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Tang PC, Millar J, Noly PE, Sicim H, Likosky DS, Zhang M, Pagani FD. Preoperative passive venous pressure-driven cardiac function determines left ventricular assist device outcomes. J Thorac Cardiovasc Surg 2024; 168:133-144.e5. [PMID: 37495169 PMCID: PMC10805966 DOI: 10.1016/j.jtcvs.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/22/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Right heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether the magnitude of this "passive cardiac output" can predict LVAD outcomes. METHODS This was a retrospective review of 383 patients who received a continuous-flow LVAD at the University of Michigan between 2012 and 2021. Pre-LVAD cardiac output driven by venous pressure was determined by dividing right atrial pressure by mean pulmonary artery pressure, multiplied by total cardiac output. Normalization to body surface area led to the passive cardiac index (PasCI). The Youden J statistic was used to identify the PasCI threshold, which predicted LVAD death by 2 years. RESULTS Increased preoperative PasCI was associated with reduced survival (hazard ratio [HR], 2.27; P < .01), and increased risk of right ventricular failure (RVF) (HR, 3.46; P = .04). Youden analysis showed that a preoperative PasCI ≥0.5 (n = 226) predicted LVAD death (P = .10). Patients with PasCI ≥0.5 had poorer survival (P = .02), with a trend toward more heart failure readmission days (mean, 45.09 ± 67.64 vs 35.13 ± 45.02 days; P = .084) and increased gastrointestinal bleeding (29.2% vs 20.4%; P = .052). Additionally, of the 97 patients who experienced readmissions for heart failure, those with pre-LVAD implantation PasCI ≥0.5 were more likely to have more than 1 readmission (P = .05). CONCLUSIONS Although right heart output can be augmented by raising venous pressure, this negatively impacts end-organ function and increases heart failure readmission days. Patients with a pre-LVAD PasCI ≥0.5 have worse post-LVAD survival and increased RVF. Using the PasCI metric in isolation or incorporated into a predictive model may improve the management of LVAD candidates with RV dysfunction.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Jessica Millar
- Department of Surgery, University of Michigan Ann Arbor, Mich
| | | | - Hüseyin Sicim
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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Färber G, Schwan I, Kirov H, Rose M, Tkebuchava S, Schneider U, Caldonazo T, Diab M, Doenst T. Durability of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. J Clin Med 2024; 13:1411. [PMID: 38592251 PMCID: PMC10932215 DOI: 10.3390/jcm13051411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/31/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days-0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2-4 points) in 19 and low (0-2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF.
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Affiliation(s)
- Gloria Färber
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Imke Schwan
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Marcel Rose
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Sophie Tkebuchava
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Ulrich Schneider
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Mahmoud Diab
- Department of Cardiac Surgery, Rotenburg Heart and Vascular Centre, 36199 Rotenburg an der Fulda, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Oren D, Oh KT, Fried JA, Clerkin KJ, Raikhelkar JK, Topkara VK, Kaku Y, Takeda K, Naka Y, Burkhoff D, Latif F, Majure D, Colombo PC, Yuzefpolskaya M, Sayer GT, Uriel N. Hemodynamic Optimization by Invasive Ramp Test in Patients Supported With HeartMate 3 Left Ventricular Assist Device. ASAIO J 2024:00002480-990000000-00420. [PMID: 38373176 DOI: 10.1097/mat.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
In patients supported by the HeartMate 3 left ventricular assist device (HM3 LVAD), pump speed adjustments may improve hemodynamics. We investigated the hemodynamic implications of speed adjustments in HM3 recipients undergoing hemodynamic ramp tests. Clinically stable HM3 recipients who underwent routine invasive hemodynamic ramp tests between 2015 and 2022 at our center were included. Filling pressure optimization, defined as central venous pressure (CVP) <12 mm Hg and pulmonary capillary wedge pressure (PCWP) <18 mm Hg, was assessed at baseline and final pump speeds. Patients with optimized pressures were compared to nonoptimized patients. Overall 60 HM3 recipients with a median age of 62 years (56, 71) and time from LVAD implantation of 187 days (124, 476) were included. Optimized filling pressures were found in 35 patients (58%) at baseline speed. Speed was adjusted in 84% of the nonoptimized patients. Consequently, 39 patients (65%) had optimized pressures at final speed. There were no significant differences in hemodynamic findings between baseline and final speeds (p > 0.05 for all). Six and 12 month readmission-free rates were higher in optimized compared with nonoptimized patients (p = 0.03 for both), predominantly due to lower cardiac readmission-free rates (p = 0.052). In stable outpatients supported with HM3 who underwent routine ramp tests, optimized hemodynamics were achieved in only 2 of 3 of the patients. Patients with optimized pressures had lower all-cause readmission rates, primarily driven by fewer cardiac-related hospitalizations.
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Affiliation(s)
- Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sharon Slomovich
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Andrea Fernandez-Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kyung T Oh
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - David Majure
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Abdelshafy M, Caliskan K, Simpkin AJ, Elkoumy A, Kimman JR, Elsherbini H, Elzomor H, de By TMMH, Gollmann-Tepeköylü C, Berchtold-Herz M, Loforte A, Reineke D, Schoenrath F, Paluszkiewicz L, Gummert J, Mohacsi P, Meyns B, Soliman O. Efficacy of levosimendan infusion in patients undergoing a left ventricular assist device implant in a propensity score matched analysis of the EUROMACS registry-the Euro LEVO-LVAD study. Eur J Cardiothorac Surg 2023; 63:ezad095. [PMID: 36912728 PMCID: PMC10693438 DOI: 10.1093/ejcts/ezad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES Early right-sided heart failure (RHF) was seen in 22% of recipients of a left ventricular assist device (LVAD) in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). However, the optimal treatment of post-LVAD RHF is not well known. Levosimendan has proven to be effective in patients with cardiogenic shock and in those with end-stage heart failure. We sought to evaluate the efficacy of levosimendan on post-LVAD RHF and 30-day and 1-year mortality. METHODS The EUROMACS Registry was used to identify adults with mainstream continuous-flow LVAD implants who were treated with preoperative levosimendan compared to a propensity matched control cohort. RESULTS In total, 3661 patients received mainstream LVAD, of which 399 (11%) were treated with levosimendan pre-LVAD. Patients given levosimendan had a higher EUROMACS RHF score [4 (2- 5.5) vs 2 (2- 4); P < 0.001], received more right ventricular assist devices (RVAD) [32 (8%) vs 178 (5.5%); P = 0.038] and stayed longer in the intensive care unit post-LVAD implant [19 (8-35) vs 11(5-25); P < 0.001]. Yet, there was no significant difference in the rate of RHF, 30-day, or 1-year mortality. Also, in the matched cohort (357 patients taking levosimendan compared to an average of 622 controls across 20 imputations), we found no evidence for a difference in postoperative severe RHF, RVAD implant rate, length of stay in the intensive care unit or 30-day and 1-year mortality. CONCLUSIONS In this analysis of the EUROMACS registry, we found no evidence for an association between levosimendan and early RHF or death, albeit patients taking levosimendan had much higher risk profiles. For a definitive conclusion, a multicentre, randomized study is warranted.
