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Staubach S, Sailer M, Koch J, Maier A, Jeron A. Tricuspid transcatheter edge-to-edge repair in a 72-year-old patient with a left ventricular assist device and prior mitral edge-to-edge repair: a case report. Eur Heart J Case Rep 2024; 8:ytae074. [PMID: 38638282 PMCID: PMC11024804 DOI: 10.1093/ehjcr/ytae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/24/2024] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Background We report a case of a 72-year-old patient developing a significant tricuspid regurgitation (TR) 6 years after a left ventricular assist device (LVAD) implantation. The aim of this case is to demonstrate the feasibility of transcatheter edge-to-edge repair (TEER) of the tricuspid valve and the excellent clinical benefit in long-term follow-up in an LVAD patient. Case summary Our patient presented with recurrent acute heart failure syndrome. After a fulminant myocarditis in 2005, his previous treatment consisted of cardiac resynchronization therapy, TEER of the mitral valve, and LVAD (HeartMate III) implantation. At that point in time, his TR was only mild to moderate. Due to recurrent hospitalization despite optimized heart failure medication, we decided to treat the patient with a tricuspid TEER. His immediate post-interventional result and 1-year follow-up showed an excellent outcome with only minimal TR on transoesophageal echocardiogram. Discussion In general, TR improves after LVAD implantation. However, there are two possible pathophysiological mechanisms, which result in an increasing TR: firstly, supporting LV dysfunction may lead to a leftward shift of the interventricular septum with restriction of the tricuspid leaflets. Secondly, the increase of venous preload with LVAD support may result in an annular dilatation with secondary TR, particularly in patients with pre-existing right ventricular dysfunction. According to the data currently available, the unpredictable course of developing TR necessitates regular clinical examination and echocardiographic investigation. Treatment with TEER appears to be feasible and safe, with excellent 1-year results in patients with previously implanted LVADs.
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Affiliation(s)
- Stephan Staubach
- Department of Cardiology, Rems-Murr-Klinikum Winnenden, Am Jakobsweg 1, 71364 Winnenden, Germany
| | - Michael Sailer
- Department of Cardiology, Rems-Murr-Klinikum Winnenden, Am Jakobsweg 1, 71364 Winnenden, Germany
| | - Johannes Koch
- Department of Cardiology, Rems-Murr-Klinikum Winnenden, Am Jakobsweg 1, 71364 Winnenden, Germany
| | - Anatol Maier
- Department of Cardiology, Rems-Murr-Klinikum Winnenden, Am Jakobsweg 1, 71364 Winnenden, Germany
| | - Andreas Jeron
- Department of Cardiology, Rems-Murr-Klinikum Winnenden, Am Jakobsweg 1, 71364 Winnenden, Germany
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Abdullah B, Gupta R, Anderson KM, Balsara K, Sheikh FH, Groninger H, Rao A. The role of palliative care for patients with left ventricular assist devices: a narrative review. Ann Palliat Med 2024; 0:apm-23-551. [PMID: 38462933 DOI: 10.21037/apm-23-551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND OBJECTIVE Left ventricular assist devices (LVADs) have revolutionized the care of patients with advanced heart failure (HF). Compared to guideline-directed medical and device therapies, LVAD technology improves quality of life and reduces mortality. Palliative care specialists have an important role to play in the pre-LVAD evaluation phase, in the post-operative longitudinal care phase, and at the endof-life in patients with LVADs. The objective of this narrative review is to describe the evidence regarding the role of palliative care for patients with LVAD across the care continuum: pre-implantation, postimplantation, and at the end-of-life. METHODS Clinical trials relevant to care of patients with HF, LVADs, and the role of palliative care were analyzed for this narrative review. KEY CONTENT AND FINDINGS Palliative care involvement in 'preparedness planning' has been described in the literature, though no standardized protocol for preparedness planning exists, to date. In the longitudinal care phase after LVAD implantation, the role of palliative care is less defined; depending on institutional culture and availability of palliative care, patients may be referred based on symptom-management needs or for advance care planning (ACP). At the end-of-life, either due to an acute event or a gradually worsening condition, palliative care is often engaged to participate in discussions regarding treatment preferences and to consider transitions in care from disease-directed treatments to comfort-focused treatments. Given the medical complexity of dying with LVADs, most patients with an LVAD die in hospital with support from palliative care teams for the physical, existential, and psychosocial distress that accompanies end-of-life and LVAD deactivation. CONCLUSIONS In this narrative review, we describe the integral role of palliative care throughout the care continuum of patients living with LVADs and suggest opportunities for further research.
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Affiliation(s)
- Badr Abdullah
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Richa Gupta
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA; MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kelley M Anderson
- Department of Nursing, Georgetown University School of Nursing, Washington, DC, USA
| | - Keki Balsara
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA; MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Farooq H Sheikh
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA; MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hunter Groninger
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA; Section of Palliative Care, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Anirudh Rao
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA; Section of Palliative Care, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Park I, Yang JH, Kim D, Choi JO, Jeon ES, Sung K, Kim WS, Cho YH. Early stroke after left ventricular assist device implantation: role of right heart failure. J Thorac Dis 2023; 15:6730-6740. [PMID: 38249868 PMCID: PMC10797350 DOI: 10.21037/jtd-23-1194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/10/2023] [Indexed: 01/23/2024]
Abstract
Background Both stroke and right heart failure (RHF) are common and serious complications after left ventricular assist device (LVAD) implantation. The objective of this study was to evaluate relation between stroke and RHF early after LVAD implantation. Methods This is a retrospective observational cohort study. From January 2012 to December 2020, patients who underwent LVAD implantation in a single-center were enrolled. Patients with a non-dischargeable LVAD or without follow-up data were excluded. Early stroke was defined as a stroke event within 6 months after implantation. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definition was used for the diagnosis of RHF. Results A total of 70 patients underwent LVAD implantation. Sixty-seven patients (95.7%) were successfully discharged and 16 patients (22.9%) died during follow-up. 14 patients (20.0%) experienced a stroke within 6 months after implantation, and 0.28 stroke events per patient-year occurred during follow-up. Postoperative RHF was more common in the stroke group (64.3% vs. 23.2%, P=0.008) and the median time from implantation to RHF was 1 day. In the Cox multivariable analysis, postoperative RHF [hazard ratio (HR): 5.063; 95% confidence interval (CI): 1.682-15.245; P=0.004], and cerebral perfusion pressure (CPP) on postoperative day (POD) 1 (HR: 0.923; 95% CI: 0.858-0.992; P=0.030) were independent predictors for early stroke. A CPP of 62 mmHg (sensitivity, 71.4%; specificity, 59.3%) was the cutoff value for early stroke according to the receiver operating characteristic (ROC) analysis. Conclusions RHF after LVAD implantation may be a risk factor for early stroke. Prevention and management of postoperative RHF with adequate CPP could prevent early stroke after LVAD implantation.
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Affiliation(s)
- Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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4
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Laimoud M, Hakami E, Maghirang MJ, Mohamed T. Impact of diastolic pulmonary gradient and pulmonary vascular remodeling on survival after left ventricular assist device implantation and heart transplantation. Egypt Heart J 2023; 75:102. [PMID: 38117355 PMCID: PMC10733249 DOI: 10.1186/s43044-023-00428-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The left ventricular assist devices (LVADs) are increasingly used for advanced heart failure as a bridge to heart transplantation or as a destination therapy. The aim of this study was to investigate the changes of diastolic pulmonary gradient (DPG), pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) after LVAD implantation and their impact on survival after LVAD and heart transplantation. RESULTS A total of 73 patients who underwent LVAD (HeartMate III) implantation between 2016 and 2022 were retrospectively studied. According to pre-LVAD catheterization, 49 (67.1%) patients had DPG < 7 mmHg and 24 (32.9%) patients had DPG ≥ 7 mmHg. The patients with a pre-VAD DPG ≥ 7 mmHg had higher frequencies of right ventricular (RV) failure (p < 0.001), RVAD insertion (p < 0.001), need for renal replacement therapy (p = 0.002), total mortality (p = 0.036) and on-VAD mortality (p = 0.04) with a longer ICU stay (p = 0.001) compared to the patients with DPG < 7 mmHg. During the follow-up period of 38 (12-60) months, 24 (32.9%) patients died. Pre-LVAD DPG ≥ 7 mmHg (adjusted HR 1.83, 95% CI 1.21-6.341, p = 0.039) and post-LVAD DPG ≥ 7 mmHg (adjusted HR 3.824, 95% CI 1.482-14.648, p = 0.002) were associated with increased risks of mortality. Neither pre-LVAD TPG ≥ 12 (p = 0.505) nor post-LVAD TPG ≥ 12 mmHg (p = 0.122) was associated with an increased risk of death. Pre-LVAD PVR ≥ 3 WU had a statistically insignificant risk of mortality (HR 2.35, 95% CI 0.803-6.848, p = 0.119) while post-LVAD PVR ≥ 3 WU had an increased risk of death (adjusted HR 2.37, 95% CI 1.241-7.254, p = 0.038). For post-transplantation mortality, post-LVAD DPG ≥ 7 mmHg (p = 0.55), post-LVAD TPG ≥ 12 mmHg (p = 0.85) and PVR ≥ 3 WU (p = 0.54) did not have statistically increased risks. The logistic multivariable regression showed that post-LVAD PVR ≥ 3 WU (p = 0.013), post-LVAD DPG ≥ 7 mmHg (p = 0.026) and RVF (p = 0.018) were the predictors of mortality after LVAD implantation. Pre-LVAD DPG ≥ 7 mmHg (p < 0.001) and pre-LVAD PVR ≥ 3 WU (p = 0.036) were the predictors of RVF after LVAD implantation. CONCLUSIONS Persistently high DPG was associated with right ventricular failure and mortality after LVAD implantation rather than after heart transplantation. DPG is a better predictor of pulmonary vascular remodeling compared to TPG and PVR. Further larger prospective studies are required in this field due to the growing numbers of patients with advanced heart failure, as possible candidates for LVAD implantation, and limitations of heart transplantation.
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Affiliation(s)
- Mohamed Laimoud
- Cardiovascular Critical Care Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
- Critical Care Medicine Department, Cairo University, Cairo, Egypt.
| | - Emad Hakami
- Cardiovascular Nursing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mary Jane Maghirang
- Cardiovascular Nursing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tahir Mohamed
- Cardiovascular Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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5
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Sahni A, McIntyre EE, Pal JD, Mukherjee D. Quantitative Assessment of Aortic Hemodynamics for Varying Left Ventricular Assist Device Outflow Graft Angles and Flow Pulsation. Ann Biomed Eng 2023; 51:1226-1243. [PMID: 36705866 DOI: 10.1007/s10439-022-03127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 12/25/2022] [Indexed: 01/28/2023]
Abstract
Left ventricular assist devices (LVADs) comprise a primary treatment choice for advanced heart failure patients. Treatment with LVAD is commonly associated with complications like stroke and gastro-intestinal (GI) bleeding, which adversely impacts treatment outcomes, and causes fatalities. The etiology and mechanisms of these complications can be linked to the fact that LVAD outflow jet leads to an altered state of hemodynamics in the aorta as compared to baseline flow driven by aortic jet during ventricular systole. Here, we present a framework for quantitative assessment of aortic hemodynamics in LVAD flows realistic human vasculature, with a focus on quantifying the differences between flow driven by LVAD jet and the physiological aortic jet when no LVAD is present. We model hemodynamics in the aortic arch proximal to the LVAD outflow graft, as well as in the abdominal aorta away from the LVAD region. We characterize hemodynamics using quantitative descriptors of flow velocity, stasis, helicity, vorticity and mixing, and wall shear stress. These are used on a set of 27 LVAD scenarios obtained by parametrically varying LVAD outflow graft anastomosis angles, and LVAD flow pulse modulation. Computed descriptors for each of these scenarios are compared against the baseline flow, and a detailed quantitative characterization of the altered state of hemodynamics due to LVAD operation (when compared to baseline aortic flow) is compiled. These are interpreted using a conceptual model for LVAD flow that distinguishes between flow originating from the LVAD outflow jet (and its impingement on the aorta wall), and flow originating from aortic jet during aortic valve opening in normal physiological state.
