1
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Thum KY, Liao S, Šeman M, Khamooshi M, Carberry J, McGiffin D, Gregory SD. Effect of RVAD Cannulation Length on Right Ventricular Thrombosis Risk: An In Silico Investigation. Ann Biomed Eng 2024; 52:1604-1616. [PMID: 38418690 PMCID: PMC11082033 DOI: 10.1007/s10439-024-03474-4] [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: 11/20/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
Left ventricular assist devices (LVADs) have been used off-label as long-term support of the right heart due to the lack of a clinically approved durable right VAD (RVAD). Whilst various techniques to reduce RVAD inflow cannula protrusion have been described, the implication of the protrusion length on right heart blood flow and subsequent risk of thrombosis remains poorly understood. This study investigates the influence of RVAD diaphragmatic cannulation length on right ventricular thrombosis risk using a patient-specific right ventricle in silico model validated with particle image velocimetry. Four cannulation lengths (5, 10, 15 and 25 mm) were evaluated in a one-way fluid-structure interaction simulation with boundary conditions generated from a lumped parameter model, simulating a biventricular supported condition. Simulation results demonstrated that the 25-mm cannulation length exhibited a lower thrombosis risk compared to 5-, 10- and 15-mm cannulation lengths due to improved flow energy distribution (25.2%, 24.4% and 17.8% increased), reduced stagnation volume (72%, 68% and 49% reduction), better washout rate (13.0%, 11.6% and 9.1% faster) and lower blood residence time (6% reduction). In the simulated scenario, our findings suggest that a longer RVAD diaphragmatic cannulation length may be beneficial in lowering thrombosis risk; however, further clinical studies are warranted.
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Affiliation(s)
- Kar Ying Thum
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.
| | - Sam Liao
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Michael Šeman
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia
| | - Mehrdad Khamooshi
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Josie Carberry
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Shaun D Gregory
- Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
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2
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James L, Smith DE. Supporting the "forgotten" ventricle: The evolution of percutaneous RVADs. Front Cardiovasc Med 2023; 9:1008499. [PMID: 36684567 PMCID: PMC9845717 DOI: 10.3389/fcvm.2022.1008499] [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: 07/31/2022] [Accepted: 11/30/2022] [Indexed: 01/06/2023] Open
Abstract
Right heart failure (RHF) can occur as the result of an acute or chronic disease process and is a challenging clinical condition for surgeons and interventionalists to treat. RHF occurs in approximately 0.1% of patients after cardiac surgery, in 2-3% of patients following heart transplantation, and in up to 42% of patients after LVAD implantation. Regardless of the cause, RHF portends high morbidity and mortality and is associated with longer hospital stays and higher healthcare costs. The mainstays of traditional therapy for severe RHF have included pharmacological support, such as inotropes and vasopressors, and surgical right ventricular (RV) assist devices. However, in recent years catheter-based mechanical circulatory support (MCS) strategies have offered novel solutions for addressing RHF without the morbidity of open surgery. This manuscript will review the pathophysiology of RHF, including the molecular underpinnings, gross structural mechanisms, and hemodynamic consequences. The evolution of techniques for supporting the right ventricle will be explored, with a focus on various institutional experiences with percutaneous ventricular assist devices.
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3
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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4
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Bravo CA, Navarro AG, Dhaliwal KK, Khorsandi M, Keenan JE, Mudigonda P, O'Brien KD, Mahr C. Right heart failure after left ventricular assist device: From mechanisms to treatments. Front Cardiovasc Med 2022; 9:1023549. [PMID: 36337897 PMCID: PMC9626829 DOI: 10.3389/fcvm.2022.1023549] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/22/2022] [Indexed: 07/21/2023] Open
Abstract
Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5-44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.
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Affiliation(s)
- Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Andrew G. Navarro
- School of Medicine, University of Washington, Seattle, WA, United States
| | - Karanpreet K. Dhaliwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, United States
| | - Parvathi Mudigonda
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Kevin D. O'Brien
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
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5
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Odeigah OO, Valdez-Jasso D, Wall ST, Sundnes J. Computational models of ventricular mechanics and adaptation in response to right-ventricular pressure overload. Front Physiol 2022; 13:948936. [PMID: 36091369 PMCID: PMC9449365 DOI: 10.3389/fphys.2022.948936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/03/2022] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is associated with substantial remodeling of the right ventricle (RV), which may at first be compensatory but at a later stage becomes detrimental to RV function and patient survival. Unlike the left ventricle (LV), the RV remains understudied, and with its thin-walled crescent shape, it is often modeled simply as an appendage of the LV. Furthermore, PAH diagnosis is challenging because it often leaves the LV and systemic circulation largely unaffected. Several treatment strategies such as atrial septostomy, right ventricular assist devices (RVADs) or RV resynchronization therapy have been shown to improve RV function and the quality of life in patients with PAH. However, evidence of their long-term efficacy is limited and lung transplantation is still the most effective and curative treatment option. As such, the clinical need for improved diagnosis and treatment of PAH drives a strong need for increased understanding of drivers and mechanisms of RV growth and remodeling (G&R), and more generally for targeted research into RV mechanics pathology. Computational models stand out as a valuable supplement to experimental research, offering detailed analysis of the drivers and consequences of G&R, as well as a virtual test bench for exploring and refining hypotheses of growth mechanisms. In this review we summarize the current efforts towards understanding RV G&R processes using computational approaches such as reduced-order models, three dimensional (3D) finite element (FE) models, and G&R models. In addition to an overview of the relevant literature of RV computational models, we discuss how the models have contributed to increased scientific understanding and to potential clinical treatment of PAH patients.