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Affiliation(s)
- Mahmoud Abdelshafy
- Discipline of Cardiology, Saolta Healthcare Group, Galway University Hospital, Health Service Executive, Galway, Ireland
- CORRIB Core Lab, University of Galway, Galway, Ireland
- Department of Cardiology, Al-Azhar University, Cairo, Egypt
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Andrew J Simpkin
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
- Insight Centre for Data Analytics, University of Galway, Galway, Ireland
| | - Ahmed Elkoumy
- Discipline of Cardiology, Saolta Healthcare Group, Galway University Hospital, Health Service Executive, Galway, Ireland
- CORRIB Core Lab, University of Galway, Galway, Ireland
- Islamic Center of Cardiology and Cardiac Surgery, Al-Azhar University, Cairo, Egypt
| | - Jesse R Kimman
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hagar Elsherbini
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hesham Elzomor
- Discipline of Cardiology, Saolta Healthcare Group, Galway University Hospital, Health Service Executive, Galway, Ireland
- CORRIB Core Lab, University of Galway, Galway, Ireland
- Islamic Center of Cardiology and Cardiac Surgery, Al-Azhar University, Cairo, Egypt
| | | | | | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Antonio Loforte
- Division of Cardiac Surgery, S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna, Bologna, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - David Reineke
- Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Lech Paluszkiewicz
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jan Gummert
- Department for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Paul Mohacsi
- HerzGefässZentrum im Park, Zürich, Switzerland
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Bart Meyns
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Osama Soliman
- Discipline of Cardiology, Saolta Healthcare Group, Galway University Hospital, Health Service Executive, Galway, Ireland
- CORRIB Core Lab, University of Galway, Galway, Ireland
- CÚRAM Centre for Medical Devices, Galway, Ireland
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5
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Wernhart S, Papathanasiou M, Jakstaite A, Hoffmann J, Schmack B, Hedderich J, Ruhparwar A, Rassaf T, Luedike P. Exercise oscillatory ventilation in patients with advanced heart failure with and without left ventricular assist device. Artif Organs 2023; 47:168-179. [PMID: 36102469 DOI: 10.1111/aor.14398] [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: 01/18/2022] [Revised: 06/25/2022] [Accepted: 08/26/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV), indicating pathological fluctuations on pulmonary arterial pressure, is associated with mortality in patients with heart failure (HF). Whether left ventricular assist device (LVAD)-induced ventricular unloading can reverse EOV and may prevent short-term rehospitalization has not been investigated. METHODS We performed a retrospective single-center in- and outpatient analysis of patients with (n = 20, LVAD) and without (n = 27, HF) circulatory support and reduced ejection fraction (EF, 22.8 ± 7.9%). The association of cardiopulmonary exercise testing (CPET) variables and 3 months-rehospitalization (3MR) as a primary outcome was analyzed. Furthermore, CPET variables were compared regarding the presence of EOV (+/-). RESULTS Lower VO2peak (11.6 ± 4.9 ml/kg/min vs. 14.4 ± 4.3 ml/kg/min, p = 0.039), lower increase of PETCO2 (CI = 0.049-1.127; p = 0.068), and higher VE/VCO2 (43.8 ± 9.5 vs. 38.3 ± 10.6; p = 0.069) were associated with 3MR. Flattening of O2 pulse (CI = 0.139-2.379; p = 0.487) had no impact on 3MR. EOV was present in 59.5% (n = 28/47) of patients, without a significant difference between LVAD and HF patients (p = 0.959). Patients with HF/EOV+ demonstrated significantly lower VO2peak compared with HF/EOV- (p = 0.039). LVAD/EOV+ displayed significantly lower EF (p = 0.004) and fewer aortic valve opening than LVAD/EOV- (p = 0.027). CONCLUSIONS Lower VO2peak , but not EOV, was associated with 3MR. EOV occurred at a similar rate in LVAD and HF patients, which may illustrate insufficient unloading during exercise in chronic LVAD therapy and may contribute to the limited exercise capacity following LVAD implantation. Simultaneous CPET and right heart catheterization studies are needed to elucidate whether EOV may serve as a non-invasive predictor of insufficient LV unloading necessitating LVAD reprograming.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Aiste Jakstaite
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Julia Hoffmann
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Clinic of Thoracic and Cardiovascular Surgery, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jürgen Hedderich
- Medistat- Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
| | - Arjang Ruhparwar
- Clinic of Thoracic and Cardiovascular Surgery, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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New Antithrombotic Strategies to Improve Outcomes With the HeartMate 3. ASAIO J 2023; 69:e3-e6. [PMID: 35947801 DOI: 10.1097/mat.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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7
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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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8
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Post-Implant Phosphodiesterase-5 Inhibitors in Patients with Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11205988. [PMID: 36294308 PMCID: PMC9604415 DOI: 10.3390/jcm11205988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the improvement in left ventricular assist device (LVAD) technology and the advent of third-generation LVADs, hemocompatibility-related events remain a significant issue. Therefore, new pharmacological treatments are necessary to optimize patient management and to further reduce hemocompatibility-related events. The purpose of the present systematic review and meta-analysis was to summarize the existing data regarding the safety and efficacy of post-implant phosphodiesterase-5 inhibitors (PDE-5i) on hemocompatibility-related events. Methods: Among the 258 articles in Pubmed, Scopus, and CENTRAL that were retrieved (1990−2022), 15 studies were included in the qualitative synthesis, and 9 studies were included in the quantitative synthesis. The fixed-effects model was used because it is statistically sound for combining a very small number of studies. The primary endpoint of the study was all-cause mortality, whereas the secondary endpoints were ischemic stroke, pump thrombosis, and gastrointestinal bleeding. Results: Mortality was significantly lower in the PDE-5i group vs. the control group (OR: 0.92 [95% CI: 0.85, 0.98]; p = 0.02). The secondary endpoints ischemic stroke (OR: 0.87 [95% CI: 0.78, 0.98]; p = 0.02) and pump thrombosis (OR: 0.90 [95% CI: 0.82, 0.99]; p = 0.04) were also lower in the PDE-5i group. The incidence of gastrointestinal bleeding was significantly higher in patients with LVAD receiving PDE-5i (OR: 1.26 [95% CI: 1.11, 1.44]; p < 0.01). In the overall analysis, the heterogeneity of outcomes was low, except for pump thrombosis. Conclusions: The use of PDE-5i post-implant was associated with lower mortality and thrombotic events but with a higher risk of gastrointestinal bleeding.
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9
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Morris KL, Haleem A, Garcia-Cortes R, Patel A, Thomas J, Sudharshan S, Chaudhry SP, Ravichandran A. A Single-center Experience of CardioMEMS in Patients With Left Ventricular Assist Devices. ASAIO J 2022; 68:e116-e117. [PMID: 34593683 DOI: 10.1097/mat.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Kathleen L Morris
- From the Department of Cardiology and Advanced Heart Failure and Cardiac Transplantation, Ascension St. Vincent Hospital, Indianapolis, Indiana
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10
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Berardi C, Bravo CA, Li S, Khorsandi M, Keenan JE, Auld J, Rockom S, Beckman JA, Mahr C. The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support. J Clin Med 2022; 11:2022. [PMID: 35407630 PMCID: PMC9000165 DOI: 10.3390/jcm11072022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/25/2022] [Accepted: 03/31/2022] [Indexed: 12/13/2022] Open
Abstract
The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.
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Affiliation(s)
- Cecilia Berardi
- Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA 01199, USA;
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Song Li
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, USA; (M.K.); (J.E.K.)
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, USA; (M.K.); (J.E.K.)
| | - Jonathan Auld
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Sunny Rockom
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Jennifer A. Beckman
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
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11
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Barac YD, Toledano R, Jawitz OK, Schroder JN, Daneshmand MA, Patel CB, Aravot D, Milano CA. Right and left ventricular assist devices are an option for bridge to heart transplant. JTCVS OPEN 2022; 9:146-159. [PMID: 36003474 PMCID: PMC9390634 DOI: 10.1016/j.xjon.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
Background Patients with a left ventricular assist device with right ventricular failure are prioritized on the heart transplant waitlist; however, their post-transplant survival is less well characterized. We aimed to determine whether pretransplant right ventricular failure affects postoperative survival in patients with a left ventricular assist device as a bridge to transplant. Methods We performed a retrospective review of the 2005-2018 Organ Procurement and Transplantation Network/United Network for Organ Sharing registry for candidates aged 18 years or more waitlisted for first-time isolated heart transplantation after left ventricular assist device implantation. Candidates were stratified on the basis of having right ventricular failure, defined as the need for right ventricular assist device or intravenous inotropes. Baseline demographic and clinical characteristics were compared among the 3 groups, and post-transplant survival was assessed. Results Our cohort included 5605 candidates who met inclusion criteria, including 450 patients with right ventricular failure, 344 patients with a left ventricular assist device and intravenous inotropes as a bridge to transplant, 106 patients with a left ventricular assist device and right ventricular assist device, and 5155 patients with a left ventricular assist device as a bridge to transplant without the need for right side support. Compared with patients without right ventricular failure, patients with a left ventricular assist device as a bridge to transplant with right ventricular failure were younger (median age 51 years, 55 vs 56 years, P < .001) and waited less time for organs (median 51 days, 93.5 vs 125 days, P < .001). These patients also had longer post-transplant length of stay (median 18 days, 20 vs 16 days, P < .001). Right ventricular failure was not associated with decreased post-transplant long-term survival on unadjusted Kaplan–Meier analysis (P = .18). Neither preoperative right ventricular assist device nor intravenous inotropes independently predicted worse survival on multivariate Cox proportional hazards analysis. However, pretransplant liver dysfunction (total bilirubin >2) was an independent predictor of worse survival (hazard ratio, 1.74; 95% confidence interval, 1.39-2.17; P < .001), specifically in the left ventricular assist device group and not in the left ventricular assist device + right ventricular assist device/intravenous inotropes group. Conclusions Patients with biventricular failure are prioritized on the waiting list, because their critical pretransplant condition has limited impact on their post-transplant survival (short-term effect only); thus, surgeons should be confident to perform transplantation in these severely ill patients. Because liver dysfunction (a surrogate marker of right ventricular failure) was found to affect long-term survival in patients with a left ventricular assist device, surgeons should be encouraged to perform transplantation in these severely ill patients after a recipient's optimization by inotropes or a right ventricular assist device because even when the bilirubin level is elevated in these patients (treated with right ventricular assist device/inotropes), their long-term survival is not affected. Future studies should assess recipients' optimization before organ acceptance to improve long-term survival.
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12
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Robinson AC, January SE, Botkin KW, Vader JM, Hartupee JC, Tellor Pennington BR. Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support. Pharmacotherapy 2021; 42:4-13. [PMID: 34655495 DOI: 10.1002/phar.2632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE This study sought to determine whether SA use is associated with bleeding in patients receiving CF-LVAD support. DESIGN A retrospective cohort analysis was conducted of all adult patients who received CF-LVAD implantation at our institution. SETTING Barnes-Jewish Hospital between July 1, 2009, and October 1, 2018. PATIENTS Patients at least 18 years of age who received a HVAD™ (HeartWare Corp.), HeartMate II™ (St. Jude Medical), or HeartMate 3™ (St. Jude Medical) CF-LVAD and survived for at least 30 days postoperatively were included. INTERVENTION Patients who received SAs (n = 203) were compared to those who did not (n = 391) from 30 days to 18 months following implantation. The primary outcome was the incidence of first bleeding events including gastrointestinal bleed (GIB), epistaxis, or intracerebral hemorrhage (ICH). MEASUREMENTS AND MAIN RESULTS During follow-up, 219 patients had bleeding events: 93 of 203 (45.8%) in the SA group versus 126 of 391 (32.2%) in the control group (p = 0.001). After adjustment for age, angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) use, history of bleeding events, history of smoking, and CF-LVAD type, SA use remained associated with bleeding (adjusted odds ratio: 1.75, 95% confidence interval: 1.22-2.51, p = 0.002). HeartMate 3™ patients experienced less bleeding than HeartMate II™ patients (adjusted odds ratio 0.46, 95% confidence interval: 0.23-0.90, p = 0.024). CONCLUSIONS In this single-center, retrospective cohort of patients supported with CF-LVADs, SA use was associated with the incidence of first bleeding events, primarily driven by GIB. Further studies are needed to assess any differential risk of bleeding among SA agents and to assess the utility of altering antithrombotic strategies.