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Affiliation(s)
- Akshita Sahni
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA
| | - Erin E McIntyre
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, Aurora, USA
| | - Jay D Pal
- Department of Surgery, University of Washington, Seattle, USA
| | - Debanjan Mukherjee
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA.
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Cagliostro M, Hundal P, Ting P, Patel S, Sudarshan S, Thomas J, Morris K, Mancini DM, Moss N, Lala A, Ravichandran A, Mitter SS. Safety and effects of SGLT-2 inhibitor use among LVAD patients with type 2 diabetes mellitus. Am Heart J Plus 2022; 18:100154. [PMID: 38559421 PMCID: PMC10978353 DOI: 10.1016/j.ahjo.2022.100154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 04/04/2024]
Abstract
SGLT-2 inhibitors have been shown to confer reduced risk of adverse cardiovascular events in patients with heart failure, and have also been studied preliminarily among heart transplant patients, with overall positive findings. Use of SGLT-2 inhibitors among patients with durable mechanical circulatory support has not been studied. Here we present our results from a combined retrospective cohort of LVAD patients on SGLT-2 inhibitors at two major academic centers, which showed a good safety profile but prompted questions for further investigation. We advocate for further research into the safety and impact of SGLT-2 inhibitors among LVAD patients.
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Affiliation(s)
- Matthew Cagliostro
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Prabhjot Hundal
- Ascension St. Vincent Indianapolis, United States of America
| | - Peter Ting
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Sonika Patel
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | - Jordan Thomas
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Kathleen Morris
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Donna M. Mancini
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Mount Sinai Hospital, The Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, United States of America
- The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Noah Moss
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Mount Sinai Hospital, The Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, United States of America
| | - Anuradha Lala
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Mount Sinai Hospital, The Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, United States of America
- The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | - Sumeet S. Mitter
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Mount Sinai Hospital, The Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, United States of America
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Bartfay SE, Kolsrud O, Wessman P, Dellgren G, Karason K. The trajectory of renal function following mechanical circulatory support and subsequent heart transplantation. ESC Heart Fail 2022; 9:2464-2473. [PMID: 35441491 PMCID: PMC9288773 DOI: 10.1002/ehf2.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/25/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022] Open
Abstract
Aim Patients with advanced heart failure (HF) frequently suffer from renal insufficiency. The impact of durable mechanical circulatory support (MCS) and subsequent heart transplantation (HTx) on kidney function is not well described. Methods and results We studied patients with advanced HF who received durable MCS as bridge to transplantation (BTT) and underwent subsequent HTx at our centre between 1996 and 2018. Glomerular filtration rate (GFR) was measured by 51Cr‐EDTA or iohexol clearance during heart failure work‐up; 3–6 months after MCS; and 1 year after HTx. Chronic kidney disease (CKD) was classified according to KDIGO criteria based on estimated GFR. A total of 88 patients (46 ± 15 years, 84% male) were included, 63% with non‐ischaemic heart disease. The median duration of MCS‐treatment was 172 (IQR 116–311) days, and 81 subjects were alive 1 year after HTx. Measured GFR increased from 54 ± 19 during HF work‐up to 60 ± 16 mL/min/1.73 m2 after MCS (P < 0.001) and displayed a slight but nonsignificant decrease to 57 ± 22 mL/min/1.73 m2 1 year after HTx (P = 0.38). The trajectory of measured GFR did not differ between pulsatile and continuous flow (CF) pumps. Among patients 35–49 years and those who were treated in the most recent era (2012–2018), measured GFR increased following MCS implantation and subsequent HTx. Estimated GFR displayed a similar course as did measured GFR. Conclusions In patients with advanced heart failure, measured GFR improved after MCS with no difference between pulsatile and CF‐pumps. The total study group showed no further increase in GFR following HTx, but in certain subgroups, including patients aged 35–54 years and those treated during the latest era (2012–2018), renal function appeared to improve after transplant.
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Affiliation(s)
- Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oscar Kolsrud
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Wessman
- Centre of Registers Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Wong KL, Ho KLC, Lee OJ, Lun KS, Bhatia I, Tam WYE, Fan YYK, Au WKT. Emerging roles of left ventricular assist device therapy as bridge to transplant in an Asian city with scarce heart transplant donor. J Thorac Dis 2021; 13:5717-5730. [PMID: 34795921 PMCID: PMC8575832 DOI: 10.21037/jtd-21-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022]
Abstract
Background Left ventricular assist device (LVAD) has been increasingly used in patients with advanced heart failure. This study aimed to assess the impact of implementation of LVAD therapy on heart transplantation (HTx) service in Hong Kong (HK). Methods LVAD program was started in 2010 in HK and patients who had been put on HTx waiting list since the start of HTx program in HK from 1992 to 2020 were included for analysis. Survival on HTx waiting list between pre-LVAD era 1992–2009 and post-LVAD era 2010–2020 were analyzed by Kaplan-Meier method and compared by log-rank test. Multivariate analysis by time-dependent Cox-proportional hazard model was used to identify independent predictors of HTx waiting list mortality. Results A total of 478 heart transplant listing episodes involving 457 patients were included for analysis. There were 232 heart transplantations (HTxs), including one re-transplantation, during the study period. There were 110 patients who received LVAD as bridge to transplantation (BTT) and 30 of them had undergone subsequent HTx. The 1-, 2- and 3-year survival on waiting list were 82.3%, 61.7% and 43.0% respectively in the pre-LVAD era (n=178), while the 1-, 2- and 3-year survival were significantly improved at 85.7%, 81.8% and 78% respectively in the post-LVAD era (n=300), (P=0.003). Time-dependent multivariate analysis revealed that LVAD support was independently associated with significant reduction of waiting list mortality [odds ratio (OR): 0.21; 95% confidence interval (CI): 0.10–0.44, P<0.001]. There was no significant difference when comparing survival after LVAD as BTT and survival after HTx up to 8 years (76.1% vs. 72% at 8 years respectively, P=0.732). Conclusions Waiting list survival improved in the post-LVAD era driven by the implementation of LVAD service. Long-term survival for LVAD recipients as BTT were comparable to heart transplant recipients in HK.
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Affiliation(s)
- Ka-Lam Wong
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, China
| | - Ka Lai Cally Ho
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | - Oswald Joseph Lee
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | - Kin Shing Lun
- Department of Paediatric Cardiology, Queen Mary Hospital, Hong Kong, China
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | | | | | - Wing Kuk Timmy Au
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
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Mulzer J, Krastev H, Hoermandinger C, Meyer A, Haese T, Stein J, Müller M, Schoenrath F, Knosalla C, Starck C, Falk V, Potapov E, Knierim J. Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices. Ann Cardiothorac Surg 2021; 10:364-374. [PMID: 34159117 DOI: 10.21037/acs-2020-cfmcs-fs-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tricuspid regurgitation (TR) after left ventricular assist device (LVAD) implantation is associated with a poor prognosis. This study evaluates the development of TR and right ventricular (RV) performance after LVAD implantation. Methods Retrospective analysis of patients who underwent LVAD implantation between March 2018 and June 2019. Patients who underwent concomitant tricuspid valve surgery and patients with congenital heart disease were excluded. Results A total of 155 patients underwent LVAD implantation. Fourteen patients were excluded. Of the remaining patients, thirty-one died during the first six months, six were lost to follow-up and two underwent transplantation. 102 patients presented at 6.3 months (5.8 to 7.0). Patients were supported with HeartWare HVAD (74%) or HeartMate 3 (26%). 50.4% were rated as INTERMACS profile 1 or 2. At six months, systolic pulmonary artery pressure dropped from 36 to 21 mmHg (P<0.001). Tricuspid annular plane systolic excursion decreased from 17.3 to 14.3 mm (P<0.001), RV fractional area change did not change (P=0.839). Twenty-two patients (22%) presented with moderate-to-severe or severe (ms-s) TR pre-operatively. Of these, eighteen (81%) showed improvement to ≤ moderate TR. At follow-up twelve patients presented with ms-s TR. Of these, only four patients (33%) had been diagnosed with ms-s TR pre-operatively. There were no differences in pre-operative echocardiographic or clinical parameters between the twelve patients with ms-s late TR and the other ninety patients in the cohort. Conclusions TR can show an impressive improvement with LVAD support. Longitudinal RV function decreases; this appears to be compensated by transverse shortening. Late TR can develop independently from pre-operative parameters including TR.
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Affiliation(s)
- Johanna Mulzer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Hristo Krastev
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | - Alexander Meyer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | | | - Marcus Müller
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Felix Schoenrath
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Starck
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Volkmar Falk
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Eidgenössiche Technische Hochschule Zürich, Department of Health Sciences and Technology, Translational Cardiovascular Technology, Zurich, Switzerland
| | - Evgenij Potapov
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Jan Knierim
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
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10
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Austin MA, Saxena A, O'Malley TJ, Maynes EJ, Moncure H, Ott N, Massey HT, Moscato F, Loforte A, Stulak JM, Tchantchaleishvili V. Computational sentiment analysis of an online left ventricular assist device support forum: positivity predominates. Ann Cardiothorac Surg 2021; 10:375-382. [PMID: 34159118 DOI: 10.21037/acs-2020-cfmcs-fs-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The impact of left ventricular assist device (LVAD) complications on the individual patient, overall sentiment, and its effect on referral patterns, is not fully understood. We sought to better understand patient attitudes towards LVAD therapy using a computational sentiment analysis approach. Methods Posts, comments, and titles were parsed from MyLVAD.com's HTML as a text file using custom Python scripts (version 3.6). Individual word frequency was computed with word classification as 'positive', 'negative', or 'neutral'. Data transformation and cleaning, sentiment determination, and analysis was performed with a binary dictionary package using R software (version 3.6). Results Sixty-six thousand eight hundred and twenty-one unique words were noted, including 4,623 (6.9%) with positive sentiment and 3,248 (4.8%) with negative sentiment. Net sentiment ratio [(number of positive words - number of negative words)/(number of total words)] was 2.1%. Positive sentiment dominated the 20 most commonly used words. Odds ratio of non-neutral words [(number of positive words/number of negative words)] was 1.42, indicating a less obvious disparity in sentiment when expanding analysis beyond the top 20 words. Word cloud analysis of positive and negative sentiments was performed, indicating common use of "infection" (208 mentions) compared to other complications such as "stroke" (29 mentions), "bleeding" (30 mentions), and "thrombosis" or "clot" (32 mentions). Conclusions Positive sentiment dominates the most frequently used words, yet this disparity decreases when considering the totality of words. "Infection" is mentioned a disproportionate number of times compared to other LVAD complications. Further research is required to address analysis limitations, including selection bias.