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Affiliation(s)
| | - Daniela Valdez-Jasso
- Department of Bioengineering, University of California, San Diego, San Diego, CA, United States
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6
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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DeFilippis EM, Topkara VK, Kirtane AJ, Takeda K, Naka Y, Garan AR. Mechanical Circulatory Support for Right Ventricular Failure. Card Fail Rev 2022; 8:e14. [PMID: 35516793 PMCID: PMC9062706 DOI: 10.15420/cfr.2021.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
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8
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Michel S, Buchholz S, Buech J, Veit T, Fabry T, Abicht J, Thierfelder N, Mueller C, Rosenthal LL, Pabst von Ohain J, Haas N, Hörer J, Hagl C. Bridging patients in cardiogenic shock with a paracorporeal pulsatile biventricular assist device to heart transplantation-a single-centre experience. Eur J Cardiothorac Surg 2022; 61:942-949. [PMID: 35020902 DOI: 10.1093/ejcts/ezab547] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/06/2021] [Accepted: 11/14/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We evaluated the outcome of patients in cardiogenic shock receiving a paracorporeal pulsatile biventricular assist device as a bridge to transplantation. METHODS We performed a retrospective single-centre analysis of all patients who received a Berlin Heart Excor® at our institution between 2004 and 2019. RESULTS A total of 97 patients (90 adults, 7 paediatric) were analysed. Eighty-four patients were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 (80 adults, 4 paediatric). Diagnoses were dilated cardiomyopathy (n = 41), ischaemic cardiomyopathy (n = 17) or myocardial infarction (n = 4), myocarditis (n = 15), restrictive cardiomyopathy (n = 2), graft failure after heart transplant (n = 7), postcardiotomy heart failure (n = 5), postpartum cardiomyopathy (n = 3), congenital heart disease (n = 1), valvular cardiomyopathy (n = 1) and toxic cardiomyopathy (n = 1). All patients were in biventricular heart failure and had secondary organ dysfunction. The mean duration of support was 63 days (0-487 days). There was a significant decrease in creatinine values after assist device implantation (from 1.83 ± 0.79 to 1.12 ± 0.67 mg/dl, P = 0.001) as well as a decrease in bilirubin values (from 3.94 ± 4.58 to 2.65 ± 3.61 mg/dl, P = 0.084). Cerebral stroke occurred in 16 patients, bleeding in 15 and infection in 13 patients. Forty-eight patients died on support, while 49 patients could be successfully bridged to transplantation. Thirty-day survival and 1-year survival were 70.1% and 41.2%, respectively. CONCLUSIONS A pulsatile biventricular assist device is a reasonable therapeutic option in cardiogenic shock, when immediate high cardiac output is necessary to rescue the already impaired kidney and liver function of the patient.
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Affiliation(s)
- Sebastian Michel
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany.,Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | | | - Joscha Buech
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Tobias Veit
- Department of Pulmonology, Ludwig Maximilian University Munich, Munich, Germany
| | - Thomas Fabry
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Jan Abicht
- Department of Anesthesiology, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaus Thierfelder
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph Mueller
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Laura Lily Rosenthal
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Jelena Pabst von Ohain
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaus Haas
- Department of Pediatric Cardiology, Ludwig Maximilian University Munich, Munich, Germany
| | - Jürgen Hörer
- Division of Congenital Heart Surgery, Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany.,Munich Heart Alliance, German Centre for Cardiovascular Research, Germany
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9
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Kremer J, El-Dor A, Sommer W, Tochtermann U, Warnecke G, Karck M, Ruhparwar A, Meyer AL. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6582577. [PMID: 35532167 PMCID: PMC9419688 DOI: 10.1093/icvts/ivac107] [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] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamila Kremer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
- Corresponding author. Department of Cardiothoracic Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany. Tel: +49-6221-5634944; e-mail: (J. Kremer)
| | - Abbas El-Dor
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Clinic of Thoracic and Cardiovascular Surgery, Essen University Hospital, Essen, Germany
| | - Anna Lassia Meyer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
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10
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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11
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In vitro Hemocompatibility Evaluation of the HeartWare Ventricular Assist Device Under Systemic, Pediatric and Pulmonary Support Conditions. ASAIO J 2021; 67:270-275. [PMID: 33627600 DOI: 10.1097/mat.0000000000001222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The development of adult use right ventricular assist devices (RVADs) and pediatric left ventricular assist devices (pediatric LVADs) have significantly lagged behind compared to adult use left ventricular assist devices (LVADs). The HeartWare ventricular assist device (HVAD) intended to be used for adult's systemic support, is increasingly used off-label for adult pulmonary and pediatric systemic support. Due to different hemodynamics and physiology, however, the HVAD's hemocompatibility profiles can be drastically different when used in adult pulmonary circulation or in children, compared to its intended usage state, which could have a direct clinical and developmental relevance. Taking these considerations in mind, we sought to conduct in vitro hemocompatibility testing of HVAD in adult systemic, pediatric systemic and adult pulmonary support conditions. Two HVADs coupled to custom-built blood circulation loops were tested for 6 hours using bovine blood at 37°C under adult systemic, pediatric systemic, and adult pulmonary flow conditions (flow rate = 5.0, 2.5, and 4.5 L/min; differential pressure = 100, 69, and 20 mm Hg, respectively). Normalized index of hemolysis for adult systemic, pediatric systemic, and adult pulmonary conditions were 0.0083, 0.0039, and 0.0017 g/100 L, respectively. No significant difference was seen in platelet activation for these given conditions. High molecular weight von Willebrand factor multimer degradation was evident in all conditions (p < 0.05). In conclusion, alterations in the usage mode produce substantial differences in hemocompatibility of the HVAD. These findings would not only have clinical relevance but will also facilitate future adult use RVAD and pediatric LVAD development.
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12
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HeartWare HVAD Flow Estimator Accuracy for Left and Right Ventricular Support. ASAIO J 2021; 67:416-422. [PMID: 33769996 DOI: 10.1097/mat.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
This study investigated the accuracy of the HeartWare HVAD flow estimator for left ventricular assist device (LVAD) support and biventricular assist device (BiVAD) support for modes of reduced speed (BiVAD-RS) and banded outflow (BiVAD-B). The HVAD flow estimator was evaluated in a mock circulatory loop under changes in systemic and pulmonary vascular resistance, heart rate, central venous pressure, and simulated hematocrit (correlated to viscosity). A difference was found between mean estimated and mean measured flow for LVAD (0.1 ± 0.3 L/min), BiVAD-RS (-0.1 ± 0.2 L/min), and BiVAD-B (0 ± 0.2 L/min). Analysis of the flow waveform pulsatility showed good correlation for LVAD (r2 = 0.98) with a modest spread in error (0.7 ± 0.1 L/min), while BiVAD-RS and BiVAD-B showed similar spread in error (0.7 ± 0.3 and 0.7 ± 0.2 L/min, respectively), with much lower correlation (r2 = 0.85 and r2 = 0.60, respectively). This study demonstrated that the mean flow error of the HVAD flow estimator is similar when the device is used in LVAD, BiVAD-RS, or BiVAD-B configuration. However, the instantaneous flow waveform should be interpreted with caution, particularly in the cases of BiVAD support.
