1
|
Kataoka N, Imamura T. How to investigate the impact of ICD therapy during durable left ventricular assist device support. Artif Organs 2024; 48:692-693. [PMID: 38517183 DOI: 10.1111/aor.14747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/27/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| |
Collapse
|
2
|
Gunawan A, Robson D, Krishnaswamy RJ, Ramanayake A, Kearney K, Muthiah K, Jain P, Adji A, Hayward CS. Longitudinal analysis left ventricular chamber responses under durable LVAD support. J Heart Lung Transplant 2024; 43:420-431. [PMID: 37844674 DOI: 10.1016/j.healun.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Left ventricular assist device (LVAD) support offers remodeling potential in some patients. Our goal was to use noninvasively derived pressure-volume (PV) loops to understand the effect of demographic and device variables on serial changes in cardiac function under pump support. METHODS Thirty-two consecutive Medtronic HeartWare Ventricular Assist Device (HVAD) patients (mean 55.9 ± 12.3 years, 81.3% male) were prospectively recruited. Single-cycle ventricular pressure and volume were estimated using a validated algorithm. PV loops (n = 77) and corresponding cardiac chamber dynamics were derived at predefined postimplant timepoints (1, 3, 6 months). Changes in PV loop parameters sustained across the 6-month period were characterized using mixed-effects modeling. The influence of demographic and device variables on the observed changes was assessed. RESULTS Across a 6-month period, the mean ventricular function parameters remained stable. Significant predictors of monthly improvement of stroke work include: lower pump speeds (2400 rpm vs 2500-2800 rpm) [0.0.051 mm Hg/liter/month (p = 0.001)], high pulsatility index (>1.0 vs <1.0) [0.052 mm Hg/liter/month (p = 0.012)], and ischemic cardiomyopathy indication for LVAD implantation (vs nonischemic) [0.0387 mm Hg/liter/month (p = 0.007)]. Various other cardiac chamber function parameters including cardiac power, peak systolic pressure, and LV elastance also showed improvements in these cohorts. CONCLUSIONS Factors associated with improvement in ventricular energetics and hemodynamics under LVAD support can be determined with noninvasive PV loops. Understanding the basis of increasing ventricular load to optimize myocardial remodeling may prove valuable in selecting eligible recovery candidates.
Collapse
Affiliation(s)
- Aaron Gunawan
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Desiree Robson
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Rohan J Krishnaswamy
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Anju Ramanayake
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Katherine Kearney
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Audrey Adji
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia.
| |
Collapse
|
3
|
Martinez J, Smegner K, Tomoda M, Motomura T, Chivukula VK. Encouraging Regular Aortic Valve Opening for EVAHEART 2 LVAD Support Using Virtual Patient Hemodynamic Speed Modulation Analysis. ASAIO J 2024; 70:207-216. [PMID: 38029749 DOI: 10.1097/mat.0000000000002093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
This study focuses on investigating the EVAHEART 2 left ventricular assist device (LVAD) toward designing optimal pump speed modulation (PSM) algorithms for encouraging aortic valve (AV) flow. A custom-designed virtual patient hemodynamic model incorporating the EVAHEART 2 pressure-flow curves, cardiac chambers, and the systemic and pulmonary circulations was developed and used in this study. Several PSM waveforms were tested to evaluate their influence on the mean arterial pressure (MAP), cardiac output (CO), and AV flow for representative heart failure patients. Baseline speeds were varied from 1,600 to 2,000 rpm. For each baseline speed, the following parameters were analyzed: 1) PSM ratio (reduced speed/baseline speed), 2) PSM duration (3-7 seconds), 3) native ventricle contractility, and 4) patient MAP of 70 and 80 mm Hg. More than 2,000 rpm virtual patient scenarios were explored. A lower baseline speed (1,600 and 1,700 rpm) produced more opportunities for AV opening and more AV flow. Higher baseline speeds (1,800 and 2,000 rpm) had lower or nonexistent AV flow. When analyzing PSM ratios, a larger reduction in speed (25%) over a longer PSM (5+ seconds) duration produced the most AV flow. Lower patient MAP and increased native ventricle contractility also contributed to improving AV opening frequency and flow. This study of the EVAHEART 2 LVAD is the first to focus on leveraging PSM to enhance pulsatility and encourage AV flow. Increased AV opening frequency can benefit aortic root hemodynamics, thereby improving patient outcomes.
Collapse
Affiliation(s)
- Jasmine Martinez
- From the Department of Biomedical Engineering and Science, Florida Institute of Technology, Melbourne, Florida
| | | | | | | | - Venkat Keshav Chivukula
- From the Department of Biomedical Engineering and Science, Florida Institute of Technology, Melbourne, Florida
| |
Collapse
|
4
|
Tanaka S, Nishinaka T, Umeki A, Murakami T, Imaoka S, Mizuno T, Tsukiya T, Ono M. Hemodynamic Evaluation of Asynchronous Speed Modulation of a Continuous-Flow Left Ventricular Assist Device in an Acute-Myocardial Injury Sheep Model. Ann Biomed Eng 2024; 52:364-375. [PMID: 37851145 DOI: 10.1007/s10439-023-03383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023]
Abstract
Asynchronous rotational-speed modulation of a continuous-flow left ventricular assist device (LVAD) can increase pulsatility; however, the feasibility of hemodynamic modification by asynchronous modulation of an LVAD has not been sufficiently verified. We evaluated the acute effect of an asynchronous-modulation mode under LVAD support and the accumulated effect of 6 consecutive hours of driving by the asynchronous-modulation mode on hemodynamics, including both ventricles, in a coronary microembolization-induced acute-myocardial injury sheep model. We evaluated 5-min LVAD-support hemodynamics, including biventricular parameters, by switching modes from constant-speed to asynchronous-modulation in the same animals ("acute-effect evaluation under LVAD support"). To determine the accumulated effect of a certain driving period, we evaluated hemodynamics including biventricular parameters after weaning from 6-hour (6 h) LVAD support by constant-speed or asynchronous-modulation mode ("6h-effect evaluation"). The acute-effect evaluation under LVAD support revealed that, compared to the constant-speed mode, the asynchronous-modulation mode increased vascular pulsatility but did not have significantly different effects on hemodynamics, including both ventricles. The 6 h-effect evaluation revealed that the hemodynamics did not differ significantly between the two groups except for some biventricular parameters which did not indicate negative effects of the asynchronous-modulation mode on both ventricles. The asynchronous-modulation mode could be feasible to increase vascular pulsatility without causing negative effects on hemodynamics including both ventricles. Compared to the constant-speed mode, the asynchronous-modulation mode increased pulsatility during LVAD support without negative effects on hemodynamics including both ventricles in the acute phase. Six hours of LVAD support with the asynchronous-modulation mode exerted no negative effects on hemodynamics, including both ventricles, after weaning from the LVAD.
Collapse
Affiliation(s)
- Shun Tanaka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
| | - Tomohiro Nishinaka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Akihide Umeki
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Takashi Murakami
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Shusuke Imaoka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Toshihide Mizuno
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Tomonori Tsukiya
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo , Tokyo, 113-8654, Japan
| |
Collapse
|
5
|
Kuroda T, Miyagi C, Polakowski AR, Flick CR, Kuban BD, Fukamachi K, Karimov JH. Preservation of pulsatility with universal ventricular assist device: In vitro assessment for biventricular support. Artif Organs 2024; 48:182-190. [PMID: 37787082 DOI: 10.1111/aor.14656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/08/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The objective of this study was to assess the pulsatility preservation capability of the universal ventricular assist device (UVAD) when used as a biventricular assist device (BVAD). This evaluation was conducted through an in vitro experiment, utilizing a pulsatile biventricular circulatory mock loop. METHODS Two UVAD pumps were tested in a dual setup (BVAD) in the circulatory model with the simulated conditions of left heart failure (HF), right HF, and moderate/severe biventricular HF (BHF). The total flow, aortic pulse pressure, the pulse augmentation factor (PAF), the energy-equivalent pressure (EEP), and the surplus hemodynamic energy (SHE) were observed at various pump speeds to evaluate the pulsatility. RESULTS The aortic pulse pressure increased from the baseline (without pump) in all simulated hemodynamic conditions. The PAF ranged from 17%-35% in healthy, left HF, right HF, and mild BHF conditions, with the highest PAF of 90% being observed in the severe BHF condition. The EEP correlated with LVAD flow in all groups (R2 = 0.87-0.97) and increased from the baseline in all cases. The SHE peaked at approximately 5-6 L/min of LVAD support and was likely to decrease at higher LVAD pump flow. The largest decrease in SHE from the baseline, 53%, was observed in the mild BHF conditions with the highest LVAD and RVAD support. CONCLUSIONS The UVAD successfully demonstrated the ability to preserve pulsatility in vitro, and to optimize the cardiac output, as an isolated circulatory support device option (RVAD or LVAD) and when used for BVAD support.
