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Echocardiography for left ventricular assist device implantation and evaluation: an indispensable tool. Heart Fail Rev 2021; 27:891-902. [PMID: 33428013 DOI: 10.1007/s10741-021-10073-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
Echocardiography is an indispensable tool in the evaluation, placement, management and follow-up of patients with left ventricular assist devices (LVAD). While transoesophageal echocardiography is the ideal tool in guiding the implantation procedure, transthoracic echocardiography is essential during the initial evaluation, patient selection and in the post-operative follow-up. This review attempts to summarize which parameters the echocardiographic assessment should focused on during each step. In particular, during the pre-operative assessment, it is of paramount importance to assess the presence of aortic regurgitation and most importantly to evaluate right ventricular function, since it is one of the strongest predictor of post-implant right ventricular failure. During the procedure, through transoesophageal echocardiography, it is possible to confirm the correct placement of the inflow cannula, to assess right ventricular function and to guide the choice of the right pump speed. Transthoracic echocardiographic is an essential part in the patient's follow-up once the LVAD has been implanted, in order to attest the onset of possible complications.
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Zuin M, Rigatelli G, Braggion G, Bacich D, Nguyen T. Cavitation in left ventricular assist device patients: a potential early sign of pump thrombosis. Heart Fail Rev 2019; 25:965-972. [PMID: 31691065 DOI: 10.1007/s10741-019-09884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Mechanical ventricular support with left ventricular assist device (LVAD) has emerged as a durable and safe therapy, both as bridge-to-transplant (BTT) or destination therapy (DT), in patients with advanced heart failure (HF). However, the occurrence of pump thrombosis (PT) still represents a serious complication, especially when LVADs of first or second generation are implanted. During the latest years, some investigations have recognized the occurrence of cavitation, evidenced through transthoracic echocardiography (TTE), as a potential early and indirect sign of PT. In the present manuscript, we reviewed the available data on the occurrence of cavitation in LVAD patients as an early potential marker of PT, also presenting the hemodynamic mechanisms involved.
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Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, Faculty of Medicine, University of Ferrara, Ferrara, Italy
| | - Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy.
| | | | - Daniela Bacich
- Department of Cardiology, Porto Viro Hospital, Porto Viro, Rovigo, Italy
| | - Thach Nguyen
- Cardiovascular Research, Methodist Hospital, Merrillville, IN, USA
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Abstract
The use of mechanical circulatory support for patients with severe heart failure is on the rist. The poeoperative, intraoperative and postoperative challenges the anaesthesiologists skills. These are discussed in this review.
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Affiliation(s)
- O P Sanjay
- Department of Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle Upon Tyne, UK
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Waller AH, Dunne R, Stewart GC, Ghosh N, Gosev I, Rybicki FJ, Blankstein R, Couper GS, Steigner M. Evaluation of bend relief disconnection in patients supported by a HeartMate II left ventricular assist device. Circ Cardiovasc Imaging 2014; 7:844-8. [PMID: 25227237 DOI: 10.1161/circimaging.114.001736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alfonso H Waller
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA.
