Left Ventricular Assist Device Implantation Research Articles

Sex Differences in the In-Hospital Outcomes of Left Ventricular Assist Device Implantation: A Population-Based National Inpatient Sample Study From 2015 to 2021.

Left ventricular assist device (LVAD) implantation can be used to manage advanced heart failure. Debates over sex differences in postoperative outcomes of LVAD implantation remain contentious; there is limited evidence available from the continuous-flow era, particularly following the introduction of third-generation devices. This study aimed to conduct a comprehensive, contemporary, and population-based analysis of the sex difference in the in-hospital outcomes following LVAD implantations. Patients who underwent LVAD implantation were selected from National Inpatient Sample from Q4 2015-2021. Multivariable logistic regression was used to compare in-hospital outcomes between females and males, where demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status were adjusted. There were 1201 (23.6%) female and 3881 (76.4%) male patients who underwent LVAD implantation. Females and males had comparable in-hospital mortality, MACE, and stroke. However, females had higher diaphragmatic paralysis (aOR = 7.94, 95 CI = 1.46-43.48, p = 0.02). Meanwhile, females had lower cardiogenic shock (aOR = 0.85, 95 CI = 0.73-0.98, p = 0.02), renal complications (aOR = 0.72, 95 CI = 0.62-0.84, p < 0.01), and infection (aOR = 0.70, 95 CI = 0.58-0.86, p < 0.01). Females also had longer hospital length of stay (44.1 ± 40.0 vs. 38.8 ± 30.6 days, p = 0.01) and higher total hospital charges (1293779.0 ± 1182139.0 vs. 1172780.0 ± 917544.0 US dollars, p = 0.04). In the contemporary era with the introduction of third-generation devices, in-hospital mortality and stroke after LVAD implantation continued to decrease and were comparable in both sexes. However, there are still notable sex-based differences in the complications of LVAD implantation, which underscores the need for sex-specific preoperative risk assessments and tailored perioperative management.

Myocardial deposition of aluminum, arsenic, cadmium, and lead accelerates heart failure and alters UPRmt in humans.

In the myocardium of control subjects and patients undergoing heart transplantation or left ventricular assist device implantation (LVAD), we analyzed concentrations of Al, As, Cd, Pb, and Ni using inductively coupled plasma mass spectrometry. Myocardial generation of oxidative-stress-induced lipid peroxidation was analyzed by quantifying concentration of 4-Hydroxynonenal (4-HNE) with ELISA and pro-apoptotic DAPK2 gene expression was determined with quantitative RT-PCR. Compared to six control hearts, myocardial samples of 128 individuals undergoing heart transplantation or LVAD implantation exhibited a moderate increase in deposition of five tested non-essential elements, which was significantly increased only for Cd and cumulative deposition of Al, As, Cd, and Pb. Patients with higher cumulative deposition of Al, As, Cd, and Pb, underwent heart transplantation or LVAD implantation at a younger age than those with lower cumulative deposition, which was not observed in individual elements. Also, Al, As, and Ni exhibited a positive correlation with DAPK2 expression. Moreover, Al, As, Cd, and Ni showed positive correlations and Pb negative correlations with several mitochondrial quality control (MQC) genes. None of the elements showed correlation with 4-HNE generation in the myocardium. There was no difference in tested non-essential element deposition between dilated and ischemic cardiomyopathy. In conclusion, patients with higher cumulative deposition of Al, As, Cd, and Pb in the myocardium underwent heart transplantation or LVAD implantation at a younger age, indicating that they may accelerate heart failure, which is associated with induction of DAPK2 expression. Deposition of Al, As, Cd, Ni, and Pb also altered the expression of several MQC genes.

Right ventricular strain as prognostic marker in patients with heart failure receiving sacubitril/valsartan: a sub-analysis of DISCOVER-ARNI, a multicenter Italian study