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Affiliation(s)
- Adam C Robinson
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kent W Botkin
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Justin M Vader
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Justin C Hartupee
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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13
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Preoperative Right Heart Dysfunction and Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices. ASAIO J 2021; 67:324-331. [PMID: 33627608 DOI: 10.1097/mat.0000000000001224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Gastrointestinal bleeding (GIB) is a common cause of morbidity among patients supported by left ventricular assist devices (LVADs). The aim of this study was to identify if pre-LVAD right ventricular (RV) dysfunction is associated with risk of GIB after LVAD implantation. Of 398 patients implanted with LVADs between July 2008 and July 2016, 130 (33%) developed GIB at a median of 2.6 months following LVAD implantation. Arteriovenous malformations (AVMs) were found in 42 (34%) GIB patients. Patients with GIB were older and more likely to have hypertension, diabetes, and ischemic cardiomyopathy. On pre-LVAD echocardiography, GIB patients had increased RV diastolic dimension (4.7 ± 0.8 vs. 4.4 ± 0.9 cm, p = 0.02), a higher rate of greater than mild tricuspid valve (TV) regurgitation (73 [60%] vs. 120 [47%], p = 0.006), and underwent TV repair more often (38 [30%] vs. 43 [16%], p = 0.0006) during LVAD implantation. After multivariable adjustment, preoperative greater than mild RV enlargement (hazard ratio [HR] 2.32, 95% CI 1.12-5.03; p = 0.03), TV regurgitation (HR 1.83, CI 1.02-3.44; p = 0.01), and TV repair (HR 3.76, confidence interval [CI] 1.02-4.44; p = 0.01) remained associated with risk of GIB. This finding was driven by the AVM-GIB subgroup. Preoperative RV enlargement and TV regurgitation are associated with post-LVAD AVM-related GIB.
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14
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Nakamura M, Imamura T, Hori M, Nakagaito M, Ueno H, Yokoyama S, Doi T, Fukahara K, Kinugawa K. Regulation of Angiopoietin-2 Before and After Mechanical Circulatory Support Therapy. ASAIO J 2021; 67:53-58. [PMID: 32740126 DOI: 10.1097/mat.0000000000001189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Gastrointestinal bleeding (GIB) during mechanical circulatory support (MCS) is a major unsolved comorbidity. Inadequate activation of angiopoietin-2-related systems is considered as a major cause of GIB. However, the regulation of angiopoietin-2 remains unknown. Consecutive 20 patients who received continuous-flow MCS therapy (MCS group) and 12 with advanced heart failure (HF; HF group) were prospectively enrolled and their angiopoetin-2 levels were compared. Angiopoietin-2 level had a moderate correlation with log10 B-type natriuretic peptide (BNP; r = 0.39, p < 0.001). The MCS group had significantly higher angiopoietin-2 level divided by log10 BNP compared with the HF group (2.80 ± 0.20 vs. 1.88 ± 0.17, p < 0.001). Angiopoetin-2 had a moderate correlation with central venous pressure and C-reactive protein during the MCS support (r = 0.51 and r = 0.45, respectively). Higher angiopoietin-2 level divided by log10 BNP (> 4.3) was significantly associated with the occurrence of GIB with a hazard ratio of 296 (95% confidence interval 2.24-38620, p = 0.0224). Angiopoietin-2 was already elevated in the HF cohort and more elevated following MCS initiation. Among the MCS cohort, angiopoietin-2 was particularly elevated in patients with systemic congestion and inflammation and was associated with higher incidence of GIB.
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Affiliation(s)
| | | | - Masakazu Hori
- From the Second Department of Internal Medicine; and
| | | | - Hiroshi Ueno
- From the Second Department of Internal Medicine; and
| | - Shigeki Yokoyama
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Toshio Doi
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Kazuaki Fukahara
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
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15
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Loyaga-Rendon RY, Kazui T, Acharya D. Antiplatelet and anticoagulation strategies for left ventricular assist devices. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:521. [PMID: 33850918 PMCID: PMC8039667 DOI: 10.21037/atm-20-4849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.
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Affiliation(s)
| | - Toshinobu Kazui
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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16
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Subramani S, Sharma A, Arora L, Hanada S, Krishnan S, Ramakrishna H. Perioperative Right Ventricular Dysfunction: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:309-320. [PMID: 33593648 DOI: 10.1053/j.jvca.2021.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Abstract
Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.1 The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.
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Affiliation(s)
- Sudhakar Subramani
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Lovkesh Arora
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Satoshi Hanada
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sundar Krishnan
- Department of Anesthesia, Duke University School of Medicine, Durham, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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17
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices. J Heart Lung Transplant 2020; 38:677-698. [PMID: 31272557 DOI: 10.1016/j.healun.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 01/21/2023] Open
Abstract
Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.
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Affiliation(s)
- Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Ersilia M DeFilippis
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Monica Colvin
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chad E Darling
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Tonya Elliott
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Eman Hamad
- Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian C Hiestand
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | | | - Keyur B Shah
- VCU Pauley Heart Center, Richmond, Virginia, USA
| | - Juliane Vierecke
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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18
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Controlling Nutritional Status Score As a Predictive Marker for Patients With Implantable Left Ventricular Assist Device. ASAIO J 2020; 66:166-172. [PMID: 30913100 DOI: 10.1097/mat.0000000000000972] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Although a correlation between the nutritional status and the prognosis of patients with heart failure has been suggested, a correlation between the nutritional status and outcomes after the left ventricular assist device (LVAD) implantation remains unclear. We aimed to investigate the efficacy of the Controlling Nutritional Status (CONUT) score (range 0-12, including serum albumin, total cholesterol, and lymphocytes) as a nutritional index in speculating the prognosis of patients undergoing LVAD implantation. We examined 63 consecutive patients who underwent the continuous-flow LVAD implantation. Using the preoperative CONUT score, patients were categorized into two groups: lower CONUT score (0-4: normal to mild malnutrition) and higher CONUT score (5-12: moderate to severe malnutrition). We compared for the backgrounds and the clinical events after LVAD implantation. The higher CONUT group exhibited a significantly higher mean right atrial pressure (10.9 ± 4.7 vs. 7.3 ± 4.1 mmHg; p = 0.0019). In that group, the mortality rate was significantly higher (25% vs. 2.6%; p = 0.0059) and the Kaplan-Meier analysis showed lower survival rate. Furthermore, more bleeding events significantly occurred in the higher CONUT group. The preoperative CONUT score may reflect systemic venous congestion and offer a useful prognostic index of clinical courses after LVAD implantation.
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19
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Imamura T, Narang N, Nitta D, Fujino T, Nguyen A, Chung B, Holzhauser L, Kim G, Raikhelkar J, Kalantari S, Smith B, Juricek C, Rodgers D, Ota T, Song T, Jeevanandam V, Sayer G, Uriel N. HeartWare Ventricular Assist Device Cannula Position and Hemocompatibility-Related Adverse Events. Ann Thorac Surg 2020; 110:911-917. [PMID: 32035046 PMCID: PMC7416438 DOI: 10.1016/j.athoracsur.2019.12.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/25/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND HeartWare ventricular assist device (HVAD) cannula position is associated with hemodynamics and heart failure readmissions. However, its impact on hemocompatibility-related adverse events (HRAEs) remains uncertain. METHODS HVAD patients were followed for 1 year after index hospitalization, when cannula coronal angle was quantified from chest x-ray film. Invasive right heart catheterization and transthoracic echocardiography were performed. One-year occurrences of each HRAE were compared between those with and without a cannula coronal angle of greater than 65 degrees. RESULTS Among 63 HVAD patients (median age 60 years, 63% male), 10 (16%) had a cannula coronal angle greater than 65 degrees. The wide-angle group had elevated intracardiac pressures and lower pulmonary artery pulsatility index (P < .05). They also had reduced right ventricular function by echocardiography. Freedom from HRAEs tended to be lower in the wide-angle group (24% vs 62%; P = .11). The rate of gastrointestinal bleeding was significantly higher in the greater than 65 degrees group (0.90 events/year vs 0.40 events/year; P = .013). The rates of stroke and pump thrombosis were statistically comparable irrespective of cannula angle (P > .05). CONCLUSIONS HVAD cannula coronal angle was associated with reduced right ventricular function and HRAEs. Prospective studies evaluating surgical techniques to ensure optimal device positioning and its effects on HRAEs are warranted.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois; Second Department of Medicine, University of Toyama, Toyama, Japan.
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Daisuke Nitta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Luise Holzhauser
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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20
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Imamura T, Mehta P, Nguyen A, Chung B, Narang N, Rodgers D, Raikhelkar J, Smith B, Song T, Ota T, Jeevanandam V, Kim G, Sayer G, Uriel N. Neurohormonal Blockade During Left Ventricular Assist Device Support. ASAIO J 2020; 66:881-885. [PMID: 32740347 DOI: 10.1097/mat.0000000000001104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Neurohormonal blockade (NHB) is the mainstay of therapy for patients with systolic heart failure (HF). However, the efficacy in patients with left ventricular assist devices (LVADs) remains unknown. Of all, 114 LVAD patients (57 [48, 65] years old and 78% male) were enrolled and followed during the early period (6 months after index discharge), and 98 were followed during the late period (6-12 months following index discharge). Of them, 46% were on beta-blocker (BB), 49% on angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin II receptor blocker (ARB), and 51% on aldosterone antagonist at baseline. Prevalence of BB and ACEi/ARB use increased during the study period. During the early period, similar event rates were found irrespective of the NHB uses. During the late period, BB was associated with reduced HF readmission, and ACEi/ARB was associated with reduced HF readmission and gastrointestinal bleeding (p < 0.05 for all). In conclusion, BB and ACEi/ARB use during the late period was associated with a reduction in HF recurrence in LVAD patients. Further prospective randomized control trials are warranted to clarify the utility of NHB therapy in LVAD patients.
