 2023; 166:1684-1694.e18. [PMID: 35643769 DOI: 10.1016/j.jtcvs.2022.04.021] [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: 03/14/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Correction of valvular disease is often undertaken during left ventricular assist device (LVAD) implantation with uncertain benefit. We analyzed clinical outcomes with HeartMate 3 (HM3; Abbott) LVAD implantation in those with various concurrent valve procedures (HM3+VP) with those with an isolated LVAD implant (HM3 alone). METHODS The study included 2200 patients with HM3 implanted within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial portfolio who underwent 820 concurrent procedures among which 466 (21.8%) were HM3+VP. VPs included 101 aortic, 61 mitral, 163 tricuspid; 85 patients had multiple VPs. Perioperative complications, major adverse events, and survival were analyzed. RESULTS Patients who underwent HM3+VP had higher-acuity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (1-2: 41% vs 31%) compared with no VPs (P < .05). The cardiopulmonary bypass time (124 vs 76 minutes; P < .0001) and hospital length of stay (20 vs 18 days; P < .0001) were longer in HM3+VP. A higher incidence of stroke (4.9% vs 2.4%), bleeding (33.9% vs 23.8%), and right heart failure (41.5% vs 29.6%) was noted in HM3+VP at 0 to 30 days (P < .01), with no difference in 30-day mortality (3.9% vs 3.3%) or 2-year survival (81.7% vs 80.8%). Analysis of individual VP showed no differences in survival compared to HM3 alone. No differences were noted among patients with either significant mitral (moderate or worse) or tricuspid (moderate or worse) regurgitation with or without corrective surgery. CONCLUSIONS Concurrent VPs, commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, with no effect on short- and long-term survival. There is sufficient equipoise to consider a randomized trial on the benefit of commonly performed VPs (such as mitral or tricuspid regurgitation correction), during LVAD implantation.
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Affiliation(s)
- Ranjit John
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minn
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pa
| | - Joseph C Cleveland
- Surgery-Cardiothoracic, University of Colorado School of Medicine, Aurora, Colo
| | - Nir Uriel
- Advanced Heart Failure and Cardiac Transplantation, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY
| | - Yoshifumi Naka
- Cardiac Surgery, Weill Cornell Medical College, New York, NY
| | | | | | - Shelley A Hall
- Transplant Cardiology and Mechanical Support/Heart Failure, Baylor University Medical Center, Dallas, Tex
| | - Jennifer A Cowger
- Mechanical Circulatory Support Team, Henry Ford Health System, Detroit, Mich
| | | | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
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Camaj A, Thourani VH, Gillam LD, Stone GW. Heart Failure and Secondary Mitral Regurgitation: A Contemporary Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101195. [PMID: 39131058 PMCID: PMC11308134 DOI: 10.1016/j.jscai.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Secondary mitral regurgitation (SMR) in patients with heart failure (HF) is associated with significant morbidity and mortality. In recent decades, SMR has received increasing scientific attention. Advances in echocardiography, computed tomography and cardiac magnetic resonance imaging have refined our ability to diagnose, quantify and characterize SMR. Concurrently, the treatment options for this high-risk patient population have continued to evolve. Guideline-directed medical therapies including beta-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors target the underlying cardiomyopathy, and along with diuretics to treat pulmonary congestion, remain the cornerstone of therapy. Cardiac resynchronization therapy also reduces MR, alleviates symptoms and prolongs life in selected HF patients with SMR. While data supporting surgical mitral valve repair or replacement for SMR are limited, transcatheter edge-to-edge repair (TEER) has been demonstrated to improve survival, reduce the rate of hospitalization for heart failure, and improve functional capacity and quality-of-life in select patients with SMR who remain symptomatic despite medical therapy. Emerging transcatheter mitral valve repair and replacement technologies are undergoing investigation in TEER-eligible and TEER-ineligible patients. The optimal management of HF patients with SMR requires a multidisciplinary team of cardiologists, cardiac surgeons, imaging experts, and other organ specialists to select the best treatment approaches to improve the prognosis of these high-risk patients.
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Affiliation(s)
- Anton Camaj
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vinod H. Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Linda D. Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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5
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Klaeske K, Schreiber C, Eifert S, Dieterlen T, Jawad K, Saeed D, Semmig-Könze S, Meyer AL, Borger MA, Dieterlen MT. Health status analysis is comparable in HM3 patients with different preoperative grades of mitral regurgitation. J Patient Rep Outcomes 2023; 7:86. [PMID: 37615830 PMCID: PMC10449706 DOI: 10.1186/s41687-023-00620-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/20/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The guidelines for mechanical circulatory support of the International Society for Heart and Lung Transplantation do not recommend the routine replacement or repair of the mitral valve at the time point of left ventricular assist device (LVAD) implantation. We investigated different parameters of health status including exercise capacity, anxiety and depression after LVAD implantation in patients with different preoperative grades of mitral regurgitation (MR). METHODS A single-center analysis of health status was performed including 45 patients with HeartMate 3 (HM 3) implantation using the 12-items Short Form Health Survey (SF-12) and the Hospital Anxiety and Depression Score (HADS) questionnaires. The study groups were classified according to echocardiographically defined preoperative grade of MR. The group without severe MR comprised 33 patients; the group with severe MR comprised 12 patients. RESULTS Demographic and preclinical characteristics as well as LVAD complications such as thrombosis and bleeding events were comparable between LVAD patients with severe and not severe MR (p > 0.05). Severe MR resolved in all patients after LVAD implantation and improved to moderate, mild or no MR in both groups in a period ranging from 6 months until 2 years. The analyses of SF-12 questionnaire revealed that the physical (p = 0.44) and mental health (p = 0.64) was comparable. The grade of anxiety (p = 0.34) and depression (p = 0.44) was comparable between the groups. Exercise capacity measured by the 6 min walk test correlated positively with the SF-12-determined physical health (p < 0.01, r = 0.518) and negatively with the HADS anxiety (p = 0.01, r = -0.399) and depression (p < 0.01, r = -0.570) scores. CONCLUSIONS Our data showed that the health status is comparable in HM 3 patients with different preoperative MR severities in the post-LVAD period. Preoperative severe MR resolves in the majority of patients early after LVAD implantation and is not associated with concomitant mitral valve repair or replacement at the time of LVAD implantation.
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Affiliation(s)
- Kristin Klaeske
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany.
| | - Constantin Schreiber
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Sandra Eifert
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Tillmann Dieterlen
- Soteria Clinic, Clinic for Addiction Medicine, Helios Park-Klinikum, Leipzig, Germany
| | - Khalil Jawad
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Diyar Saeed
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Sandra Semmig-Könze
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Anna Lassia Meyer
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Andrew Borger
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Maja-Theresa Dieterlen
- Helios Clinic, Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
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6
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Chioncel O, Adamo M, Nikolaou M, Parissis J, Mebazaa A, Yilmaz MB, Hassager C, Moura B, Bauersachs J, Harjola VP, Antohi EL, Ben-Gal T, Collins SP, Iliescu VA, Abdelhamid M, Čelutkienė J, Adamopoulos S, Lund LH, Cicoira M, Masip J, Skouri H, Gustafsson F, Rakisheva A, Ahrens I, Mortara A, Janowska EA, Almaghraby A, Damman K, Miro O, Huber K, Ristic A, Hill L, Mullens W, Chieffo A, Bartunek J, Paolisso P, Bayes-Genis A, Anker SD, Price S, Filippatos G, Ruschitzka F, Seferovic P, Vidal-Perez R, Vahanian A, Metra M, McDonagh TA, Barbato E, Coats AJS, Rosano GMC. Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology. Eur J Heart Fail 2023; 25:1025-1048. [PMID: 37312239 DOI: 10.1002/ejhf.2918] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.
