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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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Dandel M. Role of Echocardiography in the Management of Patients with Advanced (Stage D) Heart Failure Related to Nonischemic Cardiomyopathy. Rev Cardiovasc Med 2022; 23:214. [PMID: 39077176 PMCID: PMC11273760 DOI: 10.31083/j.rcm2306214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 07/31/2024] Open
Abstract
Echocardiography (ECHO) is indispensable for evaluation of patients with terminal chronic heart failure (HF) who require transplantation or mechanical circulatory support by a left- or biventricular assist device (LVAD or BiVAD, respectively). In LVAD candidates, ECHO represents the first-line investigation necessary for a timely discovery of heart-related risk factors for potentially life-threatening post-operative adverse events, including identification of patients who necessitate a biventricular support. ECHO is also required for intra-operative guiding of VAD implantation and finding of the most appropriate setting of the device for an optimal ventricular unloading, postoperative surveillance of the VAD support, and monitoring of the RV changes in LVAD recipients. Thanks to the ECHO, which has decisively contributed to the proof that prolonged VAD support can facilitate cardiac reverse remodeling and functional improvement to levels which allow successful weaning of carefully selected patients from LVAD or BiVAD, the previous opinion that chronic non-ischemic cardiomyopathy (NICMP) is irreversible could be refuted. In patients with normalized and stable right heart catheter-derived hemodynamic parameters obtained at short-term interruptions of VAD support, ECHO has proved able to predict post-weaning long-term freedom from HF recurrence in patients with pre-implant terminal chronic NICMP. The purpose of this article is to offer an actualized theoretical and practical support for clinicians engaged in this particularly challenging and topical issue especially due to the new practical aspects which have emerged in conjunction with the growing use of long-term ventricular assist devices as bridge-to-transplantation or as destination therapy, as well as the increasing evidence that, in some patients, such VAD can become a bridge-to-recovery, allowing the removal of the device after a longer support time.
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Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK) Partner Site Berlin, 10785 Berlin, Germany
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Hemamalini P, Dutta P, Attawar S. JARVIK 2000 implantation in adolescent heart: A transesophageal echo experience. Ann Card Anaesth 2021; 23:344-346. [PMID: 32687096 PMCID: PMC7559978 DOI: 10.4103/aca.aca_191_18] [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] [Indexed: 11/30/2022] Open
Abstract
Left ventricular assist devices (LVAD) have gained widespread use as an effective clinical therapy for patients with heart failure (INTERMACS 1-5) and are the standard of care for bridging patients to cardiac transplantation. Pre-implantation transesophageal echocardiography (TEE) allows interrogation of all cardiac structures and identifies potential problems such as intracardiac shunts, thrombi, aortic insufficiency, and right ventricular dysfunction that need palliation. Post-implantation exam helps in weaning from cardiopulmonary bypass (CPB) and successful LVAD initiation. ICU monitoring with TEE guides optimal intervention and should be considered in selected patients. TEE will continue to remain vital to successful outcomes in LVAD patients.
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Affiliation(s)
- P Hemamalini
- Department of Cardiac Anesthesia, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Prabhat Dutta
- Department of Transplant Anesthesia and Critical Care, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Sandeep Attawar
- Department of Cardiac Sciences Thoracic Organ Transplants, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
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Maekawa M, Minami K, Yoshitani K, Watanabe K, Kanazawa H, Tadokoro N, Fukushima S, Fujita T, Ohnishi Y. Correlation Between Intraventricular Pressure Difference and Indexed Flow of a Left Ventricular Assist Device. J Cardiothorac Vasc Anesth 2021; 35:3626-3630. [PMID: 34130898 DOI: 10.1053/j.jvca.2021.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES There is no definitive parameter for left ventricular (LV) preload in patients with a continuous-flow left ventricular assist device (LVAD). The intraventricular pressure difference (IVPD) is the maximum pressure difference between the mitral valve and LV apex during diastole; and, in past studies, the IVPD was influenced by volume loading. The authors hypothesized that IVPD in LVAD patients correlates with indexed LVAD flow and that IVPD can serve as a novel parameter of LV preload in this population. DESIGN A single-center, retrospective, observational study. SETTING A tertiary-care hospital from August 2019 to July 2020. PARTICIPANTS Sixteen ramp tests for adjustment of LVAD pump speed in 14 adult patients undergoing continuous-flow LVAD implantation. INTERVENTIONS Measurement of IVPD during ramp tests. MEASUREMENTS AND MAIN RESULTS LVAD flow and IVPD were measured at each LVAD pump speed during the ramp test for the adjustment of LVAD pump speed after patients came off cardiopulmonary bypass during LVAD implantation. A straight, longitudinal view of the left atrium and left ventricle was obtained, and the pressure difference between the mitral valve and LV apex during diastole was measured by transesophageal echocardiography. The maximum pressure difference during diastole was recorded as IVPD. The relationship between indexed LVAD flow (LVAD flow/body surface area) and IVPD was assessed by a multivariate nonlinear regression analysis with the Huber-White sandwich estimator. IVPD correlated with indexed LVAD flow (p < 0.001). CONCLUSIONS IVPD is a useful indicator of LV preload during LVAD implantation.
