End-stage Heart Failure Patients Research Articles

Outcome Predictors and Safety of Home Dobutamine Intravenous Infusion in End Stage Heart Failure Patients.

Patients in end-stage heart failure can experiment cardiogenic shock and may not be weanable from dobutamine. The fate of these patients is a challenge for doctors, patients, family, and the institution. Dobutamine use at home can be a solution. The aim of the present study was to assess the outcome, biological predictors, and safety of dobutamine use at home in dobutamine-dependent patients. All consecutive dobutamine-dependent patients discharged with continuous home intravenous dobutamine, from a single tertiary center between February 2014 and November 2019, were retrospectively analyzed. A total of 19 patients (age 65 ± 10 years) were followed for one year. At one-year, the survival rate was 32%, (6/19). Five (26%) patients had an adverse event related to the intravenous catheter. In a multivariate logistic regression analysis, the combination of a glomerular filtration rate >60 mL/min and a brain natriuretic peptide level <1000 ng/L, were highly predictive of one-year survival (HR = 10.87, IC95% (5.78–36.44), p < 0.001). Management of dobutamine-unweanable patients after cardiogenic shock may involve dobutamine at home to permit a home return. This strategy allows a significant survival and few readmissions, and, if eligible, access to surgical strategies, such as heart transplantation. Simple biological markers at discharge can identify severe patients to refer to palliative care and good responders.

Cost-effectiveness of left ventricular assist devices as destination therapy in the United Kingdom.

AimsContinuous‐flow left ventricular assist devices (LVADs) as destination therapy (DT) are a recommended treatment by National Institute for Health and Care Excellence England for end‐stage heart failure patients ineligible for cardiac transplantation. Despite the fact that DT is frequently used as an LVAD indication across other major European countries and the United States, with consistent improvements in quality‐of‐life and longevity, National Health Service (NHS) England does not currently fund DT, mainly due to concerns over cost‐effectiveness. On the basis of the recently published ENDURANCE Supplemental Trial studying DT patients, we assessed for the first time the cost‐effectiveness of DT LVADs compared with medical management (MM) in the NHS England.Methods and resultsWe developed a Markov multiple‐state economic model using NHS cost data. LVAD survival and adverse event rates were derived from the ENDURANCE Supplemental Trial. MM survival was based on Seattle Heart Failure Model estimates in the absence of contemporary clinical trials for this population. Incremental cost‐effectiveness ratios (ICERs) were calculated over a lifetime horizon. A discount rate of 3.5% per year was applied to costs and benefits. Deterministic ICER was £46 207 per quality‐adjusted life year (QALY). Costs and utilities were £204 022 and 3.27 QALYs for the LVAD arm vs. £77 790 and 0.54 QALYs for the MM arm. Sensitivity analyses confirmed robustness of the primary analysis.ConclusionsThe implantation of the HeartWare™ HVAD™ System in patients ineligible for cardiac transplantation as DT is a cost‐effective therapy in the NHS England healthcare system under the end‐of‐life willingness‐to‐pay threshold of £50 000/QALY, which applies for VAD patients.

Exercise capacity in patients implanted with left ventricular assist devices for end-stage heart failure treatment

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left ventricular assist device (LVAD) is an expanding therapy in end-stage heart failure today. Although LVAD therapy bears the potential to normalize cardiac output, a majority of patients show a severely impaired physical condition at the time of LVAD implantation. To date, no validated standardized training protocol is available, and established practices to effectively improve LVAD patients’ exercise tolerance is lacking. This study sought to investigate exercise capacity quantified by cardiopulmonary exercise testing (CPX) and a standardized six-minute walk test (6MWT) in patients after LVAD implantation. Methods We enrolled 30 end-stage heart failure patients who had received an LVAD implantation 20.7 ± 7.6 days prior to examination, mean age 54.9 ± 7.8 years, 26 males (87 %). Exercise tolerance was assessed using cardiopulmonary exercise testing (CPX) for maximal and submaximal exercise capacity, followed by a standardized (6MWT). Results Patients showed peak oxygen uptake values of 8.3 ± 2.4 ml/min/kg at a mean workload of 46.7 ± 11.3 watts and a mean anaerobic threshold of 6.7 ± 1.7 ml/min/kg at a workload of 32.6 ± 6.9 watts. Mean standardized 6-minute walking distance was at 183.8 ± 71.4 meters. There were no adverse events during exercise testing. Conclusions Cardiopulmonary exercise testing (CPX) and standardized 6MWT show severely impaired cardiopulmonary exercise capacity in patients after LVAD implantation, warranting further studies for dedicated training protocols, specifically focusing on LVAD patients to improve exercise tolerance at an acceptable safety profile.

