1
|
Money JE, Al Danaf J, Nelson M, Mckellar SH, Drakos SG, Kemeyou L. Loss of Pulsatility: Another Cause of Syncope in Patients with Left Ventricular Assist Devices. ASAIO J 2021; 66:e128-e130. [PMID: 33136607 DOI: 10.1097/mat.0000000000001137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We report a case of a 55-year-old man who presented with recurrent syncope 15 months after HeartWare left ventricular assist device (LVAD) implantation and was found to have diminished LVAD flow and pulsatility on tilt table testing leading to severe orthostatic hypotension (OH). The prevalence of OH is common, but autonomic dysfunction leading to OH has not been well described in patients with chronic LVAD support. The diagnosis of OH in this setting is challenging due to the decreased pulsatility in the flow generated by LVADs, and tilt table testing can be useful in the evaluation of OH in these patients.
Collapse
Affiliation(s)
- Joel E Money
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jad Al Danaf
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marisca Nelson
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephen H Mckellar
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stavros G Drakos
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Line Kemeyou
- From the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
2
|
Stephens AF, Gregory SD, Burrell AJC, Marasco S, Stub D, Salamonsen RF. Physiological principles of Starling-like control of rotary ventricular assist devices. Expert Rev Med Devices 2020; 17:1169-1182. [PMID: 33094673 DOI: 10.1080/17434440.2020.1841631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: This review explores the Starling-like physiological control method (SLC) for rotary ventricular assist devices (VADs) for severe heart failure. The SLC, based on mathematical models of the circulation, has two functions modeling each ventricle. The first function controls the output of the VAD to the arterial pool according to Starling's law, while the second function accounts for how the blood returns to the heart from the veins. The article aims to expose clinicians to SLC in an accessible and clinically relevant discussion. Areas Covered: The article explores the physiology underlying the controller, its development and how that physiology can be adapted to SLC. Examples of controller performance are demonstrated and discussed using a benchtop model of the cardiovascular system. A discussion of the limitations and criticisms of SLC is presented, followed by a future outlook on the clinical adoption of SLC. Expert Opinion: Due to its simplicity and emulation of the natural cardiac autoregulation, SLC is the superior physiological control method for rotary VADs. However, current technical and regulatory challenges prevent the clinical translation of SLC of VADs. Further technical and regulatory development will enable the clinical translation of SLCs of VADs in the coming years.
Collapse
Affiliation(s)
- Andrew F Stephens
- Department of Mechanical and Aerospace Engineering, Monash University , Melbourne, Australia.,Cardiorespiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute , Melbourne, Australia
| | - Shaun D Gregory
- Department of Mechanical and Aerospace Engineering, Monash University , Melbourne, Australia.,Cardiorespiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute , Melbourne, Australia
| | | | - Silvana Marasco
- Department of Cardiothoracic Surgery, Alfred Hospital , Melbourne, Australia
| | - Dion Stub
- Cardiorespiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute , Melbourne, Australia.,Department of Cardiology, Alfred Hospital , Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Australia
| | - Robert F Salamonsen
- Intensive Care Unit, Alfred Hospital , Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Australia
| |
Collapse
|
3
|
Corrà U, Pistono M. Exercise capacity in left ventricular assistance device recipients: exercise tolerance to be fit. J Cardiovasc Med (Hagerstown) 2020; 21:481-482. [PMID: 32487864 DOI: 10.2459/jcm.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ugo Corrà
- Exercise Pathophysiology Laboratory, Istituti Clinici Scientifici Maugeri, Veruno Institute, Via per Revislate
| | - Massimo Pistono
- Laboratory for the analysis of Cardio-Respiratory Signals, Istituti Clinici Scientifici Maugeri, Veruno Institute, Veruno (NO), Italy
| |
Collapse
|
4
|
Interpretation of Physiologic and Left Ventricular Assist Device Parameters: Implications for Physical Therapist Decision-Making. Cardiopulm Phys Ther J 2020. [DOI: 10.1097/cpt.0000000000000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
5
|
Lilliu M, Onorati F, Luciani GB, Faggian G. The determinants of functional capacity in left ventricular assist device patients: many actors with not well defined roles. J Cardiovasc Med (Hagerstown) 2020; 21:472-480. [DOI: 10.2459/jcm.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
6
|
Laoutaris ID. Restoring pulsatility and peakVO 2 in the era of continuous flow, fixed pump speed, left ventricular assist devices: 'A hypothesis of pump's or patient's speed?'. Eur J Prev Cardiol 2019; 26:1806-1815. [PMID: 31180758 DOI: 10.1177/2047487319856448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite significant improvement in survival and functional capacity after continuous flow left ventricular assist device implantation, the patient's quality of life may remain limited by complications such as aortic valve insufficiency, thromboembolic episodes and gastrointestinal bleeding attributed to high shear stress continuous flow with attenuated or absence of pulsatile flow and by a reduced peak oxygen consumption (peakVO2) primarily associated with a fixed pump speed operation. Revision of current evidence suggests that high technology pump speed algorithms, a 'hypothesis of decreasing pump's speed' to promote pulsatile flow and a 'hypothesis of increasing pump's speed' to increase peakVO2, may only partially reverse these barriers. A 'hypothesis of increasing patient's speed' is introduced, suggesting that exercise training may further contribute to the patient's recovery, enhancing peakVO2 and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field.
