1
|
Dandel M. Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy. J Clin Med 2023; 12:6451. [PMID: 37892589 PMCID: PMC10607800 DOI: 10.3390/jcm12206451] [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: 08/16/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
Long-term mechanical circulatory support by a left ventricular assist device (LVAD), with or without an additional temporary or long-term right ventricular (RV) support, is a life-saving therapy for advanced heart failure (HF) refractory to pharmacological treatment, as well as for both device and surgical optimization therapies. In patients with chronic non-ischemic cardiomyopathy (NICM), timely prediction of HF's transition into its end stage, necessitating life-saving heart transplantation or long-term VAD support (as a bridge-to-transplantation or destination therapy), remains particularly challenging, given the wide range of possible etiologies, pathophysiological features, and clinical presentations of NICM. Decision-making between the necessity of an LVAD or a biventricular assist device (BVAD) is crucial because both unnecessary use of a BVAD and irreversible right ventricular (RV) failure after LVAD implantation can seriously impair patient outcomes. The pre-operative or, at the latest, intraoperative prediction of RV function after LVAD implantation is reliably possible, but necessitates integrative evaluations of many different echocardiographic, hemodynamic, clinical, and laboratory parameters. VADs create favorable conditions for the reversal of structural and functional cardiac alterations not only in acute forms of HF, but also in chronic HF. Although full cardiac recovery is rather unusual in VAD recipients with pre-implant chronic HF, the search for myocardial reverse remodelling and functional improvement is worthwhile because, for sufficiently recovered patients, weaning from VADs has proved to be feasible and capable of providing survival benefits and better quality of life even if recovery remains incomplete. This review article aimed to provide an updated theoretical and practical background for those engaged in this highly demanding and still current topic due to the continuous technical progress in the optimization of long-term VADs, as well as due to the new challenges which have emerged in conjunction with the proof of a possible myocardial recovery during long-term ventricular support up to levels which allow successful device explantation.
Collapse
Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK), 10785 Berlin, Germany
| |
Collapse
|
2
|
Carr MJ, Smith SA, Slaughter MS, Pahwa S. Managing valvular pathology during LVAD implantation. Indian J Thorac Cardiovasc Surg 2023; 39:101-113. [PMID: 37525709 PMCID: PMC10387021 DOI: 10.1007/s12055-023-01567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
Since the time of their invention, implantable continuous flow left ventricular assist devices (LVADs) have improved the quality of life and extended survival for patients with advanced heart failure. The decision surgeons and their physician colleagues make with these patients to undergo implantation must come with full understanding of the immediate, short-term, and long-term implications of such a life-changing procedure. The presence of pathology regarding the aortic, mitral, and tricuspid valves introduces particularly complex problems for the surgical treatment strategy. Concomitant valve repair or replacement increases cardiopulmonary bypass and cross clamp times, and could potentially lead to worse outcomes in the perioperative setting. Following perioperative recovery, valvular pathology may worsen or arise de novo given the often drastic immediate physiologic changes in blood flow, septal function, and, over time, ventricular remodeling. Over the past two decades, there has been vast improvement in the device manufacturing, surgical techniques, and medical management surrounding LVAD implantation. Yet, addressing concomitant valvular pathology remains a complex question with no perfect solutions. This review aims to briefly describe the evolution of approach to valvular pathology in the LVAD patient and offer our opinion and treatment rationale.
Collapse
Affiliation(s)
- Michael J. Carr
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Susan Ansley Smith
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| |
Collapse
|
3
|
Pya Y, Mussayev A, Novikova S, Bekbossynova M, Alimbayev S, Khissamutdinov N, Kapyshev T, Kuanyshbek A, Lesbekov T. Case report: A novel surgical technique for rapid valve-in-ring implantation into the native aortic annulus during left ventricular assist device implantation. Front Cardiovasc Med 2023; 10:1091420. [PMID: 37089890 PMCID: PMC10117784 DOI: 10.3389/fcvm.2023.1091420] [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: 11/07/2022] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
The implantation of a left ventricular assist device (LVAD) has become an essential requirement for managing patients with end-stage heart failure. However, aortic valve insufficiency is a contraindication for LVAD implantation in patients with end-stage heart failure, partly because of the decreasing efficiency of mechanical circulatory support and the eventual development of right ventricular failure. Herein, we present the first case of performing transcatheter aortic valve replacement in valve-in-ring along with LVAD implantation for the treatment of a 60-year-old male suffering from refractory heart failure due to dilated cardiomyopathy and pure aortic insufficiency in need of a new aortic bioprosthesis. A balloon-expandable bioprosthetic transcatheter heart valve was implanted into a previously sewn annulus ring into the aortic root via transaortic access. Subsequently, a centrifugal-flow LVAD was implanted. Postoperatively, the patient was in New York Heart Association Functional Class (NYHA) II with 6-min walk test of 310 m. The patient has completed 6 months of follow-up with no events. This novel and feasible surgical technique reduced the cardiopulmonary bypass time and duration of surgery. Furthermore, it avoids the risk of redo sternotomy and decreases the chances of paravalvular leakage and worsening of aortic regurgitation.
