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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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Cikes M, Yuzefpolskaya M, Gustafsson F, Mehra MR. Antithrombotic Strategies with Left Ventricular Assist Devices. J Card Fail 2024:S1071-9164(24)00318-X. [PMID: 39154903 DOI: 10.1016/j.cardfail.2024.07.024] [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: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/20/2024]
Abstract
Long-term outcomes of patients with advanced heart failure treated with durable left ventricular assist devices (LVADs) have been augmented due to improved durability and hemocompatibility on the backbone of pump engineering enhancements. The incidence of hemocompatibility-related adverse events (pump thrombosis, stroke and non-surgical bleeding events) are device-specific and vary by type of engineered pump. A fully magnetically levitated rotor containing LVAD in concert with use of antithrombotic therapy has successfully overcome an increased risk of thrombosis albeit with only modest reduction in bleeding events. Modifications to antithrombotic strategies have focused on reduced dose vitamin K antagonist use or use of direct oral anticoagulants with demonstration of safety, and progress in reduction of mucosal bleeding episodes with elimination of antiplatelet agents. This review outlines the current landscape of advances in anticoagulation management in LVAD patients, highlighting the need for ongoing research and cautious application of emerging therapies and technologies.
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Affiliation(s)
- Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Melana Yuzefpolskaya
- Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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Widhalm G, Aigner P, Gruber B, Moscato F, Moayedifar R, Schaefer AK, Dimitrov K, Zimpfer D, Riebandt J, Schlöglhofer T. Preoperative anatomical landmarks and longitudinal HeartMate 3 pump position in X-rays: Relevance for adverse events. Artif Organs 2024. [PMID: 39105573 DOI: 10.1111/aor.14837] [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: 04/23/2024] [Revised: 07/08/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Left ventricular assist device (LVAD) malposition has been linked to hemocompatibility-related adverse events (HRAEs). This study aimed to identify preoperative anatomical landmarks and postoperative pump position, associated with HRAEs during LVAD support. METHODS Pre- and postoperative chest X-ray measures (≤14 days pre-implantation, first postoperative standing, 6, 12, 18, and 24 months post-implantation) were analyzed for their association with HRAEs over 24 months in 33 HeartMate 3 (HM3) patients (15.2% female, age 66 (9.5) years). RESULTS HM3 patients with any HRAE showed significantly lower preoperative distances between left ventricle and thoracic outline (dLVT) (25.3 ± 10.2 mm vs. 40.3 ± 15.5 mm, p = 0.004). A ROC-derived cutoff dLVT ≤ 29.2 mm provided 85.7% sensitivity and 72.2% specificity predicting any HRAE during HM3 support (76.2% (>29.2 mm) vs. 16.7% (≤29.2 mm) freedom from HRAE, p < 0.001) and significant differences in cardiothoracic ratio (0.58 ± 0.04 vs. 0.62 ± 0.04, p = 0.045). Postoperative X-rays indicated lower pump depths in patients with ischemic strokes (9.1 ± 16.2 mm vs. 38.0 ± 18.5 mm, p = 0.007), reduced freedom from any neurological event (pump depth ≤ 28.7 mm: 45.5% vs. 94.1%, p = 0.004), and a significant correlation between pump depth and inflow cannula angle (r = 0.66, p < 0.001). Longitudinal changes were observed in heart-pump width (F(4,60) = 5.61, p < 0.001). CONCLUSION Preoperative X-ray markers are associated with postoperative HRAE occurrence. Applying this knowledge in clinical practice may enhance risk stratification, guide therapy optimization, and improve HM3 recipient management.
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Affiliation(s)
- Gregor Widhalm
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Aigner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Gruber
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Roxana Moayedifar
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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4
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Schurr JW, Ambrosi L, Fitzgerald J, Bermudez C, Genuardi MV, Brahier M, Elliot T, McGowan K, Zaaqoq A, Laskar S, Pope SM, Givertz MM, Mallidi H, Sylvester KW, Seifert FC, McLarty AJ. Multicenter evaluation of left ventricular assist device implantation with or without ECMO bridge in cardiogenic shock. Artif Organs 2024; 48:921-931. [PMID: 38459758 DOI: 10.1111/aor.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/26/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. METHODS AND RESULTS INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. CONCLUSIONS Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.
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Affiliation(s)
- James W Schurr
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lara Ambrosi
- Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jillian Fitzgerald
- Stony Brook University Hospital, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Christian Bermudez
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael V Genuardi
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark Brahier
- Medstar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Tonya Elliot
- Medstar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Kevin McGowan
- Medstar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Akram Zaaqoq
- UVA Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Sonjoy Laskar
- Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stuart M Pope
- Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hari Mallidi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn W Sylvester
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frank C Seifert
- Stony Brook University Hospital, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Allison J McLarty
- Stony Brook University Hospital, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
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5
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Ludomirsky A, Edelson JB. Time is of the Essence: A Response to "Impact of Ventricular Assist Device Use on Pediatric Heart Transplant Waitlist Mortality: Analysis of the Scientific Registry of Transplant Recipients Database". Pediatr Transplant 2024; 28:e14827. [PMID: 39039036 DOI: 10.1111/petr.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/05/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Avital Ludomirsky
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan B Edelson
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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6
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Fu S, Samson R. Hemodynamic Ramp Testing for Left Ventricular Assist Devices: Overcoming Biology. ASAIO J 2024; 70:651-652. [PMID: 39078516 DOI: 10.1097/mat.0000000000002271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Affiliation(s)
- Sheng Fu
- From the Advanced Heart Failure Therapies Program, University of Louisville Health-Heart Hospital, Louisville, Kentucky
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Shah P, Sayer G, Sinha SS, Kanwar MK, Cowger JA, Pagani FD, Nayak A, Mehra MR, Cleveland JC, Psotka MA, Singh R, Desai SS, Lu Q, Hu Y, Connolly A, Kormos RL, Uriel N. Dynamic Risk Estimation of Adverse Events in Ambulatory LVAD Patients: A MOMENTUM 3 Analysis. JACC. HEART FAILURE 2024:S2213-1779(24)00486-4. [PMID: 39066758 DOI: 10.1016/j.jchf.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/26/2024] [Accepted: 05/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Hemocompatibility-related adverse events affect patients after left ventricular assist device (LVAD) implantation but are hard to predict. OBJECTIVES Dynamic risk modeling with a multistate model can predict risk of gastrointestinal bleeding (GIB), stroke, or death in ambulatory patients. METHODS This was a secondary analysis of the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial. HeartMate 3 LVAD recipients who survived to hospital discharge and were followed for up to 2 years. A total of 145 variables were included in the multistate model with multivariate logistic regression. Model performance was assessed with the area under the curve in a holdout validation cohort. A risk stratification tool was created by dividing patients into categories of predicted risk using the final model variables and associated OR. RESULTS Among 2,056 LVAD patients, the median age was 59.4 years (20.4% women, 28.6% Black). At 2 years, the incidence of GIB, stroke, and death was 25.6%, 6.0%, and 12.3%, respectively. The multistate model included 39 total variables to predict risk of GIB (16 variables), stroke (10 variables), and death (19 variables). When ambulatory patients were classified according to their risk category, the 30-day observed event rate in the highest risk group for GIB, stroke, or death was 26.9%, 1.8%, and 4.8%, respectively. The multistate model predicted GIB, stroke, and death at any 30-day period with an area under the curve of 0.70, 0.69, and 0.86, respectively. CONCLUSIONS The multistate model informs 30-day risk in ambulatory LVAD recipients and allows recalculation of risk as new patient-specific data become available. The model allows for accurate risk stratification that predicts impending adverse events and may guide clinical decision making. (MOMENTUM 3 IDE Clinical Study Protocol; NCT02224755).
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Affiliation(s)
- Palak Shah
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Gabriel Sayer
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
| | | | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Aditi Nayak
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Ramesh Singh
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | | | | | | | | | | | - Nir Uriel
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
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Schnoering L, Khattab MA, Akhyari P, Moza A, Haneya A, Diab AH, Abugameh A, Lotfi S, Zayat R. Pressure-dimension index and left ventricular sphericity index following HeartMate II and HeartMate 3 implantation. ESC Heart Fail 2024. [PMID: 38840435 DOI: 10.1002/ehf2.14839] [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: 11/06/2023] [Revised: 02/27/2024] [Accepted: 04/06/2024] [Indexed: 06/07/2024] Open
Abstract
AIMS This study aimed to compare the changes in the left ventricle (LV) and right ventricle (RV) geometry and performance after the implantation of HeartMate II (HMII) and HeartMate 3 (HM3). In addition, we investigated whether the echocardiographic parameters LV sphericity index (LVSI) and the novel pressure-dimension index (PDI) can predict post-operative right ventricular failure (RVF). METHODS AND RESULTS Between 2012 and 2020, 46 patients [HMII (n = 22) and HM3 (n = 24)] met the study's criteria and had echocardiography tests pre-operatively, 6 and 12 months post-operatively. The LVSI and PDI were calculated together with the standard LV and RV echocardiographic parameters. The mean follow-up was 24 ± 7 months. In both groups, the LV end-diastolic diameter (LVEDD) significantly decreased 12 months post-operatively compared with the pre-operative values (HMII: 6.4 ± 1.4 cm vs. 5.7 ± 0.9 cm, P = 0.040; HM3: 6.7 ± 1.3 cm vs. 5.5 ± 0.9 cm, P < 0.01, respectively). RV function 12 months post-operatively was better in the HM3 group than in the HMII group, as indicated by a significantly higher RV fractional area change (RVFAC) in the HM3 group than in the HMII group 12 months post-operatively (35 ± 12% vs. 26 ± 16%, P = 0.039), significantly higher tricuspid annular plane systolic excursion (TAPSE) in the HM3 group 12 months post-operatively compared with the HMII group (13.9 ± 1.9 mm vs. 12.0 ± 2.1 mm, P = 0.002), and the tissue Doppler estimated tricuspid annular systolic velocity (TASV) was also significantly higher in the HM3 group 12 months post-operatively compared with the HMII group (11.5 ± 2.7 mm/s vs. 9.9 ± 1.5 mm/s, P = 0.020). The LVSI value was significantly higher 12 months post-operatively in the HMII group than in the HM3 group (1.2 ± 0.4 vs. 0.8 ± 0.2, P = 0.001, respectively), indicating worse geometric changes. The PDI decreased 12 months post-operatively in the HM3-group compared with the baseline (3.4 ± 1.4 mmHg/cm2 vs. 2.0 ± 0.8 mmHg/cm2, P < 0.001). In the univariate and multivariate analyses, only the pre-operative PDI was a predictor of post-operative RVF [odds ratio: 3.84 (95% CI: 1.53-18.16, P = 0.022)]. The area under the curve for pre-operative PDI was 0.912. The 2 year survival was significantly better in the HM3 group (log-rank, P = 0.042). CONCLUSIONS The design of HM3 offered better geometrical preservation of the LV and enabled normal PDI values, leading to improved RV function, as indicated by better RVFAC, TAPSE, and TASV values. The use of pre-operative PDI as an additional tool for established risk scores might offer a better pre-operative predictor of RVF.