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Affiliation(s)
- Masaki Maekawa
- Department of Anesthesiology, Toranomon Hospital, Tokyo, Japan
| | - Kimito Minami
- Department of Surgical Intensive Care, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenji Watanabe
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroko Kanazawa
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoki Tadokoro
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
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Patients with left ventricle assist devices presenting for thoracic surgery and lung resection: tips, tricks and evidence. Curr Opin Anaesthesiol 2020; 33:17-26. [PMID: 31815821 DOI: 10.1097/aco.0000000000000817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Over a thousand left ventricular-assist device (LVAD) implants were performed for heart failure destination therapy in 2017. With increasing survival, we are seeing increasing numbers of patients present for noncardiac surgery, including resections for cancer. This article will review the relevant literature and guidelines for patients with LVADs undergoing thoracic surgery, including lung resection. RECENT FINDINGS The International Society for Heart and Lung Transplant Mechanically Assisted Circulatory Support Registry has received data on more than 16 000 patients with LVADs. Four-year survival is more than 60% for centrifugal devices. There are increasing case reports, summaries and recommendations for patients with LVADs undergoing noncardiac surgery. However, data on thoracic surgery is restricted to case reports. SUMMARY Successful thoracic surgery requires understanding of the LVAD physiology. Modern devices are preload dependent and afterload sensitive. The effects of one-lung ventilation, including hypoxia and hypercapnia, may increase pulmonary vascular resistance and impair the right ventricle. Successful surgery necessitates a multidisciplinary approach, including thorough preoperative assessment; optimization and planning of intraoperative management strategies; and approaches to anticoagulation, right ventricular failure and LVAD flow optimization. This article discusses recent evidence on these topics.
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De Lazzari C, Capoccia M, Marconi S. How can LVAD support influence ventricular energetics parameters in advanced heart failure patients? A retrospective study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 172:117-126. [PMID: 30902123 DOI: 10.1016/j.cmpb.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Here we present a retrospective analysis of six heart failure patients previously discussed at a multidisciplinary team meeting. Only three out of six patients underwent LVAD insertion as the most appropriate management option. METHODS We sought to reproduce the baseline conditions of these patients on hospital admission using our cardiovascular software simulator (CARDIOSIM©). Subsequently, we simulated the effects of LVAD support and drug administration on left and right ventricular energetics parameters. LVAD assistance was delivered by CARDIOSIM© based on the module reproducing the behaviour of the Berlin Heart INCOR pump. RESULTS The results of our simulations were in agreement with the multidisciplinary team meeting outcome. The analysis of ventricular energetics parameters based on external work and pressure volume area confirmed LVAD support as a beneficial therapeutic option for the three patients considered eligible for this type of treatment. The effects induced by LVAD support and drugs administration showed specific patterns between the two groups of patients. CONCLUSION A quantitative approach with the ability to predict outcome during patient's assessment may well be an aid and not a substitute for clinical decision-making.
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Affiliation(s)
- Claudio De Lazzari
- National Research Council, Institute of Clinical Physiology (IFC-CNR), Via Palestro, 32, 00185 Rome, Italy; National Institute for Cardiovascular Research (I.N.R.C.), Via Irnerio, 48, 40126 Bologna, Italy.
| | - Massimo Capoccia
- Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK; Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
| | - Silvia Marconi
- National Research Council, Institute of Clinical Physiology (IFC-CNR), Via Palestro, 32, 00185 Rome, Italy.
