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Iversen IJ, Gustafsson F, Rossing K, Møller-Sørensen PH, Olsen PS, Møller CH. Single center outcomes after temporary mechanical circulatory assist device prior to Heartmate 3 implantation - a retrospective cohort study. SCAND CARDIOVASC J 2024; 58:2353066. [PMID: 38962929 DOI: 10.1080/14017431.2024.2353066] [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: 12/07/2023] [Accepted: 05/05/2024] [Indexed: 07/05/2024]
Abstract
Objectives. Temporary mechanical circulatory support (TMCS) has become a component in the therapeutic strategy for treatment of cardiogenic shock as a bridge-to-decision. TMCS can facilitate recovery of cardiopulmonary function, end-organ function, and potentially reduce the surgical risk of left ventricular assist device (LVAD) implantation. Despite the improvements of hemodynamics and end-organ function, post-LVAD operative morbidity might be increased in these high-risk patients. The aim of the study was to compare outcomes after Heartmate 3 (HM3) implantation in patients with and without TMCS prior to HM3 implant. Methods. In this retrospective cohort study of all HM3 patients in the period between November 2015 and October 2021, patients with and without prior TMCS were compared. Patients' demographics, baseline clinical characteristics, laboratory tests, intraoperative variables, postoperative outcomes, and adverse events were collected from patient records. Results. The TMCS group showed an improvement in hemodynamics prior to LVAD implantation. Median TMCS duration was 19.5 (14-26) days. However, the TMCS group were more coagulopathic, had more wound infections, neurological complications, and more patients were on dialysis compared with patient without TMCS prior to HM3 implantation. Survival four years after HM3 implantation was 80 and 82% in the TMCS (N = 22) and non-TMCS group (N = 41), respectively. Conclusion. Patients on TMCS had an acceptable short and long-term survival and comparable to patients receiving HM3 without prior TMCS. However, they had a more complicated postoperative course.
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Affiliation(s)
- Imran Jamal Iversen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Hasse Møller-Sørensen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Holdflod Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024; 43:1529-1628.e54. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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3
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Alexander PMA, Di Nardo M, Combes A, Vogel AM, Antonini MV, Barrett N, Benedetti GM, Bettencourt A, Brodie D, Gómez-Gutiérrez R, Gorga SM, Hodgson C, Kapoor PM, Le J, MacLaren G, O'Neil ER, Ostermann M, Paden ML, Patel N, Rojas-Peña A, Said AS, Sperotto F, Willems A, Vercaemst L, Yoganathan AP, Lorts A, Del Nido PJ, Barbaro RP. Definitions of adverse events associated with extracorporeal membrane oxygenation in children: results of an international Delphi process from the ECMO-CENTRAL ARC. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:773-780. [PMID: 39299748 DOI: 10.1016/s2352-4642(24)00132-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/21/2024] [Accepted: 05/20/2024] [Indexed: 09/22/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a high-risk and low-volume life support with increasing clinical study. However, heterogenous outcome definitions impede data assimilation into evidence to guide practice. The Academic Research Consortium (ARC), an international collaborative forum committed to facilitating the creation of stakeholder-driven consensus nomenclature and outcomes for clinical trials of medical devices, supported the ECMO Core Elements Needed for Trials Regulation And quality of Life (ECMO-CENTRAL) ARC. The ECMO-CENTRAL ARC was assembled to develop definitions of paediatric ECMO adverse events for use in clinical trials and regulatory device evaluation. An initial candidate list of ECMO adverse events derived from the mechanical circulatory support ARC was supplemented with a review of ECMO-relevant adverse event definitions collated from literature published between Jan 1, 1988, and Feb 20, 2023. Distinct teams of international topic experts drafted separate adverse event definitions that were harmonised to existing literature when appropriate. Draft definitions were revised for paediatric ECMO relevance with input from patients, families, and an international expert panel of trialists, clinicians, statisticians, biomedical engineers, device developers, and regulatory agencies. ECMO-CENTRAL ARC was revised and disseminated across research societies and professional organisations. Up to three rounds of internet-based anonymous surveys were planned as a modified Delphi process. The expert panel defined 13 adverse event definitions: neurological, bleeding, device malfunction, acute kidney injury, haemolysis, infection, vascular access-associated injury, non-CNS thrombosis, hepatic dysfunction, right heart failure, left ventricular overload, lactic acidaemia, and hypoxaemia. Definitional structure varied. Among 165 expert panel members, 114 were eligible to vote and 111 voted. Consensus was achieved for all proposed definitions. Agreement ranged from 82% to 95%. ECMO-CENTRAL ARC paired rigorous development with methodical stakeholder involvement and dissemination to define paediatric ECMO adverse events. These definitions will facilitate new research and the assimilation of data across clinical trials and ECMO device evaluation in children.
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Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matteo Di Nardo
- Paediatric Intensive Care Unit, Bambino Gesù Children's Hospital, Scientific Institute for Research, Hospitalization and Healthcare, Rome, Italy
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Hôpital Pitié-Salpêtrière, Paris, France
| | - Adam M Vogel
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | | | - Nicholas Barrett
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK; Department of Critical Care and Nephrology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giulia M Benedetti
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Daniel Brodie
- Department of Medicine, School of Medicine, John Hopkins University, Baltimore, MD, USA
| | - René Gómez-Gutiérrez
- TecSalud, University Hospitals School of Medicine, Monterrey Institute of Technology and Higher Education, Monterrey, Mexico
| | - Stephen M Gorga
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesia, Cardiothoracic and Neuroscience Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Erika R O'Neil
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, TX, USA; Division of Pediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Neil Patel
- Neonatal Unit, The Royal Hospital for Children, Glasgow, UK
| | - Alvaro Rojas-Peña
- Section of Transplantation Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Extracorporeal Life Support Lab, Department of Surgery Research, University of Michigan, Ann Arbor, MI, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care Medicine, St Louis Children's Hospital, Washington University School of Medicine in St Louis, St Louis, MO, USA; Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Francesca Sperotto
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Pediatrics, University Children's Hospital Queen Fabiola-University Hospital of Brussels, Brussels, Belgium
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium
| | - Ajit P Yoganathan
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA; Susan B Meister Child Health Evaluation and Research Center, Division of General Pediatrics, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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4
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Lorts A, VanderPluym C, Adachi I, Perry T, Alexander PMA, Almond CS, Auerbach SR, Barbaro RP, Bhavsar S, Bourque K, Conway J, Danziger-Isakov LA, Davies RR, Eghtesady P, Hirata Y, Ichord RN, Kormos RL, Kroslowitz R, Krucoff M, Lantz J, Mehegan M, Mehran R, Morales DLS, Murray J, Niebler RA, O'Connor MJ, Pagani FD, Peng DM, Rossano JW, Spitzer E, Steiner ME, Sutcliffe DL, Taylor JM, Villa CR, Wearden PD, Rosenthal D. ACTION-ARC Pediatric and Adult Congenital Heart Disease Ventricular Assist Device Adverse Event Definitions-2023. ASAIO J 2024:00002480-990000000-00567. [PMID: 39330959 DOI: 10.1097/mat.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024] Open
Abstract
Adverse events (AEs) experienced by children and adults with congenital heart disease (CHD) on ventricular assist devices (VADs) are sometimes unique to these populations. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and the Academic Research Consortium (ARC) aimed to harmonize definitions of pediatric and CHD AEs for use in clinical trials, registries, and regulatory evaluation. Data from the ACTION registry and adjudication committee were used to adapt general mechanical circulatory support ARC definitions. This ACTION-ARC international expert panel of trialists, clinicians, patients, families, statisticians, biomedical engineers, device developers, and regulatory agencies drafted and iterated definitions harmonized to ACTION data and existing literature during sessions conducted between December 2022 and May 2023, followed by dissemination across clinical/research audiences and professional organizations and further revision. Both email-linked, internet-based surveys and in-person discussions were used as a modified Delphi process. Nineteen AE types were identified and defined, including seven new event types and six event types that were deleted and will no longer be collected, achieving consensus. ACTION-ARC paired rigorous development with methodical stakeholder involvement and dissemination to define pediatric VAD AEs to facilitate assimilation of data across future clinical trials and evaluation of devices for VAD-supported children and adults with CHD.
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Affiliation(s)
- Angela Lorts
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, Texas
| | - Tanya Perry
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peta M A Alexander
- Division of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher S Almond
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Scott R Auerbach
- The Heart Institute, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Ryan P Barbaro
- Division of Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lara A Danziger-Isakov
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ryan R Davies
- Division of Cardiac Surgery, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas
| | - Pirooz Eghtesady
- Division of Cardiac Surgery, Washington University, St. Louis Children's Hospital, St. Louis, Missouri
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Rebecca N Ichord
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert L Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, Texas
| | | | - Mitchell Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Jodie Lantz
- Division of Cardiac Surgery, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas
| | - Mary Mehegan
- Division of Cardiac Surgery, Washington University, St. Louis Children's Hospital, St. Louis, Missouri
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L S Morales
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jenna Murray
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Robert A Niebler
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Matthew J O'Connor
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - David M Peng
- Division of Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph W Rossano
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota
| | - David L Sutcliffe
- Department of Cardiology, Children's Mercy Hospital-Kansas City, Kansas City, Missouri
| | - J Michael Taylor
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chet R Villa
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter D Wearden
- Department of Cardiovascular Services, Nemours Children's Health, Orlando, Florida
| | - David Rosenthal
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
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5
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Chimura M, Ohtani T, Sera F, Nakamoto K, Akazawa Y, Kajitani K, Higuchi R, Kagiya T, Sakata Y. Ratio of pulmonary artery diameter to ascending aortic diameter and its association with right ventricular failure after left ventricular assist device implantation. Int J Cardiol 2024:132596. [PMID: 39326703 DOI: 10.1016/j.ijcard.2024.132596] [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: 06/22/2024] [Revised: 09/06/2024] [Accepted: 09/23/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Several invasive hemodynamic parameters help predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. However, prediction using non-invasive parameters alone has not been established. The ratio of the diameters of the pulmonary artery (PAD) to those of the ascending aorta (AoD) may indicate past hemodynamic load and cardiac dysfunction. We aimed to investigate a predictive model for RVF after LVAD implantation using non-invasive parameters including PAD/AoD ratio. METHODS We studied 141 patients who underwent primary LVAD implantation and 117 healthy individuals with computed tomography (CT) data. RVF was defined as the need for a subsequent right ventricular assist device or intravenous inotrope administration for more than 30 days after LVAD implantation. The PAD/AoD ratio was measured at the level of the pulmonary artery bifurcation on the CT transaxial slices. RESULTS RVF was observed in 29 patients. The correlation between PAD and AoD differed among healthy individuals, patients with and without RVF. Patients with RVF had higher total bilirubin and log brain natriuretic peptide (BNP) levels, a lower left ventricular end-diastolic diameter (LVDd) index, and a higher PAD/AoD ratio than those without RVF. Decision tree analysis indicated that the subgroup with a high PAD/AoD ratio (≥1.09) and a small LVDd index (<35.4 mm/m2) showed the highest probability of RVF (100 %), while the subgroup with a low PAD/AoD ratio (<1.09) and low log BNP (<2.79) showed the lowest probability of RVF (1 %). CONCLUSION Combining non-invasive parameters with the PAD/AoD ratio can predict RVF with high accuracy.