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Affiliation(s)
- Melissa A Austin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Henry Moncure
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathan Ott
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Antonio Loforte
- Department of Cardio-Thorac-Vascular Surgery, St. Orsola Hospital, Bologna University, Bologna, Italy
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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11
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McNamara N, Narroway H, Williams M, Brookes J, Farag J, Cistulli D, Bannon P, Marasco S, Potapov E, Loforte A. Contemporary outcomes of continuous-flow left ventricular assist devices-a systematic review. Ann Cardiothorac Surg 2021; 10:186-208. [PMID: 33842214 DOI: 10.21037/acs-2021-cfmcs-35] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background End stage heart failure is a major cause of morbidity and mortality, and its prevalence is expected to rise with the ageing population. For suitable patients, orthotopic heart transplantation remains the gold standard therapy, however, a paucity of donor organs has led to the development of left ventricular assist devices (LVAD). These devices can be utilized as either a bridge-to-transplant (BTT) or as an alternative to heart transplantation. While these devices can prolong life and improve quality of life, they are associated with a significant number of adverse events. We aim to systematically review the literature to quantify survival and the incidence of adverse events following implantation of continuous-flow LVADs (cf-LVAD). Methods A systematic review was performed to determine outcomes following implantation of a cf-LVAD. Primary outcomes were survival and frequency of adverse events (such as bleeding, infection, thrombosis, stroke and right ventricular failure). Secondary outcomes included quality of life and assessment of functional status. Results Sixty-three studies reported clinical outcomes of 9,280 patients. Survival after cf-LVAD varied between studies. Industry-funded trials generally reported better overall survival than the single- and multi-center case series, which showed significant variation. The largest registry report documented twelve, twenty-four and forty-eight-month survival rates of 82%, 72% and 57% respectively. The most commonly reported adverse events were gastrointestinal bleeding (GIB), device-related infection, neurological events and right heart failure (RHF). Bleeding, RHF and infection were the most frequent complications experienced by those supported with cf-LVAD, occurring in up to 35%, 40% and 55% of patients, respectively. Quality of life as measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and functional status as measured with the 6-minute walk test (6MWT) improved after cf-LVAD implantation with no decline evident two years after implantation. Conclusions The paucity of donor hearts has led to the development of left-ventricular assist devices as a BTT or as a destination therapy (DT). Outcomes after cf-LVAD implantation are excellent, with short-term survival comparable to heart transplantation, but long-term survival remains limited due to the incidence of post-implantation adverse events. Despite these complications, quality of life and functional status improve significantly post-implantation and remain improved over the long-term. This study demonstrates the potential benefits of cf-LVAD therapy whilst also identifying adverse events as an area of increased morbidity and mortality.
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Affiliation(s)
- Nicholas McNamara
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Harry Narroway
- Department of Vascular Surgery, Gosford Hospital, Gosford, Australia
| | - Michael Williams
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - John Brookes
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - James Farag
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - David Cistulli
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Bannon
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Silvana Marasco
- Cardiothoracic Surgical Department, The Alfred, Melbourne, Australia.,Department of Medicine and Surgery, Monash University, Melbourne, Australia
| | - Evgenij Potapov
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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12
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Mariani S, Li T, Bounader K, Boethig D, Schöde A, Hanke JS, Michaelis J, Napp LC, Berliner D, Dogan G, Lorusso R, Haverich A, Schmitto JD. Sex differences in outcomes following less-invasive left ventricular assist device implantation. Ann Cardiothorac Surg 2021; 10:255-267. [PMID: 33842220 DOI: 10.21037/acs-2020-cfmcs-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Worse outcomes in women compared to men undergoing left ventricular assist device (LVAD) implantation remain an underestimated problem in heart failure (HF) patients. With device miniaturization, less-invasive LVAD implantation techniques have gained relevance, but their impact on outcomes in women is unknown. This study investigates sex-related differences in patients undergoing LVAD implantation through less-invasive procedures. Methods This retrospective single-center cohort study included patients who underwent isolated LVAD implantation between 2011 and 2018 through less-invasive techniques. Propensity score matching (PSM) was utilized to balance preoperative heterogeneity. Primary endpoint was two-year survival, and secondary endpoints included long-term survival, surgical outcomes and postoperative adverse events. Results Baseline analysis of 191 patients (females 18.3%) showed differences in terms of age [female (median, 52; IQR, 47-61); male (median, 58.5; IQR, 49-66); P=0.005], underlying diagnosis (P<0.001), INTERMACS profile (P=0.009), history of previous cardiac surgery (P=0.049) and preoperative creatinine values [female (median, 110; IQR, 71-146); male (median, 126; IQR, 9-168); P=0.049]. Over a follow-up of 460.68 patient-years, Kaplan-Meyer analysis showed better survival in females (P=0.027) and a similar probability of cardiac transplantation (P=0.288). After PSM, females showed higher needs for intraoperative fresh frozen plasma (P=0.044) and platelets (P=0.001) but comparable postoperative outcomes. No sex-related differences were noticed regarding two-year outcomes, long-term survival and adverse events. LVAD-related infections remained the most common complication with males experiencing more pump infections than women (P=0.050). Conclusions Patients receiving less-invasive LVAD implantation do not show significant sex-related differences in short and long-term outcomes and survival. Prospective studies are needed to evaluate the role of less-invasive techniques in reducing sex-based disparities after LVAD implantation.
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Affiliation(s)
- Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Karl Bounader
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexandra Schöde
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jana Michaelis
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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13
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Loforte A, Bottio T, Attisani M, Suarez SM, Tarzia V, Pocar M, Botta L, Gerosa G, Rinaldi M, Pacini D. Conventional and alternative sites for left ventricular assist device inflow and outflow cannula placement. Ann Cardiothorac Surg 2021; 10:281-288. [PMID: 33842225 DOI: 10.21037/acs-2020-cfmcs-28] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Left ventricular assist device (LVAD) therapy is a well accepted and effective strategy to treat advanced heart failure. The miniaturized third-generation centrifugal pumps HeartWare HVAD (Medtronic, Dublin, Ireland) and HeartMate 3 (Abbott, Illinois, USA) are the two most commonly implanted systems in the contemporary era. Their design has allowed clinicians to pioneer several alternate and less invasive implantation techniques to tackle a broad spectrum of clinical scenarios. A brief review and discussion of alternative surgical techniques for both inflow and outflow cannula insertion, in the contemporary LVAD surgery era, are herein reported.
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Affiliation(s)
- Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tomaso Bottio
- Department of Cardiac Surgery, Centro Gallucci, Padua University, Padua, Italy
| | - Matteo Attisani
- Department of Cardiac Surgery, Città della Salute e della Scienza, Turin University, Turin, Italy
| | - Sofia Martin Suarez
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vincenzo Tarzia
- Department of Cardiac Surgery, Centro Gallucci, Padua University, Padua, Italy
| | - Marco Pocar
- Department of Cardiac Surgery, Città della Salute e della Scienza, Turin University, Turin, Italy
| | - Luca Botta
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gino Gerosa
- Department of Cardiac Surgery, Centro Gallucci, Padua University, Padua, Italy
| | - Mauro Rinaldi
- Department of Cardiac Surgery, Città della Salute e della Scienza, Turin University, Turin, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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14
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Moscato F, Gross C, Maw M, Schlöglhofer T, Granegger M, Zimpfer D, Schima H. The left ventricular assist device as a patient monitoring system. Ann Cardiothorac Surg 2021; 10:221-232. [PMID: 33842216 DOI: 10.21037/acs-2020-cfmcs-218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Technological progress of left ventricular assist devices (LVADs) towards rotary blood pumps and the optimization of medical management contributed to the significant improvements in patient survival as well as LVAD support duration. Even though LVAD therapy is now well-established for end-stage heart failure patients, the long-term occurrence of adverse events (AE) such as bleeding, infection or stroke, still represent a relevant burden. An early detection of AE, before onset of major symptoms, can lead to further optimization of patient treatment and thus mitigate the burden of AE. Continuous patient monitoring facilitates identification of pathophysiological states and allows anticipation of AE to improve patient management. In this paper, methods, algorithms and possibilities for continuous patient monitoring based on LVAD data are reviewed. While experience with continuous LVAD monitoring is currently limited to a few centers worldwide, the pace of developments in this field is fast and we expect these technologies to have a global impact on the well-being of LVAD patients.
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Affiliation(s)
- Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Christoph Gross
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Martin Maw
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcus Granegger
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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15
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Kiyatkin ME, Zuver AM, Gaudig A, Javaid A, Mabasa M, Royzman E, McDonnell BJ, Yuzefpolskaya M, Colombo PC, Stöhr EJ, Willey JZ. Carotid artery structure and hemodynamics and their association with adverse vascular events in left ventricular assist device patients. J Artif Organs 2021; 24:182-90. [PMID: 33459911 DOI: 10.1007/s10047-020-01229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
Left ventricular assist devices (LVADs) are associated with major vascular complications including stroke and gastrointestinal bleeding (GIB). These adverse vascular events may be the result of widespread vascular dysfunction resulting from pre-LVAD abnormalities or continuous flow during LVAD therapy. We hypothesized that pre-existing large artery atherosclerosis and/or abnormal blood flow as measured in carotid arteries using ultrasonography are associated with a post-implantation composite adverse outcome including stroke, GIB, or death. We retrospectively studied 141 adult HeartMate II patients who had carotid ultrasound duplex exams performed before and/or after LVAD surgery. Structural parameters examined included plaque burden and stenosis. Hemodynamic parameters included peak-systolic, end-diastolic, and mean velocity as well as pulsatility index. We examined the association of these measures with the composite outcome as well as individual subcomponents such as stroke. After adjusting for established risk factors, the composite adverse outcome was associated with pre-operative moderate-to-severe carotid plaque (OR 5.08, 95% CI 1.67-15.52) as well as pre-operative internal carotid artery stenosis (OR 9.02, 95% CI 1.06-76.56). In contrast, altered hemodynamics during LVAD support were not associated with the composite outcome. Our findings suggest that pre-existing atherosclerosis possibly in combination with LVAD hemodynamics may be an important contributor to adverse vascular events during mechanical support. This encourages greater awareness of carotid morphology pre-operatively and further study of the interaction between hemodynamics, pulsatility, and structural arterial disease during LVAD support.
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16
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Lee JH, Park I, Lee H, Sung K, Lee YT, Kim D, Yang JH, Choi JO, Jeon ES, Cho YH. Use of durable left ventricular assist devices for high-risk patients: Korean experience before insurance coverage. J Thorac Dis 2020; 12:7236-7244. [PMID: 33447412 PMCID: PMC7797861 DOI: 10.21037/jtd-20-1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Left ventricular assist devices (LVADs) were not covered by the Korean national insurance until September 2018, and they were implanted at the patient’s own or a third party’s expense. However, there have been no reports on using an LVAD without insurance coverage or manufacturer support. Methods We reviewed 23 patients who underwent durable LVAD implantation at our institution from August 2012 to September 2018. Patients with temporary LVADs using extracorporeal or paracorporeal circulation were excluded. The available devices were the HeartMate IITM (HMII) and HeartWareTM Ventricular Assist Device (HVAD). The primary outcome was 30-day mortality. The secondary outcomes were postoperative complications and late mortality. Results The mean age of the patients was 68.7±9.9 years. The study sample comprised six female (26.1%) and 17 male (73.9%) patients. All patients had modifiable (bridge to candidacy) or unmodifiable absolute (destination therapy) contraindications for heart transplantation (HT). Among the patients in this study, 12 (52.2%) had ischemic cardiomyopathy and 11 (47.8%) had non-ischemic cardiomyopathy. Nine patients (39.1%) had temporary mechanical circulatory support such as extracorporeal membrane oxygenation or a temporary LVAD in place preoperatively. The average duration of LVAD support was 618.6±563.2 days (range, 59–2,285 days). There was no 30-day mortality. Four patients (17.4%) underwent HT. Six patients (26.1%) underwent re-exploration for postoperative bleeding, and one patient (4.3%) had a disabling stroke after discharge. The estimated survival rates at 12 and 24 months were 89.2% and 68.8%, respectively. Conclusions All patients who received LVADs before insurance coverage had contraindications for HT. The overall outcomes were comparable with those reported in the international registry.