Collapse
Affiliation(s)
- Yuriy Pya
- Department of Cardiac Surgery, National Research Cardiac Surgery Center, Astana, Kazakhstan
| | - Abdurashid Mussayev
- Department of Interventional Cardiology, National Research Cardiac Surgery Center, Astana, Kazakhstan
| | - Svetlana Novikova
- Department of Cardiac Surgery, National Research Cardiac Surgery Center, Astana, Kazakhstan
| | | | - Serik Alimbayev
- Department of Interventional Cardiology, National Research Cardiac Surgery Center, Astana, Kazakhstan
| | - Nail Khissamutdinov
- Department of Cardiology, National Research Cardiac Surgery Center, Astana, Kazakhstan
| | - Timur Kapyshev
- Department of Anesthesiology, Resuscitation and Intensive Care(Adult), Astana, Kazakhstan
| | - Aidyn Kuanyshbek
- Department of Anesthesiology, Resuscitation and Intensive Care(Adult), Astana, Kazakhstan
| | - Timur Lesbekov
- Department of Cardiac Surgery, National Research Cardiac Surgery Center, Astana, Kazakhstan
| |
Collapse
|
4
|
Iqbal K, Arif TB, Rathore SS, Ahmed J, Kumar P, Shahid I, Iqbal A, Shariff M, Kumar A. Outcomes of concomitant aortic valve procedures and left ventricular assist device implantation: A systematic review and meta-analysis. Artif Organs 2023; 47:470-480. [PMID: 36537993 DOI: 10.1111/aor.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Left ventricular assist device (LVAD) implantation is frequently employed in patients with end-stage heart failure. The outcomes of addressing the repair of all substantial aortic valvular disease at the time of LVAD implantation remain unclear. We sought to assess the clinical outcomes in patients undergoing LVAD implantation concomitant with aortic valve procedures (AVPs) compared with isolated LVAD implantation. METHODS A literature search was performed using PubMed, Embase, and Cochrane library from inception till June 2022. Primary outcomes included short-term mortality and long-term survival. Random effects models were used to compute mean differences and odds ratios with 95% confidence intervals (CIs). RESULTS A total of 14 observational studies (N = 52 693) met our inclusion criteria. Concomitant LVAD implantation and AVPs were associated with higher short-term mortality (OR = 1.61 [95% CI, 1.06-2.42]; p = 0.02) and mean CPBt (MD = 43.25 [95% CI, 22.95-63.56]; p < 0.0001), and reduced long-term survival (OR = 0.70 [95% CI, 0.55-0.88]; p = 0.003) compared with isolated LVAD implantation. No difference in the odds of cerebrovascular accident (OR = 1.05 [95% CI, 0.79-1.39]; p = 0.74) and mean length of hospital stay (MD = 2.89 [95% CI, -4.04 to 9.82]; p = 0.41) was observed between the two groups. On adjusted analysis, short-term mortality was significantly higher in the LVAD group with concurrent AVPs when compared with the isolated LVAD group (aHR = 1.50 [95% CI, 1.20-1.87]; p = 0.0004). CONCLUSIONS Concurrent AVPs were associated with higher short-term mortality and reduced long-term survival in patients undergoing LVAD implantation compared with isolated LVAD implantation.
Collapse
Affiliation(s)
- Kinza Iqbal
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Taha Bin Arif
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sawai Singh Rathore
- Department of Internal Medicine, Dr. Sampurnanand Medical College, Jodhpur, India
| | - Jawad Ahmed
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Pankaj Kumar
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Izza Shahid
- Department of Internal Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Ayman Iqbal
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariam Shariff
- Department of Surgery, Mayo Clinic, Rochester, New York, USA
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio, USA.,Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio, USA
| |
Collapse
|
5
|
Vriz O, Mushtaq A, Shaik A, El-Shaer A, Feras K, Eltayeb A, Alsergnai H, Kholaif N, Al Hussein M, Albert-Brotons D, Simon AR, Tsai FW. Reciprocal interferences of the left ventricular assist device and the aortic valve competence. Front Cardiovasc Med 2023; 9:1094796. [PMID: 36698950 PMCID: PMC9870593 DOI: 10.3389/fcvm.2022.1094796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach via percutaneous occluding device or transcatheter aortic valve implantation. In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.
Collapse
Affiliation(s)
- Olga Vriz
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia,*Correspondence: Olga Vriz,
| | - Ali Mushtaq
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah Shaik
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed El-Shaer
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Khalid Feras
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdalla Eltayeb
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hani Alsergnai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Naji Kholaif
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mosaad Al Hussein
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dimpna Albert-Brotons
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Andre Rudiger Simon
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Felix Wang Tsai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
6
|
Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
Collapse
Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| |
Collapse
|
7
|
Investigation on Imaging Features and Clinical Significance of Cardiac CT in Comprehensive Evaluation of Aortic Valve and Root before Percutaneous Aortic Valve Replacement. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5838670. [PMID: 36177061 PMCID: PMC9514922 DOI: 10.1155/2022/5838670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/04/2022] [Accepted: 08/20/2022] [Indexed: 11/18/2022]
Abstract
Medical imaging feature analysis is the basis of medical image processing and analysis. The solution of this problem not only directly affects the successful application of computer graphics and image technology in medicine but also has important theoretical and practical significance. In this paper, the imaging characteristics and clinical significance are discussed by studying the comprehensive evaluation of aortic valve and root before aortic valve replacement. In recent years, preoperative comprehensive evaluation of the aortic valve and root has been gradually carried out. Compared with traditional methods, minimally invasive surgery brings more accurate diagnosis to patients, quick recovery and discharge after surgery, and less pain. This study retrospectively includes patients with severe aortic stenosis who underwent TAVR with routine computed tomography. Based on CT images, the determination and grouping of bicuspid aortic valve and tricuspid aortic valve were completed. Thirteen cross-sectional levels of the aorta-iliac-femoral vascular access were completed. The results showed that 3 people had stroke (17.6%) and 5 people had myocardial infarction (29.4%) during the follow-up period. Atrial fibrillation occurred in 5 patients (29.4%), permanent pacemaker implantation was performed in 1 patient (5.9%), and acute kidney injury occurred in 7 patients (41.2%). No patient died due to surgery-related causes, and the analysis of imaging features and clinical significance in the preoperative comprehensive evaluation of the aortic valve and root played a crucial role. In the training stage, the principal component analysis method was used to train the shape, and the model of the shape intensity of the aortic valve and the shape change of each principal component was obtained. The most probable aortic valve region in the target image was obtained by matching the similarity of all atlases, and the correct aortic valve segmentation was obtained by using the first level set of shape intensity. The experimental part verified the accuracy of the algorithm.