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Affiliation(s)
- Misato Chimura
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Fusako Sera
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasuhiro Akazawa
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenji Kajitani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Rie Higuchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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6
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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Shah P, Looby M, Dimond M, Bagchi P, Shah B, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, Sinha SS, O'Connor CM. Evaluation of the Hemocompatibility of the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices: The DOAC LVAD Study. JACC. HEART FAILURE 2024; 12:1540-1549. [PMID: 38795110 DOI: 10.1016/j.jchf.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Patients receiving left ventricular assist device (LVAD) support require long-term anticoagulation to reduce the risk of thromboembolic complications. Apixaban is a direct oral anticoagulant that has become first-line therapy; however, its safety in LVAD recipients has not been well described. OBJECTIVES This study sought to investigate whether, in patients with a fully magnetically levitated LVAD, treatment with apixaban would be feasible and comparable with respect to safety and freedom from the primary composite outcome of death or major hemocompatibility-related adverse events (HRAEs) (stroke, device thrombosis, major bleeding, aortic root thrombus, and arterial non-central nervous system thromboembolism) as compared with treatment with warfarin. METHODS The DOAC LVAD (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices) trial was a phase 2, open label trial of LVAD recipients randomized 1:1 to either apixaban 5 mg twice daily or warfarin therapy. All patients were required to take low-dose aspirin. Patients were followed up for 24 weeks to evaluate the primary composite outcome. RESULTS A total of 30 patients were randomized: 14 patients to warfarin and 16 patients to apixaban. The median patient age was 60 years (Q1-Q3: 52-71 years), and 47% were Black patients. The median time from LVAD implantation to randomization was 115 days (Q1-Q3: 56-859 days). At 24 weeks, the primary composite outcome occurred in no patients receiving apixaban and in 2 patients (14%) receiving warfarin (P = 0.12); these 2 patients experienced major bleeding from gastrointestinal sources. CONCLUSIONS Anticoagulation with apixaban was feasible in patients with an LVAD without an excess of HRAEs or deaths. This study informs future pivotal clinical trials evaluating the safety and efficacy of apixaban in LVAD recipients. (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices [DOAC LVAD]; NCT04865978).
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Affiliation(s)
- Palak Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Mary Looby
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Matthew Dimond
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Pramita Bagchi
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Bhruga Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Iyad Isseh
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Allman T Rollins
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Ahmad A Abdul-Aziz
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Daniel G Tang
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Katherine M Klein
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Samantha Casselman
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Christen Vermeulen
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Wendy Sheaffer
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Meredith Snipes
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
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8
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Tsuji M, Kurihara T, Isotani Y, Bujo C, Ishida J, Amiya E, Hatano M, Shimada A, Imai H, Kimura M, Shimada S, Ando M, Ono M, Komuro I. Right Heart Reserve Function Assessed With Fluid Loading Predicts Late Right Heart Failure After Left Ventricular Assist Device Implantation. Can J Cardiol 2024; 40:1745-1754. [PMID: 38402951 DOI: 10.1016/j.cjca.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND A left ventricular assist device (LVAD) is an effective therapeutic option for advanced heart failure. Late right heart failure (LRHF) is a complication after LVAD implantation that is associated with increasing morbidity and mortality; however, the assessment of right heart function, including right heart reserve function after LVAD implantation, has not been established. We focused on a fluid-loading test with right heart catheterization to evaluate right heart preload reserve function and investigate its impact on LRHF. METHODS Patients aged > 18 years who received a continuous-flow LVAD between November 2007 and December 2022 at our institution, and underwent right heart catheterization with saline loading (10 mL/kg for 15 minutes) 1 month after LVAD implantation, were included. RESULTS Overall, 31 cases of LRHF or death (right heart failure [RHF] group) occurred in 149 patients. In the RHF vs the non-RHF groups, the pulmonary artery pulsatility index (PAPi) at rest (1.8 ± 0.89 vs 2.5 ± 1.4, P = 0.02) and the right ventricular stroke work index (RVSWi) change ratio with saline loading (0.96 ± 0.32 vs 1.1 ± 0.20, P = 0.03) were significantly different. The PAPi at rest and the RVSWi change ratio with saline loading were identified as postoperative risks for LRHF and death. The cohort was divided into 3 groups based on whether the PAPi at rest and the RVSWi change ratio were low. The event-free curve differed significantly among the 3 groups (P < 0.001). CONCLUSIONS Hemodynamic assessment with saline loading can evaluate the right ventricular preload reserve function of patients with an LVAD. A low RVSWi change with saline loading was a risk factor for LRHF following LVAD implantation.
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Affiliation(s)
- Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
| | - Takahiro Kurihara
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Advanced Medical Center for Heart Failure, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Asako Shimada
- Department of Organ Transplantation, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroko Imai
- Department of Organ Transplantation, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Frontier Cardiovascular Science, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; International University of Health and Welfare, Tokyo, Japan
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9
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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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10
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Masiero G, Arturi F, Panza A, Tarantini G. Mechanical Circulatory Support with Impella: Principles, Evidence, and Daily Practice. J Clin Med 2024; 13:4586. [PMID: 39200728 PMCID: PMC11354798 DOI: 10.3390/jcm13164586] [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: 06/03/2024] [Revised: 07/23/2024] [Accepted: 08/03/2024] [Indexed: 09/02/2024] Open
Abstract
The Impella (Abiomed, Danvers, MA, USA) microaxial pump is a percutaneous mechanical circulatory support (MCS) that has been shown to increase coronary perfusion, reduce myocardial oxygen demand, and improve peripheral organ perfusion. Therefore, indications for the Impella device include emergency use for cardiogenic shock (CS) and pre-emptive implantation during high-risk percutaneous coronary intervention (HR-PCI). However, despite their exponential use in cardiovascular practice over the past decade, there is limited randomized evidence to support the benefits of this therapy and growing concern regarding complication rates. In this review, we summarize the principles, evidence, and practical considerations of the most widely used Impella CP percutaneous left ventricular support in both CS and HR-PCI settings, moving from the historical background to current issues and future expectations for this device.
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Affiliation(s)
| | | | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, 35128 Padua, Italy; (G.M.); (F.A.); (A.P.)
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11
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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12
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Jeyakumar S, Nguyen H, Robson D, Olsen N, Schnegg B, Macdonald P, Fraser CL, Liew G, Jiang J, Hayward C, Muthiah K. Retinal microvascular remodeling associates with adverse events in continuous-flow left ventricular assist device supported patients. J Heart Lung Transplant 2024:S1053-2498(24)01750-9. [PMID: 39089605 DOI: 10.1016/j.healun.2024.07.017] [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: 12/14/2023] [Revised: 06/13/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Continuous-flow left ventricular assist device (cfLVAD) use is effective in supporting patients with end-stage heart failure (ESHF). Reduced flow pulsatility within the systemic circulation in cfLVAD-supported patients may lead to alterations within the microcirculation. Temporal changes in microvasculature in relation to adverse events in cfLVAD supported patients has not been studied. We aimed to profile changes within retinal microvasculature and its association with adverse events. METHODS Retinal photography was performed using Topcon TRC-NW8 non-mydriatic fundus camera in cfLVAD supported patients and ESHF control patients. Retinal measurements including arteriolar and venular caliber, fractal dimension, branching angle, and vessel tortuosity were evaluated using a validated semi-automated program. Demographic and adverse event data were documented. RESULTS 172 images were recorded from 48 patients (n=29 cfLVAD, n=19 ESHF, mean age 54.2 ± 11.9 years). There were significant trends in retinal arteriolar caliber (B = -0.53 µm, 95% CI: -0.96 - -0.10, p = 0.016) and retinal fractal dimension parameters (B = 0.014, 95% CI: 0.001 - 0.002, p = 0.016) in linear mixed model regressions. Amongst cfLVAD patients, there was a significant association between the incidence of gastrointestinal bleeding and stepwise increases in retinal arteriolar-venular caliber ratio (HR: 3.03, 95% CI: 2.06 - 4.45, p = 0.005), a measure of arteriolar narrowing. CONCLUSIONS We have observed for the first time that alterations in retinal microvasculature in cfLVAD-supported patients may be associated with gastrointestinal bleeding. While understanding these temporal changes may predict future adverse events in cfLVAD-supported patients, further multi-center studies are required to confirm the associations observed.
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Affiliation(s)
| | - Helen Nguyen
- Westmead Institute for Medical Research, The University of Sydney
| | | | | | | | - Peter Macdonald
- University of New South Wales Sydney; St. Vincent's Hospital Sydney; Victor Chang Cardiac Research Institute
| | | | - Gerald Liew
- University of New South Wales Sydney; Westmead Institute for Medical Research, The University of Sydney
| | | | - Christopher Hayward
- University of New South Wales Sydney; St. Vincent's Hospital Sydney; Victor Chang Cardiac Research Institute
| | - Kavitha Muthiah
- University of New South Wales Sydney; St. Vincent's Hospital Sydney; Victor Chang Cardiac Research Institute.
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13
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Kikoïne J, Nowacka A, Schukraft S, Abdurashidova T, Yerly P, Tozzi P, Ltaief Z, Rosner L, Hullin R, Kirsch M. Clinical outcomes of HeartMate 3 left ventricular assist device support with a Bridge to Transplant vs a Destination Therapy strategy: a single-centre retrospective cohort. Swiss Med Wkly 2024; 154:3529. [PMID: 39137373 DOI: 10.57187/s.3529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION Real-world outcomes with the HeartMate 3 left ventricular assist device (LVAD) depending on whether it's a bridge to transplantation (BTT) or destination therapy (DT) are poorly studied. We aimed to compare the profile and clinical outcomes of patients supported with HeartMate 3 according to a BTT or a DT pre-implantation strategy. METHODS All patients consecutively implanted with HeartMate 3 at our centre (University Hospital of Lausanne, Switzerland) in 2015-2022 were analysed in a retrospective observational study. Indications for HeartMate 3 implantation were advanced heart failure despite optimal medical treatment. Patients were treated with a vitamin K antagonist anticoagulant combined with antiplatelet therapy after HeartMate 3 implantation and were followed up monthly at our institution. RESULTS Among 71 patients implanted with HeartMate 3 between 2015 and 2022, 51 (71.8%) were implanted as a BTT and 20 (28.2%) as DT. Their median age was 58 (IQR: 52-69) years and 84% of patients were classified as INTERMACS profiles 2-4. The median follow-up duration was 18.3 (IQR: 7.5-33.9) months. Patients in the DT group were older than those in the BTT group (p <0.001) and had more chronic renal failure (p <0.001). They also had a lower 5-year survival rate (mean ± standard error: 87.3 ± 5.6% vs 49.4 ± 15.1%) and more adverse events such as renal dysfunction requiring temporary perioperative dialysis (p = 0.08) or bleeding (p = 0.06). CONCLUSION Although patients supported with HeartMate 3 have favourable survival, those with LVAD-DT have poorer outcomes. There is a need to better select patients eligible for LVAD-DT in order to limit the burden of adverse events and improve their prognosis.
