1
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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:S1053-2498(24)01679-6. [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] [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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Idrovo A, Hollander SA, Neumayr TM, Bell C, Munoz G, Choudhry S, Price J, Adachi I, Srivaths P, Sutherland S, Akcan-Arikan A. Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients. Pediatr Nephrol 2024; 39:1289-1300. [PMID: 37971519 DOI: 10.1007/s00467-023-06190-8] [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: 05/26/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown. METHODS We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6-12 months of CF-VAD support. RESULTS We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD. CONCLUSIONS In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.
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Affiliation(s)
- Alexandra Idrovo
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA.
- Renal Section, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
- Division of Nephrology, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Genevieve Munoz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Swati Choudhry
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Jack Price
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
| | - Scott Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ayse Akcan-Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
- Department of Pediatrics Critical Care Section, Baylor College of Medicine, Texas Children's, Houston, TX, USA
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3
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Roehm B, Agdamag AC. eGFR Trajectory in LVAD Recipients with Right Heart Failure: Status Quo or a Steady Decline? J Am Heart Assoc 2024; 13:e033925. [PMID: 38420779 PMCID: PMC10944075 DOI: 10.1161/jaha.124.033925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Bethany Roehm
- Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasTX
| | - Arianne C. Agdamag
- Department of Cardiovascular MedicineCleveland Clinic FoundationClevelandOH
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Bhardwaj A, Pirlamarla P, Brailovsky Y, Nair A, Rajapreyar I. Combined Heart Kidney Transplantation Versus Heart Transplant in Patients with Renal Failure: Contemporary Insights and Future Perspectives. Curr Cardiol Rep 2024; 26:83-90. [PMID: 38294626 DOI: 10.1007/s11886-023-02017-y] [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] [Accepted: 12/22/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW In this review, we aim to outline the criteria regarding the evaluation of patients with chronic renal disease (CKD) awaiting heart transplantation and discuss the outcomes of combined heart/kidney transplantation. Herein, we also review pathophysiology and risk factors that predispose to chronic kidney disease (CKD) and acute kidney injury (AKI) in patients with HF and after OHT. RECENT FINDINGS In patients with end-stage systolic heart failure (HF) and an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, orthotopic heart transplantation (OHT) alone is a relative contraindication, with a consensus that these patients are better served with heart-kidney transplant (HKT). However, there is significant variation between institutions regarding timing and indication for heart/kidney transplantation, with little data available to predict post-transplant outcomes. A Scientific Statement from American Heart Association was published detailing the indications, evaluation, and outcomes for Heart-Kidney Transplantation, and noted a steady rise in the incidence of heart/kidney dual organ transplants. Recently, the Organ Procurement and Transplantation Network (OPTN) Multi-Organ Transplantation Committee implemented a safety net policy for heart transplant recipients who do need meet criteria for simultaneous heart-kidney transplant in 2023 but with a likely need for sequential kidney transplantation. Optimization of organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection. This review also outlines the criteria regarding the evaluation of patients with CKD awaiting heart transplantation and outcomes of combined HKT.
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Affiliation(s)
- Anju Bhardwaj
- Texas Medical Center, University of Texas/McGoven Medical School, Houston, TX, USA
| | - Preethi Pirlamarla
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA.
| | | | - Ajith Nair
- Baylor College of Medicine, Texas Heart Institute, Dallas, TX, USA
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5
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Antonopoulos M, Bonios MJ, Dimopoulos S, Leontiadis E, Gouziouta A, Kogerakis N, Koliopoulou A, Elaiopoulos D, Vlahodimitris I, Chronaki M, Chamogeorgakis T, Drakos SG, Adamopoulos S. Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices. J Cardiovasc Dev Dis 2024; 11:61. [PMID: 38392275 PMCID: PMC10888700 DOI: 10.3390/jcdd11020061] [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: 01/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
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Affiliation(s)
- Michael Antonopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Michael J Bonios
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Evangelos Leontiadis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Aggeliki Gouziouta
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Nektarios Kogerakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ioannis Vlahodimitris
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Maria Chronaki
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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daSilva-deAbreu A, Faaborg-Andersen C, Joury A, Tutor A, Desai S, Eiswirth C, Krim SR, Wever-Pinzon J, Lavie CJ, Ventura HO. Outcomes of Patients With Left Ventricular Assist Devices Requiring Intermittent Hemodialysis: Single-Center Cohort, Systematic Review, and Individual-Participant Data Meta-Analysis. Curr Probl Cardiol 2024; 49:102090. [PMID: 37734691 DOI: 10.1016/j.cpcardiol.2023.102090] [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: 09/10/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
Patients with left ventricular assist devices (LVADs) who require intermittent hemodialysis (iHD) are considered to have a poor prognosis despite a paucity of supportive evidence, mostly from small single-center cohorts and extrapolations from studies of patients who received continuous renal replacement therapy but no iHD. We conducted a systematic review and individual-participant-data meta-analysis of the literature including our single-center cohort to examine the outcomes of patients initiated on iHD following LVAD implantation. Sixty-four patients from 5 cohorts met selection criteria (age 57.5 [46-64.5] years, 87% HeartMate II, mostly bridge to transplantation). Follow-up after iHD initiation was 87.5 (38.5-269.5) days, although it was considerably longer in our center than in other cohorts (601.5 [93-1559] days vs 65 [26-180] days, P = 0.0007). The estimated median survival was 308 (76-912.5) days and varied significantly among cohorts, ranging from 60 (57-65) to 838 (103-1872) days (P = 0.0096). Twelve (18.8%) patients achieved either heart transplantation (HT) or remission during follow-up. Patients who received HT had an 8-fold longer estimated median survival (1972 [799-1972] days vs 244 [64-838] days, P = 0.0112). Being from a more recent cohort was associated with better 1-year survival. Renal recovery occurred in eight patients (13.1%) at 30 days and its cumulative incidence increased to 73% (27/37 patients with available data) at 1 year. Most patients initiated on iHD after LVAD experienced renal recovery within the first year after implantation. Improved survival was observed for patients who received HT and in those from more recent cohorts. Some patients were able to survive on LVAD and iHD support for several years.
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Affiliation(s)
| | | | - Abdulaziz Joury
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC, Canada; King Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Austin Tutor
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Sapna Desai
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
| | - Clement Eiswirth
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
| | - Selim R Krim
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
| | - James Wever-Pinzon
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
| | - Hector O Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA
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7
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Roehm B, Hedayati SS, Vest AR, Gulati G, Tighiouart H, Weiner DE, Inker LA. Postoperative Acute Kidney Injury Requiring Dialysis and Glomerular Filtration Rate at Follow-up in Patients With Left Ventricular Assist Device. Am J Kidney Dis 2024; 83:119-122. [PMID: 37516300 DOI: 10.1053/j.ajkd.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/11/2023] [Accepted: 04/22/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Bethany Roehm
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - S Susan Hedayati
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amanda R Vest
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Gaurav Gulati
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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8
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Suzuki T, Sugiura R. Improvement of persistent anuria in severe myocardial infarction: the potential role of Impella 5.5 as a bridge to decision. BMJ Case Rep 2023; 16:e255462. [PMID: 38129092 DOI: 10.1136/bcr-2023-255462] [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] [Indexed: 12/23/2023] Open
Abstract
A man in his 40s with ST-segment elevation myocardial infarction complicating cardiogenic shock was transferred to our hospital. Emergent percutaneous coronary intervention for the left anterior descending and left circumflex arteries supported with Impella CP was performed. However, his cardiac function was severely impaired, and anuria developed, necessitating continuous renal replacement therapy (CRRT). After Impella CP was removed on day 6, the patient remained dependent on inotropes and CRRT. Following volume reduction to manage pulmonary congestion, symptoms of low perfusion appeared. Then, Impella 5.5 was inserted on day 38 as a bridge to decision. On day 52, the urine volume reached >2000 mL/day, and CRRT was discontinued. On day 56, the patient was transferred to a certified facility for left ventricular assist device implantation or heart transplantation. This case suggests the potential of Impella 5.5 as a bridge to decision in patients with organ failure caused by low cardiac output.
