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Nickel I, Potapov E, Sun B, Zimpfer D, Koliopoulou A, Adachi I, Anyanwu A, Falk V, Atluri P, Faerber G, Goldstein D, Yarboro L, Slaughter MS, Milano C, Tsukashita M, D'Alessandro D, Silvestry S, Kirov H, Bommareddi S, Lanmüller P, Doenst T, Selzman CH. Deactivation of LVAD support for myocardial recovery-surgical perspectives. J Heart Lung Transplant 2024; 43:1489-1500. [PMID: 38744354 DOI: 10.1016/j.healun.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
Left ventricular assist devices (LVADs) are excellent therapies for advanced heart failure patients either bridged to transplant or for lifetime use. LVADs also allow for reverse remodeling of the failing heart that is often associated with functional improvement. Indeed, growing enthusiasm exists to better understand this population of patients, whereby the LVAD is used as an adjunct to mediate myocardial recovery. When patients achieve benchmarks suggesting that they no longer need LVAD support, questions related to the discontinuation of LVAD therapy become front and center. The purpose of this review is to provide a surgical perspective on the practical and technical issues surrounding LVAD deactivation.
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Affiliation(s)
- Ian Nickel
- Department of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Benjamin Sun
- Division of Cardiothoracic Surgery, Abbott Northwestern Hospital, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, Athens, Greece
| | - Iki Adachi
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Anelechi Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany; Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital-Friedrich Schiller University of Jena, Jena, Germany
| | - Daniel Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Leora Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Carmelo Milano
- Department of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina
| | - Masaki Tsukashita
- Department of Cardiothoracic Surgery, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - David D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott Silvestry
- Department of Cardiothoracic Surgery, AdventHealth Transplant Institute, Orlando, Florida
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital-Friedrich Schiller University of Jena, Jena, Germany
| | - Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Pia Lanmüller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital-Friedrich Schiller University of Jena, Jena, Germany
| | - Craig H Selzman
- Department of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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Hillner R, Perry L, Hill N, Badheka AV, Chivukula VK. EXCOR membrane motion analyzer (EMMA) to quantify and assess hemodynamic performance of the EXCOR pediatric heart assist device. Perfusion 2024:2676591241265052. [PMID: 39034158 DOI: 10.1177/02676591241265052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND Pediatric heart failure is associated with high mortality rates and is a current clinical burden. There is only one FDA approved pediatric VAD, Berlin Heart EXCOR, for treatment. Thrombo-embolic complications are a significant clinical challenge, which can lead to devastating complications such as stroke and impair efficient EXCOR function. Currently, clinicians perform largely qualitative periodic assessment of EXCOR operation by observing the motion of a rapidly moving membrane, which can be prone to human error and can lead to missing out on crucial information. METHODS In this study, we design and implement a quantitative early warning system for accurate and quantitative assessment of the EXCOR membrane, named EXCOR Membrane Motion Analyzer (EMMA). Using a combination of image analysis, computer vision and custom designed algorithm, we perform rigorous frame by frame analysis of EXCOR membrane video data. We developed specialized metrics to identify relative smoothness between successive peaks, time between peaks and overall smoothness indicators to quantify and compare between multiple cases. RESULTS Our results demonstrate that EMMA can successfully identify the motion and wrinkles on each video frame and quantify the smoothness and identify the phases of each cardiac cycle. Moreover, EMMA can obtain the smoothness of each frame and the temporal evolution of membrane smoothness across all image frames for the video sequence. CONCLUSIONS EMMA allows for a fast, accurate, quantitative assessment to be completed and reduces user error. This enables EMMA to be used effectively as an early warning system to rapidly identify device abnormalities.