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Zormpas C, Mueller-Leisse J, Koenig T, Schmitto JD, Veltmann C, Duncker D. Electrocardiographic changes after implantation of a left ventricular assist device - Potential implications for subcutaneous defibrillator therapy. J Electrocardiol 2018; 52:29-34. [PMID: 30476635 DOI: 10.1016/j.jelectrocard.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Implantation of a left ventricular assist device (LVAD) leads to a diverse spectrum of changes on the twelve-lead surface electrocardiogram (ECG). We aimed to elucidate the changes of the surface ECG in patients after LVAD implantation potentially impacting ECG based screening tests of subcutaneous implantable cardioverter-defibrillators (S-ICD). METHODS Patients from 2005 until 2017 with a documented twelve-lead ECG before and after LVAD implantation were included. Baseline parameters were obtained through hospital records. The twelve-lead ECGs registered before and after LVAD implantation were analyzed. RESULTS From 415 patients undergoing an LVAD implantation, complete datasets were available for 253 patients. 216 patients (85%) were male. Mean age at time of LVAD implantation was 54.7 ± 12.4 years. The underlying etiology was ischemic cardiomyopathy in 119 (47%), dilated cardiomyopathy in 112 (44%), myocarditis in 8 (3%) and other in 14 (6%). We observed a reduction in the amplitude of the R wave in lead I (p < 0.0001), lead II (p < 0.0001), lead III (p < 0.004), lead aVL (p < 0.001) and lead aVF (p < 0.0001) as well as of the S wave in lead III (p < 0.001) and lead aVR (p < 0.0001) after LVAD implantation. We also noticed a reduction of the R:T ratio in lead I (p < 0.0001) as well as in lead II (p = 0.100) and lead aVF (p = 0.292) although statistically non-significant. CONCLUSION LVAD implantation leads to significant alterations of the surface ECG, especially the R:T ratio in leads I, II and aVF. These leads correlate with the vectors of the ECG based S-ICD screening test. Thus, these ECG changes may impact the continuous eligibility for subcutaneous ICD therapy in patients after LVAD implantation.
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Affiliation(s)
- Christos Zormpas
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johanna Mueller-Leisse
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Thorben Koenig
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiac, Thoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Veltmann
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - David Duncker
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
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8
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Demirozu ZT, Arat N, Kucukaksu DS. Fine-tuning management of the Heart Assist 5 left ventricular assist device with two- and three-dimensional echocardiography. Cardiovasc J Afr 2016; 27:208-212. [PMID: 27841907 PMCID: PMC5340905 DOI: 10.5830/cvja-2015-083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 11/14/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction: Left ventricular assist device (LVAD) implantation is a viable therapy for patients with severe end-stage heart failure, providing effective haemodynamic support and improved quality of life. The Heart Assist 5 (Micromed Cardiovascular Inc, Houston, TX) continuous-flow LVAD has been on the market in Europe since May 2009. Methods: We evaluated nine Heart Assist 5 LVAD patients with two- and three-dimensional transthoracic echocardiographic (TTE) and transoesophageal echocardiographic (TEE) parameters between December 2011 and December 2013. The pre-operative TTE LVAD evaluations included left ventricular (LV) function and structure, quantification of right ventricular (RV) function and tricuspid regurgitation (TR), assessment of aortic and mitral regurgitation, and presence of patent foramen ovale and intra-cardiac clots. Peri-operative TEE determined the inflow cannula and septum position, and assessed the de-airing process while weaning from cardiopulmonary bypass. Post-operative serial follow-up TTE showed the surgical results of LVAD implantation, determined the overall structure and function of the LV, RV and TR, and observed the inflow and outflow cannula position. Results: Nine patients who had undergone Heart Assist 5 LVAD implantation and had been followed up for more than 30 days were included in this study. Eight patients had ischaemic cardiomyopathy and one had adriamycin-induced cardiomyopathy. Pre-implantation data: the mean age of the patients was 52 ± 13 (34–64) years, mean body surface area (BSA) was 1.8 ± 0.2 (1.6–2.0) m2, mean cardiac index (CI) was 2.04 ± 0.4 (1.5–2.6) l/min/m2, mean cardiac output (CO) was 3.7 ± 0.7 (2.6–4.2) l/min, mean ejection fraction (EF) was 23 ± 5 (18–28)%, and right ventricular fractional area contraction (RVFAC) was 43 ± 9 (35–55)%. One patient had aortic valve replacement (AVR) during the LVAD implantation, and excess current alarms and increased power were suspected to be caused by a possible thrombus. Close follow up with TTE studies were carried out to clear the LV of thrombus formation, and the inflow cannula position was checked to maintain the septum in the midline, so preventing the suction cascade. Four patients were followed up for more than two years, and two were followed up for more than a year. Three patients died due to multi-organ failure. Follow-up speed-change TTE studies of six patients showed that the mean speed was 9 800 ± 600 (9 500–10 400) rpm, and mean CO was 4.7 ± 0.3 (4.3– 5.0) l/min during the three-month post-implant period. Conclusion: We believe that TTE can play a major role in managing LVAD patients to achieve optimal settings for each patient. A large series is mandatory for assessment of echocardiographic studies on Heart Assist 5 LVAD.
