1
|
Hwang B, Doyle M, Williams ML, Joshi Y, Iyer A, Watson A, Jansz P, Hayward C. Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis. Artif Organs 2024. [PMID: 38989991 DOI: 10.1111/aor.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 05/25/2024] [Accepted: 06/21/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. METHODS A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. RESULTS Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). CONCLUSIONS Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.
Collapse
Affiliation(s)
- Bridget Hwang
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Mathew Doyle
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Yashutosh Joshi
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Arjun Iyer
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Alasdair Watson
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Chris Hayward
- Department of Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Luo Y, Leng J, Shi R, Jiang Y, Chen D, Wu Q, Tie H. Concomitant tricuspid valve surgery in patients undergoing left ventricular assist device: a systematic review and meta-analysis. Int J Surg 2024; 110:3039-3049. [PMID: 38348836 DOI: 10.1097/js9.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION This study aims to investigate the effect of concomitant tricuspid valve surgery (TVS) during left ventricular assist device (LVAD) implantation due to the controversy over the clinical outcomes of concomitant TVS in patients undergoing LVAD. METHODS A systematic literature search was performed in PubMed and EMbase from the inception to 1 August 2023. Studies comparing outcomes in adult patients undergoing concomitant TVS during LVAD implantation (TVS group) and those who did not (no-TVS group) were included. The primary outcomes were right heart failure (RHF), right ventricular assist device (RVAD) implantation, and early mortality. All meta-analyses were performed using random-effects models, and a two-tailed P <0.05 was considered significant. RESULTS Twenty-one studies were included, and 16 of them were involved in the meta-analysis, with 660 patients in the TVS group and 1291 in the no-TVS group. Patients in the TVS group suffered from increased risks of RHF [risk ratios (RR)=1.31, 95% CI: 1.01-1.70, P =0.04; I2 =38%, pH =0.13), RVAD implantation (RR=1.56, 95% CI: 1.16-2.11, P =0.003; I2 =0%, pH =0.74), and early mortality (RR=1.61, 95% CI: 1.07-2.42, P =0.02; I2 =0%, pH =0.75). Besides, the increased risk of RHF holds true in patients with moderate to severe tricuspid regurgitation (RR=1.36, 95% CI: 1.04-1.78, P =0.02). TVS was associated with a prolonged cardiopulmonary bypass time. No significant differences in acute kidney injury, reoperation requirement, hospital length of stay, or ICU stay were observed. CONCLUSIONS Concomitant TVS failed to show benefits in patients undergoing LVAD, and it was associated with increased risks of RHF, RVAD implantation, and early mortality.
Collapse
Affiliation(s)
- Yuxiang Luo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jiajie Leng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Rui Shi
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yingjiu Jiang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qingchen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| |
Collapse
|
3
|
Färber G, Schwan I, Kirov H, Rose M, Tkebuchava S, Schneider U, Caldonazo T, Diab M, Doenst T. Durability of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. J Clin Med 2024; 13:1411. [PMID: 38592251 PMCID: PMC10932215 DOI: 10.3390/jcm13051411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/31/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days-0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2-4 points) in 19 and low (0-2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF.
Collapse
Affiliation(s)
- Gloria Färber
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Imke Schwan
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Marcel Rose
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Sophie Tkebuchava
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Ulrich Schneider
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421 Homburg/Saar, Germany
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| | - Mahmoud Diab
- Department of Cardiac Surgery, Rotenburg Heart and Vascular Centre, 36199 Rotenburg an der Fulda, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07743 Jena, Germany
| |
Collapse
|
4
|
Mitra A, Castleberry A, Urban M, Siddique A. Does concomitant tricuspid valve intervention at the time of left ventricular assist device placement for patients with significant tricuspid regurgitation lead to improved outcomes compared to isolated left ventricular assist device placement? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae005. [PMID: 38216526 PMCID: PMC10850842 DOI: 10.1093/icvts/ivae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with advanced heart failure (HF) and moderate to severe functional tricuspid regurgitation (TR) undergoing left ventricular assist device (LVAD) placement is concomitant tricuspid valve intervention (TVI) superior for the clinical outcomes of survival, right ventricular failure, rehospitalizations for HF, functional status, and quality of life?' Altogether, 56 papers were found using the reported search, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Our search found no significant clinical benefit for concomitant TVI at the time of LVAD placement. We conclude that patient with moderate-to-severe TR should not routinely undergo concomitant TVI with LVAD placement.