Effects of Continuous-Flow Left Ventricular Assist Device Therapy on Peripheral Vascular Function

The peripheral vascular effects of continuous-flow left ventricular assist device (CF-LVAD) implantation are still unclear. The aim of the current study was to determine peripheral vascular function before and after implantation of CF-LVAD in patients with end-stage heart failure (HF), and to compare this data to age- and sex-matched chronic heart failure with reduced ejection fraction (HFrEF) patients. Forty-three consecutive end-stage HF patients (New York Heart Association [NYHA] class III/IV; three women and 40 men; mean age 53 ± 11 years) who planned to receive CF-LVAD implantation comprised the LVAD patient population, and their clinical characteristics, preoperative and third postoperative month peripheral vascular function assessment data including flow-mediated dilation (FMD) and pulsatility index (PI) assessed by ultrasound Doppler in brachial artery were compared to age- and sex-matched chronic, stable HFrEF patients (NYHA class II; five women and 30 men; mean age 51 ± 10 years). After CF-LVAD implantation, median FMD decreased from 5.4 to 3.7% (p &lt; 0.001), and median PI decreased from 6.9 to 1.4 (p &lt; 0.001). In patients with end-stage HF before CF-LVAD implantation, FMD and PI were significantly lower compared to the chronic HFrEF patients (FMD: 5.4% ± 0.9% vs. 7.6% ± 1.1%; p &lt; 0.001, respectively) and (PI: 6.9 ± 1.3 vs. 7.4 ± 1.2; p = 0.023, respectively). The current study revealed impaired peripheral vascular function in the end-stage HF patients compared to stable HFrEF patients, and documented the deterioration of peripheral vascular function after CF-LVAD implantation. These results suggest that impaired peripheral vascular function in the CF-LVAD patients compared to preoperative assessment is a consequence of the nonpulsatile blood flow due to the continuous-flow mechanical support.

833 Evolution of sleep disordered breathing types in heart failure

Abstract Introduction Central sleep apnea is commonly seen in patients with heart failure. Here we present a case demonstrating shifting of predominant apneic events from central to obstructive type after placement of left ventricular assist device (LVAD) in end stage heart failure patient. Report of case(s) Case Presentation: 66 year-old African American male has past medical history of chronic congestive heart failure diabetes, hypertension, paroxysmal atrial fibrillation, anemia, hypothyroidism, chronic kidney disease and sleep apnea. Prior to his LVAD placement, his left ventricular ejection fraction (EF) was &amp;lt;10%. Patient was diagnosed with central sleep apnea with AHI of 58 (with 92% of apneic events being central events), oxygen nadir of 74%. Subsequently, patient had LVAD placed for symptomatic heart failure and repeat polysomnogram repeated at six month demonstrated an improved AHI of 45.8 with predominantly obstructive and mixed apneic events, with only 12.5% being central events. Conclusion This case report highlights not only the improvement of the sleep apnea in CHF treated with LVAD but also shows the shift of apneic events from predominantly central to obstructive type post LVAD. Support (if any) 1. Henein MY, Westaby S, Poole-Wilson PA, Cowie MR, Simonds AK. Resolution of central sleep apnoea following implantation of a left ventricular assist device. Int J Cardiol. 2010 Feb 4;138(3):317–9. PMID: 18752859. 2. Köhnlein T, Welte T, Tan LB, Elliott MW. Central sleep apnoea syndrome in patients with chronic heart disease: a critical review of the current literature. Thorax. 2002 Jun;57(6):547–54. PMID: 12037232 3. Monda C, Scala O, Paolillo S, Savarese G, Cecere M, D’Amore C, Parente A, Musella F, Mosca S, Filardi PP. Apnee notturne e scompenso cardiaco: fisiopatologia, diagnosi e terapia [Sleep apnea and heart failure: pathophysiology, diagnosis and therapy]. G Ital Cardiol (Rome). 2010 Nov;11(11):815–22. Italian. PMID: 21348318.