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Affiliation(s)
- Teruhiko Imamura
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Priya Mehta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Section of Cardiothoracic Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Valluvan Jeevanandam
- Section of Cardiothoracic Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
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21
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Xanthopoulos A, Tryposkiadis K, Triposkiadis F, Fukamachi K, Soltesz EG, Young JB, Wolski K, Blackstone EH, Starling RC. Postimplant Phosphodiesterase Type 5 Inhibitors Use Is Associated With Lower Rates of Thrombotic Events After Left Ventricular Assist Device Implantation. J Am Heart Assoc 2020; 9:e015897. [PMID: 32648508 PMCID: PMC7660717 DOI: 10.1161/jaha.119.015897] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Left ventricular assist device (LVAD) thrombosis is clinically devastating and impacts the cost effectiveness of LVAD therapy for advanced heart failure. Anticoagulation and antiplatelet therapies represent the standard of care to mitigate LVAD thrombosis. Phosphodiesterase type 5 inhibitors (PDE-5is) exhibit hemodynamic, antiplatelet, and antithrombotic effects. Using a national registry, we examined the relationship of PDE-5i use on thrombotic events in patients with continuous-flow LVADs. Methods and Results We obtained data from 13 772 patients with continuous flow LVADs participating in a national registry. Patients implanted with primary LVADs from 2012 to 2017 were included in the analysis. The primary end point was a composite of LVAD thrombosis and ischemic stroke. Patients were analyzed according to any use of PDE-5i after LVAD implantation (PDE-5i group) versus no use after LVAD implantation (no PDE-5i group). The primary end point was significantly lower in the PDE-5i group compared with the no PDE-5i group (hazard ratio [HR], 0.84; 95% CI, 0.77-0.91; P<0.001) at 48 months. The components of the primary end point (LVAD thrombosis: HR, 0.82; 95% CI, 0.74-0.90; P<0.001; and ischemic stroke: HR, 0.85; 95% CI, 0.75-0.97; P=0.019), as well as the secondary end point all-cause mortality (HR, 0.86; 95% CI, 0.79-0.93; P<0.001) were lower in the PDE-5i group versus the no PDE-5i at 48 months post LVAD. The favorable results observed with postimplant PDE-5i use were consistent with both axial and centrifugal flow devices. Conclusions The postimplant use of PDE-5i was associated with fewer thrombotic events and improved survival in LVAD patients. A randomized clinical trial is warranted to confirm these findings.
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Affiliation(s)
- Andrew Xanthopoulos
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | | | | | - Kiyotaka Fukamachi
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Edward G Soltesz
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - James B Young
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Kathy Wolski
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Eugene H Blackstone
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Randall C Starling
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
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22
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Darling CE, Martindale JL, Hiestand BC, Bonnell M, Colvin M, DeFilippis EM, Elliott T, Hamad E, Pinney SP, Shah KB, Vierecke J, Givertz MM. An Emergency Medicine-focused Summary of the HFSA/SAEM/ISHLT Clinical Consensus Document on the Emergency Management of Patients With Ventricular Assist Devices. Acad Emerg Med 2020; 27:618-629. [PMID: 32176420 DOI: 10.1111/acem.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
Mechanical circulatory support is increasingly used as a long-term treatment option for patients with end-stage heart failure. Patients with implanted ventricular assist devices are at high risk for a range of diverse medical urgencies and emergencies. Given the increasing prevalence of mechanical circulatory support devices, this expert clinical consensus document seeks to help inform emergency medicine and prehospital providers regarding the approach to acute medical and surgical conditions encountered in these complex patients.
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Affiliation(s)
- Chad E. Darling
- UMass Memorial Medical Center UMass Medical School Worcester MA
| | | | | | | | | | | | | | - Eman Hamad
- Temple University Hospital Philadelphia PA
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23
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Imamura T, Narang N, Nitta D, Fujino T, Nguyen A, Kim G, Raikhelkar J, Rodgers D, Ota T, Jeevanandam V, Sayer G, Uriel N. Optimal cannula positioning of HeartMate 3 left ventricular assist device. Artif Organs 2020; 44:e509-e519. [PMID: 32557769 DOI: 10.1111/aor.13755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/30/2022]
Abstract
Cannula position in HeartMate II and HeartWare left ventricular assist devices (LVADs) is associated with clinical outcome. This study aimed to investigate the clinical implication of the device positioning in HeartMate 3 LVAD cohort. Consecutive patients who underwent HeartMate 3 LVAD implantation were followed for one year from index discharge. At index discharge, chest X-ray parameters were measured: (a) cannula coronal angle, (b) height of pump bottom, (c) cannula sagittal angle, and (d) cannula lumen area. The association of each measurement of cannula position with one-year clinical outcomes was investigated. Sixty-four HeartMate 3 LVAD patients (58 years old, 64% male) were enrolled. In the multivariable Cox regression model, the cannula coronal angle was a significant predictor of death or heart failure readmission (hazard ratio 1.27 [1.01-1.60], P = .045). Patients with a cannula coronal angle ≤28° had lower central venous pressure (P = .030), lower pulmonary capillary wedge pressure (P = .027), and smaller left ventricular size (P = .019) compared to those with the angle >28°. Right ventricular size and parameters of right ventricular function were also better in the narrow angle group, as was one-year cumulative incidence of death or heart failure readmission (10% vs. 50%, P = .008). Narrow cannula coronal angle in patients with HeartMate 3 LVADs was associated with improved cardiac unloading and lower incidence of death or heart failure readmission. Larger studies to confirm the implication of optimal device positioning are warranted.
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Affiliation(s)
- Teruhiko Imamura
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA.,Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Nikhil Narang
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Daisuke Nitta
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Takeo Fujino
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Ann Nguyen
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Gene Kim
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Daniel Rodgers
- Division of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Gabriel Sayer
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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24
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Cruz Rodriguez JB, Stewart GC, Pamboukian SV, Tallaj JA, Rajapreyar I, Kirklin JK, Holman WL, Hoopes CW, Mukherjee D, Mallawaarachchi I, Dwivedi A, Acharya D. Clinical characteristics and outcomes of patients requiring prolonged inotropes after left ventricular assist device implantation. Artif Organs 2020; 44:E382-E393. [PMID: 32242954 DOI: 10.1111/aor.13692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 01/14/2023]
Abstract
Limited data exist regarding patients with continuous-flow left ventricular assist device (LVAD) support who require long-term inotropes. Our primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU). Secondary endpoints were to compare predictors of PIU, mortality, risk of late re-initiation of inotropes, time to gastrointestinal bleed (GIB), infection, and arrhythmias. Retrospective cohort study was conducted on adult patients with primary continuous-flow LVADs implanted from January 2008 to February 2017 and the patients were followed up through February 2018. We defined PIU as ≥14 days of inotrope support. Kaplan-Meier method, competing risk models and Cox proportional hazard models were used. Final analytic sample was 203 patients, 58% required PIU, and 10% were discharged on inotropes. There was no difference in preimplant characteristics. One-year survival rate was 87% if no PIU required, 74% if PIU required, and 72% if discharged on inotropes. PIU was associated with longer length of stay and higher incidence of GIB. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. Adjusted hazard risk of death was increased in patients with PIU (HR = 1.66, P = .046), older age (HR = 1.28, P = .031), and higher creatinine levels (HR = 1.60, P = .007). Prolonged inotrope use is frequently encountered following LVAD implantation and is associated with adverse prognosis but remains a therapeutic option. Inability to wean inotropes prior to hospital discharge is a marker of patients at particularly higher risk of mortality following LVAD implantation.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jose A Tallaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William L Holman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles W Hoopes
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Indika Mallawaarachchi
- Department of Epidemiology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Alok Dwivedi
- Department of Epidemiology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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25
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The Combination of Tricuspid Annular Plane Systolic Excursion and HeartMate Risk Score Predicts Right Ventricular Failure After Left Ventricular Assist Device Implantation. ASAIO J 2020; 65:247-251. [PMID: 29734261 DOI: 10.1097/mat.0000000000000808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Right ventricular (RV) failure is difficult to predict and is a major determinant of poor outcomes after left ventricular assist device (LVAD) implantation. We evaluated the associations of the following variables with severe RV failure in LVAD patients: tricuspid annular plane systolic excursion (TAPSE), pulmonary artery pulsatility index (PAPi), simplified RV contraction pressure index (sRVCPI), and HeartMate Risk Score (HMRS). We performed a retrospective case-control study on 216 patients who underwent continuous-flow LVAD implantation between 2008 and 2014. The primary analysis assessed the ability of HMRS, PAPi, sRVCPI, and TAPSE to predict severe RV failure. A secondary analysis evaluated the incremental benefit of combining predictive variables. Seventy-four patients developed severe RV failure (24%). Compared with the control group, the severe RV failure group had lower TAPSE (1.30 vs. 1.55; p < 0.001), lower PAPi (1.77 vs. 2.47; p = 0.001), lower sRVCPI (42.71 vs. 57.82; p < 0.001), and higher HMRS (2.12 vs. 1.65; p < 0.001). All four variables had similar receiver operating characteristic curves with modest area under the receiver operating characteristic curve (0.63-0.67, all p values < 0.001). In the evaluation of combined predictive variables, the combination of TAPSE with HMRS was found to be best for predicting severe RV failure. In summary, patients at risk for severe RV failure after LVAD implantation were successfully identified using TAPSE, PAPi, sRCPI, and HMRS. The combination of TAPSE and HMRS-incidentally, the least invasive and most readily available variables-proved to be superior to RV-centric metrics for predicting severe RV failure. The predictive and clinical use of these two variables should be tested prospectively.
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Mathews L, Ishigami J, Ding N, Hoogeveen RC, Kucharska-Newton A, Ballantyne CM, Gottesman R, Selvin E, Matsushita K. Cardiac Biomarkers and Subsequent Risk of Hospitalization With Bleeding in the Community: Atherosclerosis Risk in Communities Study. J Am Heart Assoc 2020; 9:e013560. [PMID: 32114886 PMCID: PMC7335570 DOI: 10.1161/jaha.119.013560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background hs‐cTnT (high‐sensitivity cardiac troponin T), but not NT‐proBNP (N‐terminal pro–B natriuretic peptide), has been shown to predict bleeding in patients with atrial fibrillation. Whether these biomarkers are independently associated with bleeding in the general population is unknown. Methods and Results We used Cox proportional hazards models to examine the association of hs‐cTnT and NT‐proBNP with incident bleeding (defined by International Classification of Diseases, Ninth Revision [ICD‐9] codes) among 9550 middle‐aged men and women without a history of cardiovascular disease or bleeding. There were 847 hospitalizations with bleeding (92% from gastrointestinal bleeding) during a median follow‐up of 9.0 years. Serum levels of hs‐cTnT were associated with bleeding in a graded fashion, with a hazard ratio of 1.28 (95% CI, 1.06–1.59) for 6 to <9 ng/L, 1.52 (1.21–1.91) for 9 to <14, and 2.05 (1.56–2.69) for ≥14 versus <3 ng/L. For NT‐proBNP, the highest category (≥264 versus <42 pg/mL) showed a hazard ratio of 2.00 (1.59–2.61), and the remaining 3 categories had hazard ratios ranging from 1.2 to 1.3. Individuals in the highest category of both hs‐cTnT and NT‐proBNP had a hazard ratio of 3.03 (1.97–4.68) compared with those in the lowest categories. Conclusions In a community‐based population, elevated hs‐cTnT and NT‐proBNP were associated with bleeding‐related hospitalizations. These biomarkers may have a high utility in identifying people at high risk for bleeding. There is a need for research on the underlying mechanisms linking subclinical cardiac abnormalities and bleeding.