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Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Maria Nikolaou
- Cardiology Department, General Hospital 'Sismanogleio-Amalia Fleming', Athens, Greece
| | - John Parissis
- Heart Failure Unit and University Clinic of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alexandre Mebazaa
- Université Paris Cité, MASCOT Inserm, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, Paris, France
| | - Mehmet Birhan Yilmaz
- Division of Cardiology, Department of Internal Medical Sciences, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of Porto, Porto, Portugal
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Elena-Laura Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Tuvia Ben-Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| | - Vlad Anton Iliescu
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Cardiology Department, Cairo University, Cairo, Egypt
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius; Centre of Innovative Medicine, Vilnius, Lithuania
| | | | - Lars H Lund
- Karolinska Institute, Department of Medicine, and Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | | | - Josep Masip
- Research Direction, Consorci Sanitari Integral, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Amina Rakisheva
- Scientific and Research Institute of Cardiology and Internal Disease, Almaty, Kazakhstan
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Ewa A Janowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Kurt Huber
- Medical Faculty, Sigmund Freud University, Vienna, Austria
- 3rd Medical Department, Wilhelminen Hospital, Vienna, Austria
| | - Arsen Ristic
- Department of Cardiology of the University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Alaide Chieffo
- Vita Salute-San Raffaele University, Milan, Italy
- IRCCS San Raffaele Scientific, Institute, Milan, Italy
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Pasquale Paolisso
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Susanna Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, Athens University Hospital, Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich, Zurich, Switzerland
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rafael Vidal-Perez
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Alec Vahanian
- University Paris Cite, INSERM LVTS U 1148 Bichat, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Theresa A McDonagh
- Department of Cardiology, King's College Hospital London, London, UK
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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7
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Duggal NM, Lei I, Wu X, Aaronson KD, Pagani FD, Lam HYK, Tang PC. Mitral regurgitation severity at left ventricular assist device implantation is associated with distinct myocardial transcriptomic signatures. J Thorac Cardiovasc Surg 2023; 166:141-152.e1. [PMID: 34689984 PMCID: PMC11217920 DOI: 10.1016/j.jtcvs.2021.08.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We examined for differences in pre-left ventricular assist device (LVAD) implantation myocardial transcriptome signatures among patients with different degrees of mitral regurgitation (MR). METHODS Between January 2018 and October 2019, we collected left ventricular (LV) cores during durable LVAD implantation (n = 72). A retrospective chart review was performed. Total RNA was isolated from LV cores and used to construct cDNA sequence libraries. The libraries were sequenced with the NovaSeq system, and data were quantified using Kallisto. Gene Set Enrichment Analysis (GSEA) and Gene Ontology analyses were performed, with a false discovery rate <0.05 considered significant. RESULTS Comparing patients with preoperative mild or less MR (n = 30) and those with moderate-severe MR (n = 42), the moderate-severe MR group weighted less (P = .004) and had more tricuspid valve repairs (P = .043), without differences in demographics or comorbidities. We then compared both groups with a group of human donor hearts without heart failure (n = 8). Compared with the donor hearts, there were 3985 differentially expressed genes (DEGs) for mild or less MR and 4587 DEGs for moderate-severe MR. Specifically altered genes included 448 DEGs for specific for mild or less MR and 1050 DEGs for moderate-severe MR. On GSEA, common regulated genes showed increased immune gene expression and reduced expression of contraction and energetic genes. Of the 1050 genes specific for moderate-severe MR, there were additional up-regulated genes related to inflammation and reduced expression of genes related to cellular proliferation. CONCLUSIONS Patients undergoing durable LVAD implantation with moderate-severe MR had increased activation of genes related to inflammation and reduction of cellular proliferation genes. This may have important implications for myocardial recovery.
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Affiliation(s)
- Neal M Duggal
- Department of Anesthesiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | | | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
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8
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Carr MJ, Smith SA, Slaughter MS, Pahwa S. Managing valvular pathology during LVAD implantation. Indian J Thorac Cardiovasc Surg 2023; 39:101-113. [PMID: 37525709 PMCID: PMC10387021 DOI: 10.1007/s12055-023-01567-8] [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: 02/21/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
Since the time of their invention, implantable continuous flow left ventricular assist devices (LVADs) have improved the quality of life and extended survival for patients with advanced heart failure. The decision surgeons and their physician colleagues make with these patients to undergo implantation must come with full understanding of the immediate, short-term, and long-term implications of such a life-changing procedure. The presence of pathology regarding the aortic, mitral, and tricuspid valves introduces particularly complex problems for the surgical treatment strategy. Concomitant valve repair or replacement increases cardiopulmonary bypass and cross clamp times, and could potentially lead to worse outcomes in the perioperative setting. Following perioperative recovery, valvular pathology may worsen or arise de novo given the often drastic immediate physiologic changes in blood flow, septal function, and, over time, ventricular remodeling. Over the past two decades, there has been vast improvement in the device manufacturing, surgical techniques, and medical management surrounding LVAD implantation. Yet, addressing concomitant valvular pathology remains a complex question with no perfect solutions. This review aims to briefly describe the evolution of approach to valvular pathology in the LVAD patient and offer our opinion and treatment rationale.