Collapse
Affiliation(s)
- Taiyo Kuroda
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chihiro Miyagi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony R Polakowski
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine R Flick
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Barry D Kuban
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Section of Heart Failure and Cardiac Transplant Medicine, Cleveland, Ohio, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Section of Heart Failure and Cardiac Transplant Medicine, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Section of Heart Failure and Cardiac Transplant Medicine, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Parodi F, Severi I, Flora G, Cioni S, Vallone IM, Betti V, Martini G, Tassi R. Concurrent subarachnoid haemorrhage and internal carotid artery dissection: a transcranial colour-coded sonography diagnosis. J Ultrasound 2023; 26:771-776. [PMID: 35482247 PMCID: PMC10632309 DOI: 10.1007/s40477-022-00686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022] Open
Abstract
We report the case of a young woman affected by an aneurysmal subarachnoid haemorrhage (SAH) and numerous anatomic abnormalities. A Transcranial Colour-Coded Duplex Sonography, performed with the aim of monitoring the vasospasm, showed a non-pulsatile flow with loss of sharp systolic peak and lowering of mean flow velocities in the right extracranial Internal Carotid Artery (ICA) and all its intra-cranial branches. This event suggested a possible concomitant acute right ICA sub-occlusion with a lack of collateral circulation. This type of flow is typically found in systemic and brain arteries of patients undergoing to venous-arterial extracorporeal membrane oxygenation or to left ventricular assist devices. The absence of an adequate cerebral collateral circulation might be the explanation for this type of atypical flow. Aneurysms and arterial dissections contribute to SAH and ischemic stroke events, leading to long-term physical and cognitive disability. In our case, the prompt neurosonological diagnosis leaded to patient's good outcome.
Collapse
Affiliation(s)
- Francesca Parodi
- Stroke Unit, Department of Emergency and Transplantation, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Ilaria Severi
- Stroke Unit, Department of Emergency and Transplantation, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Giammarco Flora
- Unit of Interventional Neuroradiology, Department of Neurology and Human Movement Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Samuele Cioni
- Unit of Interventional Neuroradiology, Department of Neurology and Human Movement Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Ignazio Maria Vallone
- Unit of Interventional Neuroradiology, Department of Neurology and Human Movement Sciences, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Veronica Betti
- Anesthesia and Neuro-ICU, Department of Neurological and Sensorineural, Azienda Opsedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Giuseppe Martini
- Stroke Unit, Department of Emergency and Transplantation, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Emergency and Transplantation, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Viale Mario Bracci, 16, 53100, Siena, Italy.
| |
Collapse
|
7
|
Kalra A, Kang JK, Wilcox C, Brown P, Rycus P, Anders MM, Zaaqoq AM, Brodie D, Whitman GJR, Cho SM. Impact of Pulse Pressure on Acute Brain Injury in Venoarterial ECMO Patients with Cardiogenic Shock During the First 24 Hours of ECMO Cannulation: Analysis of the Extracorporeal Life Support Organization Registry. RESEARCH SQUARE 2023:rs.3.rs-3646443. [PMID: 38045281 PMCID: PMC10690326 DOI: 10.21203/rs.3.rs-3646443/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background : Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. Methods : We retrospectively analyzed adults (≥18 years) on "peripheral" VA-ECMO support for cardiogenic shock in the Extracorporeal Life Support Organization Registry (1/2018-7/2023). Cubic splines were used to establish a threshold (PP≤10 mmHg at 24 hours of ECMO support) for "early low" PP. ABI included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP≤10 mmHg was associated with ABI. Covariates included age, sex, body mass index, pre-ECMO variables (temporary mechanical support, vasopressors, cardiac arrest), on-ECMO variables (pH, PaO 2 , PaCO 2 ), and on-ECMO complications (hemolysis, arrhythmia, renal replacement therapy). Results : Of 9,807 peripheral VA-ECMO patients (median age=57.4 years, 67% male), 8,294 (85%) had PP>10 mmHg vs. 1,513 (15%) had PP≤10 mmHg. Patients with PP≤10 mmHg experienced ABI more frequently vs. PP>10 mmHg (15% vs. 11%, p<0.001). After adjustment, PP≤10 mmHg was independently associated with ABI (adjusted odds ratio [aOR]=1.25, 95% confidence interval [CI]=1.06-1.48, p=0.01). CNS ischemia and brain death were more common in patients with PP≤10 mmHg vs. PP>10 mmHg (8% vs. 6%, p=0.008; 3% vs. 1%, p<0.001). PP≤10 mmHg was associated with CNS ischemia (aOR=1.26, 95%CI=1.02-1.56, p=0.03) but not intracranial hemorrhage (aOR=1.14, 95%CI=0.85-1.54, p=0.38). Conclusions : Early low PP (≤10 mmHg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.
Collapse
|
8
|
Zaidi D, Kirkpatrick JN, Fedson SE, Hull SC. Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework. JACC. HEART FAILURE 2023; 11:1481-1490. [PMID: 37768252 DOI: 10.1016/j.jchf.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/06/2023] [Accepted: 08/08/2023] [Indexed: 09/29/2023]
Abstract
Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.
Collapse
Affiliation(s)
- Danish Zaidi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Savitri E Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA.
| |
Collapse
|
9
|
Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
Collapse
Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| |
Collapse
|
10
|
Grewal JS, Diaz-Castrillon CE, Witer L, Griffin JM, Hajj J, Houston BA, Kilic A, Tedford RJ. Duration of Durable cf-LVAD Support and Heart Transplant Outcomes. JACC. HEART FAILURE 2023; 11:1157-1159. [PMID: 37611992 DOI: 10.1016/j.jchf.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 08/25/2023]
|
11
|
Sahni A, McIntyre EE, Cao K, Pal JD, Mukherjee D. The Relation Between Viscous Energy Dissipation and Pulsation for Aortic Hemodynamics Driven by a Left Ventricular Assist Device. Cardiovasc Eng Technol 2023; 14:560-576. [PMID: 37340092 DOI: 10.1007/s13239-023-00670-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Abstract
Left ventricular assist device (LVAD) provides mechanical circulatory support for patients with advanced heart failure. Treatment using LVAD is commonly associated with complications such as stroke and gastro-intestinal bleeding. These complications are intimately related to the state of hemodynamics in the aorta, driven by a jet flow from the LVAD outflow graft that impinges into the aorta wall. Here we conduct a systematic analyses of hemodynamics driven by an LVAD with a specific focus on viscous energy transport and dissipation. We conduct a complementary set of analysis using idealized cylindrical tubes with diameter equivalent to common carotid artery and aorta, and a patient-specific model of 27 different LVAD configurations. Results from our analysis demonstrate how energy dissipation is governed by key parameters such as frequency and pulsation, wall elasticity, and LVAD outflow graft surgical anastomosis. We find that frequency, pulsation, and surgical angles have a dominant effect, while wall elasticity has a weaker effect, in determining the state of energy dissipation. For the patient-specific scenario, we also find that energy dissipation is higher in the aortic arch and lower in the abdominal aorta, when compared to the baseline flow without an LVAD. This further illustrates the key hemodynamic role played by the LVAD outflow jet impingement, and subsequent aortic hemodynamics during LVAD operation.
Collapse
Affiliation(s)
- Akshita Sahni
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA
| | - Erin E McIntyre
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, USA
| | - Kelly Cao
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA
| | - Jay D Pal
- Department of Surgery, University of Washington, Seattle, USA
| | - Debanjan Mukherjee
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA.
| |
Collapse
|
12
|
Barghash M, Mahmood K, Pinney SP. Durable LVADs as a Bridge to Transplantation: Still a Good Idea. JACC. HEART FAILURE 2023; 11:1160-1163. [PMID: 37611993 DOI: 10.1016/j.jchf.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Maya Barghash
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean P Pinney
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
13
|
Alnsasra H, Khalil F, Kanneganti Perue R, Azab AN. Depression among Patients with an Implanted Left Ventricular Assist Device: Uncovering Pathophysiological Mechanisms and Implications for Patient Care. Int J Mol Sci 2023; 24:11270. [PMID: 37511030 PMCID: PMC10379142 DOI: 10.3390/ijms241411270] [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: 05/25/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Depression is a common and devastating mental illness associated with increased morbidity and mortality, partially due to elevated rates of suicidal attempts and death. Select patients with end-stage heart failure on a waiting-list for a donor heart undergo left ventricular assist device (LVAD) implantation. The LVAD provides a circulatory flow of oxygenated blood to the body, mimicking heart functionality by operating on a mechanical technique. LVAD improves functional capacity and survivability among patients with end-stage heart failure. However, accumulating data suggests that LVAD recipients suffer from an increased incidence of depression and suicide attempts. There is scarce knowledge regarding the pathological mechanism and appropriate treatment approach for depressed LVAD patients. This article summarizes the current evidence on the association between LVAD implantation and occurrence of depression, suggesting possible pathological mechanisms underlying the device-associated depression and reviewing the current treatment strategies. The summarized data underscores the need for a rigorous pre-(LVAD)-implantation psychiatric evaluation, continued post-implantation mental health assessment, and administration of antidepressant treatment as necessary.