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Affiliation(s)
- Lena Mathews
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD.,Division of Cardiology Johns Hopkins School of Medicine Baltimore MD
| | - Junichi Ishigami
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Ning Ding
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Ron C Hoogeveen
- Department of Medicine Baylor College of Medicine Houston TX
| | - Anna Kucharska-Newton
- Gillings School of Global Public Health University of North Carolina at Chapel Hill NC.,College of Public Health University of Kentucky Lexington KY
| | | | - Rebecca Gottesman
- Department of Neurology Johns Hopkins School of Medicine Baltimore MD
| | - Elizabeth Selvin
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Kunihiro Matsushita
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
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27
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Taylor C, Bittner K, Bartell N, Aranez J, Alexis JD, Carlson B, Chen L, McNitt S, Kothari T, Kaul V, Kothari S. Outcomes of gastrointestinal bleeding in patients with left ventricular assist devices: a tertiary care experience. Endosc Int Open 2020; 8:E301-E309. [PMID: 32140555 PMCID: PMC7055617 DOI: 10.1055/a-1090-7200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Left ventricular assist device (LVAD) placement is a therapeutic modality for patients with end-stage heart failure. Gastrointestinal bleeding is a common complication following LVAD implantation. The aim of this study was to report our experience in management and outcomes of gastrointestinal bleeding in a large cohort of patients with LVADs. Patients and methods We performed a retrospective review of all patients who underwent LVAD implantation at the University of Rochester Medical Center from January 2008 to June 2017. Data were collected on patient characteristics, clinical aspects of gastrointestinal bleeding events, and procedural interventions. A Cox proportional hazard model was utilized to identify potential risk factors for a gastrointestinal bleeding event. Results During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2 %) experienced 297 gastrointestinal bleeding events resulting in 533 endoscopic procedures. The diagnostic yield of endoscopy in determining a bleeding source was 49.5 %. If required, therapeutic interventions were successful in achieving homeostasis in 96.2 % of procedures. Our 30-day overall post-procedure adverse event (AE) rate was 6.6 %. Procedure-related (bleeding, infection, and perforation) AEs were very minimal (2.8 %). A Cox proportional hazard model indicated that older age at implant, female sex, African-American race, diabetes mellitus, and pulmonary hypertension were statistically significant predictors of a gastrointestinal bleeding event following LVAD implantation. Conclusions LVAD patients have a high risk of gastrointestinal bleeding. Endoscopy was able to safely locate a bleeding lesion in approximately half of our patients and was successful in treating bleeding lesions in a majority of the cases.
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Affiliation(s)
- Caren Taylor
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Krystle Bittner
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Nicholas Bartell
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jose Aranez
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jeffrey D Alexis
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Beth Carlson
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Leway Chen
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Scott McNitt
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Truptesh Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Vivek Kaul
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Shivangi Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
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28
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Imamura T, Nitta D, Fujino T, Smith B, Kalantari S, Nguyen A, Narang N, Holzhauser L, Rodgers D, Song T, Ota T, Jeevanandam V, Kim G, Sayer G, Uriel N. Deep Y-Descent in Right Atrial Waveforms Following Left Ventricular Assist Device Implantation. J Card Fail 2020; 26:360-367. [PMID: 31935459 DOI: 10.1016/j.cardfail.2020.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/17/2019] [Accepted: 01/02/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Characterization of right heart catheterization (RHC) waveforms provides diagnostic and clinical information in heart failure patients. We aimed to investigate the implication of RHC waveforms, specifically the y-descent, in patients with left ventricular assist device (LVAD). METHODS AND RESULTS Patients underwent RHC and waveforms were quantified prior to and 6 months after LVAD implantation. The impact of a deep y-descent (>3 mmHg) on echocardiographic measures of right heart function and 1-year hemocompatibility-related adverse event rates were investigated. Eighty-nine patients (median 59 years old, 65 male) underwent RHC. RHC waveform showed unique changes following LVAD implantation, particularly an increase in the steepness of the y-descent. A post-LVAD deep y-descent was associated with reduced right ventricular function and enlarged right heart. Patients with post-LVAD deep y-descent had higher rates of gastrointestinal bleeding (0.866 vs 0.191 events/year) and stroke (0.199 vs 0 events/year) compared with those without (P< .05 for both). CONCLUSION RHC waveforms characterized by deep y-descent on RHC waveform during LVAD support was associated with impaired right ventricular function and worse clinical outcomes.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
| | - Daisuke Nitta
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeo Fujino
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Luise Holzhauser
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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29
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Imamura T, Nguyen A, Rodgers D, Kim G, Raikhelkar J, Kalantari S, Narang N, Juricek C, Ota T, Jeevanandam V, Sayer G, Uriel N. Omega-3 and hemocompatibility-related adverse events. J Card Surg 2019; 35:405-412. [PMID: 31850548 DOI: 10.1111/jocs.14384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hemocompatibility-related clinical adverse events (HRAEs) are major causes of readmission in patients with left ventricular assist devices (LVADs). Omega-3 is an unsaturated fatty acid that possesses anti-inflammatory and antiangiogenic properties. We aimed to investigate the impact of omega-3 therapy on HRAEs during LVAD support. METHODS Consecutive LVAD patients who were followed for 6 months were enrolled, and stratified by the use of omega-3. Freedom from any HRAEs and net burden of HRAEs, which was calculated by using a hemocompatibility score (using 4 escalating tiers of hierarchal severity to derive a total score for events), were compared between those with and without omega-3 therapy. RESULTS Among 169 LVAD patients (57 years old and 124 males), 31 patients received 4 g/d of omega-3 therapy and 138 patients were in the control group. During the 6-month observational period, freedom from any HRAEs was 90% in the omega-3 group compared with 70% in the control group with a hazard ratio of 0.35 (95% confidence interval 0.11-0.87 and P = .042). The average hemocompatibility score in the omega-3 group was significantly lower compared with the control group (0.23 vs 0.91; P = .042), due to reduced Tier I scores (mild HRAE; P = .003) and Tier IIIB scores (severe HRAE; P < .001). The similar trends remained at propensity-matched populations. CONCLUSIONS Omega-3 therapy was associated with reduced HRAEs including both bleeding and thromboembolic events in LVAD patients.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.,Second Department of Medicine, University of Toyama, Toyama, Japan
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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30
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Ventricular arrhythmias in patients with biventricular assist devices. J Interv Card Electrophysiol 2019; 58:243-252. [PMID: 31838665 PMCID: PMC7293581 DOI: 10.1007/s10840-019-00682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Ventricular arrhythmias (VAs) are common in patients after left ventricular assist device (LVAD) implant and are associated with worse outcomes. However, the prevalence and impact of VA in patients with durable biventricular assist device (BIVAD) is unknown. We performed a retrospective cohort study of patients with BIVADs to evaluate the prevalence of VA and their clinical outcomes. METHODS Consecutive patients who received a BIVAD between June 2014 and July 2017 at our medical center were included. The prevalence of VA, defined as sustained ventricular tachycardia or fibrillation requiring defibrillation or ICD therapy, was compared between BIVAD patients and a propensity-matched population of patients with LVAD from our center. The occurrence of adverse clinical events was compared between BIVAD patients with and without VA. RESULTS Of the 13 patients with BIVADs, 6 patients (46%) experienced clinically significant VA, similar to a propensity-matched LVAD population (38%, p = 1.00). There were no differences in baseline characteristics between the two cohorts, except patients in the non-VA group who had worse hemodynamics (mitral regurgitation and right-sided indices), had less history of VA, and were younger. BIVAD patients with VA had a higher incidence of major bleeding (MR 3.05 (1.07-8.66), p = 0.036) and worse composite outcomes (log-rank test, p = 0.046). The presence of VA was associated with worse outcomes in both LVAD and BIVAD groups. CONCLUSIONS Ventricular arrhythmias are common in patients with BIVADs and are associated with worse outcomes. Future work should assess whether therapies such as ablation improve the outcome of BIVAD patients with VA.
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31
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The incidence, risk factors, and outcomes of gastrointestinal bleeding in patients with a left ventricular assist device: a Japanese single-center cohort study. J Artif Organs 2019; 23:27-35. [PMID: 31705323 DOI: 10.1007/s10047-019-01138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 10/05/2019] [Indexed: 01/12/2023]
Abstract
Continuous flow-left ventricular assist devices (CF-LVADs) have become a therapeutic option in the management of advanced heart failure. Several studies show that patients with CF-LVAD are at an increased risk of gastrointestinal bleeding (GIB). However, few reports have presented the characteristics of GIB in Japanese populations. We investigated the incidence, etiology, and outcome of GIB in patients with CF-LVAD. Records of adult patients who received CF-LVADs between October 2008 and January 2017 were reviewed. GIB was defined as detection of bleeding sites by any type of diagnostic imaging. 54 patients received CF-LVAD, of which eight (14%) presented with overt GIB (12 events). GIB patients are significantly older (p = 0.04) and their pre-operative inferior vena cava diameter was larger (p = 0.02). Multivariate analysis revealed that the use of Jarvik 2000 (p = 0.003) was a risk factor for GIB. In total, 85.8% of patients were free from GIB at 1 year. The most common site was the small intestine (67%). The most common cause was angiodysplasia (50%). Six patients required blood transfusion (nine events) and four underwent endoscopic clippings (five events); however, no patients needed surgeries. The incidence of GIB in our cohort was similar to the global registry data. Double balloon endoscopy is useful for diagnosis and treatment of small intestinal lesions. Future efforts to further understand the incidence of GIB in Japanese populations by multicenter data are needed.