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Affiliation(s)
- Michael J. Carr
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Susan Ansley Smith
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
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9
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Sharma H, Liu B, Yuan M, Shakeel I, Morley-Smith A, Hatch A, Bradley J, Chue C, Myerson SG, Steeds RP, Lim S. Predictors and clinical implications of residual mitral regurgitation following left ventricular assist device therapy. Open Heart 2023; 10:e002240. [PMID: 37316326 DOI: 10.1136/openhrt-2022-002240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/23/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Correction of mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation remains controversial. There is conflicting evidence regarding the clinical impact of residual MR, and studies have not examined whether MR aetiology or right heart function impacts the likelihood of residual MR. METHODS This is a retrospective single-centre study of 155 consecutive patients with LVAD implantation from January 2011 to March 2020. Exclusion criteria were no MR pre-LVAD (n=8), inaccessible echocardiography (n=9), duplicate records (n=10) and concomitant mitral valve repair (n=1). Statistical analysis was performed using STATA V.16 and SPSS V.24. RESULTS Carpentier IIIb MR aetiology was associated with more severe MR pre-LVAD (severe 18/27 (67%) vs non-severe 32/91 (35%), p=0.004) and a higher likelihood of residual MR (8/11 (72%) vs 30/74 (41%), p=0.045). Of 95 patients with significant MR pre-LVAD, 15 (16%) had persistent significant MR, which was associated with higher mortality (p=0.006), post-LVAD right ventricle (RV) dilatation (10/15 (67%) vs 28/80 (35%), p=0.022) and RV dysfunction (14/15 (93%) vs 35/80 (44%), p<0.001). Aside from ischaemic aetiology, other pre-LVAD parameters that were associated with significant residual MR included left ventricular end-systolic diameter (LVESD) (6.9 cm (5.7-7.2) vs 5.9 cm (5.5-6.5), p=0.043), left atrial volume index (LAVi) (78 mL/m2 (56-88) vs 57 mL/m2 (47-77), p=0.021), posterior leaflet displacement (2.5 cm (2.3-2.9) vs 2.3 cm (1.9-2.7), p=0.042) and basal right ventricular end-diastolic diameter (RVEDD) (5.1±0.8 cm vs 4.5±0.8 cm, p=0.010). CONCLUSION LVAD therapy improves MR and tricuspid regurgitation severity in the majority, but 14% have persistent significant residual MR, associated with right ventricular dysfunction and higher long-term mortality. This may be predicted pre-LVAD by greater LVESD, RVEDD and LAVi and by ischaemic aetiology.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Boyang Liu
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mengshi Yuan
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Iqra Shakeel
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Andrew Morley-Smith
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alice Hatch
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joseph Bradley
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin Chue
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saul G Myerson
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Richard Paul Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sern Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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10
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Manikala VK, Nguyen Q, Fu Q, Neufeld A, MacArthur R, Conway J, Buchholz H. Left ventricular assist device inflow obstruction. Indian J Thorac Cardiovasc Surg 2023; 39:165-169. [PMID: 36785610 PMCID: PMC9918624 DOI: 10.1007/s12055-022-01435-x] [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: 07/21/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022] Open
Abstract
Inflow cannula obstruction is a rare complication of left ventricular assist device implantation. In this report, we present a case of inflow obstruction that was successfully treated with left ventricle myectomy and mitral valvectomy. Transesophageal echocardiogram was essential in diagnosing this condition.
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Affiliation(s)
- Vinod Kumar Manikala
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Quynh Nguyen
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Qiang Fu
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Angela Neufeld
- Mazankowski Alberta Heart Institute, Edmonton, Canada
- Division of Anesthesiology & Pain Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Roderick MacArthur
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Jennifer Conway
- Mazankowski Alberta Heart Institute, Edmonton, Canada
- Division of Pediatric Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Holger Buchholz
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Canada
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11
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Loforte A, Nersesian G, Lewin D, Lanmueller P, Gliozzi G, Stein J, Cavalli GG, Schoenrath F, Netuka I, Zimpfer D, de By TMMH, Gummert J, Falk V, Meyns B, Faerber G, Pacini D, Potapov E. Impact of preoperative mitral regurgitation on left ventricular assist device patients: propensity score-matched analysis of the EUROMACS dataset. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6986977. [PMID: 36637204 DOI: 10.1093/ejcts/ezad013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/02/2022] [Accepted: 01/11/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Mitral regurgitation (MR) is frequently observed in patients undergoing left ventricular assist device implantation. We investigated the impact of preoperative MR on left ventricular assist device patients. METHODS A retrospective propensity score-matched analysis of adult patients enrolled in the EUROMACS registry between 1 January 2011 and 30 November 2021 was performed. Patients were divided into 2 groups according to the grade of preoperative MR: none-to-mild (MR 0-II) or moderate-to-severe (MR III-IV). RESULTS Following 1:1 propensity score matching, each group consisted of 914 patients. Incidence of postoperative temporary right ventricular support, reoperation for bleeding and dialysis was similar. MR III-IV demonstrated shorter median intensive care unit stay [14 days (6; 27.8) vs 10 days (5; 22), P = 0.004] and ventilation time [72 h (22, 320) vs 31 h (18, 150), P < 0.001]. Mortality was lower for MR III-IV patients [subdistribution hazard ratio: 0.66, 95% confidence interval (CI): 0.59-0.73, P < 0.001]. The 1-year survival was 68.1% (95% CI: 65.1-71.3%) in MR 0-II and 75% (95% CI: 72.1-78%) in MR III-IV. A lower incidence of total complications [odds ratio (OR): 0.93 (0.89-0.98), P = 0.003] and trend towards a lower risk of neurological dysfunction (subdistribution hazard ratio: 0.79; 95% CI: 0.61-1.01, P = 0.063) and sustained ventricular tachycardia [OR: 0.93 (0.54-1.03), P = 0.074] were demonstrated for MR III-IV. The risk of fatal stroke and pump thrombosis was similar. CONCLUSIONS Moderate-to-severe MR in patients undergoing left ventricular assist device implantation is associated with better mid-term survival and lower incidence of total major adverse events and complications. The incidence of severe postoperative complications including fatal stroke and device thrombosis was similar.
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Affiliation(s)
- Antonio Loforte
- Department of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Gregorio Gliozzi
- Department of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Julia Stein
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | | | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Daniel Zimpfer
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jan Gummert
- Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Centre), North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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12
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Si MS, Sood V, Biniwale R, Peng D. Considerations of valvular heart disease in children with ventricular assist devices. Front Cardiovasc Med 2023; 10:1056663. [PMID: 37034354 PMCID: PMC10075362 DOI: 10.3389/fcvm.2023.1056663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Ventricular assist devices have become a valuable tool in the treatment of heart failure in children. The use of ventricular assist devices has decreased mortality in children with end-stage heart failure awaiting transplant. It is not uncommon for children with end-stage heart failure associated with cardiomyopathy or congenital heart disease to have significant systemic semilunar and atrioventricular valve regurgitation, which can impact the efficiency and efficacy of hemodynamic support provided by a ventricular assist device. Therefore, implanting clinicians should carefully assess for valve abnormalities that may need repair and impact device selection and cannulation strategy to effectively support this diverse population. The purpose of this review is to provide an overview of this important and relevant topic and to discuss strategies for managing these patients.
