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Zavorsky GS, Agostoni P. Two is better than one: the double diffusion technique in classifying heart failure. ERJ Open Res 2024; 10:00644-2023. [PMID: 38226067 PMCID: PMC10789268 DOI: 10.1183/23120541.00644-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/15/2023] [Indexed: 01/17/2024] Open
Abstract
Background Heart failure (HF) is a chronic condition in which the heart does not pump enough blood to meet the body's demands. Diffusing capacity of the lung for nitric oxide (DLNO) and carbon monoxide (DLCO) may be used to classify patients with HF, as DLNO and DLCO are lung function measurements that reflect pulmonary gas exchange. Our objectives were to determine 1) if DLNO added to DLCO testing predicts HF better than DLCO alone and 2) whether the binary classification of HF is better when DLNO z-scores are combined with DLCO z-scores than using DLCO z-scores alone. Methods This was a retrospective secondary data analysis in 140 New York Heart Association Class II HF patients (ejection fraction <40%) and 50 patients without HF. z-scores for DLNO, DLCO and DLNO+DLCO were created from reference equations from three articles. The model with the lowest Bayesian Information Criterion was the best predictive model. Binary HF classification was evaluated with the Matthews Correlation Coefficient (MCC). Results The top two of 12 models were combined z-score models. The highest MCC (0.51) was from combined z-score models. At most, only 32% of the variance in the odds of having HF was explained by combined z-scores. Conclusions Combined z-scores explained 32% of the variation in the likelihood of an individual having HF, which was higher than models using DLNO or DLCO z-scores alone. Combined z-score models had a moderate ability to classify patients with HF. We recommend using the NO-CO double diffusion technique to assess gas exchange impairment in those suspected of HF.
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Affiliation(s)
- Gerald S. Zavorsky
- Department of Physiology and Membrane Biology, University of California Davis, Sacramento, CA, USA
| | - Piergiuseppe Agostoni
- Department of Critical Cardiology, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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2
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Chwiedź A, Minarowski Ł, Mróz RM, Razak Hady H. Non-Invasive Cardiac Output Measurement Using Inert Gas Rebreathing Method during Cardiopulmonary Exercise Testing-A Systematic Review. J Clin Med 2023; 12:7154. [PMID: 38002766 PMCID: PMC10671909 DOI: 10.3390/jcm12227154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The use of inert gas rebreathing for the non-invasive cardiac output measurement has produced measurements comparable to those obtained by various other methods. However, there are no guidelines for the inert gas rebreathing method during a cardiopulmonary exercise test (CPET). In addition, there is also a lack of specific standards for assessing the non-invasive measurement of cardiac output during CPET, both for healthy patients and those suffering from diseases and conditions. AIM This systematic review aims to describe the use of IGR for a non-invasive assessment of cardiac output during cardiopulmonary exercise testing and, based on the information extracted, to identify a proposed CPET report that includes an assessment of the cardiac output using the IGR method. METHODS This systematic review was conducted by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines. PubMed, Web of Science, Scopus, and Cochrane Library databases were searched from inception until 29 December 2022. The primary search returned 261 articles, of which 47 studies met the inclusion criteria for this review. RESULTS AND CONCLUSIONS This systematic review provides a comprehensive description of protocols, indications, technical details, and proposed reporting standards for a non-invasive cardiac output assessment using IGR during CPET. It highlights the need for standardized approaches to CPET and identifies gaps in the literature. The review critically analyzes the strengths and limitations of the studies included and offers recommendations for future research by proposing a combined report from CPET-IGR along with its clinical application.
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Affiliation(s)
- Agnieszka Chwiedź
- I Department of General and Endocrine Surgery, Medical University of Bialystok, 15-276 Bialystok, Poland
- II Department of Lung Diseases and Tuberculosis, Medical University of Bialystok, 15-540 Bialystok, Poland
| | - Łukasz Minarowski
- II Department of Lung Diseases and Tuberculosis, Medical University of Bialystok, 15-540 Bialystok, Poland
| | - Robert M Mróz
- II Department of Lung Diseases and Tuberculosis, Medical University of Bialystok, 15-540 Bialystok, Poland
| | - Hady Razak Hady
- I Department of General and Endocrine Surgery, Medical University of Bialystok, 15-276 Bialystok, Poland
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Apostolo A, Vignati C, Cittar M, Baracchini N, Mushtaq S, Cattadori G, Sciomer S, Trombara F, Piepoli M, Agostoni P. Determinants of exercise performance in heart failure patients with extremely reduced cardiac output and left ventricular assist device. Eur J Prev Cardiol 2023; 30:ii63-ii69. [PMID: 37819220 DOI: 10.1093/eurjpc/zwad239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 10/13/2023]
Abstract
The evaluation of exercise capacity and cardiac output (QC) is fundamental in the management of patients with advanced heart failure (AdHF). QC and peak oxygen uptake (VO2) have a pivotal role in the prognostic stratification and in the definition of therapeutic interventions, including medical therapies and devices, but also specific treatments such as heart transplantation and left ventricular assist device (LVAD) implantation. Due to the intertwined relationship between exercise capacity and daily activities, exercise intolerance dramatically has impact on the quality of life of patients. It is a multifactorial process that includes alterations in central and peripheral haemodynamic regulation, anaemia and iron deficiency, pulmonary congestion, pulmonary hypertension, and peripheral O2 extraction. This paper aims to review the pathophysiological background of exercise limitations in HF patients and to examine the complex physiology of exercise in LVAD recipients, analysing the interactions between the cardiopulmonary system, the musculoskeletal system, the autonomic nervous system, and the pump. We performed a literature review to highlight the current knowledge on this topic and possible interventions that can be implemented to increase exercise capacity in AdHF patients-including administration of levosimendan, rehabilitation, and the intriguing field of LVAD speed changes. The present paper confirms the role of CPET in the follow-up of this peculiar population and the impact of exercise capacity on the quality of life of AdHF patients.