Platelet activation and aggregation in different centrifugal-flow left ventricular assist devices

Left-ventricular assist devices (LVADs) improve outcomes in end-stage heart failure patients. Two centrifugal-flow LVAD systems are currently approved, HeartMate 3 (HM3) and Medtronic/Heartware HVAD (HVAD). Clinical findings suggest differences in thrombogenicity between both systems. We compared markers of platelet activation and aggregation between HM3 and HVAD. We prospectively included 59 LVAD patients (40 HM3, 19 HVAD). Platelet P-selectin expression, activated glycoprotein (GP) IIb/IIIa and monocyte-platelet aggregates (MPA) were assessed by flow-cytometry. Platelet aggregation was measured by light-transmission aggregometry (LTA) and multiple-electrode aggregometry (MEA). Von-Willebrand factor (VWF) antigen (VWF:Ag), VWF activity (VWF:Ac), and VWF multimer pattern analysis were determined. Soluble P-selectin (sP-selectin) was measured with an enzyme-linked immunoassay. P-selectin, GPIIb/IIIa and MPA levels in vivo and in response to arachidonic acid, adenosine diphosphate, and thrombin receptor activating peptide were similar between HM3 and HVAD (all p > .05). Likewise, agonist-inducible platelet aggregation by LTA and MEA did not differ between HM3 and HVAD (all p > .05). VWF:Ag levels and FVIII:C were similar between both systems (both p > .05), but patients with HVAD had significantly lower VWF:Ac (p = .011) and reduced large VWF multimers (p = .013). Finally, sP-selectin levels were similar in patients with HVAD and HM3 (p = .845). In conclusion, on-treatment platelet activation and aggregation are similar in HM3 and HVAD patients. Potential clinical implications of observed differences in VWF profiles between both LVAD systems need to be addressed in future clinical trials.

Predicting Right Ventricular Failure Following Left Ventricular Assist Device Support: A Derivation-Validation Multicenter Risk Score

<h3>Purpose</h3> Despite several models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support, poor performance when externally validated has limited their widespread use. We sought to derive a predictive model for RVF after LVAD implantation, and ascertain its performance in an independent cohort. <h3>Methods</h3> End-stage heart failure (HF) patients requiring continuous-flow LVAD were prospectively enrolled at one US program (n=477, derivation cohort), with two other US medical centers forming the validation cohort (n=321). The primary outcome was RVF incidence, defined as the need for right ventricular assist device or inotropes for >14 days. Multivariable logistic regression in the derivation set yielded a RVF predictive model, which was subsequently applied to the validation cohort, and a risk score was ultimately developed. <h3>Results</h3> Derivation cohort included patients less likely to be African-Americans (7% vs 37%; p<0.001), Hispanics (7% vs 30%; p<0.001), have a remote history of hypertension (49% vs 60%; p=0.002) or be bridged with short-term MCS (8% vs 16%; p=0.001), compared to the validation set. RVF incidence was 16% in the derivation and 36% in the validation cohort (p<0.001). Multivariable analysis identified 7 variables <b>(Figure)</b> as predictive of RVF, with the model achieving a C statistic of 0.734 (95% CI=0.674-0.794) in the derivation and 0.709 (95% CI=0.651-0.767) in the heterogeneous validation cohort. Patients were stratified into 3 RVF risk groups (all comparisons; p<0.001) <b>(Figure)</b>. <h3>Conclusion</h3> We propose a novel scoring system to predict post-LVAD RVF, achieving high discriminative performance in distinct, heterogeneous LVAD cohorts.

