Management of arrhythmias in left ventricular assist device recipients.

The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: A 10- Year Update

Left Ventricular Assist Devices and Renal Ramifications.

ORAL PRESENTATION

Background: The longitudinal success of the heart failure (HF) patient with a left ventricular assist device (LVAD) depends on medications to maintain the device, such as antithrombotic agents to prevent pump thrombosis and antihypertensives to reduce stroke risk. However, the role of traditional, evidence-based HF medications for patients with concurrent LVAD support is not well known. This study aimed to determine use, temporal trends, and factors associated with prescription of HF medications at discharge among patients with advanced HF with and without LVADs, and to examine patient and hospital-level factors associated with HF medication prescription among LVAD recipients. Methods: We conducted a retrospective, observational analysis of 4,580 advanced HF patients from 215 hospitals participating in the Get With The Guidelines-Heart Failure registry from January 2009 to March 2015. We examined patterns of HF medication use at hospital discharge among patients with an in-hospital (n=258) or prior (n=326) LVAD implant, and those with advanced HF without an LVAD, as defined by a reduced left ventricular ejection fraction and intravenous inotrope or vasopressin antagonist receipt (n=3,996). Results: For beta-blocker and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARB), discharge prescriptions were 58.9% and 53.5% for new LVAD recipients, 62.9% and 51.4% for prior LVAD recipients, and 78.7% and 60.7% for patients without LVAD support, respectively (p<0.0001 and p=0.0005). There was no significant difference in aldosterone antagonist use among the three groups (p=0.23) but its use quadrupled among LVAD patients during the study period (p<0.0001, see figure). Approximately 54% of new and prior LVAD patients and 66% of patients without an LVAD were discharged on two of the three HF medications (p<0.0001). In the multivariable analysis of LVAD patients, patient age was inversely associated with beta-blocker, ACE/ARB, and aldosterone antagonist use. Conclusion: Traditional HF therapies are commonly prescribed to LVAD recipients, although less frequently than to advanced HF patients without LVAD support. Aldosterone antagonists are prescribed increasingly to LVAD patients. Further research is needed on the optimal medical regimen for patients with LVADs.

Axial-flow LVADs have become an integral tool in the management of end-stage heart failure. Consequently, nonsurgical bleeding has emerged as a major source of morbidity and mortality in this fragile population. The mechanisms responsible for these adverse events include acquired von Willebrand disease, GI tract angiodysplasia formation, impaired platelet aggregation, and overuse of anticoagulation therapy. Because of ongoing concerns for pump thrombosis and thromboembolic events, the thrombotic/bleeding paradigm has led to a difficult clinical dilemma for those managing patients treated with axial flow LVADs. As the field progresses, advances in the understanding of the pathological mechanisms underlying bleeding/thrombosis risk, careful risk stratification, and potential use of novel anticoagulants will all play a role in the management of the LVAD patient.

Recurrent orthostatic syncope due to left atrial and left ventricular collapse after a continuous-flow left ventricular assist device implantation

Right ventricular dysfunction is best managed with a total artificial heart

Adverse Events During Hemodialysis in LVAD Recipients

Left ventricular assist device (LVAD) implantation is a well-known treatment option for patients with advanced heart failure refractory to medical therapy and is recognized both as bridge to transplant and a destination therapy. The risk of ventricular arrhythmias (VAs) is common after LVAD implantation. We review the pathophysiology and recent advances in the management of VA in LVAD patients. VAs are most likely to occur in the early post-operative periods after LVAD implantation and a prior history of VA is the most important risk factor. Post-LVAD VAs are usually well tolerated with less morbidity and decreased risk of sudden cardiac death. However, risk of right heart failure in the setting of persistent VAs is being increasingly recognized. The mechanisms of post-LVAD VAs may vary depending on the time from LVAD implantation. Electrical remodeling may play an important role in the immediate post-implant phase. Preexisting myocardial scar and to a lesser extent mechanical irritation from the LVAD cannula are important in the later phases. Most LVAD patients have a previously placed implantable cardioverter-defibrillator (ICD). The benefit of implanting a new ICD in LVAD patients is unknown and should be individualized. For ICD programming, a conservative strategy with higher detection zones and prolonged time to detection is usually recommended aiming to minimize ICD shocks. More aggressive programming is appropriate if the VA results in hemodynamic instability. Antiarrhythmic drugs including amiodarone, mexiletine, and beta blockers are usually the first-line therapy for VAs. Catheter ablation has been shown to be safe and effective in LVAD recipients with recurrent VAs not responsive to antiarrhythmic drugs. LVAD-related VA is most frequently reentrant secondary to myocardial scar and usually well tolerated. Management options include antiarrhythmic drugs and catheter ablation.