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Affiliation(s)
- John Kikoïne
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Anna Nowacka
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
| | - Sara Schukraft
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | | | - Patrick Yerly
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
| | - Zied Ltaief
- Department of Intensive Care Medicine, University Hospital, Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anaesthesiology, University Hospital, Lausanne, Switzerland
| | - Roger Hullin
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
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14
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Pieri M, Ortalda A, Altizio S, Bertoglio L, Nardelli P, Fominskiy E, Lapenna E, Ajello S, Scandroglio AM. Prolonged Impella 5.0/5.5 support within different pathways of care for cardiogenic shock: the experience of a referral center. Front Cardiovasc Med 2024; 11:1379199. [PMID: 39015682 PMCID: PMC11250607 DOI: 10.3389/fcvm.2024.1379199] [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: 01/30/2024] [Accepted: 06/03/2024] [Indexed: 07/18/2024] Open
Abstract
Aims Impella 5.0 and 5.5 are promising low-invasive left ventricle (LV) temporary mechanical circulatory supports (tMCS) for cardiogenic shock due to LV mechanical unloading and are paired with powerful hemodynamic support. This study aimed to analyze data and destinies of patients supported with Impella 5.0/5.5 at a national referral center for cardiogenic shock and to assess the parameters associated with myocardial recovery and successful weaning. Methods A single-center observational study was conducted on all patients treated with Impella 5.0 or 5.5 from March 2018 to July 2023. Results A total of 59 patients underwent Impella 5.0/5.5 implantation due to profound cardiogenic shock, with acute myocardial infarction being the most frequent cause of shock (42 patients, 71%). The median duration of Impella support was 13 days (maximum duration of 52 days). Axillary cannulation was feasible in almost all patients, and 36% were mobilized during support. A total of 44 patients (75%) survived to the next therapy/recovery: 21 patients experienced recovery and 15 and 8 were bridged to long-term LVAD and heart transplantation, respectively. The global survival rate was 66%. The predictors of native heart recovery at multivariate analysis were the number of days on tMCS before upgrade to Impella 5.0/5.5 [hazard ratio (HR) 0.68 (0.51-9) p = 0.0068] and improvement of LVEF within the first 7-10 days of support [HR 4.72 (1.34-16.7), p = 0.016]. Conclusions Transcatheter systems such as Impella 5.0/5.5 revolutionized the field of tMCS. Myocardial recovery is the primary clinical target. Its prognostication and promotion are key to ensure the most proficuous course for each patient from cardiogenic shock to long-term event-free survival.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- School of Medicine, Brescia University School of Medicine, Brescia, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Crespo-Diaz R, Mudy K, Khan N, Samara M, Eckman PM, Sun B, Hryniewicz K. Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival. ASAIO J 2024; 70:570-577. [PMID: 38373178 DOI: 10.1097/mat.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 ( p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.
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Affiliation(s)
- Ruben Crespo-Diaz
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Karol Mudy
- Department of Cardiothoracic Surgery, Baptist Health, Little Rock, Arkansas
| | - Nadeem Khan
- Department of Cardiovascular Diseases, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Michael Samara
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Peter M Eckman
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Benjamin Sun
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Katarzyna Hryniewicz
- Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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16
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Aslam S, Cowger J, Shah P, Stosor V, Copeland H, Reed A, Morales D, Giblin G, Mathew J, Morrissey O, Morejon P, Nicoara A, Molina E. The International Society for Heart and Lung Transplantation (ISHLT): 2024 infection definitions for durable and acute mechanical circulatory support devices. J Heart Lung Transplant 2024; 43:1039-1050. [PMID: 38691077 DOI: 10.1016/j.healun.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
Infections remain a significant concern in patients receiving mechanical circulatory support (MCS), encompassing both durable and acute devices. This consensus manuscript provides updated definitions for infections associated with durable MCS devices and new definitions for infections in acute MCS, integrating a comprehensive review of existing literature and collaborative discussions among multidisciplinary specialists. By establishing consensus definitions, we seek to enhance clinical care, facilitate consistent reporting in research studies, and ultimately improve outcomes for patients receiving MCS.
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Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California.
| | - Jennifer Cowger
- Division of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Valentina Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah Copeland
- Department of Surgery, Lutheran Hospital of Indiana/Indiana School of Medicine, Fort Wayne, Indiana
| | - Anna Reed
- Respiratory & Transplant Medicine, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - David Morales
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Gerard Giblin
- Cardiology Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jacob Mathew
- Cardiology Department, Royal Children's Hospital, Melbourne, Australia
| | - Orla Morrissey
- Department of Infectious Diseases, Monash University and Physician at Alfred Health, Melbourne, Australia
| | | | - Alina Nicoara
- Division of Cardiothoracic Anesthesia, Duke University, Durham, North Carolina
| | - Ezequiel Molina
- Samsky Heart Failure Center, Piedmont Heart Institute, Atlanta, Georgia
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17
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Ardito V, Rognoni C, Pieri M, Barbone A, Briguori C, Cigala E, Gerosa G, Iannaccone M, Loforte A, Marini M, Montalto A, Oreglia J, Pacini D, Pennacchi M, Pestrichella V, Porto I, Stefano P, Tarantini G, Valente S, Vandoni P, Tarricone R, Scandroglio AM. Impella versus VA-ECMO for the treatment of patients with cardiogenic shock: the Impella Network Project - observational study protocol for cost-effectiveness and budget impact analyses. BMJ Open 2024; 14:e078358. [PMID: 38926145 PMCID: PMC11216050 DOI: 10.1136/bmjopen-2023-078358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION The treatment of patients with cardiogenic shock (CS) encompasses several health technologies including Impella pumps and venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, while they are widely used in clinical practice, information on resource use and quality of life (QoL) associated with these devices is scarce. The aim of this study is, therefore, to collect and comparatively assess clinical and socioeconomic data of Impella versus VA-ECMO for the treatment of patients with severe CS, to ultimately conduct both a cost-effectiveness (CEA) and budget impact (BIA) analyses. METHODS AND ANALYSIS This is a prospective plus retrospective, multicentre study conducted under the scientific coordination of the Center for Research on Health and Social Care Management of SDA Bocconi School of Management and clinical coordination of Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute in Milan. The Impella Network stemmed for the purposes of this study and comprises 17 Italian clinical centres from Northern to Southern Regions in Italy. The Italian network qualifies as a subgroup of the international Impella Cardiac Surgery Registry. Patients with CS treated with Impella pumps (CP, 5.0 or 5.5) will be prospectively recruited, and information on clinical outcomes, resource use and QoL collected. Economic data will be retrospectively matched with data from comparable patients treated with VA-ECMO. Both CEA and BIA will be conducted adopting the societal perspective in Italy. This study will contribute to generate new socioeconomic evidence to inform future coverage decisions. ETHICS AND DISSEMINATION As of May 2024, most of the clinical centres submitted the documentation to their ethical committee (N=13; 76%), six centres received ethical approval and two centres started to enrol patients. Study results will be published in peer-reviewed publications and disseminated through conference presentations.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | | | - Carlo Briguori
- Mediterranea Cardiocentro, Clinica Mediterranea SpA, Napoli, Italy
| | - Emanuele Cigala
- UOC Cardiologia Interventistica, Ospedale Monaldi, Napoli, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy
| | - Antonio Loforte
- Dipartimento di Scienze Chirurgiche, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Marini
- Dipartimento di Scienze Cardiovascolari, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Andrea Montalto
- Azienda Ospedaliera di Caserta Sant'Anna e San Sebastiano, Caserta, Italy
| | | | | | - Mauro Pennacchi
- Dipartimento Cardio Toraco Vascolare, U.O. Cardiologia Interventistica, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | | | - Italo Porto
- DICATOV-CardioThoracic and Vascular, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
- University of Genova, Policlinico San Martino IRCCS, Università degli Studi di Genova Scuola di Scienze Mediche e Farmaceutiche, Genova, Italy
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | | | | | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
- Department of Social and Political Sciences, Bocconi University, Milano, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Italy
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18
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Adamopoulos S, Bonios M, Ben Gal T, Gustafsson F, Abdelhamid M, Adamo M, Bayes-Genis A, Böhm M, Chioncel O, Cohen-Solal A, Damman K, Di Nora C, Hashmani S, Hill L, Jaarsma T, Jankowska E, Lopatin Y, Masetti M, Mehra MR, Milicic D, Moura B, Mullens W, Nalbantgil S, Panagiotou C, Piepoli M, Rakisheva A, Ristic A, Rivinius R, Savarese G, Thum T, Tocchetti CG, Tops LF, Van Laake LW, Volterrani M, Seferovic P, Coats A, Metra M, Rosano G. Right heart failure with left ventricular assist devices: Preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2024. [PMID: 38853659 DOI: 10.1002/ejhf.3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/11/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024] Open
Abstract
Right heart failure (RHF) following implantation of a left ventricular assist device (LVAD) is a common and potentially serious condition with a wide spectrum of clinical presentations with an unfavourable effect on patient outcomes. Clinical scores that predict the occurrence of right ventricular (RV) failure have included multiple clinical, biochemical, imaging and haemodynamic parameters. However, unless the right ventricle is overtly dysfunctional with end-organ involvement, prediction of RHF post-LVAD implantation is, in most cases, difficult and inaccurate. For these reasons optimization of RV function in every patient is a reasonable practice aiming at preparing the right ventricle for a new and challenging haemodynamic environment after LVAD implantation. To this end, the institution of diuretics, inotropes and even temporary mechanical circulatory support may improve RV function, thereby preparing it for a better adaptation post-LVAD implantation. Furthermore, meticulous management of patients during the perioperative and immediate postoperative period should facilitate identification of RV failure refractory to medication. When RHF occurs late during chronic LVAD support, this is associated with worse long-term outcomes. Careful monitoring of RV function and characterization of the origination deficit should therefore continue throughout the patient's entire follow-up. Despite the useful information provided by the echocardiogram with respect to RV function, right heart catheterization frequently offers additional support for the assessment and optimization of RV function in LVAD-supported patients. In any patient candidate for LVAD therapy, evaluation and treatment of RV function and failure should be assessed in a multidimensional and multidisciplinary manner.
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Affiliation(s)
- Stamatis Adamopoulos
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Michael Bonios
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Magdy Abdelhamid
- Faculty of Medicine, Department of Cardiology, Cairo University, Giza, Egypt
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Bayes-Genis
- Heart Failure and Cardiac Regeneration Research Program, Health Sciences Research Institute Germans Trias i Pujol, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- Cardiology Service, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Michael Böhm
- Clinic for Internal Medicine III (Cardiology, Intensive Care Medicine and Angiology), Saarland University Medical Center, Homburg, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | | | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands
| | - Concetta Di Nora
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Shahrukh Hashmani
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden
| | - Ewa Jankowska
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russian Federation
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Sanem Nalbantgil
- Cardiology Department, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Chrysoula Panagiotou
- Heart Failure and Transplant Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Massimo Piepoli
- IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Rasmus Rivinius
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Heidelberg, Germany
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) and Rebirth Center for Translational Regenerative Therapies, Hannover Medical School, Hannover, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Serbia Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- St. George's Hospitals NHS Trust University of London, London, UK
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19
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Movahedi F, Antaki JF. Improving the Prediction of 1-Year Right Ventricular Failure After Left Ventricular Assist Device Implantation. ASAIO J 2024; 70:495-501. [PMID: 38346283 PMCID: PMC11147739 DOI: 10.1097/mat.0000000000002152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Previous predictive models for postimplant right heart failure (RHF) following left ventricular assist device (LVAD) implantation have demonstrated limited performance on validation datasets and are susceptible to overfitting. Thus, the objective of this study was to develop an improved predictive model with reduced overfitting and improved accuracy in predicting RHF in LVAD recipients. The study involved 11,967 patients who underwent continuous-flow LVAD implantation between 2008 and 2016, with an RHF incidence of 9% at 1 year. Using an eXtreme Gradient Boosting (XGBoost) algorithm, the training data were used to predict RHF at 1 year postimplantation, resulting in promising area under the curve (AUC)-receiver operating characteristic (ROC) of 0.8 and AUC-precision recall curve (PRC) of 0.24. The calibration plot showed that the predicted risk closely corresponded with the actual observed risk. However, the model based on data collected 48 hours before LVAD implantation exhibited high sensitivity but low precision, making it an excellent screening tool but not a diagnostic tool.