Adaptive Sensorless Control of LVAD Using Deep Convolutional Neural Network

Purpose Left ventricular assist devices (LVADs) play a vital role for end-stage heart failure (HF) patients during destination therapy. However, the speed of LVADs are set at a constant speed mode which can result in insufficient perfusion and hazardous events such as ventricular suction and pulmonary congestion. A preload-based physiological control system, a “smart pump”, can be employed to adjust the LVAD speed automatically and therefore improve prefusion and deal with the hazardous events. Although most of these physiological control systems require direct measurement of preload, long-term implantation of a pressure sensor can lead to drift or thrombus formation. Preload can instead be estimated using pump intrinsic variables. This study presents a sensorless control of LVAD across different patient conditions without relying on any implantable sensors. Methods An adaptive preload-based physiological controller was employed to adjust the speed of HeartWare HVAD pump to handle interpatient and intrapatient variations using a computer simulation. A deep convolutional neural network (CNN) model was designed to estimated preload based on the 600 samples of pump flow in real-time mode. The proposed CNN model was trained and validated on 100 different patient conditions and tested over new 30 patient conditions and a range of changes to the cardiovascular system, including changes in PVR, SVR and rest to exercise. Finally, the physiological controller and preload estimator were combined to create a sesnorless preload-based physiological control system for LVADs. Results Preload was accurately estimated using the proposed deep convolutional neural network model, which was successfully trained, tested and validated using computer simulation data. The results for all scenarios show the correlation coefficient of 0.97 and RMSE of 0.84 (mmHg). Furthermore, the sesnorless preload-based physiological control was able to prevent ventricular suction and pulmonary congestions over new 30 patients. Conclusion The sesnorless preload-based physiological control can be useful for estimation of preload and control of LVAD speed in a real-time mode for HF patients without implantation of pressure sensors. This controller can improve the HF patients’ quality of lives and lifespan by increasing perfusion, preventing suction and congestion.

Survival Outcomes with Regards to Implant Strategies in Heart Transplantation

Purpose Strategies underlying the use of Left ventricular assist devices (LVAD) for patients with end-stage heart failure include its use as bridge to transplant (BTT) or as destination therapies (DT). Survival outcomes of patients undergoing these LVAD implant strategies were evaluated and compared. Methods A retrospective analysis of single center database heart transplant patients that received LVADs from Nov. 2009 to Sep. 2020 (n=137). Patients were placed into the following cohorts based on the implant strategy: 1) BTT (n=31), 2) DT (n=106). Demographics were compared between groups for significance. Kaplan Meier curves were calculated and compared via log rank tests, and Cox Regression Analysis was performed. P-values Results Demographics between the groups were: diagnosis (p=0.257), CPB time (p=0.957), XC time (p=0.763), ischemic time (p=0.478), warm ischemic time (p=0.332), age (p=0.323), race (p=0.067), length of stay (p=0.355) and PRA (p=0.701). Of 137 patients that received LVADs used for BTT or DT prior to heart transplant, the BTT group had better survival outcomes than DT (p=0.0467). Median survival time for DT group was 2554 days, and median survival time for BTT group was 3030 days. The type of LVADs used between the two groups were significantly different (p=0.0009), therefore cox regression was run to control for statistically significant variables, with device showing no significant effect on survival. In cox regression BTT had a protective effect over DT with a hazard ratio of 1.439, p=0.0364. Conclusion Implant strategies for LVAD as BTT or DT show a difference in survival outcomes for end-stage heart failure patients, however both had reasonable outcomes. This paper supports the current literature in that LVADs are viable for use in patients of all types, with slightly better effects in BTT patients.