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Affiliation(s)
- Zumrut Tuba Demirozu
- Department of Heart Transplant and Mechanical Circulatory Support, Istanbul Bilim Medical Faculty, Sisli Florence Nightingale Hospital, Istanbul, Turkey; Department of Cardiovascular Surgery, Koc University Hospital, Istanbul, Turkey.
| | - Nurcan Arat
- Department of Cardiology, Istanbul Bilim Medical Faculty, Sisli Florence Nightingale Hospital, Istanbul, Turkey
| | - Deniz Suha Kucukaksu
- Department of Heart Transplant and Mechanical Circulatory Support, Istanbul Bilim Medical Faculty, Sisli Florence Nightingale Hospital, Istanbul, Turkey
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Blum FE, Weiss GM, Cleveland JC, Weitzel NS. Postoperative Management for Patients With Durable Mechanical Circulatory Support Devices. Semin Cardiothorac Vasc Anesth 2016; 19:318-30. [PMID: 26660056 DOI: 10.1177/1089253214568528] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mechanical circulatory support devices have been approved as bridge to transplantation, as bridge to recovery, or as destination therapy to treat end-stage heart failure. The perioperative challenges for the anesthesiologist and the intensivist caring for these patients include device-related complications, hemodynamic instability, arrhythmias, right ventricular failure, and coagulopathy. Perioperative management in this high-risk population has a significant impact on patient outcomes. This review focuses immediate postoperative intensive care unit management of device-related complications.
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The emergency management of ventricular assist devices. Am J Emerg Med 2016; 34:1294-301. [DOI: 10.1016/j.ajem.2016.04.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 04/11/2016] [Accepted: 04/20/2016] [Indexed: 11/18/2022] Open
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Grinstein J, Kruse E, Collins K, Sayer G, Fedson S, Kim GH, Sarswat N, Adatya S, Ota T, Jeevanandam V, Mor-Avi V, Uriel N, Lang RM. Screening for Outflow Cannula Malfunction of Left Ventricular Assist Devices (LVADs) With the Use of Doppler Echocardiography: New LVAD-Specific Reference Values for Contemporary Devices. J Card Fail 2016; 22:808-14. [PMID: 27288845 DOI: 10.1016/j.cardfail.2016.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/06/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Echocardiographic assessment of left ventricular assist devices (LVADs) is used as a screening tool to evaluate the integrity and mechanics of the pump and circuit. We aimed to 1) establish the normal range and upper reference limit of peak velocity of the outflow cannula for the modern era of LVADs and 2) assess the clinical performance of the currently cited and newly proposed reference limits in patients with continuous-flow LVADs as a screening tool for cannula malfunction. METHODS LVAD outflow peak CW velocities were measured with the use of Doppler transthoracic echocardiography (TTE) in 57 patients with LVADs (44 with Heartmate II (HM2), 13 with Heartware (HW)). The average velocity and the upper and lower normal reference limits (defined as ±2 standard deviations from the mean) for each LVAD type was calculated. The upper reference limit was then used as a screening threshold for cannula malfunction. RESULTS The average outflow cannula peak velocity for the normal HM2 cohort was 1.86 ± 0.44 m/s with upper and lower reference limits of 2.73 m/s and 0.98 m/s, respectively. The average outflow cannula peak velocity for the normal HW cohort was 2.36 ± 0.53 m/s with upper and lower reference limits of 3.42 m/s and 1.3 m/s, respectively, which was significantly higher than the HM2 cohort (P = .004). CONCLUSIONS In both HM2 and HW LVADs, the average peak outflow velocity and reference limit for the normal population, as measured by Doppler TTE, was markedly higher than the currently used LVAD reference limits of 2 m/s and are significantly different between devices. Patients with peak outflow velocities above our upper reference limits should be evaluated for LVAD outflow cannula malfunction.