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Affiliation(s)
- Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Medical Center, Hanyang University School of Medicine, Seoul, Korea
| | - Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Gyeonggi-do, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, 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
| | - Darae Kim
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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17
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Gyoten T, Rojas SV, Fox H, Schramm R, Hakim-Meibodi K, Ruiz-Cano M, Gummert JF, Morshuis M, Sandica E. Mechanical circulatory support as a bridge to candidacy in adults with transposition of the great arteries and a systemic right ventricle. Eur J Cardiothorac Surg 2020; 59:ezaa373. [PMID: 33226086 DOI: 10.1093/ejcts/ezaa373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Clinical experience with continuous flow ventricular assist devices (VADs) in patients with transposition of the great arteries (TGA) including dextro-TGA and congenitally corrected TGA is rare, and indications as well as potential benefits or specific hurdles remain unclear. Therefore, our goal was to report on our experience regarding VAD therapy in adult patients with TGA as a bridge to candidacy. METHODS We performed a single-centre retrospective study of all adult patients with TGA with systemic right ventricular failure who had continuous flow VAD implants between 2010 and 2018. Study end points were all causes of death, major cardiac and cerebrovascular adverse events or pump thrombosis. Follow-up continued until the time of the heart transplant. RESULTS A total of 6 patients (4 men) had a continuous flow VAD implanted in the context of a failing systemic right ventricle (dextro-TGA after the Mustard procedure: n = 3; congenitally corrected TGA: n = 3). Demographics: mean age 32 ± 5.7 years; median Interagency Registry for Mechanically Assisted Circulatory Support: level II (range 1-4), mean pulmonary artery 48 ± 13 mmHg, mean pulmonary vascular resistance 5.6 ± 3.5 Wood units. Postoperative data: intensive care unit stay: 16 ± 9.7 days; in-hospital survival: 100%; no early VAD-related complications occurred. Mean follow-up: 33 ± 18 months; persistent left-side paresis: n = 1; minor (non-disabling) stroke: n = 2. Post-VAD pulmonary artery: 19 ± 3.4 mmHg; P < 0.005; post-VAD pulmonary resistance: 2.2 ± 0.55 Wood units; P = 0.066. Four patients had heart transplants after a mean waiting time of 30 months after the VAD was implanted; 2 patients are still on the waiting list (waiting time: 52 and 24 months). CONCLUSIONS Continuous flow VAD therapy is a feasible therapeutic option in adult patients with TGA and a failing systemic right ventricle as a bridge to candidacy and a bridge to a heart transplant.
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Affiliation(s)
- Takayuki Gyoten
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Sebastian V Rojas
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - René Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Kavous Hakim-Meibodi
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Maria Ruiz-Cano
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Eugen Sandica
- Center for Congenital Heart Defects, Heart and Diabetes Centre, North Rhine Westphalia, Bad Oeynhausen, Germany
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18
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Cho SM, Moazami N, Katz S, Bhimraj A, Shrestha NK, Frontera JA. Stroke Risk Following Infection in Patients with Continuous-Flow Left Ventricular Assist Device. Neurocrit Care 2019; 31:72-80. [PMID: 30644037 DOI: 10.1007/s12028-018-0662-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Infection has been associated with stroke in patients with left ventricular assist devices (LVAD); however, little data exist on the timing, type and mortality impact of infection-related stroke. METHODS Prospectively collected data of HeartMate II (N = 332) and HeartWare (N = 70) LVAD patients from a single center were reviewed. Only strokes (ischemic or hemorrhagic) that occurred within 6 weeks following a LVAD infection were considered in analyses. The association between LVAD infections (wound, pump pocket, driveline and/or bloodstream infection [BSI]), specific pathogens and ischemic and hemorrhagic strokes was evaluated using multivariable logistic regression analysis. The impact of infection-related stroke on cumulative survival was assessed using Kaplan-Meier analysis. RESULTS Of 402 patients, LVAD infection occurred in 158 (39%) including BSI in 107 (27%), driveline infection in 67 (17%), wound infection in 31 (8%) and pump pocket infection in 24 (6%). LVAD infection-related stroke occurred in 20/158 (13%) patients in a median of 4 days (0-36 days) from documented infection. In multivariable analysis, ischemic stroke was associated with wound infection (aOR 9.0, 95% CI 2.4-34.0, P = 0.001) and BSI (aOR 7.7, 95% CI 0.9-66.0, P = 0.064), and hemorrhagic stroke was associated with BSI in 100% of cases (P = 0.01). There was no association with driveline or pump pocket infection. The cumulative survival rate among patients with infection-related stroke was significantly lower compared to those with LVAD infection but no stroke (log-rank P < 0.001). There was a trend toward shorter stroke-free survival among patients with LVAD infection. CONCLUSIONS LVAD infections, particularly BSI, are significantly associated with stroke, and infection-related stroke conferred significantly lower cumulative survival.
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19
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Suarez L, Dunlay SM, Schettle SD, Stulak JM, Staab JP. Associations of depressive symptoms with outcomes in patients implanted with left ventricular assist devices. Gen Hosp Psychiatry 2020; 64:93-98. [PMID: 32008725 DOI: 10.1016/j.genhosppsych.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We examined characteristics of depressive symptoms in patients who received left ventricular assist devices (LVAD) to assess their effects on negative outcomes post-implantation. METHODS We retrospectively identified 203 adults with pre-operative PHQ-9 scores who underwent LVAD placement as bridge to transplant (BTT) or destination therapy (DT). We analyzed effects of PHQ-9 total, somatic, and cognitive/affective scores and proportion of patients with clinical depression on all-cause mortality, rehospitalization, major bleeding, and neurologic events post-implantation, controlling for demographics and other medical comorbidities. RESULTS Mean total PHQ-9 scores did not differ between 81 BTT and 122 DT patients (BTT 6.4 vs. DT 7.5, p = 0.12). A higher proportion of DT patients had clinical depression (BTT 22% vs. DT 39%, p = 0.015). Somatic symptoms accounted for three-quarters of total scores in both groups. PHQ-9 domains were not associated with negative outcomes post-implantation. CONCLUSION Depression severity did not differ based on implant strategy, but more DT patients had clinical depression. Somatic symptoms were the biggest contributor to depressive symptoms. Pre-implantation PHQ-9 scores were not associated with outcomes, possibly because depression was mild in both groups. Additional work is needed in LVAD patients to better characterize depressive symptoms and their unique effects on clinical course and well-being.
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Affiliation(s)
- Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America; Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
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20
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Inui T, Kohno H, Matsuura K, Ueda H, Tamura Y, Watanabe M, Inage Y, Yakita Y, Matsumiya G. A case of left ventricular assist device application for chemotherapy-related cardiomyopathy caused by trastuzumab and anthracycline. J Artif Organs 2020; 23:270-4. [PMID: 31897739 DOI: 10.1007/s10047-019-01151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
Left ventricular assist device (LVAD) is an established therapy for patients with severe heart failure. Because the incidence of cardiotoxicity owing to anticancer agents is low, it is difficult to predict the recovery prospects when the cause of heart failure is due to anticancer agents. In this context, cancer patients who present with severe symptoms of heart failure and who fail medical therapy for heart failure may pose a dilemma, especially in countries such as Japan where implantable LVADs are not approved for purposes other than bridging to transplant. Recently, we encountered a 32-year-old woman with chemotherapy-related cardiomyopathy that developed after anticancer treatment using trastuzumab and anthracycline. LVAD therapy was the only option to save the young woman. The patient received an extracorporeal LVAD, her cardiac function gradually recovered while on support, and the device was successfully removed.
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21
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Patel S, Rizvi SSA, Choi JH, Horan DP, Weber MP, Maynes EJ, Luc JGY, Aburjania N, Entwistle JW, Morris RJ, Massey HT, Tchantchaleishvili V. Management and outcomes of left ventricular assist device-associated endocarditis: a systematic review. Ann Cardiothorac Surg 2019; 8:600-609. [PMID: 31832350 DOI: 10.21037/acs.2019.04.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Left ventricular assist device (LVAD)-associated endocarditis remains poorly studied, especially in newer continuous-flow LVADs (CF-LVADs). The aim of this review was to assess outcomes of patients with LVAD-associated endocarditis, as stratified by CF-LVAD and pulsatile LVAD (P-LVAD) use as well as by different interventions and pathogen types. Methods An electronic search was performed to identify studies in the English literature on LVAD-associated endocarditis. Results Overall, 16 articles with 26 patients were included; seven had CF-LVADs and 19 had P-LVADs; time to development of endocarditis was 91 days (152 vs. 65 days, respectively, P=0.05). Eleven of 25 patients were treated with antibiotics only. Remaining 14 patients received antibiotics, however, they also underwent additional surgical intervention. One patient was treated with embolization alone for mycotic aneurysm and was therefore excluded. At a median follow-up time of 344 days post implant, there was no difference in overall mortality between CF-LVAD and P-LVAD-associated endocarditis patients (57.9% vs. 42.9%, P=0.81). Patients who underwent additional surgical intervention had higher overall survival compared to those treated with antibiotics alone (71.4% vs. 27.3%, P=0.07); with no difference in outcomes amongst those who underwent surgical device exchange as compared to heart transplantation (80.0% vs. 66.7%; P=0.23). Conclusions Compared to patients with P-LVADs, CF-LVAD patients appeared to be resistant to early development of LVAD-associated endocarditis. There was a trend towards high survival observed amongst patients who underwent additional surgical intervention as compared to those treated with antibiotics alone, with no difference amongst surgical device exchange as compared to heart transplantation. Advantages of additional surgical intervention vs. medical therapy alone deserves further exploration to determine its applicability in CF-LVADs.