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Affiliation(s)
- Luisa Schnoering
- Department of Cardiac Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mohammad Amen Khattab
- Department of Cardiac Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ajay Moza
- Department of Cardiac Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Assad Haneya
- Department of Cardiothoracic Surgery, Heart Centre Trier, Barmherzigen Brueder Hospital, Trier, Germany
| | - Abdel Hannan Diab
- Department of Cardiothoracic Surgery, Heart Centre Trier, Barmherzigen Brueder Hospital, Trier, Germany
| | - Ahmad Abugameh
- Department of Cardiothoracic Surgery, Heart Centre Trier, Barmherzigen Brueder Hospital, Trier, Germany
| | - Shahram Lotfi
- Department of Cardiac Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Rashad Zayat
- Department of Cardiothoracic Surgery, Heart Centre Trier, Barmherzigen Brueder Hospital, Trier, Germany
- Department of Thoracic Surgery, Faculty of Medicine, RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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9
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Bernhardt AM, Reichenspurner H. Anticoagulation in LVAD recipients and thrombembolic complications: Where do we stand? Where are we going to? J Heart Lung Transplant 2024; 43:876-877. [PMID: 38431240 DOI: 10.1016/j.healun.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
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10
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Carey MR, Marshall D, Clerkin K, Laracuente R, Sanchez J, Jain SS, Raikhelkar JK, Leb JS, Kaku Y, Yuzefpolskaya M, Naka Y, Colombo PC, Sayer GT, Takeda K, Uriel N, Topkara VK, Fried JA. Aortic Root Thrombosis in patients with HeartMate 3 left ventricular assist device support. J Heart Lung Transplant 2024; 43:866-875. [PMID: 37739242 DOI: 10.1016/j.healun.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 08/07/2023] [Accepted: 08/26/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Aortic root thrombosis(ART) is a complication of continuous-flow left ventricular assist device therapy. However, the incidence and related complications of ART in HeartMate 3 (HM3) patients remain unknown. METHODS Patients who underwent HM3 implantation from November 2014 to August 2020 at a quaternary academic medical center were included. Demographics and outcomes were abstracted from the medical record. Echocardiograms and contrast-enhanced computed tomography studies were reviewed to identify patients who developed ART and/or moderate or greater aortic insufficiency (AI) on HM3 support. RESULTS The study cohort included 197 HM3 patients with a median postimplant follow-up of 17.5 months. Nineteen patients (9.6%) developed ART during HM3 support, and 15 patients (7.6%) developed moderate or greater AI. Baseline age, gender, race, implantation strategy, and INTERMACS classification were similar between the ART and no-ART groups. ART was associated with an increased risk of death, stroke, or aortic valve (AV) intervention (subhazard ratio [SHR] 3.60 [95% confidence interval (CI) 1.71-7.56]; p = 0.001) and moderate or greater AI (SHR 11.1 [CI 3.60-34.1]; p < 0.001) but was not associated with a statistically significantly increased risk of death or stroke on HM3 support (2.12 [0.86-5.22]; p = 0.10). Of the 19 patients with ART, 6 (31.6%) developed moderate or greater AI, necessitating more frequent AV interventions (ART: 5 AV interventions [3 surgical repairs, 1 surgical replacement, 1 transcatheter replacement; 26.3%]; no-ART: 0). CONCLUSIONS Nearly 10% of HM3 patients developed ART during device support. ART was associated with increased risk of a composite end-point of death, stroke, or AV intervention as well as moderate or greater AI.
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Affiliation(s)
- Matthew R Carey
- Department of Internal Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Dylan Marshall
- Division of Cardiology, NewYork-Presbyterian/Weill Cornell Medical College, New York, New York
| | - Kevin Clerkin
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Ronald Laracuente
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph Sanchez
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jayant K Raikhelkar
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Jay S Leb
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York.
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Dimond M, Looby M, Shah B, Sinha SS, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, O'connor CM, Shah P. Design and Rationale for the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices (DOAC LVAD) Study. J Card Fail 2024; 30:819-828. [PMID: 37956897 DOI: 10.1016/j.cardfail.2023.10.473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Abstract
Implantable left ventricular assist device (LVAD) therapy is used to improve quality of life, alleviate symptoms and extend survival rates in patients with advanced heart failure. Patients with LVADs require chronic anticoagulation to reduce the risk of thromboembolic complications, and they commonly experience bleeding events. Apixaban is a direct oral anticoagulant that has become first-line therapy for patients with nonvalvular atrial fibrillation and venous thromboembolism; however, its safety in patients with LVADs has not been well characterized. The evaluation of the hemocompatibility in the DOAC LVAD (Direct Oral Anti-Coagulant apixaban in Left Ventricular Assist Devices) trial is a phase 2, open-label trial of patients with LVADs who were randomized to either apixaban or warfarin therapy. Patients randomized to apixaban will be started on a dosage of 5 mg twice daily, whereas those randomized to warfarin will be managed at an International Normalized Ratio goal of 2.0-2.5. All patients will be treated with aspirin at 81 mg daily. We plan to randomize and follow as many as 40 patients for 24 weeks to evaluate the primary outcomes of freedom from death or hemocompatibility-related adverse events (stroke, device thrombosis, bleeding, aortic root thrombus, and arterial non-CNS thromboembolism). The DOAC LVAD trial will establish the feasibility of apixaban anticoagulant therapy in patients with LVADs. Clinicaltrials.gov: NCT04865978.
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Affiliation(s)
- Matthew Dimond
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Mary Looby
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Bhruga Shah
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Shashank S Sinha
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Iyad Isseh
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Allman T Rollins
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Ahmad A Abdul-Aziz
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Jamie Kennedy
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Daniel G Tang
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Katherine M Klein
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Samantha Casselman
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Christen Vermeulen
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Wendy Sheaffer
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Meredith Snipes
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | | | - Palak Shah
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA.
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12
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Shah P, Looby M, Dimond M, Bagchi P, Shah B, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, Sinha SS, O'Connor CM. Evaluation of the Hemocompatibility of the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices: The DOAC LVAD Study. JACC. HEART FAILURE 2024:S2213-1779(24)00333-0. [PMID: 38795110 DOI: 10.1016/j.jchf.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Patients receiving left ventricular assist device (LVAD) support require long-term anticoagulation to reduce the risk of thromboembolic complications. Apixaban is a direct oral anticoagulant that has become first-line therapy; however, its safety in LVAD recipients has not been well described. OBJECTIVES This study sought to investigate whether, in patients with a fully magnetically levitated LVAD, treatment with apixaban would be feasible and comparable with respect to safety and freedom from the primary composite outcome of death or major hemocompatibility-related adverse events (HRAEs) (stroke, device thrombosis, major bleeding, aortic root thrombus, and arterial non-central nervous system thromboembolism) as compared with treatment with warfarin. METHODS The DOAC LVAD (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices) trial was a phase 2, open label trial of LVAD recipients randomized 1:1 to either apixaban 5 mg twice daily or warfarin therapy. All patients were required to take low-dose aspirin. Patients were followed up for 24 weeks to evaluate the primary composite outcome. RESULTS A total of 30 patients were randomized: 14 patients to warfarin and 16 patients to apixaban. The median patient age was 60 years (Q1-Q3: 52-71 years), and 47% were Black patients. The median time from LVAD implantation to randomization was 115 days (Q1-Q3: 56-859 days). At 24 weeks, the primary composite outcome occurred in no patients receiving apixaban and in 2 patients (14%) receiving warfarin (P = 0.12); these 2 patients experienced major bleeding from gastrointestinal sources. CONCLUSIONS Anticoagulation with apixaban was feasible in patients with an LVAD without an excess of HRAEs or deaths. This study informs future pivotal clinical trials evaluating the safety and efficacy of apixaban in LVAD recipients. (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices [DOAC LVAD]; NCT04865978).
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Affiliation(s)
- Palak Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Mary Looby
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Matthew Dimond
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Pramita Bagchi
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Bhruga Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Iyad Isseh
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Allman T Rollins
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Ahmad A Abdul-Aziz
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Daniel G Tang
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Katherine M Klein
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Samantha Casselman
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Christen Vermeulen
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Wendy Sheaffer
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Meredith Snipes
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
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Bender M, Escher A, Messner B, Rohrich M, Fischer MB, Hametner C, Laufer G, Kertzscher U, Zimpfer D, Jakubek S, Granegger M. An Atraumatic Mock Loop for Realistic Hemocompatibility Assessment of Blood Pumps. IEEE Trans Biomed Eng 2024; 71:1651-1662. [PMID: 38133971 DOI: 10.1109/tbme.2023.3346206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Conventional mock circulatory loops (MCLs) cannot replicate realistic hemodynamic conditions without inducing blood trauma. This constrains in-vitro hemocompatibility examinations of blood pumps to static test loops that do not mimic clinical scenarios. This study aimed at developing an atraumatic MCL based on a hardware-in-the-loop concept (H-MCL) for realistic hemocompatibility assessment. METHODS The H-MCL was designed for 450 ± 50 ml of blood with the polycarbonate reservoirs, the silicone/polyvinyl-chloride tubing, and the blood pump under investigation as the sole blood-contacting components. To account for inherent coupling effects a decoupling pressure control was derived by feedback linearization, whereas the level control was addressed by an optimization task to overcome periodic loss of controllability. The HeartMate 3 was showcased to evaluate the H-MCL's accuracy at typical hemodynamic conditions. To verify the atraumatic properties of the H-MCL, hemolysis (bovine blood, n = 6) was evaluated using the H-MCL in both inactive (static) and active (minor pulsatility) mode, and compared to results achieved in conventional loops. RESULTS Typical hemodynamic scenarios were replicated with marginal coupling effects and root mean square error (RMSE) below 1.74 ± 1.37 mmHg while the fluid level remained within ±4% of its target value. The normalized indices of hemolysis (NIH) for the inactive H-MCL showed no significant differences to conventional loops ( ∆NIH = -1.6 mg/100 L). Further, no significant difference was evident between the active and inactive mode in the H-MCL ( ∆NIH = +0.3 mg/100 L). CONCLUSION AND SIGNIFICANCE Collectively, these findings indicated the H-MCL's potential for in-vitro hemocompatibility assessment of blood pumps within realistic hemodynamic conditions, eliminating inherent setup-related risks for blood trauma.