Collapse
|
8
|
Zaidi SH, Minhas AMK, Sagheer S, ManeshGangwani K, Dani SS, Goel SS, Alam M, Sheikh AB, Hirji S, Wasty N. Clinical Outcomes of Transcatheter Aortic Valve Replacement (TAVR) vs. Surgical Aortic Valve Replacement (SAVR) in Patients With Durable Left Ventricular Assist Device (LVAD). Curr Probl Cardiol 2022; 47:101313. [PMID: 35817155 DOI: 10.1016/j.cpcardiol.2022.101313] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients with left ventricular assist device often develop aortic insufficiency requiring an intervention on the aortic valve. We sought to analyze the outcomes of patients with a history of LVAD who underwent either transcatheter aortic valve replacement or surgical aortic valve replacement. METHODS The Nationwide Readmission Database was used to extract relevant patient information from January 1, 2016, to December 31, 2018. The NRD is a nationally representative sample of all-payer discharges from U.S. non-federal hospitals. The primary outcome of interest was in-hospital mortality. Secondary outcomes included length of stay, clinical outcomes, costs, and 30-day all-cause readmissions. Complex samples multivariable logistic and linear regression models were used to determine the association of procedure type with outcomes. RESULTS Among 148 hospitalizations with a history of LVAD, 87 underwent TAVR, and 61 underwent SAVR. The inpatient mortality in SAVR group was numerically higher compared to the TAVR cohort, however, it did not reach statistical significance. The use of invasive mechanical ventilation, and rates of cardiogenic shock, bleeding, and vascular complications were higher in the SAVR cohort compared to the TAVR cohort. The mean length of stay and costs were higher in the SAVR cohort compared to the TAVR cohort. The 30-day all-cause readmission rate was numerically higher in the SAVR group but not statistically significant. CONCLUSIONS TAVR in patients with LVAD may be a viable treatment option for patients with AI with potential for better inpatient mortality and inpatient outcomes compared to patients who undergo SAVR in appropriately selected patients.
Collapse
Affiliation(s)
- Syeda Humna Zaidi
- Division of Internal Medicine, Karachi Medical and Dental College, Pakistan
| | | | - Shazib Sagheer
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | | | - Sourbha S Dani
- Division of Cardiology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston TX, USA
| | - Mahboob Alam
- Michael E. DeBakey Veterans Affair Medical Center & Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Abu Baker Sheikh
- Division of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Sameer Hirji
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Najam Wasty
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ, USA
| |
Collapse
|
9
|
Ishigaki T, Wakasa S. A simple closure method for a mechanical aortic valve in left ventricular assist device implantation. Gan To Kagaku Ryoho 2022; 70:677-679. [PMID: 35391606 DOI: 10.1007/s11748-022-01812-8] [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: 12/21/2021] [Accepted: 03/20/2022] [Indexed: 11/26/2022]
Abstract
Because a mechanical aortic valve is a contraindication for the implantation of left ventricular assist device, complicated additional procedures such as a replacement with a bioprosthesis and a closure of the left ventricular outflow tract are required to implant the device. Among such procedures, a sandwich plug technique using vascular clips is one of the simple and feasible procedures. However, this technique requires an off-label use of vascular clips within the aorta that could be associated with a risk of dislodgement and embolization. Thus, we developed a modified sandwich technique without using vascular clips, where the valve leaflets were fixed in the closed position using felt patches and sutures instead of vascular clips. This modified technique is a simple and secure method to close the mechanical aortic valve with the minimum use of artificial materials.