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Affiliation(s)
- Anna Apostolo
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138, Milano, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138, Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via della Commenda 19, 20122, Milano, Italy
| | - Marco Cittar
- Cardiovascular Department, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Via Costantino Costantinides, 2, 34128, Trieste, Italy
| | - Nikita Baracchini
- Cardiovascular Department, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Via Costantino Costantinides, 2, 34128, Trieste, Italy
| | - Saima Mushtaq
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138, Milano, Italy
| | - Gaia Cattadori
- Cardio-rehabilitation Unit, Multimedica IRCCS, Via Milanese, 300, 20099, Milano, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, 'Sapienza', Rome University, Viale dell'Università, 37, 00185, Rome, Italy
| | - Filippo Trombara
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138, Milano, Italy
| | - Massimo Piepoli
- Clinical Cardiology, Policlinico San Donato IRCCS, University of Milan, Piazza Edmondo Malan, 2, 20097, Milan, Italy
- Department of Preventive Cardiology, Wroclaw Medical University, Wybrzeże L. Pasteura 1, 50-367, Wroclaw, Poland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138, Milano, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via della Commenda 19, 20122, Milano, Italy
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Mattavelli I, Vignati C, Farina S, Apostolo A, Cattadori G, De Martino F, Pezzuto B, Zaffalon D, Agostoni P. Beyond VO2: the complex cardiopulmonary exercise test. Eur J Prev Cardiol 2023; 30:ii34-ii39. [PMID: 37819225 DOI: 10.1093/eurjpc/zwad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/21/2023] [Accepted: 05/06/2023] [Indexed: 10/13/2023]
Abstract
Cardiopulmonary exercise test (CPET) is a valuable diagnostic tool with a specific application in heart failure (HF) thanks to the strong prognostic value of its parameters. The most important value provided by CPET is the peak oxygen uptake (peak VO2), the maximum rate of oxygen consumption attainable during physical exertion. According to the Fick principle, VO2 equals cardiac output (Qc) times the arteriovenous content difference [C(a-v)O2], where Ca is the arterial oxygen and Cv is the mixed venous oxygen content, respectively; therefore, VO2 can be reduced both by impaired O2 delivery (reduced Qc) or extraction (reduced arteriovenous O2 content). However, standard CPET is not capable of discriminating between these different impairments, leading to the need for 'complex' CPET technologies. Among non-invasive methods for Qc measurement during CPET, inert gas rebreathing and thoracic impedance cardiography are the most used techniques, both validated in healthy subjects and patients with HF, at rest and during exercise. On the other hand, the non-invasive assessment of peripheral muscle perfusion is possible with the application of near-infrared spectroscopy, capable of measuring tissue oxygenation. Measuring Qc allows, by having haemoglobin values available, to discriminate how much any VO2 deficit depends on the muscle, anaemia or heart.
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Affiliation(s)
- Irene Mattavelli
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Stefania Farina
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
- Cytogenetics and Medical Genetics, University of Milano-Bicocca, Milan, Italy
| | - Anna Apostolo
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
| | - Gaia Cattadori
- Multimedica IRCCS, Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milan, Italy
| | - Fabiana De Martino
- Casa di Cura Tortorella, Dipartimento Medico, Unità funzionale di Cardiologia, Casa di Cura Tortorella, Salerno, Italy
| | - Beatrice Pezzuto
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
| | - Denise Zaffalon
- Cardiovascular Department, 'Azienda Sanitaria Universitaria Giuliano-Isontina', Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, Milan 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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Grinstein J, Belkin MN, Kalantari S, Bourque K, Salerno C, Pinney S. Adverse Hemodynamic Consequences of Continuous Left Ventricular Mechanical Support: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:70-81. [PMID: 37380306 DOI: 10.1016/j.jacc.2023.04.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 06/30/2023]
Abstract
Left ventricular assist devices (LVADs) provide lifesaving therapy for patients with advanced heart failure. The recognition of pump thrombosis, stroke, and nonsurgical bleeding as hemocompatibility-related adverse events (HRAEs) led to pump design improvements and reduced adverse event rates. However, continuous flow can predispose patients to right-sided heart failure (RHF) and aortic insufficiency (AI), especially as patients live longer with their device. Given the hemodynamic contributions to AI and RHF, these comorbidities can be classified as hemodynamic-related events (HDREs). Hemodynamic-driven events are time dependent and often manifest later than HRAEs. This review examines the emerging strategies to mitigate HDREs, with a focus on defining best practices for AI and RHF. As we head into the next generation of LVAD technology, it is important to differentiate HDREs from HRAEs so that we can continue to advance the field and improve the true durability of the pump-patient continuum.
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Affiliation(s)
- Jonathan Grinstein
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA.
| | - Mark N Belkin
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Sara Kalantari
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Kevin Bourque
- Heart Failure Division, Abbott, Burlington, Massachusetts, USA
| | - Christopher Salerno
- Section of Cardiac Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Sean Pinney
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Giannoni A, Borrelli C, Gentile F, Sciarrone P, Spießhöfer J, Piepoli M, Richerson GB, Floras JS, Coats AJS, Javaheri S, Emdin M, Passino C. Autonomic and respiratory consequences of altered chemoreflex function: clinical and therapeutic implications in cardiovascular diseases. Eur J Heart Fail 2023; 25:642-656. [PMID: 36907827 PMCID: PMC10989193 DOI: 10.1002/ejhf.2819] [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: 09/14/2022] [Revised: 02/10/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023] Open
Abstract
The importance of chemoreflex function for cardiovascular health is increasingly recognized in clinical practice. The physiological function of the chemoreflex is to constantly adjust ventilation and circulatory control to match respiratory gases to metabolism. This is achieved in a highly integrated fashion with the baroreflex and the ergoreflex. The functionality of chemoreceptors is altered in cardiovascular diseases, causing unstable ventilation and apnoeas and promoting sympathovagal imbalance, and it is associated with arrhythmias and fatal cardiorespiratory events. In the last few years, opportunities to desensitize hyperactive chemoreceptors have emerged as potential options for treatment of hypertension and heart failure. This review summarizes up to date evidence of chemoreflex physiology/pathophysiology, highlighting the clinical significance of chemoreflex dysfunction, and lists the latest proof of concept studies based on modulation of the chemoreflex as a novel target in cardiovascular diseases.