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14
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Dual SA, Cowger J, Roche E, Nayak A. The Future of Durable Mechanical Circulatory Support: Emerging Technological Innovations and Considerations to Enable Evolution of the Field. J Card Fail 2024; 30:596-609. [PMID: 38431185 DOI: 10.1016/j.cardfail.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 03/05/2024]
Abstract
The field of durable mechanical circulatory support (MCS) has undergone an incredible evolution over the past few decades, resulting in significant improvements in longevity and quality of life for patients with advanced heart failure. Despite these successes, substantial opportunities for further improvements remain, including in pump design and ancillary technology, perioperative and postoperative management, and the overall patient experience. Ideally, durable MCS devices would be fully implantable, automatically controlled, and minimize the need for anticoagulation. Reliable and long-term total artificial hearts for biventricular support would be available; and surgical, perioperative, and postoperative management would be informed by the individual patient phenotype along with computational simulations. In this review, we summarize emerging technological innovations in these areas, focusing primarily on innovations in late preclinical or early clinical phases of study. We highlight important considerations that the MCS community of clinicians, engineers, industry partners, and venture capital investors should consider to sustain the evolution of the field.
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Affiliation(s)
- Seraina A Dual
- KTH Royal Institute of Technology, Department of Biomedical Engineering and Health Systems, Stockholm, Sweden
| | | | - Ellen Roche
- Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Aditi Nayak
- Baylor University Medical Center, Dallas, Texas.
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15
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Garmany A, Inglis SS, Behfar A, Rosenbaum AN. Biventricular catheterization combined with pressure-volume loop monitoring provides insight into the dynamic effects of left ventricular assist devices ramp on right ventricular function. Catheter Cardiovasc Interv 2024; 103:799-802. [PMID: 38461378 PMCID: PMC11037112 DOI: 10.1002/ccd.30993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/11/2024]
Abstract
Ramp studies are utilized for speed optimization of continuous flow left ventricular assist devices (CF-LVADs). We here report the utility of combined left and right heart catheterization during a ramp study to ensure a comprehensive understanding of the hemodynamic implications on both ventricles. Pressure-volume loop (PV loop) monitoring uncovered compromised systolic and mildly compromised right ventricular function with increasing LVAD speeds, despite improvement in left ventricular unloading. These findings informed patient management and highlight the potential utility of PV loop monitoring as an adjunct to left and right heart catheterization during ramp studies of next-generation LVADs.
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Affiliation(s)
- Armin Garmany
- Graduate School of Biomedical Sciences, Alix School of Medicine, Medical Scientist Training Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara S. Inglis
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
| | - Atta Behfar
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration. Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
| | - Andrew N. Rosenbaum
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
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16
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Schmitto JD, Shaw S, Garbade J, Gustafsson F, Morshuis M, Zimpfer D, Lavee J, Pya Y, Berchtold-Herz M, Wang A, Gazzola C, Potapov E, Saeed D. Fully magnetically centrifugal left ventricular assist device and long-term outcomes: the ELEVATE registry. Eur Heart J 2024; 45:613-625. [PMID: 38036414 PMCID: PMC10959573 DOI: 10.1093/eurheartj/ehad658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 07/06/2023] [Accepted: 08/17/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND AIMS HeartMate 3 (HM3) is a fully magnetically levitated continuous flow left ventricular assist device, which received CE marking in 2015. The ELEVATE Registry was initiated to collect real-world outcomes in patients treated with HM3 post-CE Mark approval. METHODS A total of 540 subjects implanted at 26 centres between March 2015 and February 2017 were included in this registry. Of these, 463 received the device as a primary implant (primary implant cohort, PIC), 19 as a pump exchange (pump exchange cohort), and in 58 patients, only anonymized survival data were collected (anonymized cohort, AC). Patients in the PIC contributed to the baseline demographics, survival, adverse events, quality of life (QoL) (EuroQoL-5 Dimensions-5 Levels visual analogue scale), and functional capacity (6 min walk distance) assessments, while patients in the AC contributed only to survival. RESULTS Primary implant cohort patients had a mean age of 56 years and were predominantly male (89%) with 48% ischaemic aetiology. The majority of subjects was designated bridge to transplant (66%) and had INTERMACS Profiles 1-3 (70%). At baseline, the subjects had poor functional capacity (104 ± 140 m) and impaired QoL (35 ± 19 points). The overall survival rate of the PIC was 63.3% and survival free of stroke was 58.1% at 5 years. Significant improvements in functional capacity and QoL were observed and maintained for 5 years (301 ± 131 m and 64 ± 20 points, respectively). CONCLUSIONS Real-world data from the ELEVATE registry demonstrate an overall survival rate for primary implants of 63.3%. In the PIC, reductions in adverse events for patients in the extended follow-up and improved QoL and functional capacity were observed at 5 years in this patient population with advanced heart failure.
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Affiliation(s)
- Jan D Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, OE 6210, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Steven Shaw
- The Transplant Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Jens Garbade
- Department of Cardiothoracic Surgery, Klinikum Links der Weser, Bremen, Germany
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michiel Morshuis
- Department of Cardiothoracic Surgery, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Heart Center, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yuriy Pya
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | | | | | | | | | - Diyar Saeed
- Department for Cardiac Surgery, Heart Center, Leipzig, Germany
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18
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Schlöglhofer T, Gross C, Abart T, Schaefer AK, Marko C, Röhrich M, Widhalm G, Kaufmann F, Weigel I, Al Asadi H, Karner B, Riebandt J, Wiedemann D, Laufer G, Schima H, Zimpfer D. HeartMate 3 Snoopy: Noninvasive cardiovascular diagnosis of patients with fully magnetically levitated blood pumps during echocardiographic speed ramp tests and Valsalva maneuvers. J Heart Lung Transplant 2024; 43:251-260. [PMID: 37769887 DOI: 10.1016/j.healun.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/30/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023] Open
Abstract
PURPOSE The HeartMate 3 (HM3) left ventricular assist device (LVAD) has demonstrated excellent clinical outcomes; however, pump speed optimization is challenging with the available HM3 monitoring. Therefore, this study reports on clinical HM3 parameters collected with a noninvasive HM3 monitoring system (HM3 Snoopy) during echocardiographic speed ramp tests and Valsalva maneuvers. METHODS In this prospective, single-center study, the HM3 data communication between the controller and pump was recorded with a novel data acquisition system. Twelve pump parameters sampled every second (1 Hz) and clinical assessments (echocardiography, electrocardiogram (ECG), and blood pressure measurement) during speed ramp tests were analyzed using Pearson's correlation (r, median [IQR]). The cause for the occurrence of pulsatility index (PI)-events during ramp speed tests and valsalva maneuvers was investigated. RESULTS In 24 patients (age: 58.9 ± 8.8 years, body mass index: 28.1 ± 5.1 kg/m2, female: 20.8%), 35 speed ramp tests were performed with speed changes in the range of ±1000 rpm from a baseline speed of 5443 ± 244 rpm. Eight HM3 pump parameters from estimated flow, motor current, and LVAD speed together with blood pressure showed positive collinearities (r = 0.9 [0.1]). Negative collinearities were observed for pump flow pulsatility, pulsatility index, rotor noise, and left ventricular diameters (r = -0.8 [0.1]), whereas rotor displacement and heartrate showed absence of collinearities (r = -0.1 [0.08]). CONCLUSIONS In this study, the HM3 Snoopy was successfully used to acquire more parameters from the HM3 at a higher sampling rate. Analysis of HM3 per-second data provide additional clinical diagnostic information on heart-pump interactions and cause of PI-events.
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Affiliation(s)
- Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.
| | - Christoph Gross
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Theodor Abart
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christiane Marko
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Röhrich
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Widhalm
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Friedrich Kaufmann
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Ingo Weigel
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Hebe Al Asadi
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Barbara Karner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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Yaranov DM, Baldridge AS, Gonzalez M, Biglane JB, Tanaka D, Fischer W, Larkin C, Ullah R, Chaudhry SP, Pham DT. Anticoagulation Bridging in Patients With Left Ventricular Assist Device: A Regional Analysis of HeartMate 3 Recipients. ASAIO J 2024; 70:93-98. [PMID: 37862687 DOI: 10.1097/mat.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
Advances in left ventricular assist device technologies have led to an improvement in pump hemocompatibility and outcomes. Because of concerns of thromboembolic complications in prior generations of left ventricular assist devices, bridging with parenteral anticoagulants was routinely. Management strategies of subtherapeutic INRs and their effects on the current generation of devices deserve review. We performed analysis of the MOMENTUM 3 trial including 6 centers in the mid-America region. Patients with subtherapeutic INRs (INR < 2) occurring after the index admission underwent chart review to determine the management strategies taken by clinicians. Strategies were divided into two groups, bridging or nonbridging. Of the 225 patients included in the analysis, 130 (58%) patients had a total of 235 subtherapeutic international normalized ratio (INR) events. Most (n = 179, 76.2%) of these INRs were not bridged (n = 100 warfarin dose adjustment, n = 79 no change in warfarin dose). Among those INRs (n = 56, 23.8%) treated with bridging, approximately half (n = 30, 53.6%) were treated with subcutaneous agents and other half (n = 26, 46.4%) were treated with intravenous agents. There was no difference in individual outcomes or composite endpoints of death, rehospitalization, CVA, or bleeding events between the groups.
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Affiliation(s)
| | | | | | | | | | | | - Chris Larkin
- Ascension Saint Thomas West, Nashville, Tennessee
| | - Rafath Ullah
- Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | | | - Duc Thinh Pham
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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20
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Bierewirtz T, Narayanaswamy K, Giuffrida R, Rese T, Bortis D, Zimpfer D, Kolar JW, Kertzscher U, Granegger M. A Novel Pumping Principle for a Total Artificial Heart. IEEE Trans Biomed Eng 2024; 71:446-455. [PMID: 37603484 DOI: 10.1109/tbme.2023.3306888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Total artificial hearts (TAH) serve as a temporary treatment for severe biventricular heart failure. The limited durability and complication rates of current devices hamper long-term cardiac replacement. The aim of this study was to assess the feasibility of a novel valveless pumping principle for a durable pulsatile TAH (ShuttlePump). METHODS The pump features a rotating and linearly shuttling piston within a cylindrical housing with two in- and outlets. With a single moving piston, the ShuttlePump delivers pulsatile flow to both systemic and pulmonary circulation. The pump and actuation system were designed iteratively based on analytical and in silico methods, utilizing finite element methods (FEM) and computational fluid dynamics (CFD). Pump characteristics were evaluated experimentally in a mock circulation loop mimicking the cardiovascular system, while hemocompatibility-related parameters were calculated numerically. RESULTS Pump characteristics cover the entire required operating range for a TAH, providing 2.5-9 L/min of flow rate against 50-160 mmHg arterial pressures at stroke frequencies of 1.5-5 Hz while balancing left and right atrial pressures. FEM analysis showed mean overall copper losses of 8.84 W, resulting in a local maximum blood temperature rise of <2 K. The CFD results of the normalized index of hemolysis were 3.57 mg/100 L, and 95% of the pump's blood volume was exchanged after 1.42 s. CONCLUSION AND SIGNIFICANCE This study indicates the feasibility of a novel pumping system for a TAH with numerical and experimental results substantiating further development of the ShuttlePump.
