Implantation of Left Ventricular Assist Device Results in Immediate Improvement of Glucose Metabolism in Patients With and Without Diabetes Mellitus

Impact of Diabetes and Glycemia on Cardiac Improvement and Adverse Events Following Mechanical Circulatory Support

BACKGROUND

Type 2 diabetes is prevalent in cardiovascular disease and contributes to excess morbidity and mortality. We sought to investigate the effect of glycemia on functional cardiac improvement, morbidity, and mortality in durable left ventricular assist device (LVAD) recipients.

METHODS AND RESULTS

Consecutive patients with an LVAD were prospectively evaluated (n=531). After excluding patients missing pre-LVAD glycated hemoglobin (HbA1c) measurements or having inadequate post-LVAD follow-up, 375 patients were studied. To assess functional cardiac improvement, we used absolute left ventricular ejection fraction change (ΔLVEF: LVEF post-LVAD-LVEF pre-LVAD). We quantified the association of pre-LVAD HbA1c with ΔLVEF as the primary outcome, and all-cause mortality and LVAD-related adverse event rates (ischemic stroke/transient ischemic attack, intracerebral hemorrhage, gastrointestinal bleeding, LVAD-related infection, device thrombosis) as secondary outcomes. Last, we assessed HbA1c differences pre- and post-LVAD. Patients with type 2 diabetes were older, more likely men suffering ischemic cardiomyopathy, and had longer heart failure duration. Pre-LVAD HbA1c was inversely associated with ΔLVEF in patients with nonischemic cardiomyopathy but not in those with ischemic cardiomyopathy, after adjusting for age, sex, heart failure duration, and left ventricular end-diastolic diameter. Pre-LVAD HbA1c was not associated with all-cause mortality, but higher pre-LVAD HbA1c was shown to increase the risk of intracerebral hemorrhage, LVAD-related infection, and device thrombosis by 3 years on LVAD support (P<0.05 for all). HbA1c decreased from 6.68±1.52% pre-LVAD to 6.11±1.33% post-LVAD (P<0.001).

CONCLUSIONS

Type 2 diabetes and pre-LVAD glycemia modify the potential for functional cardiac improvement and the risk for adverse events on LVAD support. The degree and duration of pre-LVAD glycemic control optimization to favorably affect these outcomes warrants further investigation.

Propensity matched post-transplant survival in durable CF-axial pump BTT patients with and without diabetes: A UNOS database analysis

Diabetes and post-transplant survival have been linked. However, the impact on post-transplant survival of patients supported on Continuous Flow (CF) axial left ventricular assist devices (LVAD) as a bridge to transplant (BTT) with diabetes has not been widely studied. This study attempts to assess the impact of diabetes type II (DM type II) as a comorbidity influencing survival patterns in the post-cardiac transplant population supported on LVADs and to test if the presence of a pre- transplant durable LVAD acts as an independent risk factor in long-term post-transplant survival. The UNOS database population from 2004 to 2015 was used to construct the cohorts. A total of 21,032 were transplanted during this period. The transplant data were further queried to extract CF-axial flow pumps BTT (HMII-BTT) patients and patients who did not have VAD support before the transplant. A total of 4224 transplant recipients had HMII at the time of transplant, and 13,131 did not have VAD support. Propensity analysis was performed, and 4107 recipients of similar patient characteristics to those in the BTT group were selected for comparison. The patients with a VAD had significantly reduced survival at 2 years post-transplant (p = 0.00514) but this trend did not persist at 5 years (p = 0.0617) and 10 years post-transplant (p = 0.183). Patients with diabetes and a VAD significantly decreased survival at 2 years (p = 0.00204), 5 years (p = 0.00029), and 10 years (p = 0.00193). The presence of a durable LVAD is not an independent risk factor for long-term survival. Diabetes has a longstanding effect on the posttransplant survival of BTT patients.