Collapse
Affiliation(s)
- Hilmi Alnsasra
- Cardiology Division, Soroka University Medical Center, Beer-Sheva 8410501, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Abed N Azab
- Cardiology Division, Soroka University Medical Center, Beer-Sheva 8410501, Israel
- Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| |
Collapse
|
14
|
Sohn SH, Kang Y, Hwang HY, Chee HK. Optimal timing of heart transplantation in patients with an implantable left ventricular assist device. KOREAN JOURNAL OF TRANSPLANTATION 2023; 37:79-84. [PMID: 37435145 PMCID: PMC10332290 DOI: 10.4285/kjt.23.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/28/2023] [Indexed: 07/13/2023] Open
Abstract
Heart transplantation (HTPL) has been established as the gold-standard surgical treatment for end-stage heart failure. However, the use of a left ventricular assist device (LVAD) as a bridge to HTPL has been increasing due to the limited availability of HTPL donors. Currently, more than half of HTPL patients have a durable LVAD. Advances in LVAD technology have provided many benefits for patients on the waiting list for HTPL. Despite their advantages, LVADs also have limitations such as loss of pulsatility, thromboembolism, bleeding, and infection. In this narrative review, the benefits and shortcomings of LVADs as a bridge to HTPL are summarized, and the available literature evaluating the optimal timing of HTPL after LVAD implantation is reviewed. Because only a few studies have been published on this issue in the current era of third-generation LVADs, future studies are needed to draw a definite conclusion.
Collapse
Affiliation(s)
- Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| |
Collapse
|
15
|
Shou BL, Wilcox C, Florissi I, Kalra A, Caturegli G, Zhang LQ, Bush E, Kim B, Keller SP, Whitman GJR, Cho SM. Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury. Neurocrit Care 2023; 38:612-621. [PMID: 36167950 PMCID: PMC10040467 DOI: 10.1007/s12028-022-01607-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO. METHODS We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI. RESULTS We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI. CONCLUSIONS Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.
Collapse
Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Isabella Florissi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lucy Q Zhang
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol Bush
- Division of General Thoracic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
16
|
Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
Collapse
Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
17
|
Huang F, Lei H, Ying S, Fu Y, Li Q, Ruan X. Numerical hemolysis performance evaluation of a rotary blood pump under different speed modulation profiles. Front Physiol 2023; 14:1116266. [PMID: 36818439 PMCID: PMC9931726 DOI: 10.3389/fphys.2023.1116266] [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: 12/05/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction: Speed modulation methods have been studied and even used clinically to create extra pulsation in the blood circulatory system with the assistance of a continuous flow rotary blood pump. However, fast speed variations may also increase the hemolysis potential inside the pump. Methods: This study investigates the hemolysis performance of a ventricular assist rotary blood pump under sinusoidal, square, and triangular wave speed modulation profiles using the computational fluid dynamics (CFD) method. The CFD boundary pressure conditions of the blood pump were obtained by combining simulations with the pump's mathematical model and a complete cardiovascular lumped parameter model. The hemolysis performance of the blood pump was quantified by the hemolysis index (HI) calculated from a Eulerian scalar transport equation. Results: The HI results were obtained and compared with a constant speed condition when the blood pump was run under three speed profiles. The speed modulations were revealed to slightly affect the pump hemolysis, and the hemolysis differences between the different speed modulation profiles were insignificant. Discussion: This study suggests that speed modulations could be a feasible way to improve the flow pulsatility of rotary blood pumps while not increasing the hemolysis performance.
Collapse
Affiliation(s)
- Feng Huang
- School of Mechanical and Energy Engineering, Zhejiang University of Science and Technology, Hangzhou, China,State Key Laboratory of Fluid Power and Mechatronic Systems, Zhejiang University, Hangzhou, China,*Correspondence: Feng Huang, ; Qipeng Li,
| | - Huan Lei
- School of Mechanical and Energy Engineering, Zhejiang University of Science and Technology, Hangzhou, China
| | - Shunv Ying
- Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Clinical Research Center for Oral Diseases of Zhejiang Province, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, China
| | - Yang Fu
- School of Mechanical and Energy Engineering, Zhejiang University of Science and Technology, Hangzhou, China
| | - Qipeng Li
- School of Mechanical and Energy Engineering, Zhejiang University of Science and Technology, Hangzhou, China,*Correspondence: Feng Huang, ; Qipeng Li,
| | - Xiaodong Ruan
- State Key Laboratory of Fluid Power and Mechatronic Systems, Zhejiang University, Hangzhou, China
| |
Collapse
|
18
|
Sahni A, McIntyre EE, Pal JD, Mukherjee D. Quantitative Assessment of Aortic Hemodynamics for Varying Left Ventricular Assist Device Outflow Graft Angles and Flow Pulsation. Ann Biomed Eng 2023; 51:1226-1243. [PMID: 36705866 DOI: 10.1007/s10439-022-03127-4] [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: 06/17/2022] [Accepted: 12/25/2022] [Indexed: 01/28/2023]
Abstract
Left ventricular assist devices (LVADs) comprise a primary treatment choice for advanced heart failure patients. Treatment with LVAD is commonly associated with complications like stroke and gastro-intestinal (GI) bleeding, which adversely impacts treatment outcomes, and causes fatalities. The etiology and mechanisms of these complications can be linked to the fact that LVAD outflow jet leads to an altered state of hemodynamics in the aorta as compared to baseline flow driven by aortic jet during ventricular systole. Here, we present a framework for quantitative assessment of aortic hemodynamics in LVAD flows realistic human vasculature, with a focus on quantifying the differences between flow driven by LVAD jet and the physiological aortic jet when no LVAD is present. We model hemodynamics in the aortic arch proximal to the LVAD outflow graft, as well as in the abdominal aorta away from the LVAD region. We characterize hemodynamics using quantitative descriptors of flow velocity, stasis, helicity, vorticity and mixing, and wall shear stress. These are used on a set of 27 LVAD scenarios obtained by parametrically varying LVAD outflow graft anastomosis angles, and LVAD flow pulse modulation. Computed descriptors for each of these scenarios are compared against the baseline flow, and a detailed quantitative characterization of the altered state of hemodynamics due to LVAD operation (when compared to baseline aortic flow) is compiled. These are interpreted using a conceptual model for LVAD flow that distinguishes between flow originating from the LVAD outflow jet (and its impingement on the aorta wall), and flow originating from aortic jet during aortic valve opening in normal physiological state.
Collapse
Affiliation(s)
- Akshita Sahni
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA
| | - Erin E McIntyre
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, Aurora, USA
| | - Jay D Pal
- Department of Surgery, University of Washington, Seattle, USA
| | - Debanjan Mukherjee
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA.
| |
Collapse
|
19
|
Toward a Self-Actuating Continuous Flow Ventricular Assist Device: The Pudding Is in the Proof. ASAIO J 2023; 69:59-60. [PMID: 36583771 DOI: 10.1097/mat.0000000000001881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
20
|
Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
Collapse
Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| |
Collapse
|
21
|
Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| |
Collapse
|
22
|
Kyriakopoulos CP, Taleb I, Drakos SG. Does cardiac recovery favorably impact adverse events and outcomes of LVAD patients? J Heart Lung Transplant 2022; 41:1029-1031. [PMID: 35878939 PMCID: PMC9990470 DOI: 10.1016/j.healun.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Christos P Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA.
| |
Collapse
|
23
|
LVAD as a Bridge to Remission from Advanced Heart Failure: Current Data and Opportunities for Improvement. J Clin Med 2022; 11:jcm11123542. [PMID: 35743611 PMCID: PMC9225013 DOI: 10.3390/jcm11123542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Left ventricular assist devices (LVADs) are an established treatment modality for advanced heart failure (HF). It has been shown that through volume and pressure unloading they can lead to significant functional and structural cardiac improvement, allowing LVAD support withdrawal in a subset of patients. In the first part of this review, we discuss the historical background, current evidence on the incidence and assessment of LVAD-mediated cardiac recovery, and out-comes including quality of life after LVAD support withdrawal. In the second part, we discuss current and future opportunities to promote LVAD-mediated reverse remodeling and improve our pathophysiological understanding of HF and recovery for the benefit of the greater HF population.