Abstract Background Angiotensin receptor/Neprilysin inhibitors (ARNI) have shown to considerably improve the clinical outcome of patients with heart failure and reduced ejection fraction (HFrEF). Identifying individuals who may benefit from ARNI the most could markedly enhance patient management. The aim of this sub-analysis of DISCOVER-ARNI was to evaluate the prognostic significance of speckle tracking echocardiography (STE) parameters in patients undergoing ARNI. Methods DISCOVER-ARNI multicenter Italian register retrospectively enrolled 341 patients with HFrEF referred for ARNI. Clinical, biohumoral and echocardiographic evaluation was performed at baseline. Among those with available right ventricular STE data, long-term follow-up was conducted by telephone interview or on-site visits. The primary composite endpoint included all-cause or cardiovascular mortality, HF hospitalization, heart transplantation, left ventricular assist device (LVAD) implantation. Results Overall, 136 HFrEF patients were included (mean age 65±10 years, 82% male). Mean follow up was 40±18 months: 32 patients reached the primary endpoint (14 deaths of which 10 cardiovascular deaths, 22 hospitalization, 3 heart transplantation, 1 LVAD implantation). Patients with events had higher LV volumes and EF, lower but preserved tricuspid annular plane systolic excursion (TAPSE) and higher systolic pulmonary artery pressures, reduced LV, left atrial (LA) and free wall right ventricular longitudinal strain (fwRVLS). Using Cox Proportional Hazard Model including LVEF, TAPSE, LV strain, LA strain, fwRVLS, the latest emerged as the sole independent predictor of the combined endpoint(odds ratio=1.12 [1.05;1.2], p=0.001). Receiver operating characteristic (ROC) curves determined that fwRVLS=-20% was the optimal prognostic cut-off(AUC=0.70). Kaplan Meier survival curves, demonstrated effective risk stratification of fwRVLS&amp;gt;-20% for the primary endpoint. Conclusions fwRVLS by STE holds promise as a valuable parameter to assess response to ARNI therapy in terms of overall survival, HF hospitalizations, heart transplantation or LVAD implantation.

The experience of bodily image for patients with left ventricular assist device

IntroductionMechanical Cardiac Support and Left Ventricular Assist Devices (LVAD) have been demonstrated to prolong Heart Failure patients' survival and improve their quality of life. LVAD implantation has a considerable effect on patients' body image. Patients find it hard to accept the device as an extension of their body, especially the driveline. The study aimed to examine the relationships between anxiety and depressive symptoms, acceptance of illness, beliefs about pain control, and quality of life with body image among LVAD-implanted patients.MethodsThe cross-sectional study included 54 conveniently recruited patients who completed the Body Image Scale, SF-12, Acceptance of Illness Scale, Beliefs about Pain Control Questionnaire, NRS, HADS, and demographic and clinical data. Multiple regression analyses examined the associations between the research variable.ResultsThe mean Age of the participants was 59.64 (SD=9.63), and 96.3% were men. The mean scores were: Body Image Scale – 28.33 (SD=5,91); Acceptance of Illness Scale – 25.51 (SD=5.92); beliefs about pain control: internal factors – 15.85 (SD=4.96), the influence of physicians – 17.57 (SD=3.15), random events – 14.37(SD=3.32), NRS=2.80(SD=1.86), HADS anxiety – 5.33 (SD=4.12), HADS depression – 4.66 (SD=3.10), SF12MCS-45.49 (SD=6.48), SF-12PCS-41,33 (SD=6.48). The presence of anxiety and depressive symptoms and complications after LVAD significantly predicted low body image concerns.DiscussionHealthcare professionals should be aware of challenges regarding body image faced by LVAD-implanted patients and address related factors, especially anxiety and depression.

Implantable Cardioverter-Defibrillators and Cardiovascular Resynchronization Therapy with Left Ventricular Assist Devices: A MOMENTUM 3 Trial Analysis.

The benefit of implantable cardioverter-defibrillators (ICD) and cardiovascular resynchronization therapy (CRT-D) in patients supported with a HeartMate 3 left ventricular assist device (LVAD) remains uncertain. An analysis of the MOMENTUM 3 randomized clinical trial and the first 1000 patients in the Continued Access Protocol trial. Patients were divided into three groups based on the presence of ICD and/or CRT-D: No device (n=153, 11%), ICD only (n=699, 50.4%), CRT-D (n=535, 38.6%). We assessed the association of ICD or CRT-D with overall mortality, ventricular arrhythmias (VA), rehospitalization rates, quality of life and six-minute walk test distance at 2-years of follow-up. Patients with ICD or CRT-D had similar survival to those without (HR 1.3, 95% CI 0.8-2.1, p=0.36) with no differences in rehospitalizations, quality-of-life or six-minute walk test distance. VA occurred more frequently in patients with ICD or CRT-D (HR 2.4, 95% CI 1.3-4.3, p=0.006). Compared to ICD alone, patients with CRT-D demonstrated similar survival (HR 1.1, 95% CI 0.9-1.5, p=0.36), however, had increased rates of VA (HR 1.3, 95% CI 1.0-1.7, p=0.03). There were no differences in rate of rehospitalization between those with ICD or CRT-D and those without (p=0.19) or between those with ICD and those with CRT-D (p=0.32). A propensity-matched sensitivity analysis confirmed these findings. In this post-hoc analysis of the MOMENTUM 3 trial, the presence of ICD or CRT-D at the time of HM3 LVAD implantation was associated with an increased incidence of VA but was not associated with survival, quality of life or functional capacity. Momentum 3 portfolio, NCT02224755 (Pivotal) and NCT02892955 (CAP).