Application of mechanical cardiac support now requires consideration of a wider range of goals beyond bridging to transplantation to include destination therapy and perhaps bridging to recovery.1,2 Responsible dissemination of the technology requires identification of patient populations from which to select candidates most likely to benefit. At this early stage, benefit is most apparent against a high background mortality from end-stage heart failure. Heart failure affects an estimated 5 million patients in the United States. Of those, ≈60% have heart failure with left ventricular dilation and reduced ejection fraction. Trials demonstrating benefit of therapies for heart failure have focused primarily on mild–moderate heart failure with reduced ejection fraction, generally with annual mortality in the range of 8% to 18%.3 Advanced heart failure has been defined as symptoms limiting daily activity (New York Heart Association class III and IV) despite attempted therapy with angiotensin-converting enzyme inhibitors, β-blockers, digoxin, and diuretics,4 a description that applies to ≈300 000 to 800 000 patients in the United States. Although often labeled as “refractory,” many patients enjoy improved quality of life and decreased hospitalizations after referral to experienced heart failure centers, where aggressive medical strategies focus on relief of congestion. Surgical approaches include complex revascularization, valvular repair/replacement, or ventricular reconstruction. When technically successful, biventricular pacing can improve functional status for many of the 25% to 40% of patients with marked ventricular asynchrony.5 If early stabilization allows institution of β-adrenergic–blocking agents, prognosis is further improved.6 Dedicated heart failure management programs that facilitate patient education, compliance, and fluid balance have been integral to benefits observed with these therapies. The highest-risk heart failure populations are best identified after optimization of current therapies. Low left ventricular ejection fraction is not sufficient description of either function or prognosis once heart failure has become advanced. Neither …

Impact Of Atrial Fibrillation On Readmission After LVAD Implantation: Insight From National Readmission Database.

Introduction Implantable Cardioverter-Defibrillators (ICDs) improve survival in advanced heart failure with reduced ejection fraction (HFrEF) and prevent sudden cardiac death. However, the prognostic benefits of ICDs among patients with a Left Ventricular Assist Device (LVAD) remain uncertain and controversial. Therefore, we conducted a systematic review and meta-analysis to assess the effectiveness and safety of ICD implantation among LVAD recipients. Methods We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed and EMBASE for the peer-reviewed articles published in English assessing the impact of ICD implantation among LVAD recipients, till 10/01/2024. ICD implantation was defined as implantation before LVAD, simultaneous implantation with LVAD, or within 30 days of LVAD insertion. Two independent review authors assessed the quality and risk of bias of the included studies. A random-effect model was used to combine data in forest plots. The primary outcome was all-cause mortality associated with ICD implantation compared to no ICD implantation, and the secondary outcomes included ventricular arrhythmia (VT), and hemorrhagic stroke. Heterogeneity was assessed using Q test and I2, with I2 > 50% indicating marked heterogeneity. Results A total of 13 observational studies comprising 54571 recipients of LVAD were included in the analysis of the primary outcome. All-cause mortality was similar among patients with ICD versus no ICD (Odds Ratio [OR]= 0.77; 95% CI, 0.57-1.04, I2= 89%, P=0.09), as shown in Figure 1. Likewise, ICD implantation was associated with similar rates of VT and hemorrhagic stroke (VT: OR= 1.81, 95% Cl, 0.82-4.01, I2= 90%, P=0.14; hemorrhagic stroke: OR= 1.01, 95% Cl, 0.81-1.25, I2= 0%, P= 0.95). Conclusion Among patients with HFrEF and LVAD as advanced heart failure therapy, ICD implantation didn’t provide additional prognostic survival benefit, suggesting possible use of LVAD without ICD implantation.Figure 1.Forest plot of mortality

Hemodynamic transesophageal echocardiography in left ventricular assist device care: a complementary technology.