Arterial Pulsatility in Patients with Continuous Flow Left Ventricular Assist Device Support: Comparing Velocity and Mean Arterial Pressure

<h3>Purpose</h3> An increasing number of end-stage heart failure patients are supported by continuous-flow Left Ventricular Assist Devices (cfLVADs) as a bridge to heart transplantation. Accurate assessment of arterial pulsatility remains a challenge because of diminished pulse pressure, which itself can be associated with adverse events such as gastrointestinal bleeding and stroke. Our study investigates the value of simultaneous arterial pressure and arterial blood velocity assessment in cfLVAD patients. <h3>Methods</h3> Brachial artery flow velocity (cm/s, Huntleigh) and brachial cuff oscillometry pressure (mmHg, Sphygmocor XCel) data were collected during outpatient visit. Velocity measurements obtained included peak, minimum, average velocity as well as pulsatility index. Pressure measurements obtained were systolic, diastolic as well as mean arterial pressure. <h3>Results</h3> Twelve velocity and pressure measurements were obtained from a total of nine VAD patients. Mean age was 57 years (Range 44-71). Mean device support duration was 187 days (Range 44-471). Mean brachial MAP was 92 mmHg (Range 74-112), whereas mean peak brachial artery velocity was 11 cm/s (Range 6-26). Mean pulsatility index was 3 (range 1-8). Correlation analysis using Spearman's rho demonstrated a significant inverse relationship between Brachial MAP and Peak velocity (Rho=-0.72, p=0.08). <h3>Conclusion</h3> Arterial flow measurements may provide incremental value over purely pressure-based assessment. Discrepancies between these modalities may provide further information regarding the arterial vasculature, specifically pertaining to the impact of higher MAP on blood flow.

Heart Transplantation in an Aging Society: Impact of Recipient Age on Postoperative Outcome

Purpose Heart transplantation (HTx) represents the preferred therapy for end-stage heart failure patients. In an aging society, a rising number of older patients suffers from heart failure today. Simultaneously, the number of performed HTx is limited by the lack of suitable donor organs. Therefore, the questions arise whether older patients should be transplanted or not. In contrast to donor age, which definitely impacts the outcome after HTx, the impact of recipient age is less well analyzed. Methods Between 2010 and mid 2020 a total of 178 patients underwent HTx in our department. Mean recipient age at transplantation was 54.18±11.61 years (minimum 21.71 years, maximum 72.63 years). Patients were retrospectively divided into three groups according to their age (Group 1: age 60 years, n=65. Results Donor age significantly differed between the three groups (Group 1: 40.63±10.74 years; Group 2: 41.40±13.61 years; Group 3: 46.57±12.54 years, p=0.02). In addition, patients of group 1 were significantly more often listed high urgency listing status (p=0.03). However, preoperative mechanical ventricular assistance, cardiac graft function and allograft ischemia were comparable between all groups. We did not find significant differences for the incidence of severe primary graft dysfunction necessitating mechanical circulatory support (p=0.44) as well as common postoperative major morbidity such as haemodialysis (p=0.10), neurological events (p=0.60), bleeding complications (p=0.79), infections (p=0.40) and early graft rejection (>1R) (p=0.32). Postoperative hospitalization and mechanical ventilation times did not differ either. Furthermore, Fisher-Freeman-Halton test revealed no significant differences concerning the 30-day survival (Group 1: 96.6%; Group 2: 87.5%; Group 3: 87.7%, p=0.44) as well as one-year survival of the three groups (Group 1: 79.2%; Group 2: 82.1%; Group 3: 69.8%, p=0.29). Conclusion In our single-center analysis recipient age did not significantly impact the outcome after HTx. Both postoperative morbidity and mortality were comparable for patients of different age groups. We did not observe any significant disadvantages for recipients older than 60 years compared with their younger counterparts. Thus, after careful and individual selection we support HTx in elderly patients.