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Affiliation(s)
- Rachel Hillner
- Biomedical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, USA
| | - Luke Perry
- Biomedical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, USA
| | - Natalie Hill
- Biomedical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, USA
| | - Aditya V Badheka
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
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Lippy M, Still B, Dhawan R. Stepwise Mechanical Circulatory Support in a Pediatric Patient With Respiratory Failure Facilitating Mobilization and Recovery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00361-6. [PMID: 38890079 DOI: 10.1053/j.jvca.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Mitchell Lippy
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Brady Still
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
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Rohde S, Miera O, Sliwka J, Sandica E, Amodeo A, Veen K, de By TMMH, Bogers AJJC, Schweiger M. Durable left ventricular assist device explantation following recovery in paediatric patients: Determinants and outcome after explantation. Eur J Cardiothorac Surg 2024; 65:ezae126. [PMID: 38613845 DOI: 10.1093/ejcts/ezae126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/31/2024] [Accepted: 04/11/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES Myocardial recovery in children supported by a durable left ventricular assist device is a rare, but highly desirable outcome because it could potentially eliminate the need for a cardiac transplant and the lifelong need for immunosuppressant therapy and the risk of complications. However, experience with this specific outcome is extremely limited. METHODS All patients < 19 years old supported by a durable left ventricular assist device from the European Registry for Patients with Mechanical Circulatory Support database were included. Participating centres were approached for additional follow-up data after explantation. Associated factors for explantation due to myocardial recovery were explored using Cox proportional hazard models. RESULTS The incidence of recovery in children supported by a durable left ventricular assist device was 11.7% (52/445; median duration of support, 122.0 days). Multivariable analyses showed body surface area (hazard ratio 0.229; confidence interval 0.093-0.565; P = 0.001) and a primary diagnosis of myocarditis (hazard ratio 4.597; confidence interval 2.545-8.303; P < 0.001) to be associated with recovery. Left ventricular end-diastolic diameter in children with myocarditis was not associated with recovery. Follow-up after recovery was obtained for 46 patients (88.5%). Sustained myocardial recovery was reported in 33/46 (71.7%) at the end of the follow-up period (28/33; >2 year). Transplants were performed in 6/46 (11.4%) (in 5 after a ventricular assist device was reimplanted). Death occurred in 7/46 (15.2%). CONCLUSIONS Myocardial recovery occurs in a substantial portion of paediatric patients supported with durable left ventricular assist devices, and sustainable recovery is seen in around three-quarters of them. Even children with severely dilated ventricles due to myocarditis can show recovery. Clinicians should be attentive to (developing) myocardial recovery. These results can be used to develop internationally approved paediatric weaning guidelines.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum der Charité, Berlin, Germany
| | - Joanna Sliwka
- Department of Cardiac Surgery, Transplantology and Vascular Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Eugen Sandica
- Clinic for Pediatric Cardiac Surgery and Congenital Heart Defects, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Antonio Amodeo
- Heart Failure, Transplant and MCS Unit, Bambino Gesù Children Hospital & Research Institute, Rome, Italy, Catholic University of Sacred Heart, Department of Cardiac Surgery, Rome, Italy
| | - Kevin Veen
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children's Hospital Zurich, Pediatric Heart Centre, Department for congenital heart surgery, Zurich, Switzerland
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Rohde S, de By TMMH, Bogers AJJC, Schweiger M. Myocardial recovery in children supported with a durable ventricular assist device-a systematic review. Eur J Cardiothorac Surg 2023; 64:ezad263. [PMID: 37498565 PMCID: PMC10560320 DOI: 10.1093/ejcts/ezad263] [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: 02/11/2023] [Revised: 06/18/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES A small percentage of paediatric patients supported with a ventricular assist device (VAD) can have their device explanted following myocardial recovery. The goal of this systematic review is to summarize the current literature on the clinical course in these children after weaning. METHODS A systematic literature search was performed on 27 May 2022 using Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar to include all literature on paediatric patients supported by a durable VAD during the last decade. Overlapping study cohorts and registry-based studies were filtered out. RESULTS Thirty-seven articles were included. Eighteen of them reported on the incidence of recovery in cohort studies, with an overall incidence rate of 8.7% (81/928). Twenty-two of the included articles reported on clinical outcomes after VAD explantation (83 patients). The aetiologies varied widely and were not limited to diseases with a natural transient course like myocarditis. Most of the patients in the included studies (70; 84.3%) were supported by a Berlin Heart EXCOR, and in 66.3% (55/83), only the left ventricle had to be supported. The longest follow-up period was 19.1 years, and multiple studies reported on long-term myocardial recovery. Fewer than half of the reported deaths had a cardiac cause. CONCLUSIONS Myocardial recovery during VAD support is dependent on various contributing components. The interactions among patient-, device-, time- and hospital-related factors are complex and not yet fully understood. Long-term recovery after VAD support is achievable, even after a long duration of VAD support, and even in patients with aetiologies different from myocarditis or post-cardiotomy heart failure. More research is needed on this favourable outcome after VAD support.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children′s Hospital Zurich, Pediatric Heart Centre, Department for Congenital Heart Surgery, Zurich, Switzerland
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Stiller B, Kubicki R. The little ones are catching up-mechanical circulatory support with a pulsatile pneumatic ventricular assist device. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6935787. [PMID: 36534818 DOI: 10.1093/ejcts/ezac570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Brigitte Stiller
- Department of Congenital Heart Disease and Paediatric Cardiology, University Heart Centre Freiburg, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Rouven Kubicki
- Department of Congenital Heart Disease and Paediatric Cardiology, University Heart Centre Freiburg, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
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