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Affiliation(s)
- Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | | | - Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
| | | | - Jens Spießhöfer
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- University of Aachen, Aachen, Germany
| | | | | | - John S Floras
- Division of Cardiology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | | | - Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, Ohio, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, and Division of Cardiology, The Ohio State University, Columbus, Ohio USA
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
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7
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Mapelli M, Mattavelli I, Salvioni E, Banfi C, Ghilardi S, De Martino F, Gugliandolo P, Mantegazza V, Volpato V, Basile C, Branco Pires MIF, Sassi V, Nusca B, Vignati C, Contini M, Sforza C, Biondi ML, Perrone Filardi P, Agostoni P. Impact of Sacubitril/Valsartan on surfactant binding proteins, central sleep apneas, lung function tests and heart failure biomarkers: Hemodynamic or pleiotropism? Front Cardiovasc Med 2022; 9:971108. [PMID: 36186983 PMCID: PMC9520298 DOI: 10.3389/fcvm.2022.971108] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeLittle is known about the mechanism underlying Sacubitril/Valsartan effects in patients with heart failure (HFrEF). Aim of the study is to assess hemodynamic vs. non-hemodynamic Sacubitril/Valsartan effects by analyzing several biological and functional parameters.MethodsSeventy-nine patients (86% males, age 66 ± 10 years) were enrolled. At baseline and 6 months after reaching the maximum Sacubitril/Valsartan tolerated dose, we assessed biomarkers, transthoracic echocardiography, polysomnography, spirometry, and carbon monoxide diffusing capacity of the lung (DLCO).ResultsMean follow-up was 8.7 ± 1.4 months with 83% of patients reaching Sacubitril/Valsartan maximum dose (97/103 mg b.i.d). Significant improvements were observed in cardiac performance and biomarkers: left ventricular ejection fraction increased (31 ± 5 vs. 37 ± 9 %; p < 0.001), end-diastolic and end-systolic volumes decreased; NT-proBNP decreased (1,196 [IQR 648–2891] vs. 958 [IQR 424-1,663] pg/ml; p < 0.001) in parallel with interleukin ST-2 (28.4 [IQR 19.4–36.6] vs. 20.4 [IQR 15.1–29.2] ng/ml; p < 0.001) and circulating surfactant binding proteins (proSP-B: 58.43 [IQR 40.42–84.23] vs. 50.36 [IQR 37.16–69.54] AU; p = 0.014 and SP-D: 102.17 [IQR 62.85–175.34] vs. 77.64 [IQR 53.55-144.70] AU; p < 0.001). Forced expiratory volume in 1 second and forced vital capacity improved. DLCO increased in the patients' subgroup (n = 39) with impaired baseline values (from 65.3 ± 10.8 to 70.3 ± 15.9 %predicted; p = 0.013). We also observed a significant reduction in central sleep apneas (CSA).ConclusionSacubitril/Valsartan effects share a double pathway: hemodynamic and systemic. The first is evidenced by NT-proBNP, proSP-B, lung mechanics, and CSA improvement. The latter is confirmed by an amelioration of DLCO, ST-2, SP-D as well as by reverse remodeling echocardiographic parameters.
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Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Mattavelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Cristina Banfi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Stefania Ghilardi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Fabiana De Martino
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paola Gugliandolo
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Mantegazza
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Volpato
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Christian Basile
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Valentina Sassi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | | | - Carlo Vignati
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Chiarella Sforza
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Maria Luisa Biondi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Piergiuseppe Agostoni ;
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Caraffa R, Bejko J, Carrozzini M, Bifulco O, Tarzia V, Lorenzoni G, Bottigliengo D, Gregori D, Castellani C, Bottio T, Angelini A, Gerosa G. A Device Strategy-Matched Comparison Analysis among Different Intermacs Profiles: A Single Center Experience. J Clin Med 2022; 11:jcm11164901. [PMID: 36013140 PMCID: PMC9410490 DOI: 10.3390/jcm11164901] [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: 08/01/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background: The present study evaluates outcomes of LVAD patients, taking into account the device strategy and the INTERMACS profile. Methods: We included 192 LVAD-patients implanted between January 2012 and May 2021. The primary and secondary end-points were survival and major adverse events between Profiles 1–3 vs. Profile 4, depending on implantation strategies (Bridge-to-transplant-BTT; Bridge-to-candidacy-BTC; Destination-Therapy-DT). Results: The overall survival was 67% (61–75) at 12 months and 61% (54–70) at 24 months. Profile 4 patients showed significantly higher survival (p = 0.018). Incidences of acute right-ventricular-failure (RVF) (p = 0.046), right-ventricular-assist-device (RVAD) implantation (p = 0.015), and continuous-venovenous-hemofiltration (CVVH) (p = 0.006) were higher in Profile 1–3 patients, as well as a longer intensive care unit stays (p = 0.050) and in-hospital-mortality (p = 0.012). Twelve-month and 24-month survival rates were higher in the BTT rather than in BTC (log-rank = 0.410; log-rank = 0.120) and in DT groups (log-rank = 0.046). In the BTT group, Profile 1–3 patients had a higher need for RVAD support (p = 0.042). Conclusions: LVAD implantation in elective patients was associated with better survival and lower complications incidence. LVAD implantation in BTC patients has to be considered before their conditions deteriorate. DT should be addressed to elective patients in order to guarantee acceptable results.
