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Kanwar MK, Selzman CH, Ton VK, Miera O, Cornwell WK, Antaki J, Drakos S, Shah P. Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support. J Heart Lung Transplant 2022; 41:1324-1334. [PMID: 35835680 PMCID: PMC10257189 DOI: 10.1016/j.healun.2022.05.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022] Open
Abstract
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Massachusetts General Hospital, Harvard Medical School, Boston, Maryland
| | - Oliver Miera
- Department of Congenital Heart Disease, Pediatric Cardiology, German Heart Center, Berlin, Germany
| | - William K Cornwell
- Department of Medicine Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Stavros Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
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Denfeld QE, Lee CS, Woodward WR, Hiatt SO, Mudd JO, Habecker BA. Sympathetic Markers are Different Between Clinical Responders and Nonresponders After Left Ventricular Assist Device Implantation. J Cardiovasc Nurs 2020; 34:E1-E10. [PMID: 31094762 PMCID: PMC6527339 DOI: 10.1097/jcn.0000000000000580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Clinical response to left ventricular assist devices (LVADs), as measured by health-related quality of life, varies among patients after implantation; however, it is unknown which pathophysiological mechanisms underlie differences in clinical response by health-related quality of life. OBJECTIVE The purpose of this study was to compare changes in sympathetic markers (β-adrenergic receptor kinase-1 [βARK1], norepinephrine [NE], and 3,4-dihydroxyphenylglycol [DHPG]) between health-related quality of life clinical responders and nonresponders from pre- to post-LVAD implantation. METHODS We performed a secondary analysis on a subset of data from a cohort study of patients from pre- to 1, 3, and 6 months after LVAD implantation. Clinical response was defined as an increase of 5 points or higher on the Kansas City Cardiomyopathy Questionnaire Clinical Summary score from pre- to 6 months post-LVAD implantation. We measured plasma βARK1 level with an enzyme-linked immunosorbent assay and plasma NE and DHPG levels with high-performance liquid chromatography with electrochemical detection. Latent growth curve modeling was used to compare the trajectories of markers between groups. RESULTS The mean (SD) age of the sample (n = 39) was 52.9 (13.2) years, and most were male (74.4%) and received LVADs as bridge to transplantation (69.2%). Preimplantation plasma βARK1 levels were significantly higher in clinical responders (n = 19) than in nonresponders (n = 20) (P = .001), but change was similar after LVAD (P = .235). Preimplantation plasma DHPG levels were significantly lower in clinical responders than in nonresponders (P = .002), but the change was similar after LVAD (P = .881). There were no significant differences in plasma NE levels. CONCLUSIONS Preimplantation βARK1 and DHPG levels are differentiating factors between health-related quality of life clinical responders and nonresponders to LVAD, potentially signaling differing levels of sympathetic stimulation underlying clinical response.
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Affiliation(s)
- Quin E. Denfeld
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
| | - Christopher S. Lee
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - William R. Woodward
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
- Oregon Health & Science University Department of Neurology, Portland, OR, USA
| | - Shirin O. Hiatt
- Oregon Health & Science University School of Nursing, Portland, OR, USA
| | - James O. Mudd
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
| | - Beth A. Habecker
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
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Cutler NS, Rasmussen BM, Bredeck JF, Lata AL, Khanna AK. Angiotensin II for Critically Ill Patients With Shock After Heart Transplant. J Cardiothorac Vasc Anesth 2020; 35:2756-2762. [PMID: 32868151 DOI: 10.1053/j.jvca.2020.07.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 12/18/2022]
Abstract
Patients undergoing heart transplant are at high risk for vasodilatory shock in the postoperative period, due to a combination of vascular dysfunction from end-stage heart failure and inflammatory response to cardiopulmonary bypass and, increasingly, long-term exposure to nonpulsatile blood flow in those who have received a left ventricular assist device as a bridge to transplant. Patients who have this vasoplegic syndrome, which may be refractory to traditional agents used in the treatment of shock, are vulnerable to organ dysfunction and death. Angiotensin II (ANG-2) is of increasing interest as an adjunct to traditional therapy, both for improvement in blood pressure and for sparing the use of high-dose catecholamine vasopressors. This case series describes the use of ANG-2 in 4 clinical scenarios for the treatment of shock due to heart transplant surgery, supporting its use in this role and justifying further prospective studies to clarify the appropriate place for ANG-2 in the hierarchy of adjunctive therapies.
