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Siddegowda-Bangalore B, Devaraj S, Rao RA, Jafri SH, Ilonze OJ, Denlinger CE, Guglin M. No Evidence for Oversizing Hearts and Donor Size Impact on 1-Year Survival in Heart Failure Patients With Left Ventricular Assist Device. Am J Cardiol 2023; 207:215-221. [PMID: 37751669 DOI: 10.1016/j.amjcard.2023.08.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
The predicted heart mass (PHM) ratio has recently emerged as a better metric for donor-to-recipient size-matching than weight ratios. It is unknown whether this applies to transplant candidates on left ventricular assist device (LVAD) support. Our study examines if PHM ratio is optimal for size-matching specifically in the LVAD patient population. Patients with LVAD who received a heart transplant from January 1997 to December 2020 in the Scientific Registry of Transplant Recipients database were studied. We compared 5 size-matching metrics, including donor-recipient ratios of weight, height, body mass index, body surface area, and PHM. Single and multivariable Cox proportional hazards models for 1-year mortality were calculated. Our sample consisted of 11,891 patients. In our multivariate analysis, we found that patients in the undersized group with PHM ratios <0.83 had a hazard ratio for 1-year mortality of 1.34 (95% confidence interval 1.08 to 1.65, p = 0.007) suggestive of increased mortality with the use of undersized donors. There was no statistical difference in mortality between the matched (PHM ratio 0.83 to 1.2) and oversized group (PHM ratio ≥1.2). In heart transplant recipients on LVAD support, the PHM ratio provides better risk stratification than other metrics. Use of undersized donor hearts with PHM ratio <0.83 confers higher 1-year mortality. Using oversized donor hearts for transplantation in recipients on LVAD support has no benefit.
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Affiliation(s)
- Bhavana Siddegowda-Bangalore
- Division of Cardiovascular Medicine, Orlando Health Heart & Vascular Institute, Orlando, Florida; Miller College of Business, Ball State University, Muncie, Indiana; Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana
| | - Srikant Devaraj
- Miller College of Business, Ball State University, Muncie, Indiana
| | - Roopa A Rao
- Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana
| | - S Hammad Jafri
- Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana.
| | - Onyedika J Ilonze
- Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana
| | - Chadrick E Denlinger
- Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana
| | - Maya Guglin
- Advanced Heart Failure and Transplant Fellowship, Indiana University, Indianapolis, Indiana.
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2
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George TJ, Aldrich A, Smith RL, Ryan WH, DiMaio JM, Kabra N, Afzal A, Rawitscher DA. Development of a non‐transplant left ventricular assist device program. J Card Surg 2022; 37:3188-3198. [DOI: 10.1111/jocs.16790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Timothy J. George
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Allison Aldrich
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Robert L. Smith
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - William H. Ryan
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - J. Michael DiMaio
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Nitin Kabra
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Aasim Afzal
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - David A. Rawitscher
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
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3
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Park Y, Kim D, Yang JH, Cho YH, Choi JO, Jeon ES. Clinical outcome in patients with end-stage heart failure who underwent continuous-flow left ventricular assist devices in a single center. Korean J Intern Med 2022; 37:340-349. [PMID: 34871480 PMCID: PMC8925944 DOI: 10.3904/kjim.2021.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The continuous flow left ventricular assist device (cf-LVAD) has improved the survival of chronic end-stage heart failure (HF) patients. Here we describe our clinical experience of the initial 50 LVAD patients from a single center. METHODS A total of 50 patients underwent LVAD implantation as bridge to transplantation (BTT; n = 28, 56%), bridge to candidacy (BTC; n = 2, 4%), or as destination therapy (DT; n = 20, 40%) from 2012 to 2019. Pre-implant characteristics and clinical outcomes were compared between BTT/BTC and DT. RESULTS The median age of patients was 67 years (range, 59 to 73). Men were more likely to receive LVAD (76% vs. 24%) than women. DT patients were older, had smaller body surface area, and worse laboratory profiles than BTT/BTC patients. There was no in-hospital mortality. During an average of 14 months (range, 8 to 23), the all-cause mortality was 22%. The first-year survival was 86 and 90% in BTT/BTC and DT groups, respectively. Hemorrhagic stroke was the most common cause (27%) of death. In the BTT/BTC group, 22 patients successfully underwent heart transplantation during median duration of 10 months (range, 7 to 14). The most common post-LVAD complication during the first year of LVAD implantation was major bleeding (44%). A significant proportion (76%) of patients experienced rehospitalization with gastrointestinal bleeding as the most common cause. CONCLUSION We describe short-term clinical outcome of LVAD patients from a single center for the first time in Korea. With the newer generation LVAD and a dedicated team approach, improved clinical outcomes of LVAD for end-stage HF are expected.
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Affiliation(s)
- Yoonjee Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine, Seoul,
Korea
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4
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Goldstein DJ, Naka Y, Horstmanshof D, Ravichandran AK, Schroder J, Ransom J, Itoh A, Uriel N, Cleveland JC, Raval NY, Cogswell R, Suarez EE, Lowes BD, Kim G, Bonde P, Sheikh FH, Sood P, Farrar DJ, Mehra MR. Association of Clinical Outcomes With Left Ventricular Assist Device Use by Bridge to Transplant or Destination Therapy Intent: The Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) Randomized Clinical Trial. JAMA Cardiol 2021; 5:411-419. [PMID: 31939996 PMCID: PMC6990746 DOI: 10.1001/jamacardio.2019.5323] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Question In patients with advanced heart failure, do outcomes with left ventricular assist device implantation differ by the initial intended goal of therapy as a bridge to transplant or destination therapy? Findings In this randomized clinical trial, the composite end point of survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years was significantly better with the magnetically levitated centrifugal-flow HeartMate 3 than the mechanical-bearing axial-flow HeartMate II, irrespective of preimplant therapeutic intent. Event-free survival was not different between patients in the bridge to transplant or destination therapy groups treated with the HeartMate 3 pump. Meaning Per this randomized clinical trial, use of categorizations based on current or future transplant eligibility should be abandoned in favor of a single treatment indication for use of left ventricular assist devices. Importance Left ventricular assist devices (LVADs) are well established in the treatment of advanced heart failure, but it is unclear whether outcomes are different based on the intended goal of therapy in patients who are eligible vs ineligible for heart transplant. Objective To determine whether clinical outcomes in the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) trial differed by preoperative categories of bridge to transplant (BTT) or bridge to transplant candidacy (BTC) vs destination therapy (DT). Design, Setting, and Participants This study was a prespecified secondary analysis of the MOMENTUM 3 trial, a multicenter randomized clinical trial comparing the magnetically levitated centrifugal-flow HeartMate 3 (HM3) LVAD to the axial-flow HeartMate II (HMII) pump. It was conducted in 69 centers with expertise in managing patients with advanced heart failure in the United States. Patients with advanced heart failure were randomized to an LVAD, irrespective of the intended goal of therapy (BTT/BTC or DT). Main Outcomes and Measures The primary end point was survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years. Secondary end points included adverse events, functional status, and quality of life. Results Of the 1020 patients with implants (515 with HM3 devices [50.5%] and 505 with HMII devices [49.5%]), 396 (38.8%) were in the BTT/BTC group (mean [SD] age, 55 [12] years; 310 men [78.3%]) and 624 (61.2%) in the DT group (mean [SD] age, 63 [12] years; 513 men [82.2%]). Of the patients initially deemed as transplant ineligible, 84 of 624 patients (13.5%) underwent heart transplant within 2 years of LVAD implant. In the primary end point analysis, HM3 use was superior to HMII use in patients in the BTT/BTC group (76.8% vs 67.3% for survival free of disabling stroke and reoperation; hazard ratio, 0.62 [95% CI, 0.40-0.94]; log-rank P = .02) and patients in the DT group (73.2% vs 58.7%; hazard ratio, 0.61 [95% CI, 0.46-0.81]; log-rank P < .001). For patients in both BTT/BTC and DT groups, there were not significantly different reductions in rates of pump thrombosis, stroke, and gastrointestinal bleeding with HM3 use relative to HMII use. Improvements in quality of life and functional capacity for either pump were not significantly different regardless of preimplant strategy. Conclusions and Relevance In this trial, the superior treatment effect of HM3 over HMII was similar for patients in the BTT/BTC or DT groups. It is possible that use of arbitrary categorizations based on current or future transplant eligibility should be clinically abandoned in favor of a single preimplant strategy: to extend the survival and improve the quality of life of patients with medically refractory heart failure. Trial Registration ClinicalTrials.gov identifier: NCT02224755