Collapse
Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony Castleberry
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marian Urban
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aleem Siddique
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
5
|
Vinogradsky A, Ning Y, Kurlansky P, Kirschner M, Yuzefpolskaya M, Colombo P, Sayer G, Uriel N, Naka Y, Takeda K. Less is better? Comparing effects of median sternotomy and thoracotomy surgical approaches for left ventricular assist device implantation on postoperative outcomes and valvulopathy. J Thorac Cardiovasc Surg 2024; 167:731-743.e3. [PMID: 36008179 PMCID: PMC9669283 DOI: 10.1016/j.jtcvs.2022.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/06/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Our objective was to compare outcomes after left ventricular assist device implantation performed via median sternotomy or lateral thoracotomy. METHODS We retrospectively analyzed 222 adult patients with the HeartMate3 (Abbott Lab) left ventricular assist device implanted between November 2014 and November 2021. Outcomes stratified by surgical approach were evaluated in propensity score-matched groups. The primary outcome was 1-year survival. Secondary outcomes included in-hospital morbidity and mortality, readmissions, and significant valvular regurgitation. RESULTS Our cohort consisted of 60 patients (27%) who underwent lateral thoracotomy and 162 patients (73%) who underwent median sternotomy. Propensity score matching compared 45 patients who underwent lateral thoracotomy with 68 patients who underwent median sternotomy. There were no differences in intensive care unit or hospital stay duration (median, 10 vs 11 days, P = .58; 46 vs 40 days, P = .279), time to extubation (median, 2 days, P = .627), vasoactive-inotropic scores at intensive care unit arrival (18.20 vs 16.60, P = .654), or in-hospital mortality (2 [5%] vs 4 [6.1%] patients, P = 1). One-year survival (95.56% vs 90.61%, P = .48) and all-cause hospital readmission rate (Gray's test: P = .532) were also comparable. Patients who underwent lateral thoracotomy had significantly less early right ventricular failure (24.4% vs 53.7%, P = .004), although they had more follow-up tricuspid regurgitation (17.6% vs 0%, P = .030) and volume overload readmissions (Gray's test: P = .0005). CONCLUSIONS Our data suggest that lateral thoracotomy is a safe although not necessarily superior alternative to median sternotomy for HeartMate 3 implantation in the perioperative and postoperative periods, because it precludes concomitant tricuspid valve repairs and may be associated with increased risk of late tricuspid regurgitation and volume overload readmissions.
Collapse
Affiliation(s)
- Alice Vinogradsky
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Michael Kirschner
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.
| |
Collapse
|
6
|
Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
Collapse
Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| |
Collapse
|
7
|
Rajapreyar I, Soliman O, Brailovsky Y, Tedford RJ, Gibson G, Mohacsi P, Hajduczok AG, Tchantchaleishvili V, Wieselthaler G, Rame JE, Caliskan K. Late Right Heart Failure After Left Ventricular Assist Device Implantation: Contemporary Insights and Future Perspectives. JACC. HEART FAILURE 2023; 11:865-878. [PMID: 37269258 DOI: 10.1016/j.jchf.2023.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.