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Affiliation(s)
- Sinal Patel
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Syed Saif Abbas Rizvi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan P Horan
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nana Aburjania
- Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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22
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Kuroda K, Seguchi O, Matama H, Kimura Y, Iwasaki K, Toda K, Kikuchi N, Kumai Y, Nakajima S, Matsumoto Y, Watanabe T, Yanase M, Fukushima S, Tomoyuki F, Kobayashi J, Fukushima N. Left ventricular assist device implantation in an adult male with Danon disease. J Cardiol Cases 2019; 20:106-109. [PMID: 31497177 PMCID: PMC6718825 DOI: 10.1016/j.jccase.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/05/2019] [Accepted: 06/10/2019] [Indexed: 11/26/2022] Open
Abstract
Danon disease is an extremely rare inherited disorder characterized by cardiac involvement, myopathy, and intellectual disability. As patients with Danon disease die at an early age, mainly as a result of cardiac involvement, implantation of a left ventricular assist device (LVAD) and/or heart transplantation are essential options. However, various comorbidities associated with Danon disease should be assessed when these patients are being considered as potential heart transplant candidates. We report the case of an adult male patient with dilated-phase hypertrophic cardiomyopathy secondary to Danon disease, who received an LVAD as a bridge to transplantation. <Learning objective: Some patients with Danon disease who underwent heart transplantation have been reported in Japan, but all were female. Male patients with Danon disease have more severe systemic comorbidities than females and heart failure progression is usually too rapid for them to be listed as heart transplant candidates. We present a rare case of an adult male with Danon disease who successfully underwent implantation of a left-ventricular assist device as a bridge to transplantation.>
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Affiliation(s)
- Kensuke Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hideo Matama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yuki Kimura
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Keiichiro Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Koichi Toda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Noriko Kikuchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yuto Kumai
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Seiko Nakajima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yorihiko Matsumoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Fujita Tomoyuki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Japan
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23
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Imamura T, Kinugawa K, Ono M, Kinoshita O, Fukushima N, Shiose A, Matsui Y, Yamazaki K, Saiki Y, Usui A, Niinami H, Matsumiya G, Arai H, Sawa Y. Implication of Preoperative Existence of Atrial Fibrillation on Hemocompatibility-Related Adverse Events During Left Ventricular Assist Device Support. Circ J 2019; 83:1286-1292. [PMID: 31019163 DOI: 10.1253/circj.cj-18-1215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hemocompatibility-related adverse events (HRAEs) are substantial issues in patients with left ventricular assist devices (LVADs). Atrial fibrillation (AF) is associated with worse prognosis in patients with heart failure (HF), but its effect on HRAEs following LVAD implantation remain uncertain.Methods and Results:Data from the Japanese Mechanically Assisted Circulatory Support registry of consecutive patients who received HeartMate II LVADs and were followed for 1 year were retrospectively reviewed. Among 190 patients, 23 had AF and 167 had sinus rhythm. The AF group had comparable baseline characteristics with the non-AF group except for their higher age (53 vs. 42 years, P<0.001). Following LVAD implantation, most cases of AF (73%) persisted. Antiplatelet therapy, anticoagulation therapy, and LVAD speed following LVAD implantation were comparable between groups (P>0.05 for all). The 1-year survival free from HRAEs was comparable between groups (83% vs. 76%, P=0.52). Event rates of the breakdown of HRAEs were comparable between groups except for a relatively higher rate of surgically managed pump thrombosis in the AF group (0.16 vs. 0.04, incidence rate ratio 3.75, 95% confidence interval 0.87-16.1, P=0.075). These trends still remained with propensity score-matched comparison. CONCLUSIONS Existence of AF had no effect on the development of HRAEs following LVAD implantation. The need to aggressively treat AF before or after LVAD implantation needs further investigation.
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Affiliation(s)
| | | | - Minoru Ono
- Department of Cardiac Surgery, the University of Tokyo Hospital
| | - Osamu Kinoshita
- Department of Cardiac Surgery, the University of Tokyo Hospital
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, Tokyo Women's Medical University
| | | | - Akihiko Usui
- Department of Cardiovascular Surgery, Nagoya University Hospital
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Saitama Kokusai Medical Center
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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24
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Hohmann S, Veltmann C, Duncker D, König T, Berliner D, Hanke J, Dogan G, Chatterjee A, Feldmann C, Lynch B, Burkhoff D, Haverich A, Bauersachs J, Schmitto JD. Initial experience with telemonitoring in left ventricular assist device patients. J Thorac Dis 2019; 11:S853-S863. [PMID: 31183165 DOI: 10.21037/jtd.2018.10.37] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Left ventricular assist devices (LVAD) are increasingly used in patients with end stage heart failure. The HeartAssist 5 and aVAD LVADs offer telemetric monitoring capabilities. Here we report our initial single centre experience with the largest telemonitoring cohort of LVAD patients. Methods Eleven patients (9 males) received a telemonitoring-capable LVAD and were included in our telemonitoring cohort. Waveforms and alarm data were obtained from the telemonitoring system and hospital records were reviewed for clinical data. Results Mean age at LVAD implantation was 59±5.1 years (mean ± standard deviation). Seven patients had non-ischemic cardiomyopathy and 4 patients had ischemic cardiomyopathy. Median LVEF at implant was 16% (IQR, 15-20%). The total follow-up time was 2,438 patient-days. A total of 6,216 alarm messages were generated in 11 patients. Most common were low flow alarms due to hypovolemia, followed by low flow alarms because of suspected pump thrombosis. One patient died during follow-up, one received a cardiac transplant and one had the LVAD explanted because of pump thrombosis. Pump thrombosis was suspected in 5 patients with 8 episodes of sudden flow decreases and laboratory signs of haemolysis. Conclusions Real-time telemonitoring of LVAD pump flow, motor speed and power consumption is a promising tool in the follow-up of LVAD recipients. Trending pump flow over hours or days can assist in the early detection of complications, especially flow reductions due to hypovolemia and LVAD thrombosis. Further studies are warranted to delineate the impact of remote monitoring on patients' prognosis.
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Affiliation(s)
- Stephan Hohmann
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Thorben König
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jasmin Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Daniel Burkhoff
- Presbyterian Hospital, Columbia University, New York City, NY, USA
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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25
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Zhigalov K, Szczechowicz M, Mashhour A, Kadyraliev BK, Mkalaluh S, Easo J, Ennker J, Eichstaedt HC, Weymann A. Left ventricular assist device implantation with concomitant tricuspid valve repair: is there really a benefit? J Thorac Dis 2019; 11:S902-S912. [PMID: 31183169 DOI: 10.21037/jtd.2018.11.116] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The objectives of this study was to investigate if concomitant tricuspid valve repair in patients undergoing continuous flow left ventricular assist device (LVAD) implantation has an impact on the outcome regarding survival and adverse events. Methods Between June 2007 and February 2018, 124 consecutive patients received HeartMate II (HMII) [74 (59.7%)] HeartWare (HVAD) [16 (12.9%)], or HeartMate III (HM III) [34 (27.4%)] for end-stage heart failure. Mean age was 63.5±10.9 years. Two 18-patient groups were identified; with [tricuspid valve reconstruction (TVR)] group and without (non-TVR group) accompanying TVR. The primary endpoint was overall survival after device implantation. Secondary endpoints were adverse events during the follow-up period. Results Survival was not significantly different between the groups (P>0.05). In TVR group, there was a higher need for open chest after surgery and a prolonged inotrope use because of right heart failure (RHF), a higher incidence of acute kidney dysfunction requiring dialysis, as well as a higher need for packed red blood cells due to postoperative bleeding (P<0.05). Conclusions In this cohort of patients, LVAD implantation with a concurrent tricuspid valve repair appears to have a worse outcome regarding RHF, bleeding tendency and renal dysfunction (P<0.05). However, the survival was comparable in both TVR and Non-TVR groups (P>0.05).
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Affiliation(s)
- Konstantin Zhigalov
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Bakitbek K Kadyraliev
- Federal Center of Cardiovascular Surgery named after S.G. Sukhanov, Perm State Medical University, Perm, Russia
| | - Sabreen Mkalaluh
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Juergen Ennker
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Harald C Eichstaedt
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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26
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Abstract
Surgical maneuvers for implantation of a continuous-flow ventricular assist device are revolutionary concepts that have been associated with a reduction in pump-related complications. With the advancement of technology, surgical implant strategy continues to evolve, incorporating less-invasive approaches into the armamentarium of the experienced surgeon.
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Affiliation(s)
- Colleen Pietras
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Silverstein, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Silverstein, Philadelphia, PA 19104, USA.
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27
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Ricklefs M, Heimeshoff J, Hanke JS, Chatterjee A, Dogan G, Shrestha M, Feldmann C, Wert L, Haverich A, Schmitto JD. The influence of less invasive ventricular assist device implantation on renal function. J Thorac Dis 2018; 10:S1737-S1742. [PMID: 30034846 PMCID: PMC6035947 DOI: 10.21037/jtd.2017.10.03] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/29/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND End-stage heart failure is associated with severe after-effects such as heart valve insufficiency, cardiac arrhythmias or end-organ dysfunctions. Renal failure or 'cardiorenal syndrome' is a critical end-organ disorder associated with advanced heart failure, which occurs due to low-output failure. Drug therapy or surgical interventions involving left ventricular assist device (LVAD) implantation may impede the progress of heart insufficiency and its after-effects including renal failure. In this study, we investigated the impact of a minimally invasive ventricular assist device implantation through upper hemisternotomy combined with anterolateral thoracotomy on renal function, in patients with perioperative renal failure. METHODS We analyzed data obtained from 103 patients (80 males, 23 females; mean age 53.8±11.7) who underwent LVAD implantation at our clinic within a 15-year interval (2001-2016) and were dialyzed due to renal dysfunction. 90 patients were operated with the conventional LVAD implantation technique (standard approach surgery, SAS) and 13 underwent less invasive approach implantation (less invasive surgery, LIS). RESULTS For all patients, data analysis showed significant increase of glomerular filtration rate (GFR) (44.2±56.48 mL/min; 95% CI: 33.81-55.28; P<0.001) along with a significant decrease in the levels of creatinine (-1.08±1.83 mg/dL; 95% CI: 0.75-1.46; P<0.001) and urea (-4.62±13.66 mmol/L; 95% CI: 1.95-7.29; P<0.001). There was a considerable difference in change of renal parameters in patients treated with LIS in comparison to patients who underwent SAS, which was however not statistically significant (GFR: P=0.494; creatinine: P=0.543; urea P=0.918). CONCLUSIONS LVAD implantation improves kidney function in patients with renal dysfunction. A considerable difference in the change of renal parameters was detected in patients with LIS as compared to SAS, which was not significant possibly due to the limited size of the patient cohort (n=13).
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Affiliation(s)
- Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Heimeshoff
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Leonhard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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28
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Ricklefs M, Deodhar C, Chatterjee A, Feldmann C, Hanke JS, Heimeshoff J, Merz C, Deniz E, Dogan G, Haverich A, Schmitto JD. A new tool for an explantation strategy of HeartMate 3™ left ventricular assist device. J Thorac Dis 2018; 10:S1825-S1828. [PMID: 30034859 PMCID: PMC6035945 DOI: 10.21037/jtd.2018.04.57] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/04/2018] [Indexed: 11/06/2022]
Abstract
Although rare, recovery of cardiac function after mechanical support of the left ventricle is the most desirable therapeutic goal in the treatment of end-stage heart failure.Herein, we present a novel implantable device for explantation of the HeartMate 3™ left ventricular assist device (LVAD) in patients, following cardiac recovery, avoiding (re-) sternotomy.This article demonstrates the feasibility of applying this novel device, which fits into the sewing ring of the LVAD.This custom-made mechanical plug offers a promising alternative to standard device-explantation procedures.