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Affiliation(s)
- Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | | | | | - John Ransom
- Baptist Health Medical Center, Little Rock, Arkansas
| | - Akinobu Itoh
- Washington University School of Medicine, St Louis, Missouri
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | - Nirav Y Raval
- Advent Health Transplant Institute, Orlando, Florida
| | | | | | | | - Gene Kim
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois.,University of Chicago Medical Center, Chicago, Illinois
| | | | | | | | | | - Mandeep R Mehra
- Heart and Vascular Center, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Kosaka R, Sakota D, Nishida M, Maruyama O, Yamane T. Improvement of hemolysis performance in a hydrodynamically levitated centrifugal blood pump by optimizing a shroud size. J Artif Organs 2021; 24:157-163. [PMID: 33428006 DOI: 10.1007/s10047-020-01240-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
We have developed a hydrodynamically levitated centrifugal blood pump. In the blood pump having hydrodynamic bearings, the narrow bearing gap has a potential for high hemolysis. The purpose of the this study is to improve hemolysis performance in a hydrodynamically levitated centrifugal blood pump by optimizing a shroud size. The impeller was levitated passively at the position where the thrust forces acting on the impeller were balanced. We focused on a size of a bottom shroud with a hydrodynamic bearing that could change the bottom hydrodynamic force to balance the thrust force at the wide bearing gap for reducing hemolysis. Five test models with various shroud size were compared: 989 mm2 (HH-10.5), 962 mm2 (HH-12), 932 mm2 (HH-13.5), 874 mm2 (HH-16), and 821 mm2 (HH-18). A numerical analysis was first performed to estimate the bearing gaps in the test model. The bearing gaps were then measured to validate the numerical analysis. Finally, an in vitro hemolysis test was performed. The numerical analysis revealed that the HH-13.5 model had the widest bearing gap of 129 µm. In the measurement test, the estimation error for the bearing gap was less than 10%. In the hemolysis test, the HH-13.5 model achieved the lowest hemolysis level among the five models. The present study demonstrated that the numerical analysis was found to be effective for determining the optimal should size, and the HH-13.5 model had the optimal shroud size in the developed hydrodynamically levitated centrifugal blood pump to reduce hemolysis.
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Affiliation(s)
- Ryo Kosaka
- Artificial Organ Research Group, Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan.
| | - Daisuke Sakota
- Artificial Organ Research Group, Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan
| | - Masahiro Nishida
- Artificial Organ Research Group, Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan
| | - Osamu Maruyama
- Artificial Organ Research Group, Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan
| | - Takashi Yamane
- Artificial Organ Research Group, Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 1-2-1 Namiki, Tsukuba, Ibaraki, 305-8564, Japan
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6
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Patel S, Rizvi SSA, Choi JH, Horan DP, Weber MP, Maynes EJ, Luc JGY, Aburjania N, Entwistle JW, Morris RJ, Massey HT, Tchantchaleishvili V. Management and outcomes of left ventricular assist device-associated endocarditis: a systematic review. Ann Cardiothorac Surg 2019; 8:600-609. [PMID: 31832350 DOI: 10.21037/acs.2019.04.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Left ventricular assist device (LVAD)-associated endocarditis remains poorly studied, especially in newer continuous-flow LVADs (CF-LVADs). The aim of this review was to assess outcomes of patients with LVAD-associated endocarditis, as stratified by CF-LVAD and pulsatile LVAD (P-LVAD) use as well as by different interventions and pathogen types. Methods An electronic search was performed to identify studies in the English literature on LVAD-associated endocarditis. Results Overall, 16 articles with 26 patients were included; seven had CF-LVADs and 19 had P-LVADs; time to development of endocarditis was 91 days (152 vs. 65 days, respectively, P=0.05). Eleven of 25 patients were treated with antibiotics only. Remaining 14 patients received antibiotics, however, they also underwent additional surgical intervention. One patient was treated with embolization alone for mycotic aneurysm and was therefore excluded. At a median follow-up time of 344 days post implant, there was no difference in overall mortality between CF-LVAD and P-LVAD-associated endocarditis patients (57.9% vs. 42.9%, P=0.81). Patients who underwent additional surgical intervention had higher overall survival compared to those treated with antibiotics alone (71.4% vs. 27.3%, P=0.07); with no difference in outcomes amongst those who underwent surgical device exchange as compared to heart transplantation (80.0% vs. 66.7%; P=0.23). Conclusions Compared to patients with P-LVADs, CF-LVAD patients appeared to be resistant to early development of LVAD-associated endocarditis. There was a trend towards high survival observed amongst patients who underwent additional surgical intervention as compared to those treated with antibiotics alone, with no difference amongst surgical device exchange as compared to heart transplantation. Advantages of additional surgical intervention vs. medical therapy alone deserves further exploration to determine its applicability in CF-LVADs.
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Affiliation(s)
- Sinal Patel
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Syed Saif Abbas Rizvi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan P Horan
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nana Aburjania
- Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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7
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Axtell AL, Fiedler AG, Chang DC, Yeh H, Lewis GD, Villavicencio MA, D'Alessandro DA. The effect of donor age on posttransplant mortality in a cohort of adult cardiac transplant recipients aged 18-45. Am J Transplant 2019; 19:876-883. [PMID: 30106231 DOI: 10.1111/ajt.15073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/11/2018] [Accepted: 08/08/2018] [Indexed: 01/25/2023]
Abstract
Hearts from older donors are increasingly utilized for transplantation due to unmet demand. Conflicting evidence exists regarding the prognosis of recipients of advanced age donor hearts, especially in young recipients. A retrospective analysis was performed on 11 433 patients aged 18 to 45 who received a cardiac transplant from 2000 to 2017. Overall, 10 279 patients received hearts from donors less than 45 and 1145 from donors greater than 45. Recipients of older donors were older (37 vs. 34 years, P < .01) and had higher rates of inotropic dependence (48% vs. 42%, P < .01). However, groups were similar in terms of comorbidities and dependence on mechanical circulatory support. Median survival for recipients of older donors was reduced by 2.6 years (12.6 vs. 15.2, P < .01). Multivariable analysis demonstrated donor age greater than 45 to be a predictor of mortality (HR 1.18 [1.05-1.33], P = .01). However, when restricting the analysis to patients who received a donor with a negative preprocurement angiogram, donor age only had a borderline association with mortality (HR 1.20 [0.98-1.46], P = .06). Older donor hearts in young recipients are associated with decreased long-term survival, however this risk is reduced in donors without atherosclerosis. The long-term hazard of this practice should be carefully weighed against the risk of waitlist mortality.