Collapse
Affiliation(s)
- Takahiro Ishigaki
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| |
Collapse
|
10
|
Loforte A, de By TMMH, Gliozzi G, Schönrath F, Mariani C, Netuka I, Pya Y, Zimpfer D, Cavalli GG, Gummert J, Meyns B, Pacini D, Potapov E. Impact of concomitant cardiac valvular surgery during implantation of continuous-flow left ventricular assist devices: A European registry for patients with mechanical circulatory support (EUROMACS) analysis. Artif Organs 2021; 46:813-826. [PMID: 34904255 DOI: 10.1111/aor.14143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/22/2021] [Accepted: 12/08/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND We investigated the clinical outcomes after cardiac valvular surgery procedures concomitant (CCPs) with left ventricular assist device (LVAD) implantation compared to propensity score (PS) matched controls using the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data. METHODS Between 2006 and 2018, 2760 continuous-flow LVAD patients were identified. Of these, 533 underwent a CCP during the LVAD implant. RESULTS Cardiopulmonary bypass time (p < 0.001) and time for implant (p < 0.001) were both significantly longer in the LVAD+CCP group. Hospital mortality was comparable between the two groups from the unmatched population (15.7% vs. 14.1%, p = 0.073). Similarly, short-to-mid-term survival was similar in both groups, with 1-year, 3-year, and 5-year survival rates of 67.9%, 48.2%, and 27.7% versus 66.4%, 46.1%, and 26%, respectively (log-rank, p = 0.25). The results were similar in the PS-matched population. Hospital mortality was comparable between the two groups (18.9% vs. 17.4%, p = 0.074). The short-to-mid-term Kaplan-Meier survival analysis was similar for both groups, with 1-year, 3-year, and 5-year survival rates of 63.4%, 49.2%, and 24.7% versus 66.5%, 46%, and 25.1%, respectively (log-rank, p = 0.81). In the unmatched population, LVAD+CCP patients had longer intensive care unit (ICU) stays (p < 0.0001), longer mechanical ventilation time (p = 0.001), a higher rate of temporary right ventricular assist device (RVAD) support (p = 0.033), and a higher rate of renal replacement therapy (n = 35, 6.6% vs. n = 89, 4.0%, p = 0.014). In the PS-matched population, the LVAD+CCP patients had longer ICU stays (p = 0.019) and longer mechanical ventilation time (p = 0.002). CONCLUSIONS The effect of additive valvular procedures (CCPs) does not seem to affect short-term survival, significantly, based on our registry data analysis. However, the decision to perform CCPs should be balanced with the projected type of surgery and preoperative characteristics. LVAD+CCP patients remain a delicate population and adverse device-related events should be strictly monitored and managed.
Collapse
Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | - Carlo Mariani
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Yuriy Pya
- National Research Cardiac Surgery Center, Astana Kazakhstan, Kazakhstan
| | | | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Jan Gummert
- Heart and Diabetes Center North-Rhine Westphalia, Ruhr-Un, Bad Oeynhausen, Germany
| | - Bart Meyns
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | | | | |
Collapse
|
11
|
Tulimat T, Osman B, Beresian J, Sfeir P, Borgi J. Management of a mechanical aortic valve during left ventricular assist device implantation in a previously replaced aortic root. Int J Artif Organs 2021; 45:152-154. [PMID: 33583241 DOI: 10.1177/0391398821990667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of left ventricular assist device (LVAD) in patients with mechanical aortic valves may result in thromboembolic events due to blood stasis around the valve and intermittent valve opening. Mechanical aortic valves encountered during LVAD implantation are managed by replacement with a tissue valve, or closure of the valve with a patch. Closure of the valve carries the risk of sudden death in cases of LVAD stoppage. Replacing the whole mechanical valve conduit is time consuming and carries a significant risk of bleeding and right ventricular (RV) failure. We describe an alternative technique of replacing a mechanical aortic valve by breaking its inner leaflets and sewing a tissue valve on top of the mechanical valve ring.
Collapse
Affiliation(s)
- Tamam Tulimat
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassam Osman
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean Beresian
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Pierre Sfeir
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamil Borgi
- American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
12
|
Hetzer R, Javier MFDM, Dandel M, Loebe M, Javier Delmo EM. Mechanical circulatory support systems: evolution, the systems and outlook. Cardiovasc Diagn Ther 2021; 11:309-322. [PMID: 33708502 DOI: 10.21037/cdt-20-283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The joint efforts in the fields of surgery, medicine and biomedical engineering, sponsored by both the government and the industry, have led to the development of mechanical support devices that can provide reliable circulatory support, which can temporarily support a patient's circulation until either the heart recovers or until a new heart can be transplanted or permanently replace a failed heart. Their development has been driven by the shortage of donor organs. Various systems have eventually evolved for short or long-term support of patients suffering from cardiogenic and/or advanced heart failure (HF). Over time, several have been withdrawn from the market due to high rate of thromboembolism and pump-related complications, but many others remained with modern principles of circulatory support proved to be durable and reliable. Hopefully, the ever-evolving technology will yield several devices aimed at their miniaturization, with an energy supply without risk of infection, a system which is simple to implant and to exchange, minimalization of thrombus formation by optimal interior pump design, new antithrombotic medications and a system with demand-based pump activity. It is important to remember that such devices are only implanted to keep a patient alive or in an immediate life-threatening stage. In such circumstances, attribution of aforementioned difficulties to pump limitations or to advanced disease states remains difficult. In the coming years, ventricular assist devices (VADs) could be the most common surgical preference for treating severe HF.