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13
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Farag J, Woldendorp K, McNamara N, Bannon PG, Marasco SF, Loforte A, Potapov EV. Contemporary outcomes of continuous-flow biventricular assist devices. Ann Cardiothorac Surg 2021; 10:311-328. [PMID: 34159113 DOI: 10.21037/acs-2021-cfmcs-34] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Significant right ventricular failure (RVF) complicating left ventricular assist device (LVAD) placement has been reported at 10-30%. Although primarily indicated for left ventricular failure, ventricular assist devices (VADs) have become utilized in a biventricular setup to combat right ventricular failure (RVF) following LVAD implantation. With the advent of continuous-flow LVADs (CF-LVADs) superseding their pulsatile predecessors, the shift towards CF-biventricular assist devices (CF-BiVADs) come with the prospect of improved outcomes over previous pulsatile BiVADs. We aim to review the literature and determine the outcomes of CF-BiVAD recipients. Methods A systematic review was performed to determine the outcomes of CF-BiVADs. Pre-operative demographics and device configuration data was collected. Primary outcomes evaluated were short-term survival, long-term survival, duration of support, and survival to transplant. Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (ICU-LOS and HLOS, respectively), pump thrombosis, pump exchange. Median and interquartile range was reported where appropriate. A major limitation was the likely overlap of cohorts across publications, which may have contributed to some selection bias. Results Of 1,282 screened, 12 publications were evaluated. Sample size ranged from 4 to 93 CF-BiVAD recipients, and follow-up ranged from 6 to 24 months. Mean age ranged from 34 to 52 years old. Forty-five percent of CF-BiVADs had right atrial (RA-) inflow cannulation, with the remaining being right ventricular (RV). Thirty-day survival was a median of 90% (IQR 82-97.8%) and 12-month survival was a median of 58.5% (IQR 47.5-62%). Where reported, rate of pump thrombosis (predominantly the right VAD) was a median of 31% (IQR 14-36%), although pump exchange was only 9% (IQR 1.5-12.5%). Conclusions RVF post-LVAD implantation is a high morbidity and mortality complication. There is no on-label continuous-flow RVAD currently available. Thus, the modifications of LVADs for right ventricular support to combat pump thrombosis has resulted in various techniques. BiVAD recipients are predominantly transplant candidates, and complications of pump thrombosis and driveline infection whilst on wait-list are of great consequence. This study demonstrates the need for an on-label CF-BiVAD.
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Affiliation(s)
- James Farag
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Kei Woldendorp
- Cardiothoracic Surgical Department, Royal North Shore Hospital, Sydney, Australia
| | - Nicholas McNamara
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - Paul G Bannon
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Silvana F Marasco
- Cardiothoracic Surgical Department, The Alfred, Melbourne, Australia.,Department of Medicine and Surgery, Monash University, Melbourne, Australia
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Evgenij V Potapov
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
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14
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Abstract
Right ventricular dysfunction presents unique challenges in patients with cardiopulmonary disease. When optimal medical therapy fails, mechanical circulatory support is considered. Devices can by classified according to whether they are deployed percutaneously or surgically, whether the pump is axial or centrifugal, whether the right ventricle is bypassed directly or indirectly, and whether the support is short term or long term. Each device has advantages and disadvantages. Acute mechanical circulatory support is a suitable temporizing strategy in advanced heart failure. Future research in right ventricular mechanical circulatory support will optimize device management, refine patient selection, and ultimately improve clinical outcomes.
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Affiliation(s)
- Akbarshakh Akhmerov
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard, Suite A3105, Los Angeles, CA 90048, USA
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard, Suite A3105, Los Angeles, CA 90048, USA.
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15
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Lo Coco V, De Piero ME, Massimi G, Chiarini G, Raffa GM, Kowalewski M, Maessen J, Lorusso R. Right ventricular failure after left ventricular assist device implantation: a review of the literature. J Thorac Dis 2021; 13:1256-1269. [PMID: 33717597 PMCID: PMC7947472 DOI: 10.21037/jtd-20-2228] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation remains a major complication which may significantly impair patient outcome. The genesis of RVF is, however, multifactorial, and the mechanisms underlying such a condition have not been fully elucidated, making its prevention challenging and the course not always predictable. Although preoperative risks factors can be associated with RV impairment, the physiologic changes after the LV support, can still hamper the function of the RV. Current medical treatment options are limited and sometimes, patients with a severe post-LVAD RVF may be unresponsive to pharmacological therapy and require more aggressive treatment, such as temporary RV support. We retrieved 11 publications which we assessed and divided in groups based on the RV support [extracorporeal membrane oxygenation (ECMO), right ventricular assist device (RVAD), TandemHeart with ProtekDuo cannula]. The current review comprehensively summarizes the main studies of the literature with particular attention to the RV physiology and its changes after the LVAD implantation, the predictors and prognostic score as well as the different modalities of temporary mechanical cardio-circulatory support, and its effects on patient prognosis for RVF in such a setting. In addition, it provides a decision making of the pre-, intra and post-operative management in high- and moderate- risk patients.
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Affiliation(s)
- Valeria Lo Coco
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Maria Elena De Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Anesthesia/Intensive Care, San Giovanni, Turin, Italy
| | - Giulio Massimi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Cardiac Surgery, Circolo Hospital, University of Insurbia, Varese, Italy
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Division of Anesthesiology, Intensive Care and Emergency medicine, Spedali Civili University, Brescia, Italy
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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16
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Abstract
The need for biventricular support poses significant challenges for patients who require a mechanical bridge to transplantation. Recent improvements in ventricular assist device (VAD) technology has made possible the use of two centrifugal flow VADs as a total artificial heart (TAH) replacement. The HeartMate 3 (HM3; [Full MagLev, Abbott Laboratories, Chicago, Illinois]) was recently approved as a destination therapy; this VAD has a number of unique advantages that allow for its off-label use for biventricular support. Here, we describe the use of two HM3s as a TAH in a patient as a bridge to transplant.
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17
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Marasco S, Simon AR, Tsui S, Schramm R, Eifert S, Hagl CM, Paç M, Kervan Ü, Fiane AE, Wagner FM, Garbade J, Özbaran M, Hayward CS, Zimpfer D, Schmitto JD. International experience using a durable, centrifugal-flow ventricular assist device for biventricular support. J Heart Lung Transplant 2020; 39:1372-1379. [PMID: 32917479 DOI: 10.1016/j.healun.2020.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Heart transplantation is limited by the scarcity of suitable donors. Patients with advanced biventricular failure may require biventricular support to provide optimal cardiac output and end-organ perfusion. We highlight the outcomes of using the HeartWare HVAD System (HVAD) in a biventricular configuration. METHODS This retrospective study included patients implanted with HVAD as a biventricular assist device (BiVAD) between 2009 and 2017 at 12 participating centers. When used as a right ventricular assist device (VAD) (RVAD), the HVAD can be attached to the right ventricle (RV) or the right atrium (RA). Kaplan-Meier survival estimates were calculated comparing the 2 RVAD implant locations. Comparisons were also made between the timing of RVAD implantation (primary vs staged) on adverse event (AE) profiles and survival. RESULTS Among the 93 patients who were implanted with a HVAD BiVAD, Kaplan-Meier survivals at 1-year and 2-year were 56% and 47%, respectively. Survival was independent of the location of the HVAD RVAD implant or whether there was an interval between left VAD and RVAD implantation. The most common AEs were bleeding (35.5%), infection (25.8%), and respiratory failure (20.4%). CONCLUSIONS This study illustrated similar survival in patients receiving a primary or staged HVAD BiVAD implant at 1 year and 2 years. This study also established that the locations of the RVAD implant (RV or RA) result in similar AE profiles.