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Affiliation(s)
- Toshiaki Suzuki
- Cardiovascular Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Ryo Sugiura
- Cardiovascular Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
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9
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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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10
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Cordero-Cabán K, Ssembajjwe B, Patel J, Abramov D. How to select a patient for LVAD. Indian J Thorac Cardiovasc Surg 2023; 39:8-17. [PMID: 37525705 PMCID: PMC10386996 DOI: 10.1007/s12055-022-01428-w] [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: 06/09/2022] [Revised: 08/19/2022] [Accepted: 10/10/2022] [Indexed: 12/16/2022] Open
Abstract
Left ventricular assist device (LVAD) implantation leads to improvement in symptoms and survival in patients with advanced heart failure. An important factor in improving outcomes post-LVAD implantation is optimal preoperative patient selection and optimization. In this review, we highlight the latest on the evaluation of patients with advanced heart failure for LVAD candidacy, including discussion of patient selection, implantation timing, laboratory and other testing considerations, and the importance of psychosocial evaluation. Such thorough evaluation by multidisciplinary team can serve to improve the outcomes of a complex group of patients with advanced heart failure being evaluated for LVAD.
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Affiliation(s)
- Kathia Cordero-Cabán
- Internal Medicine Department, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354 USA
| | - Brian Ssembajjwe
- Internal Medicine Department, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354 USA
| | - Jay Patel
- Division of Cardiology, Loma Linda Veterans Administration Healthcare System, Loma Linda, CA USA
| | - Dmitry Abramov
- Cardiology Department, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354 USA
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11
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Haddad O, Sareyyupoglu B, Goswami RM, Bitargil M, Patel PC, Jacob S, El-Sayed Ahmed MM, Leoni Moreno JC, Yip DS, Landolfo K, Pham SM. Short-term outcomes of heart transplant patients bridged with Impella 5.5 ventricular assist device. ESC Heart Fail 2023. [PMID: 37137732 PMCID: PMC10375168 DOI: 10.1002/ehf2.14391] [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: 05/03/2022] [Revised: 01/15/2023] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
AIMS We sought to investigate the outcomes of heart transplant patients supported with Impella 5.5 temporary mechanical circulatory support. METHODS AND RESULTS Patient demographics, perioperative data, hospital timeline, and haemodynamic parameters were followed during initial admission, Impella support, and post-transplant period. Vasoactive-inotropic score, primary graft failure, and complications were recorded. Between March 2020 and March 2021, 16 advanced heart failure patients underwent Impella 5.5 temporary left ventricular assist device support through axillary approach. Subsequently, all these patients had heart transplantation. All patients were either ambulatory or chair bound during their temporary mechanical circulatory support until heart transplantation. Patients were kept on Impella support median of 19 days (3-31) with the median lactate dehydrogenase level of 220 (149-430). All Impella devices were removed during heart transplantation. During Impella support, patients had improved renal function with median creatinine serum level of 1.55 mg/dL decreased to 1.25 (P = 0.007), pulmonary artery pulsatility index scores increased from 2.56 (0.86-10) to 4.2 (1.3-10) (P = 0.048), and right ventricular function improved (P = 0.003). Patients maintained improved renal function and favourable haemodynamics after their heart transplantation as well. All patients survived without any significant morbidity after their heart transplantation. CONCLUSIONS Impella 5.5 temporary left ventricular assist device optimizes care of heart transplant recipients providing superior haemodynamic support, mobility, improved renal function, pulmonary haemodynamics, and right ventricular function. Utilizing Impella 5.5 as a direct bridging strategy to heart transplantation resulted in excellent outcomes.
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Affiliation(s)
- Osama Haddad
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Rohan M Goswami
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Macit Bitargil
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Parag C Patel
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Magdy M El-Sayed Ahmed
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | | | - Daniel S Yip
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
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12
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Zhang YQ, Liu XG, Ding Q, Berguson M, Morris RJ, Liu H, Goldhammer JE. Perioperative Renin-Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery: A Propensity-Adjusted Cohort Study. Ann Surg 2023; 277:e948-e954. [PMID: 35166263 DOI: 10.1097/sla.0000000000005408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to study the association of perioperative administration of renin angiotensin system inhibitors (RASi) and clinical outcomes of patients with heart failure (HF) undergoing cardiac surgery. SUMMARY BACKGROUND DATA It is controversial whether the perioperative RASi should be administered in HF patients undergoing cardiac surgery. METHODS A total of 2338 patients with HF and undergoing CABG and/or valve surgeries at multiple hospitals from 2001 to 2015 were identified from STS database. After adjustment using propensity score and instrumental variable, logistic regression was conducted to analyze the influence of preoperative continuation of RASi (PreRASi) on short-term in-hospital outcomes. Independent risk factors of 30-day mortality, major adverse cardiovascular events (MACE), and renal failure were analyzed by use of stepwise logistic regression. The effects of pre- and postoperative use of RASi (PostRASi) on long-term mortality were analyzed using survival analyses. Stepwise Cox regression was conducted to analyze the independent risk factors of 6-year mortality. The relationships of HF status and surgery type with perioperative RASi, as well as PreRASi-PostRASi, were also evaluated by subgroup analyses. RESULTS PreRASi was associated with lower incidences of 30-day mortality [ P < 0.0001, odds ratio (OR): 0.556, 95% confidence interval (CI) 0.405-0.763], stroke ( P =0.035, OR: 0.585, 95% CI: 0.355-0.962), renal failure ( P =0.007, OR: 0.663, 95% CI: 0.493-0.894). Both PreRASi ( P =0.0137) and PostRASi ( P =0.007) reduced 6-year mortality compared with the No-RASi groups. CONCLUSIONS Pre- and postoperative use of RASi was associated with better outcomes for the patients who have HF and undergo CABG and/or valve surgeries. Preoperative continuation and postoperative restoration are warranted in these patients.
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Affiliation(s)
- Yan-Qing Zhang
- Department of Anesthesiology, School of Anesthesiology, The First Hospital, Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Xiao-Gang Liu
- The Key Laboratory of Biomedical information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qian Ding
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Mark Berguson
- Department of Anesthesiology, Lankenau Medical Center, Wynnewood, PA
| | - Rohinton J Morris
- Division of Cardiothoracic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hong Liu
- Department of Anesthesiology, University of California Davis Medical Center, Sacramento, CA
| | - Jordan E Goldhammer
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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13
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Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review. Curr Probl Cardiol 2023; 48:101509. [PMID: 36402213 DOI: 10.1016/j.cpcardiol.2022.101509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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14
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Roehm B, Hedayati S, Vest AR, Gulati G, Miao J, Tighiouart H, Weiner DE, Inker LA. Long-Term Changes in Estimated Glomerular Filtration Rate in Left Ventricular Assist Device Recipients: A Longitudinal Joint Model Analysis. J Am Heart Assoc 2023; 12:e025993. [PMID: 36734339 PMCID: PMC9973635 DOI: 10.1161/jaha.122.025993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/28/2022] [Indexed: 02/04/2023]
Abstract
Background Advanced kidney disease is often a relative contraindication to left ventricular assist device (LVAD) implantation because of concerns for poor outcomes including worsening kidney disease. Data are lacking on long-term changes and sex-based differences in estimated glomerular filtration rate (eGFR), with published data limited by potential bias introduced by the competing risks of death and heart transplantation. Methods and Results We conducted a longitudinal analysis of 288 adults receiving durable continuous-flow LVADs from January 2010 to December 2017 at a single center. A joint model was constructed to evaluate change in eGFR over 2 years, the prespecified primary outcome, adjusted for the competing risks of death and heart transplantation. Median baseline eGFR was 60 mL/min per 1.73 m2 (interquartile range 42-78). At 2 years, 74 patients died and 104 received a heart transplant. In unadjusted analysis, LVAD recipients had a modest initial increase in eGFR of ≈2 mL/min per 1.73 m2 within the first 6 months after implantation, followed by a decrease in eGFR below baseline values at 1 and 2 years. Men experienced an eGFR decline of 5 to 10 mL/min per 1.73 m2 over the first year which then stabilized, while women had an ≈5 mL/min per 1.73 m2 increase in eGFR within the first 6 months followed by decline towards baseline eGFR levels (interaction P=0.005). Conclusions Estimated GFR remains relatively stable in most patients following LVAD implantation. Larger studies are needed to investigate sex-based differences in eGFR and to evaluate eGFR trajectory and mortality in LVAD recipients with lower eGFR.