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Affiliation(s)
- Raphael Caraffa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Jonida Bejko
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Massimiliano Carrozzini
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Vincenzo Tarzia
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemilogy and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Daniele Bottigliengo
- Unit of Biostatistics, Epidemilogy and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemilogy and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Chiara Castellani
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Tomaso Bottio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-0498-212-410; Fax: +39-0498-212-409
| | - Annalisa Angelini
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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Marginal versus Standard Donors in Heart Transplantation: Proper Selection Means Heart Transplant Benefit. J Clin Med 2022; 11:jcm11092665. [PMID: 35566789 PMCID: PMC9105473 DOI: 10.3390/jcm11092665] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/01/2022] [Accepted: 05/07/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND In this study, we assessed the mid-term outcomes of patients who received a heart donation from a marginal donor (MD), and compared them with those who received an organ from a standard donor (SD). METHODS All patients who underwent HTx between January 2012 and December 2020 were enrolled at a single institution. The primary endpoints were early and long-term survival of MD recipients. Risk factors for primary graft failure (PGF) and mortality in MD recipients were also analyzed. The secondary endpoint was the comparison of survival of MD versus SD recipients. RESULTS In total, 238 patients underwent HTx, 64 (26.9%) of whom received an organ from an MD. Hospital mortality in the MD recipient cohort was 23%, with an estimated 1 and 5-year survival of 70% (59.2-82.7) and 68.1% (57.1-81), respectively. A multivariate analysis in MD recipients showed that decreased renal function and increased inotropic support of recipients were associated with higher mortality (p = 0.04 and p = 0.03). Cold ischemic time (p = 0.03) and increased donor inotropic support (p = 0.04) were independent risk factors for PGF. Overall survival was higher in SD than MD (85% vs. 68% at 5 years, log-rank = 0.008). However, risk-adjusted mortality (p = 0.2) and 5-year conditional survival (log-rank = 0.6) were comparable. CONCLUSIONS Selected MDs are a valuable resource for expanding the cardiac donor pool, showing promising results. The use of MDs after prolonged ischemic times, increased inotropic support of the MD or the recipient and decreased renal function are associated with worse outcomes.
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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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11
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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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12
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Schmid Daners M, Hall S, Sündermann S, Cesarovic N, Kron M, Falk V, Starck C, Meboldt M, Dual SA. Real-Time Ventricular Volume Measured Using the Intracardiac Electromyogram. ASAIO J 2021; 67:1312-1320. [PMID: 33899813 PMCID: PMC8614557 DOI: 10.1097/mat.0000000000001444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Left ventricular end-diastolic volume (EDV) is an important parameter for monitoring patients with left ventricular assist devices (LVADs) and might be useful for automatic LVAD work adaptation. However, continuous information on the EDV is unavailable to date. The depolarization amplitude (DA) of the noncontact intracardiac electromyogram (iEMG) is physically related to the EDV. Here, we show how a left ventricular (LV) volume sensor based on the iEMG might provide beat-wise EDV estimates. The study was performed in six pigs while undergoing a series of controlled changes in hemodynamic states. The LV volume sensor consisted of four conventional pacemaker electrodes measuring the far-field iEMG inside the LV blood pool, using a novel unipolar amplifier. Simultaneously, noninvasive measurements of EDV and hematocrit were recorded. The proposed EDV predictor was tested for statistical significance using a mixed-effect model and associated confidence intervals. A statistically significant (p = 3e-07) negative correlation was confirmed between the DA of the iEMG and the EDV as measured by electric impedance at a slope of -0.069 (-0.089, -0.049) mV/mL. The DA was slightly decreased by increased hematocrit (p = 0.039) and moderately decreased with the opening of the thorax (p = 0.003). The DA of the iEMG proved to be a significant, independent predictor of EDV. The proposed LV volume sensor is simple to integrate into the inflow cannula of an LVAD and thus has the potential to inform the clinician about the state of LV volume in real time and to automatically control the LVAD.
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Affiliation(s)
| | - Sophie Hall
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
| | - Simon Sündermann
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiovascular Surgery, Berlin, Germany
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Nikola Cesarovic
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Division for Surgical Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Mareike Kron
- Division for Surgical Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Volkmar Falk
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiovascular Surgery, Berlin, Germany
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Christoph Starck
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | - Mirko Meboldt
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
| | - Seraina A. Dual
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
- Radiology, Stanford University, Stanford, California
- Cardiovascular Institute, Stanford University, Stanford, California
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13
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Performance of the Jarvik 2000 left ventricular assist device on mid-term hemodynamics and exercise capacity. J Artif Organs 2021; 25:204-213. [PMID: 34826019 DOI: 10.1007/s10047-021-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
The hemodynamic and exercise capacity performance of the Jarvik 2000 left ventricular assist device (LVAD), which is generally used in patients with small body size and relatively preserved cardiac function, is not well understood. We retrospectively examined 18 patients implanted with the Jarvik 2000 LVAD. Pump rotation speed was optimized by the hemodynamic ramp test one year after implantation based on the criteria of mean pulmonary capillary wedge pressure (PCWP) < 18 mmHg, mean right atrial pressure (RAP) < 12 mmHg, and cardiac index (CI) > 2.2 L/min/m2 as well as echocardiographic parameters. Exercise capacity was assessed by cardiopulmonary exercise test in an optimized setting. To investigate the impacts of larger body surface area (BSA) and extremely impaired pre-implantation cardiac function on hemodynamics and exercise capacity, two correlation analyses based on BSA and original CI were performed. At a pump speed of 9500 ± 707 rpm, the mean pulmonary artery pressure, PCWP, RAP, and CI were 17 ± 5 mmHg, 9 ± 5 mmHg, 6 ± 4 mmHg, and 2.82 ± 0.54 L/min/m2, respectively. Only one patient failed to achieve the hemodynamic criteria. The peak VO2 and VE/VCO2 slope were 12.9 ± 3.1 mL/min/kg and 37.7 ± 15.0, respectively. There was an inverse correlation between original CI and heart rate (r = -0.60, p = 0.01), and a weak correlation between BSA and PCWP (r = 0.43, p = 0.08). Based on this study, the overall performance of the Jarvik 2000 device was acceptable, and the patients' body size and original cardiac function had minimum effect on the performance of this device.