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Affiliation(s)
- Andrea L Axtell
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Amy G Fiedler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory D Lewis
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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8
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Tadmouri A, Blomkvist J, Landais C, Seymour J, Azmoun A. Cost-effectiveness of left ventricular assist devices for patients with end-stage heart failure: analysis of the French hospital discharge database. ESC Heart Fail 2017; 5:75-86. [PMID: 28741873 PMCID: PMC5793974 DOI: 10.1002/ehf2.12194] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/25/2017] [Accepted: 06/20/2017] [Indexed: 01/20/2023] Open
Abstract
AIMS Although left ventricular assist devices (LVADs) are currently approved for coverage and reimbursement in France, no French cost-effectiveness (CE) data are available to support this decision. This study aimed at estimating the CE of LVAD compared with medical management in the French health system. METHODS AND RESULTS Individual patient data from the 'French hospital discharge database' (Medicalization of information systems program) were analysed using Kaplan-Meier method. Outcomes were time to death, time to heart transplantation (HTx), and time to death after HTx. A micro-costing method was used to calculate the monthly costs extracted from the Program for the Medicalization of Information Systems. A multistate Markov monthly cycle model was developed to assess CE. The analysis over a lifetime horizon was performed from the perspective of the French healthcare payer; discount rates were 4%. Probabilistic and deterministic sensitivity analyses were performed. Outcomes were quality-adjusted life years (QALYs) and incremental CE ratio (ICER). Mean QALY for an LVAD patient was 1.5 at a lifetime cost of €190 739, delivering a probabilistic ICER of €125 580/QALY [95% confidence interval: 105 587 to 150 314]. The sensitivity analysis showed that the ICER was mainly sensitive to two factors: (i) the high acquisition cost of the device and (ii) the device performance in terms of patient survival. CONCLUSIONS Our economic evaluation showed that the use of LVAD in patients with end-stage heart failure yields greater benefit in terms of survival than medical management at an extra lifetime cost exceeding the €100 000/QALY. Technological advances and device costs reduction shall hence lead to an improvement in overall CE.
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Affiliation(s)
- Abir Tadmouri
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Josefin Blomkvist
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Cécile Landais
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Jerome Seymour
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
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9
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Seco M, Zhao DF, Byrom MJ, Wilson MK, Vallely MP, Fraser JF, Bannon PG. Long-term prognosis and cost-effectiveness of left ventricular assist device as bridge to transplantation: A systematic review. Int J Cardiol 2017; 235:22-32. [PMID: 28285802 DOI: 10.1016/j.ijcard.2017.02.137] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND This systematic review aimed to evaluate the clinical outcomes and cost-effectiveness of left ventricular assist devices (LVADs) used as bridge to transplantation (BTT), compared to orthotopic heart transplantation (OHT) without a bridge. METHOD Systematic searches were performed in electronic databases with available data extracted from text and digitized figures. Meta-analysis of short and long-term term post-transplantation outcomes was performed with summation of cost-effectiveness analyses. RESULTS Twenty studies reported clinical outcomes of 4575 patients (1083 LVAD BTT and 3492 OHT). Five studies reported cost-effectiveness data on 837 patients (339 VAD BTT and 498 OHT). There was no difference in long-term post-transplantation survival (HR 1.24, 95% CI 1.00-1.54), acute rejection (HR 1.10, 95% CI 0.93-1.30), or chronic rejection and cardiac allograft vasculopathy (HR 0.99, 95% CI 0.73-1.36). No differences were found in 30-day post-operative mortality (OR 0.91, 95% CI 0.42-2.00), stroke (OR 1.64, 95% CI 0.43-6.27), renal failure (OR 1.43, 95% CI 0.58-3.54), bleeding (OR 1.56, 95% CI 0.78-3.13), or infection (OR 2.44, 95% CI 0.81-7.38). Three of the five studies demonstrated incremental cost-effectiveness ratios below the acceptable maximum threshold. The total cost of VAD BTT ranged from $316,078 to $1,025,500, and OHT ranged from $179,051 to $802,200. CONCLUSION LVADs used as BTT did not significantly alter post-transplantation long-term survival, rejection, and post-operative morbidity. LVAD BTT may be cost-effective, particularly in medium and high-risk patients with expected prolonged waiting times, renal dysfunction, and young patients.
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Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Dong Fang Zhao
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Michael J Byrom
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Heart and Lung Surgeons, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Heart and Lung Surgeons, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Heart and Lung Surgeons, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Heart and Lung Surgeons, Sydney, Australia.
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10
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Scherr K, Jensen L, Koshal A. Characteristics and Outcomes of Patients Bridged to Cardiac Transplantation on Centrifugal Ventricular Assist Devices: A Case Series of the Early Experience of One Canadian Transplant Centre. Eur J Cardiovasc Nurs 2016; 3:173-81. [PMID: 15234321 DOI: 10.1016/j.ejcnurse.2004.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2002] [Revised: 02/25/2004] [Accepted: 03/24/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Centrifugal ventricular assist devices (VADs) have been used successfully to bridge patients in cardiogenic shock to cardiac transplantation, though complications are frequent and often life-threatening. PURPOSE To describe characteristics and examine outcomes of patients bridged to cardiac transplantation on centrifugal VADs. METHODS A retrospective health record review was conducted on all adults over a 12 year period (N=20) placed on centrifugal VADs with the intent to bridge to cardiac transplantation at a major Canadian transplant centre. RESULTS Complications of VAD support necessitated removal of 12 patients from the transplant list; seven (35%) survived to cardiac transplantation. Of the seven recipients, five survived to discharge and four remain alive and well. CONCLUSIONS Bridging patients on centrifugal VADs to cardiac transplantation requires improvement, including maintaining patient stability during the period of early VAD institution, aggressively managing complications of VAD support, and consideration of long-term pulsatile devices. However, if patients survive to transplantation, good long-term outcomes are expected.
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Affiliation(s)
- Kimberly Scherr
- Division of Cardiothoracic Surgery, University of Alberta Hospital, 3A2.34 Walter Mackenzie Centre, 8440-112th Street, Edmonton, AB, Canada T6G 2B7
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11
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Abstract
Mechanical circulatory support (MCS) has been viewed, until recently, as a rescue therapy to be applied when all else fails. Not surprisingly, this has resulted in suboptimal outcomes. Fortunately, the perseverance of a few dedicated groups has produced improved outcomes and the concept of MCS as an elective therapy is now steadily gaining acceptance. This is particularly true in the postcardiotomy setting, where a large number of new options are now available. The recently completed REMATCH study has demonstrated the feasibility and efficacy of permanent MCS as a therapy for end-stage heart failure, despite a high rate of device complications. Donor availability is decreasing and biological solutions will not be available for many years. New generation implantable rotary pumps, a fully implantable left ventricular assist device and a total artificial heart are all undergoing clinical evaluation, and several new exciting designs are in preclinical evaluation. A new paradigm for the treatment of terminal heart failure is emerging, where an unpredictable and expensive medically managed death in an intensive care unit setting is being exchanged for a more predictable high-cost, front-loaded therapy with management from the outpatient clinic. The perfusionist community has much to contribute to this emerging life support field, not only in the perioperative period, but also in providing ongoing technical support to hospital staff, recipients and their families.
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Affiliation(s)
- D R Wheeldon
- World Heart Corporation, Ottawa, Ontario, Canada.