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Affiliation(s)
- Bethany Roehm
- Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasTX
| | - Susan Hedayati
- Division of NephrologyUniversity of Texas Southwestern Medical CenterDallasTX
| | | | | | | | - Hocine Tighiouart
- Tufts Medical CenterInstitute for Clinical Research and Health Policy StudiesBostonMA
- Tufts University, Tufts Clinical and Translational Science InstituteBostonMA
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15
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Walther CP, Benoit JS, Lamba HK, Civitello AB, Erickson KF, Mondal NK, Liao KK, Navaneethan SD. Distinctive kidney function trajectories following left ventricular assist device implantation. J Heart Lung Transplant 2022; 41:1798-1807. [PMID: 36182652 PMCID: PMC10091513 DOI: 10.1016/j.healun.2022.08.024] [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: 09/27/2021] [Revised: 05/04/2022] [Accepted: 08/31/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this study was to assess for distinct kidney function trajectories following left ventricular assist device (LVAD) placement. Cohort studies of LVAD recipients demonstrate that kidney function tends to increase early after LVAD placement, followed by decline and limited sustained improvement. Inter-individual differences in kidney function response may be obscured. METHODS We identified continuous flow LVAD implantations in US adults (2016-2017) from INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Primary outcomes were estimated glomerular filtration rate (eGFR) trajectories pre-implantation to ∼12 months. Latent class mixed models were applied to primary and validation samples. Clinical differences among trajectory groups were investigated. RESULTS Among 4,615 LVAD implantations, 5 eGFR trajectory groups were identified. The 2 largest groups (Groups 1 and 2) made up >80% of the cohort, and were similar to group average trajectories previously reported, with early eGFR rise followed by decline and stabilization. Three novel trajectory groups were found: worsening followed by sustained low kidney function (Group 3, 10.1%), sustained improvement (Group 4, 3.3%), and worsening followed by variation (Group 5, 1.7%). These groups differed in baseline characteristics and outcomes. Group 4 was younger and had more cardiogenic shock and pre-implantation dialysis; Group 3 had higher rates of pre-existing chronic kidney disease, along with older age. CONCLUSIONS Novel eGFR trajectories were identified in a national cohort, possibly representing distinct cardiorenal processes. Type 1 cardiorenal syndrome may have been predominant in Group 4, and parenchymal kidney disease may have been predominant in Group 3.
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Affiliation(s)
- Carl P Walther
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas.
| | - Julia S Benoit
- Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, Texas
| | - Harveen K Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Andrew B Civitello
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Advanced Heart Failure Center of Excellence, Baylor College of Medicine, Houston, Texas
| | - Kevin F Erickson
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas; Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Nandan K Mondal
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kenneth K Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sankar D Navaneethan
- Department of Medicine, Baylor College of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, Houston, Texas; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
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16
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Weber MP, O'Malley TJ, Maynes EJ, Choi JH, Morris RJ, Massey HT, Tchantchaleishvili V. Continuous-flow left ventricular assist devices associated survival awaiting heart and heart-kidney transplant. Artif Organs 2022; 47:770-776. [PMID: 36448269 DOI: 10.1111/aor.14473] [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: 05/26/2022] [Revised: 07/30/2022] [Accepted: 08/30/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Improvement in continuous-flow left ventricular assist device (CF-LVAD) technology has translated to better outcomes for patients on CF-LVAD support as a bridge-to-transplant. However, data are lacking regarding the subset of CF-LVAD patients with renal failure awaiting simultaneous heart-kidney transplant (HKTx). We sought to better understand the characteristics and outcomes of patients in this group. METHODS The United Network for Organ Sharing (UNOS) database was used to identify adult patients listed for heart transplant (HTx) or HKTx from January 1, 2009 to March 31, 2017. Patients were followed from time on waitlist to either removal from waitlist or transplantation. Demographic and clinical data for HTx and HKTx patients were assessed. Kaplan-Meier analysis assessed waitlist and post-transplant survival. For waitlisted patients, both death and removal from the waitlist due to deteriorating medical condition were considered events. RESULTS Overall, 26 638 patients registered for transplant were analyzed. 25 111 (94%) were listed for HTx, and 1527 (6%) for HKTx. 7683 (29%) patients listed for HTx had CF-LVAD support. For those listed for HKTx, 441 (28%) underwent dialysis alone, 256 (17%) had CF-LVAD support alone, and 85 (6%) were treated with both CF-LVAD and dialysis. 15 567 (58%) underwent HTx, and 621 (2%) underwent HKTx. In these groups, post-transplant survival was similar (p = 0.06). Patients listed for HKTx treated with both dialysis and CF-LVAD had significantly worse waitlist survival compared to HKTx recipients (p < 0.001). CONCLUSION Post-transplant survival is comparable between HTx and HKTx, and early survival is similar between HTx patients and those listed for HTx with CF-LVAD support. However, outcomes on the waitlist for HKTx in CF-LVAD patients on dialysis is significantly worse compared to HKTx recipients. This highlights the need to better account for this patient population when allocating organs.
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Affiliation(s)
- Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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17
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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18
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Giménez-Milà M, Sandoval E, Farrero M. Let's Reduce Bleeding Complications in Patients With Left Ventricular Assist Device. J Cardiothorac Vasc Anesth 2022; 36:3435-3438. [PMID: 35691855 DOI: 10.1053/j.jvca.2022.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Marc Giménez-Milà
- Department of Anesthesia and Intensive Care, Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain.
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Marta Farrero
- Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain; Department of Cardiology. Hospital CLINIC de Barcelona, Universitat de Barcelona, Barcelona, Spain
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19
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Tibrewala A, Khush KK, Cherikh WS, Foutz J, Stehlik J, Rich JD. Risk of Renal Dysfunction Following Heart Transplantation in Patients Bridged with a Left Ventricular Assist Device. ASAIO J 2022; 68:646-653. [PMID: 34419984 DOI: 10.1097/mat.0000000000001558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute renal failure (ARF) and chronic kidney disease (CKD) are associated with short- and long-term morbidity and mortality following heart transplantation (HT). We investigated the incidence and risk factors for developing ARF requiring hemodialysis (HD) and CKD following HT specifically in patients with a left ventricular assist device (LVAD). We examined the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry for heart transplant patients between January 2000 and June 2015. We compared patients bridged with durable continuous-flow LVAD to those without LVAD support. Primary outcomes were ARF requiring HD before discharge following HT and CKD (defined as creatinine >2.5 mg/dl, permanent dialysis, or renal transplant) within 3 years. There were 18,738 patients, with 4,535 (24%) bridged with LVAD support. Left ventricular assist device patients had higher incidence of ARF requiring HD and CKD at 1 year, but no significant difference in CKD at 3 years compared to non-LVAD patients. Among LVAD patients, body mass index (BMI) (odds ratio [OR] = 1.79, p < 0.001), baseline estimated glomerular filtration rate (eGFR) (OR = 0.43, p < 0.001), and ischemic time (OR = 1.28, p = 0.014) were significantly associated with ARF requiring HD. Similarly, BMI (hazard ratio [HR] = 1.49, p < 0.001), baseline eGFR (HR = 0.41, p < 0.001), pre-HT diabetes mellitus (DM) (HR = 1.37, p = 0.011), and post-HT dialysis before discharge (HR = 3.93, p < 0.001) were significantly associated with CKD. Left ventricular assist device patients have a higher incidence of ARF requiring HD and CKD at 1 year after HT compared with non-LVAD patients, but incidence of CKD is similar by 3 years. Baseline renal function, BMI, ischemic time, and DM can help identify LVAD patients at risk of ARF requiring HD or CKD following HT.
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Affiliation(s)
- Anjan Tibrewala
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Wida S Cherikh
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Julia Foutz
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Bartfay SE, Kolsrud O, Wessman P, Dellgren G, Karason K. The trajectory of renal function following mechanical circulatory support and subsequent heart transplantation. ESC Heart Fail 2022; 9:2464-2473. [PMID: 35441491 PMCID: PMC9288773 DOI: 10.1002/ehf2.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/25/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022] Open
Abstract
Aim Patients with advanced heart failure (HF) frequently suffer from renal insufficiency. The impact of durable mechanical circulatory support (MCS) and subsequent heart transplantation (HTx) on kidney function is not well described. Methods and results We studied patients with advanced HF who received durable MCS as bridge to transplantation (BTT) and underwent subsequent HTx at our centre between 1996 and 2018. Glomerular filtration rate (GFR) was measured by 51Cr‐EDTA or iohexol clearance during heart failure work‐up; 3–6 months after MCS; and 1 year after HTx. Chronic kidney disease (CKD) was classified according to KDIGO criteria based on estimated GFR. A total of 88 patients (46 ± 15 years, 84% male) were included, 63% with non‐ischaemic heart disease. The median duration of MCS‐treatment was 172 (IQR 116–311) days, and 81 subjects were alive 1 year after HTx. Measured GFR increased from 54 ± 19 during HF work‐up to 60 ± 16 mL/min/1.73 m2 after MCS (P < 0.001) and displayed a slight but nonsignificant decrease to 57 ± 22 mL/min/1.73 m2 1 year after HTx (P = 0.38). The trajectory of measured GFR did not differ between pulsatile and continuous flow (CF) pumps. Among patients 35–49 years and those who were treated in the most recent era (2012–2018), measured GFR increased following MCS implantation and subsequent HTx. Estimated GFR displayed a similar course as did measured GFR. Conclusions In patients with advanced heart failure, measured GFR improved after MCS with no difference between pulsatile and CF‐pumps. The total study group showed no further increase in GFR following HTx, but in certain subgroups, including patients aged 35–54 years and those treated during the latest era (2012–2018), renal function appeared to improve after transplant.