Outcomes over One and a Half Decade Following HeartMate II versus HeartMate 3 Left Ventricular Assist Device Therapy: The Rotterdam Experience

<h3>Purpose</h3> Continuous-flow left ventricular assist device (LVAD) therapy has become an indispensable treatment modality for patient with end-stage heart failure. Therefore, our aim is to evaluate our results with 2 contemporary generations of the mainstream LVAD device types, being the HeartMate II (HMII) and HeartMate 3 (HM3), with over one and a half decade of experience, in the treatment of end-stage heart failure patients within our tertiary referral center. <h3>Methods</h3> We included all adult patients implanted with an LVAD from December 2006 until December 2019. The primary outcome was early and late survival. Secondary outcomes included multiple adverse events, both early and late. <h3>Results</h3> In total, 133 patients (mean age 56 ± 12 year, 77% male) underwent implantation of an LVAD: 64 (48%) received an HMII and 69 (52%) received an HM3, with a median follow-up period of 768 days [IQR 221-1206] and 427 days [IQR 269 - 962], respectively. The HM3 patients were compared to the HM II group older (57 ±10 vs 49±12), had a higher median body mass index (25.6 [IQR 22.5-28.1] vs 22.8 [IQR 20.7-25.1]) and less frequently implanted as bridge-to-transplant (26 (30%) vs 61 (70%)). However, despite the increased age and rate of morbidity, survival (both early and late) were similar for both patient groups, as displayed in the <b>Figure</b>. Furthermore, bleeding events, rates of stroke, re-thoracotomy rates, and confirmed pump-thrombosis rates did not differ between both groups. <h3>Conclusion</h3> Despite the older age and relatively higher risk profile of the second era HM 3 patients compared with the HM II patients, the rate of adverse events did not differ between both groups. Similarly, the survival remains favorable regardless of a lower transplantation rate and higher destination therapy strategy in the HM3 group. Therefore, LVAD therapy remains an excellent modality to improve both the quality of life and survival in a broad range of end-stage heart failure patients.

MiR-132/212 Impairs Cardiomyocytes Contractility in the Failing Heart by Suppressing SERCA2a.

Compromised cardiac function is a hallmark for heart failure, mostly appearing as decreased contractile capacity due to dysregulated calcium handling. Unfortunately, the underlying mechanism causing impaired calcium handling is still not fully understood. Previously the miR-132/212 family was identified as a regulator of cardiac function in the failing mouse heart, and pharmaceutically inhibition of miR-132 is beneficial for heart failure. In this study, we further investigated the molecular mechanisms of miR-132/212 in modulating cardiomyocyte contractility in the context of the pathological progression of heart failure. We found that upregulated miR-132/212 expressions in all examined hypertrophic heart failure mice models. The overexpression of miR-132/212 prolongs calcium decay in isolated neonatal rat cardiomyocytes, whereas cardiomyocytes isolated from miR-132/212 KO mice display enhanced contractility in comparison to wild type controls. In response to chronic pressure-overload, miR-132/212 KO mice exhibited a blunted deterioration of cardiac function. Using a combination of biochemical approaches and in vitro assays, we confirmed that miR-132/212 regulates SERCA2a by targeting the 3′-end untranslated region of SERCA2a. Additionally, we also confirmed PTEN as a direct target of miR-132/212 and potentially participates in the cardiac response to miR132/212. In end-stage heart failure patients, miR-132/212 is upregulated and correlates with reduced SERCA2a expression. The up-regulation of miR-132/212 in heart failure impairs cardiac contractile function by targeting SERCA2a, suggesting that pharmaceutical inhibition of miR-132/212 might be a promising therapeutic approach to promote cardiac function in heart failure patients.

The left ventricular assist device as a patient monitoring system.

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.

Comparison of levosimendan, NO, and inhaled iloprost for pulmonary hypertension reversibility assessment in heart transplant candidates.