The Pivotal Role of an Early Post-Acute Cardiac Rehabilitation as an Evidence-Based Management of Left Ventricular Assist Device Patients.

Left Ventricular Assist Device (LVAD) implantation is an important treatment option for patients with advanced CHF. Referral to an early, intensive cardiac rehabilitation (CR) program in these patients seems still underused. This observational descriptive study aimed to evaluate the feasibility and efficacy of an early intensive CR program in LVAD recipients, also comparing results with a matched group of advanced HFrEF patients. The study involved patients with LVAD implantation due to HFrEF who were admitted to our intensive post-acute CR program from several surgery wards from 2009 to 2023. They underwent a twice-a-day individualized exercise program and physiotherapeutic treatment, according to clinical stability and functional assessment. The study exclusively focused on the in-hospital rehabilitation period and documented cardiac and non-cardiac complications, including the Hemocompatibility-Related Adverse Events (HRAEs). The Barthel index (BI) was used to assess functional recovery from admission to discharge. Results in a subgroup of 210 LVAD patients matched on a 1:1 basis with an HFrEF population were also analyzed. One patient died during the inward rehabilitation period (respiratory failure). The majority (70.0%) of patients improved their disability (BI 67 ± 24 to 84 ± 23, p < 0.001). HRAEs occurred in 25 patients (9.1%). Compared to the HFrEF group, LVAD patients showed similar improvement in disability (p = 0.54). The study suggests that an early intensive post-acute CR program can significantly improve functional capacity and disability in LVAD patients, similar to HFrEF patients admitted to the same program. Our data support scientific recommendations suggesting participation of LVAD to a CR.

Aspirin and Hemocompatibility After LVAD Implantation in Patients With Atherosclerotic Vascular Disease

The Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure (ARIES-HM3) study demonstrated that aspirin may be safely eliminated from the antithrombotic regimen after HeartMate 3 (HM3 [Abbott Cardiovascular]) left ventricular assist device (LVAD) implantation. This prespecified analysis explored whether conditions requiring aspirin (prior percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], stroke, or peripheral vascular disease [PVD]) would influence outcomes differentially with aspirin avoidance. To analyze aspirin avoidance on hemocompatibility-related adverse events (HRAEs) at 1 year after implant in patients with a history of CABG, PCI, stroke, or PVD. This was an international, multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial including patients implanted with a de novo HM3 LVAD across 51 centers. Data analysis was conducted from April to July 2024. Patients were randomized in a 1:1 ratio to receive aspirin (100 mg per day) or placebo, in addition to a vitamin K antagonist (VKA) targeted to an international normalized ratio of 2 to 3 in both groups. Primary end point (assessed for noninferiority) was a composite of survival free of any nonsurgical (>14 days after implant) HRAEs including stroke, pump thrombosis, bleeding, and arterial peripheral thromboembolism at 12 months. Secondary end points included nonsurgical bleeding, stroke, and pump thrombosis events. Among 589 of 628 patients (mean [SD] age, 57.1 [13.7] years; 456 male [77.4%]) who contributed to the primary end point analysis, a history of PCI, CABG, stroke, or PVD was present in 41% (240 of 589 patients). There was no interaction between the presence of an atherosclerotic vascular condition and effect of aspirin compared with placebo (P for interaction= .23). The preset 10% noninferiority margin was not crossed for the studied subgroup of patients. Thrombotic events were rare, with no differences between aspirin and placebo in patients with and without vascular disease (P for interaction = .77). Aspirin treatment was associated with a higher rate of nonsurgical major bleeding events in the group with prior vascular condition history compared with those without aspirin (rate ratio for placebo compared with aspirin, 0.52; 95% CI, 0.35-0.79). Results of this prespecified analysis of the ARIES-HM3 randomized clinical trial demonstrate that in patients with advanced heart failure who have classical indications for antiplatelet therapy use at the time of LVAD implantation, aspirin avoidance was safe and not associated with increased thrombosis risk. Importantly, elimination of aspirin was associated with no increased thrombosis but a reduction in nonsurgical bleeding events in patients with a history of PCI, CABG, stroke, or PVD. ClinicalTrials.gov Identifier: NCT04069156.