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Affiliation(s)
- Silvana Marasco
- Cardiothoracic Department, Alfred Hospital, Melbourne, Victoria, Australia.
| | - André R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield, London, United Kingdom
| | - Steven Tsui
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - René Schramm
- Clinic for Thoracic and Cardiovasuclar Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Sandra Eifert
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Saxony, Germany
| | - Christian M Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Bavaria, Germany
| | - Mustafa Paç
- Department of Heart Transplantation, Turkey Yüksek İhtisas Education & Research Hospital, Ankara, Turkey
| | - Ümit Kervan
- Department of Heart Transplantation, Turkey Yüksek İhtisas Education & Research Hospital, Ankara, Turkey
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Florian M Wagner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Garbade
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Saxony, Germany
| | - Mustafa Özbaran
- Department of Thoracic and Cardiovascular Surgery, Ege Üniversitesi Medical Faculty Hospital, İzmir, Turkey
| | | | - Daniel Zimpfer
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
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18
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Folino G, Piperata A, Bejko J, Gerosa G, Bottio T. Biventricular assistance with 2 hm3 in a small chest patient: extra-pericardial implant. J Artif Organs 2020; 24:261-264. [PMID: 32803544 DOI: 10.1007/s10047-020-01200-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
We describe the clinical course and treatment of a 53-year-old female, with small chest dimensions, referred to our institution for a primary cardiogenic shock. The patient underwent an on-pump left ventricular assist-device (VAD) implantation with the aid of immediate post-operative paracorporeal right-VAD assistance for an acute right ventricular failure. After two unsuccessful weaning attempts, she underwent extrapericardial HM 3 RVAD implantation.
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Affiliation(s)
- Giulio Folino
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - Antonio Piperata
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Jonida Bejko
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Tomaso Bottio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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19
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Briasoulis A, Inampudi C, Hatzis G, Asleh R. Management of Patients with Heart Failure: Focus on New Pharmaceutical and Device Options. Curr Med Chem 2020; 27:4522-4535. [DOI: 10.2174/0929867326666190523083747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/06/2018] [Accepted: 02/19/2019] [Indexed: 01/14/2023]
Abstract
Hospitalization rates and survival of patients with Heart Failure (HF) have improved.
However, 5-year mortality rates remain high and the prevalence of the disease is rising likely due to
aging of the population and advances in diagnosis and treatment of other acute and chronic cardiovascular
diseases. Over the past three decades the therapeutic armamentarium of heart failure has improved
substantially with development of medications targeting neuro-hormonal activation and devices
preventing sudden cardiac death and improving cardiac synchrony. Recently, inhibition of angiotensin
receptors and neprilysin as well as sinoatrial pacemaker modulating f-current, have been
found safe and effective strategies that improve HF hospitalization rates and/or mortality. Antidiabetic
agents inhibiting sodium-glucose co-transporters 2, result in natriuresis and osmotic diuresis
and may further improve HF related outcomes. Furthermore, emerging therapies such as cardiac myosin
activators, soluble guanylate cyclase stimulators and non-steroidal mineralocorticoid receptor
antagonists are undergoing investigation in phase II and III studies of HF patients. Finally, rapid evolution
of in the management of advanced HF has occurred with the application of second and third
generation continuous flow left ventricular assist devices in clinical practice. Ongoing clinical studies
will validate the safety and efficacy of emerging therapeutic strategies in HF population underrepresented
in previous clinical trials.
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Affiliation(s)
- Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Chakradhari Inampudi
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Georgios Hatzis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN, United States
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20
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Blood trauma potential of the HeartWare Ventricular Assist Device in pediatric patients. J Thorac Cardiovasc Surg 2020; 159:1519-1527.e1. [DOI: 10.1016/j.jtcvs.2019.06.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/19/2023]
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21
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Maynes EJ, O'Malley TJ, Patel P, Prochno KW, Wood CT, Choi JH, Morris RJ, Entwistle JW, Massey HT, Tchantchaleishvili V. Right atrial versus right ventricular HeartWare HVAD position in patients on biventricular HeartWare HVAD support: A systematic review. Artif Organs 2020; 44:926-934. [PMID: 32096239 DOI: 10.1111/aor.13675] [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: 11/19/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/24/2022]
Abstract
In patients with biventricular heart failure or refractory right heart failure following HeartWare HVAD placement, off-label placement of a right-sided HeartWare HVAD has been described both in the right ventricular (RV) and right atrial (RA) positions. We sought to evaluate and compare the outcomes of right-sided HeartWare HVAD using the RA versus RV approach. An electronic search was performed in the English literature to identify all reports of left- and right-heart support with HeartWare HVAD. Of the 1,288 articles identified, 13 articles with 56 cases met inclusion criteria. Patient-level data were extracted and analyzed. The median patient age was 52 years (IQR 33.0-59.0) and 40/50 (80.0%) were male. Overall, 21/56 patients (37.5%) had RA HVAD, while 35/56 (62.5%) had RV HVAD. Most underwent concomitant HVAD placement [RA: 17/21 (81.0%) vs. RV: 31/35 (88.6%), P = .69]. In those who did not, the median time between left and right HVAD was 10 days (IQR 7-14) for RA HVAD and 12 days (IQR 8-30) for RV HVAD (P = .77). The median time of support was 351 days (IQR 136-626) for RA HVAD compared to 135 days (IQR 61-244) for RV HVAD (P = .02). Pump thrombosis occurred at a similar rate [RA: 3/10 (30.0%) vs. RV: 6/20 (30.0%), P = 1], as did GI bleeding [RA: 10/35 (28.6%) vs. RV: 5/21 (23.8%), P = .94] during the follow-up time period. Kaplan-Meier analysis when censored for transplant showed higher survival with RA HVAD compared to RV HVAD (P = .036), with an estimated survival at 1 year of 91.7% (95% CI 77.3-100.0) in RA HVAD versus 66.2% (95% CI 48.9-89.6) for RV HVAD. RA HVAD appears to be a viable option for durable right-sided support with outcomes at least comparable to RV HVAD.
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Affiliation(s)
- Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Preeyal Patel
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kyle W Prochno
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chelsey T Wood
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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22
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Gude E, Hoel TN, Sørensen G, Broch K, Meyer A, Fiane AE. Long-term continuous flow mechanical biventricular support: 9 years and counting. Interact Cardiovasc Thorac Surg 2020; 30:81-84. [PMID: 31580433 DOI: 10.1093/icvts/ivz231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 11/13/2022] Open
Abstract
We report 2 continuous flow HeartWareTM left ventricular assist devices successfully used in a patient with advanced heart failure of giant cell myocarditis origin in a biventricular configuration. Despite technical challenges of adapting a left ventricular assist device engineered for systemic pressure to function as a right ventricular assist device, the addition of dynamic banding on the right ventricular assist device outflow graft allowed successful adaptation of afterload. This patient has now been on biventricular configuration support for 9 years, and remains stable to this day.