Collapse
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | | | - Michael Dandel
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | - Matthias Loebe
- Thoracic Transplant and Mechanical Support, Miami Transplant Institute, Memorial Jackson Health System, University of Miami, Miami, FL, USA
| | | |
Collapse
|
13
|
Veenis JF, Yalcin YC, Brugts JJ, Constantinescu AA, Manintveld OC, Bekkers JA, Bogers AJJC, Caliskan K. Survival following a concomitant aortic valve procedure during left ventricular assist device surgery: an ISHLT Mechanically Assisted Circulatory Support (IMACS) Registry analysis. Eur J Heart Fail 2020; 22:1878-1887. [PMID: 32809227 PMCID: PMC7702162 DOI: 10.1002/ejhf.1989] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 11/11/2022] Open
Abstract
Aims The aim of this study was to compare early‐ and late‐term survival and causes of death between patients with and without a concomitant aortic valve (AoV) procedure during continuous‐flow left ventricular assist device (LVAD) surgery. Methods and results All adult primary continuous‐flow LVAD patients on the International Society of Heart and Lung Transplantation (ISHLT) Mechanically Assisted Circulatory Support (IMACS) Registry (n = 15 267) were included in this analysis and stratified into patients submitted to a concomitant AoV procedure (AoV replacement or AoV repair) and patients without an AoV procedure. The primary outcome was early (≤90 days) survival post‐LVAD surgery. Secondary outcomes were late survival (survival during the entire follow‐up period) and conditional survival (in patients who survived the first 90 days post‐LVAD surgery), and determinants. Patients who underwent concomitant AoV replacement (n = 457) had significantly reduced late survival compared with patients with AoV repair (n = 328) or without an AoV procedure (n = 14 482) (56% vs. 61% and 62%, respectively; P = 0.001). After adjustment for other significant predictors, concomitant AoV replacement remained an independent predictor for early [hazard ratio (HR) 1.226, 95% confidence interval (CI) 1.037–1.449] and late (HR 1.477, 95% CI 1.154–1.890) mortality. However, patients undergoing AoV replacement or repair, in whom the presence of moderate‐to‐severe AoV regurgitation was diagnosed prior to LVAD implantation, had survival similar to patients not undergoing AoV interventions. Conclusions Concomitant AoV surgery in patients undergoing LVAD implantation is an independent predictor of mortality. Additional research is needed to determine the best AoV surgical strategy at the time of LVAD surgery.
Collapse
Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Yunus C Yalcin
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Alina A Constantinescu
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Jos A Bekkers
- Department of Cardio-Thoracic Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
14
|
Goodwin ML, Bobba CM, Mokadam NA, Whitson BA, Essandoh M, Hasan A, Ganapathi AM. Continuous-Flow Left Ventricular Assist Devices and the Aortic Valve: Interactions, Issues, and Surgical Therapy. Curr Heart Fail Rep 2020; 17:97-105. [DOI: 10.1007/s11897-020-00464-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
15
|
Noly PE, Pagani FD, Noiseux N, Stulak JM, Khalpey Z, Carrier M, Maltais S. Continuous-Flow Left Ventricular Assist Devices and Valvular Heart Disease: A Comprehensive Review. Can J Cardiol 2019; 36:244-260. [PMID: 32036866 DOI: 10.1016/j.cjca.2019.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/15/2022] Open
Abstract
Mechanical circulatory support with implantable durable continuous-flow left ventricular assist devices (CF-LVADs) represents an established surgical treatment option for patients with advanced heart failure refractory to guideline-directed medical therapy. CF-LVAD therapy has been demonstrated to offer significant survival, functional, and quality-of-life benefits. However, nearly one-half of patients with advanced heart failure undergoing implantation of a CF-LVAD have important valvular heart disease (VHD) present at the time of device implantation or develop VHD during support that can lead to worsening right or left ventricular dysfunction and result in development of recurrent heart failure, more frequent adverse events, and higher mortality. In this review, we summarize the recent evidence related to the pathophysiology and treatment of VHD in the setting of CF-LAVD support and include a review of the specific valve pathologies of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR). Recent data demonstrate an increasing appreciation and understanding of how VHD may adversely affect the hemodynamic benefits of CF-LVAD support. This is particularly relevant for MR, where increasing evidence now demonstrates that persistent MR after CF-LVAD implantation can contribute to worsening right heart failure and recurrent heart failure symptoms. Standard surgical interventions and novel percutaneous approaches for treatment of VHD in the setting of CF-LVAD support, such as transcatheter aortic valve replacement or transcatheter mitral valve repair, are available, and indications to intervene for VHD in the setting of CF-LVAD support continue to evolve.
Collapse
Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - John M Stulak
- Department of Cardiac Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Zain Khalpey
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Michel Carrier
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Simon Maltais
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| |
Collapse
|
16
|
Herrmann FEM, Schramm R, Hagl C, Eifert S, Pichlmaier M. Aortic Root Replacement and Berlin Heart EXCOR Implantation in Marfan Syndrome. Ann Thorac Surg 2018; 107:e187-e189. [PMID: 30266613 DOI: 10.1016/j.athoracsur.2018.07.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 11/25/2022]
Abstract
Aortic regurgitation secondary to aortic aneurysmal disease with subsequent long-term volume overload of the left ventricle is associated with left ventricular dysfunction. In Marfan syndrome, ventricular dysfunction may exist independent of valvular disease (Marfan cardiomyopathy). We report of a 20-year-old Marfan syndrome patient presenting with severe aortic regurgitation and severe heart failure. Aortic surgery with concurrent biventricular paracorporeal assist device implantation was performed to bridge the patient to heart transplantation, which was performed successfully 21 weeks after aortic surgery. While the optimal strategy for this situation has not been described, the approach applied here appears a valid option.