Left Ventricular Assist Device Therapy in Cold and Dry Patients.

Patients with end-stage heart failure and low pulmonary capillary wedge pressure are referred to as cold and dry and represent an understudied minority in whom the benefit of left ventricular assist device (LVAD) therapy is unclear. Adults receiving LVADs between 2006 and 2017 in the Interagency Registry for Mechanically Assisted Circulatory Support database were classified as cold and wet (pulmonary capillary wedge pressure >15 mm Hg) and cold and dry (pulmonary capillary wedge pressure ≤15 mm Hg) based on pre-LVAD hemodynamics obtained via right heart catheterization. The primary outcome was 1-year survival. Secondary outcomes were rehospitalizations, change in 6-minute walk test distance, change in Kansas City Cardiomyopathy Questionnaire, and change in EuroQol questionnaire scores 1 year after LVAD. Our study included 10 310 patients with complete clinical, echocardiographic, and functional capacity profiles. The median follow-up was 364 days (interquartile range, 326-381 days). Overall, the mean pulmonary capillary wedge pressure before LVAD implantation was 25±9 mm Hg. Cold and dry patients comprised 15% of the cohort and were more frequently female, had smaller mean body size, smaller mean left ventricular size, and better mean baseline renal function. Compared with cold and wet patients, cold and dry patients also had better baseline functional capacity and quality of life and experienced milder improvements after LVAD: EuroQol (+0.11 versus +0.17; P=0.001), Kansas City Cardiomyopathy Questionnaire (+26 versus +31; P=0.031), and 6-minute walk test distance (+194 feet versus +340 feet; P=0.026). There was no statistically significant difference between the rate of hospitalizations (P=0.76), adverse events, and mortality (log-rank P=0.81) at 1 year between the 2 groups. In cold and dry patients with end-stage heart failure, LVADs are associated with milder but significant improvements in functional capacity and quality of life with a similar incidence of adverse events and survival at 1 year.

Is There an Association Between Living in a Rural Area and the Incidence of Postoperative Complications or Hospital Readmissions Following Left Ventricular Assist Device (LVAD) Implantation, Compared to Urban Lvad Recipients? A Systematic Review.

Left ventricular assist devices (LVADs) are utilized as a therapeutic option for patients with end-stage heart failure. While LVAD implantation can enhance survival rates and quality of life, the procedure has its risks, and postoperative complications are common. This review aims to investigate whether there is an association between living in a rural area and the incidence of postoperative complications or hospital readmissions following LVAD implantation, compared to urban LVAD recipients. A comprehensive literature review examined studies that compared postoperative outcomes between rural and urban LVAD recipients. Data on adverse events, hospitalizations, and mortality rates were extracted, focusing on the impact of geographic location on these outcomes. The review found that rural LVAD recipients may be at a higher risk for certain complications, including gastrointestinal bleeding, ventricular arrhythmias, LVAD complications, and stroke. Rural patients also exhibited higher instances of emergency department visits and hospital readmissions. Despite these challenges, survival rates and heart transplantation outcomes at 1 year were similar between rural and urban recipients. However, rural patients exhibited a higher driveline infection rate at 1 year. The findings of this review suggest that rural residency may be associated with an increased risk of certain postoperative complications and hospital readmissions following LVAD implantation. These results highlight the need for healthcare strategies to address the challenges faced by rural LVAD recipients. Further research is necessary to understand the relationship between geographic location and LVAD outcomes and to develop interventions that can improve postoperative care for this vulnerable population.