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Affiliation(s)
- Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oscar Kolsrud
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Wessman
- Centre of Registers Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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22
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Hullin R, Meyer P, Yerly P, Kirsch M. Cardiac Surgery in Advanced Heart Failure. J Clin Med 2022; 11:773. [PMID: 35160225 PMCID: PMC8836496 DOI: 10.3390/jcm11030773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023] Open
Abstract
Mechanical circulatory support and heart transplantation are established surgical options for treatment of advanced heart failure. Since the prevalence of advanced heart failure is progressively increasing, there is a clear need to treat more patients with mechanical circulatory support and to increase the number of heart transplantations. This narrative review summarizes recent progress in surgical treatment options of advanced heart failure and proposes an algorithm for treatment of the advanced heart failure patient at >65 years of age.
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Affiliation(s)
- Roger Hullin
- Cardiology, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
| | - Philippe Meyer
- Cardiology, Department of Medical Specialties, Geneva University Hospital, University of Geneva, Rue du Gabrielle Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Patrick Yerly
- Cardiology, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
| | - Matthias Kirsch
- Cardiac Surgery, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
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23
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Walther CP, Civitello AB, Liao KK, Navaneethan SD. Nephrology Considerations in the Management of Durable and Temporary Mechanical Circulatory Support. KIDNEY360 2022; 3:569-579. [PMID: 35582171 PMCID: PMC9034823 DOI: 10.34067/kid.0003382021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/04/2022] [Indexed: 01/10/2023]
Abstract
Durable and temporary mechanical circulatory support (MCS) use is growing for a range of cardiovascular indications. Kidney dysfunction is common in people evaluated for or receiving durable or temporary MCS and portends worse outcomes. This kidney dysfunction can be due to preexisting kidney chronic kidney disease (CKD), acute kidney injury (AKI) related to acute cardiovascular disease necessitating MCS, AKI due to cardiac procedures, and acute and chronic MCS effects and complications. Durable MCS, with implantable continuous flow pumps, is used for long-term support in advanced heart failure refractory to guideline-directed medical and device therapy, either permanently or as a bridge to heart transplantation. Temporary MCS-encompassing in this review intra-aortic balloon pumps (IABP), axial flow pumps, centrifugal flow pumps, and venoarterial ECMO-is used for diverse situations: high-risk percutaneous coronary interventions (PCI), acute decompensated heart failure, cardiogenic shock, and resuscitation after cardiac arrest. The wide adoption of MCS makes it imperative to improve understanding of the effects of MCS on kidney health/function and of kidney health/function on MCS outcomes. The complex structure and functions of the kidney, and the complex health states of individuals receiving MCS, makes investigations in this area challenging, and current knowledge is limited. Fortunately, the increasing nephrology toolbox of noninvasive kidney health/function assessments may enable development and testing of individualized management strategies and therapeutics in the future. We review technology, epidemiology, pathophysiology, clinical considerations, and future directions in MCS and nephrology.
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Affiliation(s)
- Carl P. Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Andrew B. Civitello
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas,Advanced Heart Failure Center of Excellence, Baylor College of Medicine, Houston, Texas
| | - Kenneth K. Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
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24
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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25
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Gambaro A, Lombardi G, Onorati F, Gottin L, Ribichini FL. Heart, kidney and left ventricular assist device: a complex trio. Eur J Clin Invest 2021; 51:e13662. [PMID: 34347897 DOI: 10.1111/eci.13662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure (HF) is a complex syndrome affecting the whole body, kidneys included. The left ventricular assist device (LVAD) is a valid option for patients with very severe HF. Focusing on renal function, LVAD implantation could theoretically reverse the detrimental effects of HF syndrome on kidneys. However, implanting an LVAD is a high-risk surgical procedure, and LVAD patients have higher risk of bleeding, device thrombosis, strokes, renal impairment, multi-organ failure and infections. Furthermore, an LVAD has its own particular effects on the renal system. METHODS In this review, we provide a comprehensive overview of the complex interaction between LVAD and the kidneys from the pathophysiological and clinical perspectives. An analysis of the different effects of pulsatile-flow and continuous-flow LVAD is provided. RESULTS Despite their limitations, creatinine-based estimated glomerular filtration rate (eGFR) formulas help to stratify patients by their post-LVAD placement prognosis. Poor basal renal function, the onset of acute kidney injury or the need for renal replacement therapy after LVAD implantation negatively influences a patient's prognosis. LVAD can also prompt an improvement in renal function, however, with some counterintuitive effects on a patient's prognosis. CONCLUSION It is still hard to say whether different trends in eGFR depend on different renal conditions before LVAD placement, on a patient's better overall status or on a particular patient management strategy before and/or after the device's implantation. Steps should be taken to solve this question because finding the best candidates for LVAD implantation is of paramount importance to ensure the best outcomes.
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Affiliation(s)
- Alessia Gambaro
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gianmarco Lombardi
- Division of Nephrology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Leonardo Gottin
- Unit of Cardiothoracic Anesthesia and Intensive Care, Department of Emergencies and Intensive Care, University of Verona, Verona, Italy
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26
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Baudry G, Sebbag L, Bourdin J, Hugon‐Vallet E, Jobbe Duval A, Mewton N, Pozzi M, Rossignol P, Girerd N. Haemodynamic parameters associated with renal function prior to and following heart transplantation. ESC Heart Fail 2021; 8:4944-4954. [PMID: 34520113 PMCID: PMC8712911 DOI: 10.1002/ehf2.13534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
AIMS Abnormal renal function is a common feature in patients on heart transplant waiting lists. This study aimed to identify the haemodynamic parameters associated with decreased estimated glomerular filtration rate (eGFR) in patients listed for heart transplantation (HT) and renal function improvement following HT. METHODS AND RESULTS A total of 176 adults (52 years old, 81% men) with available right heart catheterization (RHC) listed in our centre for HT between 2014 and 2019 were studied. Cardiac catheterization measurements were obtained at time of HT listing evaluation. Changes in renal function were assessed between RHC and 6 months after HT. Median eGFR was 63 mL/min/1.73 m2 at time of RHC. Central venous pressure > 10 mmHg was associated with a two-fold increase in the likelihood of eGFR < 60 mL/min/1.73 m2 at time of RHC (adjusted odd ratio, 2.2; 95% confidence interval, 1.1-4.7; P = 0.04). In the 134 patients (76%) who underwent HT during follow-up, eGFR decreased by 7.9 ± 29.7 mL/min/1.73 m2 from RHC to 6 months after HT. In these patients, low cardiac index (<2.1 L/min/m2 ) at initial RHC was associated with a (adjusted) 6 month post-HT eGFR improvement of 12.2 mL/min/1.73 m2 (P = 0.018). Patients with eGFR < 60 mL/min/1.73 m2 and low cardiac index at time of RHC exhibited the greatest eGFR improvement (delta eGFR = 18.3 mL/min/1.73 m2 ) while patients with eGFR ≥ 60 mL/min/1.73 m2 and normal cardiac index had a marked decrease in eGFR (delta eGFR = -27.7 mL/min/1.73 m2 , P < 0.001). CONCLUSIONS Central venous pressure is the main haemodynamic parameter associated with eGFR < 60 mL/min/1.73 m2 in patients listed for HT. Low cardiac index prior to HT is associated with post-transplant renal function recovery.
