Risk of stroke early after implantation of a left ventricular assist device

Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation

During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16 months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2 years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00-1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00-1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.

Mechanical circulatory support for adults in Japan: A 10-year perspective

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.

Direct Cardiac Compression Devices to Augment Heart Biomechanics and Function

The treatment of end-stage heart failure has evolved substantially with advances in medical treatment, cardiac transplantation, and mechanical circulatory support (MCS) devices such as left ventricular assist devices and total artificial hearts. However, current MCS devices are inherently blood contacting and can lead to potential complications including pump thrombosis, hemorrhage, stroke, and hemolysis. Attempts to address these issues and avoid blood contact led to the concept of compressing the failing heart from the epicardial surface and the design of direct cardiac compression (DCC) devices. We review the fundamental concepts related to DCC, present the foundational devices and recent devices in the research and commercialization stages, and discuss the milestones required for clinical translation and adoption of this technology. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Children who stroke on VAD support: when is it safe to transplant and what are their outcomes?

OBJECTIVE

Ventricular assist devices (VADs) increase waitlist survival, yet the risk of stroke remains notable. The purpose of this study was to analyze how strokes on VAD support impact post-transplant (post-Tx) outcomes in children.

METHODS

520 pediatric (<18 yo) heart transplant candidates listed from January 2011 to April 2018 with a VAD implant date were matched between the United Network of Organ Sharing and Pediatric Health Information System databases. Patients were divided into pre-Tx Stroke and No Stroke cohorts.

RESULTS

81% of the 520 patients were transplanted. 28% (n=146) had a pre-Tx Stroke. 59% (n=89) of the Stroke patients were transplanted at a median of 57 (IQR 17-102) days from stroke. Significantly more No Stroke cohort (90%) were transplanted (p<0.001). There was no difference in post-Tx survival between the Stroke and No Stroke cohorts (p=0.440). Time between stroke and transplant for patients who died within one year of transplant was 32.0 days (median) compared to 60.5 days for those alive > 1year (p=0.18). Regarding patients in whom time from stroke to transplant was more than 60 days, one-year survival of Stroke vs. No Stroke patients was 96% vs. 95% (p=0.811), respectively.

CONCLUSION

Patients with stroke during VAD support, once transplanted, enjoy similar survival compared to No Stroke patients. We hypothesize that allowing Stroke patients more time to recover could improve post-Tx outcomes. Unfortunately, the ideal duration of time between stroke and safe transplantation could not be determined and will require more detailed and larger studies in the future.

Predictive Value of Blood Parameters and Comorbidities on Three-Month Mortality in Elderly Patients With Hip Fracture

Background Knowing the factors that increase the risk of death in patients with hip fractures will help us to take precautions and intervene when necessary in the pre- and postoperative periods. Therefore, it is important to have inexpensive and practical biomarkers that can predict postoperative complications and mortality. The present study aimed to identify the factors that contribute to early mortality in elderly patients with hip fractures in the first three months after trauma, as well as the parameters that may be determinants of mortality. Methods The data of 1,015 patients over 65 years of age with femoral neck and intertrochanteric fractures admitted between January 2009 and January 2020 were retrospectively reviewed. A total of 763 patients who met the inclusion criteria were included in the study. Our study was designed to include 110 (14.4%) patients in Group 1 who were determined to have died within three months after the diagnosis of hip fracture and 653 (85.6%) patients in Group 2 who were determined not to have died within one year after the trauma. Age, gender, comorbid diseases, American Society of Anesthesiologists (ASA) score, type of anesthesia, operation time, type of implant used, time until surgery, and some biochemical blood values were compared between the two groups. Our data were analyzed statistically using the IBM Statistical Product and Service Solutions (SPSS) software for Windows, v. 25.0 (IBM SPSS Statistics for Windows, Armonk, NY). Results Of all of the patients, 370 (48.5%) were female and 393 (51.5%) were male. The patients who survived had an average age of 76.08, while the patients who died had an average age of 80.57. The mean age among the groups is significantly higher in patients who died. High creatinine, alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and low albumin values were found to be associated with mortality. Conclusion It has been determined that advanced age, delayed operation time, high ASA score, and the number of comorbid diseases are associated with mortality in elderly patients with hip fractures, and biomarkers, such as creatinine, ALT, and LDH, can be used as markers for early mortality. With the increase of studies of similar nature, it will be possible to calculate a systematic risk map for mortality in elderly patients with a proximal femur fracture.

Two-Year Follow Up of the LATERAL Clinical Trial: A Focus on Adverse Events

BACKGROUND

The LATERAL trial validated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare HVAD System, leading to Food and Drug Administration approval. We sought to analyze 24-month adverse event (AE) rates, including a temporal analysis of the risk profile, associated with the thoracotomy approach for the HVAD system.

METHODS

AEs from the LATERAL trial were evaluated over 2 years postimplant. Data was obtained from the Interagency Registry for Mechanically Assisted Circulatory Support database for 144 enrolled United States and Canadian patients. Temporal AE profiles were expressed as events per patient year.

RESULTS

During 162.5 patient years of support, there were 25 driveline infections (0.15 events per patient year), 50 gastrointestinal bleeds (0.31 events per patient year), and 21 strokes (0.13 events per patient year). Longitudinal AE analysis at follow-up intervals of <30 and 30 to 180 days, and 6 to 12 and 12 to 24 months revealed the highest AE rate at <30 days, with a decrease in total AEs within the first 6 months. After 6 months, most AE rates either stabilized or decreased through 2 years, including a 95% overall freedom from disabling stroke.

CONCLUSIONS

Two-year follow-up of the LATERAL trial revealed a favorable morbidity profile in patients supported with the HVAD system, as AE rates were more likely to occur in the first 30 days postimplant, and overall AE rates were significantly reduced after 6 months. Importantly, 2-year freedom from disabling stroke was 95%. These data further support the improving AE profile of patients on long-term HVAD support. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02268942.