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32
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Urban M, Siddique A, Moulton MM, Castleberry AW, Merritt-Genore H, Ryan T, Lowes B, Um JY. Can we expect improvements in outcomes with centrifugal vs axial flow left ventricular assist devices in patients transitioned from extracorporeal life support? J Card Surg 2019; 34:1228-1234. [PMID: 31478259 DOI: 10.1111/jocs.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several patient-related characteristics have been associated with inferior outcomes following durable left ventricular assist device (LVAD) implantation in patients transitioned from venoarterial extracorporeal membrane oxygenation (VA ECMO). The impact of LVAD pump type used is less well-known. METHODS We compared outcomes between patents who received axial and centrifugal flow LVADs following stabilization with VA ECMO. RESULTS From January 2011 to December 2018, we implanted 28 LVADs in patients transitioned from VA ECMO. This included 17 axial flow devices (HeartMate II LVAD, Abbott Laboratories, Chicago, IL) and 11 centrifugal flow pumps (eight HeartWare HVADs; Medtronic, Minneapolis, MN and three HeartMate 3 LVAS pumps; Abbott Laboratories, Chicago, IL). There was no difference in hospital mortality (23.5% vs 18.2%, P = .74) or 1-year survival (P = .31) between the devices. There were no differences in adverse event rates between the two pump types, apart from a higher rate of gastrointestinal bleeding in patients who received centrifugal flow pumps (1.44 events per 100 patient-months vs 14.67 events per 100 patient-months, P = .010). Preimplantation levels of alanine aminotransferase (hazard ratio [HR], 1.001; 95% confidence interval [CI], 1.000 to 1.002; P = .004) and elevated serum creatinine level (HR, 3.480; 95% CI, 1.121-10.807; P = .031) emerged as significant predictors of decreased 1-year survival. CONCLUSIONS Preimplantation optimization of end-organ function is the single most important determinant of successful post-LVAD survival in patients transitioned from extracorporeal life support. There is no association of pump type with LVAD outcomes up to 1-year post implantation.
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Affiliation(s)
- Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael M Moulton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Anthony W Castleberry
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - HelenMari Merritt-Genore
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Timothy Ryan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Brian Lowes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - John Y Um
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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Imamura T, Kim G, Nitta D, Fujino T, Smith B, Kalantari S, Nguyen A, Narang N, Holzhauser L, Grinstein J, Juricek C, Rodgers D, Song T, Ota T, Jeevanandam V, Sayer G, Uriel N. Aortic Insufficiency and Hemocompatibility-related Adverse Events in Patients with Left Ventricular Assist Devices. J Card Fail 2019; 25:787-794. [PMID: 31419485 DOI: 10.1016/j.cardfail.2019.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/18/2019] [Accepted: 08/06/2019] [Indexed: 11/18/2022]
Abstract
AIM Hemocompatibility-related adverse events (HRAE) are a major cause of readmissions in patients with left ventricular assist devices (LVAD). The impact of aortic insufficiency (AI) on HRAE remains uncertain. We aimed to investigate the impact of AI on HRAE. METHODS AND RESULTS Patients who underwent LVAD implantation between August 2014 and July 2017 and had echocardiograms 3 months post-LVAD implantation were enrolled. AI severity was assessed by measuring the systolic/diastolic ratio of flow and the rate of diastolic flow acceleration using Doppler echocardiography of the outflow cannula. Regurgitation fraction was derived from these parameters. Significant AI was defined as regurgitation fraction > 30%. Among 105 patients (median age, 56 years; 76% male), 36 patients (34%) had significant AI. Baseline characteristics were statistically not significantly different between those with and without significant AI except for higher rates of ischemic etiology and atrial fibrillation in the significant AI group (P < 0.05 for both). One-year survival free from HRAE was 44% in patients with AI compared to 67% in patients without significant AI (P = 0.018). The average hemocompatibility score, which defines the net burden of HRAE, was higher in the AI group (1.72 vs 0.64; P = 0.009), due mostly to higher tier I (mild HRAE; P = 0.034) and tier IIIB scores (severe HRAE; P = 0.011). CONCLUSION Significant AI, as assessed by Doppler echocardiographic parameters, was associated with HRAE during LVAD support.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daisuke Nitta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Luise Holzhauser
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jonathan Grinstein
- Division of Cardiology, MedStar Heart and Vascular Institute Advanced Heart Failure and Cardiac Transplantation, NW, Washington, D.C
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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Yin MY, Ruckel S, Kfoury AG, McKellar SH, Taleb I, Gilbert EM, Nativi-Nicolau J, Stehlik J, Reid BB, Koliopoulou A, Stoddard GJ, Fang JC, Drakos SG, Selzman CH, Wever-Pinzon O. Novel Model to Predict Gastrointestinal Bleeding During Left Ventricular Assist Device Support. Circ Heart Fail 2019; 11:e005267. [PMID: 30571195 DOI: 10.1161/circheartfailure.118.005267] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a leading cause of morbidity during continuous-flow left ventricular assist device (CF-LVAD) support. GIB risk assessment could have important implications for candidate selection, informed consent, and postimplant therapeutic strategies. The aim of the study is to derive and validate a predictive model of GIB in CF-LVAD patients. METHODS AND RESULTS CF-LVAD recipients at the Utah Transplantation Affiliated Hospitals program between 2004 and 2017 were included. GIB associated with a decrease in hemoglobin ≥2 g/dL was the primary end point. A weighted score comprising preimplant variables independently associated with GIB was derived and internally validated. A total of 351 patients (median age, 59 years; 82% male) were included. After a median of 196 days, GIB occurred in 120 (34%) patients. Independent predictors of GIB included age >54 years, history of previous bleeding, coronary artery disease, chronic kidney disease, severe right ventricular dysfunction, mean pulmonary artery pressure <18 mm Hg, and fasting glucose >107 mg/dL. A weighted score termed Utah bleeding risk score, effectively stratified patients based on their probability of GIB: low (0-1 points) 4.8%, intermediate (2-4) 39.8%, and high risk (5-9) 83.8%. Discrimination was good in the development sample (c-index: 0.83) and after internal bootstrap validation (c-index: 0.74). CONCLUSIONS The novel Utah bleeding risk score is a simple tool that can provide personalized GIB risk estimates in CF-LVAD patients. This scoring system may assist clinicians and investigators in designing tailored risk-based strategies aimed at reducing the burden posed by GIB in the individual CF-LVAD patient and healthcare systems.
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Affiliation(s)
- Michael Yaoyao Yin
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Shane Ruckel
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Abdallah G Kfoury
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Salt Lake City, UT (A.G.K., B.B.R.)
| | - Stephen H McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Iosif Taleb
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Edward M Gilbert
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Josef Stehlik
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Bruce B Reid
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Salt Lake City, UT (A.G.K., B.B.R.)
| | - Antigone Koliopoulou
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
| | - Gregory J Stoddard
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
| | - James C Fang
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Stavros G Drakos
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Omar Wever-Pinzon
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
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Peters AE, Smith LA, Ababio P, Breathett K, McMurry TL, Kennedy JLW, Abuannadi M, Bergin J, Mazimba S. Comparative Analysis of Established Risk Scores and Novel Hemodynamic Metrics in Predicting Right Ventricular Failure in Left Ventricular Assist Device Patients. J Card Fail 2019; 25:620-628. [PMID: 30790625 PMCID: PMC6945118 DOI: 10.1016/j.cardfail.2019.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 01/15/2019] [Accepted: 02/12/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Right ventricular failure (RVF) portends poor outcomes after left ventricular assist device (LVAD) implantation. Although numerous RVF predictive models have been developed, there are few independent comparative analyses of these risk models. METHODS AND RESULTS RVF was defined as use of inotropes for >14 days, inhaled pulmonary vasodilators for >48 hours or unplanned right ventricular mechanical support postoperatively during the index hospitalization. Risk models were evaluated for the primary outcome of RVF by means of logistic regression and receiver operating characteristic curves. Among 93 LVAD patients with complete data from 2011 to 2016, the Michigan RVF score (C = 0.74 [95% CI 0.61-0.87]; P = .0004) was the only risk model to demonstrate significant discrimination for RVF, compared with newer risk scores (Utah, Pitt, EuroMACS). Among individual hemodynamic/echocardiographic metrics, preoperative right ventricular dysfunction (C = 0.72 [95% CI 0.58-0.85]; P = .0022) also demonstrated significant discrimination of RVF. The Michigan RVF score was also the best predictor of in-hospital mortality (C = 0.67 [95% CI 0.52-0.83]; P = .0319) and 3-year survival (Kaplan-Meier log-rank 0.0135). CONCLUSIONS In external validation analysis, the more established Michigan RVF score-which emphasizes preoperative hemodynamic instability and target end-organ dysfunction-performed best, albeit modestly, in predicting RVF and demonstrated association with in-hospital and long-term mortality.
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Affiliation(s)
- Anthony E Peters
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - LaVone A Smith
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Priscilla Ababio
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Mohammad Abuannadi
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - James Bergin
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia.
