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Kwon JH, Skidmore SH, Bhandari K, Carnicelli AP, Yourshaw JP, Shorbaji K, Kilic A. Waitlist and transplant outcomes in heart transplant candidates bridged with temporary endovascular right ventricular assist devices. J Heart Lung Transplant 2024; 43:369-378. [PMID: 37951321 DOI: 10.1016/j.healun.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Advances in mechanical circulatory support and changes in allocation policy have shifted waitlisting practices for heart transplantation (HT) in the United States. This analysis reports waitlist and transplant outcomes among HT candidates bridged with temporary endovascular right ventricular assist devices (tRVADs). METHODS Patients awaiting HT from 2008 to 2022 in the United Network of Organ Sharing registry were grouped by the presence of tRVAD while waitlisted and propensity matched. Waitlist outcomes were HT and a competing outcome of death/deterioration requiring waitlist inactivation. Competing-risks regression was used to model waitlist outcomes. Subanalyses were performed to compare waitlist outcomes among patients with durable and temporary left ventricular assist devices (LVADs) with and without concomitant tRVADs. One-year posttransplant mortality was estimated using Kaplan-Meier analysis. RESULTS Of 41,507 HT candidates, 133 (0.3%) had tRVADs. After propensity matching, patients with tRVAD had a similar likelihood of HT and an elevated hazard for death/deterioration (hazard ratio 2.2, 95% confidence interval 1.4-3.2, p < 0.001) compared to those without tRVAD. Most patients with tRVAD (84%) had concomitant LVADs. tRVAD was associated with an elevated risk for deterioration/death among those with temporary LVADs but not durable LVADs. For patients undergoing HT, tRVAD was associated with an increased risk for 1-year mortality compared to propensity-matched recipients. CONCLUSIONS Bridging with tRVAD is uncommon and primarily used in patients requiring biventricular support. tRVADs are associated with waitlist inactivation or death, particularly with concomitant temporary LVAD support. As temporary devices are increasingly used as a bridge to HT, outcomes of patients with tRVADs should inform future allocation policy, particularly for candidates with biventricular failure.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Savannah H Skidmore
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Krishna Bhandari
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Jeffrey P Yourshaw
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Akiyama K, Colombo PC, Stöhr EJ, Ji R, Wu IY, Itatani K, Miyazaki S, Nishino T, Nakamura N, Nakajima Y, McDonnell BJ, Takeda K, Yuzefpolskaya M, Takayama H. Blood flow kinetic energy is a novel marker for right ventricular global systolic function in patients with left ventricular assist device therapy. Front Cardiovasc Med 2023; 10:1093576. [PMID: 37260947 PMCID: PMC10228750 DOI: 10.3389/fcvm.2023.1093576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/02/2023] [Indexed: 06/02/2023] Open
Abstract
Objectives Right ventricular (RV) failure remains a major concern in heart failure (HF) patients undergoing left ventricular assist device (LVAD) implantation. We aimed to measure the kinetic energy of blood in the RV outflow tract (KE-RVOT) - a new marker of RV global systolic function. We also aimed to assess the relationship of KE-RVOT to other echocardiographic parameters in all subjects and assess the relationship of KE-RVOT to hemodynamic parameters of RV performance in HF patients. Methods Fifty-one subjects were prospectively enrolled into 4 groups (healthy controls, NYHA Class II, NYHA Class IV, LVAD patients) as follows: 11 healthy controls, 32 HF patients (8 NYHA Class II and 24 Class IV), and 8 patients with preexisting LVADs. The 24 Class IV HF patients included 21 pre-LVAD and 3 pre-transplant patients. Echocardiographic parameters of RV function (TAPSE, St', Et', IVA, MPI) and RV outflow color-Doppler images were recorded in all patients. Invasive hemodynamic parameters of RV function were collected in all Class IV HF patients. KE-RVOT was derived from color-Doppler imaging using a vector flow mapping proprietary software. Kruskal-Wallis test was performed for comparison of KE-RVOT in each group. Correlation between KE-RVOT and echocardiographic/hemodynamic parameters was assessed by linear regression analysis. Receiver operating characteristic curves for the ability of KE-RVOT to predict early phase RV failure were generated. Results KE-RVOT (median ± IQR) was higher in healthy controls (55.10 [39.70 to 76.43] mW/m) than in the Class II HF group (22.23 [15.41 to 35.58] mW/m, p < 0.005). KE-RVOT was further reduced in the Class IV HF group (9.02 [5.33 to 11.94] mW/m, p < 0.05). KE-RVOT was lower in the LVAD group (25.03 [9.88 to 38.98] mW/m) than the healthy controls group (p < 0.005). KE-RVOT had significant correlation with all echocardiographic parameters and no correlation with invasive hemodynamic parameters. RV failure occurred in 12 patients who underwent LVAD implantation in the Class IV HF group (1 patient was not eligible due to death immediately after the LVAD implantation). KE-RVOT cut-off value for prediction of RV failure was 9.15 mW/m (sensitivity: 0.67, specificity: 0.75, AUC: 0.66). Conclusions KE-RVOT, a novel noninvasive measure of RV function, strongly correlates with well-established echocardiographic markers of RV performance. KE-RVOT is the energy generated by RV wall contraction. Therefore, KE-RVOT may reflect global RV function. The utility of KE-RVOT in prediction of RV failure post LVAD implantation requires further study.
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Affiliation(s)
- Koichi Akiyama
- Department of Anesthesiology, Kindai University Hospital, Osakasayama, Japan
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Paolo C. Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Eric J. Stöhr
- COR-HELIX (CardiOvascular Regulation and Exercise Laboratory-Integration and Xploration), Institute of Sport Science, Leibniz University Hannover, Hannover, Germany
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Isaac Y. Wu
- Department of Anesthesiology, University of Rochester Medical Center, Rochester, NY, United States
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Nagoya City University, Nagoya, Japan
| | | | | | - Naotoshi Nakamura
- iBLab (interdisciplinary Biology Laboratory), Division of Natural Science, Graduate School of Science, Nagoya University, Nagoya, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kindai University Hospital, Osakasayama, Japan
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Koji Takeda
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Hiroo Takayama
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
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Avci G, Nalbantgil S, Kemal H, Ertugay S, Engin C, Yagdi T, Ozabaran M. Preoperative and perioperative predictors of right ventricular failure after left ventricular assist device implantation. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2022. [DOI: 10.4103/ijca.ijca_2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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Løgstrup BB, Nemec P, Schoenrath F, Gummert J, Pya Y, Potapov E, Netuka I, Ramjankhan F, Parner ET, De By T, Eiskjaer H. Heart failure etiology and risk of right heart failure in adult left ventricular assist device support: the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). SCAND CARDIOVASC J 2020; 54:306-314. [PMID: 32552049 DOI: 10.1080/14017431.2020.1781239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Development of right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation remains a leading cause of perioperative morbidity, end-organ dysfunction and mortality. The objective of this study was to investigate whether the etiology of HF (ischemic HF versus non-ischemic HF) affects the risk of RVF within admission for LVAD implantation and during long-term follow-up. Methods: Between January 2011 and June 27, 2018, 3536 patients were prospectively enrolled into EUROMACS registry. Adult patients (>18 years) who received a first time LVAD were included. When excluding patients with congenital, restrictive, hypertrophic, valvular cardiomyopathies, and myocarditis the total population consisted of 2404 patients. Results: The total cohort consists of 2404 patients. Mean age were 55 years and predominantly male sex [2024 (84.2%)]. At the time of LVAD implantation 1355 (56.4%) patients had ischemic HF and 1049 (43.6%) patients had non-ischemic HF. The incidence of RVF was significantly increased in the non-ischemic HF group in the adjusted model (p = .026). The relative risk difference for RVF in patients with non-ischemic HF was in the adjusted model increased by an absolute value of 5.1% (95% CI: 0.61-9.6). In the ischemic HF group 76 patients (13.4%) developed late RVF and 62 patients (14.8%) in the non-ischemic HF group (p = .56). No differences in occurrence of RVF between HF etiology was observed after 2 and 4 years of follow-up, respectively (crude: p = .25, adjusted (sex and age) p = .2 and crude: p = .59, adjusted (sex and age) p = .44). Conclusions: Patients with non-ischemic HF undergoing LVAD had an increased incidence of early RVF compared to patients with ischemic HF in a large European population. During follow-up after discharge 14% patients developed RVF. We recommend HF etiology to be considered in identifying patients who are at risk for postoperative RVF after LVAD implantation.