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Affiliation(s)
- Faezeh Movahedi
- From the Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
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20
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Gallone G, Lewin D, Rojas Hernandez S, Bernhardt A, Billion M, Meyer A, Netuka I, Kooij JJ, Pieri M, Szymanski MK, Moeller CH, Akhyari P, Jawad K, Krasivskyi I, Schmack B, Färber G, Medina M, Haneya A, Zimpfer D, Nersesian G, Lanmueller P, Spitaleri A, Oezkur M, Djordjevic I, Saeed D, Boffini M, Stein J, Gustafsson F, Scandroglio AM, De Ferrari GM, Meyns B, Hofmann S, Belohlavek J, Gummert J, Rinaldi M, Potapov EV, Loforte A. Stroke outcomes following durable left ventricular assist device implant in patients bridged with micro-axial flow pump: Insights from a large registry. Artif Organs 2024. [PMID: 38803239 DOI: 10.1111/aor.14775] [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: 01/08/2024] [Revised: 04/09/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled. METHODS Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied. RESULTS Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality. CONCLUSIONS Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.
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Affiliation(s)
- Guglielmo Gallone
- City of Health and Science Hospital, Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alexander Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Michael Billion
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Anna Meyer
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ivan Netuka
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - J-J Kooij
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Payam Akhyari
- Department of Cardiovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Khalil Jawad
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Essen, Essen, Germany
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Marta Medina
- Department of Cardiac and Vascular Surgery, University of Mainz, Mainz, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Antonio Spitaleri
- City of Health and Science Hospital, Cardiac Surgery University Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University of Mainz, Mainz, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Massimo Boffini
- City of Health and Science Hospital, Cardiac Surgery University Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Julia Stein
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - F Gustafsson
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaetano Maria De Ferrari
- City of Health and Science Hospital, Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Hofmann
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Jan Belohlavek
- Second Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Jan Gummert
- Heart and Diabetes Center, North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Mauro Rinaldi
- City of Health and Science Hospital, Cardiac Surgery University Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Antonio Loforte
- City of Health and Science Hospital, Cardiac Surgery University Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
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21
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Wang X, Zhou X, Chen H, Du J, Qing P, Zou L, Chen Y, Duan F, Yuan S, Shi J, Ji B, Wu R, Zhang Y, Jin Y, Hu S. Long-term outcomes of a novel fully magnetically levitated ventricular assist device for the treatment of advanced heart failure in China. J Heart Lung Transplant 2024:S1053-2498(24)01664-4. [PMID: 38740078 DOI: 10.1016/j.healun.2024.05.004] [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: 01/30/2024] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE Left ventricular assist devices (LVADs) are well-established for treating end-stage heart failure, but this therapy is only available to Chinese patients in recent years. The CH-VAD is the first used fully magnetically levitated pump and the most widely used device in China. This study reports the long-term outcomes of a cohort supported by the CH-VAD for the first time. METHODS From June 2017 to August 2023, 50 consecutive patients received CH-VAD implantation in Fuwai Hospital. Clinical data were collected during follow-up and retrospectively analyzed. RESULTS Baseline characteristics included a mean age of 47.9±13.9 years, 90% male, and 26% ischemic etiology. The INTERMACS profile revealed 12% Profile 1, 56% Profile 2, 26% Profile 3 and 6% Profile 4. Mean support duration was 868 ± 630 days (range 33 days-6.4 years). Kaplan-Meier survival rate was 96% (95% confidence interval [CI], 85 to 99) at 6 months, 93% (95% CI, 79-98) at 1 year, 93% (95% CI, 79-98) at 2 years and 89% (95% CI, 71-96) at 3 years. 40 patients (80%) currently remain on support, 3 were bridged to recovery, 2 received transplant, and 5 expired during support. Major adverse events included right heart failure (10%), surgical related bleeding (8%), arrhythmia (8%) and driveline infection (16%). Major hemocompatibility-related adverse events were limited to 3 non-disabling strokes and 1 gastrointestinal bleeding. There was no major device malfunction during the follow-up period. CONCLUSIONS The largest single-center experience with the leading LVAD in China shows high survival with low complication rates, demonstrating the CH-VAD is safe and efficient in providing long-term support for end-stage heart failure patients.
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Affiliation(s)
- Xianqiang Wang
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xingtong Zhou
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haibo Chen
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Du
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Qing
- Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Zou
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Chen
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rong Wu
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanming Zhang
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Jin
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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22
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Scott A, Chen Z, Kligerman S, Kim P, Tran H, Adler E, Narezkina A, Contijoch F. Regional Strain of Right Ventricle From Computed Tomography Improves Risk Stratification of Right Ventricle Failure. ASAIO J 2024; 70:358-364. [PMID: 38166039 PMCID: PMC11062830 DOI: 10.1097/mat.0000000000002123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
Patients who undergo implantation of a left ventricular assist device (LVAD) are at a high risk for right ventricular failure (RVF), presumably due to poor right ventricular (RV) function before surgery. Cine computerized tomography (cineCT) can be used to evaluate RV size, function, and endocardial strain. However, CT-based strain measures in patients undergoing workup for LVAD implantation have not been evaluated. We quantified RV strain in the free wall (FW) and septal wall (SW) in patients with end-stage heart failure using cineCT. Compared to controls, both FW and SW strains were significantly impaired in heart failure patients. The difference between FW and SW strains predicted RV failure after LVAD implantation (area-under-the curve [AUC] = 0.82). Cine CT strain can be combined with RV volumetry to risk-stratify patients. In our study, patients with preserved RV volumes and poor strain had a higher rate of RV failure (57%), than those with preserved volume and preserved strain (0%). This suggests that CT could improve risk stratification of patients receiving LVADs and that strain metrics were particularly useful in risk-stratifying patients with preserved RV volumes.
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Affiliation(s)
- Anderson Scott
- Shu Chien-Gene Lay Department of Bioengineering, UC San Diego, La Jolla CA
| | - Zhennong Chen
- Shu Chien-Gene Lay Department of Bioengineering, UC San Diego, La Jolla CA
| | - Seth Kligerman
- Department of Radiology, National Jewish Health, Denver, CO
| | - Paul Kim
- Division of Cardiology, Department of Medicine, UC San Diego, La Jolla CA
| | - Hao Tran
- Division of Cardiology, Department of Medicine, UC San Diego, La Jolla CA
| | - Eric Adler
- Division of Cardiology, Department of Medicine, UC San Diego, La Jolla CA
| | - Anna Narezkina
- Division of Cardiology, Department of Medicine, UC San Diego, La Jolla CA
| | - Francisco Contijoch
- Shu Chien-Gene Lay Department of Bioengineering, UC San Diego, La Jolla CA
- Department of Radiology, UC San Diego, La Jolla CA
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23
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Stąpór M, Sobczyk D, Wasilewski G, Wierzbicki K, Gackowski A, Kleczyński P, Żmudka K, Kapelak B, Legutko J. Right ventricular-pulmonary arterial coupling in patients with implanted left ventricular assist devices. Hellenic J Cardiol 2024; 77:44-53. [PMID: 37295669 DOI: 10.1016/j.hjc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 05/17/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE Both the right ventricular (RV) contractile function and pulmonary arterial (PA) pressure influence clinical outcomes in patients supported with left ventricular assist devices (LVADs), but the impact of RV-PA coupling is unknown. This study aimed to determine the prognostic impact of RV-PA coupling in patients with implanted LVADs. METHODS Patients with implanted third-generation LVADs were retrospectively enrolled. The RV-PA coupling was assessed preoperatively by the ratio of RV free wall strain (RVFWS) derived from speckle-tracking echocardiography and noninvasively measured peak RV systolic pressure (RVSP). The primary end point was a composite of all-cause mortality or right heart failure (RHF) hospitalization. Secondary end points consisted of all-cause mortality at a 12-month follow-up and RHF hospitalization. RESULTS A total of 103 patients were screened, and 72 with good RV myocardial imaging were included. The median age was 57 years; 67 patients (93.1%) were men, and 41 (56,9%) had dilated cardiomyopathy. A receiver-operating characteristic analysis (AUC 0.703, 51.5% sensitivity, 94.9% specificity) was used to identify the optimal cutoff point (0.28%/mmHg) for the RVFWS/TAPSE threshold. Nineteen subjects (26.4%) had advanced RV-PA uncoupling. Event rates were estimated using the Kaplan-Meier method showing a strong association with an increased risk for the primary end point of death or RHF hospitalization (89.47% vs. 30.19%, p < 0.001). A similar observation applied to all-cause mortality (47.37% vs. 13.21%, p = 0.003) and RHF hospitalization (80.43% vs. 20%, p < 0.001). CONCLUSIONS An advanced RV dysfunction assessed by RV-PA coupling may serve as a predictor of adverse outcomes in patients with implanted LVADs.
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Affiliation(s)
- Maciej Stąpór
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland; Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Kraków, Poland
| | - Dorota Sobczyk
- Jagiellonian University Medical College, Institute of Cardiology, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Kraków, Poland
| | - Grzegorz Wasilewski
- Jagiellonian University Medical College, Institute of Cardiology, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Kraków, Poland
| | - Karol Wierzbicki
- Jagiellonian University Medical College, Institute of Cardiology, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Kraków, Poland
| | - Andrzej Gackowski
- Jagiellonian University Medical College, Institute of Cardiology, Department of Coronary Disease and Heart Failure, John Paul II Hospital, Kraków, Poland; Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Kraków, Poland
| | - Paweł Kleczyński
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland; Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland
| | - Krzysztof Żmudka
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland; Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland
| | - Bogusław Kapelak
- Jagiellonian University Medical College, Institute of Cardiology, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Kraków, Poland
| | - Jacek Legutko
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland; Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland.
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24
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van der Horst S, de Jong Y, van Rein N, Jukema J, Palmen M, Janssen E, Bonneville E, Klok F, Huisman M, Tops L, den Exter P. Performance of risk scores in predicting major bleeding in left ventricular assist device recipients: a comparative external validation. Res Pract Thromb Haemost 2024; 8:102437. [PMID: 38953051 PMCID: PMC11215111 DOI: 10.1016/j.rpth.2024.102437] [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: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 07/03/2024] Open
Abstract
Background Implantation of a left ventricular assist device (LVAD) is a crucial therapeutic option for selected end-stage heart failure patients. However, major bleeding (MB) complications postimplantation are a significant concern. Objectives We evaluated current risk scores' predictive accuracy for MB in LVAD recipients. Methods We conducted an observational, single-center study of LVAD recipients (HeartWare or HeartMate-3, November 2010-December 2022) in the Netherlands. The primary outcome was the first post-LVAD MB (according to the International Society on Thrombosis and Haemostasis [ISTH] and Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS], and INTERMACS combined with intracranial bleeding [INTERMACS+] criteria). Mortality prior to MB was considered a competing event. Discrimination (C-statistic) and calibration were evaluated for the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score, Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke score, Anticoagulation and Risk Factors in Atrial Fibrillation score, Outpatient Bleeding Risk Index, venous thromboembolism score, atrial fibrillation score, and Utah Bleeding Risk Score (UBRS). Results One hundred four patients were included (median age, 64 years; female, 20.2%; HeartWare, 90.4%; HeartMate-3, 9.6%). The cumulative MB incidence was 75.7% (95% CI 65.5%-85.9%) by ISTH and INTERMACS+ criteria and 67.0% (95% CI 56.0%-78.0%) per INTERMACS criteria over a median event-free follow-up time of 1916 days (range, 59-4521). All scores had poor discriminative ability on their intended prediction timeframe. Cumulative area under the receiving operator characteristic curve ranged from 0.49 (95% CI 0.35-0.63, venous thromboembolism-BLEED) to 0.56 (95% CI 0.47-0.65, UBRS) according to ISTH and INTERMACS+ criteria and from 0.48 (95% CI 0.40-0.56, Anticoagulation and Risk Factors in Atrial Fibrillation) to 0.56 (95% CI 0.47-0.65, UBRS) per INTERMACS criteria. All models showed poor calibration, largely underestimating MB risk. Conclusion Current bleeding risk scores exhibit inadequate predictive accuracy for LVAD recipients. There is a need for an accurate risk score to identify LVAD patients at high risk of MB who may benefit from patient-tailored antithrombotic therapy.