Left ventricular assist devices (LVADs) are an essential part of advanced heart failure (HF) management, either as a bridge to transplantation or destination therapy. Patients with advanced HF have a poor prognosis and may benefit from palliative care consultation (PCC). However, there is scarce data regarding the trends and predictors of PCC among patients undergoing LVAD implantation. This study aims to assess the incidence, trends, and predictors of PCC in LVAD recipients using the United States Nationwide Inpatient Sample (NIS) database from 2006 until 2014. We conducted a weighted analysis on LVAD recipients during their index hospitalization. We compared those who had PCC with those who did not. We examined the trend in palliative care utilization and calculated adjusted odds ratios (aOR) to identify demographic, social, and hospital characteristics associated with PCC using multivariable logistic regression analysis. We identified 20,675 admissions who had LVAD implantation, and of them 4% had PCC. PCC yearly rate increased from 0.6% to 7.2% (P < 0.001). DNR status (aOR 28.30), female sex (aOR 1.41), metastatic cancer (aOR: 3.53), Midwest location (aOR 1.33), and small-sized hospitals (aOR 2.52) were positive predictors for PCC along with in-hospital complications. Differently, Black (aOR 0.43) and Hispanic patients (aOR 0.25) were less likely to receive PCC. There was an increasing trend for in-hospital PCC referral in LVAD admissions while the overall rate remained low. These findings suggest that integrative models to involve PCC early in advanced HF patients are needed to increase its generalized utilization.

In this issue of Circulation, Birks et al 1 report their recent experience using the combination of continuous-flow (CF) circulatory support and pharmacological therapy to treat advanced heart failure in patients requiring left ventricular assist device (LVAD) support. Thirty-three patients underwent HeartMate II (HMII) LVAD implantation at Harefield hospital during the 3-year study period. Twenty-three patients (70%) with nonischemic cardiomyopathy were considered appropriate for the recovery protocol at the time of HMII LVAD implantation, and 20 patients (61%) who survived LVAD implantation formed the study cohort. With their strategy of aggressive neurohormonal blockade (phase I) followed by high-dose clenbuterol (phase II), 12 (60%) of the study cohort met criteria for LVAD explantation, and all 10 (50%) who survived the perioperative period demonstrated sustained recovery over 56 to 1112 days of follow-up. Therefore, 30% of all patients and 43% of all nonischemic patients undergoing HMII implantation could be managed to long-lasting recovery. In an era in which transplant waiting times have blurred the distinction between bridge-totransplant and destination therapy for some patients, this single-center experience is intriguing and offers hope for a new strategy for select patients supported with CF LVADs. Article see p 381 Reports in the literature regarding rates of cardiac recovery during pulsatile LVAD support are quite varied (Table 1). The Columbia University group reported a 1% rate of sustained cardiac recovery in 111 patients with both ischemic and nonischemic etiology of heart failure. 2 In contrast, the German Heart Institute reported that 13% of patients with nonischemic heart failure demonstrated sustained recovery (minimum follow-up of 36 months) after LVAD explantation. 3 The LVAD Working Group was the first multicenter, prospective initiative to study recovery.4 Sixty-seven LVAD patients (only 1 CF LVAD) with both ischemic and nonischemic causes underwent serial echocardiograms at reduced flow to seek recovery. Six percent of the whole cohort and 7% of all nonischemic patients could undergo LVAD explantation. None of these reports described the consistent use of pharmacological therapy during LVAD support, and it was not until the first Harefield recovery study 5 that data regarding combined pharmacological and mechanical support were available. In the first Harefield study, 15 LVAD patients (1 CF LVAD) received maximal doses of heart failure medications, followed by high-dose clenbuterol. All patients had a nonischemic etiology, and most (80%) had heart failure for 6 months. The authors reported that 75% of patients receiving clenbuterol could undergo LVAD explantation and 46% of all patients with nonischemic heart failure presenting for LVAD could be managed successfully to recovery in this way. These data from Harefield represented the most successful reported recovery strategy to date, and prompted a multicenter study in the United States (to replicate the Harefield recovery protocol) called the Harefield Recovery Protocol Study (HARPS). HARPS has now completed enrollment of 17 patients with the HMI pulsatile LVAD, 13 of whom received both maximal neurohormonal blockade and high-dose clenbuterol. Results from the US HARPS study will be presented in the near future. With the approval of the HMII LVAD for both bridge-to