Collapse
|
7
|
Adamopoulos S, Corrà U, Laoutaris ID, Pistono M, Agostoni PG, Coats AJ, Crespo Leiro MG, Cornelis J, Davos CH, Filippatos G, Lund LH, Jaarsma T, Ruschitzka F, Seferovic PM, Schmid JP, Volterrani M, Piepoli MF. Exercise training in patients with ventricular assist devices: a review of the evidence and practical advice. A position paper from the Committee on Exercise Physiology and Training and the Committee of Advanced Heart Failure of the Heart Failure Associat. Eur J Heart Fail 2018; 21:3-13. [DOI: 10.1002/ejhf.1352] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 08/06/2018] [Accepted: 08/26/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit; Onassis Cardiac Surgery Center; Athens Greece
| | - Ugo Corrà
- Cardiology Department; Istituti Clinici Scientifici Maugeri, Centro Medico di Riabilitazione di Veruno; Novara Italy
| | - Ioannis D. Laoutaris
- Heart Failure and Heart Transplantation Unit; Onassis Cardiac Surgery Center; Athens Greece
| | - Massimo Pistono
- Cardiology Department; Istituti Clinici Scientifici Maugeri, Centro Medico di Riabilitazione di Veruno; Novara Italy
| | - Pier Giuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health; Cardiovascular Section, University of Milan; Milan Italy
| | | | - Maria G. Crespo Leiro
- Heart Failure and Transplant Unit; Complexo Hospitalario Universitario A Coruña (CHUAC), INIBIC, CIBERCV, UDC; La Coruña Spain
| | - Justien Cornelis
- Faculty of Medicine and Health Sciences, Translational Pathophysiological Research; University of Antwerp; Antwerp Belgium
| | - Constantinos H. Davos
- Cardiovascular Research Laboratory; Biomedical Research Foundation, Academy of Athens; Athens Greece
| | | | - Lars H. Lund
- Department of Medicine; Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital; Stockholm Sweden
| | - Tiny Jaarsma
- Department of Nursing; University of Linköping; Linköping Sweden
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Zürich Switzerland
| | | | - Jean-Paul Schmid
- Chefarzt Kardiologie, Klinik Barmelweid AG; Barmelweid Switzerland
| | | | - Massimo F. Piepoli
- Heart Failure Unit, Cardiac Department; Guglielmo da Saliceto Hospital; Piacenza Italy
| |
Collapse
|
8
|
Management of Patients on Mechanical Circulatory Assist Devices During Noncardiac Surgery. Int Anesthesiol Clin 2018; 56:e1-e27. [PMID: 30204602 DOI: 10.1097/aia.0000000000000205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
9
|
Kadado AJ, Akar JG, Hummel JP. Arrhythmias after left ventricular assist device implantation: Incidence and management. Trends Cardiovasc Med 2018; 28:41-50. [DOI: 10.1016/j.tcm.2017.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/04/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
|
10
|
Debate: creating adequate pulse with a continuous flow ventricular assist device: can it be done and should it be done? Probably not, it may cause more problems than benefits! Curr Opin Cardiol 2017; 31:337-42. [PMID: 26998788 DOI: 10.1097/hco.0000000000000289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW The feasibility and benefits of creating adequate pulsatility with continuous flow left ventricular assist devices (LVADs) have long been debated. This review discusses recent technical and clinical findings to answer whether such intervention should be implemented in the standard patient management. RECENT FINDINGS Only a limited amount of pulsatility can be generated by periodic speed steps, both considerably smaller in flow increase and in pace rate than the natural circulation. Organ systems are not impeded in their normal function and even not in recovery by a continuous flow. Known problems such as gastrointestinal bleeding are not necessarily due to pulsatility per se, or not important for therapeutic progress, such as minor modifications of the arterial walls. SUMMARY The speculative benefits of augmented pulsatility with continuous flow LVADs could be overrated and are still incompletely evaluated. Potential risks that might arise from this strategy should be carefully weighed before implementing extensive pulsatility as standard patient management.