Collapse
|
24
|
Dorken Gallastegi A, Ergi GD, Kahraman Ü, Yağmur B, Çinar E, Karapolat H, Nalbantgil S, Engin Ç, Yağdi T, Özbaran M. Prognostic Value of Cardiopulmonary Exercise Test Parameters in Ventricular Assist Device Therapy. ASAIO J 2022; 68:808-813. [PMID: 34494984 DOI: 10.1097/mat.0000000000001571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cardiopulmonary exercise test (CPET) parameters are established prognosticators in heart failure. However, the prognostic value of preimplantation and postimplantation CPET parameters in left ventricular assist device (LVAD) therapy is unclear and it is evaluated in this study. Adult patients who were implanted with an LVAD and underwent CPET during the preimplantation or postimplantation period were retrospectively analyzed. Five CPET parameters were calculated: vO2 max, oxygen uptake efficiency slope (OUES), VE/vCO2 Slope, VE/vCO2 min, and VE/vCO2 max. The relationship between CPET parameters and postimplantation outcomes was evaluated with multivariable analysis. Pre and postimplantation CPET cohorts included 191 and 122 patients, respectively. Among preimplantation CPET parameters: vO2 max and OUES were associated with 1, 3, and 5 year mortality, VE/vCO2 min was associated with 3 and 5 year mortality, whereas VE/vCO2 Slope was associated with 5 year mortality. From postimplantation CPET parameters: vO2 max was an independent predictor of 3 and 5 year mortality, whereas VE/vCO2 max was an independent predictor of 3 year mortality following LVAD implantation. Preimplantation CPET parameters have a prognostic value for long-term survival following LVAD implantation, whereas their association with early postimplantation outcomes appears to be weaker. Postimplantation vO2 max and VE/vCO2 max values are associated with survival on device support and may provide a second chance for prognostication in patients without preimplantation CPET data.
Collapse
Affiliation(s)
| | | | | | | | - Ece Çinar
- Physical Medicine and Rehabilitation, Ege University School of Medicine, Izmir, Turkey
| | - Hale Karapolat
- Physical Medicine and Rehabilitation, Ege University School of Medicine, Izmir, Turkey
| | | | | | - Tahir Yağdi
- From the Departments of Cardiovascular Surgery
| | | |
Collapse
|
25
|
Abdelilah-Seyfried S, Iruela-Arispe ML, Penninger JM, Tournier-Lasserve E, Vikkula M, Cleaver O. Recalibrating vascular malformations and mechanotransduction by pharmacological intervention. J Clin Invest 2022; 132:160227. [PMID: 35426368 PMCID: PMC9012280 DOI: 10.1172/jci160227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | - M. Luisa Iruela-Arispe
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef M. Penninger
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elisabeth Tournier-Lasserve
- INSERM UMR 1141 Neurodiderot, University of Paris, Paris, France
- AP-HP, Department of Genetics of Neurovascular Diseases, Hôpital Saint-Louis, Paris, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, Brussels, Belgium
| | - Ondine Cleaver
- Department of Molecular Biology, UT Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
26
|
Varshney AS, DeFilippis EM, Cowger JA, Netuka I, Pinney SP, Givertz MM. Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1092-1107. [PMID: 35300822 DOI: 10.1016/j.jacc.2022.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 12/27/2022]
Abstract
As the prevalence of advanced heart failure continues to rise, treatment strategies for select patients include heart transplantation or durable left ventricular assist device (LVAD) support, both of which improve quality of life and extend survival. Recently, the HeartMate 3 has been incorporated into clinical practice, the United Network for Organ Sharing donor heart allocation system was revised, and the management of LVAD-related complications has evolved. Contemporary LVAD recipients have greater preoperative illness severity, but survival is higher and adverse event rates are lower compared with prior eras. This is driven by advances in device design, patient selection, surgical techniques, and long-term management. However, bleeding, infection, neurologic events, and right ventricular failure continue to limit broader implementation of LVAD support. Ongoing efforts to optimize management of patients implanted with current devices and parallel development of next-generation devices are likely to further improve outcomes for patients with advanced heart failure.
Collapse
Affiliation(s)
- Anubodh S Varshney
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | | | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic. https://twitter.com/netuka_ivan
| | - Sean P Pinney
- University of Chicago Medicine, Chicago, Illinois, USA. https://twitter.com/spinneymd
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
27
|
Relationship between muscle strength and rehospitalization in ventricular assist device patients. Sci Rep 2022; 12:50. [PMID: 34997047 PMCID: PMC8741760 DOI: 10.1038/s41598-021-04002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/06/2021] [Indexed: 11/09/2022] Open
Abstract
We examined the relationship between leg extensor muscle strength (LEMS) at discharge and rehospitalization within 1 year in patients with a newly implanted ventricular assist device (VAD). This study included 28 patients who had received a VAD at our institution between October 2013 and February 2019, all of whom had been discharged for 1 year. The patients were divided into two groups according to their LEMS at discharge (higher strength [group H] and lower strength [group L]), based on the median value of the 55.2 kg-force (kgf)/body weight (BW) equation. Exercise performance parameters (e.g., grip strength, 6-min walk distance, and peak VO2) and laboratory data concerning nutritional status were also collected. Nine patients (64.3%) in group L were rehospitalized within 1 year after discharge. The rehospitalization rate was significantly higher in group L than group H (p = 0.020). Compared with discharge, patients exhibited higher grip strength (56.3 vs. 48.6 kg/BW, respectively; p = 0.011), 6-min walk distances (588 vs. 470 m, respectively; p = 0.002), and peak VO2 (15.4 vs. 11.9 mL/min/kg, respectively; p < 0.001) at 1 year after discharge. However, the LEMS (57.4 vs. 58.0 kgf/BW, respectively; p = 0.798) did not increase after discharge in VAD patients who avoided rehospitalization. LEMS at discharge was associated with rehospitalization after VAD surgery; a high LEMS improves the likelihood of avoiding rehospitalization.
Collapse
|
28
|
Pan Q, Feng W, Wang R, Tabuchi A, Li P, Nitzsche B, Fang L, Kuebler WM, Pries AR, Ning G. Pulsatility damping in the microcirculation: Basic pattern and modulating factors. Microvasc Res 2022; 139:104259. [PMID: 34624307 DOI: 10.1016/j.mvr.2021.104259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
Blood flow pulsatility is an important determinant of macro- and microvascular physiology. Pulsatility is damped largely in the microcirculation, but the characteristics of this damping and the factors that regulate it have not been fully elucidated yet. Applying computational approaches to real microvascular network geometry, we examined the pattern of pulsatility damping and the role of potential damping factors, including pulse frequency, vascular viscous resistance, vascular compliance, viscoelastic behavior of the vessel wall, and wave propagation and reflection. To this end, three full rat mesenteric vascular networks were reconstructed from intravital microscopic recordings, a one-dimensional (1D) model was used to reproduce pulsatile properties within the network, and potential damping factors were examined by sensitivity analysis. Results demonstrate that blood flow pulsatility is predominantly damped at the arteriolar side and remains at a low level at the venular side. Damping was sensitive to pulse frequency, vascular viscous resistance and vascular compliance, whereas viscoelasticity of the vessel wall or wave propagation and reflection contributed little to pulsatility damping. The present results contribute to our understanding of mechanical forces and their regulation in the microcirculation.
Collapse
Affiliation(s)
- Qing Pan
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Weida Feng
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Ruofan Wang
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China
| | - Arata Tabuchi
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Peilun Li
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China
| | - Bianca Nitzsche
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Luping Fang
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Axel R Pries
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany.
| | - Gangmin Ning
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China.
| |
Collapse
|
29
|
Gambaro A, Lombardi G, Onorati F, Gottin L, Ribichini FL. Heart, kidney and left ventricular assist device: a complex trio. Eur J Clin Invest 2021; 51:e13662. [PMID: 34347897 DOI: 10.1111/eci.13662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure (HF) is a complex syndrome affecting the whole body, kidneys included. The left ventricular assist device (LVAD) is a valid option for patients with very severe HF. Focusing on renal function, LVAD implantation could theoretically reverse the detrimental effects of HF syndrome on kidneys. However, implanting an LVAD is a high-risk surgical procedure, and LVAD patients have higher risk of bleeding, device thrombosis, strokes, renal impairment, multi-organ failure and infections. Furthermore, an LVAD has its own particular effects on the renal system. METHODS In this review, we provide a comprehensive overview of the complex interaction between LVAD and the kidneys from the pathophysiological and clinical perspectives. An analysis of the different effects of pulsatile-flow and continuous-flow LVAD is provided. RESULTS Despite their limitations, creatinine-based estimated glomerular filtration rate (eGFR) formulas help to stratify patients by their post-LVAD placement prognosis. Poor basal renal function, the onset of acute kidney injury or the need for renal replacement therapy after LVAD implantation negatively influences a patient's prognosis. LVAD can also prompt an improvement in renal function, however, with some counterintuitive effects on a patient's prognosis. CONCLUSION It is still hard to say whether different trends in eGFR depend on different renal conditions before LVAD placement, on a patient's better overall status or on a particular patient management strategy before and/or after the device's implantation. Steps should be taken to solve this question because finding the best candidates for LVAD implantation is of paramount importance to ensure the best outcomes.