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Affiliation(s)
| | - Petr Nemec
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Felix Schoenrath
- Department of Cardiac, Thoracic and Vascular Surgery, German Heart Institute, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Yuri Pya
- Department of Adult Cardiac Surgery, National Research Center for Cardiac Surgery, Astana, Kazakhstan
| | - Evgenij Potapov
- Department of Cardiac, Thoracic and Vascular Surgery, German Heart Institute, Berlin, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | | | - Eric Thorlund Parner
- Department of Public Health, Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Theo De By
- EUROMACS, European Registry for Patients with Mechanical Circulatory Support, EACTS, Windsor, UK
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Dandel M, Javier MFDM, Javier Delmo EMD, Hetzer R. Accurate assessment of right heart function before and after long-term left ventricular assist device implantation. Expert Rev Cardiovasc Ther 2020; 18:289-308. [DOI: 10.1080/14779072.2020.1761790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Michael Dandel
- Department of Cardiology, Cardio Centrum Berlin, Berlin, Germany
| | | | | | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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6
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Hamdan R, Charif F, Kadri Z. Right ventricle failure in patients treated with left ventricular assist device. Ann Cardiol Angeiol (Paris) 2020; 69:51-54. [PMID: 32127195 DOI: 10.1016/j.ancard.2020.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 01/16/2020] [Indexed: 11/28/2022]
Abstract
This review article aim to highlight the right ventricular function peri left ventricular assist device implantation, and to assess the incidence, physiopathology, predictors, management and prognosis, of right ventricular failure post-implant.
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Affiliation(s)
- R Hamdan
- Cardiology department, Beirut Cardiac Institute, Beirut, Lebanon.
| | - F Charif
- Pneumology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Z Kadri
- Cardiology department, Hôtel-Dieu de France, Beirut , Lebanon
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Khorsandi M, Schroder J, Daneshmand M, Bishawi M, Bouamra O, Winterton P, Choi AY, Patel C, Rogers J, Del Rio JM, Milano C. Outcomes After Extracorporeal Right Ventricular Assist Device Combined With Durable Left Ventricular Assist Device Support. Ann Thorac Surg 2018; 107:1768-1774. [PMID: 30582926 DOI: 10.1016/j.athoracsur.2018.11.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/13/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Right heart failure occurs in 9% to 44% of left ventricular assist device (LVAD) implants, of which less than 10% require right ventricular assist device (RVAD) support either concurrently with the LVAD or staged, as a delayed procedure. We have reported our outcomes based on whether the RVAD was placed concurrently or staged. METHODS Clinical data were obtained from the Duke University Medical Center database. The study focused on all consecutive adult patients who received continuous flow LVAD with either concurrent or staged (within 7 days) extracorporeal, temporary RVAD, between October 2007 and October 2017. Adverse event profiles and ability to wean from RVAD were compared between these two groups. RESULTS Overall, 43 patients required an extracorporeal RVAD; 67% (n = 29) were implanted concurrently and 33% (n = 14) were implanted as staged after the LVAD. In all, 67% of patients (n = 29) could be weaned to an isolated LVAD. The 30-day, inhospital, and total mortality rates for our cohort were 14%, 28%, and 51% respectively. The mortality rate in the study period for the staged implants was 71% versus 45% for the concurrent implants (p = 0.101). In addition, staged RVAD implantation carried a significantly higher rate of postoperative renal failure (64% versus 28%, p = 0.044). CONCLUSIONS There was a low incidence of need for RVAD in our cohort. The majority could be weaned to an isolated LVAD. Morbidity and mortality rates of this mode of biventricular support remain high. Early institution of RVAD support was associated with reduced rates of post-LVAD renal failure rates.
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Affiliation(s)
- Maziar Khorsandi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Jacob Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Omar Bouamra
- Department of Medical Statistics, Trauma Audit and Research Network, University of Manchester, Manchester, United Kingdom
| | - Patrick Winterton
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ashley Y Choi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chetan Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - J Mauricio Del Rio
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
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Ferrari G, Górczyńska K, Mimmo R, De Lazzari C, Clemente F, Tosti G, Guaragno M. Mono and Bi-ventricular Assistance: Their Effect on Ventricular Energetics. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When mono- and bi-ventricular mechanical assistance is used for heart recovery, its control strategy and circulatory variables affect ventricular energetics (external work-EW, oxygen consumption-VO2, cardiac mechanical efficiency-CME). This study is based on the data obtained in vitro and presents an analysis of the effects of the mono- and bi-ventricular mechanical assistance on ventricular energetics. The assistance was conducted on the principle of counterpulsation with atrio-arterial connection. It includes the following stages: 1) the characterisation of the isolated ventricle model in terms of EW, VO2 and CME as a function of the filling pressure and peripheral resistance, 2) modelling of left ventricular and pulmonary dysfunction, followed by left ventricular and bi-ventricular assistance. Experimental data enable us to draw the following conclusions: • in general, the greatest hemodynamic improvement does not correspond to the highest energetic improvement, • LVAD assistance deteriorates left ventricular CME while its effect on right ventricular energetics depends on the value of right ventricular elastance (Emax). Right ventricular CME is deteriorated by BVAD assistance irrespective of right Emax, • the energetics optimisation in bi-ventricular assistance is closely related to the right Emax, which could probably be a deciding factor in the choice of the assistance mode.