AimsAssessing reversibility of pulmonary vascular changes through vasoreactivity testing (VRT) optimizes end‐stage heart failure patient selection for heart transplant. All efforts should be made to unload the left ventricle and reduce pulmonary vascular resistance to effectively exclude irreversible pulmonary hypertension.Methods and resultsWe reviewed our centre's cardiac transplant registry database (2009–2017) for VRT and compared haemodynamic responses with 40 ppm inhaled NO (n = 14), 14–17 μg inhaled iloprost (n = 7), and 24 h 0.1 μg/kg/min intravenous levosimendan (n = 14). Response to levosimendan was assessed by repeat right heart catheterization within 72 h. Baseline clinical and haemodynamic features were similar between groups. VRT was well tolerated in all patients. All drugs effectively reduced pulmonary artery pressures and transpulmonary gradient while increasing cardiac index, although levosimendan had a greater impact on cardiac index increase (P = 0.036). Levosimendan was the only drug that reduced pulmonary artery wedge pressure (P = 0.004) and central venous pressures (P < 0.001) and increased both left and right ventricular stroke work indexes (P = 0.020 and P = 0.042, respectively) and cardiac power index (P < 0.001) compared with NO and iloprost. Right ventricular end‐diastolic pressures and central venous pressure were only decreased by levosimendan. The rate of positive responses (≥10 mmHg decrease or final mean pulmonary artery pressure ≤40 mmHg with increased/unaltered cardiac index) was lower with inhaled iloprost (14%) than with either levosimendan or NO (71% and 64%, respectively; P < 0.05).ConclusionsLevosimendan may be a safe and effective alternative for pulmonary hypertension reversibility assessment or a valuable pre‐test medical optimization tool in end‐stage heart failure patient assessment for heart transplantation offering extended haemodynamic benefits. Whether it increases the rate of positive responses or allows a better selection of candidates to heart transplantation remains to be established.

Left ventricular assist device in pregnancy: Case report and review of the literature

Left ventricular assist devices have emerged as a safe and effective therapy for end-stage heart failure patients. However, little is known about the safety of these devices during pregnancy. We describe a 23-year-old woman who received a left ventricular device for nonischemic cardiomyopathy of uncertain origin. She became pregnant approximately 1 year later. With close monitoring of her hemodynamic parameters, she was able to achieve a gestational age of 34 weeks, at which time she delivered a healthy male infant by cesarean delivery. Pregnancies in women with left ventricular assist devices may be successful, but remain medically challenging and complex pregnancies. Close multidisciplinary involvement and frequent assessment of device parameters during pregnancy is warranted.

Management of sacubitril/valsartan combination in an end-stage heart failure patient hospitalized for COVID-19 pneumonia: Should we withdraw temporarily or continue?

Background: Many factors were blamed for the worse prognosis in COVID-19. Heart failure patients are thought to be under increased risk because of either immune-compromised basal status or possible interaction of viral infection with on-going medications, such as the Renin-Angiotensin-Aldosterone system (RAAS) blockers. Sacubitril is a neprilysin inhibitor and its' combination with valsartan is recommended as a novel medication for heart failure. Case Report: A 71 years of age female with end-stage heart failure was hospitalized for COVID-19 pneumonia. She was under sacubitril/valsartan combination for the heart failure, and at the end of the first week of hospitalization, clinical and laboratory parameters recovered uneventfully. Sacubitril/valsartan therapy was continued without complications during the in-hospital course. Conclusion: Specific therapies for heart failure should not be withdrawn in COVID-19. To our knowledge, this is the first case report documenting the clinical progress of a COVID-19 pneumonia patient who was already under sacubitril/valsartan treatment. [ FROM AUTHOR] Copyright of Erciyes Medical Journal / Erciyes Tip Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all Abstracts.)

End-stage heart failure patients should be treated instantly despite a pandemic with all-time available technology to ensure best outcomes.