Collapse
Affiliation(s)
- Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Osama Soliman
- Discipline of Cardiology, University Hospital Galway, School of Medicine, University of Galway, Ireland
| | - Yevgeniy Brailovsky
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory Gibson
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul Mohacsi
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander G Hajduczok
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georg Wieselthaler
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco, California, USA
| | - J Eduardo Rame
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus Medical Center University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
8
|
Carr MJ, Smith SA, Slaughter MS, Pahwa S. Managing valvular pathology during LVAD implantation. Indian J Thorac Cardiovasc Surg 2023; 39:101-113. [PMID: 37525709 PMCID: PMC10387021 DOI: 10.1007/s12055-023-01567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
Since the time of their invention, implantable continuous flow left ventricular assist devices (LVADs) have improved the quality of life and extended survival for patients with advanced heart failure. The decision surgeons and their physician colleagues make with these patients to undergo implantation must come with full understanding of the immediate, short-term, and long-term implications of such a life-changing procedure. The presence of pathology regarding the aortic, mitral, and tricuspid valves introduces particularly complex problems for the surgical treatment strategy. Concomitant valve repair or replacement increases cardiopulmonary bypass and cross clamp times, and could potentially lead to worse outcomes in the perioperative setting. Following perioperative recovery, valvular pathology may worsen or arise de novo given the often drastic immediate physiologic changes in blood flow, septal function, and, over time, ventricular remodeling. Over the past two decades, there has been vast improvement in the device manufacturing, surgical techniques, and medical management surrounding LVAD implantation. Yet, addressing concomitant valvular pathology remains a complex question with no perfect solutions. This review aims to briefly describe the evolution of approach to valvular pathology in the LVAD patient and offer our opinion and treatment rationale.
Collapse
Affiliation(s)
- Michael J. Carr
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Susan Ansley Smith
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| |
Collapse
|
9
|
Mitra A, Siddique A. Tricuspid regurgitation in the setting of LVAD support. Front Cardiovasc Med 2023; 10:1090150. [PMID: 37304950 PMCID: PMC10250620 DOI: 10.3389/fcvm.2023.1090150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Tricuspid valve regurgitation (TR) is a common complication of end-stage heart failure. Increased pulmonary venous pressures caused by left ventricular (LV) dysfunction can result in a progressive dilation of the right ventricle and tricuspid valve annulus, resulting in functional TR. Here, we review what is known about TR in the setting of severe LV dysfunction necessitating long-term mechanical support with left ventricular assist devices (LVADs), including the occurrence of significant TR, its pathophysiology, and natural history. We examine the impact of uncorrected TR on LVAD outcomes and the impact of tricuspid valve interventions at the time of LVAD placement, revealing that TR frequently improves after LVAD placement with or without concomitant tricuspid valve intervention such that the benefit of concomitant intervention remains controversial. We summarize the current evidence on which to base medical decisions and provide recommendations for future directions of study to address outstanding questions in the field.
Collapse
Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery,University of Nebraska Medical Center, Omaha, NE, United States
| |
Collapse
|
10
|
Hoopes C. Tricuspid surgery at the time of LVAD implant: A critique. Front Cardiovasc Med 2022; 9:1056414. [PMID: 36479565 PMCID: PMC9720263 DOI: 10.3389/fcvm.2022.1056414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/01/2022] [Indexed: 09/26/2023] Open
Abstract
Tricuspid regurgitation (TR) is a common finding in patients with end stage heart failure referred for implantation of left ventricular assist devices. While functional TR frequently resolves after left ventricular unloading, patients with residual and progressive TR demonstrate increased rates of RV dysfunction and poor survival. Criteria for intervention on the tricuspid valve have focused on the degree of tricuspid annular dilatation and the severity of tricuspid regurgitant volume. The surgical decision making regarding intervention on the tricuspid valve remains obscure and historical cohort data cannot distinguish cause from effect.