Prediction Of Adverse Events After Left Ventricular Assist Device Implantation Based On Pre-implantation Comorbidities

Prediction Of Adverse Events After Left Ventricular Assist Device Implantation Based On Pre-implantation Comorbidities

Genotype-phenotype correlations in hypertrophic cardiomyopathy: Insights from an HCM Center of Excellence.

Owing to the recognition of previously unknown pathogenic gene variants and reclassification of longer-known variants, gene distribution in patients with hypertrophic cardiomyopathy (HCM) is ever-changing. Conflicting data make the role of genotype in risk stratification unclear. We evaluated genotype distribution and genotype-phenotype correlations in all adult patients with HCM seen at our HCM Center of Excellence from March 31, 2010, to April 30, 2023. We also evaluated a composite outcome, including all-cause mortality, stroke, implantable cardioverter-defibrillator placement, heart failure hospitalization, left ventricular assist device implantation, heart transplantation, septal myectomy, and alcohol septal ablation, based on genotype status. All-cause mortality was separately analyzed. Of 827 patients with HCM, genotyping was completed in 754 (91.2%). We identified 202 (27%) genotype-positive (Gen-P), 163 (22%) variant of unknown significance (VUS), and 389 (51%) genotype-negative (Gen-N) patients. Mean age was 47, 57, and 58 years, respectively. The most common gene implicated was MYBPC3 (63%). More patients were on optimal medical treatment after following up with our HCM Center. Electrocardiographic, Holter, echocardiographic, and cardiac magnetic resonance imaging characteristics differed based on genotype status. The composite outcome was worse in Gen-P than Gen-N (HR 1.84, p<0.001). Although analysis of all-cause mortality showed survival was different for Gen-P and VUS patients than for Gen-N patients, this difference was not statistically significant. MYBPC3 was the most common gene implicated. Outcomes were worse in Gen-P patients. Centers of Excellence play an important role in the optimal medical management of patients with HCM.

Psychiatric Disorders and Associated Factors in Left Ventricular Assist Device Implantation and Heart Transplant Candidates.

End-stage heart failure (ESHF) remains a significant challenge despite optimal treatment, with heart transplantation (HTx) being the gold standard of care. Mechanical circulatory support (MCS) devices such as left ventricular assist devices (LVADs) are increasingly used for temporary or permanent treatment. Psychiatric comorbidities are common in patients with ESHF and may affect treatment outcomes, but the relationship between sociodemographic, clinical, and psychiatric characteristics remains unclear. A medical record based, descriptive cross-sectional study was conducted on 94 ESHF patients scheduled for HTx or LVAD therapy. Sociodemographic, clinical, and psychiatric data, including psychiatric diagnoses and systemic inflammatory markers, were collected from medical records. Univariate analyses compared patients with (PD) and without psychiatric disorders (No-PD). Of the participants, 37% had active psychopathology, with major depressive disorder (MDD) and generalized anxiety disorder (GAD) being prevalent. Approximately half of those diagnosed received their first psychiatric diagnosis at the time of assessment. Sociodemographic factors did not differ significantly between the PD and No-PD groups. While no significant difference was observed in ejection fraction (%) and inflammatory markers such as C-reactive protein (CRP), lymphocyte count was higher in the PD group. Preoperative psychiatric assessment is crucial to identify psychiatric comorbidities in ESHF patients undergoing HTx or LVAD therapy. Despite limitations, this study sheds light on previously unexplored aspects, such as the relationship between ejection fraction and psychiatric comorbidities and the relationship between depressive symptoms and inflammatory markers obtained from complete blood count. Furthermore, the fact that almost half of the patients with psychiatric comorbidity were first diagnosed during the pre-treatment psychiatric assessment underlines the importance of pre-LVAD and pre-HTX psychiatric evaluation.

Growth Differentiation Factor-15 IsAssociated With Congestion-Related Anorexia and Weight Loss in AdvancedHeartFailure.