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Affiliation(s)
- Ming-Sing Si
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
- Correspondence: Ming-Sing Si
| | - Vikram Sood
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
| | - Reshma Biniwale
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
| | - David Peng
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, Mattel Children’s Hospital, Los Angeles, CA, United States
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13
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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14
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Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
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Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
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15
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Noly PE, Duggal N, Jiang M, Nordsletten D, Bonini M, Lei I, Ela AAE, Haft JW, Pagani FD, Cascino TM, Tang PC. Role of the mitral valve in left ventricular assist device pathophysiology. Front Cardiovasc Med 2022; 9:1018295. [PMID: 36386343 PMCID: PMC9649705 DOI: 10.3389/fcvm.2022.1018295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/29/2022] [Indexed: 08/27/2023] Open
Abstract
Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Neal Duggal
- Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mulan Jiang
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | - David Nordsletten
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Mia Bonini
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Ienglam Lei
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan W. Haft
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D. Pagani
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Paul C. Tang
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
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16
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Residual Mitral Regurgitation and Worse Outcomes After LVAD Implant: Culprit or Surrogate? J Heart Lung Transplant 2022; 41:1646-1648. [DOI: 10.1016/j.healun.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/21/2022] Open
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17
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Tanveer Ud Din M, Minhas AMK, Muslim MO, Wazir MHK, Dani SS, Goel SS, Alam M, Sá MP, Seese L, Hirji S. Outcomes of MitraClip and Surgical Mitral Valve Repair in Patients With Left Ventricular Assist Device. Am J Cardiol 2022; 173:143-145. [PMID: 35437161 DOI: 10.1016/j.amjcard.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Mian Tanveer Ud Din
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | | | | | | | - Sourbha S Dani
- Division of Cardiology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Mahboob Alam
- Michael E. DeBakey Veterans Affair Medical Center; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Laura Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sameer Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Residual Mitral Regurgitation in Patients with Left Ventricular Assist Device Support – An INTERMACS Analysis. J Heart Lung Transplant 2022; 41:1638-1645. [DOI: 10.1016/j.healun.2022.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/02/2022] [Accepted: 03/02/2022] [Indexed: 11/18/2022] Open
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Pausch J, Bhadra O, Mersmann J, Conradi L, Sill B, Barten MJ, Reichenspurner H, Bernhardt AM. Prognostic impact of functional mitral regurgitation prior to left ventricular assist device implantation. J Cardiothorac Surg 2022; 17:24. [PMID: 35216595 PMCID: PMC8876108 DOI: 10.1186/s13019-021-01748-9] [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: 10/03/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is a common finding of advanced heart failure with detrimental effects. The prognostic impact of uncorrected FMR prior to left ventricular assist device (LVAD) implantation remains controversial. METHODS Between 2016 and 2019 77 patients underwent continuous-flow LVAD implantation at our institution. 34 patients showed FMR ≥ 2 (MR-group), whereas 43 patients showed FMR < 2 (Control-group). Data was retrospectively analyzed. Primary composite endpoint comprised freedom from death, stroke, pump-thrombosis, major bleeding and right heart failure (RHF) after 1 year. RESULTS Baseline characteristics, including the severity of left and right ventricular dysfunction, and periprocedural results were comparable. The overall survival during a mean follow up of 24.9 months was 55.9% in the MR-group versus 58.1% in the Control-group (p = 0.963), whereas 1-year event-free survival was 35.3% in the MR-group compared to 44.2% in the Control-group (p = 0.404). RHF within the first postoperative year occurred more frequently in the MR-group (35.3% vs. 11.6%; p = 0.017). Furthermore, RV function was significantly reduced in comparison to baseline values in the MR-group. 12 months after surgery, 74% of patients in the MR-group were classified as NYHA III in comparison to 24% of patients in the Control-group (p < 0.001). CONCLUSIONS Preoperative uncorrected FMR prior to LVAD implantation did not affect overall survival, nevertheless it was associated with an impaired RV function and increased incidence of right heart failure during follow-up. Furthermore, preoperative FMR ≥ 2 was associated with persistent symptoms of heart failure.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany.
| | - Oliver Bhadra
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Julian Mersmann
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Bjoern Sill
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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22
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Zubarevich A, Szczechowicz M, Arjomandi Rad A, Osswald A, Papathanasiou M, Luedike P, Koch A, Pizanis N, Kamler M, Schmack B, Ruhparwar A, Weymann A. Impact of severe mitral regurgitation on postoperative outcome after durable left-ventricular assist device implantation. Artif Organs 2021; 46:953-963. [PMID: 34931335 DOI: 10.1111/aor.14154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/08/2021] [Accepted: 11/29/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. METHODS From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n = 109) presented with MR 0-I°, and Group B presented with MR II-III° (n = 137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm2 ). RESULTS Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p < 0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p < 0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5-year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p = 0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p = 0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. CONCLUSION MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of developing postoperative major adverse events. Addressing the MR might be considered for these patients.
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Affiliation(s)
- Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Marcin Szczechowicz
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arian Arjomandi Rad
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Anja Osswald
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Peter Luedike
- Department of Cardiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Achim Koch
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
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Loforte A, de By TMMH, Gliozzi G, Schönrath F, Mariani C, Netuka I, Pya Y, Zimpfer D, Cavalli GG, Gummert J, Meyns B, Pacini D, Potapov E. Impact of concomitant cardiac valvular surgery during implantation of continuous-flow left ventricular assist devices: A European registry for patients with mechanical circulatory support (EUROMACS) analysis. Artif Organs 2021; 46:813-826. [PMID: 34904255 DOI: 10.1111/aor.14143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/22/2021] [Accepted: 12/08/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND We investigated the clinical outcomes after cardiac valvular surgery procedures concomitant (CCPs) with left ventricular assist device (LVAD) implantation compared to propensity score (PS) matched controls using the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data. METHODS Between 2006 and 2018, 2760 continuous-flow LVAD patients were identified. Of these, 533 underwent a CCP during the LVAD implant. RESULTS Cardiopulmonary bypass time (p < 0.001) and time for implant (p < 0.001) were both significantly longer in the LVAD+CCP group. Hospital mortality was comparable between the two groups from the unmatched population (15.7% vs. 14.1%, p = 0.073). Similarly, short-to-mid-term survival was similar in both groups, with 1-year, 3-year, and 5-year survival rates of 67.9%, 48.2%, and 27.7% versus 66.4%, 46.1%, and 26%, respectively (log-rank, p = 0.25). The results were similar in the PS-matched population. Hospital mortality was comparable between the two groups (18.9% vs. 17.4%, p = 0.074). The short-to-mid-term Kaplan-Meier survival analysis was similar for both groups, with 1-year, 3-year, and 5-year survival rates of 63.4%, 49.2%, and 24.7% versus 66.5%, 46%, and 25.1%, respectively (log-rank, p = 0.81). In the unmatched population, LVAD+CCP patients had longer intensive care unit (ICU) stays (p < 0.0001), longer mechanical ventilation time (p = 0.001), a higher rate of temporary right ventricular assist device (RVAD) support (p = 0.033), and a higher rate of renal replacement therapy (n = 35, 6.6% vs. n = 89, 4.0%, p = 0.014). In the PS-matched population, the LVAD+CCP patients had longer ICU stays (p = 0.019) and longer mechanical ventilation time (p = 0.002). CONCLUSIONS The effect of additive valvular procedures (CCPs) does not seem to affect short-term survival, significantly, based on our registry data analysis. However, the decision to perform CCPs should be balanced with the projected type of surgery and preoperative characteristics. LVAD+CCP patients remain a delicate population and adverse device-related events should be strictly monitored and managed.