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Affiliation(s)
- Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Tom N Hoel
- Department of Cardiothoracic Surgery, Oslo University Hospital. Rikshospitalet, Oslo, Norway
| | - Gro Sørensen
- Department of Cardiothoracic Surgery, Oslo University Hospital. Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Meyer
- Department of Cardiology, Elverum Hospital, Elverum, Norway
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital. Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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23
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Vargo PR, Soltesz EG. Catheter and Surgical Therapies for Right Heart Failure: Current and Future Options. Semin Thorac Cardiovasc Surg 2020; 32:389-395. [DOI: 10.1053/j.semtcvs.2020.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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24
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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25
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In Vitro Hemocompatibility Evaluation of Modified Rotary Left to Right Ventricular Assist Devices in Pulmonary Flow Conditions. ASAIO J 2019; 66:637-644. [PMID: 31335374 DOI: 10.1097/mat.0000000000001049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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26
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Turner KR. Right Ventricular Failure After Left Ventricular Assist Device Placement—The Beginning of the End or Just Another Challenge? J Cardiothorac Vasc Anesth 2019; 33:1105-1121. [DOI: 10.1053/j.jvca.2018.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/19/2022]
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27
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Abstract
Patients with Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels 1-2 who either have or are at risk for right ventricular failure face significant morbidity and mortality after continuous flow left ventricular assist device (CF-LVAD) implantation. Currently, the options for biventricular support are limited the Total Artificial Heart (TAH; CardioWest, Syncardia, Tuscon, AZ) or biventricular assist device (BiVAD), which uses bulky extracorporeal or implantable displacement pumps. We describe a successful series based on an innovative approach for biventricular support in consecutive INTERMACS levels 1-2 patients utilizing a HeartWare Ventricular Assist Device (HVAD; HeartWare, Framingham, MA) in a left ventricular (LV-HVAD) and a right atrial (RA-HVAD) configuration. From June 2014 through May 2016, 11 consecutive INTERMACS levels 1-2 patients with evidence of biventricular failure underwent implantation of a CF LVAD (10 LV-HVAD and 1 HeartMate II LVAD, Thoratec, Pleasanton, CA) and RA-HVAD pumps. A total of 4,314 BiVAD support days were accumulated in our case series. Seven patients have undergone orthotopic heart transplant, whereas 3 are ambulatory and are either waiting transplant or reconsideration for transplantation. There is one mortality in this case series, which was due to an intracranial bleed from supratherapeutic anticoagulation. Two other patients experienced hemorrhagic strokes, but without neurologic sequelae, whereas no patients have experienced ischemic strokes. There were two episodes of gastrointestinal bleeding. This is the largest series to date involving this approach with outcomes superior to those previously described in patients receiving biventricular support. We conclude this novel therapy is a viable alternative to current practices in the management of biventricular failure.
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28
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Abstract
Right ventricular failure following left ventricular assist devices implantation is a serious complication associated with high mortality. In patients with or at high risk of developing right ventricular failure, biventricular support is recommended. Because univentricular support is associated with high survival rates, biventricular support is often undertaken as a last resort. With the advent of newer right ventricular and biventricular systems under design and testing, better differentiation is required to ensure optimal patients care. Clear guidelines on patient selection, time of intervention and device selection are required to improve patient outcomes.
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Affiliation(s)
- Sajad Shehab
- Cardiology Department, St Vincent's Hospital Sydney, Australia
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29
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Mechanical Circulatory Support of the Right Ventricle for Adult and Pediatric Patients With Heart Failure. ASAIO J 2019; 65:106-116. [DOI: 10.1097/mat.0000000000000815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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30
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Riebandt J, Haberl T, Wiedemann D, Moayedifar R, Schloeglhofer T, Mahr S, Dimitrov K, Angleitner P, Laufer G, Zimpfer D. Extracorporeal membrane oxygenation support for right ventricular failure after left ventricular assist device implantation. Eur J Cardiothorac Surg 2019; 53:590-595. [PMID: 29045747 DOI: 10.1093/ejcts/ezx349] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/30/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Right ventricular (RV) failure complicating left ventricular assist device implantation is associated with increased mortality. Despite a lack of supporting evidence, venoarterial extracorporeal membrane oxygenation (ECMO) support is increasingly being used as an alternative to traditional temporary RV support. We report our institutional experience with ECMO-facilitated RV support after left ventricular assist device implantation. METHODS We retrospectively reviewed the concept of temporary ECMO support for perioperative RV failure in 32 consecutive left ventricular assist device (mean age 52 ± 14 years; male 84.4%; ischaemic cardiomyopathy 40.6%; INTERMACS Level I 71.8%; INTERMACS Level II 6.3%; INTERMACS Level III 12.5%; INTERMACS Level IV-VII 9.4%; HeartWare ventricular assist device 75%; HeartMate II: 25%) from May 2009 to April 2014. The study end points were RV recovery during ECMO support, mortality and causes of death. RESULTS Twenty-nine (90.6%) patients were successfully weaned from ECMO support after RV recovery. Three (9.4%) patients expired during ECMO support. ECMO support improved RV function and haemodynamic parameters (central venous pressure 13 mmHg vs 10 mmHg, P < 0.01; mean pulmonary artery pressure 28 mmHg vs 21 mmHg, P < 0.01; cardiac output 5.1 l/min vs 5.9 l/min, P = 0.09) over a median period of 3 (range 1-15) days. Thirty-day and in-hospital mortality were 18.8% and 25%, respectively. One-year survival was 75%, causes of death were multiorgan dysfunction syndrome (50%), sepsis (25%), haemorrhagic stroke (12.5%) and ischaemic stroke (12.5%). Causes of death during ECMO support were ischaemic stroke, sepsis and multiorgan dysfunction syndrome. CONCLUSIONS Temporary ECMO-facilitated RV support is associated with good long-term outcomes and high rates of RV recovery.
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Affiliation(s)
- Julia Riebandt
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Thomas Haberl
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - R Moayedifar
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Thomas Schloeglhofer
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
| | - Stéphane Mahr
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Philipp Angleitner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
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Dandel M, Hetzer R. Temporary assist device support for the right ventricle: pre-implant and post-implant challenges. Heart Fail Rev 2019; 23:157-171. [PMID: 29453695 DOI: 10.1007/s10741-018-9678-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Severe right ventricular (RV) failure is more likely reversible than similar magnitudes of left ventricular (LV) failure and, because reversal of both adaptive remodeling and impaired contractility require most often only short periods of support, the use of temporary RV assist devices (t-RVADs) can be a life-saving therapy option for many patients. Although increased experience with t-RVADs and progresses made in the development of safer devices with lower risk for complications has improved both recovery rate of RV function and patient survival, the mortality of t-RVAD recipients can still be high but it depends mainly on the primary cause of RV failure (RVF), the severity of end-organ dysfunction, and the timing of RVAD implantation, and much less on adverse events and complications related to RVAD implantation, support, or removal. Reduced survival of RVAD recipients should therefore not discourage appropriate application of RVADs because their underuse further reduces the chances for RV recovery and patient survival. The article reviews and discusses the challenges related to the pre-implant and post-implant decision-making processes aiming to get best possible therapeutic results. Special attention is focused on pre-implant RV assessment and prediction of RV improvement during mechanical unloading, patient selection for t-RVAD therapy, assessment of unloading-promoted RV recovery, and prediction of its stability after RVAD removal. Particular consideration is also given to prediction of RVF after LVAD implantation which is usually hampered by the complex interactions between the different risk factors related indirectly or directly to the RV potential for reverse remodeling and functional recovery.