Collapse
Affiliation(s)
- Charles Hoopes
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| |
Collapse
|
11
|
Die superiore Ministernotomie – für welche Operationen? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00501-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
12
|
Tie H, Shi R, Welp H, Martens S, Li Z, Sindermann JR, Martens S. Tricuspid Valve Surgery in Patients Receiving Left Ventricular Assist Devices. Thorac Cardiovasc Surg 2022; 70:475-481. [PMID: 35785810 DOI: 10.1055/s-0042-1743594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common and related to poor prognosis in patients after left ventricular assist device (LVAD) implantation. The concomitant tricuspid valve surgery (TVS) at the time of LVAD implantation on short and long-term outcomes are controversial in current evidence. METHODS This is a single-center, observational, retrospective study. We enrolled patients with moderate-to-severe TR who received LVAD implantations from 2009 to 2020. Postoperative right ventricular failure (RVF), right ventricular assist device (RVAD) use, hospital mortality, new-onset renal replacement therapy (RRT), and acute kidney injury (AKI) were evaluated retrospectively. RESULTS Sixty-eight patients were included, 36 with and 32 without concomitant TVS. Baseline characteristics did not differ between the two groups. Patients receiving TVS had significantly increased incidences of postoperative RVF (52.8 vs. 25.0%, p = 0.019), RVAD implantation (41.7 vs. 18.8%, p = 0.041), and new-onset RRT (22.2 vs. 0%, p = 0.004). No difference in the incidence of AKI and hospital mortality was detected. Besides, these associations remained consistent in patients who underwent LVAD implantation via median sternotomy. During a median follow-up of 2.76 years, Kaplan-Meier analysis and competing-risk analysis showed that TVS was not associated with better overall survival in patients after LVAD implantation compared with the no-TVS group. CONCLUSION Our study suggests that concomitant TVS failed to show benefits in patients receiving LVAD implantation. Even worse, concomitant TVS is associated with significantly increased incidences of RVF, RVAD use, and new-onset of RRT. Considering the small sample size and short follow-up, these findings warrant further study.
Collapse
Affiliation(s)
- Hongtao Tie
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany.,Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Shi
- Service de médecine intensive-réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Henryk Welp
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Zhenhan Li
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Jürgen R Sindermann
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Sabrina Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
13
|
(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
14
|
Loforte A. Tricuspid valve repair and mechanical right ventricular support in rescue left ventricular assist device implantations: Still a relevant issue. J Card Surg 2022; 37:1118-1120. [DOI: 10.1111/jocs.16275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery S. Orsola University Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna Bologna Italy
| |
Collapse
|
15
|
OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6527527. [DOI: 10.1093/ejcts/ezac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/06/2022] [Indexed: 11/13/2022] Open
|
16
|
Tonai K, Fukushima S, Tadokoro N, Kainuma S, Kawamoto N, Kakuta T, Koga-Ikuta A, Watanabe T, Seguchi O, Tsukamoto Y, Fukushima N, Fujita T. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 34:902-908. [PMID: 35106562 PMCID: PMC9070502 DOI: 10.1093/icvts/ivac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kohei Tonai
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naonori Kawamoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takashi Kakuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Ayumi Koga-Ikuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Corresponding author. Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shinmachi, Suita, Osaka 564-8565, Japan. Tel: +81-6-6170-1070; fax: +81-6-6170-1424; e-mail: (T. Fujita)
| |
Collapse
|
17
|
Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
Collapse
Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
18
|