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Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Carlo Mariani
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Yuriy Pya
- National Research Cardiac Surgery Center, Astana Kazakhstan, Kazakhstan
| | | | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Jan Gummert
- Heart and Diabetes Center North-Rhine Westphalia, Ruhr-Un, Bad Oeynhausen, Germany
| | - Bart Meyns
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
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Tang PC, Duggal NM, Haft JW, Romano MA, Bolling SF, El Ela AA, Wu X, Colvin MM, Aaronson KD, Pagani FD. Left Ventricular Assist Device Implantation in Patients with Preoperative Severe Mitral Regurgitation. ASAIO J 2021; 67:1139-1147. [PMID: 34570728 PMCID: PMC11177295 DOI: 10.1097/mat.0000000000001379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We examined cardiac features associated with residual mitral regurgitation (MR) following continuous-flow left ventricular assist device (cfLVAD) implant. From 2003 to 2017, 134 patients with severe MR underwent cfVLAD implant without mitral valve (MV) intervention. Echocardiographic (echo) assessment occurred pre-cfLVAD, early post-cfLVAD, and at last available echo. Ventricular and atrial volumes were calculated from established formulas and normalized to be predicted. Cluster analysis based on preoperative normalized left ventricular and atrial volumes, and MV height identified grades 1, 2, and 3 with progressively larger cardiac chamber sizes. Median early echo follow-up was 0.92 (0.55, 1.45) months and the last follow-up was 15.12 (5.28, 38.28) months. Mitral regurgitation improved early after cfLVAD by 2.10 ± 1.16 grades (p < 0.01). Mitral regurgitation severity at the last echocardiogram positively correlated with the preoperative left ventricular volume (p = 0.014, R = 0.212), left atrial volume (p = 0.007, R = 0.233), MV anteroposterior height (p = 0.032, R = 0.185), and MV mediolateral diameter (p = 0.043, R = 0.175). Morphologically, smaller grade 1 hearts were correlated with MR resolution at the late follow-up (p = 0.023). Late right ventricular failure (RVF) at the last clinical follow-up was less in grade 1 (4/48 [8.3%]) compared with grades 2 and 3 (26/86 [30.2%]), p = 0.004). Grade 1 cardiac dimensions correlates with improvement in severe MR and had less late RVF.
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Affiliation(s)
- Paul C. Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Neal M. Duggal
- Department of Anesthesiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Monica M. Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Nicoara A, Song P, Bollen BA, Paone G, Abernathy JJ, Taylor MA, Habib RH, Del Rio JM, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2021 Update on Echocardiography. Ann Thorac Surg 2021; 113:13-24. [PMID: 34536378 DOI: 10.1016/j.athoracsur.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Abstract
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.
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Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Pinping Song
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Gaetano Paone
- Department of Surgery, Emory University, Atlanta, Georgia
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | | | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Lincoln, Nebraska
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Department of Anesthesiology Vanderbilt University, Nashville, Tennessee.
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Schreiber C, Dieterlen MT, Garbade J, Borger MA, Sieg F, Spampinato R, Dobrovie M, Meyer AL. Validation of mitral regurgitation reversibility in patients with HeartMate 3 implantation. Artif Organs 2021; 46:106-116. [PMID: 34398476 DOI: 10.1111/aor.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 11/27/2022]
Abstract
The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3 years. Of 135 LVAD patients (with severe MR, n = 33; with none, mild, or moderate MR, n = 102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1 month postoperatively, and at 1, 2, and 3 years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P < .001), right ventricular end-diastolic diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), and estimated pulmonary artery pressure (P < .001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2 years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P = .073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.
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Affiliation(s)
- Constantin Schreiber
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Maja-Theresa Dieterlen
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jens Garbade
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael A Borger
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Franz Sieg
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ricardo Spampinato
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Monica Dobrovie
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Anna L Meyer
- Department of Cardiac Surgery, University Hospital, Heidelberg, Germany
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Bauer TM, Tang PC. Commentary: Surgical necessity is the mother of innovation when determining left ventricular assist device inflow access. JTCVS Tech 2021; 8:93-94. [PMID: 34401824 PMCID: PMC8350810 DOI: 10.1016/j.xjtc.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Tyler M. Bauer
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Paul C. Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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28
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Therapeutic Strategy in the era of MitraClip and Ventricular Assist Device. ASAIO J 2021; 67:e117. [PMID: 34033587 DOI: 10.1097/mat.0000000000001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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29
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Tang PC, Duggal NM, Haft JW, Aaronson KD, Pagani FD. Fate of preoperative moderate mitral regurgitation following left ventricular assist device implantation. J Card Surg 2021; 36:1843-1849. [PMID: 33604994 PMCID: PMC11196981 DOI: 10.1111/jocs.15428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We examined for improvements in preoperative moderate mitral regurgitation following continuous-flow left ventricular assist device (cfLVAD) implantation. METHODS From 2006 to 2020, 190 patients with moderate MR underwent cfVLAD implant without concomitant mitral valve (MV) surgery. Cardiac dimensions and contractility, as well as valve function, were assessed with an echocardiogram (echo) pre-cfLVAD, and at approximately 1 month post-cfLVAD. Outcomes were determined by retrospective chart review. RESULTS Median echo follow-up was 0.94 (0.53, 1.38) months. Residual significant moderate or greater MR was present in 30/190 (15.8%) on follow-up. Patients with significant residual MR had larger preoperative left ventricular internal diameters in diastole (74.4 ± 8.7 vs. 71.1.0 ± 9.1 mm, p = .034). Significant residual MR was associated with higher preoperative mean pulmonary artery pressures (OR = 1.055, p = .035) and pulmonary capillary wedge pressures (OR = 1.060, p = .034). Significant residual MR on echo was not associated with any survival difference (p = .325). The 1, 5, and 10 year survival were 89.9%, 55.2%, and 34.2%, respectively. CONCLUSIONS For patients with moderate MR undergoing LVAD implantation, the likelihood of significant residual MR is low and mitral intervention in this population is not recommended. However, select patients with larger preoperative left heart dimensions and pulmonary vascular pressures may be at risk for persistent residual MR.
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Affiliation(s)
- Paul C. Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Neal M. Duggal
- Department of Anesthesiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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30
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Inflow Cannula Position Influences Improvement in Mitral Regurgitation After Ventricular Assist Device Implantation. ASAIO J 2021; 67:423-429. [PMID: 33769997 DOI: 10.1097/mat.0000000000001248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Significant residual mitral regurgitation (MR) after left ventricular assist device (LVAD) implantation has been associated with increased morbidity and mortality. The effect of cannula position on improvement of preexisting MR has yet to be evaluated. Consecutive patients who underwent centrifugal LVAD implantation with >mild preoperative MR and without concomitant mitral repair were reviewed. Left ventricular assist device position was determined by the angle between actual and ideal inflow cannula on computed tomography. The magnitudes of angles (anterior and lateral angle) were added to form an LVAD position assessment (LVADpa). Mitral regurgitation was numerically classified, and improvement in MR was determined by difference in MR preoperatively to MR >1 month postoperatively with a median of 162 (interquartile range: 78-218) days. The primary analysis examined the relationship between LVADpa and postoperative MR. Forty-one patients were identified with >mild preoperative functional MR. Mean age was 51 ± 13 years with an ejection fraction of 16 ± 4%. Overall, MR improved from moderate-severe preoperatively to mild postoperatively (p < 0.001). On multivariable analysis, higher LVADpa deviation was associated with greater postoperative MR (odds ratio [OR] = 2.29, p = 0.005) and higher 1-month pulsatility index was associated with lower postoperative MR (OR = 0.47, p = 0.011). Inflow cannula position during centrifugal LVAD implantation is an important determinant of postoperative MR.