| | - Ruth Dunne
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Garrick C Stewart
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Nina Ghosh
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Igor Gosev
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Frank J Rybicki
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Ron Blankstein
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Gregory S Couper
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
| | - Michael Steigner
- From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (A.H.W., G.C.S., N.G., R.B.) and Radiology (A.H.W., R.D., N.G., F.J.R., R.B., M.S.), Applied Imaging Science Lab (R.D., N.G., F.J.R., M.S.), and Division of Cardiac Surgery, Department of Surgery (I.G., G.S.C.), Brigham and Women's Hospital, Boston, MA
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5
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Partyka C, Taylor B. Review article: Ventricular assist devices in the emergency department. Emerg Med Australas 2014; 26:104-12. [DOI: 10.1111/1742-6723.12171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Christopher Partyka
- Department of Emergency Medicine; Liverpool Hospital; Sydney New South Wales Australia
| | - Ben Taylor
- Department of Emergency Medicine; Liverpool Hospital; Sydney New South Wales Australia
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Bartoli CR, Ailawadi G, Kern JA. Diagnosis, Nonsurgical Management, and Prevention of LVAD Thrombosis. J Card Surg 2013; 29:83-94. [DOI: 10.1111/jocs.12238] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Carlo R. Bartoli
- Division of Cardiovascular Surgery; University of Pennsylvania Medical Center; Philadelphia Pennsylvania
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery; University of Virginia Health System; Charlottesville Virginia
| | - John A. Kern
- Division of Thoracic and Cardiovascular Surgery; University of Virginia Health System; Charlottesville Virginia
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Use of Retrospectively Gated CT Angiography to Diagnose Systolic LVAD Inflow Obstruction. ASAIO J 2013; 59:542-6. [DOI: 10.1097/mat.0b013e3182a0d367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ammar KA, Umland MM, Kramer C, Sulemanjee N, Jan MF, Khandheria BK, Seward JB, Paterick TE. The ABCs of left ventricular assist device echocardiography: a systematic approach. Eur Heart J Cardiovasc Imaging 2012; 13:885-99. [PMID: 22581283 DOI: 10.1093/ehjci/jes090] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD) implantation for patients with advanced heart failure (HF) and for serial follow-up to make management decisions in patient care post-implant. Continuous axial-flow LVAD therapy provides effective haemodynamic support for the failing left ventricle, improving both the clinical functional status and quality of life. Echocardiographers must develop a systematic approach to echocardiographic assessment of LVAD implantation and post-LVAD implant cardiac morphology and physiology. This approach must include the evaluation of left and right heart chamber morphology and physiology and the anatomy and physiology of the inflow and outflow cannulas and the rotor pump, and the determination of the degree of tricuspid regurgitation and the presence of interatrial shunts and aortic regurgitation. Collaboration among the echocardiography and HF/transplant teams is essential to obtain this comprehensive evaluation. We outline a systematic approach to evaluating patients with HF who have failed conventional therapy and require LVAD therapy as a bridge to cardiac transplantation or destination therapy.
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Affiliation(s)
- Khawaja A Ammar
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, 2801 W. Kinnickinnic River Parkway, #845, Milwaukee, WI 53215, USA
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Use of gated cardiac computed tomography angiography in the assessment of left ventricular assist device dysfunction. ASAIO J 2011; 57:32-7. [PMID: 20966744 DOI: 10.1097/mat.0b013e3181fd3405] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study is to describe the utility and limitations of gated contrast-enhanced cardiac computed tomography angiography in assessing left ventricular assist device function. Computed tomography angiography (CTA) was used in 14 patients with left ventricular assist devices (LVADs) who had persistent heart failure symptoms, hemodynamic instability, or potential problems with LVAD flows. Retrospectively gated contrast-enhanced CTA was performed on 64-detector scanner, and the CTA images were postprocessed in multiple curved projections on TeraRecon workstation. This study describes the use of CTA to identify LVAD-related issues that altered clinical management and explores the role of CTA and other techniques in evaluating LVAD function. Six of 14 LVAD patients who demonstrated no abnormality on CTA remained stable with medical management. In the remaining eight patients, CTA was abnormal, including abnormalities specifically related to the LVAD cannula. As a result of findings detected by CTA, six patients underwent surgical intervention, including device exchange and heart transplant. Computed tomography angiography is a noninvasive method that enhances diagnostic evaluation of patients with suspected LVAD dysfunction and can lead to changes in patient management.
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Topilsky Y, Maltais S, Oh JK, Atchison FW, Perrault LP, Carrier M, Park SJ. Focused review on transthoracic echocardiographic assessment of patients with continuous axial left ventricular assist devices. Cardiol Res Pract 2011; 2011:187434. [PMID: 21331332 PMCID: PMC3038659 DOI: 10.4061/2011/187434] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 12/17/2010] [Indexed: 11/20/2022] Open
Abstract
Left ventricular assist devices (LVADs) are systems for mechanical support for patients with end-stage heart failure. Preoperative, postoperative and comprehensive followup with transthoracic echocardiography has a major role in LVAD patient management. In this paper, we will present briefly the hemodynamics of axial-flow LVAD, the rationale, and available data for a complete and organized echocardiographic assessment in these patients including preoperative assessment, postoperative and long-term evaluation.