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Affiliation(s)
- G. Ferrari
- CNR Institute for Biomedical Technology, Rome - Italy
| | - K. Górczyńska
- PAN Institute of Biocybernetics and Biomedical Engineering, Warsaw - Poland
| | - R. Mimmo
- CNR Institute for Biomedical Technology, Rome - Italy
| | - C. De Lazzari
- CNR Institute for Biomedical Technology, Rome - Italy
| | - F. Clemente
- CNR Institute for Biomedical Technology, Rome - Italy
| | - G. Tosti
- CNR Institute for Biomedical Technology, Rome - Italy
| | - M. Guaragno
- CNR Institute for Biomedical Technology, Rome - Italy
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9
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Biventricular Support With Intracorporeal, Continuous Flow, Centrifugal Ventricular Assist Devices. Ann Thorac Surg 2018; 105:548-555. [DOI: 10.1016/j.athoracsur.2017.08.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/27/2017] [Accepted: 08/07/2017] [Indexed: 11/20/2022]
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10
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Frequency and Consequences of Right-Sided Heart Failure After Continuous-Flow Left Ventricular Assist Device Implantation. Am J Cardiol 2018; 121:336-342. [PMID: 29223289 DOI: 10.1016/j.amjcard.2017.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/21/2022]
Abstract
Postoperative right-sided heart failure (RHF) is a common complication after continuous-flow left ventricular assist device implantation. Studies have examined RHF in the perioperative period, but few have assessed late-onset RHF. We analyzed the incidence of early and late RHF in patients with HeartMate II and HeartWare left ventricular assist devices and associated morbidity, mortality, and independent predictors of RHF. We retrospectively analyzed records of 526 patients with chronic heart failure who underwent continuous-flow left ventricular assist device implantation; 147 (27.9%) developed RHF (early RHF, n = 87, 16.5%; late RHF, n = 74, 14.4%). We examined demographics, postoperative complications, and long-term survival rate. Patients with RHF or late RHF had higher mortality (p <0.001) than those without RHF. Patients with RHF had a higher incidence of acute kidney injury (20.4% vs 11.9%, p = 0.01). Device type did not affect the incidence of early, late, or overall RHF. Patients with severe RHF requiring right ventricular assist device support had a low success of bridge to transplantation (11.1% vs 33.3%, p = 0.02). In Cox regression models, RHF was an independent predictor of mortality (hazard ratio = 1.69, 95% confidence interval = 1.28 to 2.22, p <0.001), but no predictive variables of RHF were identified. RHF was significantly associated with increased mortality and a higher incidence of postoperative acute kidney injury. RHF decreased the success rate of bridging patients to transplantation when a right ventricular assist device was required.
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Chung BB, Sayer G, Uriel N. Mechanical circulatory support devices: methods to optimize hemodynamics during use. Expert Rev Med Devices 2018; 14:343-353. [PMID: 28448170 DOI: 10.1080/17434440.2017.1324292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Mechanical circulatory support (MCS) is an increasingly utilized mode of therapy in the management of advanced heart failure, both as bridge to heart transplantation and destination therapy. As MCS becomes more prevalent, it is ever more important to understand the complex hemodynamics of these devices, as well as the strategies for hemodynamic optimization. Areas covered: This review provides an overview of hemodynamics in the normal human heart and the failing heart. We discuss the various short-term mechanical circulatory support devices and their hemodynamic consequences. We will then discuss the differences between left ventricular assist devices, and the impact of these differences on hemodynamics. We will describe the strategies for hemodynamic optimization using echocardiographic and invasive ramp studies. Finally, we will discuss the impact of speed changes with exercise and discuss future directions for advancements in MCS therapies. Expert commentary: We advocate for a deeper understanding of the hemodynamics underpinning MCS devices. We also recommend the more widespread use of ramp studies for speed optimization, which have been well validated across a number of different left ventricular assist device types.
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Affiliation(s)
- Ben Bow Chung
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Gabriel Sayer
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Nir Uriel
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
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Shin JS, Sun K, Son HS, Kim HM, Kim KT, Ahn SS, Park SY, Rho YR, Lee HS, Min BG. A Preclinical Cadaver Fitting Study of Implantable Biventricular Assist Device - AnyHeart™. Int J Artif Organs 2018; 27:495-500. [PMID: 15293355 DOI: 10.1177/039139880402700608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A multifunctional, Korean-made artificial heart (AnyHeart™) was developed, and prior to its clinical application, a cadaver-fitting study was performed. The study proposed to determine the optimal cannulation approach, implantation technique and route of the cannula to minimize the organ compression of AnyHeart™. The anatomical feasibility and a variety of surgical techniques were evaluated using ten preserved, human cadavers. Implanting AnyHeart™ with ease is possible using various approaches, including a median sternotomy, and a right or left lateral thoracotomy. The lateral thoracotomy approach is shown to be safe and reproducible, especially in patients who have already undergone an operation that used a median sternotomy. The results of this study will guide improvements in the designs of cannulae and AnyHeart™ for future clinical applications.
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Affiliation(s)
- J S Shin
- Department of Thoracic and Cardiovascular Surgery, College of Medicine and Cardiovascular Institute of Medical Science Research Center, Korea University, Seoul, Korea
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13
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Jensen CW, Goldstone AB, Woo YJ. Treatment and Prognosis of Pulmonary Hypertension in the Left Ventricular Assist Device Patient. Curr Heart Fail Rep 2017; 13:140-50. [PMID: 27241336 DOI: 10.1007/s11897-016-0288-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This review will discuss the medical management of pulmonary hypertension in patients with left ventricular assist devices. Although much has been written on the management of primary pulmonary hypertension, also called pulmonary arterial hypertension, this review will instead focus on the treatment of pulmonary hypertension secondary to left heart disease. The relevant pharmacotherapy can be divided into medications for treating heart failure, such as diuretics and β-blockers, and medications for treating pulmonary hypertension. We also discuss important preoperative considerations in patients with pulmonary hypertension; the relationships between left ventricular assist devices, pulmonary hemodynamics, and right heart failure; as well as optimal perioperative and long-term postoperative medical management of pulmonary hypertension.
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Affiliation(s)
- Christopher W Jensen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Falk Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.
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Cohrs NH, Petrou A, Loepfe M, Yliruka M, Schumacher CM, Kohll AX, Starck CT, Schmid Daners M, Meboldt M, Falk V, Stark WJ. A Soft Total Artificial Heart-First Concept Evaluation on a Hybrid Mock Circulation. Artif Organs 2017; 41:948-958. [DOI: 10.1111/aor.12956] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 03/21/2017] [Accepted: 03/27/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nicholas H. Cohrs
- Institute for Chemical and Bioengineering; ETH Zurich; Zurich Switzerland
| | - Anastasios Petrou
- Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
| | - Michael Loepfe
- Institute for Chemical and Bioengineering; ETH Zurich; Zurich Switzerland
| | - Maria Yliruka
- Institute for Chemical and Bioengineering; ETH Zurich; Zurich Switzerland
| | | | - A. Xavier Kohll
- Institute for Chemical and Bioengineering; ETH Zurich; Zurich Switzerland
| | - Christoph T. Starck
- Department for Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Marianne Schmid Daners
- Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
| | - Mirko Meboldt
- Product Development Group Zurich, Department of Mechanical and Process Engineering; ETH Zurich; Zurich Switzerland
| | - Volkmar Falk
- Department for Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Wendelin J. Stark
- Institute for Chemical and Bioengineering; ETH Zurich; Zurich Switzerland
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15
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Cameli M, Loiacono F, Sparla S, Solari M, Iardino E, Mandoli GE, Bernazzali S, Maccherini M, Mondillo S. Systematic Left Ventricular Assist Device Implant Eligibility with Non-Invasive Assessment: The SIENA Protocol. J Cardiovasc Ultrasound 2017; 25:39-46. [PMID: 28770031 PMCID: PMC5526884 DOI: 10.4250/jcu.2017.25.2.39] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/12/2017] [Accepted: 06/12/2017] [Indexed: 11/22/2022] Open
Abstract
In patients with end-stage left ventricular (LV) heart failure who receive LV assist device (LVAD) implantation, right ventricular (RV) failure represents a possible critical complication that heavily affects morbidity and mortality. Several clinical, laboratory, hemodynamic, and echocardiographic variables have been found to be associated with RV failure occurrence after surgery. Different models and risk scores have been proposed, with poor results. No accordance has ever been reached about RV pre-operative evaluation, and time has come to introduce a standardized systematic protocol for LVAD suitability assessment according to RV function. We analyzed imaging parameters associated with LVAD implantation-related RV failure, in order to identify the minimum number for pre-operative reliable prediction of post-operative RV failure. A few echocardiographic parameters have been identified as the most reliable, or promising, and reproducible tools in this field: free-wall RV longitudinal strain, RV fractional area change, RV sphericity index, and RV ejection fraction with 3D-echocardiography. We propose the Systematic LVAD Implant Eligibility with Non-invasive Assessment protocol–the SIENA protocol–as a new and simple way of pre-operative evaluation of patients candidates to LVAD implantation.