Loforte A, de By TMMH, Gliozzi G, Schönrath F, Mariani C, Netuka I, Pya Y, Zimpfer D, Cavalli GG, Gummert J, Meyns B, Pacini D, Potapov E. Impact of concomitant cardiac valvular surgery during implantation of continuous-flow left ventricular assist devices: A European registry for patients with mechanical circulatory support (EUROMACS) analysis. Artif Organs 2021; 46:813-826. [PMID: 34904255 DOI: 10.1111/aor.14143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/22/2021] [Accepted: 12/08/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND We investigated the clinical outcomes after cardiac valvular surgery procedures concomitant (CCPs) with left ventricular assist device (LVAD) implantation compared to propensity score (PS) matched controls using the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data. METHODS Between 2006 and 2018, 2760 continuous-flow LVAD patients were identified. Of these, 533 underwent a CCP during the LVAD implant. RESULTS Cardiopulmonary bypass time (p < 0.001) and time for implant (p < 0.001) were both significantly longer in the LVAD+CCP group. Hospital mortality was comparable between the two groups from the unmatched population (15.7% vs. 14.1%, p = 0.073). Similarly, short-to-mid-term survival was similar in both groups, with 1-year, 3-year, and 5-year survival rates of 67.9%, 48.2%, and 27.7% versus 66.4%, 46.1%, and 26%, respectively (log-rank, p = 0.25). The results were similar in the PS-matched population. Hospital mortality was comparable between the two groups (18.9% vs. 17.4%, p = 0.074). The short-to-mid-term Kaplan-Meier survival analysis was similar for both groups, with 1-year, 3-year, and 5-year survival rates of 63.4%, 49.2%, and 24.7% versus 66.5%, 46%, and 25.1%, respectively (log-rank, p = 0.81). In the unmatched population, LVAD+CCP patients had longer intensive care unit (ICU) stays (p < 0.0001), longer mechanical ventilation time (p = 0.001), a higher rate of temporary right ventricular assist device (RVAD) support (p = 0.033), and a higher rate of renal replacement therapy (n = 35, 6.6% vs. n = 89, 4.0%, p = 0.014). In the PS-matched population, the LVAD+CCP patients had longer ICU stays (p = 0.019) and longer mechanical ventilation time (p = 0.002). CONCLUSIONS The effect of additive valvular procedures (CCPs) does not seem to affect short-term survival, significantly, based on our registry data analysis. However, the decision to perform CCPs should be balanced with the projected type of surgery and preoperative characteristics. LVAD+CCP patients remain a delicate population and adverse device-related events should be strictly monitored and managed.
Collapse
Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Carlo Mariani
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Yuriy Pya
- National Research Cardiac Surgery Center, Astana Kazakhstan, Kazakhstan
| | | | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Jan Gummert
- Heart and Diabetes Center North-Rhine Westphalia, Ruhr-Un, Bad Oeynhausen, Germany
| | - Bart Meyns
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | | |
Collapse
|
19
|
Results after Repair of Functional Tricuspid Regurgitation with a Three-Dimensional Annuloplasty Ring. J Clin Med 2021; 10:jcm10215080. [PMID: 34768606 PMCID: PMC8584623 DOI: 10.3390/jcm10215080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Tricuspid valve (TV) repair is the recommended treatment for severe functional tricuspid regurgitation (fTR) in patients undergoing left-sided surgery. For this purpose, a wide range of annuloplasty devices differing in form and flexibility are available. This study reports the results using a three-dimensional annuloplasty ring (Medtronic, Contour 3D Ring) for TV repair and analysis of risk factors. Methods: A cohort of 468 patients who underwent TV repair (TVr) with a concomitant cardiac procedure from December 2010 to January 2017 was retrospectively analyzed. Results: At follow-up, 96.1% of patients had no/trivial or mild TR. The 30-day mortality was 4.7%; it significantly differed between electively performed operations (2.7%) and urgent/emergent operations (11.7%). Risk factors for recurrent moderate and severe TR were LVEF < 50%, TAPSE < 16 mm, and moderate mitral valve (MV) regurgitation at follow-up. Preoperatively reduced renal function lead to a higher 30-day and overall mortality. Reoperation of the TV was required in six patients (1.6%). Risk factors for TV related reoperations were preoperative TV annulus over 50 mm and an implanted permanent pacemaker. Conclusions: TVr with the Contour 3D annuloplasty ring shows low TR recurrence and reoperation rates. Risk-factor analysis for the recurrence of TR revealed the importance of left- and right-ventricular function.