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Affiliation(s)
- S.F.B. van der Horst
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Y. de Jong
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - N. van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J.W. Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M. Palmen
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - E. Janssen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E.F. Bonneville
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - F.A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M.V. Huisman
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - L.F. Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - P.L. den Exter
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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25
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Shelley B, McAreavey R, McCall P. Epidemiology of perioperative RV dysfunction: risk factors, incidence, and clinical implications. Perioper Med (Lond) 2024; 13:31. [PMID: 38664769 PMCID: PMC11046908 DOI: 10.1186/s13741-024-00388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
In this edition of the journal, the Perioperative Quality Initiative (POQI) present three manuscripts describing the physiology, assessment, and management of right ventricular dysfunction (RVD) as pertains to the perioperative setting. This narrative review seeks to provide context for these manuscripts, discussing the epidemiology of perioperative RVD focussing on definition, risk factors, and clinical implications. Throughout the perioperative period, there are many potential risk factors/insults predisposing to perioperative RVD including pre-existing RVD, fluid overload, myocardial ischaemia, pulmonary embolism, lung injury, mechanical ventilation, hypoxia and hypercarbia, lung resection, medullary reaming and cement implantation, cardiac surgery, cardiopulmonary bypass, heart and lung transplantation, and left ventricular assist device implantation. There has however been little systematic attempt to quantify the incidence of perioperative RVD. What limited data exists has assessed perioperative RVD using echocardiography, cardiovascular magnetic resonance, and pulmonary artery catheterisation but is beset by challenges resulting from the inconsistencies in RVD definitions. Alongside differences in patient and surgical risk profile, this leads to wide variation in the incidence estimate. Data concerning the clinical implications of perioperative RVD is even more scarce, though there is evidence to suggest RVD is associated with atrial arrhythmias and prolonged length of critical care stay following thoracic surgery, increased need for inotropic support in revision orthopaedic surgery, and increased critical care requirement and mortality following cardiac surgery. Acute manifestations of RVD result from low cardiac output or systemic venous congestion, which are non-specific to the diagnosis of RVD. As such, RVD is easily overlooked, and the relative contribution of RV dysfunction to postoperative morbidity is likely to be underestimated.We applaud the POQI group for highlighting this important condition. There is undoubtedly a need for further study of the RV in the perioperative period in addition to solutions for perioperative risk prediction and management strategies. There is much to understand, study, and trial in this area, but importantly for our patients, we are increasingly recognising the importance of these uncertainties.
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Affiliation(s)
- Ben Shelley
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK.
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK.
| | - Rhiannon McAreavey
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK
| | - Philip McCall
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK
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26
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Chamogeorgakis T, Toumpoulis I, Bonios MJ, Lanfear D, Williams C, Koliopoulou A, Cowger J. Treatment Strategies and Outcomes of Right Ventricular Failure Post Left Ventricular Assist Device Implantation: An INTERMACS Analysis. ASAIO J 2024; 70:264-271. [PMID: 38029763 DOI: 10.1097/mat.0000000000002105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Right heart failure (RHF) management after left ventricular assist device (LVAD) implantation includes inotropes, right ventricular mechanical support, and heart transplantation. The purpose of this study is to compare different RHF treatment strategies in patients with a magnetically levitated centrifugal LVAD. A total of 6,632 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) patients from 2013 to 2020 were included. Of which, 769 (69.6%) patients (group 1) were supported with inotropes (≥14 days post-LVAD implantation), 233 (21.1%) patients (group 2) were supported with temporary right ventricular assist device (RVAD) that was implanted during LVAD implant, 77 (7.0%) patients (group 3) with durable centrifugal RVAD implanted during the LVAD implant, and 26 (2.4%) patients (group 4) were supported with RVAD (temporary or permanent), which was implanted at a later stage. Groups 1 and 4 had higher survival rates in comparison with group 2 (hazard ratio [HR] = 0.513, 95% confidence intervals [CIs] = 0.402-0.655, p < 0.001, versus group 1) and group 3 (HR = 0.461, 95% CIs = 0.320-0.666, p < 0.001, versus group 1). Patients in group 3 showed higher heart transplantation rates at 12 and 36 months as compared with group 1 (40.4% and 46.6% vs. 21.9% and 37.4%, respectively), group 2 (40.4% and 46.6% vs. 25.8% and 39.3%, respectively), and group 4 (40.4% and 46.6% vs. 3.8% and 12.0%, respectively). Severe RHF post-LVAD is associated with poor survival. Patients with LVAD who during the perioperative period are in need of right ventricular temporary or durable mechanical circulatory support constitute a group at particular risk. Improvement of devices tailored for right ventricular support is mandatory for further evolution of the field.
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Affiliation(s)
- Themistokles Chamogeorgakis
- From the Henry Ford, Transplant Institute, Detroit, Michigan
- 2nd Cardiac Surgery Department, Onassis Cardiac Surgery Centre, Athens, Greece
| | | | - Michael J Bonios
- 2nd Cardiac Surgery Department, Onassis Cardiac Surgery Centre, Athens, Greece
| | - David Lanfear
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Celeste Williams
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | | | - Jennifer Cowger
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
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27
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Kersten BJ, Numan L, van der Schoot MM, de Jong M, Ramjankhan F, Aarts E, Oerlemans MIFJ, van Laake LW, de Waal EEC. FLAVOUR Study: FLow profiles And postoperative VasOplegia after continUous-flow left ventriculaR assist device implantation. J Cardiovasc Transl Res 2024; 17:252-264. [PMID: 38300356 PMCID: PMC11052811 DOI: 10.1007/s12265-023-10476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/12/2023] [Indexed: 02/02/2024]
Abstract
This study aims to associate the incidence of postoperative vasoplegia and short-term survival to the implantation of various left ventricular assist devices differing in hemocompatibility and flow profiles. The overall incidence of vasoplegia was 25.3% (73/289 patients) and 30.3% (37/122), 25.0% (18/72), and 18.9% (18/95) in the axial flow (AXF), centrifugal flow (CF), and centrifugal flow with artificial pulse (CFAP) group, respectively. Vasoplegia was associated with longer intensive care (ICU) and hospital length of stay (LOS) and mortality. ICU and in-hospital LOS and 1-year mortality were the lowest in the CFAP group. Post hoc analysis resulted in a p-value of 0.43 between AXF and CF; 0.35 between CF and CFAP; and 0.06 between AXF and CFAP. Although there is a trend in diminished incidence of vasoplegia, pooled logistic regression using flow profile and variables that remained after feature selection showed that flow profile was not an independent predictor for postoperative vasoplegia.
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Affiliation(s)
- Bas J Kersten
- Department of Anesthesiology, University Medical Center Utrecht, Post Office Box 85500, 3508, Utrecht, GA, Netherlands
| | - Lieke Numan
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Michel de Jong
- Heartbeat Perfusion, University Medical Center Utrecht, Utrecht, Netherlands
| | - Faiz Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emmeke Aarts
- Department of Methodology and Statistics, Utrecht University, Utrecht, Netherlands
| | | | - Linda W van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Eric E C de Waal
- Department of Anesthesiology, University Medical Center Utrecht, Post Office Box 85500, 3508, Utrecht, GA, Netherlands.
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28
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Scheel PJ, Cubero Salazar IM, Friedman S, Haber L, Mukherjee M, Kauffman M, Weller A, Alkhunaizi F, Gilotra NA, Sharma K, Kilic A, Hassoun PM, Cornwell WK, Tedford RJ, Hsu S. Occult right ventricular dysfunction and right ventricular-vascular uncoupling in left ventricular assist device recipients. J Heart Lung Transplant 2024; 43:594-603. [PMID: 38036276 PMCID: PMC10947813 DOI: 10.1016/j.healun.2023.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Detecting right heart failure post left ventricular assist device (LVAD) is challenging. Sensitive pressure-volume loop assessments of right ventricle (RV) contractility may improve our appreciation of post-LVAD RV dysfunction. METHODS Thirteen LVAD patients and 20 reference (non-LVAD) subjects underwent comparison of echocardiographic, right heart cath hemodynamic, and pressure-volume loop-derived assessments of RV contractility using end-systolic elastance (Ees), RV afterload by effective arterial elastance (Ea), and RV-pulmonary arterial coupling (ratio of Ees/Ea). RESULTS LVAD patients had lower RV Ees (0.20 ± 0.08 vs 0.30 ± 0.15 mm Hg/ml, p = 0.01) and lower RV Ees/Ea (0.37 ± 0.14 vs 1.20 ± 0.54, p < 0.001) versus reference subjects. Low RV Ees correlated with reduced RV septal strain, an indicator of septal contractility, in both the entire cohort (r = 0.68, p = 0.004) as well as the LVAD cohort itself (r = 0.78, p = 0.02). LVAD recipients with low RV Ees/Ea (below the median value) demonstrated more clinical heart failure (71% vs 17%, p = 0.048), driven by an inability to augment RV Ees (0.22 ± 0.11 vs 0.19 ± 0.02 mm Hg/ml, p = 0.95) to accommodate higher RV Ea (0.82 ± 0.38 vs 0.39 ± 0.08 mm Hg/ml, p = 0.002). Pulmonary artery pulsatility index (PAPi) best identified low baseline RV Ees/Ea (≤0.35) in LVAD patients ((area under the curve) AUC = 0.80); during the ramp study, change in PAPi also correlated with change in RV Ees/Ea (r = 0.58, p = 0.04). CONCLUSIONS LVAD patients demonstrate occult intrinsic RV dysfunction. In the setting of excess RV afterload, LVAD patients lack the RV contractile reserve to maintain ventriculo-vascular coupling. Depression in RV contractility may be related to LVAD left ventricular unloading, which reduces septal contractility.
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Affiliation(s)
- Paul J Scheel
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ilton M Cubero Salazar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Friedman
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Leora Haber
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Kauffman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra Weller
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fatimah Alkhunaizi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Paul M Hassoun
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William K Cornwell
- Division of Cardiology, Department of Medicine, University of Anschutz Medical Campus, Aurora, Colorado; Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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29
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Sciaccaluga C, Procopio MC, Potena L, Masetti M, Bernazzali S, Maccherini M, Landra F, Righini FM, Cameli M, Valente S. Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective? Heart Fail Rev 2024; 29:559-569. [PMID: 38329583 PMCID: PMC10942886 DOI: 10.1007/s10741-024-10387-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/09/2024]
Abstract
The use of left ventricular assist devices (LVAD) has significantly increased in the last years, trying to offer a therapeutic alternative to heart transplantation, in light also to the significant heart donor shortage compared to the growing advanced heart failure population. Despite technological improvements in the devices, LVAD-related mortality is still fairly high, with right heart failure being one of the predominant predictors. Therefore, many efforts have been made toward a thorough right ventricular (RV) evaluation prior to LVAD implant, considering clinical, laboratory, echocardiographic, and invasive hemodynamic parameters. However, there is high heterogeneity regarding both which predictor is the strongest as well as the relative cut-off values, and a consensus has not been reached yet, increasing the risk of facing patients in which the distinction between good or poor RV function cannot be surely reached. In parallel, due to technological development and availability of mechanical circulatory support of the RV, LVADs are being considered even in patients with suboptimal RV function. The aim of our review is to analyze the current evidence regarding the role of RV function prior to LVAD and its evaluation, pointing out the extreme variability in parameters that are currently assessed and future prospective regarding new diagnostic tools. Finally, we attempt to gather the available information on the therapeutic strategies to use in the peri-operative phase, in order to reduce the incidence of RV failure, especially in patients in which the preoperative evaluation highlighted some conflicting results with regard to ventricular function.