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12
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Nunes AJ, MacArthur RGG, Kim D, Singh G, Buchholz H, Chatterley P, Klarenbach SW. A Systematic Review of the Cost-Effectiveness of Long-Term Mechanical Circulatory Support. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:494-504. [PMID: 27325342 DOI: 10.1016/j.jval.2014.12.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 11/28/2014] [Accepted: 12/09/2014] [Indexed: 06/06/2023]
Abstract
BACKGROUND Mechanical circulatory support (MCS) is an option for the treatment of medically intractable end-stage heart failure. MCS therapy, however, is resource intensive. OBJECTIVE The purpose of this report was to systematically review the MCS cost-effectiveness literature as it pertains to the treatment of adult patients in end-stage heart failure. METHODS We conducted a systematic search and narrative review of available cost- effectiveness and cost-utility analyses of MCS in adult patients with end-stage heart failure. RESULTS Eleven studies analyzing the cost-effectiveness or cost-utility of MCS were identified. Seven studies focused on bridge to transplantation, three studies focused on destination therapy, and one study presented analyses of both strategies. Two articles evaluated the cost-effectiveness of the HeartMate II (Thoratec Corp., Pleasanton, CA). Incremental cost-effectiveness ratios between MCS and medical management ranged between $85,025 and $200,166 for bridge to transplantation and between $87,622 and $1,257,946 for destination therapy (2012 Canadian dollars per quality-adjusted life-year). Sensitivity analyses indicated that improvements in survival and quality of life and reductions in device and initial hospital-stay costs may improve the cost-effectiveness of MCS. CONCLUSIONS Current studies suggest that MCS is likely not cost-effective with reference to generally accepted or explicitly stated thresholds. Refined patient selection, complication rates, achieved quality of life, and device/surgical costs, however, could modify the cost-effectiveness of MCS.
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Affiliation(s)
- Abraham J Nunes
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | - Roderick G G MacArthur
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | - Daniel Kim
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | - Gurmeet Singh
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | - Holger Buchholz
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | | | - Scott W Klarenbach
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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13
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Song HK, Gelow JM, Mudd J, Chien C, Tibayan FA, Hollifield K, Naftel D, Kirklin J. Limited Utility of Tricuspid Valve Repair at the Time of Left Ventricular Assist Device Implantation. Ann Thorac Surg 2016; 101:2168-74. [PMID: 27139368 DOI: 10.1016/j.athoracsur.2016.03.040] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 02/22/2016] [Accepted: 03/11/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal management of tricuspid regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is controversial. This study was undertaken to determine the impact of tricuspid valve repair (TVR) at the time of LVAD implantation on survival. METHODS The Interagency Registry for Mechanically Assisted Circulatory Support was used to analyze the outcomes of patients undergoing LVAD implantation as destination therapy with or without concomitant TVR. RESULTS Among 2,527 patients undergoing implant of a continuous flow LVAD as destination therapy during the study period, 989 (39%) had moderate or severe TR. The management of TR was not uniform among these patients. Patients with moderate and severe TR underwent TVR in 16.7% and 35.3% of cases, respectively. Moderate and severe TR at the time of LVAD implantation were associated with poorer survival over the entire follow-up period (p = 0.009). Interestingly, TVR at the time of LVAD implantation did not confer improved survival, even among patients with preimplant moderate or severe TR. A potential explanation for this finding is that patients with preimplant moderate or severe TR who underwent LVAD implant with concomitant TVR commonly experienced recurrent, late TR (21% to 27%). CONCLUSIONS Tricuspid valve repair is performed commonly at the time of LVAD implant despite the fact that it does not confer a clear survival benefit. For many patients, LVAD implant alone relieves preimplant TR as effectively as LVAD implant with TVR. Further study is necessary to determine what factors lead to recurrence of late TR in LVAD patients both with and without TVR.
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Affiliation(s)
- Howard K Song
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon.
| | - Jill M Gelow
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - James Mudd
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - Christopher Chien
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - Frederick A Tibayan
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon
| | - Kathryn Hollifield
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - David Naftel
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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14
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Patel S, Nicholson L, Cassidy CJ, Wong KYK. Left ventricular assist device: a bridge to transplant or destination therapy? Postgrad Med J 2016; 92:271-81. [PMID: 26969730 DOI: 10.1136/postgradmedj-2015-133718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/18/2016] [Indexed: 12/18/2022]
Abstract
Heart failure is a major problem worldwide; it is the leading cause of hospitalisation and is posing a huge financial burden. Advances in healthcare have contributed to increased life expectancy, with a resultant increase in the number of patients with chronic heart failure. For many patients who are still severely symptomatic despite optimal medical therapy and cardiac resynchronisation therapy, cardiac transplantation would be the preferred treatment option. However, hopes are cut short with a limited donor pool of hearts for the increasing number of patients requiring cardiac transplantation. One uprising method to fill this treatment void for patients with advanced end-stage heart failure (ESHF) is the Left Ventricular Assist Device (LVAD). Although traditionally used as a bridge to transplantation, owing to limitation of suitable donors, evidence suggests increasing potential for the use of LVAD as destination therapy (DT), that is, lifelong permanent support. Exploration of DT is a promising avenue to many patients suffering with ESHF who may never be fortunate enough to receive a heart transplant, but not without reservations of its efficacy, safety, effects on quality-adjusted life years and cost-effectiveness, especially in comparison to heart transplantation.
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Affiliation(s)
| | | | | | - Kenneth Y-K Wong
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
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15
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Chiu P, Schaffer JM, Oyer PE, Pham M, Banerjee D, Joseph Woo Y, Ha R. Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation. J Heart Lung Transplant 2016; 35:731-42. [PMID: 26856669 DOI: 10.1016/j.healun.2015.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 11/22/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Allosensitization has been shown to negatively affect post-heart transplant (HTx) survival even with a negative crossmatch. Whether allosensitization related to mechanical circulatory support (MCS) is associated with worse post-HTx survival remains controversial. METHODS Adult HTx recipients listed in the United Network for Organ Sharing database (July 2006-December 2012) were identified. Multivariate Cox regression assessed the effect of allosensitization on survival. Propensity matching was performed to compare patients who were and were not allosensitized. Kaplan-Meier survival analysis compared matched and unmatched patients in the MCS and medically managed cohorts. RESULTS We identified 11,840 HTx recipients, of whom 4,167 had MCS. MCS was associated with allosensitization in multivariate logistic regression. Each different MCS device was associated with worse post-HTx survival in multivariate Cox regression. Allosensitization did not predict post-HTx mortality in MCS patients (hazard ratio, 1.07; 95% confidence interval, 0.89-1.28; p = 0.48. Among patients without MCS, allosensitization was associated with post-HTx mortality (hazard ratio, 1.19; 95% confidence interval, 1.03-1.39; p = 0.02). Kaplan-Meier analysis revealed equivalent survival in unmatched and matched cohorts when MCS patients who were allosensitized were compared with non-allosensitized MCS patients. Among non-MCS patients, allosensitization was associated with worse survival in unmatched and matched analysis. CONCLUSIONS MCS was associated with allosensitization. For MCS patients, allosensitization did not independently predict worse post-HTx outcome. Among non-MCS patients, allosensitization was associated with worse post-HTx survival. Allosensitization appears to be a heterogeneous process influenced by presence of MCS.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Philip E Oyer
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Michael Pham
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, California
| | - Dipanjan Banerjee
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Richard Ha
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California.