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Mitral and aortic valve surgery during left ventricular assist device implantation. J Thorac Cardiovasc Surg 2021; 164:970-977. [PMID: 33865571 DOI: 10.1016/j.jtcvs.2021.01.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 12/27/2022]
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Cheema FH, Loyalka P, Rajagopal K. Commentary: Continuous-Flow Left Ventricular Assist Device Implantation as a Treatment for Functional Mitral Valve Regurgitation. Semin Thorac Cardiovasc Surg 2021; 33:998-1000. [PMID: 33609683 DOI: 10.1053/j.semtcvs.2021.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Faisal H Cheema
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Texas; HCA Research Institute, Nashville, Tennessee; Houston Heart, HCA Houston Healthcare, Houston, Texas
| | - Pranav Loyalka
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Texas; Houston Heart, HCA Houston Healthcare, Houston, Texas
| | - Keshava Rajagopal
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Texas; Houston Heart, HCA Houston Healthcare, Houston, Texas.
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Noly PE, Tang PC. Commentary: Significant Mitral Regurgitation at the Time of LVAD Implantation: Looking Together in the Same Direction But We Need to Look Closer. Semin Thorac Cardiovasc Surg 2021; 33:996-997. [PMID: 33609678 PMCID: PMC11168725 DOI: 10.1053/j.semtcvs.2021.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Paul C Tang
- University of Michigan, Ann Arbor, Michigan.
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Cruz Rodriguez JB, Chatterjee A, Pamboukian SV, Tallaj JA, Joly J, Lenneman A, Aryal S, Hoopes CW, Acharya D, Rajapreyar I. Persistent mitral regurgitation after left ventricular assist device: a clinical conundrum. ESC Heart Fail 2021; 8:1039-1046. [PMID: 33471962 PMCID: PMC8006607 DOI: 10.1002/ehf2.12919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 06/14/2020] [Accepted: 07/13/2020] [Indexed: 12/29/2022] Open
Abstract
Aims Persistent mitral valve regurgitation (MR) after continuous flow left ventricular assist device implantation (cfLVAD) is associated with pulmonary hypertension and right ventricular failure with variable effects on survival across published studies. The aim of this study is to determine the incidence and predictors of persistent MR at 6‐month follow‐up after cfLVAD implantation and its impact on survival, haemodynamics, right ventricular function, and morbidity. Methods and results We performed a retrospective review of all adult cfLVAD recipients from January 2012 to June 2017 at a single tertiary university hospital with follow‐up until April 2019. Primary outcome was to compare survival between patients with no‐to‐mild compared with persistent moderate‐to‐severe MR at 6 months. Secondary outcomes included right heart failure (RHF), length of stay, re‐hospitalizations, and composite of death, transplant, and pump exchange during the length of follow‐up. Final analytic sample was 111 patients. The incidence of persistent moderate or severe MR at 6 months was 26%. Significant predictors of persistent MR at 6 months were left atrium dimension and volume. The group with persistent moderate‐to‐severe MR at 6 months had higher incidence of RHF at 6 months (45% vs. 25%, P = 0.04). There was no difference in survival at 1 year between the groups (no‐to‐mild MR 85.5%, moderate‐to‐severe MR 87.9%, Wilcoxon P‐value = 0.63). There was no difference in re‐hospitalizations, length of stay, composite of death, transplant, or pump exchange during the length of follow‐up between the comparison groups. Conclusions Persistent moderate‐to‐severe MR after cfLVAD implantation is present in one fourth of patients and is associated with increased incidence of RHF, higher mean pulmonary pressure, and pulmonary capillary wedge pressure with no effect on 1 year survival. Increased left atrium size was associated with persistent moderate‐to‐severe MR at 6 months.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA.,Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Arka Chatterjee
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Jose A Tallaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Joanna Joly
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Andrew Lenneman
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Sudeep Aryal
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
| | - Charles W Hoopes
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, 1900 University Boulevard, Tinsley Harrison Tower 311, Birmingham, AL, 35233, USA
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Coyan GN, Pierce BR, Rhinehart ZJ, Ruppert KM, Katz W, Kilic A, Kormos RL, Sciortino CM. Impact of Pre-Existing Mitral Regurgitation Following Left Ventricular Assist Device Implant. Semin Thorac Cardiovasc Surg 2021; 33:988-995. [PMID: 33444766 DOI: 10.1053/j.semtcvs.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Optimal management of significant mitral regurgitation (SMR) during left ventricular assist device (LVAD) placement remains uncertain. This study evaluates the effect of untreated preop SMR on outcomes following LVAD implant. METHODS Adults undergoing primary LVAD placement from April 2004 to May 2017 were included. Most recent preop transthoracic echocardiogram (TTE) was used to divide patients into an SMR group with moderate or greater regurgitation, and a group without SMR. Patients underwent LVAD implant without correction of SMR. Primary endpoint was 3-year postoperative survival, with secondary endpoints of length of stay (LOS), resolution of SMR following LVAD on postdischarge (30 day) TTE, and 1-year TTE. RESULTS LVAD placement was performed in 270 patients, 172 (63.7%) without SMR and 98 (36.3%) with SMR. There were no differences in comorbidities including diabetes, hypertension, and renal disease. Preop ejection fraction was similar, but a higher pulmonary vascular resistance was recorded in the SMR group (3.6 vs 3.0 Wood Units, P = 0.048). There was no difference in 3-year mortality between the 2 cohorts (log-rank P = 0.0.803). The SMR group had decreased LOS (median 19.5 vs 22 days, P = 0.009). Of the 98 SMR patients, 91 (92.9%) had resolution of SMR to less than moderate at 30 days. At 1 year, 15% of those with preoperative SMR had recurrent SMR. CONCLUSIONS Patients undergoing LVAD placement with preop SMR experience no differences in mortality, and a majority experience resolution of MR after implant. Longer-term SMR recurrence and need for mitral intervention with LVAD implant warrant further investigation.