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Affiliation(s)
- Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S. Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Heimeshoff
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Constanze Merz
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ezin Deniz
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D. Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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29
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Dogan G, Hanke JS, Ricklefs M, Chatterjee A, Feldmann C, Mashaqi B, Deniz E, Haverich A, Schmitto JD. MitraClip procedure prior to left ventricular assist device implantation. J Thorac Dis 2018; 10:S1763-S1768. [PMID: 30034850 DOI: 10.21037/jtd.2018.05.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Functional mitral valve regurgitation is a frequent consequence of left ventricular dysfunction in patients with severe heart failure and is associated with a poor prognosis. It is hypothesized that in this patient group the mitral valve repair, respectively replacement, improves hemodynamics and clinical symptoms. As operative interventions with the help of heart-lung-machine are high risk procedures in these cases, the transcatheter mitral repair with MitraClip® (Abbott Vascular, IL, USA) has recently become frequently used. Most of these cases experience a progress in left ventricular dysfunction, which finally leads to in an implantation of a left ventricular assist device. In this report, we describe a series of six cases in which patients with end stage heart failure and consecutive functional mitral valve regurgitation were supported with a left ventricular assist device after MitraClip implantation. We aimed to investigate, whether the MitraClip implantation leads to an improvement of the hemodynamic prior left ventricular assist device (LVAD)-implantation. Methods We retrospectively analyzed the data of 6 patients (5 males, 1 female) with severe heart failure, who underwent LVAD implantation after the MitraClip procedure. The mean age at MitraClip procedure was 64.6 years, mean age at time of LVAD implantation was 65.5 years. The parameters examined were cardiac index (CI), left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD) and the pulmonary capillary wedge pressure (PCWP). Results All patients had functional mitral regurgitation (MR). Severity of MR was reduced successfully in all treated patients. All patients were discharged with MR I-II and NYHA functional class III or IV after MitraClip procedure. The mean CI was 2.93 before MitraClip procedure and 2.36 before LVAD-Implantation. Mean LVEDD was 71 mm before MitraClip, mean LVEDD was 70.6 mm before LVAD, and 63.2mm after LVAD implantation respectively. The mean PCWP was 21.5 mmHg before MitraClip and 19.8 mmHg before LVAD implantation respectively. The mean left ventricular ejection fraction (LVEF) was 19.2% before MitraClip, the mean LVEF was 17.6% before LVAD and 15% after LVAD implantation. Two of the LVAD implanted patients died due to post-operative complications. There were no complications after MitraClip procedure. Conclusions Our presented patient cohort presented little hemodynamic improvement after the MitraClip procedure. There was no clinical benefit for the patients after MitraClip procedure, progressing left ventricular dysfunction could not be prevented and resulted in subsequent LVAD implantation.
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Affiliation(s)
- Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bakr Mashaqi
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ezin Deniz
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Wert L, Hanke JS, Dogan G, Ricklefs M, Fleißner F, Chatterjee A, Feldmann C, Haverich A, Schmitto JD. Reduction of driveline infections through doubled driveline tunneling of left ventricular assist devices-5-year follow-up. J Thorac Dis 2018; 10:S1703-S1710. [PMID: 30034842 DOI: 10.21037/jtd.2018.03.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Driveline infection (DLI) is one of the leading causes for unplanned re-admissions of patients undergoing therapy with left ventricular assist devices (LVAD). In previous studies our group was able to show that a double tunneling implantation technique could significantly reduce infection rates one year after implantation. We now report the results of the five-year-follow up of patients receiving the double tunneling technique. Methods We retrospectively analyzed patients receiving LVAD therapy with the HeartWare ventricular assist device (HVAD) (Medtronic, Minnesota, MN, USA) LVAD. For 36 patients (group 1) the driveline was tunneled via a conventional technique. In the remaining 33 patients (group 2) the drivelines were implanted by means of a double tunneling technique. The double tunnel driveline technique involved placement of the driveline in the sheath of the rectus muscle in the umbilical direction and then subcutaneously to the left (alternatively right) upper quadrant. We retrospectively compared both groups. Primary outcome parameters were infection rate and mortality. Results Five years after LVAD implantation the DLI rate of patients operated by a double tunneling technique was significantly lower than in the conventional technique group [61% (n=22) group 1 vs. 30% (n=10) group 2, P=0.004]. The 5-year mortality was lower in group 2 [42% (n=15) group 1 vs. 27% (n=9) group 2] but did not achieve statistical significance (P=0.10). The days of LVAD support between the two groups were comparable (1,275.56±885.89 group 1 vs. 1,321.94±711.37 group 2). The tunnel technique itself showed to be strongly associated with the occurrence of DLI. Other elevated variables are liver disease and dilated cardiomyopathy as primary disease. Conclusions Double tunneling technique for driveline implantation leads to significantly lowered infection rates after 5 years of LVAD therapy and it is associated with a lower mortality.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleißner
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Wert L, Chatterjee A, Dogan G, Hanke JS, Boethig D, Tümler KA, Napp LC, Berliner D, Feldmann C, Kuehn C, Martens A, Shrestha ML, Haverich A, Schmitto JD. Minimally invasive surgery improves outcome of left ventricular assist device surgery in cardiogenic shock. J Thorac Dis 2018; 10:S1696-S1702. [PMID: 30034841 DOI: 10.21037/jtd.2018.01.27] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Left ventricular assist device (LVAD) (HVAD, Medtronic, Minneapolis, MN, USA) implantation is already a widely accepted treatment option for end-stage heart failure (HF) but also still considered as a rescue therapy for patients suffering from cardiogenic shock. Standard LVAD implantation techniques are often associated with high mortality rates and can result in severe complications, like bleeding or right heart failure (RHF). The aim of our study was to assess the outcome of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (so called "crash and burn" patients) undergoing a LVAD implantation by standard or less invasive surgery. Methods We performed a retrospective evaluation of the 1-year outcome of 32 consecutive HF patients in cardiogenic shock, who underwent LVAD implantation in our institution. A total of 32 INTERMACS 1 patients were emergently operated. Fourteen patients (group A) were operated by using the "Hannover-VAD-technique", which is widely known to be less invasive (upper hemisternotomy and a left-sided anterolateral thoracotomy). In contrast, 18 patients (group B) were implanted with LVAD by using the standard technique (full sternotomy). The primary endpoint was survival after 1 year without device-related re-operations. Secondary endpoints included combined analyses of rates of RHF, respiratory failure and bleeding during the trial period. Results Baseline characteristics were similar in both groups. Survival after 1 year was higher in group A (69.7% vs. 50.0%). Technique-related adverse events (AEs) were also lower in the minimally invasive group, including a lower RHF (35.7% vs. 61.1%) and of further postoperative bleeding requiring surgery (14.3% vs. 33.3%). Conclusions LVAD surgery in INTERMACS 1 patients is associated with remarkably good outcome considering the already very high mortality of those patients, and compared to previously reported surgical outcomes. Our study indicates that minimally invasive LVAD implantation in cardiogenic shock decreases mortality and the incidence of postoperative AEs.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Kirstin A Tümler
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh L Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Wert L, Hanke JS, Dogan G, Ricklefs M, Chatterjee A, Feldmann C, Ismail I, Napp LC, Haverich A, Schmitto JD. Argatroban administration as therapy for thrombosis in patients with continuous-flow ventricular assist devices. J Thorac Dis 2018; 10:S1720-S1727. [PMID: 30034844 DOI: 10.21037/jtd.2017.10.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Device thrombosis is one of the main complications in left ventricular assist devices (LVAD) therapy and remains a challenging issue. Data on device thrombosis management, especially on the application of direct thrombin inhibitors such as argatroban, is limited and a consensus on thrombosis management has not yet been established. Methods In this study we analysed retrospective clinical data obtained from 26 patients on VAD therapy who received argatroban for suspected VAD thrombosis, between April, 2012 and February, 2017. Results Thirteen patients (50%) showed resolution of thrombus after argatroban therapy. Eight of 26 patients (30.8%) were free of thrombotic events 90 days after discharge. Argatroban therapy was unsuccessful in 13 patients of the study cohort, leading to subsequent VAD-exchange. Six of 13 patients with first VAD-exchange had no thrombotic events 90 days after discharge. Six patients (23.1%) suffered from bleeding, especially gastrointestinal bleeding. No hemorrhagic strokes were observed. Three patients (11.5%) did not survive the follow-up period. Conclusions Argatroban appears to be an alternative to other pharmacological treatment options in VAD thrombosis. Efficacy and safety characteristics are acceptable, but further investigation on larger populations is necessary.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Nestorovic E, Schmitto JD, Kushwaha SS, Putnik S, Terzic D, Milic N, Mikic A, Markovic D, Trifunovic D, Ristic A, Ristic M. Successful establishment of a left ventricular assist device program in an emerging country: one year experience. J Thorac Dis 2018; 10:S1743-S1750. [PMID: 30034847 DOI: 10.21037/jtd.2018.04.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background The primary goal of this study was to evaluate the outcomes of patients with end-stage heart failure (HF) who underwent continuous flow left ventricular assist device (CF-LVAD) in a developing country and to compare to those reported by more developed countries. The secondary goal was on determining factors that may be connected to improved survival. Methods We prospectively analyzed 47 consecutive patients who underwent CF-LVAD at our institution. After one year the survival and adverse event profiles of patients were evaluated. At 3, 6 and 12 months, the cardiac, renal and liver function outcomes were assessed. Results The 30-day, 6-month and 1-year survival rates were 89%, 85% and 80%, respectively. A significant improvement in dimensions and ejection fraction of left ventricle, BNP, functional capacity, blood urea nitrogen (BUN) and total bilirubin (P<0.05 for all) were noticed 3 months post-CF-LVAD implantation, and patients were stable throughout the entire first year follow up. In the group of patients with baseline renal dysfunction (RD) there were significant improvements of renal function (P=0.004), with no changes on follow up. 57% of patients exhibited some kind of adverse event, commonly in the form of bleeding. In multivariate Cox regression analysis renal failure was found to be as an independent risk factor for the overall survival (HR =13.1, P<0.001). Conclusions In conclusion, our data extends previous findings from centers of developed countries, that CF-LVAD is an adequate treatment option for patients suffering from end-stage HF, and encourages expansion of CF-LVAD implantation in developing countries with nascent HT program.
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Affiliation(s)
- Emilija Nestorovic
- Department for Heart Transplant, LVAD and ECMO, Hospital for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sudhir S Kushwaha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Svetozar Putnik
- Department for Heart Transplant, LVAD and ECMO, Hospital for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dusko Terzic
- Department for Heart Transplant, LVAD and ECMO, Hospital for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Natasa Milic
- Department for Medical Statistics and Informatics, Medical Faculty University of Belgrade, Belgrade, Serbia.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Aleksandar Mikic
- Department for Heart Transplant, LVAD and ECMO, Hospital for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Markovic
- Center for Anesthesiology and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Arsen Ristic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Miljko Ristic
- Department for Heart Transplant, LVAD and ECMO, Hospital for Cardiac Surgery, Clinical Center of Serbia, Belgrade, Serbia
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Hanke JS, Dogan G, Wert L, Ricklefs M, Heimeshoff J, Chatterjee A, Feldmann C, Haverich A, Schmitto JD. Left ventricular assist device exchange for the treatment of HeartMate II pump thrombosis. J Thorac Dis 2018; 10:S1728-S1736. [PMID: 30034845 DOI: 10.21037/jtd.2018.01.115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Pump thrombosis is the most severe and acute complication of left ventricular assist device (LVAD) therapy and treatment remains challenging. Whilst lysis therapy is often not successful, the exchange of the occluded LVAD is currently the most applied therapeutic treatment for this event. With this study we examine the effects of minimal-invasive LVAD exchange on the rate re-thrombosis and outcomes as well as adverse events in the study group. Methods Between February 2004 and December 2015 more than 600 LVADs were implanted at our institution. We retrospectively studied a patient cohort of 41 patients who underwent LVAD exchange because of pump thrombosis at a single institution. Outcomes, rates of re-thrombosis and adverse events were analyzed. Results Between February 2004 and December 2015, 87 exchanges of LVADs were performed at a single center. In 41 cases pump thrombosis was the reason for LVAD exchange. A total of 28 patient years (10,276 days) were analyzed. Average ICU stay was 15.8±20.4 days and average in-hospital stay 38.1±37.3 days after LVAD exchange. After thirty days the survival rate was 80.5%, 75.6% after 6 months and 70.7% one year after LVAD exchange. Out of the study cohort, three patients have successfully undergone heart transplantation. Twelve patients suffered a stroke postoperatively (29%). Twelve patients needed postoperative dialysis (29%). No technical complications of the VAD were recorded in the study group. Two patients underwent successful LVAD explantation due to myocardial recovery. One year after LVAD exchange, 14 patients underwent re-exchange due to pump thrombosis (34%). Eight patients suffered from a LVAD related infection out of which two patients were treated by pump exchange. A total of 12 patients died during the complete one year follow up of this study (29%). Four patients died in the second, two in the third and one in the fourth year after LVAD exchange. The remaining 17 patients are still ongoing on the device.Conclusions: It is generally feasible to treat pump thrombosis via LVAD exchange. Yet, the exchange procedure is not without risk and the risk of re-thrombosis (34%), stroke (29%), postoperative dialysis (29%) and perioperative complications remains high.