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Affiliation(s)
- Nathan S Cutler
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Bridget M Rasmussen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Joseph F Bredeck
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Adrian L Lata
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ashish K Khanna
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH
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Grosman-Rimon L, Kachel E, McDonald MA, Lalonde SD, Yip P, Ribeiro RVP, Adamson MB, Cherney DZ, Rao V. Association Between Neurohormone Levels and Exercise Testing Measures in Patients with Mechanical Circulatory Supports. ASAIO J 2020; 66:875-880. [PMID: 32740345 DOI: 10.1097/mat.0000000000001082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Continuous-flow left ventricular assist device (CF-LVAD) recipients exhibit impaired exercise capacity. Long-term continuous blood flow also elevates norepinephrine (NE) and aldosterone (Aldo) levels. However, the relationship between exercise capacity and neurohormonal activation has not been elucidated. Our study objective was to assess the association between cardiopulmonary exercise testing (CPT) measures and neurohormonal levels in CF-LVAD recipients. Symptom-limited CPT on a treadmill, using the modified Bruce protocol was performed in 15 CF-LVAD recipients. Norepinephrine and Aldo levels were measured, and the association between their levels and CPT measures were assessed. Peak VO2 (13.6 ml/kg/min) and percent age, sex predicted VO2 max (49.4%), and oxygen pulse (O2 pulse) (9.0 ± 4.0 ml/beat) were low, whereas minute ventilation/carbon dioxide output (VE/VCO2) slope (35) was elevated. In addition, VO2 at anaerobic threshold (VO2 AT), and O2 pulse values negatively correlated with NE levels. Norepinephrine levels positively correlated with chronotropic responses and heart rate (HR) recovery. Aldo levels in CF-LVAD recipients were not related to any CPT measures. Continuous-flow left ventricular assist device recipients exhibited impaired exercise capacity and chronotropic incompetence (CI). Despite the association of NE levels with chronotropic responses at peak exercise, neither NE levels nor chronotropic responses predicted peak VO2. This suggests that CI may not be the primary factor responsible for the low peak VO2. O2 pulse, which is a combined measure for stroke volume and peripheral oxygen extraction during exercise, was an independent predictor of peak VO2. Future studies should examine the contribution of peripheral factors to exercise capacity limitations.
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Affiliation(s)
- Liza Grosman-Rimon
- From the Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto
| | - Erez Kachel
- Division of Nephrology, University Health Network, University of Toronto
| | - Michael A McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto
| | - Spencer D Lalonde
- From the Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto
| | - Paul Yip
- Laboratory Medicine and Pathobiology, University Health Network, University of Toronto
| | - Roberto V P Ribeiro
- From the Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto
| | - Mitchell B Adamson
- From the Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto
| | - David Z Cherney
- Leviev Heart Center, Academic Medical Center Hospital, Sheba, Tel Hashomer, Tel Aviv, Israel
| | - Vivek Rao
- From the Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto
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Oezpeker C, Zittermann A, Baurichter D, Morshuis M, Prohaska W, Kassner A, Erkilet G, Gummert J, Milting H. Changes in Von Willebrand factor profile predicts clinical outcomes in patients on mechanical circulatory support. J Card Surg 2018; 33:693-702. [PMID: 30199919 DOI: 10.1111/jocs.13794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The associations between mechanical circulatory support (MCS), acquired von Willebrand syndrome (AvWS), and clinical outcome are incompletely understood. METHODS In 128 heart failure patients with pulsatile MCS implants (65 total artificial heart or biventricular assist device implants, 63 left ventricular assist device [LVAD] implants) and 76 patients with continuous flow LVAD implants, we analyzed the von Willebrand factor (vWF) profile before (≤24 h) and 17.5 (standard deviation: 5.1) days after device implant. We determined vWF concentrations, vWF activity, and vWF collagen binding capacity and calculated ratios of vWF activity/binding capacity with vWF concentration. The relation of the vWF profile with clinical outcomes such as stroke, gastrointestinal bleeding, and survival was also evaluated. Events were assessed up to 1 year of device implant. RESULTS All entities of vWF were already significantly elevated preoperatively and remained high after MCS implantation. The ratios of vWF activity/concentration (vWF:RCo/Ag) and collagen binding capacity/concentration (vWF:CBA/Ag) were significantly reduced preoperatively and remained low postoperatively, indicating AvWS. The preoperative alterations in the vWF profile were already present in patients without intra-aortic balloon pump and/or extracorporeal circulatory membrane oxygenation implants. The vWF profile was unrelated to postoperative stroke. However, a higher postoperative ratio of vWF:CBA/Ag was independently associated with increased gastrointestinal bleeding. In addition, a postoperative increase in vWF concentrations and activity were independent predictors of increased 1-year mortality. CONCLUSIONS Our data indicate that AvWS is present in heart failure patients before device implantation, and is independently associated with clinical outcomes, especially with 1-year mortality.
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Affiliation(s)
- Cenk Oezpeker
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Daniela Baurichter
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Michel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Wolfgang Prohaska
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Astrid Kassner
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Gülsüm Erkilet
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center, NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Hendrik Milting
- Erich and Hanna Klessmann-Institute for Cardiovascular Research and Development, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
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