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Affiliation(s)
- Guillaume Baudry
- Service d'insuffisance cardiaque et transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de NancyF‐CRIN INI‐CRCTVandoeuvre‐lès‐Nancy54500France
| | - Laurent Sebbag
- Service d'insuffisance cardiaque et transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Juliette Bourdin
- Service d'insuffisance cardiaque et transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Elisabeth Hugon‐Vallet
- Service d'insuffisance cardiaque et transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Antoine Jobbe Duval
- Service d'insuffisance cardiaque et transplantationHôpital Cardiovasculaire Louis Pradel, Hospices Civils de LyonBronFrance
| | - Nathan Mewton
- Centre d'Investigations Clinique, Hôpital Cardiovasculaire Louis Pradel, INSERM 1407, INSERM 1060 Unité CarmenUniversité Claude Bernard Lyon 1BronFrance
| | - Matteo Pozzi
- Service de chirurgie cardiaqueHôpital Cardiovasculaire Louis PradelBronFrance
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de NancyF‐CRIN INI‐CRCTVandoeuvre‐lès‐Nancy54500France
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de NancyF‐CRIN INI‐CRCTVandoeuvre‐lès‐Nancy54500France
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27
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Chen CY, Montez-Rath ME, May LJ, Maeda K, Hollander SA, Rosenthal DN, Krawczeski CD, Sutherland SM. Hemodynamic Predictors of Renal Function After Pediatric Left Ventricular Assist Device Implantation. ASAIO J 2021; 67:1335-1341. [PMID: 34860188 PMCID: PMC8647769 DOI: 10.1097/mat.0000000000001460] [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] [Indexed: 11/26/2022] Open
Abstract
Although renal function often improves after pediatric left ventricular assist device (LVAD) implantation, recovery is inconsistent. We aimed to identify hemodynamic parameters associated with improved renal function after pediatric LVAD placement. A single-center retrospective cohort study was conducted in patients less than 21 years who underwent LVAD placement between June 2004 and December 2015. The relationship between hemodynamic parameters and estimated glomerular filtration rate (eGFR) was assessed using univariate and multivariate modeling. Among 54 patients, higher preoperative central venous pressure (CVP) was associated with eGFR improvement after implantation (p = 0.012). However, 48 hours postimplantation, an increase in CVP from baseline was associated with eGFR decline over time (p = 0.01). In subgroup analysis, these associations were significant only for those with normal pre-ventricular assist device renal function (p = 0.026). In patients with preexisting renal dysfunction, higher absolute CVP values 48 and 72 hours after implantation predicted better renal outcome (p = 0.005). Our results illustrate a complex relationship between ventricular function, volume status, and renal function. Additionally, they highlight the challenge of using CVP to guide management of renal dysfunction in pediatric heart failure. Better methods for evaluating right heart function and volume status are needed to improve our understanding of how hemodynamics impact renal function in this population.
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Affiliation(s)
- Chiu-Yu Chen
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Oxidative Stress Markers and Modified Model for End-Stage Liver Disease Are Associated with Outcomes in Patients with Advanced Heart Failure Receiving Bridged Therapy with Continuous-Flow Left Ventricular Assist Devices. Antioxidants (Basel) 2021; 10:antiox10111813. [PMID: 34829684 PMCID: PMC8615232 DOI: 10.3390/antiox10111813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 12/28/2022] Open
Abstract
Left ventricular assist device (LVAD) is well established as an alternative treatment for end-stage heart failure (HF) patients. The aim of the study was to determine the prognostic value of oxidative stress markers and the modified Model for End-Stage Liver Disease (modMELD) in patients receiving bridged therapy with continuous-flow LVAD. We prospectively analyzed 36 end-stage HF patients who received LVAD therapy between 2015 and 2018. The total antioxidant capacity (TAC) and total oxidant status (TOS) were measured by the methods described by Erel. The oxidative stress index (OSI) was defined as the ratio of the TOS to TAC levels. The modMELD scores were calculated based on the serum bilirubin, creatinine, and albumin levels. The patients’ median age was 58 (50–63.0) years. During the 1.5-years follow-up, a major adverse cardiac event—MACE (death, stroke, or pump thrombosis) was observed in 17 patients (47.2%). The area under the receiver operating characteristics curves (AUCs) indicated a good prognostic power of TAC (AUC 0.7183 (0.5417–0.8948)), TOS (AUC 0.9149 (0.8205–0.9298)), OSI (AUC 0.9628 (0.9030–0.9821)), and modMELD (AUC 0.87 (0.7494–0.9905)) to predict a MACE. Oxidative stress markers serum concentrations, as well as the modMELD score, allow the identification of patients with a risk of MACE.
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29
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Bujo C, Amiya E, Hatano M, Ishida J, Tsuji M, Kakuda N, Narita K, Saito A, Yagi H, Ando M, Shimada S, Kimura M, Kinoshita O, Ono M, Komuro I. Long-Term renal function after implantation of continuous-flow left ventricular assist devices: A single center study. IJC HEART & VASCULATURE 2021; 37:100907. [PMID: 34765720 PMCID: PMC8571723 DOI: 10.1016/j.ijcha.2021.100907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
Background Implantable continuous-flow left ventricular assist device (LVAD) improve renal function in advanced heart failure. However, the long-term effects of LVAD on renal function have not been investigated thoroughly. We aimed to assess long-term renal function in patients with LVAD support and to identify predictors for late deterioration in renal function (LDRF). Methods One hundred patients underwent LVAD implantation as a bridge to transplant at the University of Tokyo Hospital between May 2011 and December 2018. We assessed renal function at intervals (preoperative, 1, 6, 12, 18, 24 and 30 months after LVAD implantation). We divided patients into two groups: “with LDRF,” whose renal function at 30 months had decreased by >25% compared with preoperatively (n = 14), and “without LDRF” (n = 55). Results Renal function improved at 1 month, returned to preoperative levels at 6 months, and remained there up to 30 months after LVAD implantation. However, renal function impairment became evident in patients with LDRF 18 months after LVAD implantation. A ratio of right atrial pressure/pulmonary artery wedge pressure > 0.57 and left ventricular dimension diastole ≤ 67 mm were preoperative independent risk factors for LDRF. In addition, the incidence of perioperative acute kidney injury, ventricular arrhythmia, aortic insufficiency, and late right ventricular failure was significantly higher in patients with LDRF. Conclusion LDRF after LVAD implantation corresponded to several risk factors, including a small left ventricle and LVAD-related complications, such as right ventricular failure.
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Affiliation(s)
- Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Koichi Narita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
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30
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Kovvuru K, Kanduri SR, Thongprayoon C, Bathini T, Vallabhajosyula S, Kaewput W, Mao MA, Cheungpasitporn W, Kashani KB. Recovery after acute kidney injury requiring kidney replacement therapy in patients with left ventricular assist device: A meta-analysis. World J Crit Care Med 2021; 10:390-400. [PMID: 34888164 PMCID: PMC8613722 DOI: 10.5492/wjccm.v10.i6.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/07/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication after left ventricular assist device (LVAD) implantation with an incidence of 37%; 13% of which require kidney replacement therapy (KRT). Severe AKI requiring KRT (AKI-KRT) in LVAD patients is associated with high short and long-term mortality compared with AKI without KRT. While kidney function recovery is associated with better outcomes, its incidence is unclear among LVAD patients with severe AKI requiring KRT. AIM To identify studies evaluating the recovery rates from severe AKI-KRT after LVAD placement, which is defined by regained kidney function resulting in the discontinuation of KRT. Random-effects and generic inverse variance method of DerSimonian-Laird were used to combine the effect estimates obtained from individual studies. METHODS A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses. RESULTS A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses. CONCLUSION Recovery from severe AKI-KRT after LVAD occurs approximately 50.5%, and it has not significantly changed over the years despite advances in medicine.
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Affiliation(s)
- Karthik Kovvuru
- Division of Nephrology, Department of Medicine, Ochsner Clinic Foundation, New Orleans, LA 70121, United States
| | - Swetha R Kanduri
- Division of Nephrology, Department of Medicine, Ochsner Clinic Foundation, New Orleans, LA 70121, United States
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, United States
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, United States
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, United States
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, United States
| | - Kianoush B Kashani
- Department of Medicine, Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Edwards S, Allen S, Sidebotham D. Anaesthesia for heart transplantation. BJA Educ 2021; 21:284-291. [PMID: 34306729 DOI: 10.1016/j.bjae.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- S Edwards
- Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - S Allen
- Auckland City Hospital, Auckland, New Zealand
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Roehm B, Grodin JL. Left Ventricular Assist Device Implantation and Kidney Function: Chicken, Egg, or Omelet? Kidney Med 2021; 3:324-326. [PMID: 34138988 PMCID: PMC8178522 DOI: 10.1016/j.xkme.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Bethany Roehm
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA
| | - Justin L. Grodin
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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Abstract
Rationale & Objective Nearly half the patients with heart failure have chronic kidney disease. Implantation of a left ventricular assist device (LVAD) improves kidney function in some but not all patients, and lack of improvement is associated with worse outcomes. Preimplantation factors that predict change in kidney function after LVAD placement are not well described. Study Design Single-center observational study. Setting & Participants Consecutive patients undergoing LVAD implantation. Predictors 48 diverse preimplantation variables including demographic, clinical, laboratory, hemodynamic, and echocardiographic variables. Outcomes The primary outcome was change in estimated glomerular filtration rate (eGFR) at 1 month after implantation. Secondary outcomes included eGFR changes at 3, 6, and 12 months. Analytic Approach Univariable and multivariable linear regression. Results Among 131 patients, average age was 60 ± 13 years, 83% were men, 47% had pre-existing chronic kidney disease, and mean preimplantation eGFR was 57 ± 23 mL/min/1.73 m2. At 1-month following LVAD implantation, eGFR improved in 98 (75%) patients. Variables associated with 1-month increases in eGFR were younger age, absence of diabetes mellitus (DM), use of inotropes, lower implantation eGFR, and higher implantation serum urea nitrogen, alanine aminotransferase, bilirubin, and creatinine levels. In multivariable models, younger age (β = 7.14 mL/min/1.73 m2 per SD; 95% CI, 3.17-11.10), lower eGFR (β = 7.72 mL/min/1.73 m2 per SD; 95% CI, 3.10-12.34), and absence of DM (β = 10.36 mL/min/1.73 m2; 95% CI, 2.99-17.74) were each independently associated with 1-month improvement in eGFR. Only younger age and lower eGFR were associated with improvements in eGFR at later months. Limitations Single-center study. Loss to follow-up from heart transplantation and death over duration of study. Conclusions Only younger age, lower eGFR, and absence of DM were associated with improvement in eGFR at 1 month. Thus, prediction of eGFR change at 1 month and beyond is limited by using preimplantation variables.