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16
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Gaffey AC, Phillips EC, Howard J, Hung G, Han J, Emery R, Goldberg L, Acker MA, Woo YJ, Atluri P. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. Ann Thorac Surg 2015; 100:542-9. [DOI: 10.1016/j.athoracsur.2015.02.093] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/29/2022]
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17
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Harvey L, Holley CT, John R. Gastrointestinal bleed after left ventricular assist device implantation: incidence, management, and prevention. Ann Cardiothorac Surg 2014; 3:475-9. [PMID: 25452907 DOI: 10.3978/j.issn.2225-319x.2014.08.19] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 08/23/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (CF-LVADs) have become the standard of care for patients with end-stage heart failure (HF). While these devices have improved durability compared to earlier generation left ventricular assist devices (LVADs), increased frequency in some complications has been seen, including gastrointestinal bleeding (GIB), pump thrombosis and hemolysis. We discuss the incidence, management and prevention of GIB after CF-LVAD implantation. METHODS We reviewed the current literature available on the incidence, management and prevention of GIB after CF-LVAD implantation with a focus on our experience at the University of Minnesota, with data on nearly 300 patients who received a CF-LVAD from 2005 to 2013. RESULTS The incidence of GIB after CF-LVAD varies between 18-40% in numerous studies. At the University of Minnesota, out of 233 patients who underwent HeartMate II (HMII) implantation between 2005-2013, 60 GIB episodes occurred in 51 patients (22%), with an event rate of 0.17 gastrointestinal bleeds/patient-year of support. The etiology of GIB appears to be multifactorial. The main factors which have been identified include the need for chronic anticoagulation, acquired von Willebrand syndrome, platelet dysfunction and increased incidence of arteriovenous malformations due to chronic low pulse pressure. When managing an LVAD patient with GIB, a multi-disciplinary approach is needed. The main goals of treatment are evaluating the location and severity of the bleed, holding anti-coagulants and resuscitation to maintain stable hemodynamics. CONCLUSIONS GIB is a complication with considerable morbidity. Future efforts to further understand the etiology of GIB and optimize anti-coagulation are needed to improve outcomes following CF-LVAD implantation.
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Affiliation(s)
- Laura Harvey
- 1 Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA ; 2 Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Christopher T Holley
- 1 Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA ; 2 Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Ranjit John
- 1 Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA ; 2 Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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18
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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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19
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Miller JR, Lawrance CP, Silvestry SC. Current Options and Practices in Long-Term Ventricular Assist Devices. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Alba AC, McDonald M, Rao V, Ross HJ, Delgado DH. The effect of ventricular assist devices on long-term post-transplant outcomes: a systematic review of observational studies. Eur J Heart Fail 2014; 13:785-95. [DOI: 10.1093/eurjhf/hfr050] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ana C. Alba
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Michael McDonald
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery; Toronto General Hospital; Toronto Ontario Canada
| | - Heather J. Ross
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Diego H. Delgado
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
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21
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Sun W, Jeleniowski K, Zhao X, Shen P, Li D, Hammond JA. Thromboelastography (TEG)-Based Algorithm Reduces Blood Product Utilization in Patients Undergoing VAD Implant. J Card Surg 2014; 29:238-43. [PMID: 24734284 DOI: 10.1111/jocs.12302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wenyu Sun
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Ken Jeleniowski
- Department of Perfusion; Hartford Hospital; Hartford Connecticut
| | - Xin Zhao
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Peter Shen
- Department of Cytopathology; Hartford Hospital; Hartford Connecticut
| | - Dadong Li
- Department of Research Administration; Hartford Hospital; Hartford Connecticut
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22
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Schweiger M, Dave H, Lemme F, Romanchenko O, Hofmann M, Hübler M. Ventricular assist devices: initial orientation. J Thorac Dis 2013; 5:567-71. [PMID: 23991317 DOI: 10.3978/j.issn.2072-1439.2013.08.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/08/2013] [Indexed: 11/14/2022]
Abstract
Ventricular assist device (VAD) technology has come from large pulsatile-flow devices with a high rate of technical malfunctions to small continuous flow (cf) devices. Mechanical circulatory support (MCS) systems may be used as short-, mid- or long-term support. Especially if mid- or long-term support is anticipated left VADs (LVADs) have been reported with excellent one and two year survival rates and improved quality of life (QoL). Timing of implantation, patient selection, assessing function of the right ventricular and surgical considerations regarding surgical access side, valve pathology and exit side of the percutaneous lead remain crucial issues for the outcome. In contrast VADs designed for children especially for all age groups, are still underrepresented but increased experience with existing pediatric VADs as well as introduction of second and third generation VADs into in the pediatric age group, offer new perspectives.
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Affiliation(s)
- Martin Schweiger
- University Children's Hospital Zurich, Department for Congenital Cardiovascular Surgery
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23
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Engin Y, Engin C, Yagdi T, Nalbantgil S, Erkul S, Ertugay S, Ozbaran M. To bridge or not to bridge? Transplant Proc 2012; 44:1722-5. [PMID: 22841254 DOI: 10.1016/j.transproceed.2012.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs. METHODS Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support. RESULTS Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥ 130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar. CONCLUSION Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.
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Affiliation(s)
- Y Engin
- Department of Cardiovascular Surgery, Ege University Hospital, Izmir, Turkey.
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24
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Vikholm P, Schiller P, Johansson J, Hellgren L. A modified Glenn shunt improves haemodynamics in acute right ventricular failure in an experimental model. Eur J Cardiothorac Surg 2012; 43:612-8. [DOI: 10.1093/ejcts/ezs386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Shah MR, Starling RC, Schwartz Longacre L, Mehra MR. Heart transplantation research in the next decade--a goal to achieving evidence-based outcomes: National Heart, Lung, And Blood Institute Working Group. J Am Coll Cardiol 2012; 59:1263-9. [PMID: 22464255 DOI: 10.1016/j.jacc.2011.11.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 11/18/2011] [Indexed: 10/28/2022]
Abstract
The National Heart, Lung, and Blood Institute (NHLBI) convened a Working Group (WG) on August 5 to 6, 2010 in Bethesda, Maryland to discuss future directions of research in heart transplantation (HT). The WG was composed of researchers with expertise in the basic science, clinical science, and epidemiological aspects of advanced heart failure and HT. These experts were asked to identify the highest priority research gaps in the field and make recommendations for future research strategies. The WG was also asked to include approaches that capitalize on current scientific opportunities and focus on areas that required unique NHLBI leadership. Finally, the WG was charged with developing recommendations that would have short- and long-term impact on the field of HT. The WG participants reviewed key areas in HT and identified the most urgent knowledge gaps. These gaps were then organized into the following 4 specific research directions: 1) enhanced phenotypic characterization of the pre-transplant population; 2) donor-recipient optimization strategies; 3) individualized immunosuppression therapy; and, 4) investigations of immune and non-immune factors affecting late cardiac allograft outcomes. Finally, because the HT population is relatively small compared with other patient groups, the WG strongly urged concerted efforts to enroll every transplant recipient into a clinical study and to increase collaborative networks to optimize research in this field.
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Affiliation(s)
- Monica R Shah
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute/NIH, Two Rockledge Center, 6701 Rockledge Drive, Bethesda, MD 20892-7956, USA.