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Affiliation(s)
- Yan Topilsky
- Division of Cardiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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11
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Castillo JG, Anyanwu AC, Adams DH, Nyirenda T, Fischer GW. Real-time 3-dimensional echocardiographic assessment of current continuous-flow rotary left ventricular assist devices. J Cardiothorac Vasc Anesth 2010; 23:702-10. [PMID: 19789057 DOI: 10.1053/j.jvca.2009.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Indexed: 11/11/2022]
Affiliation(s)
- Javier G Castillo
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY 10029, USA
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Chumnanvej S, Wood MJ, MacGillivray TE, Melo MFV. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007; 105:583-601. [PMID: 17717209 DOI: 10.1213/01.ane.0000278088.22952.82] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventricular assist devices (VADs) are systems for mechanical circulatory support of the patient with severe heart failure. Perioperative transesophageal echocardiography is a major component of patient management, and important for surgical and anesthetic decision making. In this review we present the rationale and available data for a comprehensive echocardiographic assessment of patients receiving a VAD. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale, or other cardiac abnormality that could lead to right-to-left shunt after left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism, and atherosclerotic disease in the ascending aorta; and to assess right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm completeness of device and heart deairing, cannulas alignment and patency, and competency of device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal for the heart examination after implantation should be to exclude aortic regurgitation, or an uncovered right-to-left shunt; and to assess right ventricular function, left ventricular unloading, and the effect of device settings on global heart function. The variety of VAD models with different basic and operation principles requires specific echocardiographic assessment targeted to the characteristics of the implanted device.
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Affiliation(s)
- Siriluk Chumnanvej
- Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Jaski BE, Miller DA, Hoagland PM, Gordon JB, Chillcott SR, Stahovich MJ, Adamson RM, Baradarian S, Dembitsky WP. Assessment of Recurrent Heart Failure Associated with Left Ventricular Assist Device Dysfunction. J Heart Lung Transplant 2005; 24:2060-7. [PMID: 16364850 DOI: 10.1016/j.healun.2005.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 04/30/2005] [Accepted: 05/22/2005] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Patients with advanced heart failure may require long-term support with an intracorporeal left ventricular assist device (LVAD) before cardiac transplant, while awaiting myocardial recovery, or during destination therapy. Compared with the diagnosis of native heart dysfunction, there is less experience with the assessment of recurrent heart failure after LVAD placement. METHODS Ten patients (9 men, 1 woman; age, 58 +/- 11 years) were studied after LVAD placement. Six patients were studied because of recurrent heart failure; the remaining 4 had other indications for study and are reported here as controls. Cardiac catheterization, including LVAD and cannulae catheterization, and angiography were performed. RESULTS Inflow cannula valve regurgitation by LVAD angiography was found in 3 cases. Patients with regurgitation had a mean increased resting LVAD rate of 105 beats/min (range, 90-120); LVAD output exceeded forward cardiac output (LVAD - thermodilution cardiac output = +3.7 liters/min [0.6-6.4]). Inflow cannula obstruction identified with a filling phase pressure gradient between the left ventricle and the LVAD was found in 3 additional patients. Patients with obstruction had decreased resting LVAD rates (50 beats/min, all patients); LVAD output was less than the forward cardiac output (LVAD - thermodilution cardiac output = -2.3 liters/min [-0.8 to -3.5]). Compared with those with inflow valve regurgitation, patients with cannula obstruction had higher pulmonary capillary wedge pressures; phasic left ventricular pressure variation was reduced. Patients with cannula dysfunction underwent surgical intervention, and 4 of 6 were long-term survivors. CONCLUSIONS When heart failure recurs after LVAD placement, abnormalities of the inflow cannula are common. Cardiac catheterization can confirm the diagnosis before surgical intervention. Hemodynamic coupling between the left ventricle and the LVAD is increased with inflow valve regurgitation and reduced with cannula obstruction.