Collapse
Affiliation(s)
| | - René Schramm
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Sandra Eifert
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | | |
Collapse
|
17
|
Transcatheter Aortic Valve Replacement as a Bridge to Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:60-61. [PMID: 29461305 DOI: 10.1097/imi.0000000000000457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a case of the pre-emptive use of transcatheter aortic valve replacement in a patient with end-stage ischemic cardiomyopathy and native aortic stenosis/aortic insufficiency as a bridge to left ventricular assist device implantation. The use of this strategy can not only medically optimize patients before left ventricular assist device implantation but also provide a minimally invasive bridge to left ventricular assist device support, avoiding concomitant surgical aortic valve replacement or closure.
Collapse
|
18
|
Elmously A, Worku B, Horn EM, Wong SC, Salemi A. Transcatheter Aortic Valve Replacement as a Bridge to Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adham Elmously
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA
| | - Berhane Worku
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA
| | - Evelyn M. Horn
- Department of Cardiology, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA
| | - Shing-Chiu Wong
- Department of Cardiology, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA
| | - Arash Salemi
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA
| |
Collapse
|
19
|
Gregory SD, Stevens MC, Wu EL, Pauls JP, Kleinheyer M, Fraser JF. Mitral Valve Regurgitation with a Rotary Left Ventricular Assist Device: The Haemodynamic Effect of Inlet Cannulation Site and Speed Modulation. Ann Biomed Eng 2016; 44:2674-82. [PMID: 26932840 DOI: 10.1007/s10439-016-1579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/24/2016] [Indexed: 11/29/2022]
Abstract
Mitral valve regurgitation (MVR) is common in patients receiving left ventricular assist device (LVAD) support, however the haemodynamic effect of MVR is not entirely clear. This study evaluated the haemodynamic effect of MVR with LVAD support and the influence of inflow cannulation site and LVAD speed modulation. Left atrial (LAC) and ventricular (LVC) cannulation was evaluated in a mock circulation loop with no, mild, moderate and severe MVR with constant speed and speed modulation (±600 RPM) modes. The use of an LVAD relieved pulmonary congestion during severe MVR, by reducing left atrial pressure from 20.5 to 10.8 (LAC) and 11.5 (LVC) mmHg. However, LAC resulted in decreased left ventricular stroke work (-0.08 J), ejection fraction (-7.9%) and higher MVR volume (+12.7 mL) and pump speed (+100 RPM) compared to LVC. This suggests that LVC, in addition to reducing MVR severity, also improves ventricular washout over LAC. LVAD speed modulation in synchrony with ventricular systole reduced MVR volume and increased ejection fraction with LAC and LVC, thus demonstrating the potential benefits of this mode, despite a reduction in cardiac output.
Collapse
Affiliation(s)
- Shaun D Gregory
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Michael C Stevens
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, Australia
| | - Eric L Wu
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering, Griffith University, Southport, QLD, Australia
| | - Matthias Kleinheyer
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering, Griffith University, Southport, QLD, Australia
| | - John F Fraser
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| |
Collapse
|
20
|
Flores AS, Essandoh M, Yerington GC, Bhatt AM, Iyer MH, Perez W, Davila VR, Tripathi RS, Turner K, Dimitrova G, Andritsos MJ. Echocardiographic assessment for ventricular assist device placement. J Thorac Dis 2016; 7:2139-50. [PMID: 26793334 DOI: 10.3978/j.issn.2072-1439.2015.10.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
While many factors depend on successful implantation and outcome of left ventricular assist devices (LVAD), echocardiography remains an integral part and is vital to the success of this process. Transesophageal echocardiography (TEE) allows interrogation of all the cardiac structures and great vessels. The pre-implantation TEE exam establishes a baseline and may identify potential problems that need palliation. Among these, most significant are aortic insufficiency (AI), intracardiac thrombi, poor right ventricular (RV) function, and intracardiac shunts. The post-implantation exam allows for adequate de-airing of the heart and successful LVAD initiation. The position and flow profiles of the inflow and outflow cannulas of the LVAD may be assessed. Finally, it assists in the astute management and vigilant identification and correction of a number of complications in the immediate post-implantation period. TEE will continue to remain vital to the successful outcomes LVAD patients.
Collapse
Affiliation(s)
- Antolin S Flores
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Michael Essandoh
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Gregory C Yerington
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Amar M Bhatt
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Manoj H Iyer
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - William Perez
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Victor R Davila
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Katja Turner
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Galina Dimitrova
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| | - Michael J Andritsos
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, OH 43210, USA
| |
Collapse
|
21
|
Hetzer R, Kaufmann MEng F, Potapov E, Krabatsch T, Delmo Walter EM. Rotary Blood Pumps as Long-Term Mechanical Circulatory Support: A Review of a 15-Year Berlin Experience. Semin Thorac Cardiovasc Surg 2016; 28:12-23. [PMID: 27568128 DOI: 10.1053/j.semtcvs.2016.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
Abstract
This article reports our 15-year single-center experience with rotary blood pumps (RBPs) as long-term mechanical circulatory support (MCS) with emphasis on outcomes. For more than 15-year period, we have used various RBPs as bridge to transplantation or to myocardial recovery. Our group performed the first human implantation worldwide of RBCs, the MicroMed DeBakey ventricular assist device in November 1998 in a patient with end-stage heart failure who was supported for 47 days until his death. Based on this initial experience, we recognized the feasibility of providing long-term support and since then it has been our primary armamentarium in treating patients with heart failure. Between 1987 and September 2013, we have implanted 2208 ventricular assist devices ranging from pulsatile to continuous-flow systems, as short-term, long-term, or permanent support in patients with end-stage heart failure. In total, 1009 RBPs were implanted on 908 patients, and their outcomes are reported here. We have shared some milestones in MCS including the first implantation of Jarvik 2000 on the oldest patient (81-year old) in 2008 and the first worldwide implantation of a biventricular HeartWare. Over time, implantation techniques, anticoagulation, and postoperative care have been modified and individualized. A relevant aspect of our experience has been the incidence of pump thrombosis. This is particularly frustrating because the problem has occurred in the setting of full anticoagulation and antiplatelet therapy, guided by strict anticoagulation monitoring. It has become clear to us that the devices are still not perfect. Technical pump failures such as cable breaks also occur, prompting urgent pump exchange, and infection. A 15-year cumulative mortality rate is 46.9%. This report emphasizes that MCS with RBPs has evolved into a routine treatment in heart failure and is a highly feasible option for permanent therapy particularly for elderly patients.