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Affiliation(s)
- Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | | | - Stefania Sparla
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Marco Solari
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Elisabetta Iardino
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | | | - Sonia Bernazzali
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Massimo Maccherini
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Sergio Mondillo
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
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Are biventricular assist devices underused as a bridge to heart transplantation in patients with a high risk of postimplant right ventricular failure? J Thorac Cardiovasc Surg 2017; 153:360-367.e1. [DOI: 10.1016/j.jtcvs.2016.09.084] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 11/23/2022]
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Capoccia M. Mechanical Circulatory Support for Advanced Heart Failure: Are We about to Witness a New "Gold Standard"? J Cardiovasc Dev Dis 2016; 3:E35. [PMID: 29367578 PMCID: PMC5715724 DOI: 10.3390/jcdd3040035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/03/2016] [Accepted: 12/06/2016] [Indexed: 01/08/2023] Open
Abstract
The impact of left ventricular assist devices (LVADs) for the treatment of advanced heart failure has played a significant role as a bridge to transplant and more recently as a long-term solution for non-eligible candidates. Continuous flow left ventricular assist devices (CF-LVADs), based on axial and centrifugal design, are currently the most popular devices in view of their smaller size, increased reliability and higher durability compared to pulsatile flow left ventricular assist devices (PF-LVADs). The trend towards their use is increasing. Therefore, it has become mandatory to understand the physics and the mathematics behind their mode of operation for appropriate device selection and simulation set up. For this purpose, this review covers some of these aspects. Although very successful and technologically advanced, they have been associated with complications such as pump thrombosis, haemolysis, aortic regurgitation, gastro-intestinal bleeding and arterio-venous malformations. There is perception that the reduced arterial pulsatility may be responsible for these complications. A flow modulation control approach is currently being investigated in order to generate pulsatility in rotary blood pumps. Thrombus formation remains the most feared complication that can affect clinical outcome. The development of a preoperative strategy aimed at the reduction of complications and patient-device suitability may be appropriate. Patient-specific modelling based on 3D reconstruction from CT-scan combined with computational fluid dynamic studies is an attractive solution in order to identify potential areas of stagnation or challenging anatomy that could be addressed to achieve the desired outcome. The HeartMate II (axial) and the HeartWare HVAD (centrifugal) rotary blood pumps have been now used worldwide with proven outcome. The HeartMate III (centrifugal) is now emerging as the new promising device with encouraging preliminary results. There are now enough pumps on the market: it is time to focus on the complications in order to achieve the full potential and selling-point of this type of technology for the treatment of the increasing heart failure patient population.
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Affiliation(s)
- Massimo Capoccia
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow G81 4DY, UK.
- Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK.
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Aubin H, Petrov G, Dalyanoglu H, Saeed D, Akhyari P, Paprotny G, Richter M, Westenfeld R, Schelzig H, Kelm M, Kindgen-Milles D, Lichtenberg A, Albert A. A Suprainstitutional Network for Remote Extracorporeal Life Support. JACC-HEART FAILURE 2016; 4:698-708. [DOI: 10.1016/j.jchf.2016.03.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/18/2016] [Accepted: 03/26/2016] [Indexed: 10/21/2022]
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Abstract
Mechanical circulatory support has become an increasingly used management strategy for patients with both acute and chronic ventricular failure. This article briefly reviews the current state of mechanical circulatory support with a focus on indications, contraindications, and complications of currently available devices. Perioperative considerations for ventricular assist device implantation are discussed, including the decision-making process underlying the use of univentricular versus biventricular support, specific anesthetic considerations, and the role of transesophageal echocardiography where ventricular assist devices are concerned. The anesthetic considerations for the patient already supported by a ventricular assist device presenting for noncardiac surgery are also reviewed. The work concludes with a discussion of the rationale behind the next generation of continuous flow devices currently in human clinical trials.
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Affiliation(s)
- Marc E Stone
- Mount Sinai School of Medicine, New York, New York 10029-6574, USA.
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20
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Right Ventricular Function in Patients With Left Ventricular Assist Device Support by Pulsatile Polvad MEV and Continuous-Flow Pumps Heartware and Heartmate II. Transplant Proc 2016; 48:1786-90. [PMID: 27496492 DOI: 10.1016/j.transproceed.2016.01.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 01/21/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Left ventricular assist device (LVAD) support is increasingly used in patients with heart failure. The right ventricle (RV) plays a main role in LVAD support. Little is known about the effects of pulsatile Polvad MEV devices or continuouseconds flow pumps on RV function. We compared hemodynamic parameters of RV in patients after implantation of Polvad MEV (PM) and Heartware (HW) or Heartmate II (HMII) LVADs. METHODS Forty-four patients were retrospectively reviewed after implantation of PM (group P; n = 24 [21 M, 3 F]) or HW or HMII (group C; n = 20 [20 M, 0 F]) LVADs from April 2007 to February 2014. Hemodynamic data-mean pulmonary pressure (mPAP), central venous pressure (CVP), cardiac output (CO), and cardiac index (CI)-were collected before surgery, after surgery, and every 2 hours in the intensive care unit, with the time points numbered from 1 to 120. Right ventricular work (RVW) was calculated according to the equation: RCW = CO × (mPAP - CVP) × 0.0144 (g·m). RESULTS Baseline characteristic of the patients were similar. mPAP values were similar between groups. CVP values were higher in group P, significantly at time points 5 and 7-33. CO values were higher in group C, significantly from point 3 and almost all the time to point 43. CI reached significance at point 9, 12-14, 16-19, and 30-41. RCW was higher in group P before implantation. Post-implantation RCW values were higher in group C, significantly at time points 19, 20, 32-34, 51-53, and 55-57. CONCLUSIONS Continuous-flow pumps more effectively optimize RV function than pulsatile LVADs, which can result in more effective prevention of RV failure or insuffiency in that group.
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Grimm JC, Sciortino CM, Magruder JT, Dungan SP, Valero V, Sharma K, Tedford RJ, Russell SD, Whitman GJR, Silvestry SC, Shah AS. Outcomes in Patients Bridged With Univentricular and Biventricular Devices in the Modern Era of Heart Transplantation. Ann Thorac Surg 2016; 102:102-8. [PMID: 27068177 DOI: 10.1016/j.athoracsur.2016.01.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 12/09/2015] [Accepted: 01/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Biventricular support before orthotopic heart transplantation (OHT) has been shown to adversely affect short- and long-term outcomes, but the comparative effect of support type is largely unknown. This study determined the comparative effect of univentricular and biventricular support on survival in bridged patients after OHT. METHODS The United Network of Organ Sharing database was queried for adult patients bridged to OHT with a univentricular (left ventricular assist device [LVAD]), biventricular (biventricular assist device [BiVAD]), or total artificial heart ([TAH]) device between 2004 and 2012. Unconditional and conditional survivals were compared with the Kaplan-Meier method. Cox proportional hazards regression models were constructed to determine the risk-adjusted influence of support type on death. RESULTS Of the 4,177 patients identified, 3,457 (20.4%), 575 (3.4%), and 145 (0.9%) were bridged with an LVAD, BiVAD, and TAH, respectively. Unadjusted 30-day, 1-year, and 5-year estimated survival was greater in LVAD patients than in the BiVAD and TAH cohorts. After risk-adjustment, BiVAD and TAH were associated with an increased risk of death at all time points. Unadjusted and adjusted 5-year survival, conditional on 1-year survival, was worse, however, in only TAH patients. CONCLUSIONS Patients with biventricular failure bridged to OHT with a TAH or BiVAD experience worse short- and long-term survival comparison with those with an LVAD. This difference is most likely due to an increase in early death and depends on the type of BiVAD device implanted.