Collapse
|
20
|
Mulzer J, Krastev H, Hoermandinger C, Meyer A, Haese T, Stein J, Müller M, Schoenrath F, Knosalla C, Starck C, Falk V, Potapov E, Knierim J. Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices. Ann Cardiothorac Surg 2021; 10:364-374. [PMID: 34159117 DOI: 10.21037/acs-2020-cfmcs-fs-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tricuspid regurgitation (TR) after left ventricular assist device (LVAD) implantation is associated with a poor prognosis. This study evaluates the development of TR and right ventricular (RV) performance after LVAD implantation. Methods Retrospective analysis of patients who underwent LVAD implantation between March 2018 and June 2019. Patients who underwent concomitant tricuspid valve surgery and patients with congenital heart disease were excluded. Results A total of 155 patients underwent LVAD implantation. Fourteen patients were excluded. Of the remaining patients, thirty-one died during the first six months, six were lost to follow-up and two underwent transplantation. 102 patients presented at 6.3 months (5.8 to 7.0). Patients were supported with HeartWare HVAD (74%) or HeartMate 3 (26%). 50.4% were rated as INTERMACS profile 1 or 2. At six months, systolic pulmonary artery pressure dropped from 36 to 21 mmHg (P<0.001). Tricuspid annular plane systolic excursion decreased from 17.3 to 14.3 mm (P<0.001), RV fractional area change did not change (P=0.839). Twenty-two patients (22%) presented with moderate-to-severe or severe (ms-s) TR pre-operatively. Of these, eighteen (81%) showed improvement to ≤ moderate TR. At follow-up twelve patients presented with ms-s TR. Of these, only four patients (33%) had been diagnosed with ms-s TR pre-operatively. There were no differences in pre-operative echocardiographic or clinical parameters between the twelve patients with ms-s late TR and the other ninety patients in the cohort. Conclusions TR can show an impressive improvement with LVAD support. Longitudinal RV function decreases; this appears to be compensated by transverse shortening. Late TR can develop independently from pre-operative parameters including TR.
Collapse
Affiliation(s)
- Johanna Mulzer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Hristo Krastev
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | - Alexander Meyer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | | | - Marcus Müller
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Felix Schoenrath
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Starck
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Volkmar Falk
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Eidgenössiche Technische Hochschule Zürich, Department of Health Sciences and Technology, Translational Cardiovascular Technology, Zurich, Switzerland
| | - Evgenij Potapov
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Jan Knierim
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| |
Collapse
|
21
|
Riebandt J, Schaefer A, Wiedemann D, Schlöglhofer T, Laufer G, Sandner S, Zimpfer D. Concomitant cardiac surgery procedures during left ventricular assist device implantation: single-centre experience. Ann Cardiothorac Surg 2021; 10:248-254. [PMID: 33842219 DOI: 10.21037/acs-2020-cfmcs-30] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Additional cardiac pathologies including tricuspid or mitral valve regurgitation are common in left ventricular assist device (LVAD) recipients and whether to address them remains controversial. We present our institutional outcomes of concomitant cardiac procedures, other than temporary right ventricular (RV) support, at the time of LVAD implantation. Methods From 03/2006 to 06/2020, 352 adult patients {median age 60 [interquartile range (IQR): 52-66] years; INTERMACS level 1 29%; INTERMACS level 2 17%; INTERMACS level 3 23%, INTERMACS level 4-6 31%; male 86%} underwent continuous-flow LVAD [Medtronic HVAD® (HVAD) 50%; Abbott HeartMate IITM (HMII) 17%; Abbott HeartMate 3TM (HM3) 33%] implantation. Concomitant valvular procedures were performed in 86 patients (24%) and the majority of patients received the LVAD as bridge to candidacy (BTC) for transplant (74%). Primary study endpoints were short- and mid-term mortality, as well as need for temporary RV support. Results Tricuspid valve annuloplasty was the most frequent concomitant procedure (77%), followed by aortic valve replacements (AVRs) or Park's stitch (33%). Temporary RV support was common in the study cohort (35%) using either extracorporeal life support (ECLS, 37%) or a temporary RV assist device (RVAD, 63%). A less invasive (LIS) implantation technique was pursued in 12%. Thirty-day mortality was comparable between those with and without concomitant surgery (4% vs. 6%, P=0.426). In-hospital mortality was significantly higher for additional interventions (22% vs. 14%, P=0.05), whereas one-year survival was similar (71% vs. 79%, P=0.106). Conclusions Concomitant cardiac procedures, especially tricuspid and aortic valve surgery, are frequent but are associated with a higher perioperative morbidity and mortality.