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36
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices. J Card Fail 2019; 25:494-515. [DOI: 10.1016/j.cardfail.2019.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
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Asleh R, Schettle S, Briasoulis A, Killian JM, Stulak JM, Pereira NL, Kushwaha SS, Maltais S, Dunlay SM. Predictors and Outcomes of Renal Replacement Therapy After Left Ventricular Assist Device Implantation. Mayo Clin Proc 2019; 94:1003-1014. [PMID: 31171114 DOI: 10.1016/j.mayocp.2018.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/25/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To examine the frequency and outcomes of patients requiring renal replacement therapy (RRT) early after left ventricular assist device (LVAD) implantation. PATIENTS AND METHODS We examined use of in-hospital RRT and outcomes in consecutive adults who underwent continuous-flow LVAD implantation from February 15, 2007, through August 8, 2017. Logistic regression was used to examine predictors of RRT. The associations of RRT with outcomes were examined using Cox proportional hazards regression. RESULTS Of 354 patients who underwent LVAD implantation, 54 (15%) required in-hospital RRT. Patients receiving RRT had higher preoperative Charlson Comorbidity Index values (median, 5 vs 4; P=.03), Model for End-Stage Liver Disease scores (mean, 19.0 vs 14.5; P<.001), right atrial pressure (mean, 19.1 vs 13.4 mm Hg; P<.001), and estimated 24-hour urine protein levels (median, 357 vs 174 mg; P<.001) and lower preoperative estimated glomerular filtration rate (eGFR) (median, 43 vs 57 mL/min; P<.001) and measured GFR using 125I-iothalamate clearance (median, 33 vs 51 mL/min; P=.001) than those who did not require RRT. Approximately 40% of patients with eGFR less than 45 mL/min/1.73 m2 and 24-hour urine protein level greater than 400 mg required RRT vs 6% with eGFR greater than45 mL/min/1.73 m2 and without significant proteinuria. Lower preoperative eGFR, higher estimated 24-hour urine protein level, higher right atrial pressure, and longer cardiopulmonary bypass time were independent predictors of RRT after LVAD implantation. Of patients requiring in-hospital RRT, 18 (33%) had renal recovery, 18 (33%) required outpatient hemodialysis, and 18 (33%) died before hospital discharge. After median (Q1, Q3) follow-up of 24.3 (8.9, 49.6) months, RRT was associated with increased risk of death (adjusted hazard ratio [HR], 2.86; 95% CI, 1.90-4.33; P<.001) and gastrointestinal bleeding (adjusted HR, 4.47; 95% CI, 2.57-7.75; P<.001). CONCLUSION In-hospital RRT is associated with poor prognosis after LVAD. A detailed preoperative assessment of renal function before LVAD may be helpful in risk stratification and patient selection.
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Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Sarah Schettle
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City
| | - Jill M Killian
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Simon Maltais
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
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Miller RJH, Gregory AJ, Kent W, Banerjee D, Hiesinger W, Clarke B. Predicting Transfusions During Left Ventricular Assist Device Implant. Semin Thorac Cardiovasc Surg 2019; 32:747-755. [PMID: 31128255 DOI: 10.1053/j.semtcvs.2019.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/17/2019] [Indexed: 01/28/2023]
Abstract
Perioperative bleeding and transfusion cause morbidity and mortality in patients receiving left ventricular assist devices (LVADs). We assessed factors associated with transfusions within 30 days of durable LVAD implantation and the clinical outcomes associated with transfusions. A retrospective cohort study of patients undergoing initial durable LVAD implantation between 2014 and 2016 was performed. Rates of packed red blood cell (PRBC) or other blood product transfusions (platelets or fresh frozen plasma) were assessed. Ordinal multivariable regression analysis was performed to determine factors independently associated with transfusion. Analysis included 156 patients, mean age 54.6 years and 74.4% male, who received a mean of 11.7 units of PRBC and 10.0 units of other products within 30 days. Preimplant mechanical ventilation, dialysis, higher INR, previous sternotomy, higher model for end-stage liver disease score, and lower hemoglobin were associated with increased PRBC transfusion rates. Higher preoperative central venous pressure, mechanical ventilation, concomitant surgical procedures, previous sternotomy, and lower hemoglobin were associated with increased PRBC transfusion rates within 48 hours of implant (adjusted odds ratio [OR] 1.46, P = 0.013 per 5 mm Hg). There were no significant associations with ferritin (adjusted OR 1.00, P = 0.236) or transferrin saturation (adjusted OR 1.17, P = 0.068). Transfusions were associated with an increase in ventilation duration, intensive care unit length of stay, reoperation for bleeding, and all-cause mortality. In patients undergoing LVAD implantation, perioperative blood product exposure is common and associated with increased morbidity and mortality. Elevated central venous pressure and anemia are potentially modifiable factors associated with increased early PRBC transfusion rates.
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Affiliation(s)
- Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada; Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Alexander J Gregory
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - William Kent
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Dipanjan Banerjee
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - William Hiesinger
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Brian Clarke
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
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Imamura T, Kinugawa K, Ono M, Kinoshita O, Fukushima N, Shiose A, Matsui Y, Yamazaki K, Saiki Y, Usui A, Niinami H, Matsumiya G, Arai H, Sawa Y. Implication of Preoperative Existence of Atrial Fibrillation on Hemocompatibility-Related Adverse Events During Left Ventricular Assist Device Support. Circ J 2019; 83:1286-1292. [PMID: 31019163 DOI: 10.1253/circj.cj-18-1215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hemocompatibility-related adverse events (HRAEs) are substantial issues in patients with left ventricular assist devices (LVADs). Atrial fibrillation (AF) is associated with worse prognosis in patients with heart failure (HF), but its effect on HRAEs following LVAD implantation remain uncertain.Methods and Results:Data from the Japanese Mechanically Assisted Circulatory Support registry of consecutive patients who received HeartMate II LVADs and were followed for 1 year were retrospectively reviewed. Among 190 patients, 23 had AF and 167 had sinus rhythm. The AF group had comparable baseline characteristics with the non-AF group except for their higher age (53 vs. 42 years, P<0.001). Following LVAD implantation, most cases of AF (73%) persisted. Antiplatelet therapy, anticoagulation therapy, and LVAD speed following LVAD implantation were comparable between groups (P>0.05 for all). The 1-year survival free from HRAEs was comparable between groups (83% vs. 76%, P=0.52). Event rates of the breakdown of HRAEs were comparable between groups except for a relatively higher rate of surgically managed pump thrombosis in the AF group (0.16 vs. 0.04, incidence rate ratio 3.75, 95% confidence interval 0.87-16.1, P=0.075). These trends still remained with propensity score-matched comparison. CONCLUSIONS Existence of AF had no effect on the development of HRAEs following LVAD implantation. The need to aggressively treat AF before or after LVAD implantation needs further investigation.
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Affiliation(s)
| | | | - Minoru Ono
- Department of Cardiac Surgery, the University of Tokyo Hospital
| | - Osamu Kinoshita
- Department of Cardiac Surgery, the University of Tokyo Hospital
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, Tokyo Women's Medical University
| | | | - Akihiko Usui
- Department of Cardiovascular Surgery, Nagoya University Hospital
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Saitama Kokusai Medical Center
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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40
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Thohan V, Shi Y, Rappelt M, Yousefzai R, Sulemanjee NZ, Hastings TE, Cheema OM, Downey F, Crouch JD. The association between novel clinical factors and gastrointestinal bleeding among patients supported with continuous-flow left ventricular assist device therapy. J Card Surg 2019; 34:453-462. [PMID: 31058372 DOI: 10.1111/jocs.14062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/15/2019] [Accepted: 04/11/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study explores novel preimplantation risk factors associated with gastrointestinal bleeding (GIB) after continuous-flow left ventricular assist device (CF-LVAD) implantation. CF-LVAD therapy implantation for patients with advanced heart failure is associated with a 20% to 40% incidence of GIB. METHODS This study includes patients receiving CF-LVAD at a quaternary medical center from 2006 to 2014 (n = 254). The primary endpoint was GIB within 12 months after implantation; the secondary outcome was 3-year all-cause mortality. The Student t test or the χ2 test compared continuous or categorical variables. Competing risks analysis calculated the cumulative incidence of GIB postimplantation. Cox proportional hazards model was used for univariate/multivariate models predicting GIB. RESULTS Sixty-four patients had GIB, with incidence rates at 1, 3, and 12 months of 11.8%, 19.3%, and 25.2%, respectively. Endoscopy revealed no identified source of bleeding in 41%; 33% of lesions were localized in the upper gastrointestinal tract, with the bulk (39%) categorized as vascular. Patients with prior gastrointestinal abnormalities (n = 98) had a greater risk of GIB post-CF-LVAD (HR 1.85 [1.11-3.09]; P = 0.02) than those with normal gastrointestinal evaluation results (n = 45) and those without preimplantation gastrointestinal evaluation (n = 111). Baseline blood urea nitrogen, chronic obstructive pulmonary disease, and prior percutaneous coronary intervention were statistically associated with post-CF-LVAD GIB. The presence of GIB within 12 months of CF-LVAD implantation was associated with an increased risk of 3-year all-cause mortality (HR 2.57 [1.57-4.15]; P < 0.01). CONCLUSIONS First-year GIB is associated with increased mortality post-CF-LVAD. We advocate a closer examination of several GIB risk factors when evaluating CF-LVAD candidates.
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Affiliation(s)
- Vinay Thohan
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Yang Shi
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Matthew Rappelt
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Rayan Yousefzai
- Department of Cardiology, Brown University, Providence, Rhode Island
| | - Nasir Z Sulemanjee
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Thomas E Hastings
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Omar M Cheema
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Frank Downey
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - John D Crouch
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
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41
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Gastrointestinal Bleeding With Left Ventricular Assist Devices (LVAD): Locating the Leak and Identifying Outcomes. J Clin Gastroenterol 2019; 53:e202-e207. [PMID: 29688916 DOI: 10.1097/mcg.0000000000001041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND GOALS Gastrointestinal bleeding (GIB) is a significant complication following left ventricular assist device (LVAD) implantation. We evaluated the incidence, predictors, endoscopic findings, and outcomes of GIB in LVAD recipients. STUDY Retrospective review of 205 adult patients undergoing HeartMate II LVAD implantation from January 2012 to June 2016. Patients were reviewed and separated into GIB (n=57; 28%) and non-GIB (n=148; 72%) groups. RESULTS Median time to GIB was 55 (range, 3 to 730) days. The GIB group patients were older (61±12 vs. 56±13, P=0.0042), more often underwent concomitant tricuspid valve (TV) repair (16% vs. 4%, P=0.007), and a higher percentage were assigned for destination therapy (75% vs. 55%, P=0.01). Angioectasia (33%) was the most common identified cause of GIB. Median time to endoscopic intervention was 1 day. The total number of hospital readmissions after LVAD was higher in the GIB group (median of 5 vs. 3, P=0.001), as was the total number of blood products transfused after LVAD (29 vs. 13, P≤0.0001). GIB was associated with an increased risk of death (hazard ratio, 1.94; 95% confidence interval, 1.16-3.25; P=0.01) and the mortality rate during hospitalization for GIB was 11% (P=0.0004). Receiving a heart transplant was associated with a decreased hazard of death (hazard ratio, 0.40; 95% confidence interval, 0.19-0.85; P=0.016). CONCLUSIONS Older age and destination therapy as implant strategy were found to be associated with an increased risk of GIB, consistent with previous studies. A unique finding in our study is the association of TV repair with a higher incidence of GIB. Further studies are needed to investigate possible mechanisms by which TV repair increases the incidence of GIB.