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Schweiger M, Miera O. Not little adults: Outcomes in pediatric intra-corporeal LVAD patients. J Heart Lung Transplant 2024; 43:182-183. [PMID: 37683894 DOI: 10.1016/j.healun.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Affiliation(s)
- Martin Schweiger
- Department of Congenital Cardiovascular Surgery, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland.
| | - Oliver Miera
- Deutsches Herzzentrum der Charité, Berlin, Germany
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22
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Mehra MR, Netuka I, Uriel N, Katz JN, Pagani FD, Jorde UP, Gustafsson F, Connors JM, Ivak P, Cowger J, Ransom J, Bansal A, Takeda K, Agarwal R, Byku M, Givertz MM, Bitar A, Hall S, Zimpfer D, Vega JD, Kanwar MK, Saeed O, Goldstein DJ, Cogswell R, Sheikh FH, Danter M, Pya Y, Phancao A, Henderson J, Crandall DL, Sundareswaran K, Soltesz E, Estep JD. Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial. JAMA 2023; 330:2171-2181. [PMID: 37950897 PMCID: PMC10640705 DOI: 10.1001/jama.2023.23204] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/24/2023] [Indexed: 11/13/2023]
Abstract
IMPORTANCE Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJECTIVE To determine whether excluding aspirin as part of the antithrombotic regimen with a fully magnetically levitated LVAD is safe and decreases bleeding. DESIGN, SETTING, and PARTICIPANTS This international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/d) vs placebo with VKA therapy in patients with advanced heart failure with an LVAD was conducted across 51 centers with expertise in treating patients with advanced heart failure across 9 countries. The randomized population included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD (314 in the placebo group and 314 in the aspirin group), of whom 296 patients in the placebo group and 293 in the aspirin group were in the primary analysis population, which informed the primary end point analysis. The study enrolled patients from July 2020 to September 2022; median follow-up was 14 months. Intervention Patients were randomized in a 1:1 ratio to receive aspirin (100 mg/d) or placebo in addition to an antithrombotic regimen. MAIN OUTCOMES AND MEASURES The composite primary end point, assessed for noninferiority (-10% margin) of placebo, was survival free of a major nonsurgical (>14 days after implant) hemocompatibility-related adverse events (including stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months. The principal secondary end point was nonsurgical bleeding events. RESULTS Of the 589 analyzed patients, 77% were men; one-third were Black and 61% were White. More patients were alive and free of hemocompatibility events at 12 months in the placebo group (74%) vs those taking aspirin (68%). Noninferiority of placebo was demonstrated (absolute between-group difference, 6.0% improvement in event-free survival with placebo [lower 1-sided 97.5% CI, -1.6%]; P < .001). Aspirin avoidance was associated with reduced nonsurgical bleeding events (relative risk, 0.66 [95% confidence limit, 0.51-0.85]; P = .002) with no increase in stroke or other thromboembolic events, a finding consistent among diverse subgroups of patient characteristics. CONCLUSIONS AND RELEVANCE In patients with advanced heart failure treated with a fully magnetically levitated LVAD, avoidance of aspirin as part of an antithrombotic regimen, which includes VKA, is not inferior to a regimen containing aspirin, does not increase thromboembolism risk, and is associated with a reduction in bleeding events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04069156.
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Affiliation(s)
- Mandeep R. Mehra
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
| | - Jason N. Katz
- Duke University Medical Center, Durham, North Carolina
| | | | - Ulrich P. Jorde
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jean M. Connors
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter Ivak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - John Ransom
- Baptist Health Medical Center, Little Rock, Arkansas
| | | | - Koji Takeda
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | - Mirnela Byku
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael M. Givertz
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Omar Saeed
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | | | | | | | | | - Yuriy Pya
- National Research Center for Cardiac Surgery, Kazakhstan
| | - Anita Phancao
- Miami Transplant Institute—Jackson Memorial, Miami, Florida
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23
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Ramu B, Cogswell R, Ravichandran AK, Cleveland J, Mehra MR, Goldstein D, Uriel N, Dirckx N, Ahmed S, Yuzefpolskaya M. Clinical Outcomes With a Fully Magnetically Levitated Left Ventricular Assist Device Among Women and Men. JACC. HEART FAILURE 2023; 11:1692-1704. [PMID: 37831046 DOI: 10.1016/j.jchf.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are underused among women with advanced heart failure, but reasons remain unclear. Outcomes in women compared with men with contemporary fully magnetically levitated LVADs remain uncertain. OBJECTIVES The authors examined differences in characteristics, 2-year outcomes, and risk for key adverse events among women and men. METHODS In 2,200 HeartMate3 (HM3) (Abbott Cardiovascular) LVAD recipients in the MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3), survival free of disabling stroke or reoperation to replace or remove a malfunctioning pump at 2 years was analyzed between women and men. Other outcomes included overall 2-year survival, adverse events, and functional measures. RESULTS Women comprised 20.4% (n = 448 of 2,200) of the study population and were younger, with nonischemic cardiomyopathy, and more often were Black persons compared with men. The primary endpoint (women 79.4% vs men 75.5% (adjusted [a]HR: 0.96 [95% CI: 0.75-1.24]; P = 0.66) or survival at 2 years (women 82.4% vs men 80.2%; aHR: 1.06 [95% CI: 0.81-1.40]; P = 0.66) was no different. Women had an increased rate of stroke (adjusted incidence rate ratio [aIRR]: 1.52 [95% CI: 1.09-2.11]; P = 0.012), major bleeding (aIRR: 1.28 [95% CI: 1.15-1.42]; P < 0.0001) and infection (aIRR 1.14 [95% CI: 1.03-1.55]; P = 0.01), but these differences were not seen among older (>65 years) patients. Both groups had similar gains in 6-minute walk distance and quality-of-life measurements. CONCLUSIONS There were no differences in the primary composite endpoint or overall survival in women compared with men at 2 years of support. Reasons underlying increase in hemocompatibility-related events and infection-related morbidity in younger women deserves further study. (MOMENTUM 3 IDE [HM3], NCT02224755; MOMENTUM 3 Continued Access Protocol [MOMENTUM 3 CAP], NCT02892955).
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Affiliation(s)
| | | | | | - Joseph Cleveland
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | | | | | - Melana Yuzefpolskaya
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
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24
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Escher A, Thamsen B, Strauch C, Kertzscher U, Zimpfer D, Thamsen PU, Granegger M. In-Vitro Flow Validation of Third-Generation Ventricular Assist Devices: Feasibility and Challenges. ASAIO J 2023; 69:932-941. [PMID: 37418316 DOI: 10.1097/mat.0000000000002009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023] Open
Abstract
Computational fluid dynamics (CFD) is a powerful tool for the in-silico evaluation of rotodynamic blood pumps (RBPs). Corresponding validation, however, is typically restricted to easily accessible, global flow quantities. This study showcased the HeartMate 3 (HM3) to identify feasibility and challenges of enhanced in-vitro validation in third-generation RBPs. To enable high-precision acquisition of impeller torques and grant access for optical flow measurements, the HM3 testbench geometry was geometrically modified. These modifications were reproduced in silico , and global flow computations validated along 15 operating conditions. The globally validated flow in the testbench geometry was compared with CFD-simulated flows in the original geometry to assess the impact of the necessary modifications on global and local hydraulic properties. Global hydraulic properties in the testbench geometry were successfully validated (pressure head: r = 0.999, root mean square error [RMSE] = 2.92 mmHg; torque: r = 0.996, RMSE = 0.134 mNm). In-silico comparison with the original geometry demonstrated good agreement ( r > 0.999, relative errors < 11.97%) of global hydraulic properties. Local hydraulic properties (errors up to 81.78%) and hemocopatibility predictions (deviations up to 21.03%), however, were substantially affected by the geometric modifications. Transferability of local flow measures derived on advanced in-vitro testbenches toward original pump designs is challenged by significant local effects associated with the necessary geometrical modifications.
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Affiliation(s)
- Andreas Escher
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Bente Thamsen
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carsten Strauch
- Department of Fluid System Dynamics, Technische Universität Berlin, Berlin, Germany
| | - Ulrich Kertzscher
- Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Institute of Computer-assisted Cardiovascular Medicine, Biofluid Mechanics Laboratory, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Zimpfer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Division of Cardiac Surgery, Department of Surgery, Medical University Graz, Graz, Austria
| | - Paul Uwe Thamsen
- Department of Fluid System Dynamics, Technische Universität Berlin, Berlin, Germany
| | - Marcus Granegger
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Institute of Computer-assisted Cardiovascular Medicine, Biofluid Mechanics Laboratory, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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25
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Stöhr EJ, Ji R, Mondellini G, Braghieri L, Akiyama K, Castagna F, Pinsino A, Cockcroft JR, Silverman RH, Trocio S, Zatvarska O, Konofagou E, Apostolakis I, Topkara VK, Takayama H, Takeda K, Naka Y, Uriel N, Yuzefpolskaya M, Willey JZ, McDonnell BJ, Colombo PC. Pulsatility and flow patterns across macro- and microcirculatory arteries of continuous-flow left ventricular assist device patients. J Heart Lung Transplant 2023; 42:1223-1232. [PMID: 37098374 PMCID: PMC11078160 DOI: 10.1016/j.healun.2023.04.002] [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: 05/10/2022] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known. METHODS The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41. RESULTS In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r2 = 0.51, p < 0.0001; HM3 "continuous-flow," r2 = 0.32, p = 0.0009; HM3 "artificial pulse," r2 = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients. CONCLUSIONS The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs.