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Affiliation(s)
- Jonathan Grinstein
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Eric Kruse
- University of Chicago Medical Center, Chicago, Illinois
| | - Keith Collins
- University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Savitri Fedson
- Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, TX
| | - Gene H Kim
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nitasha Sarswat
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sirtaz Adatya
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- University of Chicago Medical Center, Chicago, Illinois; Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Valluvan Jeevanandam
- University of Chicago Medical Center, Chicago, Illinois; Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
| | - Roberto M Lang
- University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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Willemsen D, Cordes C, Bjarnason-Wehrens B, Knoglinger E, Langheim E, Marx R, Reiss N, Schmidt T, Workowski A, Bartsch P, Baumbach C, Bongarth C, Phillips H, Radke R, Riedel M, Schmidt S, Skobel E, Toussaint C, Glatz J. [Rehabilitation standards for follow-up treatment and rehabilitation of patients with ventricular assist device (VAD)]. Clin Res Cardiol Suppl 2016; 11 Suppl 1:2-49. [PMID: 26882905 DOI: 10.1007/s11789-015-0077-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.
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Affiliation(s)
- Detlev Willemsen
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland.
| | - C Cordes
- Gollwitzer-Meier-Klinik, Bad Oeynhausen, Deutschland
| | - B Bjarnason-Wehrens
- Institut für Kreislaufforschung und Sportmedizin, Deutsche Sporthochschule Köln, Köln, Deutschland
| | | | - E Langheim
- Reha-Zentrum Seehof der DRV-Bund, Teltow, Deutschland
| | - R Marx
- MediClin Fachklinik Rhein/Ruhr, Essen, Deutschland
- Universität Witten/Herdecke, Witten, Deutschland
| | - N Reiss
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - T Schmidt
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - A Workowski
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - P Bartsch
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - C Baumbach
- Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Deutschland
| | - C Bongarth
- Klinik Höhenried, Bernried am Starnberger See, Deutschland
| | - H Phillips
- Reha Parcs Steinhof, Erkrath, Deutschland
| | - R Radke
- Christiaan-Barnard-Klinik, Dahlen-Schmannewitz, Dahlen, Deutschland
| | - M Riedel
- Klinik Fallingbostel, Bad Fallingbostel, Deutschland
| | - S Schmidt
- Gollwitzer-Meier-Klinik, Bad Oeynhausen, Deutschland
| | - E Skobel
- Rehaklinik "An der Rosenquelle", Aachen, Deutschland
| | - C Toussaint
- m&i Fachklinik Herzogenaurach, Herzogenaurach, Deutschland
| | - J Glatz
- Reha-Zentrum Seehof der DRV-Bund, Teltow, Deutschland
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14
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Vilaro JR, Szady A, Ahmed MM, Dawson J, Aranda JM. Continuous Flow Left Ventricular Assist Device Therapy: A Focused Review on Optimal Patient Selection and Long-Term Follow-up Using Echocardiography. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2015. [DOI: 10.15212/cvia.2015.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Gupta B, Jacob D, Thompson R. Imaging in patients after cardiac transplantation and in patients with ventricular assist devices. J Nucl Cardiol 2015; 22:617-38. [PMID: 25832983 DOI: 10.1007/s12350-015-0115-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/29/2015] [Indexed: 02/06/2023]
Abstract
The field of cardiac imaging and the management of patients with severe heart failure have advanced substantially during the past 10 years. Cardiac transplantation offers the best long-term survival with high quality of life for the patients with end stage heart failure. However, acute cardiac rejection and cardiac allograft vasculopathy (CAV) can occur post cardiac transplantation and these problems necessitate regular surveillance. The short-term success of mechanical circulatory support devices (MCSD), such as ventricular assist devices (VADs), in improving survival and quality of life has led to a dramatic growth of the patient population with these devices. The development of optimal imaging techniques and algorithms to evaluate these advanced heart failure patients is evolving and multimodality non-invasive imaging approaches and invasive techniques are commonly employed. Most of the published studies done in the transplant and VAD population are small, and biased based on the strength of the particular program, and there is a relative lack of published protocols to evaluate these patient groups. Moreover, the techniques of echocardiography, computed tomography (CT), magnetic resonance imaging, and nuclear cardiology have all progressed rapidly in recent years. There is thus a knowledge gap for cardiologists, radiologists, and clinicians, especially regarding surveillance for CAV and ideal imaging approaches for patients with VADs. The purpose of this review article is to provide an overview of different noninvasive imaging modalities used to evaluate patients after cardiac transplantation and for patients with VADs. The review focuses on the role of echocardiography, CT, and nuclear imaging in surveillance for CAV and rejection and on the assessment of ventricular structure and function, myocardial remodeling and complications for VAD patients.