Since the earliest cases of coronavirus disease 2019 (COVID-19) infection were reported, our care delivery systems have been reorganized and challenged in unprecedent ways, specifically the cardiovascular community. COVID-19 poses a challenge for heart transplantation, affecting donor selection, immunosuppression, and posttransplant management. Left Ventricular Assist Device (LVAD) therapy is currently a viable option for patients with end-stage heart failure as a bridge to heart transplantation or destination therapy. Here, we present a therapeutic strategy for the management of acute HF with Intermacs profiles from 1 to 4, with or without Covid-19 infection, exemplified by serie of patients presenting with severe HF and successfully treated by LVAD therapy during the spread of the Covid-19 pandemic and the French national lockdown. This experience has shown that we still have the capacity to provide the right therapy for the right disease to the right patient. LVAD implantation seems to be the treatment of choice for advanced HF due to the lack of healthy donor hearts for cardiac transplantation. Covid or non-Covid context, we have to take care of our patients with end-stage HF the best we can.

Cardiac Resynchronization Therapy in continuous flow Left Ventricular Assist Device Recipients: A Systematic Review and Meta-analysis from ELECTRAM Investigators.

Whether cardiac resynchronization therapy (CRT) continues to augment left ventricular remodeling in patients with the continuous-flow left ventricular assist device (cf-LVAD) remains unclear. We performed a systematic review and meta-analysis of all clinical studies examining the role of continued CRT in end-stage heart failure patients with cf-LVAD reporting all-cause mortality, ventricular arrhythmias, and ICD shocks. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. Eight studies (7 retrospective and 1 randomized) with a total of 1,208 unique patients met inclusion criteria. There was no difference in all-cause mortality (RR 1.08, 95% CI 0.86 - 1.35, p = 0.51, I2=0%), all-cause hospitalization (RR 1.01, 95% CI 0.76-1.34, p = 0.95, I2=11%), ventricular arrhythmias (RR 1.08, 95% CI 0.83 - 1.39, p = 0.58, I2 =50%) and ICD shocks (RR 0.87, 95% CI 0.57 - 1.33, p = 0.52, I2 =65%) comparing CRT versus non-CRT. Subgroup analysis demonstrated significant reduction in ventricular arrhythmias (RR 0.76, 95% CI 0.64 - 0.90, p = 0.001) and ICD shocks (RR 0.65, 95% CI 0.44 - 0.97, p = 0.04) in "CRT on" group versus "CRT off" group. CRT was not associated with a reduction in all-cause mortality or increased risk of ventricular arrhythmias and ICD shocks compared to non-CRT in cf-LVAD patients. It remains to be determined which subgroup of cf-LVAD patients benefit from CRT. The findings of our study are intriguing, and therefore, larger studies in a randomized prospective manner should be undertaken to address this specifically.

A detailed explantation assessment protocol for patients with left ventricular assist devices with myocardial recovery.

Left ventricular assist device (LVAD) implantation for end-stage heart failure patients has been on the rise, providing a reliable long-term option. For some LVAD patients, longer term LV unloading leads to recovery; hence, the need for evaluating potential myocardial recovery and weaning eligibility has emerged. All patients who underwent contemporary LVAD explantation at our institution between 2009 and 2020 were included in the study. Patients in New York Heart Association I, left ventricular ejection fraction >40%, a cardiac index >2.4 l/min and a peak oxygen intake >50% predicted underwent a 4-phase weaning assessment. A minimally invasive approach using a titanium plug was the surgery of choice in the most recent explants. Kaplan-Meier curves were used to estimate the survival at 1 and 5 years. Twenty-six patients (17 HeartMate II, 9 HeartWare) underwent LVAD explantation after a median 317 days of support [IQ (212-518)], range 131-1437. Mean age at explant was 35.8 ± 12.7 years and 85% were males. Idiopathic dilated cardiomyopathy was the underlying diagnosis in 70% of cases. Thirteen (48%) patients were on short-term mechanical circulatory support and 60% required intensive care unit admission prior to the LVAD implantation. At 1 year, Kaplan-Meier estimated survival was 88%, whereas at 6 years, it was 77%. The average left ventricular ejection fraction at 1 year post-explant was 44.25% ± 8.44. The use of a standardized weaning protocol (echocardiographic and invasive) and a minimally invasive LVAD explant technique minimizes periprocedural complications and leads to good long-term device-free survival rates.