Collapse
Affiliation(s)
- Alessia Gambaro
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gianmarco Lombardi
- Division of Nephrology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Leonardo Gottin
- Unit of Cardiothoracic Anesthesia and Intensive Care, Department of Emergencies and Intensive Care, University of Verona, Verona, Italy
| | | |
Collapse
|
30
|
Ambardekar AV, Stratton MS, Dobrinskikh E, Hunter KS, Tatman PD, Lemieux ME, Cleveland JC, Tuder RM, Weiser-Evans MCM, Moulton KS, McKinsey TA. Matrix-Degrading Enzyme Expression and Aortic Fibrosis During Continuous-Flow Left Ventricular Mechanical Support. J Am Coll Cardiol 2021; 78:1782-1795. [PMID: 34711337 PMCID: PMC8562886 DOI: 10.1016/j.jacc.2021.08.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/28/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effects of nonphysiological flow generated by continuous-flow (CF) left ventricular assist devices (LVADs) on the aorta remain poorly understood. OBJECTIVES The authors sought to quantify indexes of fibrosis and determine the molecular signature of post-CF-LVAD vascular remodeling. METHODS Paired aortic tissue was collected at CF-LVAD implant and subsequently at transplant from 22 patients. Aortic wall morphometry and fibrillar collagen content (a measure of fibrosis) was quantified. In addition, whole-transcriptome profiling by RNA sequencing and follow-up immunohistochemistry were performed to evaluate CF-LVAD-mediated changes in aortic mRNA and protein expression. RESULTS The mean age was 52 ± 12 years, with a mean duration of CF-LVAD of 224 ± 193 days (range 45-798 days). There was a significant increase in the thickness of the collagen-rich adventitial layer from 218 ± 110 μm pre-LVAD to 410 ± 209 μm post-LVAD (P < 0.01). Furthermore, there was an increase in intimal and medial mean fibrillar collagen intensity from 22 ± 11 a.u. pre-LVAD to 41 ± 24 a.u. post-LVAD (P < 0.0001). The magnitude of this increase in fibrosis was greater among patients with longer durations of CF-LVAD support. CF-LVAD led to profound down-regulation in expression of extracellular matrix-degrading enzymes, such as matrix metalloproteinase-19 and ADAMTS4, whereas no evidence of fibroblast activation was noted. CONCLUSIONS There is aortic remodeling and fibrosis after CF-LVAD that correlates with the duration of support. This fibrosis is due, at least in part, to suppression of extracellular matrix-degrading enzyme expression. Further research is needed to examine the contribution of nonphysiological flow patterns on vascular function and whether modulation of pulsatility may improve vascular remodeling and long-term outcomes.
Collapse
Affiliation(s)
- Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Matthew S Stratton
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Evgenia Dobrinskikh
- Department of Medicine, Division of Pulmonary Sciences and Critical Care and Department of Pediatrics, Section of Neonatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Philip D Tatman
- Department of Pharmacology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Joseph C Cleveland
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rubin M Tuder
- Department of Medicine, Division of Pulmonary Sciences and Critical Care and Department of Pediatrics, Section of Neonatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mary C M Weiser-Evans
- Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Medicine, Division of Renal Medicine and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Karen S Moulton
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Timothy A McKinsey
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
31
|
Jani M, Lee S, Acharya D, Hoeksema S, Boeve T, Leacche M, Manandhar-Shrestha NK, Jovinge SV, Loyaga-Rendon RY. Decreased frequency of transplantation and lower post-transplant survival free of re-transplantation in LVAD patients with the new heart transplant allocation system. Clin Transplant 2021; 36:e14493. [PMID: 34689383 DOI: 10.1111/ctr.14493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/11/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the effect of the new heart transplant (HT) allocation system in left ventricular assist device (LVAD) supported patients listed as bridge to transplantation (BTT). METHODS Adult patients who were listed for HT between October 18, 2016 and October 17, 2019, and were supported with an LVAD, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or transplanted before or after October 18, 2018, respectively. RESULTS A total of 3261 LVAD patients were listed for transplant. Of these, 2257 were classified in the old and 1004 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status at 360-days after listing was lower in the new system (4% vs. 7%, P = .011). LVAD Patients listed in the new system had a lower frequency of transplantation within 360-days of listing (52% vs. 61%, P < .001). A total of 1843 LVAD patients were transplanted, 1004 patients in the old system and 839 patients in the new system. The post-transplant survival at 360 days was similar between old and new systems (92.3% vs. 90%, P = .08). However, LVAD patients transplanted in the new system had lower frequency of the combined endpoint, freedom of death or re-transplantation at 360 days (92.2% vs. 89.6%, P = .046). CONCLUSION The new HT allocation system has affected the LVAD-BTT population significantly. On the waitlist, LVAD patients have a decreased cumulative frequency of transplantation and a concomitant decrease in death or delisting due to worsening status. In the new system, LVAD patients have a decreased survival free of re-transplantation at 360 days post-transplant.
Collapse
Affiliation(s)
- Milena Jani
- Advanced Heart Failure Section, Spectrum Health, Grand Rapids, Michigan, USA
| | - Sangjin Lee
- Advanced Heart Failure Section, Spectrum Health, Grand Rapids, Michigan, USA
| | - Deepak Acharya
- Sarver Heart Center, University of Arizona, Tucson, Arizona, USA
| | - Sarah Hoeksema
- Advanced Heart Failure Section, Spectrum Health, Grand Rapids, Michigan, USA
| | - Theodore Boeve
- Division of Cardio Thoracic Surgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - Marzia Leacche
- Division of Cardio Thoracic Surgery, Spectrum Health, Grand Rapids, Michigan, USA
| | | | - Stefan V Jovinge
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, Michigan, USA.,DeVos Cardiovascular Research Program, Van Andel Institute/Spectrum Health, Grand Rapids, Michigan, USA.,Cardiovascular Institute, Stanford University, Palo Alto, California, USA
| | | |
Collapse
|
32
|
Cardiac Resynchronization Therapy in Patients With LVADs: Boon or Bust? JACC Clin Electrophysiol 2021; 7:1010-1012. [PMID: 34412865 DOI: 10.1016/j.jacep.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022]
|
33
|
Hinton M, Eltayeb E, Ghavami S, Dakshinamurti S. Effect of pulsatile stretch on unfolded protein response in a new model of the pulmonary hypertensive vascular wall. Biochem Biophys Rep 2021; 27:101080. [PMID: 34368469 PMCID: PMC8326203 DOI: 10.1016/j.bbrep.2021.101080] [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: 05/18/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is characterized by hypoxemia and arterial remodeling. Dynamic stretch and recoil of the arterial wall during pulsation (in normal conduit arteries, stretch 20% above diastolic diameter) maintains homeostasis; a static arterial wall is associated with remodeling. PPHN is diagnosed by echocardiography as decreased pulmonary artery wall displacement during systole, causing decreased pulmonary arterial pressure acceleration time in a stiff artery. We hypothesized that a ‘normal’ amplitude of pulsatile stretch is protective against ER stress, while the loss of stretch is a trigger for hypoxia-induced stress responses. Using a novel in vitro model of pulmonary arterial myocytes subject to repetitive stretch-relaxation cycles within a normoxic or hypoxic environment, we examined the relative impact of hypoxia (pulmonary circuit during unresolved PPHN) and cyclic mechanical stretch (diminished in PPHN) on myocyte homeostasis, specifically on signaling proteins for autophagy and endoplasmic reticulum (ER) stress. Stretch induced autophagosome abundance under electron microscopy. Hypoxia, in presence or absence of pulsatile stretch, decreased unfolded protein response (UPR) hallmark BIP (GRP78) in contractile phenotype pulmonary arterial myocytes. Inositol requiring enzyme-1 α (IRE1α) was not activated; but hypoxia induced eif2α phosphorylation, increasing expression of ATF4 (activating transcription factor-4). This was sensitive to inhibition by autophagy inhibitor bafilomycin A1. We conclude that in the pulmonary circuit, hypoxia induces one arm of the UPR pathway and causes ER stress. Pulsatile stretch ameliorates the hypoxic UPR response, and while increasing presence of autophagosomes, does not activate canonical autophagy signaling pathways. We propose that simultaneous application of hypoxia and graded levels of cyclic stretch can be used to distinguish myocyte signaling in the deformable pulmonary artery of early PPHN, versus the inflexible late stage PPHN artery.