Collapse
|
11
|
Bozkurt S, Bozkurt S. In-silico evaluation of left ventricular unloading under varying speed continuous flow left ventricular assist device support. Biocybern Biomed Eng 2017. [DOI: 10.1016/j.bbe.2017.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
12
|
Physical Capacity in LVAD Patients: Hemodynamic Principles, Diagnostic Tools and Training Control. Int J Artif Organs 2016; 39:451-459. [DOI: 10.5301/ijao.5000529] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 11/20/2022]
Abstract
Over time left ventricular assist devices (LVAD) have become an alternative to heart transplantation because of enormous technical development and miniaturization. Most patients present a significant improvement in clinical conditions and exercise capacity. Nevertheless, exercise tolerance remains markedly limited even after LVAD implantation compared to a control group. The complex physiological and hemodynamic changes in LVAD patients, both at rest and during exercise, are not yet understood, or at least not completely. It is the aim of the present paper to describe the current state of scientific knowledge. Furthermore, the spectrum of diagnostic tools, including the noninvasive inert gas rebreathing method for measurement of cardiac output and associate parameters, are discussed. Options for training control in this special patient group are presented.
Collapse
|
13
|
Fresiello L, Buys R, Timmermans P, Vandersmissen K, Jacobs S, Droogne W, Ferrari G, Rega F, Meyns B. Exercise capacity in ventricular assist device patients: clinical relevance of pump speed and power. Eur J Cardiothorac Surg 2016; 50:752-757. [DOI: 10.1093/ejcts/ezw147] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/02/2016] [Accepted: 03/04/2016] [Indexed: 11/15/2022] Open
|
14
|
Hämodynamik und körperliche Belastbarkeit bei Patienten mit Linksherzunterstützungssystem. Herz 2016; 41:507-13. [DOI: 10.1007/s00059-015-4396-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/02/2015] [Accepted: 12/12/2015] [Indexed: 11/24/2022]
|
15
|
Noor MR, Ho CH, Parker KH, Simon AR, Banner NR, Bowles CT. Investigation of the Characteristics of HeartWare HVAD and Thoratec HeartMate II Under Steady and Pulsatile Flow Conditions. Artif Organs 2015; 40:549-60. [PMID: 26611518 DOI: 10.1111/aor.12593] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to elucidate the dynamic characteristics of the Thoratec HeartMate II (HMII) and the HeartWare HVAD (HVAD) left ventricular assist devices (LVADs) under clinically representative in vitro operating conditions. The performance of the two LVADs were compared in a normothermic, human blood-filled mock circulation model under conditions of steady (nonpulsatile) flow and under simulated physiologic conditions. These experiments were repeated using 5% dextrose in order to determine its suitability as a blood analog. Under steady flow conditions, for the HMII, approximately linear inverse LVAD differential pressure (H) versus flow (Q) relationships were observed with good correspondence between the results of blood and 5% dextrose under all conditions except at a pump speed of 9000 rpm. For the HVAD, the corresponding relationships were inverse curvilinear and with good correspondence between the blood-derived and 5% dextrose-derived relationships in the flow rate range of 2-6 L/min and at pump speeds up to 3000 rpm. Under pulsatile operating conditions, for each LVAD operating at a particular pump speed, an counterclockwise loop was inscribed in the HQ domain during a simulated cardiac cycle (HQ loop); this showed that there was a variable phase relationship between LVAD differential pressure and LVAD flow. For both the HMII and HVAD, increasing pump speed was associated with a right-hand and upward shift of the HQ loop and simulation of impairment of left ventricular function was associated with a decrease in loop area. During clinical use, not only does the pressure differential across the LVAD and its flow rate vary continuously, but their phase relationship is variable. This behavior is inadequately described by the widely accepted representation of a plot of pressure differential versus flow derived under steady conditions. We conclude that the dynamic HQ loop is a more meaningful representation of clinical operating conditions than the widely accepted steady flow HQ curve.
Collapse
Affiliation(s)
- Mumin R Noor
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Chong H Ho
- Department of Bioengineering, Imperial College London, London, UK
| | - Kim H Parker
- Department of Bioengineering, Imperial College London, London, UK
| | - Andre R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, UK
| | - Nicholas R Banner
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Christopher T Bowles
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, UK.,Department of Bioengineering, Imperial College London, London, UK
| |
Collapse
|
16
|
Exercise physiology, testing, and training in patients supported by a left ventricular assist device. J Heart Lung Transplant 2015; 34:1005-16. [DOI: 10.1016/j.healun.2014.12.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 01/14/2023] Open
|
17
|
Jung MH, Gustafsson F. Exercise in heart failure patients supported with a left ventricular assist device. J Heart Lung Transplant 2015; 34:489-96. [DOI: 10.1016/j.healun.2014.11.001] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/29/2014] [Accepted: 11/04/2014] [Indexed: 12/17/2022] Open
|