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Affiliation(s)
- Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Leonard Wert
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Heimeshoff
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Volkovicher N, Kurihara C, Critsinelis A, Kawabori M, Sugiura T, Manon M 2nd, Civitello AB, Morgan JA. Effect of obesity on outcomes in patients undergoing implantation of continuous-flow left ventricular assist devices. J Artif Organs 2018; 21:180-7. [PMID: 29372417 DOI: 10.1007/s10047-017-1013-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 12/24/2017] [Indexed: 12/13/2022]
Abstract
The purpose of this study was to analyze the effect of obesity on outcomes after continuous-flow left ventricular assist device (CF-LVAD) implantation. A single-center retrospective analysis was performed on 526 chronic heart failure patients who were implanted with the HeartMate II CF-LVAD (n = 403) or HeartWare HVAD (n = 123) between November 2003 and March 2016. Patients were stratified into 4 groups based on BMI: underweight (< 18.5 kg/m2, n = 18, 3.4%), normal-weight (18.5-25 kg/m2, n = 173, 32.9%), overweight (25-30 kg/m2, n = 182, 30.2%), and obese (> 30 kg/m2, n = 153, 33.5%). The underweight group was excluded because of its small sample size. Records were reviewed to determine the incidence of postoperative complications and survival. Survival at 1, 6, 12, and 24 months were similar among normal-weight (91.3, 84.4, 76.3, and 67.6%), overweight (90.4, 80.8, 76.5, and 69.6%), and obese patients (90.7, 74.7, 65.3, and 61.3%, p = 0.24). Additionally, obesity was not a significant predictor of mortality in Cox proportional hazard models (hazard ratio 0.98, 95% confidence interval 0.766-1.277, p = 0.13). These findings suggest that appropriately selected obese patients receive similar survival benefit from CF-LVADs compared to non-obese patients, and obesity should not serve as a contraindication to CF-LVAD implantation.
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Abstract
INTRODUCTION Mechanical circulatory support (MCS) is an increasingly utilized mode of therapy in the management of advanced heart failure, both as bridge to heart transplantation and destination therapy. As MCS becomes more prevalent, it is ever more important to understand the complex hemodynamics of these devices, as well as the strategies for hemodynamic optimization. Areas covered: This review provides an overview of hemodynamics in the normal human heart and the failing heart. We discuss the various short-term mechanical circulatory support devices and their hemodynamic consequences. We will then discuss the differences between left ventricular assist devices, and the impact of these differences on hemodynamics. We will describe the strategies for hemodynamic optimization using echocardiographic and invasive ramp studies. Finally, we will discuss the impact of speed changes with exercise and discuss future directions for advancements in MCS therapies. Expert commentary: We advocate for a deeper understanding of the hemodynamics underpinning MCS devices. We also recommend the more widespread use of ramp studies for speed optimization, which have been well validated across a number of different left ventricular assist device types.
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Affiliation(s)
- Ben Bow Chung
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Gabriel Sayer
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
| | - Nir Uriel
- a Section of Cardiology , University of Chicago , Chicago , IL , USA
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Shahreyar M, Bob-Manuel T, Khouzam RN, Bashir MW, Sulaiman S, Akinseye O, Sharma A, Carter A, Latham S, Bhandari S, Jahangir A. Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device. Ann Transl Med 2018; 6:5. [PMID: 29404351 DOI: 10.21037/atm.2017.12.23] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. Methods All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. Conclusions Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.
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Affiliation(s)
- Muhammad Shahreyar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Rami N Khouzam
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Samian Sulaiman
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Oluwaseun Akinseye
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Arindam Sharma
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - April Carter
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Samuel Latham
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sanjay Bhandari
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Arshad Jahangir
- Aurora Cardiovascular Services, Aurora St. Luke's Medical Center, Milwaukee, WI, USA.,Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora St. Luke's Medical Center, Aurora Health Care, Milwaukee, WI, USA
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Yamauchi T, Masai T, Fujii K, Sawa Y, Shirai S, Kamigaki M, Itou N. Long-term clinical results of acute myocardial infarction at the left main trunk requiring percutaneous cardiopulmonary support. J Artif Organs 2017; 20:303-310. [PMID: 28887708 DOI: 10.1007/s10047-017-0972-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/25/2017] [Indexed: 11/28/2022]
Abstract
The clinical results of patients with acute myocardial infarction (AMI) at the left main trunk (LMT) remain unclear, especially in cases requiring percutaneous cardiopulmonary support (PCPS). Twenty seven cases of AMI at the LMT requiring emergent PCPS were retrospectively investigated. These 27 patients were aged 44-83 years (65.6 ± 8.6 years) and 20 (81.5%) were men. Peak creatine kinase (CK) leakage ranged from 538 to 34,010 IU/l (13,553 ± 7656 IU/l). Eight (29.6%) patients were discharged without mechanical support. Ten (37.0%) patients underwent left ventricular assist device (LVAD) implantation, five of whom with preoperative organ failure could not survive more than 6 months after implantation. The other nine (33.3%) patients died of low output syndrome or brain damage. The overall survival rates were 53.7, 41.3, 33.0, and 28.3% at 3 months, 6 months, 1 year, and 2 years, respectively. Multivariate analysis showed that Killip class 3/4 at hospital arrival was an independent risk factor for hospital mortality (odds ratio 20.4). Patients with more than 5 days of PCPS support period (n = 6), ≥ 4 h to revascularization (n = 6) or maximum CK leakage ≥20,000 IU/dl (n = 3) were not associated with successful PCPS or IABP weaning. The long-term clinical outcomes of patients with LMT disease requiring PCPS is devastating. Rapid cardiopulmonary resuscitation and coronary revascularization and timely insertion of LVAD before the onset of complications might lead to better survival.
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Affiliation(s)
- Takashi Yamauchi
- Department of Cardiovascular Surgery, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan.
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Kenji Fujii
- Department of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Shinya Shirai
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Mitsunori Kamigaki
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Naofumi Itou
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
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39
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Abstract
Mechanical circulatory assistance has become a frequent therapeutic option for patients with advanced heart failure. For patients with acute cardiogenic shock and impaired organ function, short-term assistance with venoarterial extracorporeal membrane oxygenation is the leading therapeutic option. It enables a "bridge to decision-making" i.e. withdrawal of the device after myocardial recovery or after recognition of therapeutic futility, or as a bridge-to-transplantation or to long-term mechanical support. For Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 2-6 patients, implantation of a long-term ventricular assist-device (VAD) should be considered before progression to multiple organ failure if heart transplantation is not a first-line option. Most patients receive a miniaturized axial or centrifugal fully implantable left VAD as a bridge-to-transplantation or as "destination therapy" in this setting.
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Affiliation(s)
- Alain Combes
- Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; Sorbonne University, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013 Paris, France.
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40
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Chin AI, Tong K, McVicar JP. Successful Hemodialysis Arteriovenous Fistula Creation in a Patient With Continuous-Flow Left Ventricular Assist Device Support. Am J Kidney Dis 2016; 69:314-316. [PMID: 27692441 DOI: 10.1053/j.ajkd.2016.07.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/18/2016] [Indexed: 11/11/2022]
Abstract
Heart failure necessitating left ventricular assist device (LVAD) support can lead to kidney failure requiring dialysis. Some of these patients may require long-term hemodialysis (HD). Optimal vascular access for a patient on long-term HD therapy with an LVAD remains a complex issue. The majority of LVADs are of the continuous-flow type, and it has been theorized that native arteriovenous fistula maturation may be impaired in a setting of decreased pulsatile arterial flow. We describe a case of successful creation and use of an arteriovenous fistula in an HD-dependent patient with a continuous-flow LVAD.
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Affiliation(s)
- Andrew I Chin
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Kathleen Tong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - John P McVicar
- Division of Transplant, Department of Surgery, University of California, Davis School of Medicine, Sacramento, CA
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41
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Toyama H, Takei Y, Saito K, Ota T, Kurotaki K, Ejima Y, Matsuura T, Akiyama M, Saiki Y, Yamauchi M. Management of three cardiogenic pulmonary edemas occurring in a patient scheduled for left ventricular assist device implantation: indicators for determining left ventricular assist device pump speed. J Anesth 2016; 30:711-5. [PMID: 27001080 DOI: 10.1007/s00540-016-2163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/05/2016] [Indexed: 10/22/2022]
Abstract
A male patient with Marfan syndrome underwent aortic root replacement and developed left ventricular (LV) failure. Four years later, he underwent aortic arch and aortic valve replacement. Thereafter, his LV failure progressed, and cardiogenic pulmonary edema (CPE) appeared, which we treated with extracorporeal LV assist device (LVAD) placement. Three months later, the patient developed aspiration pneumonia, which caused hyperdynamic right ventricle (RV) and CPE. We treated by changing his pneumatic LVAD to a high-flow centrifugal pump. A month later, he underwent thoracoabdominal aortic replacement. After four weeks, he developed septic thrombosis and LVAD failure, which caused CPE. We treated with LVAD circuit replacement and an additional membrane oxygenator. Four months later, he underwent DuraHeart(®) implantation. During this course, pulmonary artery wedge pressure (PAWP) varied markedly. Additionally, systolic pulmonary artery pressure (sPAP), left atrial diameter (LAD), RV end-diastolic diameter (RVEDD) and estimated RV systolic pressure (esRVP) changed with PAWP changes. In this patient, LV failure and hyperdynamic RV caused the CPEs, which we treated by adjusting the LVAD output to the RV output. Determining LVAD output, RV function and LV end-diastolic diameter are typically referred, and PAWP, LAD, RVEDD, and sPAP could be also referred.