Collapse
Affiliation(s)
- Martha Hinton
- Biology of Breathing Group, Children's Hospital Research Institute of Manitoba, 513 - 715 McDermot Avenue, Winnipeg, Canada, R3E 3P4.,Department of Physiology and Pathophysiology, University of Manitoba, 432 Basic Medical Sciences Building, 745 Bannatyne Avenue, Winnipeg, Canada, R3E 0J9
| | - Elwasila Eltayeb
- Section of Neonatology, Department of Pediatrics, University of Manitoba, Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Canada, R3A 1R9
| | - Saeid Ghavami
- Biology of Breathing Group, Children's Hospital Research Institute of Manitoba, 513 - 715 McDermot Avenue, Winnipeg, Canada, R3E 3P4.,Department of Human Anatomy and Cell Science, University of Manitoba, 130 Basic Medical Sciences Building, 745 Bannatyne Avenue, Winnipeg, Canada, R3E 0J9
| | - Shyamala Dakshinamurti
- Biology of Breathing Group, Children's Hospital Research Institute of Manitoba, 513 - 715 McDermot Avenue, Winnipeg, Canada, R3E 3P4.,Section of Neonatology, Department of Pediatrics, University of Manitoba, Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Canada, R3A 1R9.,Department of Physiology and Pathophysiology, University of Manitoba, 432 Basic Medical Sciences Building, 745 Bannatyne Avenue, Winnipeg, Canada, R3E 0J9
| |
Collapse
|
34
|
Abstract
Targeted blood pressure (BP) control is a goal of left ventricular assist device medical management, but the interpretation of values obtained from noninvasive instruments is challenging. In the MOMENTUM 3 Continued Access Protocol, paired BP values in HeartMate 3 (HM3) patients were compared from arterial (A)-line and Doppler opening pressure (DOP) (319 readings in 261 patients) and A-line and automated cuff (281 readings in 247 patients). Pearson (R) correlations between A-line mean arterial (MAP) and systolic blood pressures (SBP) were compared with DOP and cuff measures according to the presence (>1 pulse in 5 seconds) or absence of a palpable radial pulse. There were only moderate correlations between A-line and noninvasive measurements of SBP (DOP R = 0.58; cuff R = 0.47) and MAP (DOP R = 0.48; cuff R = 0.37). DOP accuracy for MAP estimation, defined as the % of readings within ± 10 mmHg of A-line MAP, decreased from 80% to 33% for DOP ≤ 90 vs. >90 mmHg, and precision also diminished (mean absolute difference [MAD] increased from 6.3 ± 5.6 to 16.1 ± 11.4 mmHg). Across pulse pressures, cuff MAPs were within ±10 mmHg of A-line 62.9%-68.8% of measures and MADs were negligible. The presence of a palpable pulse reduced the accuracy and precision of the DOP-MAP estimation but did not impact cuff-MAP accuracy or precision. In summary, DOP may overestimate MAP in some patients on HM3 support. Simultaneous use of DOP and automated cuff and radial pulse may be needed to guide antihypertensive medication titration in outpatients on HM3 support.
Collapse
|
35
|
Nezami FR, Khodaee F, Edelman ER, Keller SP. A Computational Fluid Dynamics Study of the Extracorporeal Membrane Oxygenation-Failing Heart Circulation. ASAIO J 2021; 67:276-283. [PMID: 33627601 PMCID: PMC8130419 DOI: 10.1097/mat.0000000000001221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly deployed to provide percutaneous mechanical circulatory support despite incomplete understanding of its complex interactions with the failing heart and its effects on hemodynamics and perfusion. Using an idealized geometry of the aorta and its major branches and a peripherally inserted return cannula terminating in the iliac artery, computational fluid dynamic simulations were performed to (1) quantify perfusion as function of relative ECMO flow and (2) describe the watershed region produced by the collision of antegrade flow from the heart and retrograde ECMO flow. To simulate varying degrees of cardiac failure, ECMO flow as a fraction of systemic perfusion was evaluated at 100%, 90%, 75%, and 50% of total flow with the remainder supplied by the heart calculated from a patient-derived flow waveform. Dynamic boundary conditions were generated with a three-element lumped parameter model to accurately simulate distal perfusion. In profound failure (ECMO providing 90% or more of flow), the watershed region was positioned in the aortic arch with minimal pulsatility observed in the flow to the visceral organs. Modest increases in cardiac flow advanced the watershed region into the thoracic aorta with arch perfusion entirely supplied by the heart.
Collapse
Affiliation(s)
- Farhad Rikhtegar Nezami
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Farhan Khodaee
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Elazer R Edelman
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven P Keller
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Pulmonary and Critical Care Medicine), Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
36
|
Walker MJ. A Heart without Life: Artificial Organs and the Lived Body. Hastings Cent Rep 2021; 51:28-38. [PMID: 33630322 DOI: 10.1002/hast.1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The use of artificial organs is likely to increase in the future, given technological advances, increases in chronic diseases, and limited donor organs. This article examines how artificial organs could affect people's experience and conceptualization of bodies and our understanding of the relation of body to self. I focus on artificial heart devices and argue that these have two conflicting potential influences. First, they may influence people to regard the body as machinelike and separable from the self. Second, they may effect changes to subjective experience that can be understood as changes to the self, confirming the self's embodiment. My primary purpose is to increase our understanding of what might change if it becomes more usual to have a body that is partly nonorganic. But I also argue that the analysis points to potential ethical concerns related to strengthening biomedical conceptions of the body and to the devaluing of bodies and body parts.
Collapse
|
37
|
Nguyen KT, Donoghue L, Giridharan GA, Naber JP, Vincent D, Fukamachi K, Kotru A, Sethu P. Acute Response of Human Aortic Endothelial Cells to Loss of Pulsatility as Seen during Cardiopulmonary Bypass. Cells Tissues Organs 2021; 211:324-334. [PMID: 33631743 DOI: 10.1159/000512558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022] Open
Abstract
Cardiopulmonary bypass (CPB) results in short-term (3-5 h) exposure to flow with diminished pulsatility often referred to as "continuous flow". It is unclear if short-term exposure to continuous flow influences endothelial function, particularly, changes in levels of pro-inflammatory and pro-angiogenic cytokines. In this study, we used the endothelial cell culture model (ECCM) to evaluate if short-term (≤5 h) reduction in pulsatility alters levels of pro-inflammatory/pro-angiogenic cytokine levels. Human aortic endothelial cells (HAECs) cultured within the ECCM provide a simple model to evaluate endothelial cell function in the absence of confounding factors. HAECs were maintained under normal pulsatile flow for 24 h and then subjected to continuous flow (diminished pulsatile pressure and flow) as observed during CPB for 5 h. The ECCM replicated pulsatility and flow morphologies associated with normal hemodynamic status and CPB as seen with clinically used roller pumps. Levels of angiopoietin-2 (ANG-2), vascular endothelial growth factor-A (VEGF-A), and hepatocyte growth factor were lower in the continuous flow group in comparison to the pulsatile flow group whereas the levels of endothelin-1 (ET-1), granulocyte colony stimulating factor, interleukin-8 (IL-8) and placental growth factor were higher in the continuous flow group in comparison to the pulsatile flow group. Immunolabelling of HAECs subjected to continuous flow showed a decrease in expression of ANG-2 and VEGF-A surface receptors, tyrosine protein kinase-2 and Fms-related receptor tyrosine kinase-1, respectively. Given that the 5 h exposure to continuous flow is insufficient for transcriptional regulation, it is likely that pro-inflammatory/pro-angiogenic signaling observed was due to signaling molecules stored in Weible-Palade bodies (ET-1, IL-8, ANG-2) and via HAEC binding/uptake of soluble factors in media. These results suggest that even short-term exposure to continuous flow can potentially activate pro-inflammatory/pro-angiogenic signaling in cultured HAECs and pulsatile flow may be a successful strategy in reducing the undesirable sequalae following continuous flow CPB.
Collapse
Affiliation(s)
- Khanh T Nguyen
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leslie Donoghue
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guruprasad A Giridharan
- Department of Bioengineering, J. B. Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | | | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arushi Kotru
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA,
| |
Collapse
|
38
|
Squair JW, Gautier M, Mahe L, Soriano JE, Rowald A, Bichat A, Cho N, Anderson MA, James ND, Gandar J, Incognito AV, Schiavone G, Sarafis ZK, Laskaratos A, Bartholdi K, Demesmaeker R, Komi S, Moerman C, Vaseghi B, Scott B, Rosentreter R, Kathe C, Ravier J, McCracken L, Kang X, Vachicouras N, Fallegger F, Jelescu I, Cheng Y, Li Q, Buschman R, Buse N, Denison T, Dukelow S, Charbonneau R, Rigby I, Boyd SK, Millar PJ, Moraud EM, Capogrosso M, Wagner FB, Barraud Q, Bezard E, Lacour SP, Bloch J, Courtine G, Phillips AA. Neuroprosthetic baroreflex controls haemodynamics after spinal cord injury. Nature 2021; 590:308-314. [PMID: 33505019 DOI: 10.1038/s41586-020-03180-w] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 12/11/2020] [Indexed: 01/30/2023]
Abstract
Spinal cord injury (SCI) induces haemodynamic instability that threatens survival1-3, impairs neurological recovery4,5, increases the risk of cardiovascular disease6,7, and reduces quality of life8,9. Haemodynamic instability in this context is due to the interruption of supraspinal efferent commands to sympathetic circuits located in the spinal cord10, which prevents the natural baroreflex from controlling these circuits to adjust peripheral vascular resistance. Epidural electrical stimulation (EES) of the spinal cord has been shown to compensate for interrupted supraspinal commands to motor circuits below the injury11, and restored walking after paralysis12. Here, we leveraged these concepts to develop EES protocols that restored haemodynamic stability after SCI. We established a preclinical model that enabled us to dissect the topology and dynamics of the sympathetic circuits, and to understand how EES can engage these circuits. We incorporated these spatial and temporal features into stimulation protocols to conceive a clinical-grade biomimetic haemodynamic regulator that operates in a closed loop. This 'neuroprosthetic baroreflex' controlled haemodynamics for extended periods of time in rodents, non-human primates and humans, after both acute and chronic SCI. We will now conduct clinical trials to turn the neuroprosthetic baroreflex into a commonly available therapy for people with SCI.