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Affiliation(s)
- Joshua C Grimm
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | | | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Samuel P Dungan
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Vicente Valero
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kavita Sharma
- Divison of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ryan J Tedford
- Divison of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Stuart D Russell
- Divison of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Glenn J R Whitman
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Scott C Silvestry
- Division of Cardiothoracic Surgery, Florida Hospital, Orlando, Florida
| | - Ashish S Shah
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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22
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Outcomes of biventricular mechanical support patients discharged to home to await heart transplantation. J Cardiovasc Nurs 2016; 30:E13-20. [PMID: 24901851 DOI: 10.1097/jcn.0000000000000168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of left ventricular assist devices has grown rapidly in recent years for patients with end-stage heart failure. A significant proportion of patients require both left- and right-sided support with biventricular assist devices (BiVADs) as a bridge to transplantation. Traditionally, these patients have waited in the hospital until they receive a transplant. PURPOSE The aim of this study was to characterize the clinical course of BiVAD patients discharged to home to await heart transplantation. METHODS Between November 2009 and July 2011, 24 adult patients underwent Thoratec paracorporeal BiVAD placement at the University of California Los Angeles, all with an Interagency Registry for Mechanically Assisted Circulatory Support score 1 or 2. The disposition, complications, and rehospitalizations of these subjects were retrospectively reviewed. RESULTS Fourteen of the 24 patients were successfully discharged to home, with a mean time of 60 ± 27 days from BiVAD implantation to discharge. Ninety-three percent (13/14) of the patients sent home went on to be transplanted. Eleven of the 14 (79%) came in from home to receive their transplant. The mean time from BiVAD implantation to transplantation was 100 ± 65 days. Of the 14 patients discharged to home, there were 18 readmissions in 8 patients. CONCLUSION In this small single-center review, we found that complex medical patients with BiVADs can be discharged to home and can await a heart transplant from home under the close management of multidisciplinary acute care and outpatient teams.
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Heatley G, Sood P, Goldstein D, Uriel N, Cleveland J, Middlebrook D, Mehra MR. Clinical trial design and rationale of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) investigational device exemption clinical study protocol. J Heart Lung Transplant 2016; 35:528-36. [PMID: 27044532 DOI: 10.1016/j.healun.2016.01.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 01/14/2023] Open
Abstract
The HeartMate 3 left ventricular assist system (LVAS; St. Jude Medical, Inc., formerly Thoratec Corporation, Pleasanton, CA) was recently introduced into clinical trials for durable circulatory support in patients with medically refractory advanced-stage heart failure. This centrifugal, fully magnetically levitated, continuous-flow pump is engineered with the intent to enhance hemocompatibility and reduce shear stress on blood elements, while also possessing intrinsic pulsatility. Although bridge-to-transplant (BTT) and destination therapy (DT) are established dichotomous indications for durable left ventricular assist device (LVAD) support, clinical practice has challenged the appropriateness of these designations. The introduction of novel LVAD technology allows for the development of clinical trial designs to keep pace with current practices. The prospective, randomized Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) clinical trial aims to evaluate the safety and effectiveness of the HeartMate 3 LVAS by demonstrating non-inferiority to the HeartMate II LVAS (also St. Jude Medical, Inc.). The innovative trial design includes patients enrolled under a single inclusion and exclusion criteria , regardless of the intended use of the device, with outcomes ascertained in the short term (ST, at 6 months) and long term (LT, at 2 years). This adaptive trial design includes a pre-specified safety phase (n = 30) analysis. The ST cohort includes the first 294 patients and the LT cohort includes the first 366 patients for evaluation of the composite primary end-point of survival to transplant, recovery or LVAD support free of debilitating stroke (modified Rankin score >3), or re-operation to replace the pump. As part of the adaptive design, an analysis by an independent statistician will determine whether sample size adjustment is required at pre-specified times during the study. A further 662 patients will be enrolled to reach a total of 1,028 patients for evaluation of the secondary end-point of pump replacement at 2 years.
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Affiliation(s)
| | | | - Daniel Goldstein
- Department of Cardiothoracic Surgery, Montefiore Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - Joseph Cleveland
- Department of Surgery, University of Colorado Anschutz Medical Center, Denver, Colorado, USA
| | | | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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Kitada S, Schulze PC, Jin Z, Clerkin K, Homma S, Mancini DM. Comparison of early versus delayed timing of left ventricular assist device implantation as a bridge-to-transplantation: An analysis of the UNOS dataset. Int J Cardiol 2015; 203:929-935. [PMID: 26618255 DOI: 10.1016/j.ijcard.2015.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/03/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Placement of left ventricular assist devices (LVAD) as a bridge-to-heart transplantation (HTx) has rapidly expanded due to organ donor shortage. However, the timing of LVAD implantation is variable and it remains unclear if earlier implantation improves survival. METHODS We analyzed 14,187 adult candidates from the United Network of Organ Sharing database. Patients were classified by 3 treatment strategies including patients medically treated alone (MED, n=11,009), patients on LVAD support at listing (Early-LVAD, n=1588) and patients undergoing LVAD placement while awaiting HTx (Delayed-LVAD, n=1590). Likelihood of HTx and event-free survival were assessed in patients subcategorized by clinical strategies and UNOS status at listing. RESULTS The device support strategy, despite the timing of placement, was not associated with increased likelihood of HTx compared to MED group. However, both LVAD implantation strategies showed better survival compared to MED group (Early-LVAD: HR 0.811 and 0.633, 95% CI 0.668-0.984 and 0.507-0.789, for 1A and 1B; p=0.034 and p<0.001, Delayed-LVAD: HR 0.553 and 0.696, 95% CI 0.415-0.736 and 0.571-0.847, for 1A and 1B; both p<0.001, respectively). Furthermore, there was no significant difference in survival between these LVAD implantation strategies in patients listed as 1B (p=0.500), although Early-LVAD implantation showed worse survival in patients listed as 1A (HR 1.467, 95% CI 1.076-2.000; p=0.015). CONCLUSION LVAD support strategies offer a safe bridge-to-HTx. Those candidates who receive urgent upfront LVAD implantation for HTx, and improve to 1B status, would achieve competitive survival with those who receive elective LVAD implantation.