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Affiliation(s)
- Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, Siena, Italy
| | | | - Federico Landra
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Maria Righini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Sigala MI, Harris JE, Morton C, Donahue KR, Kim JH. A case series analysis of bicarbonate-based purge solution administration via Impella ventricular assist device. Am J Health Syst Pharm 2024; 81:e115-e121. [PMID: 37952169 DOI: 10.1093/ajhp/zxad278] [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: 11/06/2023] [Indexed: 11/14/2023] Open
Abstract
PURPOSE The Impella device historically required a heparin-based purge solution to reduce the risk of biomaterial deposition to maintain pump function. In April 2022, the Food and Drug Administration approved utilization of bicarbonate-based purge solutions (BBPS) as an alternative to heparin for patients who are intolerant to heparin or in whom heparin is contraindicated. The purpose of this case series is to report patient outcomes of Impella support with BBPS use at our institution. SUMMARY Eighteen patients who received BBPS via the Impella CP or Impella 5.5 device were included in our review. Patients were included if they had BBPS administration for greater than 24 hours. All patients were followed for 72 hours after cessation of BBPS. Indications for BBPS were coagulopathy (n = 5, 28%), suspected HIT (n = 2, 11%), confirmed HIT (n = 1, 6%), and major bleeding (n = 10, 56%). Three patients (17%) experienced an Impella complication while on BBPS. One patient required pump exchange, one required removal of the Impella device, and one received alteplase for suspected purge block. Of these, two patients experienced complications greater than 21 days into BBPS therapy. CONCLUSION This case series adds to the literature describing clinical outcomes for patients on Impella support with BBPS. While BBPS offers a viable option for the management of patients on Impella devices who are unable to tolerate heparin-based purge solutions, further data is needed to determine the longevity of the Impella device with BBPS to minimize risk of Impella complications.
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Affiliation(s)
| | | | | | | | - Ju H Kim
- Advanced Heart Failure and Transplant, Houston Methodist Hospital, Methodist DeBakey Cardiology Associates, Houston, TX, USA
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Balcioglu O, Ozgocmen C, Ozsahin DU, Yagdi T. The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review. Diagnostics (Basel) 2024; 14:380. [PMID: 38396419 PMCID: PMC10888030 DOI: 10.3390/diagnostics14040380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.
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Affiliation(s)
- Ozlem Balcioglu
- Department of Cardiovascular Surgery, Faculty of Medicine, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Cemre Ozgocmen
- Department of Biomedical Engineering, Faculty of Engineering, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Dilber Uzun Ozsahin
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Faculty of Medicine, Ege University, Izmir 35100, Turkey
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Adly G, Mithoefer O, Elliott Epps J, Hajj JM, Hambright E, Jackson GR, Inampudi C, Atkins J, Griffin JM, Carnicelli AP, Witer LJ, Kilic A, Houston BA, Vanderpool RR, Tedford RJ. Right Ventricular Contractility and Pulmonary Arterial Coupling After Less Invasive Left Ventricular Assist Device Implantation. ASAIO J 2024; 70:99-106. [PMID: 37816019 DOI: 10.1097/mat.0000000000002063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Right ventricular failure contributes significantly to morbidity and mortality after left ventricular assist device implantation. Recent data suggest a less invasive strategy (LIS) via thoracotomy may be associated with less right ventricular failure than conventional median sternotomy (CMS). However, the impact of these approaches on load-independent right ventricular (RV) contractility and RV-pulmonary arterial (RV-PA) coupling remains uncertain. We hypothesized that the LIS approach would be associated with preserved RV contractility and improved RV-PA coupling compared with CMS. We performed a retrospective study of patients who underwent durable, centrifugal left ventricular assist device implantation and had paired hemodynamic assessments before and after implantation. RV contractility (end-systolic elastance [Ees]), RV afterload (pulmonary effective arterial elastance [Ea]), and RV-PA coupling (Ees/Ea) were determined using digitized RV pressure waveforms. Forty-two CMS and 21 LIS patients were identified. Preimplant measures of Ees, Ea, and Ees/Ea were similar between groups. After implantation, Ees declined significantly in the CMS group (0.60-0.40, p = 0.008) but not in the LIS group (0.67-0.58, p = 0.28). Coupling (Ees/Ea) was unchanged in CMS group (0.54-0.59, p = 0.80) but improved significantly in the LIS group (0.58-0.71, p = 0.008). LIS implantation techniques may better preserve RV contractility and improve RV-PA coupling compared with CMS.
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Affiliation(s)
- George Adly
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Oliver Mithoefer
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - John Elliott Epps
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer M Hajj
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Hambright
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory R Jackson
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Chakradhari Inampudi
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica Atkins
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jan M Griffin
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Anthony P Carnicelli
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Lucas J Witer
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Brian A Houston
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | | | - Ryan J Tedford
- From the Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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Krishnaswamy RJ, Robson D, Gunawan A, Ramanayake A, Barua S, Jain P, Adji A, Macdonald PS, Hayward CS, Muthiah K. Using pulsatility responses to breath-hold maneuvers to predict readmission rates in continuous-flow left ventricular assist device patients. Artif Organs 2024; 48:70-82. [PMID: 37819003 DOI: 10.1111/aor.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/18/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Dynamic respiratory maneuvers induce heterogenous changes to flow-pulsatility in continuous-flow left ventricular assist device patients. We evaluated the association of these pulsatility responses with patient hemodynamics and outcomes. METHODS Responses obtained from HVAD (Medtronic) outpatients during successive weekly clinics were categorized into three ordinal groups according to the percentage reduction in flow-waveform pulsatility (peak-trough flow) upon inspiratory-breath-hold, (%∆P): (1) minimal change (%∆P ≤ 50), (2) reduced pulsatility (%∆P > 50 but <100), (3) flatline (%∆P = 100). Same-day echocardiography and right-heart-catheterization were performed. Readmissions were compared between patients with ≥1 flatline response (F-group) and those without (NF-group). RESULTS Overall, 712 responses were obtained from 55 patients (82% male, age 56.4 ± 11.5). When compared to minimal change, reduced pulsatility and flatline responses were associated with lower central venous pressure (14.2 vs. 11.4 vs. 9.0 mm Hg, p = 0.08) and pulmonary capillary wedge pressure (19.8 vs. 14.3 vs. 13.0 mm Hg, p = 0.03), lower rates of ≥moderate mitral regurgitation (48% vs. 13% vs. 10%, p = 0.01), lower rates of ≥moderate right ventricular impairment (62% vs. 25% vs. 27%, p = 0.03), and increased rates of aortic valve opening (32% vs. 50% vs. 75%, p = 0.03). The F-group (n = 28) experienced numerically lower all-cause readmissions (1.51 vs. 2.79 events-per-patient-year [EPPY], hazard-ratio [HR] = 0.67, p = 0.12), reduced heart failure readmissions (0.07 vs. 0.57 EPPY, HR = 0.15, p = 0.008), and superior readmission-free survival (HR = 0.47, log-rank p = 0.04). Syncopal readmissions occurred exclusively in the F-group (0.20 vs. 0 EPPY, p = 0.01). CONCLUSION Responses to inspiratory-breath-hold predicted hemodynamics and readmission risk. The impact of inspiratory-breath-hold on pulsatility can non-invasively guide hemodynamic management decisions, patient optimization, and readmission risk stratification.
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Affiliation(s)
- Rohan Joshua Krishnaswamy
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Desiree Robson
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Aaron Gunawan
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Anju Ramanayake
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Sumita Barua
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Pankaj Jain
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Audrey Adji
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Peter Simon Macdonald
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Christopher Simon Hayward
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
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Jimba T, Hatano M, Fujiwara T, Akazawa H, Watanabe M, Kinugawa K, Ono M, Komuro I. A case of progressive right ventricular failure with ventricular arrhythmia and aortic insufficiency after implantable left ventricular assist device implantation. J Cardiol Cases 2024; 29:7-10. [PMID: 38188322 PMCID: PMC10770093 DOI: 10.1016/j.jccase.2023.08.017] [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: 03/09/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 01/09/2024] Open
Abstract
Right ventricular failure (RVF) is a serious complication after left ventricular assist device (LVAD) implantation. In this report, a case of RVF that developed over two years after LVAD implantation is presented. The patient was a 12-year-old male with dilated phase of hypertrophic cardiomyopathy. He had no risk factors for early or late-onset RVF. However, his right ventricular function worsened after he developed ventricular arrhythmia (VA), and right ventricular dysfunction became exacerbated with an increasing frequency of VAs. He also developed moderate aortic insufficiency (AI), which became severe. Two years after implantation, he was admitted for treatment of recurrent ventricular tachycardia and became inotropic-dependent during hospitalization. Finally, he underwent successful heart transplantation 2 years and 9 months after LVAD implantation. This case suggests that vicious cycle of RV dysfunction, recurrent VAs and severe AI could lead to RVF in patients without known risk factors for RVF, even long after LVAD implantation. Learning objective This report shows a progressive right ventricular failure (RVF) two years after left ventricular assist device (LVAD) implantation. Although the patient had no known risk factor, vicious circle of RV dysfunction, ventricular arrhythmias (VAs) and aortic insufficiency (AI) lead to RVF. Patients with LVAD as destination therapy will increase and require long-term LVAD management. We should recognize that these patients could develop RVF even years after LVAD implantation in association with VAs and AI.
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Affiliation(s)
- Takahiro Jimba
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Advanced Medical Center for Heart Failure, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayuki Fujiwara
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Akazawa
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Minoru Ono
- Department of Thoracic Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Landra F, Sciaccaluga C, Pastore MC, Gallone G, Barilli M, Fusi C, Focardi M, Cavigli L, D'Ascenzi F, Natali BM, Bernazzali S, Maccherini M, Valente S, Cameli M, Mandoli GE. Right ventricular myocardial work for the prediction of early right heart failure and long-term mortality after left ventricular assist device implant. Eur Heart J Cardiovasc Imaging 2023; 25:105-115. [PMID: 37542478 DOI: 10.1093/ehjci/jead193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 08/07/2023] Open
Abstract
AIMS Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant. METHODS AND RESULTS Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033). CONCLUSION RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.
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Affiliation(s)
- Federico Landra
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Carlotta Sciaccaluga
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Maria Concetta Pastore
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cittá della Salute e della Scienza, Turin, Italy
| | - Maria Barilli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Chiara Fusi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Marta Focardi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Luna Cavigli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Benedetta Maria Natali
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, Siena, Italy
| | | | - Serafina Valente
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
| | - Giulia Elena Mandoli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena 53100, Italy
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Barua S, Conte SM, Cherrett C, Kearney KL, Robson D, Bragg C, Macdonald PS, Muthiah K, Hayward CS. Major adverse kidney events predict reduced survival in ventricular assist device supported patients. ESC Heart Fail 2023; 10:3463-3471. [PMID: 37712126 PMCID: PMC10682875 DOI: 10.1002/ehf2.14533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS There is limited data describing major adverse kidney events (MAKE) in patients supported with ventricular assist devices (VAD). We aim to describe the association between MAKE and survival, risk factors for MAKE, and renal trajectory in VAD supported patients. METHODS AND RESULTS We conducted a single-centre retrospective analysis of consecutive VAD implants between 2010 and 2019. Baseline demographics, biochemistry, and adverse events were collected for the duration of VAD support. MAKE was defined as the first event to occur of sustained drop (>50%) in estimated glomerular filtration rate (eGFR), progression to stage V chronic kidney disease, initiation or continuation of renal replacement therapy beyond implant admission or death on renal replacement therapy at any time. One-hundred and seventy-three patients were included, median age 56.8 years, 18.5% female, INTERMACS profile 1 or 2 in 75.1%. Thirty-seven patients experienced MAKE. On multivariate analysis, post-implant clinical right ventricular failure and the presence of chronic haemolysis, defined by the presence of schistocytes on blood film analysis, were significantly associated with increased risk of MAKE (adjusted odds ratio 9.88, P < 0.001 and adjusted odds ratio 3.33, P = 0.006, respectively). MAKE was associated with reduced survival (hazard ratio 4.80, P < 0.001). Patients who died or experienced MAKE did not demonstrate the expected transient 3-month improvement in eGFR, seen in other cohorts. CONCLUSIONS MAKE significantly impacts survival. In our cohort, MAKE was predicted by post-implant right ventricular failure and chronic haemolysis. The lack of early eGFR improvement on VAD support may indicate higher risk for MAKE.