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Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, New York; Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Francesco Castagna
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiology Division, Montefiore Medical Center, New York, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald H Silverman
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York
| | - Samuel Trocio
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Oksana Zatvarska
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Iason Apostolakis
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koji Takeda
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Yoshifumi Naka
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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26
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Ray NA, Nair N. Durable LVAD in a SLE patient - no anticoagulation for >6 years. Acta Cardiol 2023; 78:854-857. [PMID: 37377106 DOI: 10.1080/00015385.2023.2230024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Nandini A Ray
- Division of Cardiology, Department of Medicine, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Nandini Nair
- Division of Cardiology, Department of Medicine, Texas Tech Health Sciences Center, Lubbock, TX, USA
- Division of Cardiology, Penn State Health, Milton S Hershey Medical Center, Hershey, PA, USA
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27
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Nayak A, Hall SA, Uriel N, Goldstein DJ, Cleveland JC, Cowger JA, Salerno CT, Naka Y, Horstmanshof D, Crandall D, Wang A, Mehra MR. Predictors of 5-Year Mortality in Patients Managed With a Magnetically Levitated Left Ventricular Assist Device. J Am Coll Cardiol 2023; 82:771-781. [PMID: 37612008 DOI: 10.1016/j.jacc.2023.05.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND In advanced heart failure patients implanted with a fully magnetically levitated HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD), it is unknown how preimplant factors and postimplant index hospitalization events influence 5-year mortality in those able to be discharged. OBJECTIVES The goal was to identify risk predictors of mortality through 5 years among HM3 LVAD recipients conditional on discharge from index hospitalization in the MOMENTUM 3 pivotal trial. METHODS This analysis evaluated 485 of 515 (94%) patients discharged after implantation of the HM3 LVAD. Preimplant (baseline), implant surgery, and index hospitalization characteristics were analyzed individually, and as multivariable predictors for mortality risk through 5 years. RESULTS Cumulative 5-year mortality in the cohort (median age: 62 years, 80% male, 65% White, 61% destination therapy due to transplant ineligibility) was 38%. Two preimplant characteristics (elevated blood urea nitrogen and prior coronary artery bypass graft or valve procedure) and 3 postimplant characteristics (hemocompatibility-related adverse events, ventricular arrhythmias, and estimated glomerular filtration rate <60 mL/min/1.73 m2 at discharge) were predictors of 5-year mortality. In 171 of 485 patients (35.3%) without any risk predictors, 5-year mortality was reduced to 22.6% (95% CI: 15.4%-32.7%). Even among those with 1 or more predictors, mortality was <50% at 5 years (45.7% [95% CI: 39.0%-52.8%]). CONCLUSIONS Long-term survival in successfully discharged HM3 LVAD recipients is largely influenced by clinical events experienced during the index surgical hospitalization in tandem with baseline factors, with mortality of <50% at 5 years. In patients without identified predictors of risk, long-term 5-year mortality is low and rivals that achieved with heart transplantation, even though most were implanted with destination therapy intent. (MOMENTUM 3 IDE Clinical Study Protocol, NCT02224755; MOMENTUM 3 Pivotal Cohort Extended Follow-up PAS, NCT03982979).
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Affiliation(s)
- Aditi Nayak
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | | | | | | | | | | | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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28
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Wilson SI, Ingram KE, Oh A, Moreno MR, Kassi M. The role of innovative modeling and imaging techniques in improving outcomes in patients with LVAD. Front Cardiovasc Med 2023; 10:1248300. [PMID: 37692033 PMCID: PMC10484111 DOI: 10.3389/fcvm.2023.1248300] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Heart failure remains a significant cause of mortality in the United States and around the world. While organ transplantation is acknowledged as the gold standard treatment for end stage heart failure, supply is limited, and many patients are treated with left ventricular assist devices (LVADs). LVADs extend and improve patients' lives, but they are not without their own complications, particularly the hemocompatibility related adverse events (HRAE) including stroke, bleeding and pump thrombosis. Mainstream imaging techniques currently in use to assess appropriate device function and troubleshoot complications, such as echocardiography and cardiac computed tomography, provide some insight but do not provide a holistic understanding of pump induced flow alterations that leads to HRAEs. In contrast, there are technologies restricted to the benchtop-such as computational fluid dynamics and mock circulatory loops paired with methods like particle image velocimetry-that can assess flow metrics but have not been optimized for clinical care. In this review, we outline the potential role and current limitations of converging available technologies to produce novel imaging techniques, and the potential utility in evaluating hemodynamic flow to determine whether LVAD patients may be at higher risk of HRAEs. This addition to diagnostic and monitoring capabilities could improve prevention and treatment of LVAD-induced complications in heart failure patients.
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Affiliation(s)
- Shannon I. Wilson
- Department of Biomedical Engineering, Texas A&M University, College Station, TX, United States
| | - Katelyn E. Ingram
- DeBakey Heart and Vascular- Heart Center Research, Houston Methodist Research Institute, Houston, TX, United States
| | - Albert Oh
- School of Engineering Medicine, Texas A&M University, Houston, TX, United States
| | - Michael R. Moreno
- J. Mike Walker ‘66 Department of Mechanical Engineering, Texas A&M University, College Station, TX, United States
| | - Mahwash Kassi
- Cardiology, DeBakey Heart and Vascular, Houston Methodist Hospital, Houston, TX, United States
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29
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Grinstein J, Belkin MN, Kalantari S, Bourque K, Salerno C, Pinney S. Adverse Hemodynamic Consequences of Continuous Left Ventricular Mechanical Support: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:70-81. [PMID: 37380306 DOI: 10.1016/j.jacc.2023.04.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 06/30/2023]
Abstract
Left ventricular assist devices (LVADs) provide lifesaving therapy for patients with advanced heart failure. The recognition of pump thrombosis, stroke, and nonsurgical bleeding as hemocompatibility-related adverse events (HRAEs) led to pump design improvements and reduced adverse event rates. However, continuous flow can predispose patients to right-sided heart failure (RHF) and aortic insufficiency (AI), especially as patients live longer with their device. Given the hemodynamic contributions to AI and RHF, these comorbidities can be classified as hemodynamic-related events (HDREs). Hemodynamic-driven events are time dependent and often manifest later than HRAEs. This review examines the emerging strategies to mitigate HDREs, with a focus on defining best practices for AI and RHF. As we head into the next generation of LVAD technology, it is important to differentiate HDREs from HRAEs so that we can continue to advance the field and improve the true durability of the pump-patient continuum.
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Affiliation(s)
- Jonathan Grinstein
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA.
| | - Mark N Belkin
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Sara Kalantari
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Kevin Bourque
- Heart Failure Division, Abbott, Burlington, Massachusetts, USA
| | - Christopher Salerno
- Section of Cardiac Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Sean Pinney
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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30
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Schlöglhofer T, Marschütz A, Combs P, Stonebraker C, Lupo S, Jeevanandam V, Riebandt J, Schima H, Zimpfer D, Meehan K. Quality of Anticoagulation With Phenprocoumon and Warfarin in Left Ventricular Assist Device Patients: A Multicenter Study. ASAIO J 2023; 69:595-601. [PMID: 36821448 DOI: 10.1097/mat.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
VISUAL ABSTRACT of key results. INR, international normalized ratio; TTR, time in therapeutic range; PTR, percentage of tests in range; HRAE, hemocompatibility-related adverse event; FFUV, first follow-up visit; GIB, gastrointestinal bleeding; HR, hazard ratio.http://links.lww.com/ASAIO/A961.
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Affiliation(s)
- Thomas Schlöglhofer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Angelika Marschütz
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Pamela Combs
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Corinne Stonebraker
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Sydney Lupo
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Valluvan Jeevanandam
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Julia Riebandt
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Daniel Zimpfer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Karen Meehan
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
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31
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Magkoutas K, Chala N, Wu X, Poulikakos D, Mazza E, Meboldt M, Falk V, Ferrari A, Giampietro C, Schmid Daners M. In-vitro investigation of endothelial monolayer retention on an inflow VAD cannula inside a beating heart phantom. BIOMATERIALS ADVANCES 2023; 152:213485. [PMID: 37302211 DOI: 10.1016/j.bioadv.2023.213485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023]
Abstract
Ventricular assist devices (VADs) provide an alternative solution to heart transplantation for patients with end-stage heart failure. Insufficient hemocompatibility of VAD components can result in severe adverse events, such as thromboembolic stroke, and readmissions. To enhance VAD hemocompatibility, and avoid thrombus formation, surface modification techniques and endothelialization strategies are employed. In this work, a free form patterning topography is selected to facilitate the endothelialization of the outer surface of the inflow cannula (IC) of a commercial VAD. An endothelialization protocol for convoluted surfaces such as the IC is produced, and the retainment of the endothelial cell (EC) monolayer is evaluated. To allow this evaluation, a dedicated experimental setup is developed to simulate realistic flow phenomena inside an artificial, beating heart phantom with a VAD implanted on its apex. The procedural steps of mounting the system result to the impairment of the EC monolayer, which is further compromised by the developed flow and pressure conditions, as well as by the contact with the moving inner structures of the heart phantom. Importantly, the EC monolayer is better maintained in the lower part of the IC, which is more susceptible to thrombus formation and may therefore aid in minimizing the hemocompatibility related adverse events after the VAD implantation.
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Affiliation(s)
- Konstantinos Magkoutas
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Nafsika Chala
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Xi Wu
- Experimental Continuum Mechanics, Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, Zurich, Switzerland
| | - Dimos Poulikakos
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Edoardo Mazza
- Experimental Continuum Mechanics, Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, Zurich, Switzerland; Experimental Continuum Mechanics, EMPA, Dubendorf, Switzerland
| | - Mirko Meboldt
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, 13353 Berlin, Germany; Clinic for Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, 13353 Berlin, Germany; Department of Health Sciences and Technology, ETH Zurich, 8093 Zurich, Switzerland
| | - Aldo Ferrari
- Laboratory of Thermodynamics in Emerging Technologies, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Costanza Giampietro
- Experimental Continuum Mechanics, Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zurich, Zurich, Switzerland; Experimental Continuum Mechanics, EMPA, Dubendorf, Switzerland.
| | - Marianne Schmid Daners
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland.
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Rosenbaum AN, Rossman TL, Reddy YN, Villavicencio MA, Stulak JM, Spencer PJ, Kushwaha SS, Behfar A. Pulsatile Pressure Delivery of Continuous-Flow Left Ventricular Assist Devices Is Markedly Reduced Relative to Heart Failure Patients. ASAIO J 2023; 69:445-450. [PMID: 36417497 DOI: 10.1097/mat.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although continuous-flow left ventricular assist devices (CF-LVADs) provide an augmentation in systemic perfusion, there is a scarcity of in vivo data regarding systemic pulsatility on support. Patients supported on CF-LVAD therapy (n = 71) who underwent combined left/right catheterization ramp study were included. Aortic pulsatility was defined by the pulsatile power index (PPI), which was also calculated in a cohort of high-output heart failure (HOHF, n = 66) and standard HF cohort (n = 44). PPI was drastically lower in CF-LVAD-supported patients with median PPI of 0.006 (interquartile range [IQR], 0.002-0.012) compared with PPI in the HF population at 0.09 (IQR, 0.06-0.17) or HOHF population at 0.25 (IQR, 0.13-0.37; p < 0.0001 among groups). With speed augmentation during ramp, PPI values fell quickly in patients with higher PPI at baseline. PPI correlated poorly with left ventricular ejection fraction (LVEF) in all groups. In CF-LVAD patients, there was a stronger correlation with LV dP/dt (r = 0.41; p = 0.001) than LVEF (r = 0.21; p = 0.08; pint < 0.001). CF-LVAD support is associated with a dramatic reduction in arterial pulsatility as measured by PPI relative to HOHF and HF cohorts and decreases with speed. Further work is needed to determine the applicability to the next generation of device therapy.