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Affiliation(s)
- Bhanu Gupta
- Department of Cardiology, St. Luke's Mid America Heart Institute, 4330 Wornall Rd, Suite 2000, Kansas City, MO, USA
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16
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Cohen DG, Thomas JD, Freed BH, Rich JD, Sauer AJ. Echocardiography and Continuous-Flow Left Ventricular Assist Devices. JACC-HEART FAILURE 2015; 3:554-564. [DOI: 10.1016/j.jchf.2015.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/13/2015] [Accepted: 03/06/2015] [Indexed: 10/23/2022]
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17
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Khachatryan T, Beigel R, Arsanjani R, Siegel RJ. The 'Inextricabilis Syndrome': a case with no solution. Echo Res Pract 2014; 1:K13-6. [PMID: 26693308 PMCID: PMC4676456 DOI: 10.1530/erp-14-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 11/04/2014] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED We describe a case of a 58-year-old man with cardiogenic shock who underwent triple vessel coronary artery bypass and a left ventricular assist device (LVAD) implantation. His course was complicated by stroke, worsening mitral regurgitation, aortic regurgitation, and multiple cardiac thrombi while on the device. We provide the details of the patient's hospital course, management, and echocardiographic findings. We also discuss the utility of echocardiography before LVAD insertion and its role for continued monitoring after insertion. LEARNING POINTS Ventricular assist devices (VADs) are used as bridge to decision, transplant, recovery, or destination therapy in patients with advanced heart failure and cardiogenic shock.VADs improve survival and the quality of life but have significant associated complications.Echocardiography plays an essential role before VAD insertion and for postoperative cardiac monitoring. Information provided by echocardiography is used in device selection, consideration for corrective surgical interventions, and device explantation.
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Affiliation(s)
- Tigran Khachatryan
- The Heart Institute, Cedars Sinai Medical Center , Los Angeles, California, 90048 , USA
| | - Roy Beigel
- The Heart Institute, Cedars Sinai Medical Center , Los Angeles, California, 90048 , USA
| | - Reza Arsanjani
- The Heart Institute, Cedars Sinai Medical Center , Los Angeles, California, 90048 , USA
| | - Robert J Siegel
- The Heart Institute, Cedars Sinai Medical Center , Los Angeles, California, 90048 , USA
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18
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Todaro MC, Khandheria BK, Paterick TE, Umland MM, Thohan V. The Practical Role of Echocardiography in Selection, Implantation, and Management of Patients Requiring LVAD Therapy. Curr Cardiol Rep 2014; 16:468. [DOI: 10.1007/s11886-014-0468-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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19
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Lee GY, Park SJ, Kim S, Choi N, Jeong DS, Jeon ES, Lee YT. The successful implantation of continuous-flow left ventricular assist device as a destination therapy in Korea: echocardiographic assessment. J Korean Med Sci 2014; 29:137-40. [PMID: 24431918 PMCID: PMC3890465 DOI: 10.3346/jkms.2014.29.1.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/04/2013] [Indexed: 11/20/2022] Open
Abstract
Left ventricular assist device (LVAD) is a good treatment option for the patients ineligible for cardiac transplantation. Several studies have demonstrated that a ventricular assist device improves the quality of life and prognosis of the patients with end-stage heart failure. A 75-yr-old man debilitated with New York Heart Association (NYHA) functional class III-IV due to severe left ventricular systolic dysfunction received LVAD implantation as a destination therapy. The patient was discharged with improved functional status (NYHA functional class II) after appropriate cardiac rehabilitation and education about how to manage the device and potential emergency situations. This is the first case of successful continuous-flow LVAD implantation as a destination therapy in Korea.