Collapse
Affiliation(s)
- Jordan W Squair
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Department of Neurosurgery, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland.,Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,MD/PhD Training Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthieu Gautier
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Lois Mahe
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Jan Elaine Soriano
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andreas Rowald
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Arnaud Bichat
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Newton Cho
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland.,Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark A Anderson
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Nicholas D James
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Jerome Gandar
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Anthony V Incognito
- RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Giuseppe Schiavone
- Centre for Neuroprosthetics, Institute of Microengineering, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Zoe K Sarafis
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Achilleas Laskaratos
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Kay Bartholdi
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Robin Demesmaeker
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Salif Komi
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Charlotte Moerman
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Bita Vaseghi
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Berkeley Scott
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ryan Rosentreter
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Claudia Kathe
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Jimmy Ravier
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Laura McCracken
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Xiaoyang Kang
- Centre for Neuroprosthetics, Institute of Microengineering, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Nicolas Vachicouras
- Centre for Neuroprosthetics, Institute of Microengineering, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Florian Fallegger
- Centre for Neuroprosthetics, Institute of Microengineering, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Ileana Jelescu
- Center for Biomedical Imaging, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | | | - Qin Li
- Motac Neuroscience Ltd, Manchester, UK
| | | | | | - Tim Denison
- Department of Engineering Science and Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sean Dukelow
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Rebecca Charbonneau
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian Rigby
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven K Boyd
- Department of Radiology, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Philip J Millar
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Eduardo Martin Moraud
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Marco Capogrosso
- Faculty of Biology, University of Fribourg, Fribourg, Switzerland
| | - Fabien B Wagner
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland.,Institut des Maladies Neurodégénératives, Université de Bordeaux, UMR, 5293, Bordeaux, France
| | - Quentin Barraud
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Erwan Bezard
- Motac Neuroscience Ltd, Manchester, UK.,Institut des Maladies Neurodégénératives, Université de Bordeaux, UMR, 5293, Bordeaux, France.,Institut des Maladies Neurodégénératives, CNRS, UMR, 5293, Bordeaux, France
| | - Stéphanie P Lacour
- Centre for Neuroprosthetics, Institute of Microengineering, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Jocelyne Bloch
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.,Department of Neurosurgery, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland
| | - Grégoire Courtine
- Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland. .,Department of Neurosurgery, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland. .,Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland. .,Defitech Center for Interventional Neurotherapies (.NeuroRestore), CHUV/UNIL/EPFL, Lausanne, Switzerland.
| | - Aaron A Phillips
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada. .,RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
39
|
Sailer C, Edelmann H, Buchanan C, Giro P, Babcock M, Swanson C, Spotts M, Schulte M, Pratt-Cordova A, Coe G, Beindorff M, Page RL, Ambardekar AV, Pal JD, Kohrt W, Wolfel E, Lawley JS, Tarumi T, Cornwell WK. Impairments in Blood Pressure Regulation and Cardiac Baroreceptor Sensitivity Among Patients With Heart Failure Supported With Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2021; 14:e007448. [PMID: 33464953 DOI: 10.1161/circheartfailure.120.007448] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous-flow (CF) left ventricular assist devices (LVADs) improve outcomes for patients with advanced heart failure (HF). However, the lack of a physiological pulse predisposes to side-effects including uncontrolled blood pressure (BP), and there are little data regarding the impact of CF-LVADs on BP regulation. METHODS Twelve patients (10 males, 60±11 years) with advanced heart failure completed hemodynamic assessment 2.7±4.1 months before, and 4.3±1.3 months following CF-LVAD implantation. Heart rate and systolic BP via arterial catheterization were monitored during Valsalva maneuver, spontaneous breathing, and a 0.05 Hz repetitive squat-stand maneuver to characterize cardiac baroreceptor sensitivity. Plasma norepinephrine levels were assessed during head-up tilt at supine, 30o and 60o. Heart rate and BP were monitored during cardiopulmonary exercise testing. RESULTS Cardiac baroreceptor sensitivity, determined by Valsalva as well as Fourier transformation and transfer function gain of Heart rate and systolic BP during spontaneous breathing and squat-stand maneuver, was impaired before and following LVAD implantation. Norepinephrine levels were markedly elevated pre-LVAD and improved-but remained elevated post-LVAD (supine norepinephrine pre-LVAD versus post-LVAD: 654±437 versus 323±164 pg/mL). BP increased during cardiopulmonary exercise testing post-LVAD, but the magnitude of change was modest and comparable to the changes observed during the pre-LVAD cardiopulmonary exercise testing. CONCLUSIONS Among patients with advanced heart failure with reduced ejection fraction, CF-LVAD implantation is associated with modest improvements in autonomic tone, but persistent reductions in cardiac baroreceptor sensitivity. Exercise-induced increases in BP are blunted. These findings shed new light on mechanisms for adverse events such as stroke, and persistent reductions in functional capacity, among patients supported by CF-LVADs. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078972.
Collapse
Affiliation(s)
- Christine Sailer
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | | | - Cullen Buchanan
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Pedro Giro
- Department of Medicine (C.B., P.G.), University of Colorado Anschutz Medical Campus, Aurora
| | - Matthew Babcock
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora
| | - Christine Swanson
- Department of Medicine-Endocrinology, Metabolism and Diabetes (C.S.), University of Colorado Anschutz Medical Campus, Aurora
| | - Melanie Spotts
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret Schulte
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Ashley Pratt-Cordova
- Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Greg Coe
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Mark Beindorff
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Services, Aurora (R.L.P.)
| | - Amrut V Ambardekar
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Jay D Pal
- Department of Cardiothoracic Surgery (J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| | - Wendy Kohrt
- Division of Geriatric Medicine, Department of Medicine (M.B., W.K.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Eugene Wolfel
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| | - Justin S Lawley
- Department of Sport Science, University of Innsbruck, Austria (J.S.L.)
| | - Takashi Tarumi
- Human Informatics Interaction Research Institute, National Institute of Advanced Industrial Science and Technology, Ibaraki prefecture, Japan (T.T.)
| | - William K Cornwell
- Department of Medicine-Cardiology (C.S., G.C., M.B., A.V.A., E.W., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora.,Clinical and Translational Research Center (M. Spotts, M. Schulte, A.P.-C., W.K., W.K.C.), University of Colorado Anschutz Medical Campus, Aurora
| |
Collapse
|
40
|
Jawaid O, Gaddy A, Omar HR, Guglin M. Ventricular Assist Devices and Chronic Kidney Replacement Therapy: Technology and Outcomes. Adv Chronic Kidney Dis 2021; 28:37-46. [PMID: 34389136 DOI: 10.1053/j.ackd.2021.01.002] [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: 07/31/2020] [Revised: 11/12/2020] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failure. Kidney dysfunction, if present, makes candidate selection for LVADs challenging and contributes to multiple complications while the patients are on an LVAD support. Although kidney function generally improves after LVAD implantation, some patients develop acute and then chronic kidney disease sometimes requiring kidney replacement therapies (KRTs). Overall, chronic KRT in LVAD recipients is feasible and well tolerated, but routine technique of blood pressure monitoring should be adjusted to the continuous blood flow. Both hemodialysis and peritoneal dialysis can be used. Unique challenges for chronic KRT posed by the presence of LVAD are discussed in this review.
Collapse
|
41
|
Thrombotic Risk of Rotor Speed Modulation Regimes of Contemporary Centrifugal Continuous-flow Left Ventricular Assist Devices. ASAIO J 2020; 67:737-745. [PMID: 33074865 DOI: 10.1097/mat.0000000000001297] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Contemporary centrifugal continuous-flow left ventricular assist devices (LVADs) incorporate dynamic speed modulation algorithms. Hemocompatibility of these periodic unsteady pump operating conditions has been only partially explored. We evaluated whether speed modulation induces flow alterations associated with detrimental prothrombotic effects. For this aim, we evaluated the thrombogenic profile of the HeartWare ventricular assist device (HVAD) Lavare Cycle (LC) and HeartMate3 (HM3) artificial pulse (AP) via comprehensive numerical evaluation of (i) pump washout, (ii) stagnation zones, (iii) shear stress regimens, and (iv) modeling of platelet activation status via the platelet activity state (PAS) model. Data were compared between different simulated operating scenarios, including: (i) constant rotational speed and pump pressure head, used as reference; (ii) unsteady pump pressure head as induced by cardiac pulsatility; and (iii) unsteady rotor speed modulation of the LC (HVAD) and AP (HM3). Our results show that pump washout did not improve across the different simulated scenarios in neither the HVAD nor the HM3. The LC reduced but did not eliminate flow stagnation (-57%) and did not impact metrics of HVAD platelet activation (median PAS: +0.4%). The AP reduced HM3 flow stagnation by up to 91% but increased prothrombotic shear stress and simulated platelet activation (median PAS: +124%). Our study advances understanding of the pathogenesis of LVAD thrombosis, suggesting mechanistic implications of rotor speed modulation. Our data provide rationale criteria for the future design optimization of next generation LVADs to further reduce hemocompatibility-related adverse events.