Growth differentiation factor (GDF)-15 is a pleiotropic cytokine that is associated with appetite-suppressing effects and weight loss in patients with malignancy. This study aims to investigate the relationships between GDF-15 levels, anorexia, cachexia, and clinical outcomes in patients with advanced heart failure with reduced ejection fraction (HFrEF). In this observational, retrospective analysis, a total of 344 patients with advanced HFrEF (age 58 ± 10 years, 85% male, 67% NYHA functional class III), underwent clinical and echocardiographic examination, body composition evaluation by skinfolds and dual-energy x-ray absorptiometry, circulating metabolite assessment, Minnesota Living with HeartFailure Questionnaire, and right heart catheterization. The median GDF-15 level was 1,503ng/L (Q1-Q3: 955-2,332ng/L) (reference range:<1,200ng/L). Higher GDF-15 levels were associated with more prevalent anorexia and cachexia. Patients with higher GDF-15 had increased circulating free fatty acids and beta-hydroxybutyrate, lower albumin, cholesterol, and insulin/glucagon ratio, consistent with a catabolic state. Patients with higher GDF-15 had worse congestion and more severe right ventricular dysfunction. In multivariable Cox analysis, elevated GDF-15 was independently associated with risk of the combined endpoint of death, urgent transplantation, or left ventricular assist device implantation, even after adjusting for coexisting anorexia and cachexia (T3 vs T1 HR: 2.31 [95%CI: 1.47-3.66]; P< 0.001). In patients with advanced HFrEF, elevated circulating GDF-15 levels are associated with a higher prevalence of anorexia and cachexia, right ventricular dysfunction, and congestion, as well as an independently increased risk of adverse events. Further studies are warranted to determine whether therapies altering GDF-15 signaling pathways can affect metabolic status and clinical outcomes in advanced HFrEF.

The Society of Thoracic Surgeons National Intermacs Database Risk Model for Durable Left Ventricular Assist Device Implantation.

Statistical risk models for durable left ventricular assist device (LVAD) implantation inform candidate selection, quality improvement, and evaluation of provider performance. We developed a 90-day mortality risk model utilizing The Society of Thoracic Surgeons National Intermacs Database (STS Intermacs). STS Intermacs was queried for primary durable LVAD implants from 1/ 2019 - 9/2023. Multivariable logistic regression was used to derive a model based upon pre-implant risk factors using derivation (2019-2021 implants) and validation (2022-2023 implants) cohorts. Model performance (derivation and validation cohorts) was assessed using C-statistics, Brier Scores, and calibration plots. A refined model (all patients) was generated to calculate observed/expected [O/E, 95% confidence intervals (CI)] ratios for each center. The study population consisted of 11,342 patients from 2019-2023 sequentially divided in time into derivation (n=6,775) and validation (n=4,567). Ninety-day mortality was 8.0% (9.2% in derivation cohort vs. 7.4% in validation cohort; p=0.001). Logistic regression applied to derivation and validation cohorts produced similar discrimination (area under the curve (AUC) 0.714, CI: 0.69-0.74 and AUC 0.707, CI: 0.67-0.72, respectively) and calibration (Brier score .08 vs .07), with overestimation of risk among patients with predicted risk > 0.4. The O/E analysis identified 22 (12.5%) centers with worse-than-expected mortality with a CI > 1.0 and 14 centers (8.0%) with better-than-expected mortality with a CI < 1.0 (all p < 0.05). The STS Intermacs Risk Model demonstrated satisfactory discrimination and calibration. This tool may be used to inform candidate selection, facilitate quality improvement, and assess provider performance.

Impact of Left Ventricular Size on Outcomes Following HeartMate 3 Left Ventricular Assist Device Implantation: Analysis of the European Registry for Patients With Mechanical Circulatory Support (EUROMACS).

We investigated the association of preimplant left ventricular end-diastolic diameter (LVEDD) with outcomes after HeartMate 3 (HM3) left ventricular assist device (LVAD) implantation. Patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) registry who underwent HM3 implantation from August 2014 to February 2023 (n = 834) were analyzed according to preoperative LVEDD: less than or equal to 65 (n = 251), 65-80 (n = 441), and greater than or equal to 80 mm (n = 142). The mean age was 54.4 ± 12.4 years, body surface area (BSA) 2.0 ± 0.23 m2, body mass index (BMI) 27.3 ± 5.0 kg/m2; 87.9% were male and 40% had ischemic cardiomyopathy. Patients with LVEDD less than or equal to 65 mm were older (56.1 ± 11.0 vs. 53.8 ± 13.0 vs. 53.0 ± 12.3 years; p = 0.015), more female (17.9% vs. 11.6% vs. 4.9%; p < 0.001), smaller BSA (1.95 ± 2.03 vs. 2.01 ± 0.22 vs. 2.08 ± 0.22 m2; p < 0.01) and lower BMI (26.6 ± 4.8 vs. 27.4 ± 5.1 vs. 28.2 ± 5.0; p = 0.01) compared to LVEDD 65-80 and greater than or equal to 80 mm, respectively. One year survival was associated with increasing LVEDD (75.7% vs. 84.6% vs. 89.5%; p = 0.003). Patients with LVEDD less than or equal to 65 mm had a higher risk of postoperative right heart failure (14.7% vs.10.4% vs. 6.8%; p = 0.03), the risk for postoperative stroke was similar (10% vs. 12.8% vs. 9.5%; p = 0.4). A small left ventricular (LV) size (LVEDD ≤ 65 mm) was associated with an increase in postoperative right heart failure and unadjusted 1 year mortality in adults who underwent HM3 LVAD implantation.