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Affiliation(s)
- Ga Yeon Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Cardiovascular Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Cardiovascular Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sujin Kim
- Cardiovascular Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Namgyung Choi
- Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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20
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Aortic valve opening and thrombotic events with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2014; 33:109-12. [DOI: 10.1016/j.healun.2013.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/12/2013] [Accepted: 07/16/2013] [Indexed: 11/21/2022] Open
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21
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Hessel EA. Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review. Semin Cardiothorac Vasc Anesth 2013; 18:57-70. [PMID: 24132353 DOI: 10.1177/1089253213506788] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
While originally primarily used as bridge to cardiac transplantation and bridge to recovery, more commonly ventricular assist devices (VADs) are being inserted as destination therapy. These patients are being discharged from transplant and mechanical assist centers, living as outpatients, and thus the pool of community-dwelling patients with VADs continues to expand. Not infrequently they present for surgical procedures either directly related to the device itself or more often incidental to the fact that they have a VAD. This scenario may be more common in patients with VADs placed for destination therapy because these patients tend to be older and have more comorbidities and are living longer with their device. Thus, it is important for all anesthesiologists to be aware of the special anesthesia needs of patients with VADs requiring noncardiac surgery.
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Affiliation(s)
- Eugene A Hessel
- 1University of Kentucky College of Medicine, Lexington, KY, USA
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22
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Use of Retrospectively Gated CT Angiography to Diagnose Systolic LVAD Inflow Obstruction. ASAIO J 2013; 59:542-6. [DOI: 10.1097/mat.0b013e3182a0d367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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23
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Cardiac Autonomic Dysfunction in the Early Phase after Left Ventricular Assist Device Implant: Implications for Surgery and Follow-Up? Int J Artif Organs 2013; 36:410-8. [DOI: 10.5301/ijao.5000210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2013] [Indexed: 11/20/2022]
Abstract
Purpose In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance. Methods HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 30 healthy subjects served as control groups. Inclusion criteria: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration. Results HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients. Conclusions In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.
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24
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Abstract
Although cardiac transplant remains the gold standard for the treatment of end-stage heart failure, limited donor organ availability and growing numbers of eligible recipients have increased the demand for alternative therapies. Limitations of first-generation left ventricular assist devices for long-term support of patients with end-stage disease have led to the development of newer second-generation and third-generation pumps, which are smaller, have fewer moving parts, and have shown improved durability, allowing for extended support. The HeartMate II (second generation) and HeartWare (third generation) are 2 devices that have shown great promise as potential alternatives to transplantation in select patients.
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Affiliation(s)
- Michelle Capdeville
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, 9500 Euclid Avenue, J4-331, Cleveland, OH 44195, USA.
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25
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Abstract
Right ventricular (RV) function is a strong independent predictor of outcome in a number of distinct cardiopulmonary diseases. The RV has a remarkable ability to sustain damage and recover function which may be related to unique anatomic, physiologic, and genetic factors that differentiate it from the left ventricle. This capacity has been described in patients with RV myocardial infarction, pulmonary arterial hypertension, and chronic thromboembolic disease as well as post-lung transplant and post-left ventricular assist device implantation. Various echocardiographic and magnetic resonance imaging parameters of RV function contribute to the clinical assessment and predict outcomes in these patients; however, limitations remain with these techniques. Early diagnosis of RV function and better insight into the mechanisms of RV recovery could improve patient outcomes. Further refinement of established and emerging imaging techniques is necessary to aid subclinical diagnosis and inform treatment decisions.
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Affiliation(s)
- Evan L Brittain
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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26
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Surgical treatment of tricuspid valve insufficiency promotes early reverse remodeling in patients with axial-flow left ventricular assist devices. J Thorac Cardiovasc Surg 2012; 143:1370-6. [DOI: 10.1016/j.jtcvs.2011.07.014] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/28/2011] [Accepted: 07/13/2011] [Indexed: 11/21/2022]
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27
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Role of echocardiography in the perioperative management of mechanical circulatory assistance. Best Pract Res Clin Anaesthesiol 2012; 26:199-216. [DOI: 10.1016/j.bpa.2012.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 02/01/2012] [Indexed: 11/23/2022]
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28
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Ammar KA, Umland MM, Kramer C, Sulemanjee N, Jan MF, Khandheria BK, Seward JB, Paterick TE. The ABCs of left ventricular assist device echocardiography: a systematic approach. Eur Heart J Cardiovasc Imaging 2012; 13:885-99. [PMID: 22581283 DOI: 10.1093/ehjci/jes090] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD) implantation for patients with advanced heart failure (HF) and for serial follow-up to make management decisions in patient care post-implant. Continuous axial-flow LVAD therapy provides effective haemodynamic support for the failing left ventricle, improving both the clinical functional status and quality of life. Echocardiographers must develop a systematic approach to echocardiographic assessment of LVAD implantation and post-LVAD implant cardiac morphology and physiology. This approach must include the evaluation of left and right heart chamber morphology and physiology and the anatomy and physiology of the inflow and outflow cannulas and the rotor pump, and the determination of the degree of tricuspid regurgitation and the presence of interatrial shunts and aortic regurgitation. Collaboration among the echocardiography and HF/transplant teams is essential to obtain this comprehensive evaluation. We outline a systematic approach to evaluating patients with HF who have failed conventional therapy and require LVAD therapy as a bridge to cardiac transplantation or destination therapy.