Collapse
Affiliation(s)
- Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Anne Schaefer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| |
Collapse
|
22
|
Gomez Hamacher CJ, Torregroza C, Sadat N, Scheiber D, von der Beek JC, Westenfeld R, Knorr IJ, Sager M, Lichtenberg A, Saeed D. Impact of tricuspid valve insufficiency on the performance of left ventricular assist devices. JTCVS OPEN 2020; 4:16-23. [PMID: 36004302 PMCID: PMC9390470 DOI: 10.1016/j.xjon.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/18/2020] [Indexed: 12/02/2022]
Abstract
Objective To evaluate the impact of severe tricuspid valve insufficiency (TVI) at the time of left ventricular assist device (LVAD) implantation on the hemodynamic and LVAD parameters in an acute ovine model. Methods Stable heart failure (HF) was induced in 10 ovines through the application of 3 ± 1 coronary ligations. Once stable HF was obtained (after 15 ± 5 days), the animals were supported with an LVAD. Hemodynamic data and pump parameters were obtained and compared in 2 settings; first with LVAD in place after weaning from the cardiopulmonary bypass machine (no TVI condition) and second following the induction of severe TVI through resection of the tricuspid valve (TVI condition). Results There were no statistically significant differences in the hemodynamic and pump parameters between TVI condition and no TVI conditions except for lower cardiac output in the TVI condition (2 [1.38-2.8] L/min vs 3.2 [1.55-3.7] L/min, P = .027) and the expected greater central venous pressure in the TVI condition (26 [24-31] mm Hg vs 15 [13-25] mm Hg, P = .020). A median pump flow of 2.8 (2.45-3.75) L/min versus 2.9 (2.75-3.8) L/min in the TVI condition and no TVI condition was documented (P = .160). Conclusions Results from this acute animal study suggest that severe TVI in HF with preserved right ventricular function does not have significant impact on the LVAD pump parameters. The observed reduction in cardiac output may warrant further investigations, especially under loading conditions.
Collapse
|
23
|
Briasoulis A, Yokoyama Y, Kuno T, Ueyama H, Shetty S, Alvarez P, Malik AΗ. In-Hospital Outcomes of Left Ventricular Assist Device Implantation and Concomitant Valvular Surgery. Am J Cardiol 2020; 132:87-92. [PMID: 32753267 DOI: 10.1016/j.amjcard.2020.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
Valvular heart disease is common among left ventricular assist device (LVAD) recipients. However, its management at the time of LVAD implantation remains controversial. Patients who underwent LVAD implantation and concomitant aortic (AVR), mitral (MVR), or tricuspid valve (TVR) repair or replacement from 2010 to 2017 were identified using the national inpatient sample. End points were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via ICD-9 and ICD-10 coding and analysis was performed via mixed effect models. A total of 25,171 weighted adults underwent LVAD implantation without valvular surgery, 1,329 had isolated TVR, 1,021 AVR, 377 MVR, and 615 had combined valvular surgery (411 had TVR + AVR, 115 TVR + MVR, 62 AVR + MVR, 25 AVR + MVR + TVR). During the study period, rates of AVR decreased and combined valvular surgeries increased. Patients who underwent TVR or combined valvular surgery had overall higher burden of co-morbidities than LVAD recipients with or without other valvular procedures. Postoperative bleeding was higher with AVR whereas acute kidney injury requiring dialysis was higher with TVR or combined valvular surgery. In-hospital mortality was higher with AVR, MVR, or combined surgery without differences in the rates of stroke. Length of stay did not differ significantly among groups but cost of hospitalization and nonroutine discharge rates were higher for cases of TVR and combined surgery. Approximately 1 in 9 LVAD recipients underwent concomitant valvular surgery and TVR was the most frequently performed procedure. In-hospital mortality and cost were lower among those who did not undergo valvular surgery.