Exercise and cardiac rehabilitation after LVAD implantation.

Left ventricular assist devices (LVAD) have improved mortality and quality of life for patients with end-stage heart failure by providing an alternative to cardiac transplant or as a bridge to transplantation. The improvement in functional capacity however is minimal to modest depending on the right ventricular function, optimal hemodynamics on LVAD therapy, and comorbidities. There is improvement in submaximal exercise capacity but improvement in peak aerobic capacity is limited. Exercise capacity can be improved by referral to cardiac rehabilitation after LVAD implantation. Cardiac rehabilitation is safe and effective with improvement in functional capacity, and decrease in mortality and heart failure hospitalizations. Cardiopulmonary exercise testing (CPET) is a specialized exercise stress test that measures gas exchange during exercise to determine a variety of variables that have been shown to be predictive of mortality in patients undergoing cardiac transplant. CPET is valuable for prognostication and is a predictor of adverse outcomes, including right heart failure in the immediate post-LVAD implantation period, long-term mortality. CPET is an additional testing that can aid in the decision making for LVAD explantation or decommissioning.

The Impact of Genetic Polymorphism on Complication Development in Heart Failure Patients

Background: Despite the high progress that has been made in the field of cardiology, the left ventricular assist device (LVAD) can still cause complications (thrombosis/bleeding) in heart failure (HF) patients after implantation. Complications develop due to the incorrect dose of antithrombotic therapy, due to the influence of the non-physiological shear stress of the device, and also due to inherited genetic polymorphisms. Therefore, the aim of our study is to identify the influence of the genetic polymorphisms on complication development in HF patients with implanted LVADs with prescribed antiplatelet therapy. Methods: Our study investigated 98 HF patients with/without complications who were genotyped for 21 single-nucleotide polymorphisms (SNPs) associated with cardiovascular events, the coagulation system, and the metabolism of warfarin and aspirin drugs. This study performed a more detailed analysis on genetic polymorphism in the UGT1A6 gene and its influence on aspirin dose. Results: SNP rs2070959 in the UGT1A6 gene showed a significant association with the group of HF patients with complications [(OR (95% CI): 4.40 (1.06–18.20), p = 0.044]. The genetic polymorphism of rs2070959 in the UGT1A6 gene showed a significant association in HF patients who received aspirin treatment on the 12th month after LVAD implantation [OR (95% CI): 5.10 (1.31–19.87), p = 0.018]. Moreover, our genotype distribution analysis showed that the GG genotype of rs2070959 in the UGT1A6 gene was significantly higher in the group with aspirin treatment than without treatment after the 12th month of treatment (50.0% vs. 0%, p = 0.008), especially in the group of patients with complications. A higher frequency of the GG genotype with long-lasting aspirin therapy up to the 12th month showed that 100 mg of aspirin was not an effective dose in the group of patients with complications. Conclusions: Our study identified that genotyping for genetic polymorphism rs2070959 in the UGT1A6 gene could predict the recommended dose of aspirin in HF patients, which could help to prevent and predict complication development after LVAD implantation.

Magnetic Resonance Imaging in the Assessment of the Risk of Sudden Death in Cardiac Sarcoidosis: What Is Extensive or Significant Late Gadolinium Enhancement?