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14
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Christle JW, Moneghetti KJ, Duclos S, Mueller S, Moayedi Y, Khush KK, Haddad F, Hiesinger W, Myers J, Ashley EA, Teuteberg JJ, Wheeler MT, Banerjee D. Cardiopulmonary Exercise Testing With Echocardiography to Assess Recovery in Patients With Ventricular Assist Devices. ASAIO J 2021; 67:1134-1138. [PMID: 34570726 DOI: 10.1097/mat.0000000000001383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The left ventricular assist device (LVAD) is an established treatment for select patients with end-stage heart failure. Some patients recovered and are considered for explantation. Assessing recovery involves exercise testing and echo ramping on full and minimal LVAD support. Combined cardiopulmonary exercise testing with simultaneous echo ramping (CPET-R) has not been well studied. Patients were included if they had CPET within the previous 6 months, were clinically stable, and had an INR >2.0 on the day of examination. Patients had CPET-R on two occasions within 14 days: (a) with LVAD at therapeutic speed and (b) with LVAD at the lowest speed possible. Six patients were between 29 and 75 years (two female). One patient did not complete a turn-down test due to evidence of ischemia on initial CPET-R subsequently confirmed as a significant coronary artery stenosis on angiography. There were no significant differences in CPET or echo metrics between LVAD speeds. Two patients were explanted due to presumed LV recovery and remained event free for 30 and 47 months, respectively. Serial CPET-R seems safe and feasible for the evaluation of LV and global function and may result in improved clinical decision making for LVAD explantation.
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Affiliation(s)
- Jeffrey W Christle
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| | - Kegan J Moneghetti
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| | - Sebastien Duclos
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - Stephan Mueller
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Department of Prevention, Rehabilitation and Sports Medicine, Technical University of Munich, Munich, Germany
| | - Yasbanoo Moayedi
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kiran K Khush
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - Francois Haddad
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - William Hiesinger
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - Jonathan Myers
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Division of Cardiovascular Medicine, Palo Alto Veterans Administration, Palo Alto, California
| | - Euan A Ashley
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
| | - Jeffrey J Teuteberg
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - Matthew T Wheeler
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
- Section of Heart Failure, Cardiac Transplant, Department of Medicine, Mechanical Circulatory Support, Stanford University, Stanford, California
| | - Dipanjan Banerjee
- From the Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
- Department of Cardiovascular Medicine, The Queen's Medical Center, Honolulu, Hawaii
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15
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Abstract
PURPOSE OF REVIEW Exercise causes various dynamic changes in all body parts either in healthy subject or in heart failure (HF) patients. The present review of current knowledge about HF patients with reduced ejection fraction focuses on dynamic changes along a "metabo-hemodynamic" perspective. RECENT FINDINGS Studies on the dynamic changes occurring during exercise span many years. Thanks to the availability of advanced methods, it is nowadays possible to properly characterize respiratory, hemodynamic, and muscular function adjustments and their mismatch with the pulmonary and systemic circulations. Exercise is a dynamic event that involves several body functions. In HF patients, it is important to know at what level the limitation takes place in order to better manage these patients and to optimize therapeutic strategies.
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16
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Lilliu M, Onorati F, Luciani GB, Faggian G. Effects of echo-optimization of left ventricular assist devices on functional capacity, a randomized controlled trial. ESC Heart Fail 2021; 8:2846-2855. [PMID: 33934564 PMCID: PMC8318497 DOI: 10.1002/ehf2.13359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022] Open
Abstract
Aims After the implantation of a left ventricular assist device (LVAD), many patients continue to experience exercise intolerance. VAFRACT trial evaluates the additional benefit of LVAD echo‐guided optimization (EO) on functional capacity (FC), measured by cardiopulmonary exercise test (CPET), and quality of life (QoL). Methods and results Twenty‐seven patients were randomized in a 1:1 ratio to EO (EO group) vs. standard settings (CONTROL group) at least after 3 months from LVAD implant procedure. The optimal device speed was defined as the one that allows an intermittent aortic valve opening and a neutral position of the interventricular septum without increasing aortic or tricuspid regurgitation and preserving right ventricular function. The primary endpoint was peak oxygen uptake (VO2 peak) change after 3 months. Echo‐guided optimization significantly improves VO2 peak (from 13.2 ± 2.5 to 14.2 ± 2.5 mL/kg/min; P < 0.001), oxygen pulse (from 9.75 ± 1.46 to 10.75 ± 2.2 mL; P < 0.001), CPET exercise time (from 490 ± 98 to 526 ± 116 s; P = 0.02), 6 min walk distance (from 363 ± 54 to 391 ± 52 m; P = 0.04), and QoL, using EuroQol Five Dimensions 3L (from 0.796 ± 0.1 to 0.85 ± 0.08; P < 0.001) and the Kansas City Cardiomyopathy Questionnaire (from 81.6 ± 6.9 to 84.6 ± 5.6; P = 0.025). Conclusions Echo‐guided optimization can significantly influence the FC and the QoL of LVAD patients. This procedure should represent a fundamental step in their clinical management, through the establishment of consolidated follow‐up protocols. Our study may represent a starting point for a future, adequately powered clinical trial with a longer term follow‐up.
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Affiliation(s)
- Marzia Lilliu
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Piazzale Aristide Stefani, 1, Verona, 37126, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Piazzale Aristide Stefani, 1, Verona, 37126, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Piazzale Aristide Stefani, 1, Verona, 37126, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Piazzale Aristide Stefani, 1, Verona, 37126, Italy
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17
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Ton VK, Ramani G, Hsu S, Hopkins CD, Kaczorowski D, Madathil RJ, Mak S, Tedford RJ. High Right Ventricular Afterload Is Associated with Impaired Exercise Tolerance in Patients with Left Ventricular Assist Devices. ASAIO J 2021; 67:39-45. [PMID: 32412930 DOI: 10.1097/mat.0000000000001169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with left ventricular assist device (LVAD) have poor exercise tolerance. We aimed to characterize relationship between right ventricular (RV) afterload and exercise capacity, RV reserve, and adaptation to load. Twelve well-compensated LVAD subjects underwent right heart catheterization at rest and during symptom-limited exercise. Cardiopulmonary exercise tests were also performed. Hemodynamics were compared with age- and sex-matched subjects with pulmonary arterial hypertension (PAH) and normal non-athletes. Hemodynamic changes were expressed as Δ(exercise - rest). At rest, LVAD subjects had normal biventricular pressures and cardiac output (CO). On exercise, despite similar increases in pulmonary artery wedge pressure (PAWP) between three groups, RV afterload increased only in LVAD cohort (pulmonary elastance [ΔEa] LVAD: 0.4, PAH: 0.1, normal: 0.1 mmHg/ml, p = 0.0024). This afterload increase coincided with the largest rise in right atrial pressure (RAP), lowest change in RV stroke work index, and smallest CO augmentation (ΔCO LVAD: 1.5, PAH: 4.3, normal: 5.7 L/min, p = 0.0014). Peak VO2 negatively correlated with RV afterload (Ea) (r = -0.8, p = 0.0101), while VE/VCO2 slope had the inverse correlation. During exercise, pulmonary artery pulsatility index worsened while RAP:PAWP ratio was unchanged in LVAD subjects. Well-compensated LVAD patients had poor RV reserve and adaptation to load on exercise compared with PAH and normal subjects.