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Affiliation(s)
- Andrew N Rosenbaum
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yogesh N Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sudhir S Kushwaha
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Atta Behfar
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
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33
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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Tatum R, Wong D, Martins PN, Tchantchaleishvili V. Current status and future directions in the development and optimization of thoracic and abdominal artificial organs. Artif Organs 2023; 47:451-458. [PMID: 36421073 DOI: 10.1111/aor.14458] [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: 04/13/2022] [Revised: 09/18/2022] [Accepted: 11/06/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Artificial organs are engineered devices with the capacity to be implanted or integrated into a living body to replace a failing organ, or to duplicate or augment one or multiple functions of the diseased organ. AREAS COVERED We evaluate the present landscape and future possibilities of artificial organ engineering by exploring the spectrum of four distinguishable device features: mobility, compatibility, functionality, and material composition. These mechanical and functional differences provide the framework through which we examine the current status and future possibilities of the abdominal and thoracic artificial organs. EXPERT OPINION Transforming the artificial organs landscape in ways that expand the scope of existing device capabilities and improve the clinical utility of artificial organs will require making improvements upon existing technologies and multidisciplinary cooperation to create and discover new capacities.
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Affiliation(s)
- Robert Tatum
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniella Wong
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paulo N Martins
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Kanelidis AJ, Siddiqi U, Miller T, Belkin M, Li G, Smith B, Kalantari S, Nguyen A, Chung BB, Sarswat N, Kim G, Salerno C, Jeevanandam V, Pinney S, Grinstein J. The prognostic role of advanced hemodynamic variables in patients with left ventricular assist devices. Artif Organs 2023; 47:574-581. [PMID: 36305735 PMCID: PMC10023393 DOI: 10.1111/aor.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/21/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Invasive hemodynamic variables obtained from right heart catheterization have been used for risk-stratifying patients with advanced heart failure (HF). However, there is a paucity of data on the prognostic value of invasive hemodynamic variables in patients with left ventricular assist devices (LVAD). We hypothesized that cardiac power output (CPO), cardiac power efficiency (CPE), and left ventricular stroke work index (LVSWI) can serve as prognostic markers in patients with LVADs. METHODS Baseline hemodynamic data from patients who had LVAD ramp studies at our institution from 4/2014 to 7/2018 were prospectively collected, from which advanced hemodynamic variables (CPO, CPE, and LVSWI) were retrospectively analyzed. Univariate and multivariable analyses were performed for hemocompatibility-related adverse events (HRAE), HF admissions, and mortality. RESULTS Ninety-one participants (age 61 ± 11 years, 34% women, 40% Black or African American, and 38% ischemic cardiomyopathy) were analyzed. Low CPE was significantly associated with mortality (HR 2.42, 95% CI 1.02-5.74, p = 0.045) in univariate analysis and Kaplan-Meier analysis (p = 0.04). Low LVSWI was significantly associated with mortality (HR 2.13, 95% CI 1.09-4.17, p = 0.03) in univariate analysis and Kaplan-Meier analysis (p = 0.02). CPO was not associated with mortality. CPO, CPE, and LVSWI were not associated with HRAE or HF admissions. CONCLUSIONS Advanced hemodynamic variables can serve as prognostic indicators for patients with LVADs. Low CPE and LVSWI are prognostic for higher mortality, but no variables were associated with HF admissions or HRAEs.
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Affiliation(s)
- Anthony J Kanelidis
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Umar Siddiqi
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Tamari Miller
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Mark Belkin
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - George Li
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Bryan Smith
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Sara Kalantari
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ann Nguyen
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ben B Chung
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Nitasha Sarswat
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Gene Kim
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christopher Salerno
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Valluvan Jeevanandam
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Sean Pinney
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jonathan Grinstein
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
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36
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Ravenberg KK, Gabriel MM, Leotescu A, Tran AT, Grosse GM, Schuppner R, Ernst J, Lichtinghagen R, Tiede A, Werwitzke S, Bara CL, Schmitto JD, Weissenborn K, Hanke JS, Worthmann H. Microembolic signal monitoring in patients with HeartMate 3 and HeartWare left ventricular assist devices: Association with antithrombotic treatment and cerebrovascular events. Artif Organs 2023; 47:370-379. [PMID: 36114791 DOI: 10.1111/aor.14409] [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: 04/14/2022] [Revised: 08/07/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND In patients with left ventricular assist devices (LVADs), ischemic and hemorrhagic stroke are dreaded complications. Predictive markers for these events are lacking. This study aimed to investigate the prevalence and predictive value of microembolic signals (MES) for stroke, detected by Transcranial Doppler sonography (TCD) in patients with HeartMate 3 (HM 3) or HeartWare (HW). METHODS A thirty-minute bilateral TCD monitoring of the middle cerebral artery (MCA) was performed in 62 outpatients with LVAD (HM 3 N = 31, HW N = 31) and 31 healthy controls. Prevalence and quantity of MES were investigated regarding clinical and laboratory parameters. Cerebrovascular events (CVE) were recorded on follow-up at 90 and 180 days. RESULTS MES were detected in six patients with HM 3, three patients with HW, and three controls. Within the LVAD groups, patients on monotherapy with vitamin-K-antagonist (VKA) without antiplatelet therapy were at risk for a higher count of MES (negative binomial regression: VKA: 1; VKA + ASA: Exp(B) = 0.005, 95%CI 0.001-0.044; VKA + clopidogrel: Exp(B) = 0.012, 95%CI 0.002-0.056). There was no association between the presence of MES and CVE or death on follow-up (p > 0.05). CONCLUSION For the first time, the prevalence of MES was prospectively investigated in a notable outpatient cohort of patients with HM 3 and HW. Despite optimized properties of the latest LVAD, MES remain detectable depending on antithrombotic therapy. No association between MES and CVE could be detected.
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Affiliation(s)
| | | | - Andrei Leotescu
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Anh Thu Tran
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christoph Leon Bara
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Dieter Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Jasmin Sarah Hanke
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
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Tarzia V, Tessari C, Bagozzi L, Bottigliengo D, Fagan D, Fabozzo A, Mastro FR, Pagnin C, Bottio T, Gregori D, Gerosa G. Anticoagulation alone as an effective and safe antithrombotic therapy in LVAD: When less is more. Curr Probl Cardiol 2023; 48:101506. [PMID: 36402214 DOI: 10.1016/j.cpcardiol.2022.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
To evaluate the safety and effectiveness of anticoagulation alone in HeartMate3 patients. According to antithrombotic regimen, patients were divided into 2 groups: Group-1(warfarin+aspirin) and Group-2(warfarin). A comparison of hemocompatibility-related adverse events (HRAEs), hemocompatibility score (HCS), and hemocoagulative laboratory markers, both qualitative and quantitative, between the 2 groups were performed. Fifty patients were enrolled, 28 (56%) in Group-1 and 22 in Group-2 (44%), without statistical differences at baseline. Median time of follow-up was 590 days (IQR: 410.25-1007.50). Eighteen HRAEs (36.0%) occurred: 17 in Group-1 (34%) and 1 in Group-2 (2%) (P < 0.001). The net HCS for Group-1 versus Group-2 was 24 points and 1 point (OR 12.116[2.034-233.226], P = 0.023), respectively. Hemocoagulative values turned into the normality and remained stable during follow-up, without differences between groups, except for ASPI-test (P = 0.003). HeartMate3 showed a high hemocompatibility independently from antithrombotic therapy. Aspirin avoidance resulted a safe and effective strategy since it reduced hemorrhagic events, without increasing thrombotic risk.
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Affiliation(s)
- Vincenzo Tarzia
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| | - Chiara Tessari
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Lorenzo Bagozzi
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Daniele Bottigliengo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Davide Fagan
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Assunta Fabozzo
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Florinda Rosaria Mastro
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Chiara Pagnin
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Tomaso Bottio
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gino Gerosa
- Cardiac-Surgery-Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
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Uriel N, Milano C, Agarwal R, Lee S, Cleveland J, Goldstein D, Wang A, Crandall D, Mehra MR. Incidence and clinical correlates of de-novo aortic regurgitation with a fully magnetically levitated left ventricular assist device: a MOMENTUM 3 trial portfolio analysis. Eur J Heart Fail 2023; 25:286-294. [PMID: 36404406 DOI: 10.1002/ejhf.2746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS We assessed the incidence, predictors and clinical correlates of de-novo aortic regurgitation (AR), which physiologically reduces left ventricular assist device (LVAD) effectiveness due to recirculation syndrome, in the MOMENTUM 3 trial portfolio of the fully magnetically levitated HeartMate 3 (HM3) pump using the randomized pivotal trial (PT) and post-trial continued access protocol (CAP). METHODS AND RESULTS De-novo aortic regurgitation incidence at 2 years was analysed in the randomized PT and validated in the first 1000 implanted patients of the CAP. Patients with concomitant/prior aortic valve surgery or without baseline or post-implant echocardiograms were excluded from this analysis. AR severity was assessed qualitatively by site-adjudicated echocardiograms (significant AR was defined as moderate or severe grade on echocardiogram). Of 1028 patients enrolled in the PT, 918 were eligible for inclusion in this analysis (HM3, n = 465; HMII, n = 453). At 2 years of LVAD support, freedom from significant AR was greater in the HM3 (92%) than HMII (82%) (hazard ratio 0.45, 95% confidence interval 0.27-0.75, p < 0.01). Of 907 HM3 patients analysed from the first 1000 implanted CAP patients, the rate of freedom from significant AR was 90%, consistent with the PT (p = 0.3). In the combined HM3 group (n = 1372), multivariable Cox modelling identified increasing age and female sex as significant predictors. Survival free of urgent transplant or AR corrective procedure was similar between HM3 patients with and without significant de-novo AR. CONCLUSIONS The development of moderate or severe grade de-novo AR is reduced with the fully magnetically levitated HM3 LVAD compared to the axial-flow HMII pump. The occurrence of significant de-novo AR with the HM3 pump is not associated with a worse outcome at 2 years of follow-up.