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Affiliation(s)
- Shuichi Kitada
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - P Christian Schulze
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, USA
| | - Kevin Clerkin
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Donna M Mancini
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
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25
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Garan AR, Levin AP, Topkara V, Thomas SS, Yuzefpolskaya M, Colombo PC, Takeda K, Takayama H, Naka Y, Whang W, Jorde UP, Uriel N. Early post-operative ventricular arrhythmias in patients with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2015. [PMID: 26212658 DOI: 10.1016/j.healun.2015.05.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Ventricular arrhythmias (VAs) are common in patients with a continuous-flow left ventricular assist device (CF-LVAD). The causes and clinical significance of early post-operative VAs have not previously been characterized in these patients. The purpose of this study was to assess the incidence, precipitants, and clinical impact of early VAs in patients supported by CF-LVADs. METHODS Patients with a long-term CF-LVAD receiving care between January 1, 2012, and March 1, 2014, were enrolled and followed prospectively. Implantable cardioverter-defibrillators (ICDs) were interrogated at baseline and throughout the follow-up period. VA was defined as ventricular tachycardia or ventricular fibrillation lasting >30 seconds or effectively terminated by appropriate ICD tachytherapy or external defibrillation. The primary end-point was the occurrence of early VAs (within 30 days of surgery). Secondary end-points were right ventricular (RV) failure and need for VA ablation. RESULTS There were 162 patients enrolled, and 38 (23.5%) experienced at least 1 early VA. Predictors of early VA were a history of pre-operative VAs, non-ischemic cardiomyopathy, and older age. Several conditions frequently encountered in the early post-operative period were identified as possible precipitants for VA episodes. Early VAs were associated with post-operative RV failure, particularly when patients received shocks instead of anti-tachycardia pacing. CONCLUSIONS Early VAs are common and are associated with RV failure. ICD shocks, but not anti-tachycardia pacing, for early VAs are associated with acute worsening of RV failure.
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Affiliation(s)
- Arthur R Garan
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York.
| | - Allison P Levin
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Veli Topkara
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Sunu S Thomas
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - William Whang
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Ulrich P Jorde
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, University of Chicago Medical Center, Chicago, Illinois
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Critoph C, Green G, Hayes H, Baumwol J, Lam K, Larbalestier R, Chih S. Clinical Outcomes of Patients Treated With Pulmonary Vasodilators Early and in High Dose After Left Ventricular Assist Device Implantation. Artif Organs 2015; 40:106-14. [DOI: 10.1111/aor.12502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Christopher Critoph
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Gillian Green
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Helen Hayes
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Jay Baumwol
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Kaitlyn Lam
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Robert Larbalestier
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Sharon Chih
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
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Koprivanac M, Kelava M, Sirić F, Cruz VB, Moazami N, Mihaljević T. Predictors of right ventricular failure after left ventricular assist device implantation. Croat Med J 2015; 55:587-95. [PMID: 25559829 PMCID: PMC4295071 DOI: 10.3325/cmj.2014.55.587] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Number of left ventricular assist device (LVAD) implantations increases every year, particularly LVADs for destination therapy (DT). Right ventricular failure (RVF) has been recognized as a serious complication of LVAD implantation. Reported incidence of RVF after LVAD ranges from 6% to 44%, varying mostly due to differences in RVF definition, different types of LVADs, and differences in patient populations included in studies. RVF complicating LVAD implantation is associated with worse postoperative mortality and morbidity including worse end-organ function, longer hospital length of stay, and lower success of bridge to transplant (BTT) therapy. Importance of RVF and its predictors in a setting of LVAD implantation has been recognized early, as evidenced by abundant number of attempts to identify independent risk factors and develop RVF predictor scores with a common purpose to improve patient selection and outcomes by recognizing potential need for biventricular assist device (BiVAD) at the time of LVAD implantation. The aim of this article is to review and summarize current body of knowledge on risk factors and prediction scores of RVF after LVAD implantation. Despite abundance of studies and proposed risk scores for RVF following LVAD, certain common limitations make their implementation and clinical usefulness questionable. Regardless, value of these studies lies in providing information on potential key predictors for RVF that can be taken into account in clinical decision making. Further investigation of current predictors and existing scores as well as new studies involving larger patient populations and more sophisticated statistical prediction models are necessary. Additionally, a short description of our empirical institutional approach to management of RVF following LVAD implantation is provided.
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Affiliation(s)
- Marijan Koprivanac
- Marijan Koprivanac, Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Baniyas Towers, Abu Dhabi, United Arab Emirates,
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28
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Kiernan MS, French AL, DeNofrio D, Parmar YJ, Pham DT, Kapur NK, Pandian NG, Patel AR. Preoperative Three-Dimensional Echocardiography to Assess Risk of Right Ventricular Failure After Left Ventricular Assist Device Surgery. J Card Fail 2015; 21:189-97. [DOI: 10.1016/j.cardfail.2014.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 11/21/2014] [Accepted: 12/16/2014] [Indexed: 12/31/2022]
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29
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Lebreton G, Pozzi M, Mastroianni C, Léger P, Pavie A, Leprince P. Extracorporeal life support as a bridge to bridge: a strategy to optimize ventricular assist device results. Eur J Cardiothorac Surg 2015; 48:785-91. [DOI: 10.1093/ejcts/ezu516] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/26/2014] [Indexed: 11/13/2022] Open
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30
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Holman WL, Acharya D, Siric F, Loyaga-Rendon RY. Assessment and Management of Right Ventricular Failure in Left Ventricular Assist Device Patients. Circ J 2015; 79:478-86. [DOI: 10.1253/circj.cj-15-0093] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- William L. Holman
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
| | - Deepak Acharya
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Franjo Siric
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
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Abstract
Hemodynamic instability as a clinical state represents either a perfusion failure with clinical manifestations of circulatory shock or heart failure or 1 or more out-of-threshold hemodynamic monitoring values, which may not necessarily be pathologic. Different types of causes of circulatory shock require different types of treatment modalities, making these distinctions important. Diagnostic approaches or therapies based on data derived from hemodynamic monitoring assume that specific patterns of derangements reflect specific disease processes, which respond to appropriate interventions. Hemodynamic monitoring at the bedside improves patient outcomes when used to make treatment decisions at the right time for patients experiencing hemodynamic instability.
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Affiliation(s)
- Eliezer L Bose
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 336 Victoria Hall, 3500 Victoria Street, Pittsburgh, PA 15261, USA
| | - Marilyn Hravnak
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, 336 Victoria Building, Pittsburgh, PA 15261, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Seventeen-month-long paracorporeal biventricular mechanical support as a bridge to transplantation for severe dilated cardiomyopathy. J Artif Organs 2014; 18:92-4. [PMID: 25320017 DOI: 10.1007/s10047-014-0797-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
Abstract
The long-term management of paracorporeal biventricular assist devices (BiVAD) is difficult because of significant risks of bleeding, thrombosis, and infection. Here we report the case of a 41-year-old woman with severe dilated cardiomyopathy who developed serious cerebral bleeding after receiving a paracorporeal BiVAD but recovered well after treatment. She eventually underwent cardiac transplantation 17 months after implantation of the paracorporeal BiVAD.
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Holley CT, Harvey L, John R. Left ventricular assist devices as a bridge to cardiac transplantation. J Thorac Dis 2014; 6:1110-9. [PMID: 25132978 DOI: 10.3978/j.issn.2072-1439.2014.06.46] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 06/30/2014] [Indexed: 11/14/2022]
Abstract
Heart failure remains a significant cause of morbidity and mortality, affecting over five million patients in the United States. Continuous-flow left ventricular assist devices (LVAD) have become the standard of care for patients with end stage heart failure. This review highlights the current state of LVAD as a bridge to transplant (BTT) in patients requiring mechanical circulatory support (MCS).