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Affiliation(s)
- Van-Khue Ton
- From the Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gautam Ramani
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Danielle Hopkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ronson J Madathil
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON; and
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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18
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Mirza KK, Gustafsson F. Determinants of Functional Capacity and Quality of Life After Implantation of a Durable Left Ventricular Assist Device. Card Fail Rev 2020; 6:e29. [PMID: 33133643 PMCID: PMC7592460 DOI: 10.15420/cfr.2020.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous-flow left ventricular assist devices (LVAD) are increasingly used as destination therapy in patients with end-stage heart failure and, with recent improvements in pump design, adverse event rates are decreasing. Implanted patients experience improved survival, quality of life (QoL) and functional capacity (FC). However, improvement in FC and QoL after implantation is not unequivocal, and this has implications for patient selection and preimplantation discussions with patients and relatives. This article identifies preimplantation predictors of lack of improvement in FC and QoL after continuous-flow LVAD implantation and discusses potential mechanisms, allowing for the identification of potential factors that can be modified. In particular, the pathophysiology behind insufficient improvement in peak oxygen uptake is discussed. Data are included from 40 studies, resulting in analysis of >700 exercise tests. Mean peak oxygen uptake was 13.4 ml/kg/min (equivalent to 48% of predicted value; 259 days after implantation, range 31–1,017 days) and mean 6-minute walk test distance was 370 m (182 days after implantation, range 43–543 days). Finally, the interplay between improvement in FC and QoL is discussed.
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Affiliation(s)
- Kiran K Mirza
- Department of Cardiology, Rigshospitalet Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet Copenhagen, Denmark
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19
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Okwose NC, Bouzas-Cruz N, Fernandez OG, Koshy A, Green T, Woods A, Robinson-Smith N, Tovey S, Mcdiarmid A, Parry G, Schueler S, Macgowan GA, Jakovljevic DG. Validity of Hemodynamic Monitoring Using Inert Gas Rebreathing Method in Patients With Chronic Heart Failure and Those Implanted With a Left Ventricular Assist Device. J Card Fail 2020; 27:414-418. [PMID: 33035686 DOI: 10.1016/j.cardfail.2020.09.479] [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: 06/20/2020] [Revised: 08/24/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The present study assessed agreement between resting cardiac output estimated by inert gas rebreathing (IGR) and thermodilution methods in patients with heart failure and those implanted with a left ventricular assist device (LVAD). METHODS AND RESULTS Hemodynamic measurements were obtained in 42 patients, 22 with chronic heart failure and 20 with implanted continuous flow LVAD (34 males, aged 50 ± 11 years). Measurements were performed at rest using thermodilution and IGR methods. Cardiac output derived by thermodilution and IGR were not significantly different in LVAD (4.4 ± 0.9 L/min vs 4.7 ± 0.8 L/min, P = .27) or patients with heart failure (4.4 ± 1.4 L/min vs 4.5 ± 1.3 L/min, P = .75). There was a strong relationship between thermodilution and IGR cardiac index (r = 0.81, P = .001) and stroke volume index (r = 0.75, P = .001). Bland-Altman analysis showed acceptable limits of agreement for cardiac index derived by thermodilution and IGR, namely, the mean difference (lower and upper limits of agreement) for patients with heart failure -0.002 L/min/m2 (-0.65 to 0.66 L/min/m2), and -0.14 L/min/m2 (-0.78 to 0.49 L/min/m2) for patients with LVAD. CONCLUSIONS IGR is a valid method for estimating cardiac output and should be used in clinical practice to complement the evaluation and management of chronic heart failure and patients with an LVAD.
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Affiliation(s)
- Nduka C Okwose
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Noelia Bouzas-Cruz
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Oscar Gonzalez Fernandez
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Aaron Koshy
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Thomas Green
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Woods
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nicola Robinson-Smith
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sian Tovey
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Adam Mcdiarmid
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gareth Parry
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephan Schueler
- Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Guy A Macgowan
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Departments of Cardiology and Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Cardiovascular Research Division, Faculty of Health and Life Sciences, Coventry University, Coventry, UK.
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20
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Variability in pulmonary diffusing capacity in heart failure. Respir Physiol Neurobiol 2020; 280:103473. [DOI: 10.1016/j.resp.2020.103473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
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21
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Sciomer S, Rellini C, Agostoni P, Moscucci F. A new pathophysiology in heart failure patients. Artif Organs 2020; 44:1303-1305. [PMID: 32639613 DOI: 10.1111/aor.13770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/27/2020] [Accepted: 06/30/2020] [Indexed: 01/28/2023]
Abstract
In the treatment of patients with severe heart failure, left ventricle assist device plays an important role, especially as a destination therapy. Nevertheless, even in successful cases, patients' progressive weaning is rarely taken into consideration. The recovery of more physiological circulation conditions is not a main goal. This hypothesis is discussed in this article.