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Predictors of renal replacement therapy in patients with continuous flow left ventricular assist devices. J Artif Organs 2021; 24:207-216. [PMID: 33598826 DOI: 10.1007/s10047-020-01239-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p < 0.001), reoperation for bleeding (34.3% vs 11.7%, p < 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p < 0.001). Patients requiring postoperative RRT also had poorer survival at 30 days (74.7% vs 98.8%), 6 months (48.2% vs 95.1%), and 12 months (45.3% vs 90.2%) (p < 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate < 45 mL/min/1.73 m2 (OR 3.4, 95% CI [1.5-17.8], p = 0.004), and mean right atrial pressure to pulmonary capillary wedge pressure ratio ≥ 0.54 (OR 2.6, 95% CI [1.3-5.], p = 0.01). Of the 74 RRT patients, 11 (14.9%) recovered renal function before discharge, 36 (48.6%) still required RRT after discharge, and 27 (36.5%) died before discharge. We conclude that preoperative renal and right ventricular dysfunction significantly predict postoperative renal failure and mortality after CF-LVAD implantation.
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Jawaid O, Gaddy A, Omar HR, Guglin M. Ventricular Assist Devices and Chronic Kidney Replacement Therapy: Technology and Outcomes. Adv Chronic Kidney Dis 2021; 28:37-46. [PMID: 34389136 DOI: 10.1053/j.ackd.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/12/2020] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failure. Kidney dysfunction, if present, makes candidate selection for LVADs challenging and contributes to multiple complications while the patients are on an LVAD support. Although kidney function generally improves after LVAD implantation, some patients develop acute and then chronic kidney disease sometimes requiring kidney replacement therapies (KRTs). Overall, chronic KRT in LVAD recipients is feasible and well tolerated, but routine technique of blood pressure monitoring should be adjusted to the continuous blood flow. Both hemodialysis and peritoneal dialysis can be used. Unique challenges for chronic KRT posed by the presence of LVAD are discussed in this review.
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Hemolysis induced by Left Ventricular Assist Device is associated with proximal tubulopathy. PLoS One 2020; 15:e0242931. [PMID: 33253314 PMCID: PMC7703997 DOI: 10.1371/journal.pone.0242931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/11/2020] [Indexed: 01/21/2023] Open
Abstract
Background Chronic subclinical hemolysis is frequent in patients implanted with Left Ventricular Assist Device (LVAD) and is associated with adverse outcomes. Consequences of LVADs-induced subclinical hemolysis on kidney structure and function is currently unknown. Methods Thirty-three patients implanted with a Heartmate II LVAD (Abbott, Inc, Chicago IL) were retrospectively studied. Hemolysis, Acute Kidney Injury (AKI) and the evolution of estimated Glomerular Filtration Rate were analyzed. Proximal Tubulopathy (PT) groups were defined according to proteinuria, normoglycemic glycosuria, and electrolytic disorders. The Receiver Operating Characteristic (ROC) curve was used to analyze threshold of LDH values associated with PT. Results Median LDH between PT groups were statistically different, 688 IU/L [642–703] and 356 IU/L [320–494] in the “PT” and “no PT” groups, respectively p = 0.006. To determine PT group, LDH threshold > 600 IU/L was associated with a sensitivity of 85.7% (95% CI, 42.1–99.6) and a specificity of 84.6% (95% CI, 65.1–95.6). The ROC's Area Under Curve was 0.83 (95% CI, 0.68–0.98). In the “PT” group, patients had 4.2 [2.5–5.0] AKI episodes per year of exposure, versus 1.6 [0.4–3.7] in the “no PT” group, p = 0.03. A higher occurrence of AKI was associated with subsequent development of Chronic Kidney Disease (CKD) (p = 0.02) and death (p = 0.05). Conclusions LVADs-induced subclinical hemolysis is associated with proximal tubular functional alterations, which in turn contribute to the occurrence of AKI and subsequent CKD. Owing to renal toxicity of hemolysis, measures to reduce subclinical hemolysis intensity as canula position or pump parameters should be systematically considered, as well as specific nephroprotective therapies.
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Trends, Outcomes, and Readmissions Among Left Ventricular Assist Device Recipients with Acute Kidney Injury Requiring Hemodialysis. ASAIO J 2020; 66:507-512. [PMID: 31192850 DOI: 10.1097/mat.0000000000001036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although renal function may improve after left ventricular assist devices (LVAD) implantation, acute kidney injury (AKI) requiring hemodialysis (HD) therapy can occur postoperatively. We used data from the National Readmissions Database to calculate annual rates of in-hospital outcomes and readmissions among patients who underwent implantation and developed acute kidney injury (AKI) requiring hemodialysis (HD) for years 2012-2015. We identified 178 (weighted 469) patients with AKI requiring HD after LVAD implantation. In-hospital mortality was significantly higher among LVAD recipients who required HD for AKI compared with those who did not (42.38% vs. 8.38%, p < 0.001). Rates of in-hospital mortality (from 52.1% in 2012 to 33.9% in 2014, p = 0.046) and length of stay (from 60.3 days in 2012 to 47.1 days in 2014, p = 0.003) decreased significantly, whereas there was a trend toward reduced hospital cost (from $320,414 in 2012 to $267,285 in 2014, p = 0.076) during the study period. However, postoperative bleeding increased significantly (p = 0.01). Acute kidney injury requiring HD after implantation was not associated with significantly higher rates of readmissions compared with LVAD recipients without AKI on HD, after adjustment for clinical and hospital characteristics (41.4% vs. 30.5%; odds ratio 1.28; 95% confidence interval [CI]: 0.85-1.95; P = 0.239). However, 5.42% of these patients required maintenance hemodialysis in readmissions. In-hospital mortality and length of stay are decreasing but remain unacceptably high in patients requiring HD for AKI after LVAD implantation but remain higher than LVAD recipients without AKI on HD. A minority of these patients who survive hospital discharge require maintenance hemodialysis.
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Improvement in Kidney Function After Ventricular Assist Device Implantation and Its Influence on Thromboembolism, Hemorrhage, and Mortality. ASAIO J 2020; 66:268-276. [PMID: 30883405 DOI: 10.1097/mat.0000000000000989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although heart transplantation remains the gold standard for management of heart failure, ventricular assist devices (VAD) have emerged as viable alternatives. VAD implantation improves kidney function. However, whether the improvement is sustained or associated with improved outcomes is unclear. Herein we assess kidney function improvement, predictors of improvement, and associations with thromboembolism, hemorrhage, and mortality in VAD patients. Kidney function was defined using chronic kidney disease (CKD) stages: stage 1 (glomerular filtration rate [eGFR] ≥ 90 ml/min/1.73 m), stage 2 (eGFR 60-90 ml/min/1.73 m), stage 3a (eGFR 45-59 ml/min/1.73 m), stage 3b (eGFR 30-44 ml/min/1.73 m), stage 4 (eGFR 15-30 ml/min/1.73 m), and stage 5 (eGFR < 15 ml/min/1.73 m). Improvement in kidney function was defined as an improvement in eGFR that resulted in a CKD stage change to one of lesser severity. Kidney function improved post implant, and was maintained over 1 year for all patients, except those with baseline stage 5 CKD. Younger age at implantation (OR 0.93, 95% CI: 0.90-0.96, P < 0.0001) was associated with sustained improvement in kidney function. Poor kidney function was associated increased mortality but not with thromboembolism or hemorrhage. Compared to patients with baseline eGFR > 45 ml/min/1.73 m; patients with eGFR < 45 ml/min/1.73 m had a higher mortality risk (HR 3.32, 95% CI: 1.10-9.98, p = 0.03 for stage 3b; HR 4.07, 95% CI: 1.27-13.1, p = 0.02 for stage 4; and HR 4.01, 95% CI: 1.17-13.7, p = 0.03 for stage 5 CKD). Kidney function was not associated with thromboembolism or hemorrhage, and sustained improvement was not associated with lower risk of death. However, poor kidney function at implantation was associated with an increased risk of mortality.