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Sparrow CT, LaRue SJ, Schilling JD. Intersection of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients on Left Ventricular Assist Device Support: Is There a Role for Pulmonary Vasodilators? Circ Heart Fail 2019; 11:e004255. [PMID: 29321132 DOI: 10.1161/circheartfailure.117.004255] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life in patients with advanced heart failure. Despite these benefits, combined post- and precapillary pulmonary hypertension can be particularly problematic in patients on LVAD support, often exacerbating right ventricular (RV) dysfunction. Both persistently elevated pulmonary vascular resistance and RV dysfunction are associated with adverse outcomes, including death after LVAD. These observations have led to significant interest in the use of pulmonary vasodilators to treat pulmonary hypertension and preserve RV function among LVAD-supported patients. Although pulmonary vasodilators are commonly used for the treatment of pulmonary hypertension and RV dysfunction in LVADs, the benefits of this practice remain unclear. The purpose of this review is to highlight the current challenges in managing pulmonary vascular disease and RV dysfunction in patients with heart failure on LVAD support.
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Affiliation(s)
- Christopher T Sparrow
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Shane J LaRue
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Joel D Schilling
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO.
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Risk Factors of Gastrointestinal Bleeding After Continuous Flow Left Ventricular Assist Device. ASAIO J 2019; 64:458-461. [PMID: 28957820 DOI: 10.1097/mat.0000000000000678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This study aimed to compare von Willebrand factor (vWF) levels, ristocetin cofactor levels, platelet counts, aortic valve movements, and right heart failure (RHF) as risk factors of gastrointestinal (GI) bleeding in patients with continuous flow left ventricular assist device (cf-LVAD). In a single centre, 90 patients (mean age 52.0 ± 10.5 years), of which 59 were male and 31 were female, had cf-LVAD implantation from October 2010 to November 2012. Seventy-six (84.4%) patients had HeartWare (Medtronic, Mounds View, MN) and 14 (15.5%) had Heartmate II (Thoratec, Pleasanton, CA) implanted. vWF level, ristocetin cofactor level, and platelet count were measured before and after implantation to determine the presence of acquired von Willebrand Syndrome; aortic valve movement and postoperative RHF were evaluated to compare the difference in bleeding and nonbleeding patient groups. Fifteen patients (16.6%) suffered GI bleeding after cf-LVAD implantation. A statistically significant decrease was found in vWF and ristocetin cofactor levels from preoperative period to postoperative period in both bleeding and nonbleeding patient groups (p < 0.05). There was no significant difference in bleeding and nonbleeding groups regarding aortic valve movements (p ≥ 0.05). Postoperative RHF incidence was significantly high in the bleeding patient group compared with the nonbleeding group (p < 0.05). Therefore, depending on the findings of this study, acquired von Willebrand Syndrome was seen in all cf-LVAD patients, and postoperative RHF was an important risk factor for GI bleeding.
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Abstract
Patients with Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels 1-2 who either have or are at risk for right ventricular failure face significant morbidity and mortality after continuous flow left ventricular assist device (CF-LVAD) implantation. Currently, the options for biventricular support are limited the Total Artificial Heart (TAH; CardioWest, Syncardia, Tuscon, AZ) or biventricular assist device (BiVAD), which uses bulky extracorporeal or implantable displacement pumps. We describe a successful series based on an innovative approach for biventricular support in consecutive INTERMACS levels 1-2 patients utilizing a HeartWare Ventricular Assist Device (HVAD; HeartWare, Framingham, MA) in a left ventricular (LV-HVAD) and a right atrial (RA-HVAD) configuration. From June 2014 through May 2016, 11 consecutive INTERMACS levels 1-2 patients with evidence of biventricular failure underwent implantation of a CF LVAD (10 LV-HVAD and 1 HeartMate II LVAD, Thoratec, Pleasanton, CA) and RA-HVAD pumps. A total of 4,314 BiVAD support days were accumulated in our case series. Seven patients have undergone orthotopic heart transplant, whereas 3 are ambulatory and are either waiting transplant or reconsideration for transplantation. There is one mortality in this case series, which was due to an intracranial bleed from supratherapeutic anticoagulation. Two other patients experienced hemorrhagic strokes, but without neurologic sequelae, whereas no patients have experienced ischemic strokes. There were two episodes of gastrointestinal bleeding. This is the largest series to date involving this approach with outcomes superior to those previously described in patients receiving biventricular support. We conclude this novel therapy is a viable alternative to current practices in the management of biventricular failure.
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Imamura T, Nguyen A, Kim G, Raikhelkar J, Sarswat N, Kalantari S, Smith B, Juricek C, Rodgers D, Ota T, Song T, Jeevanandam V, Sayer G, Uriel N. Optimal haemodynamics during left ventricular assist device support are associated with reduced haemocompatibility-related adverse events. Eur J Heart Fail 2018; 21:655-662. [PMID: 30592363 DOI: 10.1002/ejhf.1372] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/05/2018] [Accepted: 10/29/2018] [Indexed: 01/13/2023] Open
Abstract
AIMS Left ventricular assist device (LVAD) therapy improves the haemodynamics of advanced heart failure patients. However, it is unknown whether haemodynamic optimization improves haemocompatibility-related adverse events (HRAEs). This study aimed to assess HRAEs in patients with optimized haemodynamics. METHODS AND RESULTS Eighty-three outpatients [aged 61 (53-67) years, 50 male] underwent a haemodynamic ramp test at 253 (95-652) days after LVAD implantation, and 51 (61%) had optimized haemodynamics (defined as central venous pressure < 12 mmHg, pulmonary artery wedge pressure < 18 mmHg, cardiac index > 2.2 L/min/m2 ) following LVAD speed adjustment. One-year survival free of any HRAEs (non-surgical bleeding, thromboembolic event, pump thrombosis, or neurological event) was achieved in 75% of the optimized group and in 44% of the non-optimized group (hazard ratio 0.36, 95% confidence interval 0.18-0.73, P = 0.003). The net haemocompatibility score, using four escalating tiers of hierarchal severity to derive a total score for events, was significantly lower in the optimized group than the non-optimized group (1.02 vs. 2.00 points/patient; incidence rate ratio 0.51, 95% confidence interval 0.29-0.90, P = 0.021). CONCLUSION Left ventricular assist device patients in whom haemodynamics can be optimized had greater freedom from HRAEs compared to those without optimized haemodynamics.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
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Imamura T, Kinugawa K, Uriel N. Therapeutic Strategy for Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device. Circ J 2018; 82:2931-2938. [DOI: 10.1253/circj.cj-18-0883] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center
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Joly JM, El-Dabh A, Kirklin JK, Marshell R, Smith MG, Acharya D, Rajapreyar IN, Tallaj JA, Tresler M, Pamboukian SV. High Right Atrial Pressure and Low Pulse Pressure Predict Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device. J Card Fail 2018; 24:487-493. [DOI: 10.1016/j.cardfail.2018.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 02/11/2018] [Accepted: 03/09/2018] [Indexed: 11/17/2022]
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Association of Pulsatility with Gastrointestinal Bleeding in a Cohort of HeartMate II Recipients. ASAIO J 2018; 64:472-479. [PMID: 29489463 DOI: 10.1097/mat.0000000000000766] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Solving the Puzzle of the Hematologic-Left Ventricular Assist Device Interface One Piece at a Time. ASAIO J 2018; 64:431-432. [PMID: 29901474 DOI: 10.1097/mat.0000000000000848] [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] Open
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Preoperative Right-Sided Cardiac Congestion Is Associated with Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices. Dig Dis Sci 2018; 63:1518-1524. [PMID: 29417325 DOI: 10.1007/s10620-018-4916-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/06/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Large scale data on preoperative risk stratification for gastrointestinal bleeding (GIB) following continuous-flow left ventricular assist device (CF-LVAD) implantation are scarce. AIMS To identify independent predictors for GIB following CF-LVAD implantation. METHODS We conducted a retrospective cohort study of consecutive 243 patients who underwent CF-LVAD implantation (HeartMateII) from January 2009 to March 2015 at the University of Chicago Medical Center. GIB was defined as the presence of overt bleeding or occult GIB with ≥ 2 g/dl drop in hemoglobin (Hgb) from recorded baseline values and hemoccult-positive stool. The preoperative and postoperative data were reviewed. RESULTS Within a median follow-up duration of 408 (IQR 113-954) days, 83 (34%) patients developed GIB after a median of 149 (IQR 27-615) days after implantation of CF-LVAD. There were no significant differences between the groups of GIB and non-GIB with respect to preoperative demographics and comorbidity except for ethnicity. The source of bleeding was identified in 39 (47%) patients and arteriovenous malformation or submucosal streaming vessel was the most frequent cause of bleeding (18/39, 46%). Multivariate-adjusted analysis demonstrated preoperative central venous pressure (CVP) ≥ 18 mmHg (HR 3.56; 95% CI 1.16-10.9; p = 0.026), mean pulmonary artery pressure (mPA) ≥ 36 mmHg (HR 4.14; 95% CI 1.35-12.7; p = 0.013), and the presence of moderate/severe tricuspid valve disease (HR 1.01; 95% CI 1.01-3.86; p = 0.046) were associated with the risk of GIB. CONCLUSIONS In this study, preoperative right-sided cardiac congestion (i.e., increased CVP, mPA and the presence of moderate/severe tricuspid valve disease) was associated with GIB in patients with CF-LVAD.
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