Collapse
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Friedrich Kaufmann MEng
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
| |
Collapse
|
22
|
Doi A, Marasco SF, McGiffin DC. Is a Bioprosthetic Valve in the Aortic Position Desirable with a Continuous Flow LVAD? J Card Surg 2015; 30:466-8. [DOI: 10.1111/jocs.12541] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Atsuo Doi
- Department of Cardiothoracic Surgery; The Alfred Hospital; Melbourne Australia
| | - Silvana F. Marasco
- Department of Cardiothoracic Surgery; The Alfred Hospital; Melbourne Australia
| | - David C. McGiffin
- Department of Cardiothoracic Surgery; The Alfred Hospital; Melbourne Australia
| |
Collapse
|
23
|
|
24
|
Stepanenko A, Potapov EV, Weng Y, Pasic M, Krabatsch T, Hetzer R. Concomitant surgery during ventricular assist device implantation. Ann Cardiothorac Surg 2014; 3:630-1. [PMID: 25512908 DOI: 10.3978/j.issn.2225-319x.2014.08.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/19/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander Stepanenko
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Yuguo Weng
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Miralem Pasic
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| |
Collapse
|
25
|
Robertson JO, Naftel DC, Myers SL, Prasad S, Mertz GD, Itoh A, Pagani FD, Kirklin JK, Silvestry SC. Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: An INTERMACS database analysis. J Heart Lung Transplant 2014; 34:797-805. [PMID: 25511747 DOI: 10.1016/j.healun.2014.11.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 10/29/2014] [Accepted: 11/04/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Management of existing aortic insufficiency (AI) and mechanical aortic valves in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. Surgical options to address these issues include closure, repair or replacement of the valve. METHODS Continuous-flow LVAD/biventricular VAD patients entered into the INTERMACS database between June 2006 and December 2012 were included (n = 5,344) in this analysis. Outcomes were compared between patients who underwent aortic valve (AV) closure (n = 125), repair (n = 95) and replacement (n = 85). RESULTS Among patients who underwent an AV procedure, actuarial survival was significantly reduced for AV closures (63.2%) compared with AV repairs (76.8%) and replacements (71.8%) (p = 0.0003). Differences were greater between groups when only INTERMACS Level 1 or 2 patients were analyzed (p = 0.003). After multivariate adjustment, AV closure remained a significant risk factor for mortality (hazard ratio = 1.87, 95% confidence interval 1.39 to 2.53, p < 0.0001). At 6 to 12 months post-operatively, moderate to severe AI developed in 19%, 5%, 9% and 10% of patients with available echocardiography who underwent repair, closure, replacement and no intervention, respectively (p < 0.0001). Competing outcomes demonstrate that, at 1-year, fewer patients with AV closures were transplanted compared with patients with repairs/replacements (14% vs 19%). No differences were observed between groups with respect to cause of death, re-hospitalization, right heart failure or stroke. CONCLUSIONS AV closure was associated with increased mortality when compared with repair or replacement in patients with AI who underwent LVAD insertion. The reasons for this association require further investigation. This is the largest study to date to examine concomitant AV procedures in patients undergoing LVAD insertion.
Collapse
Affiliation(s)
- Jason O Robertson
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - David C Naftel
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Susan L Myers
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sunil Prasad
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Gail D Mertz
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Francis D Pagani
- Cardiac Surgery Department, University of Michigan, Ann Arbor, Michigan
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott C Silvestry
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
| |
Collapse
|
26
|
Clinical Outcomes After Implantation of a Centrifugal Flow Left Ventricular Assist Device and Concurrent Cardiac Valve Procedures. Circulation 2014; 130:S3-11. [DOI: 10.1161/circulationaha.113.007911] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Cardiac valve procedures are commonly performed concurrently during implantation of left ventricular assist devices, but the added procedural risk has not been studied in detail.