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Affiliation(s)
- Susanna Sciomer
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, University of Rome "Sapienza", Policlinico Umberto I, Rome, Italy
| | - Carlotta Rellini
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, University of Rome "Sapienza", Policlinico Umberto I, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Moscucci
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, University of Rome "Sapienza", Policlinico Umberto I, Rome, Italy
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22
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Trombara F, Apostolo A, Vignati C, Agostoni P. Why do left ventricular assist device recipients remain heart failure patients? Reply. Eur J Heart Fail 2020; 22:1055. [PMID: 32297429 DOI: 10.1002/ejhf.1824] [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: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
| | | | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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23
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Lilliu M, Onorati F, Luciani GB, Faggian G. The determinants of functional capacity in left ventricular assist device patients: many actors with not well defined roles. J Cardiovasc Med (Hagerstown) 2020; 21:472-480. [DOI: 10.2459/jcm.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Trombara F, Apostolo A, Vignati C, Naliato M, Ceriani R, Agostoni P. Effects of left ventricular assist device on cardiopulmonary exercise performance. Eur J Heart Fail 2020; 22:381-382. [DOI: 10.1002/ejhf.1680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Filippo Trombara
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
| | - Anna Apostolo
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
- Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of Milano Milan Italy
| | - Moreno Naliato
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
| | - Roberto Ceriani
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, University of Milan, IRCCS Milan Italy
- Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of Milano Milan Italy
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25
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Guihaire J, Haddad F, Hoppenfeld M, Amsallem M, Christle JW, Owyang C, Shaikh K, Hsu JL. Physiology of the Assisted Circulation in Cardiogenic Shock: A State-of-the-Art Perspective. Can J Cardiol 2020; 36:170-183. [PMID: 32036862 PMCID: PMC7121859 DOI: 10.1016/j.cjca.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 01/18/2023] Open
Abstract
Mechanical circulatory support (MCS) has made rapid progress over the last 3 decades. This was driven by the need to develop acute and chronic circulatory support as well as by the limited organ availability for heart transplantation. The growth of MCS was also driven by the use of extracorporeal membrane oxygenation (ECMO) after the worldwide H1N1 influenza outbreak of 2009. The majority of mechanical pumps (ECMO and left ventricular assist devices) are currently based on continuous flow pump design. It is interesting to note that in the current era, we have reverted from the mammalian pulsatile heart back to the continuous flow pumps seen in our simple multicellular ancestors. This review will highlight key physiological concepts of the assisted circulation from its effects on cardiac dynamic to principles of cardiopulmonary fitness. We will also examine the physiological principles of the ECMO-assisted circulation, anticoagulation, and the haemocompatibility challenges that arise when the blood is exposed to a foreign mechanical circuit. Finally, we conclude with a perspective on smart design for future development of devices used for MCS.
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Affiliation(s)
- Julien Guihaire
- Department of Cardiac Surgery, Research and Innovation Unit, RHU BioArt Lung 2020, Marie Lannelongue Hospital, Paris-Sud University, Le Plessis-Robinson, France.
| | - Francois Haddad
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Mita Hoppenfeld
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Clark Owyang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Khizer Shaikh
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joe L Hsu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
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26
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Van Iterson EH. Left Ventricular Assist Device Support Complicates the Exercise Physiology of Oxygen Transport and Uptake in Heart Failure. Card Fail Rev 2019; 5:162-168. [PMID: 31768273 PMCID: PMC6848979 DOI: 10.15420/cfr.2019.10.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/15/2019] [Indexed: 11/05/2022] Open
Abstract
Low-output forward flow and impaired maximal exercise oxygen uptake (VO2 max) are hallmarks of patients in advanced heart failure. The continuous-flow left ventricular assist device is a cutting-edge therapy proven to increase forward flow, yet this therapy does not yield consistent improvements in VO2 max. The science of how adjustable artificial forward flow impacts the exercise physiology of heart failure and physical O2 transport between the central and peripheral systems is unclear. This review focuses on the exercise physiology of axial continuous-flow left ventricular assist device support and the impact that pump speed has on the interactive convective and diffusive components of whole-body physical O2 transport and VO2.
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Affiliation(s)
- Erik H Van Iterson
- Section of Preventive Cardiology and Rehabilitation, Heart and Vascular Institute, Cleveland Clinic, Cleveland OH, US
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27
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Severin R, Sabbahi A, Ozemek C, Phillips S, Arena R. Approaches to improving exercise capacity in patients with left ventricular assist devices: an area requiring further investigation. Expert Rev Med Devices 2019; 16:787-798. [PMID: 31453716 DOI: 10.1080/17434440.2019.1660643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Introduction: Left ventricular assist device (LVAD) implantation has become a well-established treatment option for patients with end stage heart failure (HF) who are refractory to medical therapy. While LVADs implantation does effectively improve hemodynamic performance many patients still possess peripheral pathological adaptations often present in end-stage HF. Therefore, increased attention has been placed on investigating the effects of exercise training for patients with LVADs to improve clinical outcomes. However, the available evidence on exercise training for patients with LVADs is limited. Areas covered: The purpose of this narrative review is to summarize: 1) The evolution of LVAD technology and usage; 2) The physiological responses to exercise in patients with LVADs; 3) The available evidence regarding exercise training; 4) Potential strategies to implement exercise training programs for this patient population. Expert opinion: The available evidence for exercise training to improve physical function and clinical outcomes for patients with LVADs is promising but limited. Future research is needed to further elucidate the ideal exercise training parameters, method of delivery for exercise training, and unique barriers and facilitators to exercise training for patients receiving LVAD implantation.
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Affiliation(s)
- Richard Severin
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Ahmad Sabbahi
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Cemal Ozemek
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Shane Phillips
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
| | - Ross Arena
- Department of Physical Therapy, University of Illinois , Chicago , IL , USA
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28
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Han JJ, Atluri P. Commentary: Optimize the speed, enhance the patient's life. J Thorac Cardiovasc Surg 2019; 159:1326-1327. [PMID: 31375377 DOI: 10.1016/j.jtcvs.2019.06.065] [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: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa.