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Affiliation(s)
- Michael Dandel
- DZHK (German Centre for Heart and Circulatory Research), Partner site Berlin, Berlin, Germany. .,Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Roland Hetzer
- Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Cardio Centrum Berlin, Berlin, Germany
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Saito S, Toda K, Nakamura T, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Kainuma S, Yoshida S, Sawa Y. Rescuing Patients With Severe Biventricular Failure in the Era of Continuous-Flow Left Ventricular Assist Device. Circ J 2018; 83:379-385. [PMID: 30531119 DOI: 10.1253/circj.cj-18-0958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We evaluated clinical outcomes of left ventricular assist device (LVAD) support in patients with or without severe right heart failure, in order to determine what kind of organ allocation system could help severe biventricular failure patients to be safely bridged to heart transplantation (HTx), even in Japan where the waiting time for HTx is extremely long. Methods and Results: One hundred and seventy consecutive patients who were implanted with continuous-flow LVAD at the present institution were included in this study. The patients were divided into 2 groups: 158 patients with isolated LVAD (group-LVF) and 12 patients who required long-term mechanical or inotropic right heart support (group-BVF). Post-LVAD survival in group-BVF was significantly worse than in group-LVF (P<0.0001). Given that many patients in group-BVF died between 1 and 2 years after LVAD implantation, Kaplan-Meier survival curve simulation was carried out under the condition that all the patients in group-BVF who died on LVAD support >1 year after LVAD implantation had received HTx at 365 days after LVAD implantation and survived thereafter. In this simulation, no significant difference in survival was seen between the groups (P=0.2424). CONCLUSIONS A new allocation system that allows severe right heart failure patients to receive HTx at around 1 year would enable rescue of the patients with severe right heart failure.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiac Surgery, International University of Health and Welfare, School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Teruya Nakamura
- Department of Cardiac Surgery, International University of Health and Welfare, School of Medicine
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shohei Yoshida
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Stephens AF, Gregory SD, Salamonsen RF. The Importance of Venous Return in Starling-Like Control of Rotary Ventricular Assist Devices. Artif Organs 2018; 43:E16-E27. [PMID: 30094842 DOI: 10.1111/aor.13342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/05/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
Rotary ventricular assist devices (VADs) are less sensitive to preload than the healthy heart, resulting in inadequate flow regulation in response to changes in patient cardiac demand. Starling-like physiological controllers (SLCs) have been developed to automatically regulate VAD flow based on ventricular preload. An SLC consists of a cardiac response curve (CRC) which imposes a nonlinear relationship between VAD flow and ventricular preload, and a venous return line (VRL) which determines the return path of the controller. This study investigates the importance of a physiological VRL in SLC of dual rotary blood pumps for biventricular support. Two experiments were conducted on a physical mock circulation loop (MCL); the first compared an SLC with an angled physiological VRL (SLC-P) against an SLC with a vertical VRL (SLC-V). The second experiment quantified the benefit of a dynamic VRL, represented by a series of specific VRLs, which could adapt to different circulatory states including changes in pulmonary (PVR) and systemic (SVR) vascular resistance versus a fixed physiological VRL which was calculated at rest. In both sets of experiments, the transient controller responses were evaluated through reductions in preload caused by the removal of fluid from the MCL. The SLC-P produced no overshoot or oscillations following step changes in preload, whereas SLC-V produced 0.4 L/min (12.5%) overshoot for both left and right VADs. Additionally, the SLC-V had increased settling time and reduced controller stability as evidenced by transient controller oscillations. The transient results comparing the specific and standard VRLs demonstrated that specific VRL rise times were improved by between 1.2 and 4.7 s ( x ¯ = 3.05 s), while specific VRL settling times were improved by between 2.8 and 16.1 seconds ( x ¯ = 8.38 s) over the standard VRL. This suggests only a minor improvement in controller response time from a dynamic VRL compared to the fixed VRL. These results indicate that the use of a fixed physiologically representative VRL is adequate over a wide variety of physiological conditions.
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Affiliation(s)
- Andrew F Stephens
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Engineering and Built Environment, Griffith University, QLD, Australia
| | - Shaun D Gregory
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Engineering and Built Environment, Griffith University, QLD, Australia.,School of Mechanical and Aerospace Engineering, Monash University, VIC, Australia
| | - Robert F Salamonsen
- Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia.,Intensive Care Unit, Alfred Hospital, Prahran, VIC, Australia
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36
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Abstract
Aortic regurgitation (AR), mitral regurgitation (MR), and tricuspid regurgitation (TR) after continuous-flow left ventricular assist device (LVAD) are common and may increase with prolonged LVAD support. The aim of this study was to simulate severe valvular regurgitation (AR, MR, and TR) within a 4-elemental pulsatile mock circulatory loop (MCL) and observe their impact on isolated LVAD and biventricular assist device (BiVAD) with HeartWare HVAD. Aortic regurgitation, MR, and TR were achieved via the removal of one leaflet from bileaflet mechanical valve from the appropriate valves of the left or right ventricles. The impact of alteration of LVAD pump speed (LVAD 2200-4000 RPM, right ventricular assist device [RVAD] 2400 RPM) and altered LVAD preload (10-25 mm Hg) was assessed. With each of the regurgitant valve lesions, there was a decrease in isolated LVAD pump flow pulsatility. Isolated LVAD provided sufficient support in the setting of severe MR or TR compared with control, and flows were enhanced with BiVAD support. In severe AR, there was no benefit of BiVAD support over isolated LVAD, and actual loop flows remained low. High LVAD flows combined with low RVAD flows and dampened aortic pressures are good indicators of AR. The 4-elemental MCL successfully simulated several control and abnormal valvular conditions using various pump speeds. Current findings are consistent with conservative management of MR and TR in the setting of mechanical support, but emphasize the importance of the correction of AR.