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26
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Krabatsch T, Schweiger M, Stepanenko A, Drews T, Potapov E, Pasic M, Weng Y, Huebler M, Hetzer R. [Improvements in implantable mechanical circulatory support systems : literature overview and update]. Herz 2012; 36:622-9. [PMID: 21912911 DOI: 10.1007/s00059-011-3509-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In recent years, ventricular assist devices (VAD) supporting the left (LVAD), the right (RVAD) or both ventricles (BVAD) have rapidly emerged as the standard of care for advanced heart failure patients. Both the numbers and ages of patients in which they are used are rising worldwide, especially when used as a permanent support (bridge to destination, BTD). Due to the continuing lack of donor organs, these devices now represent a viable alternative to bridge patients to transplantation (BTT), with a 1-year survival rate of 86%. BTD, especially in long-term support, might be a valid, and the sole, option for those patients in whom heart transplantation is contraindicated. Patient selection, pre- and intra-operative preparation, as well as the timing of VAD implantation are important factors critical to successful circulatory support. While BTT remains the goal in the majority of patients, the number of permanent VADs (i. e. BTD) is rising significantly. Although explantation of a VAD system as a bridge to recovery (BTR) can be considered in only a small number of patients, it represents a very special part of this therapy modality.
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27
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Cantillon DJ, Bianco C, Wazni OM, Kanj M, Smedira NG, Wilkoff BL, Starling RC, Saliba WI. Electrophysiologic characteristics and catheter ablation of ventricular tachyarrhythmias among patients with heart failure on ventricular assist device support. Heart Rhythm 2012; 9:859-64. [PMID: 22293139 DOI: 10.1016/j.hrthm.2012.01.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventricular tachyarrhythmias (VT) are common among ventricular assist device (VAD) recipients, yet electrophysiologic (EP) characteristics and catheter ablation outcomes remain uncharacterized. OBJECTIVE To evaluate the EP characteristics and catheter ablation outcomes for VTs among heart failure patients on VAD support. METHODS The Cleveland Clinic registry of consecutive patients undergoing VAD placement in 1991-2010 with medically refractory, symptomatic VT referred for EP study and catheter ablation. RESULTS Among 611 recipients of VAD (mean age 53.3 ± 12.4 years, 80% men), 21 patients (3.4%) were referred for 32 EP procedures, including 11 patients (52%) presenting with implantable cardioverter-defibrillator therapy (13 shocks, 26 antitachycardia pacing). Data from 44 inducible tachycardias (mean cycle length 339 ± 59 ms) demonstrated monomorphic VT (n = 40, 91%; superior axis 52%, right bundle branch block morphology 41%) and polymorphic ventricular tachycardia (PMVT)/ventricular fibrillation (n = 4, 8%). Electroanatomic mapping of 28 tachycardias in 20 patients demonstrated reentrant VT related to intrinsic scar (n = 21 of 28, 75%) more commonly than the apical inflow cannulation site (n = 4 of 28, 14%), focal/microreentry VT (n = 2 of 28, 7%), or bundle branch reentry (n = 1 of 28, 3.5%). Catheter ablation succeeded in 18 of 21 patients (86%). VT recurred in 7 of 21 patients (33%) at a mean of 133 ± 98 days, and 6 patients (29%) required repeat procedures, with subsequent recurrence in 4 of 21 patients (19%). CONCLUSIONS Catheter ablation of VT is effective among recipients of VAD. Intrinsic myocardial scar, rather than the apical device cannulation site, appears to be the dominant substrate.
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Affiliation(s)
- Daniel J Cantillon
- Cleveland Clinic, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland, OH 44195, USA.
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28
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Iver RHM, McGee EC, McCarthy PM. Cardiac Transplantation for Ischemic Heart Disease. Coron Artery Dis 2012. [DOI: 10.1007/978-1-84628-712-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Moreno SG, Novielli N, Cooper NJ. Cost-effectiveness of the implantable HeartMate II left ventricular assist device for patients awaiting heart transplantation. J Heart Lung Transplant 2011; 31:450-8. [PMID: 22115674 DOI: 10.1016/j.healun.2011.10.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/06/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are being proposed as a life-saving therapeutic alternative to conventional medical management for people with end-stage heart failure awaiting transplantation. However, cost-effectiveness assessments of first-generation LVADs have not been encouraging. The cost-effectiveness of the enhanced second-generation LVAD HeartMate II (Thoratec, Pleasanton, CA) is estimated here. METHODS A probabilistic Markov model was developed to extrapolate survival, utility, and resource use over the total lifetime of a hypothetic cohort of patients with end-stage heart failure under the 2 competing therapeutic strategies, using the most robust and recently published evidence about their performance. Cost data are based on UK activity to consider reimbursement in the UK National Health Service setting. RESULTS HeartMate II had a mean cost per quality-adjusted life-year (QALY) of £258,922 ($414,275). The sensitivity analysis showed that 2 factors mainly explain why HeartMate II is not a cost-effectiveness strategy as a bridge-to-transplant: (1) the survival of heart transplant candidates treated conventionally while on the waiting list has significantly improved in recent years, and (2) the high acquisition cost of the device, £94,200 ($150,720). CONCLUSIONS Although HeartMate II LVAD implantation significantly increases survival compared with conventional medical management, it does not provide good value for the money spent according to established thresholds of cost-effectiveness in the UK. HeartMate II is unlikely to become cost-effective unless the additional survival gained by its use raises and/or the device is given free of charge. Therefore, its implantation to transplant candidates lacks justification in terms of cost-effectiveness.
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Affiliation(s)
- Santiago G Moreno
- Department of Evaluation of Innovation & New Technologies, Fundació Clínic, Barcelona, Spain.
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McKelvie RS, Moe GW, Cheung A, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, Floras J, Giannetti N, Grzeslo A, Harkness K, Heckman GA, Howlett JG, Kouz S, Leblanc K, Mann E, O'Meara E, Rajda M, Rao V, Simon J, Swiggum E, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Haddad H, Isaac DL, Leblanc MH, Liu P, Sussex B, Ross HJ. The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care. Can J Cardiol 2011; 27:319-38. [DOI: 10.1016/j.cjca.2011.03.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022] Open
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Engin C, Ayik F, Oguz E, Eygi B, Yagdi T, Karakula S, Ozbaran M. Ventricular Assist Device as a Bridge to Heart Transplantation in Adults. Transplant Proc 2011; 43:927-30. [DOI: 10.1016/j.transproceed.2011.01.147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Krabatsch T, Schweiger M, Stepanenko A, Kukucka M, Vierecke J, Lehmkuhl HB, Huebler M, Hennig E, Potapov E, Hetzer R. Mechanical Circulatory Support—Results, Developments and Trends. J Cardiovasc Transl Res 2011; 4:332-9. [PMID: 21394530 DOI: 10.1007/s12265-011-9268-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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Right Ventricular Failure—A Continuing Problem in Patients with Left Ventricular Assist Device Support. J Cardiovasc Transl Res 2010; 3:604-11. [DOI: 10.1007/s12265-010-9216-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 08/11/2010] [Indexed: 01/23/2023]
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Predictive value of the Seattle Heart Failure Model in patients undergoing left ventricular assist device placement. J Heart Lung Transplant 2010; 29:1021-5. [DOI: 10.1016/j.healun.2010.05.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 05/01/2010] [Accepted: 05/01/2010] [Indexed: 11/24/2022] Open
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Romano MA, Cowger J, Aaronson KD, Pagani FD. Diagnosis and Management of Right-Sided Heart Failure in Subjects Supported With Left Ventricular Assist Devices. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 12:420-30. [DOI: 10.1007/s11936-010-0091-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Thompson KA, Philip KJ, Simsir S, Schwarz ER. Review: The New Concept of ‘‘Interventional Heart Failure Therapy’’: Part 2—Inotropes, Valvular Disease, Pumps, and Transplantation. J Cardiovasc Pharmacol Ther 2010; 15:231-43. [DOI: 10.1177/1074248410369111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent advances in heart failure therapy include a variety of mechanical and device-based technologies that target structural aspects of heart failure that cannot be treated with drug therapy alone; these newer therapies can collectively be described as interventional heart failure therapy. This article is the second in a 2-part series reviewing interventional heart failure therapy. Interventions included in this discussion include those indicated for the treatment of end-stage refractory heart failure, including interventional medical therapy, interventional treatment of valvular disease, mechanical assist devices, and heart transplantation. Also included is a review of the currently available catheter-based pumps, which are intended to provide temporary support in patients with acute hemodynamic compromise. The use of cellular or stem cell therapy for the treatment of heart failure is an emerging interventional therapy and data supporting its use for the treatment heart failure will also be presented, as will a discussion of the role of palliative care and self-care in heart failure therapy.