Effect of Diabetes Mellitus on Outcomes in Patients With Left Ventricular Assist Device - Analysis of Data From a Japanese National Database

BACKGROUND

The objective of this study is to investigate the effect of preoperative diabetes on all-cause mortality and major postoperative complications among patients with continuous-flow left ventricular assist device (LVAD) by using data from a national database.Methods and Results: The 545 study patients who underwent primary HeartMateII implantation between 2013 and 2019 were divided into 2 groups according to their diabetes mellitus (DM) status; patients with DM (n=116) and patients without DM (n=429). First, the on-device survival and incidence of adverse events were evaluated. Second, after adjusting for patients' backgrounds, the change of laboratory data in the 2 groups were compared. Overall, on-device survival at 1, 2, and 3 years was almost equivalent between the 2 groups; it was 95%, 94%, and 91% in patients without DM, and 93%, 91%m and 91% in patients with DM (P=0.468) The incidence of adverse events was similar between 2 groups of patients, except for driveline exit site infection in the adjusted cohort. Cox proportional hazards regression analysis revealed younger age (HR: 0.98 (95% confidence interval (CI): 0.97-0.99, P=0.001) and presence of DM (HR: 1.83 (95% CI: 1.14-2.88), P=0.016) as significant predictors of driveline infection. Laboratory findings revealed no differences between groups throughout the periods.

CONCLUSIONS

The clinical results after LVAD implantation in DM patients were comparable with those in non-DM patients, except for the driveline exit site infection.

Insulin Receptors and Insulin Action in the Heart: The Effects of Left Ventricular Assist Devices

This year, 2022, marks the 100th anniversary of the isolation of human insulin and its administration to patients suffering from diabetes mellitus (DM). Insulin exerts many effects on the human body, including the cardiac tissue. The pathways implicated include the PKB/Akt signaling pathway, the Janus kinase, and the mitogen-activated protein kinase pathway and lead to normal cardiac growth, vascular smooth muscle regulation, and cardiac contractility. This review aims to summarize the existing knowledge and provide new insights on insulin pathways of cardiac tissue, along with the role of left ventricular assist devices on insulin regulation and cardiac function.

The impact of diabetes on short-, intermediate- and long-term mortality following left ventricular assist device implantation

OBJECTIVES

Type 2 diabetes mellitus (DM) is a frequent comorbidity among patients suffering from advanced heart failure necessitating a left ventricular assist device (LVAD) implant. The goal of this study was to evaluate the impact of type 2 DM on early and long-term outcomes of patients following an LVAD implant.

METHODS

We performed an observational cohort study in a large tertiary care centre in Israel. All data of patients who underwent a continuous flow LVAD implant between 2006 and 2020 were extracted from our departmental database. Patients were divided into 2 groups: group I (patients without diabetes) and group II (patients with diabetes). We compared short-term (30-day and 3-month) mortality, intermediate-term (1- and 3-year) mortality and long-term (5 year) mortality between the 2 groups.

RESULTS

The study population included 154 patients. Group I (patients without diabetes) comprised 88 patients and group II (patients with diabetes) comprised 66 patients. The mean follow-up duration was 38.2 ± 30.3 months. Short- and intermediate-term mortality (30 days, 1 year and 3 years) was higher in the group with DM compared with the group without DM but did not reach any statistically significant difference: 16.1% vs 9.8% (P = 0.312), 24.2% vs 17.3% (P = 0.399) and 30.6% vs 21.9% (P = 0.127) respectively. Long-term 5-year mortality was significantly higher in the group with DM compared to the group without: 38.7% vs 24.4% (P = 0.038). Furthermore, predictors of long-term mortality included diabetes (hazard ratio 2.09, confidence interval 1.34-2.84, P = 0.004), as demonstrated by regression analysis.

CONCLUSIONS

Patients with diabetes and those without diabetes have similar 30-day and short- and intermediate-term mortality rates. The mortality risk of diabetic patients begins to increase 3 years after an LVAD implant. Diabetes is an independent predictor of long-term, 5-year mortality after an LVAD implant.

CLINICAL TRIAL REGISTRATION

Ethical Committee of Sheba Medical Centre, Israel, on 2 December 2014, Protocol 4257.

HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge

The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.

Are the current evaluation tools for advanced therapies biased?

PURPOSE OF REVIEW

Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear.

RECENT FINDINGS

As documented in other settings, racial bias appears to operate in HF providers' consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias.

SUMMARY

Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.

Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.