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A Versatile Hybrid Mock Circulation for Hydraulic Investigations of Active and Passive Cardiovascular Implants. ASAIO J 2018; 65:495-502. [PMID: 30045051 PMCID: PMC6615934 DOI: 10.1097/mat.0000000000000851] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Supplemental Digital Content is available in the text. During the development process of active or passive cardiovascular implants, such as ventricular assist devices or vascular grafts, extensive in-vitro testing is required. The aim of the study was to develop a versatile hybrid mock circulation (HMC) which can support the development of such implants that have a complex interaction with the circulation. The HMC operates based on the hardware-in-the-loop concept with a hydraulic interface of four pressure-controlled reservoirs allowing the interaction of the implant with a numerical model of the cardiovascular system. Three different conditions were investigated to highlight the versatility and the efficacy of the HMC during the development of such implants: 1) biventricular assist device (BiVAD) support with progressive aortic valve insufficiency, 2) total artificial heart (TAH) support with increasing pulmonary vascular resistance, and 3) flow distribution in a total cavopulmonary connection (TCPC) in a Fontan circulation during exercise. Realistic pathophysiologic waveforms were generated with the HMC and all hemodynamic conditions were simulated just by adapting the software. The results of the experiments indicated the potential of physiologic control during BiVAD or TAH support to prevent suction or congestion events, which may occur during constant-speed operation. The TCPC geometry influenced the flow distribution between the right and the left pulmonary artery, which was 10% higher in the latter and led to higher pressures. Together with rapid prototyping methods, the HMC may enhance the design of implants to achieve better hemodynamics. Validation of the models with clinical recordings is suggested for increasing the reliability of the HMC.
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38
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Westerhof BE, Saouti N, van der Laarse WJ, Westerhof N, Vonk Noordegraaf A. Treatment strategies for the right heart in pulmonary hypertension. Cardiovasc Res 2018; 113:1465-1473. [PMID: 28957540 PMCID: PMC5852547 DOI: 10.1093/cvr/cvx148] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 09/01/2017] [Indexed: 02/06/2023] Open
Abstract
The function of the right ventricle (RV) determines the prognosis of patients with pulmonary hypertension. While much progress has been made in the treatment of pulmonary hypertension, therapies for the RV are less well established. In this review of treatment strategies for the RV, first we focus on ways to reduce wall stress since this is the main determinant of changes to the ventricle. Secondly, we discuss treatment strategies targeting the detrimental consequences of increased RV wall stress. To reduce wall stress, afterload reduction is the essential. Additionally, preload to the ventricle can be reduced by diuretics, by atrial septostomy, and potentially by mechanical ventricular support. Secondary to ventricular wall stress, left-to-right asynchrony, altered myocardial energy metabolism, and neurohumoral activation will occur. These may be targeted by optimising RV contraction with pacing, by iron supplement, by angiogenesis and improving mitochondrial function, and by neurohumoral modulation, respectively. We conclude that several treatment strategies for the right heart are available; however, evidence is still limited and further research is needed before clinical application can be recommended.
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Affiliation(s)
- Berend E Westerhof
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.,Department of Medical Biology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nabil Saouti
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Willem J van der Laarse
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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40
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Shah P, Ha R, Singh R, Cotts W, Adler E, Kiernan M, Brambatti M, Meehan K, Phillips S, Kidambi S, Macaluso GP, Banerjee D, Mooney D, Pham D, Pretorius VD. Multicenter experience with durable biventricular assist devices. J Heart Lung Transplant 2018; 37:1093-1101. [PMID: 30173824 DOI: 10.1016/j.healun.2018.05.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/10/2018] [Accepted: 05/15/2018] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Severe right ventricular failure necessitating a right ventricular assist device (RVAD) complicates 6% to 11% of left ventricular assist device (LVAD) implants. Patient outcomes for those receiving durable continuous-flow VADs in a biventricular configuration (i.e., BiVAD) have been reported in limited case series. METHODS Data from United States centers with ≥ 6 BiVAD implants were collected. Characteristics and outcomes of patients receiving contemporaneous (i.e., same surgery) vs staged implantation of the HVAD as a BiVAD were compared. RESULTS From 2011 to 2017, 46 patients received durable BiVADs and had the following characteristics: median age, 46 years (interquartile range [IQR], 19-67 years), non-ischemic cardiomyopathy (80%), bridge to transplant (83%), Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 or 2 (92%), use of temporary circulatory support (37%), right atrial pressure 19 mm Hg (IQR, 14-23 mm Hg), and cardiac index of 1.6 liters/min/m2 (IQR, 1.2-2.1 liters/min/m2). Operative mortality was 33%. Equal numbers of patients received a right atrial or right ventricular implant. Contemporaneous BiVAD implantation occurred in 31 patients (67%), and compared with 15 patients (33%) with staged implants, these patients had a shorter intensive care unit length of stay of 12 days (IQR, 7-23 days) vs 42 days (IQR, 28-48 days, p = 0.035) and were more likely to be discharged from the hospital on BiVAD support (61% vs 27%, p = 0.04). RVAD thrombosis developed in 17 patients (37%). Patients with contemporaneous BiVAD implants had a 1-year survival of 74% compared with 40% in staged BiVAD patients (p = 0.11). CONCLUSIONS Patients receiving durable BiVADs represent a critically ill patient population with severe biventricular failure who have high operative mortality and RVAD thrombosis rates. The 1-year survival for patients receiving contemporaneous BiVADs in experienced centers mirrors other contemporary durable biventricular support strategies.
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Affiliation(s)
- Palak Shah
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia.
| | - Richard Ha
- Department of Cardiac Surgery, Stanford University, Palo Alto, California
| | - Ramesh Singh
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - William Cotts
- Department of Heart Failure and Transplantation, Advocate Christ Medical Center, Chicago, Illinois
| | - Eric Adler
- Department of Heart Failure and Transplantation, University of California San Diego, San Diego, California
| | - Michael Kiernan
- Department of Heart Failure and Transplantation, Tufts University, Boston, Massachusetts
| | - Michela Brambatti
- Department of Heart Failure and Transplantation, University of California San Diego, San Diego, California
| | - Karen Meehan
- Department of Heart Failure and Transplantation, Advocate Christ Medical Center, Chicago, Illinois
| | - Sheila Phillips
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Sumanth Kidambi
- Department of Cardiac Surgery, Stanford University, Palo Alto, California
| | - Gregory P Macaluso
- Department of Heart Failure and Transplantation, Advocate Christ Medical Center, Chicago, Illinois
| | - Dipanjan Banerjee
- Department of Cardiac Surgery, Stanford University, Palo Alto, California
| | - Dierdre Mooney
- Department of Heart Failure and Transplantation, Tufts University, Boston, Massachusetts
| | - Duc Pham
- Department of Cardiac Surgery, Northwestern University, Chicago, Illinois
| | - Victor D Pretorius
- Department of Heart Failure and Transplantation, University of California San Diego, San Diego, California
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41
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Bishawi M, Roan JN, Richards J, Brown Z, Blue L, Daneshmand MA, Schroder JN, Bowles DE, Milano CA. Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart. J Vis Exp 2018. [PMID: 29806848 DOI: 10.3791/55961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ventricular assist devices (VADs) for support of the left ventricle. However, certain clinical scenarios warrant biventricular mechanical support. One strategy for some patients is the excision of both ventricles and the implantation of two VAD pumps as a total artificial heart (TAH). This has recently been made possible by the improvements in device design and the small profile of centrifugal devices. This TAH approach remains experimental with many important challenges such as the device settings to balance the right and left circulation, the orientation of the devices and the outflow graft with their influence on hemolysis and stability, and the outcome of chronic support using such an orientation. This protocol aims to provide a reproducible approach for total artificial heart replacement with two intracorporeal centrifugal VADs in a cow model.