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Affiliation(s)
- Hiroaki Toyama
- Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Yusuke Takei
- Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kazutomo Saito
- Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takahisa Ota
- Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kenji Kurotaki
- Department of Anesthesiology, Tohoku University Hospital, 1-1 Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yutaka Ejima
- Division of Surgical Center and Supply, Sterilization, Tohoku University Hospital, Sendai, Japan
| | - Takeshi Matsuura
- Division of Clinical Engineering, Tohoku University Hospital, Sendai, Japan
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Masanori Yamauchi
- Anesthesiology and Perioperative Medicine, Tohoku University School of Medicine, Sendai, Japan
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Abstract
In this case, the patient's ventricular tachycardia (VT) was specifically induced by coughing, which has not previously been described. Decreasing the rotational speed of the left ventricular assist device (LVAD) and increasing preload by stopping the patient's nitrates and reducing diuretic dose allowed improved filling of the left ventricle (LV) and increased LV volumes. When coughing recurred, the effects on the LV cavity were less pronounced and thus VT was reduced. Although ventricular arrhythmias are common after LVAD placement, this is a unique case in which VT was caused by coughing, which is ordinarily not considered arrhythmogenic.
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Affiliation(s)
- Emily Sue Ruckdeschel
- Section of Electrophysiology, Cardiology Division, University of Colorado, Aurora, CO, USA
| | - Eugene Wolfel
- Section of Electrophysiology, Cardiology Division, University of Colorado, Aurora, CO, USA
| | - Duy Thai Nguyen
- Section of Electrophysiology, Cardiology Division, University of Colorado, Aurora, CO, USA.
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43
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Abstract
Left ventricular support for the failing heart has evolved to include short-term and long-term devices. These devices are implanted percutaneously and surgically. This manuscript provides a general overview of the contemporary, typically practiced, implant techniques with additional insight on minimally invasive approaches.
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Affiliation(s)
- Bryan A Whitson
- Department of Surgery, Division of Cardiac Surgery, Ohio State University Medical Center, Columbus, OH 43210, USA
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Akin S, Soliman OI, Constantinescu AA, Akca F, Birim O, van Domburg RT, Manintveld O, Caliskan K. Haemolysis as a first sign of thromboembolic event and acute pump thrombosis in patients with the continuous-flow left ventricular assist device HeartMate II. Neth Heart J. 2016;24:134-142. [PMID: 26689927 PMCID: PMC4722006 DOI: 10.1007/s12471-015-0786-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Despite advances in pump technology, thromboembolic events/acute pump thrombosis remain potentially life-threatening complications in patients with continuous-flow left ventricular assist devices (CF-LVAD). We sought to determine early signs of thromboembolic event/pump thrombosis in patients with CF-LVAD, which could lead to earlier intervention. Methods We analysed all HeartMate II recipients (n = 40) in our centre between December 2006 and July 2013. Thromboembolic event/pump thrombosis was defined as a transient ischaemic attack (TIA), ischaemic cerebrovascular accident (CVA), or pump thrombosis. Results During median LVAD support of 336 days [IQR: 182–808], 8 (20 %) patients developed a thromboembolic event/pump thrombosis (six TIA/CVA, two pump thromboses). At the time of the thromboembolic event/pump thrombosis, significantly higher pump power was seen compared with the no-thrombosis group (8.2 ± 3.0 vs. 6.4 ± 1.4 W, p = 0.02), as well as a trend towards a lower pulse index (4.1 ± 1.5 vs. 5.0 ± 1.0, p = 0.05) and a trend towards higher pump flow (5.7 ± 1.0 vs. 4.9 ± 1.9 L m, p = 0.06). The thrombosis group had a more than fourfold higher lactate dehydrogenase (LDH) median 1548 [IQR: 754–2379] vs. 363 [IQR: 325–443] U/L, p = 0.0001). Bacterial (n = 4) or viral (n = 1) infection was present in 5 out of 8 patients. LDH > 735 U/L predicted thromboembolic events/pump thrombosis with a positive predictive value of 88 %. Conclusions In patients with a CF-LVAD (HeartMate II), thromboembolic events and/or pump thrombosis are associated with symptoms and signs of acute haemolysis as manifested by a high LDH, elevated pump power and decreased pulse index, especially in the context of an infection.
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45
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Abstract
Left ventricular assist devices (LVADs) have been shown to markedly improve survival and quality of life in patients with end-stage heart failure. However, despite ongoing improvements in survival and quality of life, significant challenges still exist in the management of these patients, including a high rate of recurrent heart failure and rehospitalizations. Similar challenges exist in the non-LVAD heart failure population as well, and recent efforts to utilize remote hemodynamic monitoring techniques to improve outcomes have shown promise. No data currently exist demonstrating extension of this benefit into the LVAD population, although a theoretical benefit can be extrapolated. Herein we review current remote hemodynamic methods and potential applications towards LVAD patients.
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Affiliation(s)
- Brent C Lampert
- The Ohio State University Wexner Medical Center, 473 W. 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
| | - Sitaramesh Emani
- The Ohio State University Wexner Medical Center, 473 W. 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
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46
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Abstract
The widespread acceptance of left ventricular assist device (LVAD) implantation in the treatment of heart failure has revolutionized the way end stage heart failure is treated. Advances in LVAD technology combined with a better understanding of patient selection has led to unparalleled survival as well as a reduction in the adverse event profile of these pumps. As our understanding of heart failure continues to grow, there is little doubt that LVADs will continue to play a pivotal role as a therapeutic option for those suffering from heart failure.
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Affiliation(s)
- Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center; Columbus, OH, USA
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47
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Abstract
Temporary mechanical circulatory support (MCS) refers to a group of devices generally used for less than 30 days to maintain adequate organ perfusion by compensating for a failure of the pumping mechanism of the heart. The increased availability and rapid adoption of new temporary MCS strategies necessitate physicians to become familiar with devices placed both percutaneously and via median sternotomy. This review will examine the different options for commonly used temporary MCS devices including intra-aortic balloon pumps (IABPs), veno-arterial-extracorporeal membrane oxygenation (VA-ECMO), TandemHeart(®) (CardiacAssist, Pittsburg, PA, USA) Impella(®) and BVS 5000(®) (both Abiomed Inc., Danvers, MA, USA), CentriMag(®) and Thoratec percutaneous ventricular assist device (pVAD)(®) (both Thoratec Corporation, Pleasanton, CA, USA). A specific emphasis will be made to describe relevant mechanisms of action, standard placement strategies, hemodynamic effects, relevant contraindications and complications, and important daily management considerations.
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Affiliation(s)
- Areo Saffarzadeh
- 1 Integrated Cardiothoracic Surgery Resident, 2 Director of Mechanical Circulatory Support, Center for Advanced Heart Failure and Transplantation, Yale School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - Pramod Bonde
- 1 Integrated Cardiothoracic Surgery Resident, 2 Director of Mechanical Circulatory Support, Center for Advanced Heart Failure and Transplantation, Yale School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
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48
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Cheng A. Minimally invasive left ventricular assist device placement. J Vis Surg 2015; 1:25. [PMID: 29075614 DOI: 10.3978/j.issn.2221-2965.2015.12.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND The use of left ventricular assist device (LVAD) as bridge-to-transplant and destination therapy has increased significantly in the recent years along with the rapidly increasing heart failure patient population worldwide. It is crucial to be familiar with the standard surgical technique of LVAD implantation, but also to further advance the technique to optimize patient outcomes. Numerous studies have shown minimally invasive cardiac surgeries, including cardiac valves procedures can improve patient outcomes with decrease post-operative bleeding, reduced blood transfusion requirement, shorter hospital stay, faster recovery rate and lower hospital cost. With the advancement of mechanical circulatory support, the smaller and current generation of centrifugal continuous-flow LVADs has made minimally invasive LVAD implantation feasible. In this review, we described our surgical technique of minimally invasive LVAD placement. METHODS In addition to the standard pre-LVAD implantation evaluation, multiple studies, including chest radiography, chest computed tomography and echocardiography are further examined for patient selection and planning of the operation. Instead of a full standard sternotomy, a lateral mini-thoracotomy and hemi-sternotomy or second intercostal space anterior mini-thoracotomy are utilized. Special techniques are also applied to allow easy access for future re-entry, e.g., heart transplantation and to improve post-operative outcomes. Off-pump approach is our prefer approach for the minimally invasive procedure. RESULTS With minimally invasive approach, avoiding a full sternotomy, can reduce surgical trauma and post-operative bleeding, and can make subsequent LVAD explantation and heart transplantation less technically challenging and will allow patients to have a faster post-operative recovery rate. With the intact pericardium, the right ventricle can be protected from acute unrestricted dilation and further right heart failure after LVAD placement. The use of off-pump approach allows the avoidance of cardiopulmonary bypass and will decrease the incidence of post-operative vasoplegia and coagulopathy. CONCLUSIONS With the current generation of LVADs, minimally invasive surgical approach is very feasible and may improve patient outcomes. Further large prospective randomized studies will help to further demonstrate the potential advantages and disadvantage of minimally invasive LVAD placement. The upcoming generations of LVADs and minimally invasive instrumentations are currently being evaluate and will further advance the success of LVAD therapy.
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Affiliation(s)
- Allen Cheng
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, USA
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49
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Jabbar HR, Abbas A, Ahmed M, Klodell CT Jr, Chang M, Dai Y, Draganov PV. The Incidence, Predictors and Outcomes of Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device (LVAD). Dig Dis Sci 2015; 60:3697-706. [PMID: 26072320 DOI: 10.1007/s10620-015-3743-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 06/02/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate rate, recurrence, and predictors of gastrointestinal bleeding (GIB) and impact of endoscopy in left ventricular assist device (LVAD) patients. METHODS This is a cohort study of all patients who received the current-generation continuous-flow HeartMate II LVAD from 2005 to 2013 at our institution. Patients were followed up, and GIB events recorded until death, time of heart transplantation, or end of observation. RESULTS LVAD was implanted in 112 patients (median age 67 years, 88% male). A total of 44 patients (39%) had 74 GIB events occurring at a rate of 42.9 per 100 p-y. Endoscopy was performed in 77% of patients, and GIB source was identified in 57% with upper GIB found in almost two-third of cases. Right ventricular dysfunction and post-LVAD ejection fraction >30% were associated with higher GIB rates. Higher pulsatility index was associated with lower GIB rates. Re-bleeding occurred in 19 (43%) patients at a rate of 62.5 per 100 p-y and was not affected by endoscopic therapy at the index endoscopy. CONCLUSIONS GIB in LVAD patients is common, occurring primarily in the upper GI tract. Upper endoscopy is the preferred strategy though lower endoscopy is also recommended for a full workup. Endoscopy can identify GIB lesions in about 50% of patients, but re-bleeding is common. Right ventricular dysfunction and post-LVAD ejection fraction >30% are associated with higher GIB rates. Higher pulsatility index is associated with lower GIB rates. Reduction in pump speed is a potential strategy for managing and preventing GIB.
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50
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Abstract
There have been many factors that have allowed for progressive improvement in outcomes and lower complication rates. These include the improvement in left ventricular assist device (LVAD) technologies, combined with better understanding of patient management, all these. Nowadays the numbers of LVAD implantations exceed the number of annual heart transplants worldwide. Minimally invasive procedures are shown to improve the surgical outcome in both LVAD insertion and replacement. These minimally invasive techniques can be grouped grossly into shifting from on-pump to off-pump implantation, alternative access for implantation other than sternotomy, and a combination of both, which should be the ultimate aim of minimally invasive LVAD implantation. Here we describe the alternative techniques and configurations of minimally invasive and sites of implantation.
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Affiliation(s)
- George Makdisi
- Indiana University School of Medicine & Indiana University Health, Indianapolis, IN, USA
| | - I-Wen Wang
- Indiana University School of Medicine & Indiana University Health, Indianapolis, IN, USA
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