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Thongprayoon C, Lertjitbanjong P, Cheungpasitporn W, Hansrivijit P, Fülöp T, Kovvuru K, Kanduri SR, Davis PW, Vallabhajosyula S, Bathini T, Watthanasuntorn K, Prasitlumkum N, Chokesuwattanaskul R, Ratanapo S, Mao MA, Kashani K. Incidence and impact of acute kidney injury on patients with implantable left ventricular assist devices: a Meta-analysis. Ren Fail 2020; 42:495-512. [PMID: 32434422 PMCID: PMC7301695 DOI: 10.1080/0886022x.2020.1768116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background: We aimed to evaluate the acute kidney injury (AKI) incidence and its associated risk of mortality in patients with implantable left ventricular assist devices (LVAD).Methods: A systematic literature search in Ovid MEDLINE, EMBASE, and Cochrane Databases was conducted through January 2020 to identify studies that provided data on the AKI incidence and AKI-associated mortality risk in adult patients with implantable LVADs. Pooled effect estimates were examined using random-effects, generic inverse variance method of DerSimonian-Laird.Results: Fifty-six cohort studies with 63,663 LVAD patients were enrolled in this meta-analysis. The pooled incidence of reported AKI was 24.9% (95%CI: 20.1%-30.4%) but rose to 36.9% (95%CI: 31.1%-43.1%) when applying the standard definition of AKI per RIFLE, AKIN, and KDIGO criteria. The pooled incidence of severe AKI requiring renal replacement therapy (RRT) was 12.6% (95%CI: 10.5%-15.0%). AKI incidence did not differ significantly between types of LVAD (p = .35) or indication for LVAD use (p = .62). While meta-regression analysis did not demonstrate a significant association between study year and overall AKI incidence (p = .55), the study year was negatively correlated with the incidence of severe AKI requiring RRT (slope = -0.068, p < .001). The pooled odds ratios (ORs) of mortality at 30 days and one year in AKI patients were 3.66 (95% CI, 2.00-6.70) and 2.22 (95% CI, 1.62-3.04), respectively. The pooled ORs of mortality at 30 days and one year in severe AKI patients requiring RRT were 7.52 (95% CI, 4.58-12.33) and 5.41 (95% CI, 3.63-8.06), respectively.Conclusion: We found that more than one-third of LVAD patients develop AKI based on standard definitions, and 13% develop severe AKI requiring RRT. There has been a potential improvement in the incidence of severe AKI requiring RRT for LVAD patients. AKI in LVAD patients was associated with increased 30-day and 1 year mortality.
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Affiliation(s)
| | | | | | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, USA
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Service, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Karthik Kovvuru
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Swetha R. Kanduri
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Paul W. Davis
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, USA
| | | | | | | | - Supawat Ratanapo
- Division of Cardiology, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic Health System, Jacksonville, FL, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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40
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Davies RR. Commentary: Chicken or egg: Does risk-adjustment hide the deleterious consequences of bridging to transplant with temporary devices? J Thorac Cardiovasc Surg 2020; 163:149-150. [PMID: 34756382 DOI: 10.1016/j.jtcvs.2020.09.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Health, Dallas, Tex.
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41
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Austin D, McCanny P, Aneman A. Post-operative renal failure management in mechanical circulatory support patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:833. [PMID: 32793678 PMCID: PMC7396231 DOI: 10.21037/atm-20-1172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) occurs commonly in patients requiring mechanical circulatory support (MCS) after cardiothoracic surgery. The prognostic implications of AKI in this patient group relate closely to the pathophysiology and risk factors associated with the underlying disease; pre-operative, intra-operative, and post-operative variables; hemodynamic factors; and type of support device used. General approaches to AKI management, including prevention strategies, medical management, and hemodynamic support, are also applicable in patients requiring MCS. Approaches to renal replacement therapy vary depend on patient factors, device-specific factors, and local preferences and experience. In this invited narrative review, we discuss the pathophysiology, risk factors, and prognostic implications of AKI in post-operative adult patients following institution of MCS. Management strategies for AKI are presented with a focus on those supported with either extracorporeal membrane oxygenation or a ventricular assist device.
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Affiliation(s)
- Danielle Austin
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Peter McCanny
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Abstract
In patients with end-stage heart failure, advanced therapies such as heart transplantation and long-term mechanical circulatory support (MCS) with a left ventricular assist device (LVAD) have to be considered. LVADs can be implanted as a bridge to transplantation or as an alternative to heart transplantation: destination therapy. In the Netherlands, long-term LVAD therapy is gaining importance as a result of increased prevalence of heart failure together with a low number of heart transplantations due to shortage of donor hearts. As a result, the difference between bridge to transplantation and destination therapy is becoming more artificial since, at present, most patients initially implanted as bridge to transplantation end up receiving extended LVAD therapy. Following LVAD implantation, survival after 1, 2 and 3 years is 83%, 76% and 70%, respectively. Quality of life improves substantially despite important adverse events such as device-related infection, stroke, major bleeding and right heart failure. Early referral of potential candidates for long-term MCS is of utmost importance and positively influences outcome. In this review, an overview of the indications, contraindications, patient selection, clinical outcome and optimal time of referral for long-term MCS is given.
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Welches ventrikuläre Assistenzsystem für welchen Patienten? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00375-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Tsay J, Pinkhas D, Lee BC, Guo A, Ferrall J, Derbala MH, Lampert BC, Emani S, Whitson BA, Smith SA. Worsening Renal Function in Cardiac Mechanical Support. Heart Lung Circ 2020; 29:1247-1255. [DOI: 10.1016/j.hlc.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 03/19/2019] [Accepted: 11/18/2019] [Indexed: 01/27/2023]
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Cheshire C, Bhagra CJ, Bhagra SK. A review of the management of patients with advanced heart failure in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:828. [PMID: 32793673 PMCID: PMC7396251 DOI: 10.21037/atm-20-1048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite progress in the medical and device therapy for heart failure (HF), the prognosis for those with advanced HF remains poor. Acute heart failure (AcHF) is the rapid development of, or worsening of symptoms and signs of HF typically leading to hospitalization. Whilst many HF decompensations are managed at a ward-based level, a proportion of patients require higher acuity care in the intensive care unit (ICU). Admission to ICU is associated with a higher risk of in-hospital mortality, and in those who fail to respond to standard supportive and medical therapy, a proportion maybe suitable for mechanical circulatory support (MCS). The optimal pre-operative management of advanced HF patients awaiting durable MCS or cardiac transplantation (CTx) is vital in improving both short and longer-term outcomes. This review will summarize the clinical assessment, hemodynamic profiling and management of the patient with AcHF in the ICU. The general principles of pre-surgical optimization encompassing individual systems (the kidneys, the liver, blood and glycemic control) will be discussed. Other factors impacting upon post-operative outcomes including nutrition and sarcopenia and pre-surgical skin decolonization have been included. Issues specific to durable MCS including the assessment of the right ventricle and strategies for optimization will also be discussed.
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Affiliation(s)
- Caitlin Cheshire
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Catriona Jane Bhagra
- Department of Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sai Kiran Bhagra
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Correale M, Monaco I, Tricarico L, Bottigliero D, Sicuranza M, Del Forno B, Godeas G, Teri A, Maiorano A, Perulli R, Centola A, De Bonis M, Di Biase M, Brunetti ND. Advanced heart failure: non-pharmacological approach. Heart Fail Rev 2020; 24:779-791. [PMID: 30972521 DOI: 10.1007/s10741-019-09786-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with advanced heart failure have poor prognosis despite traditional pharmacological therapies. The early identification of these subjects would allow them to be addressed on time in dedicated centers to select patients eligible for heart transplantation or ventricular assistance. In this article we will report the current management of these patients based on latest international guidelines, underlining some critical aspects, with reference to future perspectives.