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Affiliation(s)
- Brian E Jaski
- Department of Cardiology, San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California 92123, USA.
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Costantini TW, Taylor JH, Beilman GJ. Abdominal Complications of Ventricular Assist Device Placement. Surg Infect (Larchmt) 2005; 6:409-18. [PMID: 16433605 DOI: 10.1089/sur.2005.6.409] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventricular assist devices (VADs) provide a bridge to transplantation for patients awaiting heart transplant. Because of its intra-abdominal placement, the potential exists for major abdominal complications. The purpose of this study is to identify VAD-associated abdominal complications and their incidence, and to describe preventive measures. METHODS Records of patients having had VAD placement were identified from our registry from April 12, 1995, when the first VAD placement occurred, to July 15, 2003. Each patient was evaluated for the occurrence of an abdominal complication, defined as mechanical small bowel obstruction, infection with an abdominal source, hernia, or other abdominal pathology occurring after VAD placement. RESULTS One hundred twenty-four VADs were implanted in 100 patients. Of these patients, 82 received one VAD, 13 received two devices, four received three devices, and one patient received four devices. Twelve abdominal complications occurred in 11 patients (11%). There was a 36% (4/11) pre-transplant mortality rate in patients with an abdominal complication, compared to 17% (15/89) pre-transplant mortality in patients without an abdominal complication (p = 0.21). Three of five patients with abdominal infection died. CONCLUSIONS Abdominal complications after VAD placement are common. Intra-abdominal VAD infection is the most common and serious complication, leading to a mortality rate of 60% in our population. Additionally, small bowel obstructions, incisional and inguinal hernias, acalculous cholecystitis, and pancreatitis also occurred. Appropriate preventive measures may decrease the risk of developing many of these complications.
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Affiliation(s)
- Todd W Costantini
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Horton SC, Khodaverdian R, Chatelain P, McIntosh ML, Horne BD, Muhlestein JB, Long JW. Left Ventricular Assist Device Malfunction. J Am Coll Cardiol 2005; 45:1435-40. [PMID: 15862415 DOI: 10.1016/j.jacc.2005.01.037] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2004] [Revised: 01/01/2005] [Accepted: 01/11/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVES A protocol using transthoracic echocardiography was designed to diagnose the common malfunctions of patients on chronic support with a left ventricular assist device (LVAD). BACKGROUND Mechanical circulatory support, primarily with a LVAD, is increasingly used for treatment of advanced heart failure as a bridge to transplant and for long-term treatment of heart failure. The LVAD dysfunction is a recognized complication. To date, no studies have defined the role of transthoracic echocardiography in evaluating long-term mechanical complications of chronic LVAD support. METHODS Transthoracic echocardiography was used in a protocol designed to detect the common types of mechanical malfunction. Patients were followed up with serial echocardiograms, and clinical validations were made with findings from a catheter-based protocol and inspection at the time of cardiac transplant or corrective surgery. RESULTS Thirty-two patients with 44 LVADs were followed up during a four-year period using this protocol that correctly identified 11 patients with inflow valve regurgitation, 2 with intermittent inflow conduit obstruction, 1 with severe kinking of the outflow graft, and 9 with new insufficiency of the native aortic valve. CONCLUSIONS As LVAD use for end-stage heart failure becomes widespread, and durations of support are extended, dysfunction will be increasingly prevalent. Transthoracic echocardiography provides a practical method to accurately identify the causes of mechanical dysfunction with patients on chronic LVAD support.
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Affiliation(s)
- Steven C Horton
- Department of Cardiology, LDS Hospital, Salt Lake City, Utah, USA.