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Affiliation(s)
- Garrett N Coyan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian R Pierce
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zachary J Rhinehart
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kristen M Ruppert
- Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Katz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher M Sciortino
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Kreusser MM, Hamed S, Weber A, Schmack B, Volz MJ, Geis NA, Grossekettler L, Pleger ST, Ruhparwar A, Katus HA, Raake PW. MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure. ESC Heart Fail 2020; 7:3891-3900. [PMID: 33107214 PMCID: PMC7754960 DOI: 10.1002/ehf2.12982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
Aims Mitral valve regurgitation (MR) is common in patients with advanced heart failure (HF). Percutaneous mitral valve repair (PMVR) via MitraClip (MC) has emerged as a feasible treatment strategy for these high‐risk patients. However, as HF often further progresses, there is a frequent need for left ventricular assist device (LVAD) implantation in these patients. We aimed to investigate whether prior MC implantation affects the subsequent LVAD implantation and outcome. Methods and results Thirty‐seven patients with advanced HF and significant MR who underwent LVAD implantation were retrospectively analysed. Follow‐up data were collected at 1 year after LVAD implantation. Primary endpoint was all‐cause mortality. Secondary endpoint included peri‐operative parameters and clinical development depicted as New York Heart Association (NYHA) class and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Seventeen patients initially received a MC device (MC group), resulting in a significant reduction in MR grade. After MC, NYHA class and INTERMACS level further worsened, leading to subsequent LVAD implantation after a median time of 475 days in the MC group. At LVAD implantation, overall characteristics were comparable with those of the patients undergoing LVAD implantation without prior MC placement (no‐MC group). Procedural data revealed a higher incidence of right ventricular (RV) failure needing mechanical RV assistance and a longer need for nitric oxide ventilation in the MC group after LVAD implantation. One‐year survival was slightly better in the no‐MC group compared with the MC group [41% (n = 7/17) vs. 65% (n = 13/20); P = 0.15], albeit event‐free survival was comparable between both groups, MC and no‐MC. Conclusions LVAD implantation after MC is feasible and safe. However, in patients with advanced HF and severe MR, PMVR may only delay a needed LVAD implantation and thereby lead to poorer peri‐operative RV function and impaired outcome. Arguably, these patients might benefit from the timely management of advanced HF by the means of early LVAD implantation or heart transplantation.
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Affiliation(s)
- Michael M Kreusser
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Sonja Hamed
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Andreas Weber
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany.,Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Martin J Volz
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Nicolas A Geis
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Leonie Grossekettler
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Sven T Pleger
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany.,Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Hugo A Katus
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany
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Hayashi H, Naka Y, Sanchez J, Takayama H, Kurlansky P, Ning Y, Topkara VK, Yuzefpolskaya M, Colombo PC, Sayer GT, Uriel N, Takeda K. Consequences of functional mitral regurgitation and atrial fibrillation in patients with left ventricular assist devices. J Heart Lung Transplant 2020; 39:1398-1407. [PMID: 32994093 DOI: 10.1016/j.healun.2020.08.020] [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: 03/18/2020] [Revised: 08/15/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (MR) (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. This study aimed to investigate the characteristics and prognostic significance of FMR and AF in patients with LVADs. METHODS We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We defined significant FMR as the ratio of MR color jet area to left atrial area of >20% and persistent or permanent AF (PeAF) as persistent or permanent AF at LVAD implantation. RESULTS A total of 380 patients were included in this analysis. Patients were divided into 6 groups: patients with no PeAF and no significant FMR (Group 1), patients with no PeAF but with significant FMR (Group 2), patients with PeAF but no significant FMR (Group 3), patients with PeAF and significant FMR (Group 4), patients with concomitant mitral valve surgery (MVS) at LVAD implantation and without PeAF (Group 5), and patients with concomitant MVS and with PeAF (Group 6). A total of 56 patients (15%) died within 2 years. Kaplan-Meier curve analysis demonstrated a 2-year survival of 81% in Group 1, 89% in Group 2, 87% in Group 3, 47% in Group 4, 87% in Group 5, and 79 % in Group 6 (log-rank test, p < 0.001). The multivariable Cox proportional-hazards model showed that classification in Group 4 was an independent predictor of mortality (hazard ratio, 4.31; 95% CI: 2.19-8.46; p < 0.001). CONCLUSIONS The coexistence of significant FMR and PeAF may represent a poor prognostic marker in patients undergoing LVAD implantation.
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Affiliation(s)
| | | | | | | | | | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
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Psychiatric Comorbidity and Outcomes After Left Ventricular Assist Device Implantation for End-Stage Heart Failure. JACC-HEART FAILURE 2020; 8:569-577. [DOI: 10.1016/j.jchf.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/22/2022]
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Pagani FD. Understanding the impact of mitral regurgitation at the time of LVAD implantation. J Heart Lung Transplant 2020; 39:538-540. [DOI: 10.1016/j.healun.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/25/2022] Open
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40
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Mullan C, Caraballo C, Ravindra NG, Miller PE, Mori M, McCullough M, Clarke JRD, Anwer M, Velazquez EJ, Geirsson A, Desai NR, Ahmad T. Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation. J Heart Lung Transplant 2020; 39:926-933. [PMID: 32593561 DOI: 10.1016/j.healun.2020.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/29/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in patients with end-stage heart failure receiving left ventricular assist devices (LVADs), but the benefit of concomitant tricuspid valve procedures (TVPs) remains uncertain. This study examined the impact of TVP at the time of LVAD implantation on clinical outcomes and quality of life (QOL) metrics. METHODS We included adult patients in the Interagency Registry for Mechanical Circulatory Support database with various degrees of TR who received continuous-flow LVADs from 2008 to 2017. Patients undergoing concomitant TVP were compared with those without the intervention in a stratified analysis. Descriptive analyses, survival analyses, and Andersen‒Gill hazard models were used as appropriate to examine associations with clinical and patient-centered QOL outcomes. RESULTS Our analysis included 8,263 (53.1%) mild, 4,252 (33.3%) moderate, and 2,100 (13.5%) severe TR cases. TVP rate increased with severity: 8.6% of mild, 18.0% of moderate, and 43.9% of severe cases. TVP was not associated with survival benefit in cases of mild (adjusted hazard ratio [aHR]: 0.97, 95% CI: 0.79-1.19, p = 0.75), moderate (aHR: 1.03, 95% CI: 0.88-1.20, p = 0.72), or severe (aHR: 1.20, 95% CI: 0.98-1.48, p = 0.08) TR. For patients with combined moderate or severe TR, TVP was associated with increased mortality (log-rank p < 0.01, aHR: 1.13, 95% CI: 1.00-1.27, p = 0.04). After adjusting for TR severity, TVP was associated with increased risk of bleeding, arrhythmia, and stroke (p < 0.01 each) and no improvements in QOL (p > 0.05). CONCLUSIONS TVP at the time of LVAD implantation was not associated with either improved survival or QOL, and there were associations with increased risk of adverse events among patients with moderate and severe TR.
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Affiliation(s)
- Clancy Mullan
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Neal G Ravindra
- Cardiovascular Research Center and Department of Computer Science, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Yale National Clinician Scholars Program, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Megan McCullough
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - John-Ross D Clarke
- Department of Internal Medicine (Bridgeport Hospital), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Nihar R Desai
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Tariq Ahmad
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut.