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Affiliation(s)
- Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Viale Pinto 1, 71122, Foggia, Italy
| | - Ilenia Monaco
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Dario Bottigliero
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Monica Sicuranza
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Benedetto Del Forno
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Giulia Godeas
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Antonino Teri
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Annamaria Maiorano
- Nephrology Dialysis and Transplantation Unit, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Rossella Perulli
- Nephrology Dialysis and Transplantation Unit, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Antonio Centola
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Matteo Di Biase
- Santa Maria Hospital, Gruppo Villa Maria Research and Care, Bari, Italy
| | - Natale Daniele Brunetti
- Cardiology Department, Ospedali Riuniti University Hospital, Viale Pinto 1, 71122, Foggia, Italy.
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Ajmal MS, Parikh UM, Lamba H, Walther C. Chronic Kidney Disease and Acute Kidney Injury Outcomes Post Left Ventricular Assist Device Implant. Cureus 2020; 12:e7725. [PMID: 32432003 PMCID: PMC7234002 DOI: 10.7759/cureus.7725] [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] [Indexed: 11/05/2022] Open
Abstract
Introduction Left ventricular assist devices (LVAD) are used as a bridge to heart transplant or destination therapy for patients with the New York Heart Association (NYHA) class 3 or 4 heart failure. Acute kidney injury (AKI) or need for renal replacement therapy (RRT) post-LVAD implant can lead to poor outcomes. Identifying risk factors of AKI post-LVAD implant can help stratify potential LVAD candidates. Methods This is a retrospective study of all patients who received continuous-flow LVAD at our institution from January 2015 until August 2017. We calculated the incidence of AKI and the need for RRT post-LVAD implant, as well as the rate of renal recovery and survival rates at 30 days and 1-year post-LVAD implant. The presence of chronic kidney disease (CKD) and proteinuria was assessed, and kidney ultrasound results were reviewed on all patients, if available. CKD was present if estimated glomerular filtration rate (eGFR) was <60 mL/min per 1.73m2 for ≥3 months preceding LVAD implant and/or presence of proteinuria ≥ 20 mg/dL on two or more urine samples prior to LVAD implant and/or an abnormal kidney ultrasound with increased echogenicity, small size <9 cm or scarring. AKI was defined as per the current Kidney Disease Initiative Global Outcomes (KDIGO) guidelines. Results A total of 137 patients received LVAD during this time period. There were 112 males and 25 females with a mean age of 59.2 years. Incidence of AKI and the need for RRT post-LVAD implant were 64% and 19.7%, respectively. Sub-group analysis was performed based on the presence of CKD, advanced CKD stage (Stage 1-2 vs 3-5), proteinuria and abnormal kidney ultrasound. The incidence of AKI post-LVAD implant was significantly higher if baseline CKD was present (P = 0.028), and patient had an advanced CKD stage (P = 0.008). The need for RRT post-LVAD implant was significantly higher if baseline CKD was present (P = 0.015), and the patient had an abnormal kidney ultrasound (P = 0.04). Thirty-day and one-year mortality rates post-LVAD implants were 4.3% and 21.1%, respectively for the entire cohort. Out of the 27 patients requiring RRT, nine (33.3%) came off RRT before one year. Compared to the eGFR on the day of LVAD implant, eGFR at 30 days post-LVAD implant was higher in 57% and lower in 42% patients. At one year, this eGFR improvement reversed and eGFR was lower in 67% and higher in 32% patients. Conclusion The incidence of AKI and need for RRT post-LVAD implant are very high. The presence of CKD, advanced CKD stage, and an abnormal kidney ultrasound are statistically significant risk factors of AKI post-LVAD implant and/or need for RRT. Identifying these renal risk factors can help stratify the potential LVAD candidates. Only one out of three patients requiring RRT achieved dialysis independence by one-year post-LVAD implant.
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Affiliation(s)
| | | | | | - Carl Walther
- Nephrology, Baylor College of Medicine, Houston, USA
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The mid-term effect of left ventricular assist devices on renal functions. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:320-328. [PMID: 32082879 DOI: 10.5606/tgkdc.dergisi.2019.17568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/31/2019] [Indexed: 11/21/2022]
Abstract
Background In this study, we aimed to investigate the mid-term effects of left ventricular assist devices on kidney functions. Methods Between January 2015 and December 2017, a total of 61 patients (53 males, 8 females; mean age 46.4±11.2 years; range, 20 to 67 years) who underwent left ventricular assist device implantation were retrospectively analyzed. Glomerular filtration rate was evaluated preoperatively and at 24 and 48 h, at one week, and at one, three, and six months postoperatively. According to the preoperative glomerular filtration rates, the patients were divided into three groups: glomerular filtration rates ?60 mL/min/1.73 m2 ( Group 1 ), g lomerular f iltration rates 61-90 mL/min/1.73 m2 (Group 2), and glomerular filtration rates >90 mL/min/1.73 m2 (Group 3). Results In all groups, the glomerular filtration rate significantly increased at one week and one month postoperatively, compared to preoperative values (p<0.001 and p<0.01, respectively). However, the glomerular filtration values at six months significantly decreased, compared to the values at one week and one month postoperatively (p<0.001 and p<0.001, respectively). The most significant drop to preoperative values was observed in Group 3 (p=0.02) at three months and it dropped below the preoperative level at six months (p<0.001). Conclusion Our study results suggest that left ventricular assist devices can significantly increase the glomerular filtration rate in short-term, irrespective of baseline values. However, this improvement may recede later, particularly in patients with normal renal functions, and it may even disappear following the third postoperative month.
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Jha AK, Lata S. Kidney transplantation and cardiomyopathy: Concepts and controversies in clinical decision-making. Clin Transplant 2020; 34:e13795. [PMID: 31991012 DOI: 10.1111/ctr.13795] [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: 06/04/2019] [Revised: 08/21/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
Increasing comorbidities and an aging population have led to a tremendous increase in the burden of both kidney and cardiac dysfunction. Concomitant cardiomyopathy exposes the patients with kidney disease to further physiological, hemodynamic, and pathologic alterations. Kidney transplantation imposes lesser anesthetic and surgical complexities compared to another solid organ transplant. The surgical decision-making remains an unsettled issue in these conditions. The surgical choices, techniques, and sequences in kidney transplant and cardiac surgery depend on the pathophysiological perturbations and perioperative outcomes. The absence of randomized controlled trials eludes us from suggesting definite management protocol in patients with end-stage kidney disease with cardiomyopathy. Nevertheless, in this review, we extracted data from published literature to understand the pathophysiologic interactions between end-stage renal diseases with cardiomyopathy and also proposed the management algorithm in this challenging scenario. The proposed management algorithm would ensure consensus across all stakeholders involved in decision-making. Our simplistic evidence-based approach would augur future randomized trials and would further ensure refinement in our management approach after the emergence of more definitive evidence.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Schaefer JJ, Sajgalik P, Kushwaha SS, Olson LJ, Stulak JM, Johnson BD, Schirger JA. Left ventricle assist device pulsatility index at the time of implantation is associated with follow-up pulmonary hemodynamics. Int J Artif Organs 2020; 43:452-460. [PMID: 31984834 DOI: 10.1177/0391398819899403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
HeartMate II left ventricular assist device controllers provide data including pulsatility index, reflecting the relationship between pump function and hemodynamics. We propose that a higher pulsatility index at hospital discharge following implant may be associated with less vascular congestion and improved clinical outcomes. A retrospective analysis of 40 patients (age 59.2 ± 10.3 years) supported with the HeartMate II devices was conducted. Data revealed moderate Pearson correlations between pulsatility index at discharge and right atrial pressure, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure, respectively, post-surgery (median of 377 days), demonstrating a stronger relationship when analyzed for the EPC controller (n = 28) only (r = -.57, p < .01; r = -.38, p < .05; r = -.59, p < .01; r = -.47, p = .01 and r = -.53, p < .01, respectively). The pulsatility index derived from the EPC controller was associated with the significant risk of re-hospitalization within 1 and 2 years after the implantation of left ventricular assist device; hazard ratio = 0.557 with 95% confidence interval (0.315-0.983), p = .04 and hazard ratio = .579 (0.341-0.984), p = .04. A higher pulsatility index at discharge was associated with greater volume unloading, lower pulmonary pressures, and lower risk of all-cause re-hospitalizations within 1 and 2 years post-surgery. As such, pump-derived data may provide additional value in predicting left ventricular assist device hemodynamics.
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Affiliation(s)
- Jacob J Schaefer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Pavol Sajgalik
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Lyle J Olson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - John A Schirger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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