Collapse
|
24
|
Ramsdell GC, Nelson JA, Pislaru SV, Ramakrishna H. Tricuspid Regurgitation in Congestive Heart Failure: Management Strategies and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2020; 35:1205-1214. [PMID: 32622710 DOI: 10.1053/j.jvca.2020.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/11/2022]
Abstract
Tricuspid regurgitation is a notable aspect of congestive heart failure and is linked with worse outcomes if untreated. Functional tricuspid regurgitation commonly is seen in patients with heart failure, particularly in patients presenting for surgical management, such as those for mechanical cardiac assist device implantation. This review aims to study the published data related to the surgical management of tricuspid regurgitation in the cardiac surgical population comprehensively.
Collapse
Affiliation(s)
- Geoffrey C Ramsdell
- Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
25
|
Russo M, Zilberszac R, Werner P, Kocher A, Wiedemann D, Schneider M, Mascherbauer J, Laufer G, Rosenhek R, Andreas M. Isolated tricuspid valve regurgitation. J Cardiovasc Med (Hagerstown) 2020; 21:406-414. [DOI: 10.2459/jcm.0000000000000933] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
26
|
Mullan C, Caraballo C, Ravindra NG, Miller PE, Mori M, McCullough M, Clarke JRD, Anwer M, Velazquez EJ, Geirsson A, Desai NR, Ahmad T. Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation. J Heart Lung Transplant 2020; 39:926-933. [PMID: 32593561 DOI: 10.1016/j.healun.2020.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/29/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in patients with end-stage heart failure receiving left ventricular assist devices (LVADs), but the benefit of concomitant tricuspid valve procedures (TVPs) remains uncertain. This study examined the impact of TVP at the time of LVAD implantation on clinical outcomes and quality of life (QOL) metrics. METHODS We included adult patients in the Interagency Registry for Mechanical Circulatory Support database with various degrees of TR who received continuous-flow LVADs from 2008 to 2017. Patients undergoing concomitant TVP were compared with those without the intervention in a stratified analysis. Descriptive analyses, survival analyses, and Andersen‒Gill hazard models were used as appropriate to examine associations with clinical and patient-centered QOL outcomes. RESULTS Our analysis included 8,263 (53.1%) mild, 4,252 (33.3%) moderate, and 2,100 (13.5%) severe TR cases. TVP rate increased with severity: 8.6% of mild, 18.0% of moderate, and 43.9% of severe cases. TVP was not associated with survival benefit in cases of mild (adjusted hazard ratio [aHR]: 0.97, 95% CI: 0.79-1.19, p = 0.75), moderate (aHR: 1.03, 95% CI: 0.88-1.20, p = 0.72), or severe (aHR: 1.20, 95% CI: 0.98-1.48, p = 0.08) TR. For patients with combined moderate or severe TR, TVP was associated with increased mortality (log-rank p < 0.01, aHR: 1.13, 95% CI: 1.00-1.27, p = 0.04). After adjusting for TR severity, TVP was associated with increased risk of bleeding, arrhythmia, and stroke (p < 0.01 each) and no improvements in QOL (p > 0.05). CONCLUSIONS TVP at the time of LVAD implantation was not associated with either improved survival or QOL, and there were associations with increased risk of adverse events among patients with moderate and severe TR.
Collapse
Affiliation(s)
- Clancy Mullan
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Neal G Ravindra
- Cardiovascular Research Center and Department of Computer Science, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Yale National Clinician Scholars Program, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Megan McCullough
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - John-Ross D Clarke
- Department of Internal Medicine (Bridgeport Hospital), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Nihar R Desai
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut
| | - Tariq Ahmad
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Connecticut.
| |
Collapse
|