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Affiliation(s)
- Muath Bishawi
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University;
| | - Jun-Neng Roan
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University; Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital and College of Medicine
| | - Jordan Richards
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
| | - Zachary Brown
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
| | - Laura Blue
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
| | - Dawn E Bowles
- Division of Surgical Sciences, Department of Surgery, Duke University
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University
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Baldwin ACW, Cohn WE, Morgan JA, Frazier OH. Long-Term Continuous-Flow Biventricular Support in a 63-Year-Old Woman. Tex Heart Inst J 2018; 45:110-112. [PMID: 29844746 DOI: 10.14503/thij-17-6348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We describe the successful use of long-term biventricular continuous-flow mechanical circulatory support as a bridge to transplantation in a small-framed 63-year-old woman with long-standing nonischemic cardiomyopathy. After placement of a left-sided HeartWare HVAD, persistent right-sided heart failure necessitated implantation of a second HeartWare device for long-term right ventricular support. After 262 days, the patient underwent successful orthotopic heart transplantation and was discharged from the hospital. This report indicates the feasibility of biventricular device support in older patients of relatively small stature, and our results may encourage others to consider this therapy in similar patient populations.
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Biventricular Support With Intracorporeal, Continuous Flow, Centrifugal Ventricular Assist Devices. Ann Thorac Surg 2018; 105:548-555. [DOI: 10.1016/j.athoracsur.2017.08.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/27/2017] [Accepted: 08/07/2017] [Indexed: 11/20/2022]
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Successful support of biventricular heart failure patients by new EXCOR® Adult pumps with bileaflet valves: a prospective study. Clin Res Cardiol 2018; 107:413-420. [DOI: 10.1007/s00392-017-1200-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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45
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Application of multiobjective neural predictive control to biventricular assistance using dual rotary blood pumps. Biomed Signal Process Control 2018. [DOI: 10.1016/j.bspc.2017.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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46
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HeartWare HVAD for Biventricular Support in Children and Adolescents: The Stanford Experience. ASAIO J 2017; 62:e46-51. [PMID: 26919182 DOI: 10.1097/mat.0000000000000356] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite increasing use of mechanical circulatory support in children, experience with biventricular device implantation remains limited. We describe our experience using the HeartWare HVAD to provide biventricular support to three patients and compare these patients with five patients supported with HeartWare left ventricular assist device (LVAD). At the end of the study period, all three biventricular assist device (BiVAD) patients had been transplanted and were alive. LVAD patients were out of bed and ambulating a median of 10.5 days postimplantation. The BiVAD patients were out of bed a median of 31 days postimplantation. Pediatric patients with both left ventricular and biventricular heart failure can be successfully bridged to transplantation with the HeartWare HVAD. Rapid improvement in functional status following HVAD implantation for isolated left ventricular support is seen. Patients supported with BiVAD also demonstrate functional recovery, albeit more modestly. In the absence of infection, systemic inflammatory response raises concern for inadequate support.
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47
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Hetzer R, Delmo Walter EM. Existing issues and valid concerns in continuous-flow ventricular assist devices. Expert Rev Med Devices 2017; 14:949-959. [DOI: 10.1080/17434440.2017.1409112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiac, Transplantation, Thoracic and Vascular Surgery, Hannover Medical School, Hannover, Germany
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48
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Usefulness of 2 centrifugal ventricular assist devices in a total artificial heart configuration: A preliminary report. J Heart Lung Transplant 2017; 36:1266-1268. [DOI: 10.1016/j.healun.2017.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/23/2017] [Accepted: 05/18/2017] [Indexed: 11/16/2022] Open
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49
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Right Ventricular Failure Post LVAD Implantation Corrected with Biventricular Support: An In Vitro Model. ASAIO J 2017; 63:41-47. [PMID: 28033201 DOI: 10.1097/mat.0000000000000455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Right ventricular failure after left ventricular assist device (LVAD) implantation is associated with high mortality. Management remains limited to pharmacologic therapy and temporary mechanical support. Delayed right ventricular assist device (RVAD) support after LVAD implantation is associated with poorer outcomes. With the advent of miniaturized, durable, continuous flow ventricular assist device systems, chronic RVAD and biventricular assist device (BiVAD) support has been used with some success. The purpose of this study was to assess combined BiVAD and LVAD with delayed RVAD support within a four-elemental mock circulatory loop (MCL) simulating the human cardiovascular system. Our hypothesis was that delayed continuous flow RVAD (RVAD) would produce similar hemodynamic and flow parameters to those of initial BiVAD support. Using the MCL, baseline biventricular heart failure with elevated right and left filling pressures with low cardiac output was simulated. The addition of LVAD within a biventricular configuration improved cardiac output somewhat, but was associated with persistent right heart failure with elevated right-sided filling pressures. The addition of an RVAD significantly improved LVAD outputs and returned filling pressures to normal throughout the circulation. In conclusion, RVAD support successfully restored hemodynamics and flow parameters of biventricular failure supported with isolated LVAD with persistent elevated right atrial pressure.
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Sensor-Based Physiologic Control Strategy for Biventricular Support with Rotary Blood Pumps. ASAIO J 2017; 64:338-350. [PMID: 28938308 DOI: 10.1097/mat.0000000000000671] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rotary biventricular assist devices (BiVAD) are becoming a clinically accepted treatment option for end-stage biventricular failure. To improve BiVAD efficacy and safety, we propose a control algorithm to achieve the clinical objectives of maintaining left-right-sided balance, restoring physiologic flows, and preventing ventricular suction. The control algorithm consists of two proportional-integral (PI) controllers for left and right ventricular assist devices (LVAD and RVAD) to maintain differential pump pressure across LVAD (ΔPL) and RVAD (ΔPR) to provide left-right balance and physiologic flow. To prevent ventricular suction, LVAD and RVAD pump speed differentials (ΔRPML, ΔRPMR) were maintained above user-defined thresholds. Efficacy and robustness of the proposed algorithm were tested in silico for axial and centrifugal flow BiVAD using 1) normal and excessive ΔPL and/or ΔPR setpoints, 2) rapid threefold increase in pulmonary vascular or vena caval resistances, 3) transient responses from exercise to rest, and 4) ventricular fibrillation. The study successfully demonstrated that the proposed BiVAD algorithm achieved the clinical objectives but required pressure sensors to continuously measure ΔPL and ΔPR. The proposed control algorithm is device independent, should not require any modifications to the pump or inflow/outflow cannulae/grafts, and may be directly applied to current rotary blood pumps for biventricular support.
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