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Affiliation(s)
| | - Laura Harvey
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
| | - Ranjit John
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
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Steffen RJ, Halbreiner MS, Zhang L, Fukamachi K, Soltesz EG, Starling RC, Moazami N. Mechanical circulatory support for the right ventricle in the setting of a left ventricular assist device. Expert Rev Med Devices 2014; 11:587-93. [DOI: 10.1586/17434440.2014.940316] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Groves DS, Blum FE, Huffmyer JL, Kennedy JL, Ahmad HB, Durieux ME, Kern JA. Effects of Early Inhaled Epoprostenol Therapy on Pulmonary Artery Pressure and Blood Loss During LVAD Placement. J Cardiothorac Vasc Anesth 2014; 28:652-60. [DOI: 10.1053/j.jvca.2013.05.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Indexed: 11/11/2022]
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Lim CP, Sivathasan C, Tan TE, Lim CH, Kerk KL, Sim DKL. Use of Left Ventricular Assist Device (HeartMate II): A Singapore Experience. Artif Organs 2014; 38:543-8. [DOI: 10.1111/aor.12247] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Inoue T, Kitamura T, Torii S, Hanayama N, Oka N, Itatani K, Tomoyasu T, Irisawa Y, Shibata M, Hayashi H, Ono M, Miyaji K. Five-week use of a monopivot centrifugal blood pump as a right ventricular assist device in severe dilated cardiomyopathy. J Artif Organs 2013; 17:95-8. [DOI: 10.1007/s10047-013-0740-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 10/27/2013] [Indexed: 11/24/2022]
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Dandel M, Potapov E, Krabatsch T, Stepanenko A, Löw A, Vierecke J, Knosalla C, Hetzer R. Load Dependency of Right Ventricular Performance Is a Major Factor to be Considered in Decision Making Before Ventricular Assist Device Implantation. Circulation 2013; 128:S14-23. [DOI: 10.1161/circulationaha.112.000335] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Left ventricular assist devices (LVADs) provide better outcome than biventricular devices, but it is a challenge to predict the impact of LV mechanical unloading on postoperative right ventricular (RV) function preoperatively. We assessed the load dependency in RV performance before and after LVAD implantation aiming to improve preoperative decision making.
Methods and Results—
Laboratory, echocardiography, and right heart catheterization data collected from 205 patients before LVAD implantation were tested for relationship with postoperative RV function. Comparing patients with different time-course of RV function after LVAD implantation, we found significant differences (
P
<0.01) in preoperative RV end-diastolic short-/long-axis and long-axis/length-area ratios, tricuspid annulus peak systolic velocity, RV peak longitudinal global systolic strain rate, systolic pressure gradient between RV and right atrium (Δ
P
RV−RA
), tricuspid regurgitation velocity-time integral, and pulmonary arterial pressure between patients with and without postoperative RV failure. High predictive values for postoperative RV failure were found for end-diastolic short-/long-axis ratio ≥0.6, tricuspid annulus peak systolic velocity <8 cm/s, and peak systolic longitudinal strain rate <0.6/s in patients with maximum Δ
P
RV−RA
<35 mm Hg. These parameters also seemed predictive for RV failure in patients with tricuspid regurgitation grade >2 and pulmonary arterial pressure <50 mm Hg. End-diastolic short-/long-axis ratio <0.6, tricuspid annulus peak systolic velocity ≥8 cm/s, and peak systolic longitudinal strain rate ≥0.6 in patients with maximum Δ
P
RV−RA
≥35 mm Hg showed high predictive values for postoperative freedom from RV failure. The RV load adaptation index seemed particularly predictive for RV function after LVAD implantation.
Conclusions—
RV geometry and velocity of contraction before LVAD implantation become more predictive for postoperative RV function and can improve decision making before VAD implantation if preoperative RV pressure load and tricuspid regurgitation are also considered.
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Affiliation(s)
- Michael Dandel
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Evgenij Potapov
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Thomas Krabatsch
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Alexander Stepanenko
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Alexandra Löw
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Juliane Vierecke
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Christoph Knosalla
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
| | - Roland Hetzer
- From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany (M.D., E.P., T.K., A.S., A.L., J.V., C.K., R.H.); and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany (R.H.)
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Moravec R, Neitzel T, Stiller M, Hofmann B, Metz D, Bucher M, Silber R, Bushnaq H, Raspé C. First experiences with a combined usage of veno-arterial and veno-venous ECMO in therapy-refractory cardiogenic shock patients with cerebral hypoxemia. Perfusion 2013; 29:200-9. [PMID: 23996694 DOI: 10.1177/0267659113502832] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) is becoming a popular tool in the treatment of cardiogenic shock. We present two case reports where classical veno-arterial peripherally cannulated ECMO therapy proved insufficient with profuse cerebral hypoxemia. After augmenting the setting into veno-veno-arterial ECMO, we achieved a remarkable improvement of all oxygenation parameters. The simultaneous use of veno-venous and veno-arterial ECMO might display as a novel strategy to counteract the coronary and cerebral hypoxemia in veno-arterial ECMO therapy in patients with therapy-refractory cardiogenic shock or in combined cardiopulmonary failure. In this manuscript, the veno-veno-arterial ECMO setup is described in full detail and different venous cannulas are discussed.
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Affiliation(s)
- R Moravec
- Department of Anesthesiology and Critical care medicine, Halle-Wittenberg University, Germany
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41
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Hehir DA, Niebler RA, Brabant CC, Tweddell JS, Ghanayem NS. Intensive care of the pediatric ventricular assist device patient. World J Pediatr Congenit Heart Surg 2013; 3:58-66. [PMID: 23804685 DOI: 10.1177/2150135111420888] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Utilization of ventricular assist devices (VADs) in children is increasing, as is the complexity of patients supported. We review the intensive care management of pediatric patients with VAD in the perioperative and rehabilitation phases, highlighting the technical aspects and physiology of VADs which impact care. Indications for VAD placement and the preoperative assessment of risk are discussed. Specific aspects of postoperative and long-term care including device troubleshooting, hemostasis and anticoagulation, support of the right ventricle, incidence and prevention of neurologic injury, and other complications are reviewed.
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Affiliation(s)
- David A Hehir
- Division of Pediatric Critical Care, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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Predicting right ventricular failure in the modern, continuous flow left ventricular assist device era. Ann Thorac Surg 2013; 96:857-63; discussion 863-4. [PMID: 23791165 DOI: 10.1016/j.athoracsur.2013.03.099] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/01/2013] [Accepted: 03/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the era of destination continuous flow left ventricular assist devices (LVAD), the decision of whether a patient will tolerate isolated LVAD support or will need biventricular support (BIVAD) can be challenging. Incorrect decision making with delayed right ventricular (RV) assist device implantation results in increased morbidity and mortality. Continuous flow LVADs have been shown to decrease pulmonary hypertension and improve RV function. We undertook this study to determine predictors in the continuous flow LVAD era that identify patients who are candidates for isolated LVAD therapy as opposed to biventricular support. METHODS We reviewed demographic, hemodynamic, laboratory, and echocardiographic variables for 218 patients who underwent VAD implant from 2003 through 2011 (LVAD=167, BIVAD=51), during the era of continuous flow LVADs. RESULTS Fifty preoperative risk factors were compared between patients who were successfully managed with an LVAD and those who required a BIVAD. Seventeen variables demonstrated statistical significance by univariate analysis. Multivariable logistic regression analysis identified central venous pressure>15 mmHg (OR 2.0, "C"), severe RV dysfunction (OR 3.7, "R"), preoperative intubation (OR 4.3, "I"), severe tricuspid regurgitation (OR 4.1, "T"), heart rate>100 (OR 2.0, Tachycardia-"T")-CRITT as the major criteria predictive of the need for biventricular support. Utilizing these data, a highly sensitive and easy to use risk score for determining RV failure was generated that outperformed other established risk stratification tools. CONCLUSIONS We present a preoperative risk calculator to determine suitability of a patient for isolated LVAD support in the current continuous flow ventricular assist device era.