Collapse
|
42
|
Mondal NK, Ghanta RK. Commentary: Improving ventricular assist device design. Much achieved with further innovation on the horizon. JTCVS OPEN 2020; 3:152-153. [PMID: 36003882 PMCID: PMC9390532 DOI: 10.1016/j.xjon.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
|
43
|
Melmed KR, Mondellini G, Roh D, Boehme A, Park S, Yuzefpolkya M, Naka Y, Uriel N, Agarwal S, Connolly ES, Claassen J, Colombo PC, Willey JZ. Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients. World Neurosurg 2020; 143:e384-e390. [PMID: 32745643 DOI: 10.1016/j.wneu.2020.07.169] [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: 05/20/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality. METHODS We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome. RESULTS Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study's inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL3 (interquartile range [IQR], 8.6-46.9 mL3), and the median ICH score was 1 (IQR, 1-2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4-4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4-6.2). CONCLUSIONS HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.
Collapse
Affiliation(s)
- Kara R Melmed
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, New York, USA; Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.
| | - Giulio Mondellini
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - David Roh
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Amelia Boehme
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Melana Yuzefpolkya
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sachin Agarwal
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Jan Claassen
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| |
Collapse
|
44
|
Stöhr EJ, McDonnell BJ. The unique physiology of left ventricular assist device patients – keep your finger on the pulse! Exp Physiol 2020; 105:747-748. [DOI: 10.1113/ep088602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Eric J. Stöhr
- School of Sport & Health SciencesCardiff Metropolitan University Cardiff CF5 2YB UK
- Department of MedicineDivision of CardiologyColumbia University Irving Medical Center New York NY USA
| | - Barry J. McDonnell
- School of Sport & Health SciencesCardiff Metropolitan University Cardiff CF5 2YB UK
| |
Collapse
|
45
|
Stöhr EJ, Cornwell WK, Kanwar M, Cockcroft JR, McDonnell BJ. Bionic women and men - Part 1: Cardiovascular lessons from heart failure patients implanted with left ventricular assist devices. Exp Physiol 2020; 105:749-754. [PMID: 32104940 DOI: 10.1113/ep088323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/19/2020] [Indexed: 12/17/2022]
Abstract
NEW FINDINGS What is the topic of this review? Patients with advanced heart failure who are implanted with left ventricular assist devices (LVADs) present an opportunity to understand the human circulation under extreme conditions. What advances does it highlight? LVAD patients have a unique circulation that is characterized by a reduced or even absent arterial pulse. The remarkable survival of these patients is accompanied by circulatory complications, including stroke, gastrointestinal bleeding and right-heart failure. Understanding the mechanisms related to the complications in LVAD patients will help the patients and also advance our fundamental understanding of the human circulation in general. ABSTRACT Some humans with chronic, advanced heart failure are surgically implanted with a left ventricular assist device (LVAD). Because the LVAD produces a continuous flow, a palpable pulse is often absent in these patients. This allows for a unique investigation of the human circulation and has created a controversy around the 'need' for a pulse. The medical debate has also generated a more generic, fundamental discussion into what is 'normal' arterial physiology and health. The comprehensive study and understanding of the arterial responses to drastically altered haemodynamics due to continuous-flow LVADs, at rest and during activity, presents an opportunity to significantly increase our current understanding of the fundamental components of arterial regulation (flow, blood pressure, sympathetic activity, endothelial function, pulsatility) in a way that could never have been studied previously. In a series of four articles, we summarize the talks presented at the symposium entitled 'Bionic women and men - Physiology lessons from implantable cardiac devices' presented at the 2019 Annual Meeting of The Physiological Society in Aberdeen, UK. The articles highlight the novel questions generated by physiological phenomena observed in LVAD patients and propose future areas of interest within the field of cardiovascular physiology.
Collapse
Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK.,Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - William K Cornwell
- Department of Medicine-Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| |
Collapse
|
46
|
Veraar CM, Rinösl H, Kühn K, Skhirtladze-Dworschak K, Felli A, Mouhieddine M, Menger J, Pataraia E, Ankersmit HJ, Dworschak M. Non-pulsatile blood flow is associated with enhanced cerebrovascular carbon dioxide reactivity and an attenuated relationship between cerebral blood flow and regional brain oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:426. [PMID: 31888721 PMCID: PMC6937980 DOI: 10.1186/s13054-019-2671-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2). METHODS In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control. RESULTS MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow. CONCLUSIONS Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed. TRIAL REGISTRATION The study was retrospectively registered on October 30, 2018, with Clinical Trial.gov (NCT03732651).
Collapse
Affiliation(s)
- Cecilia Maria Veraar
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Rinösl
- Department of Anaesthesia and Intensive Care Medicine, LKH Feldkirch, Feldkirch, Austria
| | - Karina Kühn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Klinikum Traunstein, Traunstein, Germany
| | - Keso Skhirtladze-Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alessia Felli
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Mohamed Mouhieddine
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Johannes Menger
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ekaterina Pataraia
- Department of Neurology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Hendrik Jan Ankersmit
- Division of Thoracic Surgery, Department of Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
47
|
Truby LK, Farr MA, Garan AR, Givens R, Restaino SW, Latif F, Takayama H, Naka Y, Takeda K, Topkara VK. Impact of Bridge to Transplantation With Continuous-Flow Left Ventricular Assist Devices on Posttransplantation Mortality. Circulation 2019; 140:459-469. [PMID: 31203669 DOI: 10.1161/circulationaha.118.036932] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bridge to transplantation (BTT) with left ventricular assist devices (LVADs) is a mainstay of therapy for heart failure in patients awaiting heart transplantation (HT). Criteria for HT listing do not differ between patients medically managed and those mechanically bridged to HT. The objectives of the present study were to evaluate the impact of BTT with LVAD on posttransplantation survival, to describe differences in causes of 1-year mortality in medically and mechanically bridged patients, and to evaluate differences in risk factors for 1-year mortality between those with and those without LVAD at the time of HT. METHODS Using the United Network of Organ Sharing database, we identified 5486 adult, single-organ HT recipients transplanted between 2008 and 2015. Patients were propensity matched for likelihood of LVAD at the time of HT. Kaplan-Meier survival estimates were used to assess the impact of BTT on 1- and 5-year mortality. Logistic regression analysis was used to evaluate the odds ratio of 1-year mortality for patients BTT with LVAD compared with those with medical management across clinically significant variables at various thresholds. RESULTS Early mortality was higher in mechanically bridged patients: 9.5% versus 7.2% mortality at 1 year (P<0.001). BTT patients incurred an increased risk of 1-year mortality with an estimated glomerular filtration rate of 40 to 60 mL·min-1·1.73 m-2 (odds ratio, 1.69; P=0.003) and <40 mL·min-1·1.73 m-2 (odds ratio, 2.16; P=0.005). A similar trend was seen in patients with a body mass index of 25 to 30 kg/m2 (odds ratio, 1.88; P=0.024) and >30 kg/m2 (odds ratio, 2.11; P<0.001). When patients were stratified by BTT status and the presence of risk factors, including age >60 years, estimated glomerular filtration rate <40 mL·min-1·1.73 m-2, and body mass index >30 kg/m2, there were significant differences in 1-year mortality between medium- and high-risk medically and mechanically bridged patients, with 1-year mortality in high-risk BTT patients at 17.6% compared with 10.4% in high-risk medically managed patients. CONCLUSIONS Bridge to HT with LVAD, although necessary because of organ scarcity and capable of improving wait list survival, confers a significantly higher risk of early posttransplantation mortality. Patients bridged with mechanical support may require more careful consideration for transplant eligibility after LVAD placement.
Collapse
Affiliation(s)
- Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T.)
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - A Reshad Garan
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Raymond Givens
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Susan W Restaino
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Farhana Latif
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N., K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N., K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N., K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY
| |
Collapse
|
48
|
Stöhr EJ, McDonnell BJ, Colombo PC, Willey JZ. CrossTalk proposal: Blood flow pulsatility in left ventricular assist device patients is essential to maintain normal brain physiology. J Physiol 2018; 597:353-356. [PMID: 30560570 DOI: 10.1113/jp276729] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Eric J Stöhr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, 10032, USA.,School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, CF5 2YB, UK
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Joshua Z Willey
- Department of Neurology, Neurological Institute of New York, Columbia University Irving Medical Center, New York, NY, 10032, USA
| |
Collapse
|