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Affiliation(s)
- Keith A. Thompson
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Kiran J. Philip
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Sinan Simsir
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ernst R. Schwarz
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA,
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Update on inotropic therapy in the management of acute heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 9:443-9. [PMID: 18221596 DOI: 10.1007/s11936-007-0039-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The use of classic inotropic agents activating the beta-receptor-cyclic adenosine monophosphate (cAMP) pathway (ie, dobutamine or milrinone) should be restricted to a "rescue" therapy in patients with acute heart failure and signs of peripheral hypoperfusion (hypotension, renal dysfunction) that is refractory to volume replacement, diuretics, and vasodilators. This approach is largely supported by observations from clinical trials suggesting that both short-term treatment of acute heart failure without an essential requirement of inotropic support as well as long-term inotropic therapy in patients with severe chronic heart failure with classical inotropic agents can increase arrhythmia and mortality. Vice versa, beta-receptor blockade, whenever tolerated, improves survival in patients with severe stable heart failure, further supporting the concept that beta-receptor stimulation has adverse long-term effects. Positive inotropic therapy stimulating the beta-receptor-cAMP pathway should, therefore, be used with caution, given the potential harmful effects. Levosimendan, a novel calcium sensitizer, has recently attracted substantial clinical interest and may be superior to classical inotropes with respect to improving cardiac mechanical efficiency and avoiding adverse effects such as increasing myocardial oxygen uptake or cardiomyocyte death. Earlier clinical studies have suggested a beneficial effect on survival compared with dobutamine or placebo in patients with acute heart failure (LIDO , RUSSLAN , and CASINO trials). However, more recent data from two large clinical trials (SURVIVE and REVIVE trials) did not confirm these beneficial effects on mortality. Therefore, additional data are required with respect to the optimum dosing of levosimendan and patient selection to reach a definitive conclusion about the role of levosimendan in the management of patients with acute heart failure.
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Bull DA, Reid BB, Selzman CH, Mesley R, Drakos S, Clayson S, Stoddard G, Gilbert E, Stehlik J, Bader F, Kfoury A, Budge D, Eckels DD, Fuller A, Renlund D, Patel AN. The impact of bridge-to-transplant ventricular assist device support on survival after cardiac transplantation. J Thorac Cardiovasc Surg 2010; 140:169-73. [PMID: 20451930 DOI: 10.1016/j.jtcvs.2010.03.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 03/05/2010] [Accepted: 03/21/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the impact of bridge-to-transplant ventricular assist device support on survival after cardiac transplantation. METHODS From January 1, 1993, to April 30, 2009, a total of 525 cardiac transplants were performed. Ventricular assist devices were placed as a bridge to transplant in 110 patients. We focused our analysis on the 2 most common causes of end-stage heart failure requiring transplantation: idiopathic dilated cardiomyopathy (n = 201) and coronary artery disease (n = 213). Data including gender, age, date of transplant, cause of heart failure, prior heart transplant, placement of a ventricular assist device, type of ventricular assist device, and panel-reactive antibody sensitization were analyzed to derive Kaplan-Meier survival probabilities and multivariable Cox regression models. RESULTS In patients with idiopathic dilated cardiomyopathy who received a ventricular assist device as a bridge to transplant, survival was decreased at 1 year (P = .008) and 5 years (P = .019), but not at 10 years, posttransplant. In patients with coronary artery disease, the use of a ventricular assist device as a bridge to transplant did not influence survival at 1, 5, and 10 tears posttransplant. In patients with idiopathic dilated cardiomyopathy who received a Heartmate I (Thoratec Corp, Pleasanton, Calif) ventricular assist device as a bridge to a cardiac transplant, elevation in the pretransplant panel-reactive antibody correlated with a decrease in long-term survival. CONCLUSION In patients with idiopathic dilated cardiomyopathy, placement of a Heartmate I ventricular assist device as a bridge to a cardiac transplant is associated with an elevation in the pretransplant panel-reactive antibody and a decrease in 1- and 5-year survivals after cardiac transplantation.
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Affiliation(s)
- David A Bull
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah 84132, USA.
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John R, Pagani FD, Naka Y, Boyle A, Conte JV, Russell SD, Klodell CT, Milano CA, Rogers J, Farrar DJ, Frazier OH. Post-cardiac transplant survival after support with a continuous-flow left ventricular assist device: impact of duration of left ventricular assist device support and other variables. J Thorac Cardiovasc Surg 2010; 140:174-81. [PMID: 20447659 DOI: 10.1016/j.jtcvs.2010.03.037] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 01/07/2010] [Accepted: 03/26/2010] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Although left ventricular assist devices (LVADs) are associated with excellent outcomes in patients with end-stage heart failure, there are conflicting reports on posttransplant survival in these patients. Furthermore, prior studies with pulsatile LVADs have shown that transplantation, either early (<6 weeks) or late (>6 months) after LVAD implantation, adversely affected post-cardiac transplant survival. We sought to determine factors related to posttransplant survival in patients supported with continuous-flow LVADs. METHODS The HeartMate II LVAD (Thoratec Corporation, Pleasanton, Calif) was implanted in 468 patients as a bridge to transplant at 36 centers in a multicenter trial. Patients who underwent transplantation after support were stratified by demographics: gender, age, etiology, body mass index, duration of device support, and by adverse events during support. The median age was 54 years (range 18-73 years); 43% had ischemic etiology, and 18% were women. Survival was determined at the specific intervals of 30 days and 1 year after transplantation. RESULTS Of 468 patients, 250 (53%) underwent cardiac transplant after a median duration of LVAD support of 151 days (longest: 3.2 years), 106 (23%) died, 12 (2.6%) recovered ventricular function and the device was removed, and 100 (21%) were still receiving LVAD support. The overall 30-day and 1-year posttransplant survivals were 97% and 87%. There were no significant differences in survival based on demographic factors or LVAD duration of less than 30 days, 30 to 90 days, 90 to 180 days, and more than 180 days. Patients requiring more than 2 units of packed red blood cells in 24 hours during LVAD support had a statistically significant decreased 1-year survival (82% vs 94%) when compared with patients who did not require more than 2 units of packed red blood cells in 24 hours during LVAD support (P = .03). There was a trend for slightly lower survival at 1 year in patients with percutaneous lead infections during LVAD support versus no infection (75% vs 89%; P = .07). CONCLUSIONS Post-cardiac transplant survival in patients supported with continuous-flow devices such as the HeartMate II LVAD is equivalent to that with conventional transplantation. Furthermore, posttransplant survival is not influenced by the duration of LVAD support. The improved durability and reduced short- and long-term morbidity associated with the HeartMate II LVAD has reduced the need for urgent cardiac transplantation, which may have adversely influenced survival in the pulsatile LVAD era. This information may have significant implications for changing the current United Network for Organ Sharing criteria regarding listing of heart transplant candidates.