Methods and Results—
Data from patients receiving the HeartWare Ventricular Assist Device in the ADVANCE bridge to transplant (BTT) trial and continued access protocol were reviewed. Of 382 consecutive patients who completed follow-up between August 2008 and June 2013 (mean time on support 389 days, median 271 days), 262 (68.6%) underwent isolated HeartWare Ventricular Assist Device implantation, 75 (19.6%) a concurrent valve procedure, and 45 (11.8%) concurrent nonvalvular procedures. Of the concurrent valve procedures, 56 were tricuspid, 13 aortic, and 6 mitral. Survival was similar between groups (79% for concurrent valve procedures and 85% for HeartWare Ventricular Assist Device only at 1 year;
P
=0.33). Concurrent valve procedures were also associated with increased unadjusted early right heart failure (RHF). A multivariable analysis for death and RHF (121 total events) identified female sex (odds ratio=2.0 [95% confidence interval, 1.2–3.3;
P
=0.0053]) and preimplant tricuspid regurgitation severity (odds ratio=2.9 [95% confidence interval, 1.8–4.8,
P
<0.0001]) as independent predictors while concurrent tricuspid valve procedures (TVP) were not predictors. Furthermore, patients with significant preimplant tricuspid regurgitation who did not receive a TVP experienced an increased rate of late RHF compared with those who received TVP (0.19 versus 0.05 events per patient-year, respectively;
P
=0.024).
Conclusions—
Compared with HeartWare Ventricular Assist Device alone, survival was equivalent for the concurrent valve procedure group. Tricuspid regurgitation severity was the most important predictor of increased postoperative RHF, and concurrent TVP was not an independent predictor of RHF overall. Concurrent TVP may reduce the rate of late RHF for patients with significant preimplant tricuspid insufficiency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00751972.
Collapse
|
27
|
Rechtsventrikuläre Funktion bei Implantation eines linksventrikulären Unterstützungssystems. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1057-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
28
|
Bansal S, Sai-Sudhakar CB, Whitson BA. Outcomes of continuous flow ventricular assist devices. World J Surg Proced 2014; 4:1-8. [DOI: 10.5412/wjsp.v4.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
Heart transplantation is commonplace, the supply is limited. Many exciting changes in the field of mechanical circulatory support have occurred in the past few years, including the axial flow pump. Left ventricular assist device (LVAD) therapy is ever evolving. As the use of LVAD therapy increases it is important to understand the indications, surgical considerations and outcomes.
Collapse
|
29
|
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]
|
30
|
John R, Naka Y, Park SJ, Sai-Sudhakar C, Salerno C, Sundareswaran KS, Farrar DJ, Milano CA. Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices. J Thorac Cardiovasc Surg 2014; 147:581-9; discussion 589. [DOI: 10.1016/j.jtcvs.2013.10.024] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/16/2013] [Accepted: 10/12/2013] [Indexed: 11/28/2022]
|
31
|
Jaik N, Higgins RSD, Whitson BA. Simultaneous Procedures During Left Ventricular Assist Device Implantation: Is Less Always More? Curr Heart Fail Rep 2013; 11:98-102. [DOI: 10.1007/s11897-013-0179-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
32
|
Schweiger M, Dave H, Lemme F, Romanchenko O, Hofmann M, Hübler M. Ventricular assist devices: initial orientation. J Thorac Dis 2013; 5:567-71. [PMID: 23991317 DOI: 10.3978/j.issn.2072-1439.2013.08.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/08/2013] [Indexed: 11/14/2022]
Abstract
Ventricular assist device (VAD) technology has come from large pulsatile-flow devices with a high rate of technical malfunctions to small continuous flow (cf) devices. Mechanical circulatory support (MCS) systems may be used as short-, mid- or long-term support. Especially if mid- or long-term support is anticipated left VADs (LVADs) have been reported with excellent one and two year survival rates and improved quality of life (QoL). Timing of implantation, patient selection, assessing function of the right ventricular and surgical considerations regarding surgical access side, valve pathology and exit side of the percutaneous lead remain crucial issues for the outcome. In contrast VADs designed for children especially for all age groups, are still underrepresented but increased experience with existing pediatric VADs as well as introduction of second and third generation VADs into in the pediatric age group, offer new perspectives.
Collapse
Affiliation(s)
- Martin Schweiger
- University Children's Hospital Zurich, Department for Congenital Cardiovascular Surgery
| | | | | | | | | | | |
Collapse
|
33
|
Northern LR, Dhawan R, Petra Bas H, Vidal-Melo MF, Mohr FW, Garbade J. CASE 1-2014 Left Ventricular Assist Device Insertion and the Mitral Valve. J Cardiothorac Vasc Anesth 2013; 28:174-180. [PMID: 23938398 DOI: 10.1053/j.jvca.2013.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Luke R Northern
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL.
| | - Heidi Petra Bas
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Marcos F Vidal-Melo
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Jens Garbade
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| |
Collapse
|
34
|
Baum C, Seiffert M, Treede H, Reichenspurner H, Deuse T. Concomitant transcatheter aortic valve and left ventricular assist device implantation. ASAIO J 2013; 59:90-2. [PMID: 23271392 DOI: 10.1097/mat.0b013e318277a835] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Relevant aortic regurgitation (AR) requires surgical repair at the time of left ventricular assist device (LVAD) implantation to reduce recirculation and ensure adequate forward flow. We report here on a patient with moderate AR in a noncalcified aortic valve and extensive calcification of the ascending aorta. The latter precluded aortic-crossclamping and, thus, surgical intervention on the aortic valve. Although there were no valvular or annular calcifications, a JenaValve transcatheter heart valve was successfully placed transapically with subsequent LVAD implantation in one operation. We believe concomitant transcatheter aortic valve implantation (TAVI) and LVAD implantation is a promising hybrid procedure, even in patients with pure AR.
Collapse
|