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Horton SC, Khodaverdian R, Powers A, Revenaugh J, Renlund DG, Moore SA, Rasmusson B, Nelson KE, Long JW. Left ventricular assist device malfunction: a systematic approach to diagnosis. J Am Coll Cardiol 2004; 43:1574-83. [PMID: 15120814 DOI: 10.1016/j.jacc.2003.11.055] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2003] [Revised: 11/18/2003] [Accepted: 11/24/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES A protocol was designed to diagnose the common malfunctions of a left ventricular assist device (LVAD). BACKGROUND Mechanical circulatory support, primarily with an LVAD, is increasingly used for treatment of advanced heart failure (HF). Left ventricular assist device dysfunction is a recognized complication; but heretofore, a systematic method to accurately diagnose LVAD dysfunction has not been thoroughly described. METHODS We developed a catheter-based protocol designed to characterize a normally functioning LVAD and diagnose multiple types of dysfunction. A total of 15 studies of 10 patients supported with an LVAD were reviewed. All patients had been evaluated due to concerns regarding LVAD dysfunction. RESULTS Of 15 examinations performed, 11 documented severe LVAD inflow valve regurgitation. One of these cases proved to have coexistent severe mitral valve regurgitation. One case was diagnosed with distortion of the LVAD outflow graft. One case of suspected embolization from the pumping chamber excluded the outflow graft as the source of emboli. One study had aortic insufficiency. CONCLUSIONS As LVAD use for treatment of end-stage HF becomes widespread and durations of support are extended, dysfunction will be increasingly prevalent. This catheter-based protocol provided a practical method to diagnose multiple causes of LVAD dysfunction.
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Affiliation(s)
- Steven C Horton
- Department of Cardiology, LDS Hospital and University of Utah School of Medicine, Salt Lake City, 84103, USA.
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Abstract
Patients in severely progressed states of heart failure can be bridged to successful heart transplantation with mechanical assist devices. Experience has demonstrated that patient selection and timing of device implantation are crucial for obtaining acceptable results when using this expensive technology. The degree of irreversible secondary organ dysfunction before re-establishing adequate cardiac output determines the chance of reaching transplantation. Patients who recover during support from all sequelae of end stage heart failure have an excellent outcome after heart transplantation.
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Abstract
PURPOSE OF REVIEW Recent advances in technology as well as new indications for implantation have appeared in the field of ventricular assist devices. Progress has also been made in the understanding of the underlying mechanisms of myocardial recovery after ventricular assist device support. RECENT FINDINGS Technological progress includes the development of fully implantable pulsatile and continuous flow pumps, either axial flow or centrifugal, for left ventricular and total heart assistance. Among the new indications for ventricular assist device support, the most important is the use of the device as permanent treatment for end-stage cardiac failure patients. Increased knowledge has been acquired regarding the effects of mechanical assistance and of unloading of the heart on haemodynamics, as well as on the cellular, molecular and electrophysiological characteristics of the failing heart. All these findings suggest that depressed myocardial function can sometimes recover with ventricular assist device therapy. Ventricular assist device support, however, still carries a high rate of complications: the device itself can fail, bleeding and thromboembolism are common, immunity is disturbed and the incidence of infection remains high. SUMMARY In patients with end-stage heart failure, ventricular assist devices can be used as a bridge to transplantation or to recovery, but they are now also considered as a long-term myocardial replacement therapy. Which device is the most appropriate for each indication, however, remains to be defined. Even if the underlying mechanisms of myocardial recovery are progressively clarified, the use of ventricular assist devices as a bridge to recovery still has limited clinical success. Clinical trials with the fully implantable devices are in their early stages, but these pumps appear promising in terms of efficacy, reliability and complication rate, as well as being easy to implant. Because more patients will benefit from ventricular assist device placement in the future, anaesthesiologists must be prepared to manage patients undergoing ventricular assist device placement or presenting for noncardiac surgery while under ventricular assist device support.
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Affiliation(s)
- Edith Collard
- Department of Anaesthesiology, Université Catholique de Louvain, Belgium.
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