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Affiliation(s)
- Ranjit John
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minn 55455, USA.
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Lund LH, Matthews J, Aaronson K. Patient selection for left ventricular assist devices. Eur J Heart Fail 2010; 12:434-43. [DOI: 10.1093/eurjhf/hfq006] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lars H. Lund
- Department of Cardiology, Section for Heart Failure; Karolinska University Hospital; N305 171 76 Stockholm Sweden
| | - Jennifer Matthews
- Division of Cardiovascular Medicine, Department of Internal Medicine; University of Michigan; Ann Arbor MI USA
| | - Keith Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine; University of Michigan; Ann Arbor MI USA
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Cantillon DJ, Tarakji KG, Kumbhani DJ, Smedira NG, Starling RC, Wilkoff BL. Improved survival among ventricular assist device recipients with a concomitant implantable cardioverter-defibrillator. Heart Rhythm 2010; 7:466-71. [DOI: 10.1016/j.hrthm.2009.12.022] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 12/22/2009] [Indexed: 11/16/2022]
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Pal JD, Piacentino V, Cuevas AD, Depp T, Daneshmand MA, Hernandez AF, Felker GM, Lodge AJ, Rogers JG, Milano CA. Impact of Left Ventricular Assist Device Bridging on Posttransplant Outcomes. Ann Thorac Surg 2009; 88:1457-61; discussion 1461. [DOI: 10.1016/j.athoracsur.2009.07.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 07/07/2009] [Accepted: 07/10/2009] [Indexed: 11/16/2022]
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Genovese EA, Dew MA, Teuteberg JJ, Simon MA, Kay J, Siegenthaler MP, Bhama JK, Bermudez CA, Lockard KL, Winowich S, Kormos RL. Incidence and patterns of adverse event onset during the first 60 days after ventricular assist device implantation. Ann Thorac Surg 2009; 88:1162-70. [PMID: 19766801 DOI: 10.1016/j.athoracsur.2009.06.028] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 06/04/2009] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although ventricular assist devices (VADs) provide effective treatment for end-stage heart failure, VAD support remains associated with significant risk for adverse events (AEs). To date there has been no detailed assessment of the incidence of a full range of AEs using standardized event definitions. We sought to characterize the frequency and timing of AE onset during the first 60 days of VAD support, a period during which clinical observation suggests the risk of incident AEs is high. METHODS A retrospective analysis was performed utilizing prospectively collected data from a single-site clinical database including 195 patients aged 18 or greater receiving VADs between 1996 and 2006. Adverse events were coded using standardized criteria. Cumulative incidence rates were determined, controlling for competing risks (death, transplantation, recovery-wean). RESULTS During the first 60 days after implantation, the most common AEs were bleeding, infection, and arrhythmias (cumulative incidence rates, 36% to 48%), followed by tamponade, respiratory events, reoperations, and neurologic events (24% to 31%). Other events (eg, hemolysis, renal, hepatic events) were less common (rates <15%). Some events (eg, bleeding, arrhythmias) showed steep onset rates early after implantation. Others (eg, infections, neurologic events) had gradual onsets during the 60-day period. Incidence of most events did not vary by implant era (1996 to 2000 vs 2001 to 2006) or by left ventricular versus biventricular support. CONCLUSIONS Understanding differential temporal patterns of AE onset will allow preventive strategies to be targeted to the time periods when specific AE risks are greatest. The AE incidence rates provide benchmarks against which future studies of VAD-related risks may be compared.
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Affiliation(s)
- Elizabeth A Genovese
- Artificial Heart Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Daneshmand MA, Milano CA. Surgical Treatments for Advanced Heart Failure. Surg Clin North Am 2009; 89:967-99, x. [DOI: 10.1016/j.suc.2009.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Ventricular assist devices are an important therapeutic option for advanced congestive heart failure. A left ventricular assist device (LVAD) can be implanted as a bridge to transplantation or for the purpose of destination therapy. LVADs improve end-organ function and reduce morbidity and mortality in appropriately selected patients. The development of axial flow pumps has overcome many of the limitations of the first-generation pulsatile flow LVADs. However, many complications of LVAD therapy remain. Treating these complications requires an understanding of LVAD physiology. Ongoing research is directed at reducing the incidence of many of these complications and may allow for wider use of LVADs.
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Affiliation(s)
- Gabriel Sayer
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, NY, USA
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Abstract
Cardiac transplantation and mechanical circulatory support are possible options for improving survival and quality of life in patients with isolated cardiac disease and end-stage heart failure. Transplantation is limited by donor availability but has a median survival of 10 years. Post-transplant immunosuppression is often transplant center dependent, but a tacrolimus and mycophenolate mofetil-based regimen may be preferred. Sirolimus may reduce the progression rate of transplant vasculopathy. There has been a trend toward continuous-flow left ventricular assist devices because of their increased durability and reduced size. A variety of surgical and percutaneous ventricular assist devices may be used as a bridge to decision on a patient's candidacy for transplantation. Mechanical circulatory support as destination therapy has not been widely implemented because of poor device durability, but this is expected to change with newer devices. Mechanical circulatory support as a bridge to myocardial recovery has been successful only in a few patients.
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Affiliation(s)
- Andrew Boyle
- University of Minnesota, 420 SE Delaware Street, Minneapolis, MN 55455, USA.
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Fitzpatrick JR, Frederick JR, Hsu VM, Kozin ED, O'Hara ML, Howell E, Dougherty D, McCormick RC, Laporte CA, Cohen JE, Southerland KW, Howard JL, Jessup ML, Morris RJ, Acker MA, Woo YJ. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant 2009; 27:1286-92. [PMID: 19059108 DOI: 10.1016/j.healun.2008.09.006] [Citation(s) in RCA: 301] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 07/09/2008] [Accepted: 09/03/2008] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Right ventricular (RV) failure after left ventricular assist device (LVAD) placement is a serious complication and is difficult to predict. In the era of destination therapy and the total artificial heart, predicting post-LVAD RV failure requiring mechanical support is extremely important. METHODS We reviewed patient characteristics, laboratory values and hemodynamic data from 266 patients who underwent LVAD placement at the University of Pennsylvania from April 1995 to June 2007. RESULTS Of 266 LVAD recipients, 99 required RV assist device (BiVAD) placement (37%). We compared 36 parameters between LVAD (n = 167) and BiVAD patients (n = 99) to determine pre-operative risk factors for RV assist device (RVAD) need. By univariate analysis, 23 variables showed statistically significant differences between the two groups (p < or = 0.05). By multivariate logistic regression, cardiac index < or =2.2 liters/min/m(2) (odds ratio [OR] 5.7), RV stroke work index < or =0.25 mm Hg . liter/m(2) (OR 5.1), severe pre-operative RV dysfunction (OR 5.0), pre-operative creatinine > or =1.9 mg/dl (OR 4.8), previous cardiac surgery (OR 4.5) and systolic blood pressure < or =96 mm Hg (OR 2.9) were the best predictors of RVAD need. CONCLUSIONS The most significant predictors for RVAD need were cardiac index, RV stroke work index, severe pre-operative RV dysfunction, creatinine, previous cardiac surgery and systolic blood pressure. Using these data, we constructed an algorithm that can predict which LVAD patients will require RVAD with >80% sensitivity and specificity.
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Affiliation(s)
- J Raymond Fitzpatrick
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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