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Affiliation(s)
- Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richa Agarwal
- Section of Advanced Heart Failure and Cardiac Transplantation, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Sangjin Lee
- Division of Medicine, Advanced Heart Failure and Transplantation, Spectrum Health Meijer Heart & Vascular Institute, Grand Rapids, MI, USA
| | - Joseph Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Daniel Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Einstein Center for Heart and Vascular Care, Bronx, NY, USA
| | - AiJia Wang
- Clinical Biostatistics - Heart Failure, Abbott, Burlington, MA, USA
| | - Daniel Crandall
- Global Clinical Affairs - Heart Failure, Abbott, Pleasanton, CA, USA
| | - Mandeep R Mehra
- Heart and Vascular Center, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Chan CHH, Murashige T, Bieritz SA, Semenzin C, Smith A, Leslie L, Simmonds MJ, Tansley GD. Mitigation effect of cell exclusion on blood damage in spiral groove bearings. J Biomech 2023; 146:111394. [PMID: 36462474 DOI: 10.1016/j.jbiomech.2022.111394] [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: 04/26/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 11/27/2022]
Abstract
Cell exclusion in spiral groove bearing (SGB) excludes red blood cells from high shear regions in the bearing gaps and potentially reduce haemolysis in rotary blood pumps. However, this mechanobiological phenomenon has been observed in ultra-low blood haematocrit only, whether it can mitigate blood damage in a clinically-relevant blood haematocrit remains unknown. This study examined whether cell exclusion in a SGB alters haemolysis and/or high-molecular-weight von Willebrand factor (HMW vWF) multimer degradation. Citrated human blood was adjusted to 35 % haematocrit and exposed to a SGB (n = 6) and grooveless disc (n = 3, as a non-cell exclusion control) incorporated into a custom-built Couette test rig operating at 2000RPM for an hour; shearing gaps were 20, 30, and 40 μm. Haemolysis was assessed via spectrophotometry and HMW vWF multimer degradation was detected with gel electrophoresis and immunoblotting. Haemolysis caused by the SGB at gaps of 20, 30 and 40 μm were 10.6 ± 3.3, 9.6 ± 2.7 and 10.5 ± 3.9 mg/dL.hr compared to 23.3 ± 2.6, 12.8 ± 3.2, 9.8 ± 1.8 mg/dL.hr by grooveless disc. At the same shearing gap of 20 µm, there was a significant reduced in haemolysis (P = 0.0001) and better preserved in HMW vWF multimers (p < 0.05) when compared SGB to grooveless disc. The reduction in blood damage in the SGB compared to grooveless disc is indicative of cell exclusion occurred at the gap of 20 µm. This is the first experimental study to demonstrate that cell exclusion in a SGB mitigates the shear-induced blood damage in a clinically-relevant blood haematocrit of 35 %, which can be potentially utilised in future blood pump design.
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Affiliation(s)
- Chris Hoi Houng Chan
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.
| | - Tomotaka Murashige
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; School of Engineering, Tokyo Institute of Technology, Meguro, Japan
| | - Shelby A Bieritz
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Department of Bioengineering, Rice University, Houston, TX, USA
| | - Clayton Semenzin
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Amanda Smith
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Laura Leslie
- Mechanical, Biomedical and Design Group, Aston University, Birmingham, UK
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Geoff D Tansley
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
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40
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Biological Response to Sintered Titanium in Left Ventricular Assist Devices: Pseudoneointima, Neointima, and Pannus. ASAIO J 2023; 69:1-10. [PMID: 35649199 DOI: 10.1097/mat.0000000000001777] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Titanium alloys have traditionally been used in blood-contacting cardiovascular devices, including left ventricular assist devices (LVADs). However, titanium surfaces are susceptible to adverse coagulation, leading to thrombogenesis and stroke. To improve hemocompatibility, LVAD manufacturers introduced powder sintering on blood-wetted surfaces in the 1980s to induce endothelialization. This technique has been employed in multiple contemporary LVADs on the pump housing, as well as the interior and exterior of the inflow cannula. Despite the wide adoption of sintered titanium, reported biologic response over the past several decades has been highly variable and apparently unpredictable-including combinations of neointima, pseudoneoimtima, thrombus, and pannus. We present a history of sintered titanium used in LVAD, a review of accumulated clinical outcomes, and a synopsis of gross appearance and composition of various depositions found clinically and in animal studies, which is unfortunately confounded by the variability and inconsistency in terminology. Therefore, this review endeavors to introduce a unified taxonomy to harmonize published observations of biologic response to sintered titanium in LVADs. From these data, we are able to deduce the natural history of the biologic response to sintered titanium, toward development of a deterministic model of the genesis of a hemocompatible neointima.
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New Antithrombotic Strategies to Improve Outcomes With the HeartMate 3. ASAIO J 2023; 69:e3-e6. [PMID: 35947801 DOI: 10.1097/mat.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Belkin MN, Imamura T, Rodgers D, Kanelidis AJ, Henry MP, Fujino T, Kagan V, Meehan K, Okray J, Creighton S, LaBuhn C, Song T, Ota T, Jeevanandam V, Nguyen AB, Chung BB, Smith BA, Kalantari S, Grinstein J, Sarswat N, Pinney SP, Sayer G, Kim G, Uriel N. Postoperative tolvaptan use in left ventricular assist device patients: The TOLVAD randomized pilot study. Artif Organs 2022; 46:2382-2390. [PMID: 36574590 PMCID: PMC10227625 DOI: 10.1111/aor.14375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Tolvaptan, a selective vasopressin type-2 antagonist, has been shown to increase serum sodium (Na) and urine output in hyponatremic left ventricular assist device (LVAD) patients in retrospective studies. In this prospective randomized pilot study, we aimed to assess the efficacy of tolvaptan in this population. METHODS We conducted a prospective, randomized, non-blinded pilot study of LVAD recipients with post-operative hyponatremia (Na < 135 mEq/L) (NCT05408104). Eligible participants were randomized to receive tolvaptan 15 mg daily in addition to usual care versus usual care alone. The primary outcome was a change in Na level and estimated glomerular filtration rate (eGFR), from the first post-operative day of hyponatremia (the day of randomization) to discharge. RESULTS A total of 33 participants were enrolled, and 28 underwent randomization (median age 55 [IQR 50-62]), 21% women, 54% Black, 32% ischemic cardiomyopathy, median baseline Na 135 (IQR 134-138). Fifteen participants were randomized to tolvaptan (TLV) and 13 were randomized to usual care alone (No-TLV). Mean change in Na from randomization to discharge in the TLV group was 2.7 mEq/L (95%CI 0.7-4.7, p = 0.013) and 1.8 (95%CI 0.5-4.0, p = 0.11) in the No-TLV group, though baseline and final Na levels were similar between groups. The mean change in eGFR was 2.6 ml/min/1.73 m2 (95%CI 10.1-15.3, p = 0.59) in TLV versus 7.5 ml/min/1.73 m2 (95%CI 5.2-20.2, p = 0.15) in No-TLV. TLV participants had significantly more urine output than No-TLV patients during their first 24 h after randomization (3294 vs 2155 ml, p = 0.043). CONCLUSION TLV significantly increases urine output, with nominal improvement in Na level, in hyponatremic post-operative LVAD patients without adversely impacting renal function.
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Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Daniel Rodgers
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | | | | | | | | | - Karen Meehan
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | - Justin Okray
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | | | - Colleen LaBuhn
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | - Tae Song
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | - Takeyoshi Ota
- Cardiac Surgery, UChicago Medicine, Chicago, Illinois, USA
| | | | - Ann B. Nguyen
- Cardiology, UChicago Medicine, Chicago, Illinois, USA
| | - Ben B. Chung
- Cardiology, UChicago Medicine, Chicago, Illinois, USA
| | | | | | | | | | | | - Gabriel Sayer
- Columbia University Irving Medical Center, Weill Cornell Medicine, New York, New York, USA
| | - Gene Kim
- Cardiology, UChicago Medicine, Chicago, Illinois, USA
| | - Nir Uriel
- Columbia University Irving Medical Center, Weill Cornell Medicine, New York, New York, USA
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Choi JJ, Oldham MA, Pancharovski T, Rubano A, Walsh P, Alexis JD, Gosev I, Lee HB. Cognitive Change After Left Ventricular Assist Device Implantation: A Case Series and Systematic Review. J Acad Consult Liaison Psychiatry 2022; 63:599-606. [PMID: 36116764 PMCID: PMC9809990 DOI: 10.1016/j.jaclp.2022.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/08/2022] [Accepted: 09/08/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Chronic cerebral hypoperfusion is a potential mechanism that causes cognitive impairment in patients with heart failure. Cognitive impairment in this population is associated with an increased mortality and poorer quality of life. Understanding the etiopathogenesis of cognitive impairment is crucial to developing effective treatment. A left ventricular assist device (LVAD) is a durable mechanical circulatory support device that restores systemic perfusion in patients with heart failure, potentially reversing cerebral hypoperfusion and cognitive impairment. OBJECTIVE This case series and systematic review examines the effect of LVAD implantation on cognition in patients with heart failure. METHODS We report a case series of 4 LVAD recipients at a tertiary academic center who underwent preimplant and postimplant cognitive testing. We also conducted a systematic review of studies with adult recipients of a continuous-flow LVAD whose cognition was measured before and after implantation. We searched Medline, EMBASE, SCOPUS, and the Cochrane library (start of database to July 16, 2021) for longitudinal, peer-reviewed studies written in English. RESULTS Cognitive improvement after LVAD implantation was observed in the case series, with improvement on phonemic fluency and digit symbol coding assessments. Two out of 4 cases in the case series improved on Clinical Dementia Rating: one from moderate dementia to mild cognitive impairment and another from mild cognitive impairment to unimpaired. Seven studies were included in the systematic review and were heterogeneous regarding cognitive tests employed, follow-up period, and measured outcomes. Montreal Cognitive Assessment and Trail-Making Test Part B were used most commonly. Cognitive improvement was reported in all 7 studies with at least 1 study reporting statistically significant improvements in each the following cognitive domains: delayed and immediate recall, executive function, visuospatial function, verbal function, attention, and processing speed. Most studies had small sample sizes and lacked a control group. CONCLUSIONS LVAD implantation appears to be associated with improved cognition. Adequately powered, prospective studies are needed to examine the effect of LVAD on cognitive function in patients with heart failure. Additionally, studies that directly examine cerebral blood flow in conjunction with cognitive assessment are needed to establish the relationship between the reversal of cerebral hypoperfusion and improved cognition.
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Affiliation(s)
- Joy J Choi
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | - Amanda Rubano
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Patrick Walsh
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Jeffrey D Alexis
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Hochang B Lee
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
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Duque ER, Alvarez P, Yang Y, Khalid M, Kshetri R, Doulamis IP, Panos A, Briasoulis A. Impact of Pre-Operative Right Ventricular Response to Hemodynamic Optimization on Outcomes in Patients with LVADs. J Clin Med 2022; 11:jcm11206111. [PMID: 36294432 PMCID: PMC9605231 DOI: 10.3390/jcm11206111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ±12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14−16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24−13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6−25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation.