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29
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Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
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30
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Laoutaris ID. Restoring pulsatility and peakVO 2 in the era of continuous flow, fixed pump speed, left ventricular assist devices: 'A hypothesis of pump's or patient's speed?'. Eur J Prev Cardiol 2019; 26:1806-1815. [PMID: 31180758 DOI: 10.1177/2047487319856448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite significant improvement in survival and functional capacity after continuous flow left ventricular assist device implantation, the patient's quality of life may remain limited by complications such as aortic valve insufficiency, thromboembolic episodes and gastrointestinal bleeding attributed to high shear stress continuous flow with attenuated or absence of pulsatile flow and by a reduced peak oxygen consumption (peakVO2) primarily associated with a fixed pump speed operation. Revision of current evidence suggests that high technology pump speed algorithms, a 'hypothesis of decreasing pump's speed' to promote pulsatile flow and a 'hypothesis of increasing pump's speed' to increase peakVO2, may only partially reverse these barriers. A 'hypothesis of increasing patient's speed' is introduced, suggesting that exercise training may further contribute to the patient's recovery, enhancing peakVO2 and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field.
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31
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Impact of LVAD speed change on physiologic functions. J Heart Lung Transplant 2019; 38:877-878. [PMID: 31160161 DOI: 10.1016/j.healun.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/20/2022] Open
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32
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Vignati C, Morosin M, Fusini L, Pezzuto B, Spadafora E, De Martino F, Salvioni E, Rovai S, Filardi PP, Sinagra G, Agostoni P. Do rebreathing manoeuvres for non-invasive measurement of cardiac output during maximum exercise test alter the main cardiopulmonary parameters? Eur J Prev Cardiol 2019; 26:1616-1622. [DOI: 10.1177/2047487319845967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Inert gas rebreathing has been recently described as an emergent reliable non-invasive method for cardiac output determination during exercise, allowing a relevant improvement of cardiopulmonary exercise test clinical relevance. For cardiac output measurements by inert gas rebreathing, specific respiratory manoeuvres are needed which might affect pivotal cardiopulmonary exercise test parameters, such as exercise tolerance, oxygen uptake and ventilation vs carbon dioxide output (VE/VCO2) relationship slope. Method We retrospectively analysed cardiopulmonary exercise testing of 181 heart failure patients who underwent both cardiopulmonary exercise testing and cardiopulmonary exercise test+cardiac output within two months (average 16 ± 15 days). All patients were in stable clinical conditions (New York Heart Association I–III) and on optimal medical therapy. Results The majority of patients were in New York Heart Association Class I and II (78.8%), with a mean left ventricular ejection fraction of 31 ± 10%. No difference was found between the two tests in oxygen uptake at peak exercise (1101 (interquartile range 870–1418) ml/min at cardiopulmonary exercise test vs 1103 (844–1389) at cardiopulmonary exercise test-cardiac output) and at anaerobic threshold. However, anaerobic threshold and peak heart rate, peak workload (75 (58–101) watts and 64 (42–90), p < 0.01) and carbon dioxide output were significantly higher at cardiopulmonary exercise testing than at cardiopulmonary exercise test+cardiac output, whereas VE/VCO2 slope was higher at cardiopulmonary exercise test+cardiac output (30 (27–35) vs 33 (28–37), p < 0.01). Conclusion The similar anaerobic threshold and peak oxygen uptake in the two tests with a lower peak workload and higher VE/VCO2 slope at cardiopulmonary exercise test+cardiac output suggest a higher respiratory work and consequent demand for respiratory muscle blood flow secondary to the ventilatory manoeuvres. Accordingly, VE/VCO2 slope and peak workload must be evaluated with caution during cardiopulmonary exercise test+cardiac output.
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Affiliation(s)
- Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
| | - Marco Morosin
- Centro Cardiologico Monzino, IRCCS, Italy
- Cardiovascular Department, Azienda Sanitaria-Universitaria Integrata of Trieste, Italy
| | | | | | | | | | | | - Sara Rovai
- Centro Cardiologico Monzino, IRCCS, Italy
- Università degli Studi di Padova, Italy
| | - Pasquale P Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria-Universitaria Integrata of Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
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33
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Adamopoulos S, Corrà U, Laoutaris ID, Pistono M, Agostoni PG, Coats AJ, Crespo Leiro MG, Cornelis J, Davos CH, Filippatos G, Lund LH, Jaarsma T, Ruschitzka F, Seferovic PM, Schmid JP, Volterrani M, Piepoli MF. Exercise training in patients with ventricular assist devices: a review of the evidence and practical advice. A position paper from the Committee on Exercise Physiology and Training and the Committee of Advanced Heart Failure of the Heart Failure Associat. Eur J Heart Fail 2018; 21:3-13. [DOI: 10.1002/ejhf.1352] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 08/06/2018] [Accepted: 08/26/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit; Onassis Cardiac Surgery Center; Athens Greece
| | - Ugo Corrà
- Cardiology Department; Istituti Clinici Scientifici Maugeri, Centro Medico di Riabilitazione di Veruno; Novara Italy
| | - Ioannis D. Laoutaris
- Heart Failure and Heart Transplantation Unit; Onassis Cardiac Surgery Center; Athens Greece
| | - Massimo Pistono
- Cardiology Department; Istituti Clinici Scientifici Maugeri, Centro Medico di Riabilitazione di Veruno; Novara Italy
| | - Pier Giuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health; Cardiovascular Section, University of Milan; Milan Italy
| | | | - Maria G. Crespo Leiro
- Heart Failure and Transplant Unit; Complexo Hospitalario Universitario A Coruña (CHUAC), INIBIC, CIBERCV, UDC; La Coruña Spain
| | - Justien Cornelis
- Faculty of Medicine and Health Sciences, Translational Pathophysiological Research; University of Antwerp; Antwerp Belgium
| | - Constantinos H. Davos
- Cardiovascular Research Laboratory; Biomedical Research Foundation, Academy of Athens; Athens Greece
| | | | - Lars H. Lund
- Department of Medicine; Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital; Stockholm Sweden
| | - Tiny Jaarsma
- Department of Nursing; University of Linköping; Linköping Sweden
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Zürich Switzerland
| | | | - Jean-Paul Schmid
- Chefarzt Kardiologie, Klinik Barmelweid AG; Barmelweid Switzerland
| | | | - Massimo F. Piepoli
- Heart Failure Unit, Cardiac Department; Guglielmo da Saliceto Hospital; Piacenza Italy
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