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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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43
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Imamura T, Nnanabu J, Rodgers D, Raikehlkar J, Kalantar S, Smith B, Nguyen A, Chung B, Narang N, Ota T, Song T, Burkhoff D, Jeevanandam V, Kim G, Sayer G, Uriel N. Hemodynamic Effects of Concomitant Mitral Valve Surgery and Left Ventricular Assist Device Implantation. ASAIO J 2020; 66:355-361. [PMID: 30985304 PMCID: PMC7081836 DOI: 10.1097/mat.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
There are conflicting data regarding whether concomitant mitral valve surgery (MVS) at left ventricular assist device (LVAD) implantation is beneficial. This study aimed to assess the hemodynamic effects of concomitant MVS. Of all 73 enrolled patients, 44 patients had undergone concomitant MVS and 29 patients had not. Before LVAD implantation, MVS group had higher pulmonary capillary wedge pressure (p = 0.04). After LVAD implantation, MVS group had higher mean pulmonary artery pressure and cardiac output (CO). During the hemodynamic ramp study, MVS group had steeper CO slopes (0.18 [0.13 0.28] vs. 0.15 [0.08, 0.20] L/min/step; p = 0.04) at incremental LVAD speed and achieved a higher CO at the optimized set speed (5.5 [4.7, 6.9] vs. 4.9 [4.0, 5.7] L/min; p = 0.03). One-year freedom from death or heart failure readmission was statistically comparable between the two groups (61% vs. 80%, p = 0.20). Thus far, after LVAD implantation and concomitant MVS, patients had increased pulmonary hypertension, despite having higher CO and a better response of CO at incremental LVAD speed. The implication of hemodynamic features after concomitant MVS on clinical outcomes warrants further investigation.
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Affiliation(s)
- Teruhiko Imamura
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Jerry Nnanabu
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikehlkar
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantar
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Burkhoff
- Columbia University Medical Center, and Cardiovascular Research Foundation, New York, New York
| | | | - Gene Kim
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- From the Department of Medicine; University of Chicago Medical Center, Chicago, Illinois
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Gu K, Guan Z, Chang Y, Gao B, Ling Y, Song Z, Wan F. Hemodynamic effects of pulsatile unloading of left ventricular assist devices (LVAD) on intraventricular flow and ventricular stress. J Biomech 2020; 103:109425. [DOI: 10.1016/j.jbiomech.2019.109425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 12/21/2022]
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Kanwar MK, Rajagopal K, Itoh A, Silvestry SC, Uriel N, Cleveland JC, Salerno CT, Horstmanshof D, Goldstein DJ, Naka Y, Bailey S, Gregoric ID, Chuang J, Sood P, Mehra MR. Impact of left ventricular assist device implantation on mitral regurgitation: An analysis from the MOMENTUM 3 trial. J Heart Lung Transplant 2020; 39:529-537. [PMID: 32279919 DOI: 10.1016/j.healun.2020.03.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/06/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mitral regurgitation (MR) determines pathophysiology and outcome in advanced heart failure. The impact of left ventricular assist device (LVAD) placement on clinically significant MR and its contribution to long-term outcomes has been sparsely evaluated. METHODS We evaluated the effect of clinically significant MR on patients implanted in the MOMENTUM 3 trial with either the HeartMate II (HMII) or the HeartMate 3 (HM3) at 2 years. Clinical significance was defined as moderate or severe grade MR determined by site-based echocardiograms. RESULTS Of 927 patients with LVAD implants without a prior or concomitant mitral valve procedure, 403 (43.5%) had clinically significant MR at baseline. At 1-month of support, residual MR was present in 6.2% of patients with HM3 and 14.3% of patients with HMII (relative risk = 0.43; 95% CI, 0.22-0.84; p = 0.01) with a low rate of worsening at 2 years. Residual MR at 1-month post-implant did not impact 2-year mortality for either the HM3 (hazard ratio [HR],1.41; 95% CI, 0.52-3.89; p = 0.50) or HMII (HR, 0.91; 95% CI, 0.37-2.26; p = 0.84) LVAD. The presence or absence of baseline MR did not influence mortality (HM3 HR, 0.86; 95% CI, 0.56-1.33; p = 0.50; HMII HR, 0.81; 95% CI, 0.54-1.22; p = 0.32), major adverse events or functional capacity. In multivariate analysis, severe baseline MR (p = 0.001), larger left ventricular dimension (p = 0.002), and implantation with the HMII instead of the HM3 LVAD (p = 0.05) were independently associated with an increased likelihood of persistent MR post-implant. CONCLUSIONS Hemodynamic unloading after LVAD implantation improves clinically significant MR early, sustainably, and to a greater extent with the HM3 LVAD. Neither baseline nor residual MR influence outcomes after LVAD implantation.
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Affiliation(s)
| | - Keshava Rajagopal
- The University of Texas Health Science Center at Houston and Memorial Hermann Hospital's Heart & Vascular Institute, Houston, Texas
| | - Akinobu Itoh
- Washington University School of Medicine, St Louis, Missouri
| | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York
| | | | | | | | - Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York
| | | | - Igor D Gregoric
- The University of Texas Health Science Center at Houston and Memorial Hermann Hospital's Heart & Vascular Institute, Houston, Texas
| | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts.
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Rajapreyar I, Rame JE, Fiorilli P, Pamboukian SV, Hoopes CW, Silvestry SC, Pagani FD, Rajagopal K. Pathological insights into persistent mitral regurgitation following continuous flow left ventricular assist device implantation. J Heart Lung Transplant 2020; 39:184-186. [DOI: 10.1016/j.healun.2019.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022] Open
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Noly PE, Pagani FD, Noiseux N, Stulak JM, Khalpey Z, Carrier M, Maltais S. Continuous-Flow Left Ventricular Assist Devices and Valvular Heart Disease: A Comprehensive Review. Can J Cardiol 2019; 36:244-260. [PMID: 32036866 DOI: 10.1016/j.cjca.2019.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/15/2022] Open
Abstract
Mechanical circulatory support with implantable durable continuous-flow left ventricular assist devices (CF-LVADs) represents an established surgical treatment option for patients with advanced heart failure refractory to guideline-directed medical therapy. CF-LVAD therapy has been demonstrated to offer significant survival, functional, and quality-of-life benefits. However, nearly one-half of patients with advanced heart failure undergoing implantation of a CF-LVAD have important valvular heart disease (VHD) present at the time of device implantation or develop VHD during support that can lead to worsening right or left ventricular dysfunction and result in development of recurrent heart failure, more frequent adverse events, and higher mortality. In this review, we summarize the recent evidence related to the pathophysiology and treatment of VHD in the setting of CF-LAVD support and include a review of the specific valve pathologies of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR). Recent data demonstrate an increasing appreciation and understanding of how VHD may adversely affect the hemodynamic benefits of CF-LVAD support. This is particularly relevant for MR, where increasing evidence now demonstrates that persistent MR after CF-LVAD implantation can contribute to worsening right heart failure and recurrent heart failure symptoms. Standard surgical interventions and novel percutaneous approaches for treatment of VHD in the setting of CF-LVAD support, such as transcatheter aortic valve replacement or transcatheter mitral valve repair, are available, and indications to intervene for VHD in the setting of CF-LVAD support continue to evolve.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - John M Stulak
- Department of Cardiac Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Zain Khalpey
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Michel Carrier
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Simon Maltais
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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48
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Bertrand PB, Namasivayam M. Left ventricular assist device after percutaneous mitral valve repair: Can we go there? Int J Cardiol 2019; 288:55-56. [DOI: 10.1016/j.ijcard.2019.03.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 03/24/2019] [Indexed: 11/26/2022]
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49
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Optimal patient selection for MitraClip system in the era of continuous-flow left ventricular assist device. Int J Cardiol 2019; 288:61. [PMID: 31101231 DOI: 10.1016/j.ijcard.2019.03.065] [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: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 11/20/2022]
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50
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 239] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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