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Affiliation(s)
- Khawaja A Ammar
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, 2801 W. Kinnickinnic River Parkway, #845, Milwaukee, WI 53215, USA
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29
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Stout M, Ravindran R, Miller C, Pearce K. Preimplant transthoracic echocardiographic assessment of continuous flow left ventricular assist device. Echocardiography 2011; 29:52-8. [PMID: 22176345 DOI: 10.1111/j.1540-8175.2011.01533.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
For many patients with end-stage heart failure, heart transplantation is the only remaining option to prolong survival and provide symptom relief. Transthoracic echo is the modality of choice in assessing a patient for potential left ventricular assist device (LVAD) insertion. There are currently no guidelines available, and assessing this specific patient population can prove extremely challenging. As such, an understanding of LVAD mechanism, the important physiological consequences of device implantation together with the related echocardiographic examination is vital to accurately and effectively gauge correct patient selection and also improve implantation success. This review aims to highlight the common devices implanted, how these devices affect cardiac physiology and hemodynamics, and therefore discuss the major echocardiographic variables that should be assessed predevice implantation. (Echocardiography 2012;29:52-58).
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Affiliation(s)
- Martin Stout
- North West Heart Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, UK.
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30
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Topilsky Y, Hasin T, Oh JK, Borgeson DD, Boilson BA, Schirger JA, Clavell AL, Frantz RP, Tsutsui R, Liu M, Maltais S, Kushwaha SS, Pereira NL, Park SJ. Echocardiographic variables after left ventricular assist device implantation associated with adverse outcome. Circ Cardiovasc Imaging 2011; 4:648-61. [PMID: 21940507 DOI: 10.1161/circimaging.111.965335] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative mortality after left ventricular assist device (LVAD) implantation is heavily influenced by patient selection and the technical difficulty of surgery. However, how we treat our patients and LVAD setting may affect the patient outcome beyond this period. We postulated that the presence of echocardiographic variables 1 month after surgery suggesting appropriate degree of LV unloading and an adequate forward flow would be important in determining clinical outcomes after the initial successful LVAD implantation. METHODS AND RESULTS We retrospectively analyzed various variables in echocardiographic examinations performed 30 days after LVAD implant in 76 consecutive patients receiving continuous flow device for their association with a compound end point (90-day mortality, readmission for heart failure, or New York Heart Association class III or higher at the end of the 90-day period). The echocardiographic associations examined included estimated LVAD flow, with and without native LV contribution, interventricular septal position, the status of aortic valve opening, an estimated left atrial pressure (ELAP), the mitral flow E-wave deceleration time, and the ratio of deceleration time to E-wave velocity (mitral deceleration index [MDI]). Four patients died during the 30- to 90-day period, 6 patients were readmitted for heart failure, and 25 patients were considered to have New York Heart Association class III or higher at the end of the 90-day period. Variables associated with adverse outcome included increased ELAP (odds ratio, 1.30 [1.16-1.48]; P<0.0001), MDI <2 ms/[cm/s] (odds ratio, 4.4 implantation [1.22-18]; P=0.02) and decreased tricuspid lateral annulus velocity (odds ratio, 0.70 implantation [0.48-0.95]; P=0.02). A leftward deviation of interventricular septum was associated with a worse outcome (odds ratio, 3.03 implantation [1.21-13.3]; P=0.01). CONCLUSIONS Mortality and heart failure after LVAD surgery appear to be predominantly determined by echocardiographic evidence of inefficient unloading of the left ventricle and persistence of right ventricular dysfunction. Increased estimated LA pressure and short MDI are associated with worse mid term outcome. Leftward deviation of the septum is associated with worse outcome as well.
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Affiliation(s)
- Yan Topilsky
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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