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Affiliation(s)
- Sumita Barua
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Sean M. Conte
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- School of MedicineUniversity of Notre Dame AustraliaSydneyAustralia
| | - Callum Cherrett
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
| | - Katherine L. Kearney
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Desiree Robson
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
| | | | - Peter S. Macdonald
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Kavitha Muthiah
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Christopher S. Hayward
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Faculty of HealthUniversity of TechnologySydneyAustralia
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Chavali S, Barua S, Adji A, Robson D, Raven LM, Greenfield JR, Eckford H, Macdonald PS, Hayward CS, Muthiah K. Safety and tolerability of sodium-glucose cotransporter-2 inhibitors in bridge-to-transplant patients supported with centrifugal-flow left ventricular assist devices. Int J Cardiol 2023; 391:131259. [PMID: 37574028 DOI: 10.1016/j.ijcard.2023.131259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The safety and tolerability of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with end-stage heart failure supported with left-ventricular-assist-devices (LVADs), irrespective of diabetes mellitus, is not known. METHODS A retrospective analysis of 31 outpatients implanted with LVADs as bridge-to-transplant (BTT) was conducted. Patients with biventricular support, aged under 18 years, who were discharged from the index hospitalisation, or were prescribed SGLT2i prior to their first outpatient clinic were excluded. Patient demographics, laboratory studies, pump haemodynamic and adverse event data was collected. RESULTS Sixteen (51.6%) of 31 patients were prescribed SGLT2i over median 101.5 days (37.5-190.8). No patients discontinued SGLT2i use or reported attributable adverse symptoms. No significant differences between patients prescribed SGLT2i compared to those SGLT2i-naïve were seen in: [1] renal function; [2] weight; [3] mean arterial pressure. There were numerically lower infection-related (n = 4 vs 7, HR 0.32 (0.08-1.28), p = 0.11) and haemocompatibility-related (n = 3 vs 4, HR 0.52 (0.09-2.83), p = 0.45) adverse events in the SGLT2i group, albeit non-significant. CONCLUSIONS We found SGLT2i to be safe and well-tolerated in the BTT LVAD cohort with no significant difference in rates of infection or haemocompatibility-related adverse events with SGLT2i use. Larger studies will inform further beneficial effects of SGLT2i prescription in this cohort.
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Affiliation(s)
- Sanjay Chavali
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Sumita Barua
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Audrey Adji
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | | | - Lisa M Raven
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia
| | - Hunter Eckford
- St Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Peter S Macdonald
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kavitha Muthiah
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia.
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Soriano-Colomé T, Barrabés JA, Gevaert S, Sambola A. Editorial: Management of right ventricular failure: pathophysiology, medical treatment and use of ventricular assist devices. Front Cardiovasc Med 2023; 10:1297652. [PMID: 38028474 PMCID: PMC10666619 DOI: 10.3389/fcvm.2023.1297652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Toni Soriano-Colomé
- Department of Cardiology, University Hospital Vall d'Hebron, University Autonomous of Barcelona, Barcelona, Spain
- Department of Cardiology, Research Institut Vall d’Hebron, Barcelona, Spain
- Department of Cardiology, CIBERCV, Barcelona, Spain
| | - José Antonio Barrabés
- Department of Cardiology, University Hospital Vall d'Hebron, University Autonomous of Barcelona, Barcelona, Spain
- Department of Cardiology, Research Institut Vall d’Hebron, Barcelona, Spain
- Department of Cardiology, CIBERCV, Barcelona, Spain
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Antonia Sambola
- Department of Cardiology, University Hospital Vall d'Hebron, University Autonomous of Barcelona, Barcelona, Spain
- Department of Cardiology, Research Institut Vall d’Hebron, Barcelona, Spain
- Department of Cardiology, CIBERCV, Barcelona, Spain
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Cowger JA, Basir MB, Baran DA, Hayward CS, Rangaswami J, Walton A, Tita C, Minear S, Hakemi E, Klein L, Cheng R, Wu R, Mohanty BD, Heuring JJ, Neely E, Shah P. Safety and Performance of the Aortix Device in Acute Decompensated Heart Failure and Cardiorenal Syndrome. JACC. HEART FAILURE 2023; 11:1565-1575. [PMID: 37804307 DOI: 10.1016/j.jchf.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Cardiorenal syndrome (CRS) complicates 33% of acute decompensated heart failure (ADHF) admissions, and patients with persistent congestion at discharge have high 30-day event rates. OBJECTIVES The purpose of this study was to evaluate a novel catheter-deployed intra-aortic entrainment pump (IAEP) in patients with ADHF with CRS and persistent congestion. METHODS A multicenter (n = 14), nonrandomized, single-arm, safety and feasibility study of IAEP therapy was conducted. Within patient changes (post-pre IAEP therapy) in fluid loss, hemodynamics, patient-reported dyspnea, and serum biomarkers were assessed using Wilcoxon signed-rank testing. RESULTS Of 21 enrolled patients, 18 received Aortix therapy. Mean ± SD patient age was 60.3 ± 7.9 years. The median left ventricular ejection fraction was 22.5% (25th-75th percentile: 10.0%-53.5%); 27.8% had a left ventricular ejection fraction ≥50%. Pre-therapy, patients received 8.7 ± 4.1 days of loop diuretic agents and 44% were on inotropes. Pump therapy averaged 4.6 ± 1.6 days, yielding net fluid losses of 10.7 ± 6.5 L (P < 0.001) and significant (P < 0.01) reductions in central venous pressure (change from baseline: -8.5 mm Hg [25th-75th percentile: -3.5 to -10.0 mm Hg]), pulmonary capillary wedge pressure (-11.0 mm Hg [25th-75th percentile: -5.0 to -14.0 mm Hg]), and serum creatinine (-0.2 mg/dL [25th-75th percentile: -0.1 to -0.5 mg/dL]) with improved estimated glomerular filtration rate (+5.0 mL/min/1.73 m2 [25th-75th percentile: 2.0-9.0 mL/min/1.73 m2]) and patient-reported dyspnea score (+16 [25th-75th percentile: 3-37]). Dyspnea scores, natriuretic peptides, and renal function improvements persisted through 30 days. CONCLUSIONS This pilot study of patients with ADHF, persistent congestion, and worsening renal function due to CRS supports the potential for safely achieving decongestion using IAEP therapy. These initial promising results provide the basis for future randomized clinical trials of this novel pump. (An Evaluation of the Safety and Performance of the Aortix System for Intra-Aortic Mechanical Circulatory Support in Patients with Cardiorenal Syndrome [The Aortix CRS Pilot Study]; NCT04145635).
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Affiliation(s)
- Jennifer A Cowger
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | - Mir B Basir
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | | | - Christopher S Hayward
- St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | | | | | - Cristina Tita
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | | | - Emad Hakemi
- Cleveland Clinic Florida, Weston, Florida, USA
| | - Liviu Klein
- University of California San Francisco, San Francisco, California, USA
| | - Richard Cheng
- University of California San Francisco, San Francisco, California, USA
| | - Robby Wu
- Tampa General Hospital and University of South Florida Heart and Vascular Institute, Tampa, Florida, USA
| | - Bibhu D Mohanty
- Tampa General Hospital and University of South Florida Heart and Vascular Institute, Tampa, Florida, USA
| | | | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
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Kunioka S, Seguchi O, Hada T, Mochizuki H, Shimojima M, Watanabe T, Tsukamoto Y, Tadokoro N, Kainuma S, Fukushima S, Fujita T, Kamiya H, Fukushima N. Successful echocardiography-guided medical management of severe early post-implant right ventricular failure in a patient with left ventricular assist device support: a case report. J Cardiothorac Surg 2023; 18:269. [PMID: 37794433 PMCID: PMC10552193 DOI: 10.1186/s13019-023-02368-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/25/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Post-implant right heart failure (RHF) has been recognized as a crucial prognostic factor in patients receiving left ventricular assist devices (LVADs), and its management has long attracted attention from cardiologists and surgeons. CASE PRESENTATION This report described an 18-year-old female with acutely deteriorating heart failure due to dilated cardiomyopathy who underwent paracorporeal pulsatile-flow LVAD and developed early post-implant RHF. At postoperative day (POD) six, she was almost asymptomatic at rest on 2.5 mg/kg/min of dobutamine; however, the echocardiogram, performed as part of the daily postoperative care, revealed a severely enlarged right ventricle with a decompressed left ventricle, implying the development of post-implant RHF. Bolus infusion of saline and reduction of pump flow (6.0 L/min to 3.0 L/min) led to normalization of both ventricular shapes in 30 s, suggesting that RHF could be managed without surgical interventions. Milrinone was started on POD six, followed by sildenafil administration on POD seven. Fluid balance was strictly adjusted under the close observation of daily echocardiograms. Milrinone and dobutamine were discontinued on PODs 18 and 21, respectively. The patient was listed for a heart transplant on POD 40. Despite reduced right ventricular function (right ventricular stroke work index of 182.34 mmHg*ml/m- 2, body surface area 1.5 m2), she was successfully converted to implantable LVAD on POD 44 with no recurrence of post-implant RHF thereafter for four years. CONCLUSIONS In post-implant RHF management, early detection, together with proper and prompt medical management, is crucial to avoiding any surgical intervention. Close observation of daily echocardiograms might be helpful in detecting subclinical RHF and is useful for post-implant medical management.
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Affiliation(s)
- Shingo Kunioka
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Tasuku Hada
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroki Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masaya Shimojima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoki Tadokoro
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Kainuma
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
- Department of Nursing, Senri Kinran University, Suita, Osaka, 565-0873, Japan.
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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Schurr JW, Sigal I, Usman A, Patel P, Lefebvre B, Kurcik K, Atluri P, Acker M, Bermudez C, Rame JE, Hanff T, Cevasco M, Wald J. Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study. ASAIO J 2023; 69:907-914. [PMID: 37578995 DOI: 10.1097/mat.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.
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Affiliation(s)
- James W Schurr
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Sigal
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prakash Patel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy Kurcik
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Movahedi F, Kanwar MK, Antaki JF. Timelines of adverse event journeys of LVAD patients. Artif Organs 2023; 47:1604-1612. [PMID: 37306077 PMCID: PMC10615676 DOI: 10.1111/aor.14596] [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: 03/08/2023] [Revised: 05/18/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The INTERMACS Events data set contains an expansive collection of temporal evidence of the course of adverse events (AEs) of >15 000 patients that have received a left ventricular assist device (LVAD). The chronology of AEs may contain insightful information of the "AE journeys" of LVAD patients. The purpose of this study is to investigate the timelines of AEs within the INTERMACS database. METHODS Descriptive statistics were applied to 86 912 recorded AEs of 15 820 patients with a continuous flow-LVAD between 2008 to 2016, extracted from INTERMACS registry. The characteristics of the timelines of AE journeys were investigated by posing six descriptive research questions. RESULTS The analysis revealed several time-related characteristics and patterns of the AE journey after LVAD including the most common time of occurrences of AEs after surgery, duration of AEs journeys, the time of first and last AEs, and the time gaps between AEs. CONCLUSION The INTERMACS Event dataset is a valuable resource for research about the timeline of AE journeys of patients who received an LVAD. It is necessary for future studies to first explore and consider the time-related characteristics of the data set such as diversity and sparsity to effectively choose an appropriate scope of time and time granularity and to acknowledge potential challenges.