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Affiliation(s)
- Ernesto Ruiz Duque
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Yingchi Yang
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Muhammad Khalid
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Rupesh Kshetri
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Ilias P. Doulamis
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Anthony Panos
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +319-678-8418; Fax: +319-353-6343
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Post-Implant Phosphodiesterase-5 Inhibitors in Patients with Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11205988. [PMID: 36294308 PMCID: PMC9604415 DOI: 10.3390/jcm11205988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the improvement in left ventricular assist device (LVAD) technology and the advent of third-generation LVADs, hemocompatibility-related events remain a significant issue. Therefore, new pharmacological treatments are necessary to optimize patient management and to further reduce hemocompatibility-related events. The purpose of the present systematic review and meta-analysis was to summarize the existing data regarding the safety and efficacy of post-implant phosphodiesterase-5 inhibitors (PDE-5i) on hemocompatibility-related events. Methods: Among the 258 articles in Pubmed, Scopus, and CENTRAL that were retrieved (1990−2022), 15 studies were included in the qualitative synthesis, and 9 studies were included in the quantitative synthesis. The fixed-effects model was used because it is statistically sound for combining a very small number of studies. The primary endpoint of the study was all-cause mortality, whereas the secondary endpoints were ischemic stroke, pump thrombosis, and gastrointestinal bleeding. Results: Mortality was significantly lower in the PDE-5i group vs. the control group (OR: 0.92 [95% CI: 0.85, 0.98]; p = 0.02). The secondary endpoints ischemic stroke (OR: 0.87 [95% CI: 0.78, 0.98]; p = 0.02) and pump thrombosis (OR: 0.90 [95% CI: 0.82, 0.99]; p = 0.04) were also lower in the PDE-5i group. The incidence of gastrointestinal bleeding was significantly higher in patients with LVAD receiving PDE-5i (OR: 1.26 [95% CI: 1.11, 1.44]; p < 0.01). In the overall analysis, the heterogeneity of outcomes was low, except for pump thrombosis. Conclusions: The use of PDE-5i post-implant was associated with lower mortality and thrombotic events but with a higher risk of gastrointestinal bleeding.
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Mehra MR, Goldstein DJ, Cleveland JC, Cowger JA, Hall S, Salerno CT, Naka Y, Horstmanshof D, Chuang J, Wang A, Uriel N. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA 2022; 328:1233-1242. [PMID: 36074476 PMCID: PMC9459909 DOI: 10.1001/jama.2022.16197] [Citation(s) in RCA: 159] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Although durable left ventricular assist device (LVAD) therapy has emerged as an important treatment option for patients with advanced heart failure refractory to pharmacological support, outcomes, including survival, beyond 2 years remain poorly characterized. OBJECTIVE To report the composite end point of survival to transplant, recovery, or LVAD support free of debilitating stroke (Modified Rankin Scale score >3) or reoperation to replace the pump 5 years after the implant in participants who received the fully magnetically levitated centrifugal-flow HeartMate 3 or axial-flow HeartMate II LVAD in the MOMENTUM 3 randomized trial and were still receiving LVAD therapy at the 2-year follow-up. DESIGN, SETTING, AND PARTICIPANTS This observational study was a 5-year follow-up of the MOMENTUM 3 trial, conducted in 69 US centers, that demonstrated superiority of the centrifugal-flow LVAD to the axial-flow pump with respect to survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump at 2 years. A total of 295 patients were enrolled between June 2019 to April 2021 in the extended-phase study, with 5-year follow-up completed in September 2021. EXPOSURES Of 1020 patients in the investigational device exemption per-protocol population, 536 were still receiving LVAD support at 2 years, of whom 289 received the centrifugal-flow pump and 247 received the axial-flow pump. MAIN OUTCOMES AND MEASURES There were 10 end points evaluated at 5 years in the per-protocol population, including a composite of survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump between the centrifugal-flow and axial-flow pump groups and overall survival between the 2 groups. RESULTS A total of 477 patients (295 enrolled and 182 provided limited data) of 536 patients still receiving LVAD support at 2 years contributed to the extended-phase analysis (median age, 62 y; 86 [18%] women). The 5-year Kaplan-Meier estimate of survival to transplant, recovery, or LVAD support free of debilitating stroke or reoperation to replace the pump in the centrifugal-flow vs axial-flow group was 54.0% vs 29.7% (hazard ratio, 0.55 [95% CI, 0.45-0.67]; P < .001). Overall Kaplan-Meier survival was 58.4% in the centrifugal-flow group vs 43.7% in the axial-flow group (hazard ratio, 0.72 [95% CI, 0.58-0.89]; P = .003). Serious adverse events of stroke, bleeding, and pump thrombosis were less frequent in the centrifugal-flow pump group. CONCLUSIONS AND RELEVANCE In this observational follow-up study of patients from the MOMENTUM 3 randomized trial, per-protocol analyses found that receipt of a fully magnetically levitated centrifugal-flow LVAD vs axial-flow LVAD was associated with a better composite outcome and higher likelihood of overall survival at 5 years. These findings support the use of the fully magnetically levitated LVAD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02224755 and NCT03982979.
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Affiliation(s)
| | | | | | | | | | | | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Medical College, New York, New York
| | | | | | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, New York
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Goodman D, Stulak J, Rosenbaum AN. Left ventricular assist devices: A historical perspective at the intersection of medicine and engineering. Artif Organs 2022; 46:2343-2360. [PMID: 35929377 DOI: 10.1111/aor.14371] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
Abstract
Over the last half-century, left ventricular assist device (LVAD) technology has progressed from conceptual therapy for failed cardiopulmonary bypass weaning to an accepted destination therapy for advanced heart failure. The history of LVAD engineering is defined by an initial development phase, which demonstrated the feasibility of such an approach, to the more recent three major generations of commercial devices. In this review, we explore the engineering challenges of LVADs, how they were addressed over time, and the clinical outcomes that resulted from each major technological development. The first generation of commercial LVADs were pulsatile devices, which lacked the appropriate durability due to their number of moving components and hemocompatibility. The second generation of LVADs was defined by replacement of complex, pulsatile pumps with primarily axial, continuous-flow systems with an impeller in the blood passageway. These devices experienced significant commercial success, but the presence of excessive trauma to the blood and in-situ bearing resulted in an unacceptable burden of adverse events. Third generation centrifugal-flow pumps use magnetically suspended rotors within the pump chamber. Superior outcomes with this newest generation of devices have been observed, particularly with respect to hemocompatibility-related adverse events including pump thrombosis, with fully magnetically levitated devices. The future of LVAD engineering includes wireless charging foregoing percutaneous drivelines and more advanced pump control mechanisms, including synchronization of the pump flow with the native cardiac cycle, and varying pump output based on degree of physical exertion using sensor or advanced device-level data triggers.
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Affiliation(s)
- Daniel Goodman
- College of Osteopathic Medicine, Des Moines University, Des Moines, Iowa, USA
| | - John Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Diseases, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Vidula H, Takeda K, Estep JD, Silvestry SC, Milano C, Cleveland JC, Goldstein DJ, Uriel N, Kormos RL, Dirckx N, Mehra MR. Hospitalization Patterns and Impact of a Magnetically-Levitated Left Ventricular Assist Device in the MOMENTUM 3 Trial. JACC. HEART FAILURE 2022; 10:470-481. [PMID: 35772857 DOI: 10.1016/j.jchf.2022.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND In the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) pivotal trial, the HeartMate 3 (HM3) fully magnetically levitated left ventricular assist device (LVAD) demonstrated superiority over the axial-flow HeartMate II (HMII) LVAD. The patterns and predictors of hospitalizations with the HM3 LVAD have not been characterized. OBJECTIVES This study sought to determine causes, predictors, and impact of hospitalizations during LVAD support. METHODS Patients discharged after LVAD implantation were analyzed. In the pivotal trial, 485 recipients of HM3 were compared with 471 recipients of HMII. The pivotal trial HM3 group was also compared to 949 recipients of HM3 in the postapproval phase within the trial portfolio. Predictors of cause-specific rehospitalization were analyzed. RESULTS The rates of rehospitalization were lower with HM3 LVAD than with HMII LVAD in the pivotal trial (225.7 vs 246.4 events per 100 patient-years; P < 0.05). Overall, rehospitalization rates and duration were similar in the HM3 postapproval phase and pivotal trial but prolonged hospitalizations (>7 days) were less frequent (rate ratio: 0.90 [95% CI: 0.80-0.98]; P < 0.05). In HM3 recipients, the most frequent causes of rehospitalization included infection, heart failure (HF)-related events, and bleeding. First rehospitalization caused by HF-related event versus other causes was associated with reduced survival (HR: 2.2 [95% CI: 1.3-3.9]; P = 0.0014). Male sex, non-White race, presence of cardiac resynchronization therapy/implantable cardioverter-defibrillator, obesity, higher right atrial pressure, smaller LV size, longer duration of index hospitalization, and lower estimated glomerular filtration rate at index discharge predicted HF hospitalizations. CONCLUSIONS Contemporary support with the HM3 fully magnetically levitated LVAD is associated with a lower hospitalization burden than with prior pumps; however, rehospitalizations for infection, HF, and bleeding remain important challenges for progress in the patient journey. (MOMENTUM 3 IDE Clinical Study, NCT02224755; MOMENTUM 3 Continued Access Protocol [MOMENTUM 3 CAP], NCT02892955).
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Affiliation(s)
- Himabindu Vidula
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Jerry D Estep
- Kaufman Center for Heart Failure and Recovery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott C Silvestry
- Thoracic Transplant, Thoracic, and Cardiovascular Surgery Program, AdventHealth Transplant Institute, Orlando, Florida, USA
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel J Goldstein
- Department of Cardiothoracic Surgery, Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | | | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
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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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Outcomes in Smaller Body Size Adults after HeartMate 3 Left Ventricular Assist Device Implantation. Ann Thorac Surg 2022; 114:2262-2269. [PMID: 35452663 DOI: 10.1016/j.athoracsur.2022.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/21/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Outcomes in patients with smaller body size following HeartMate 3 Left Ventricular Assist Device (HM3) implantation are not well characterized. We sought to evaluate outcomes in smaller vs. larger BSA patients in the MOMENTUM 3 pivotal trial and its Continued Access Protocol cohort. METHODS The analysis cohort included 1015 HM3 patients divided into 2 groups: BSA≤1.70 m2 (small patients, n=82) and BSA>1.70 m2 (large patients, n=933). The composite primary endpoint was survival at 2-years free of disabling stroke or reoperation to replace or remove a malfunctioning device. Adverse events were compared between groups. RESULTS Smaller patients were more frequently women (56.1% vs. 17.7%, P<.001), had lower prevalence of diabetes (28.1% vs. 43.9%, P=.005) and hypertension (51.2% vs. 71.9%, P<.001), larger median indexed LVEDD (normalized by BSA, 40 vs. 33 mm/m2, P<.001), and lower median serum creatinine (1.1 vs. 1.3 mg/dl, P<.001). The proportion of patients achieving the composite endpoint at 2-years was 77% in both groups (adjusted HR = 1.14 [95% confidence interval: 0.68-1.91], P=.62). Two-year adverse event rates were also similar between groups except for sepsis (6.1% vs. 14.9%, P=.029) and cardiac arrhythmias (24.4% vs. 35.3%, P=.005), which were higher in the larger patients. CONCLUSIONS Outcomes following HM3 implantation were comparable between small and large patients. Smaller body size should not be used to deny HM3 implantation in patients who are otherwise suitable durable MCS candidates.
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