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Raina A, Seetha Rammohan HR, Gertz ZM, Rame JE, Woo YJ, Kirkpatrick JN. Postoperative right ventricular failure after left ventricular assist device placement is predicted by preoperative echocardiographic structural, hemodynamic, and functional parameters. J Card Fail 2013; 19:16-24. [PMID: 23273590 DOI: 10.1016/j.cardfail.2012.11.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/17/2012] [Accepted: 11/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation results in significant morbidity and mortality. Preoperative parameters from transthoracic echocardiography (TTE) that predict RVF after LVAD implantation might identify patients in need of temporary or permanent right ventricular (RV) mechanical or inotropic support. METHODS AND RESULTS Records of all patients who had preoperative TTE before implantation of a permanent LVAD at our institution from 2008 to 2011 were screened, and 55 patients (age 54 ± 16 years, 71% male) were included: 26 had LVAD implantation alone with no postoperative RVF, 16 had LVAD implantation alone but experienced postoperative RVF, and 13 had initial biventricular assist devices (BIVADs). The LVAD with RVF and BIVAD groups (RVF group) were pooled for comparison with the LVAD patients without RVF (No RVF group). RV fractional area change (RV FAC) was significantly lower in the RVF group versus the No RVF group (24% vs 30%; P = .04). Tricuspid annular plane systolic excursion was not different among the groups (1.6 cm vs 1.5 cm; P = .53). Estimated right atrial pressure (RAP) was significantly higher in the RVF group versus the No RVF group (11 mm Hg vs 8 mm Hg; P = .04). Left atrial volume (LAV) index was lower in patients with RVF versus No RVF (27 mL/m(2) vs 40 mL/m(2); P = .008). Combining RV FAC, estimated RAP, and LAV index into an echocardiographic scoring system revealed that the TTE score was highly predictive of RVF (5.0 vs 2.8; P = .0001). In multivariate models combining the TTE score with clinical variables, the score was the most predictive of RVF (odds ratio 1.66, 95% confidence interval 1.06-2.62). CONCLUSIONS Preoperative RV FAC, estimated RAP, and LAV index predict postoperative RVF in patients undergoing LVAD implantation. These parameters may be combined into a simple echocardiographic scoring system to provide an additional tool to risk-stratify patients being evaluated for LVAD implantation.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212-4772, USA.
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Marzec LN, Ambardekar AV. Preoperative Evaluation and Perioperative Management of Right Ventricular Failure After Left Ventricular Assist Device Implantation. Semin Cardiothorac Vasc Anesth 2013; 17:249-61. [DOI: 10.1177/1089253213488246] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Right ventricular (RV) failure continues to be a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Preoperative evaluation of RV function with a variety of clinical, laboratory, echocardiographic, and hemodynamic variables is essential to ensure appropriate patient selection for LVAD therapy but remains imperfect. Therefore, clinicians involved in the care of these patients need to be prepared to manage RV failure after LVAD placement. Perioperative management of RV failure after LVAD implantation requires minimization of intraoperative RV ischemia, maintenance of appropriate filling pressure, supportive therapy with pulmonary vasodilators and inotropes, and surgical interventions such as RV assist devices in select cases. This article reviews the incidence of RV failure with LVAD implantation, preoperative predictors of RV failure, and perioperative management strategies.
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Loforte A, Stepanenko A, Potapov EV, Musumeci F, Dranishnikov N, Schweiger M, Montalto A, Pasic M, Weng Y, Dandel M, Siniawski H, Kukucka M, Krabatsch T, Hetzer R. Temporary Right Ventricular Mechanical Support in High-Risk Left Ventricular Assist Device Recipients Versus Permanent Biventricular or Total Artificial Heart Support. Artif Organs 2013; 37:523-30. [DOI: 10.1111/aor.12038] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Antonio Loforte
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome; Italy
| | - Alexander Stepanenko
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Evgenij V. Potapov
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Francesco Musumeci
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome; Italy
| | - Nikolay Dranishnikov
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Martin Schweiger
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Andrea Montalto
- Department of Cardiac Surgery and Transplantation; S. Camillo Hospital; Rome; Italy
| | - Miralem Pasic
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Yuguo Weng
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Michael Dandel
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Henryk Siniawski
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Marian Kukucka
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin; Germany
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Postcardiac transplant survival in the current era in patients receiving continuous-flow left ventricular assist devices. J Thorac Cardiovasc Surg 2013; 145:575-81. [PMID: 23321132 DOI: 10.1016/j.jtcvs.2012.09.095] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/07/2012] [Accepted: 09/27/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Continuous-flow left ventricular assist devices have become the standard of care for patients with heart failure requiring mechanical circulatory support as a bridge to transplant. However, data on long-term post-transplant survival for these patients are limited. We evaluated the effect of continuous-flow left ventricular assist devices on postcardiac transplant survival in the current era. METHODS All patients who received a continuous-flow left ventricular assist device as a bridge to transplant at a single center from June 2005 to September 2011 were evaluated. RESULTS Of the 167 patients who received a continuous-flow left ventricular assist device as a bridge to transplant, 77 (46%) underwent cardiac transplantation, 27 died before transplantation (16%), and 63 (38%) remain listed for transplantation and continued with left ventricular assist device support. The mean age of the transplanted patients was 54.5 ± 11.9 years, 57% had an ischemic etiology, and 20% were women. The overall mean duration of left ventricular assist device support before transplantation was 310 ± 227 days (range, 67-1230 days). The mean duration of left ventricular assist device support did not change in patients who had received a left ventricular assist device in the early period of the study (2005-2008, n = 62) compared with those who had received a left ventricular assist device later (2009-2011, n = 78, 373 vs 392 days, P = NS). In addition, no difference was seen in survival between those patients supported with a left ventricular assist device for fewer than 180 days or longer than 180 days before transplantation (P = NS). The actuarial survival after transplantation at 30 days and 1, 3, and 5 years by Kaplan-Meier analysis was 98.7%, 93.0%, 91.1%, and 88.0%, respectively. CONCLUSIONS The short- and long-term post-transplant survival for patients bridged with a continuous-flow left ventricular assist device in the current era has been excellent. Furthermore, the duration of left ventricular assist device support did not affect post-transplant survival. The hemodynamic benefits of ventricular unloading with continuous-flow left ventricular assist devices, in addition to their durability and reduced patient morbidity, have contributed to improved post-transplant survival.
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Echocardiographic Evaluation of Ventricular Assist Devices in Pediatric Patients. J Am Soc Echocardiogr 2013; 26:41-9. [DOI: 10.1016/j.echo.2012.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Indexed: 11/23/2022]
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Saito S, Sakaguchi T, Miyagawa S, Nishi H, Yoshikawa Y, Fukushima S, Daimon T, Sawa Y. Recovery of right heart function with temporary right ventricular assist using a centrifugal pump in patients with severe biventricular failure. J Heart Lung Transplant 2012; 31:858-64. [DOI: 10.1016/j.healun.2012.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 02/07/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022] Open
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