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Affiliation(s)
- Faezeh Movahedi
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Manreet K Kanwar
- Department of Medicine, Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY
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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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46
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Francica A, Loforte A, Attisani M, Maiani M, Iacovoni A, Nisi T, Comisso M, Terzi A, De Bonis M, Vendramin I, Boffini M, Musumeci F, Luciani GB, Rinaldi M, Pacini D, Onorati F. Five-Year Outcome After Continuous Flow LVAD With Full-Magnetic (HeartMate 3) Versus Hybrid Levitation System (HeartWare): A Propensity-Score Matched Study From an All-Comers Multicentre Registry. Transpl Int 2023; 36:11675. [PMID: 37727385 PMCID: PMC10505657 DOI: 10.3389/ti.2023.11675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/08/2023] [Indexed: 09/21/2023]
Abstract
Despite the withdrawal of the HeartWare Ventricular Assist Device (HVAD), hundreds of patients are still supported with this continuous-flow pump, and the long-term management of these patients is still under debate. This study aims to analyse 5 years survival and freedom from major adverse events in patients supported by HVAD and HeartMate3 (HM3). From 2010 to 2022, the MIRAMACS Italian Registry enrolled all-comer patients receiving a LVAD support at seven Cardiac Surgery Centres. Out of 447 LVAD implantation, 214 (47.9%) received HM3 and 233 (52.1%) received HVAD. Cox-regression analysis adjusted for major confounders showed an increased risk for mortality (HR 1.5 [1.2-1.9]; p = 0.031), for both ischemic stroke (HR 2.08 [1.06-4.08]; p = 0.033) and haemorrhagic stroke (HR 2.6 [1.3-4.9]; p = 0.005), and for pump thrombosis (HR 25.7 [3.5-188.9]; p < 0.001) in HVAD patients. The propensity-score matching analysis (130 pairs of HVAD vs. HM3) confirmed a significantly lower 5 years survival (81.25% vs. 64.1%; p 0.02), freedom from haemorrhagic stroke (90.5% vs. 70.1%; p < 0.001) and from pump thrombosis (98.5% vs. 74.7%; p < 0.001) in HVAD cohort. Although similar perioperative outcome, patients implanted with HVAD developed a higher risk for mortality, haemorrhagic stroke and thrombosis during 5 years of follow-up compared to HM3 patients.
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Affiliation(s)
| | - Antonio Loforte
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
- City of Health and Science Hospital, Cardiac Surgery University Unit, University of Turin, Turin, Italy
| | - Matteo Attisani
- City of Health and Science Hospital, Cardiac Surgery University Unit, University of Turin, Turin, Italy
| | - Massimo Maiani
- Division of Cardiac Surgery, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Attilio Iacovoni
- Division of Cardiac Surgery, Papa Giovanni XXII Hospital of Bergamo, Bergamo, Italy
| | - Teodora Nisi
- Division of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Marina Comisso
- Division of Cardiac Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Amedeo Terzi
- Division of Cardiac Surgery, Papa Giovanni XXII Hospital of Bergamo, Bergamo, Italy
| | - Michele De Bonis
- Division of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Igor Vendramin
- Division of Cardiac Surgery, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Massimo Boffini
- City of Health and Science Hospital, Cardiac Surgery University Unit, University of Turin, Turin, Italy
| | - Francesco Musumeci
- Division of Cardiac Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Mauro Rinaldi
- City of Health and Science Hospital, Cardiac Surgery University Unit, University of Turin, Turin, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University Hospital of Verona, Verona, Italy
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47
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Oehler D, Oehler H, Sigetti D, Immohr MB, Böttger C, Bruno RR, Haschemi J, Aubin H, Horn P, Westenfeld R, Bönner F, Akhyari P, Kelm M, Lichtenberg A, Boeken U. Early Postoperative Neurologic Events Are Associated With Worse Outcome and Fatal Midterm Survival After Adult Heart Transplantation. J Am Heart Assoc 2023; 12:e029957. [PMID: 37548172 PMCID: PMC10492937 DOI: 10.1161/jaha.123.029957] [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: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023]
Abstract
Background Neurologic events during primary stay in heart transplant (HTx) recipients may be associated with reduced outcome and survival, which we aim to explore with the current study. Methods and Results We screened and included all patients undergoing HTx in our center between September 2010 and December 2022 (n=268) and checked for the occurrence of neurologic events within their index stay. Neurologic events were defined as ischemic stroke, hemorrhage, hypoxic ischemic injury, or acute symptomatic neurologic dysfunction without central nervous system injury. The cohort was then divided into recipients with (n=33) and without (n=235) neurologic events after HTx. Using a multivariable Cox regression model, the association of neurologic events after HTx and survival was assessed. Recipients with neurologic events displayed a longer intensive care unit stay (30 versus 16 days; P=0.009), longer mechanical ventilation (192 versus 48 hours; P<0.001), and higher need for blood transfusion, and need for hemodialysis after HTx was substantially higher (81% versus 55%; P=0.01). Resternotomy (36% versus 26%; P=0.05) and mechanical life support (extracorporeal life support) after HTx (46% versus 24%; P=0.02) were also significantly higher in patients with neurologic events. Covariable-adjusted multivariable Cox regression analysis revealed a significant independent association of neurologic events and increased 30-day (hazard ratio [HR], 2.5 [95% CI, 1.0-6.0]; P=0.049), 1-year (HR, 2.2 [95% CI, 1.1-4.3]; P=0.019), and overall (HR, 2.5 [95% CI, 1.5-4.2]; P<0.001) mortality after HTx and reduced Kaplan-Meier survival up to 5 years after HTx (P<0.001). Conclusions Neurologic events after HTx were strongly and independently associated with worse postoperative outcome and reduced survival up to 5 years after HTx.
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Affiliation(s)
- Daniel Oehler
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hannah Oehler
- Department of NeurologyHeidelberg UniversityHeidelbergGermany
| | - Dennis Sigetti
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | | | - Charlotte Böttger
- Department of Diagnostic and Interventional RadiologyHeinrich‐Heine UniversityDuesseldorfGermany
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Jafer Haschemi
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hug Aubin
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Patrick Horn
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Florian Bönner
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Payam Akhyari
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular MedicineHeinrich‐Heine UniversityDuesseldorfGermany
- CARID, Cardiovascular Research Institute DüsseldorfMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Artur Lichtenberg
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
| | - Udo Boeken
- Department of Cardiac SurgeryHeinrich‐Heine UniversityDuesseldorfGermany
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48
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Rajapreyar I, Soliman O, Brailovsky Y, Tedford RJ, Gibson G, Mohacsi P, Hajduczok AG, Tchantchaleishvili V, Wieselthaler G, Rame JE, Caliskan K. Late Right Heart Failure After Left Ventricular Assist Device Implantation: Contemporary Insights and Future Perspectives. JACC. HEART FAILURE 2023; 11:865-878. [PMID: 37269258 DOI: 10.1016/j.jchf.2023.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.
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Affiliation(s)
- Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Osama Soliman
- Discipline of Cardiology, University Hospital Galway, School of Medicine, University of Galway, Ireland
| | - Yevgeniy Brailovsky
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory Gibson
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul Mohacsi
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander G Hajduczok
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georg Wieselthaler
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco, California, USA
| | - J Eduardo Rame
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus Medical Center University Medical Center, Rotterdam, the Netherlands
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49
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Van Edom CJ, Gramegna M, Baldetti L, Beneduce A, Castelein T, Dauwe D, Frederiks P, Giustino G, Jacquemin M, Janssens SP, Panoulas VF, Pöss J, Rosenberg A, Schaubroeck HAI, Schrage B, Tavazzi G, Vanassche T, Vercaemst L, Vlasselaers D, Vranckx P, Belohlavek J, Gorog DA, Huber K, Mebazaa A, Meyns B, Pappalardo F, Scandroglio AM, Stone GW, Westermann D, Chieffo A, Price S, Vandenbriele C. Management of Bleeding and Hemolysis During Percutaneous Microaxial Flow Pump Support: A Practical Approach. JACC Cardiovasc Interv 2023; 16:1707-1720. [PMID: 37495347 DOI: 10.1016/j.jcin.2023.05.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 07/28/2023]
Abstract
Percutaneous ventricular assist devices (pVADs) are increasingly being used because of improved experience and availability. The Impella (Abiomed), a percutaneous microaxial, continuous-flow, short-term ventricular assist device, requires meticulous postimplantation management to avoid the 2 most frequent complications, namely, bleeding and hemolysis. A standardized approach to the prevention, detection, and treatment of these complications is mandatory to improve outcomes. The risk for hemolysis is mostly influenced by pump instability, resulting from patient- or device-related factors. Upfront echocardiographic assessment, frequent monitoring, and prompt intervention are essential. The precarious hemostatic balance during pVAD support results from the combination of a procoagulant state, due to critical illness and contact pathway activation, together with a variety of factors aggravating bleeding risk. Preventive strategies and appropriate management, adapted to the impact of the bleeding, are crucial. This review offers a guide to physicians to tackle these device-related complications in this critically ill pVAD-supported patient population.
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Affiliation(s)
- Charlotte J Van Edom
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Mario Gramegna
- Cardiac and Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Baldetti
- Cardiac and Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Dieter Dauwe
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pascal Frederiks
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Gennaro Giustino
- Department of Cardiology, The Zena & Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, New York
| | - Marc Jacquemin
- Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Stefan P Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Vasileios F Panoulas
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Janine Pöss
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Alexander Rosenberg
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Benedikt Schrage
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Guido Tavazzi
- Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo IRCCS, Pavia, Italy
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Leen Vercaemst
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Vlasselaers
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Hasselt, Belgium
| | - Jan Belohlavek
- Second Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Kurt Huber
- Departments of Cardiology and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University, Medical School, Vienna, Austria
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, Paris, France
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, Azienda Ospedaliera Nazionale Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Anna M Scandroglio
- Cardiac and Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gregg W Stone
- Department of Cardiology, The Zena & Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, New York
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Susanna Price
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
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50
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Numan L, Schramm R, Oerlemans MIFJ, van der Kaaij NP, Aarts E, Ramjankhan FZ, Oppelaar AM, Morshuis M, Guenther SPW, Zimpfer D, Riebandt J, Wiedemann D, Asselbergs FW, Van Laake LW. Survival after HeartMate 3 left ventricular assist device implantation: real-world data from Europe. ESC Heart Fail 2023. [PMID: 37394283 PMCID: PMC10375103 DOI: 10.1002/ehf2.14444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/28/2023] [Accepted: 06/08/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Lieke Numan
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rene Schramm
- Clinic for Thoracic- and Cardiovascular Surgery, Heart and Diabetes Center Northrhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Marish I F J Oerlemans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Emmeke Aarts
- Department of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands
| | - Faiz Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Anne-Marie Oppelaar
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Michiel Morshuis
- Clinic for Thoracic- and Cardiovascular Surgery, Heart and Diabetes Center Northrhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Sabina P W Guenther
- Clinic for Thoracic- and Cardiovascular Surgery, Heart and Diabetes Center Northrhine Westfalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Faculty of Population Health Sciences, Institute of Cardiovascular Science, University College London, London, UK
- Health Data Research UK and Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Linda W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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