Cardiac sarcoidosis involves a significant but difficult-to-define risk of sudden cardiac death (SCD). Current guidelines recommend consideration of an implantable cardioverter defibrillator for patients with extensive or significant myocardial late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging. However, extensive/significant LGE is not defined. A nationwide cardiac sarcoidosis registry was screened for patients entered before 2020 with cardiac magnetic resonance imaging done before or <3 months after diagnosis. Available studies were re-analyzed for LGE mass as a percentage of left ventricular (LV) mass and the number of LGE-positive LV segments in a 17-segment model. The occurrence of fatal or aborted SCD and ventricular tachycardia (VT) prompting therapy was recorded until the end of 2020 and subjected to cumulative incidence analyses, including competing events (LV assist device implantations, heart transplantations, and fatalities other than SCD). The predictors of SCD/VT were assessed using Fine and Gray modeling and time-dependent receiver operating characteristic analysis. Altogether, 305 patients (66% women, median age 51) with clinically manifest, definite (45%) or probable cardiac sarcoidosis (55%) were analyzed. On follow-up (median, 4.0 years), 21 SCDs, 60 VTs, and 14 competing events were noted. Both LGE mass and the number of LGE segments predicted the composite of SCD/VT (P<0.001), with receiver operating characteristic analyses identifying LGE mass ≥9.9% and ≥6 LGE segments as discriminative thresholds. At presentation, 70 patients were free of class I and class IIa implantable cardioverter defibrillator indications unrelated to LGE. Their 5-year rate of SCD/VT was 6.3% (0.0-14.8%) with LGE mass <9.9% versus 21.5% (6.5-36.6%) with higher LGE mass, and 6.9% (0.0-16.3%) with <6 LGE segments versus 20.5% (5.9-35.2%) with ≥6 segments. In cardiac sarcoidosis, myocardial LGE making up ≥9.9% of LV mass or affecting ≥6 LV segments may suggest prognostically significant LV involvement and a high risk of SCD. However, prospective validation of the thresholds is needed.

Facilitators and Barriers to Values Discussions Following LVAD Implantation: Perspectives from Diverse Patients and Family Caregivers.

Background Delivering care that is responsive to who or what is most important to patients and family caregivers is a key aspect of quality care, yet it remains unclear how clinicians can best support individuals in expressing their personal values. We aimed to describe patient- and family caregiver-identified facilitators and barriers to engaging in values discussions with clinicians following implantation of a left ventricular assist device (LVAD). Methods and results Using a qualitative descriptive approach, patients with an LVAD and their caregivers participated in one-on-one semi structured interviews and self-reported sociodemographics (January 2023-July 2023). Qualitative data were analyzed using thematic analysis and descriptive statistics were computed for quantitative data. Results Patients (n=27; ages 30-76 years) were predominantly male (59%) and non-Hispanic Black (67%). Caregivers (n=21; ages 27-76) were female (76%), non-Hispanic Black (67%), and a spouse/partner (62%). Facilitators (5 shared across patient/caregiver groups; 8 unique across patient/caregiver groups) included a perceived close relationship (patient/caregiver), values alignment (patient/caregiver), clinician discussion initiation (patient/caregiver), facing an impending decision (patient/caregiver), 1-on-1 dyadic interactions (patient/caregiver), being assertive (patient), positive dyadic communication (caregiver), and involvement of a third party (caregiver). Barriers (2 shared; 7 unique) included belief their values are already known (patient/caregiver), sensitivity about values (patient/caregiver), uncertainty about timing (patient), poor clinical communication (patient), patient hopelessness (patient), perceived lack of clinician time (caregiver), and having a reserved personality (caregiver). Conclusion Findings offer insight into actionable facilitators and barriers to discussions promoting incorporation of patient and family values into LVAD maintenance and chronic disease management.

Clinical outcomes of modified left ventricular assist device driveline management.

Left ventricular assist devices (LVADs) are implanted in patients with heart failure to support cardiac circulation. However, no standardized methods have been established for LVAD driveline exit site management for the prevention of infections. Therefore, this study evaluated the efficacy of modified driveline management compared with that of conventional driveline management. We retrospectively assessed the outcomes of 262 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2023 at Osaka University in Japan. In conventional driveline management, an LVAD driveline penetrates the skin along the body surface and is fixed near the penetration site (n = 224). In contrast, in our modified fixation method, the LVAD driveline vertically penetrates the skin to prevent ischemia at the driveline exit site and is fixed at a distant abdominal site to prevent the movement of the driveline exit site due to body movement (n = 38). The rates of freedom from LVAD driveline infection in patients with conventional driveline management were 86, 75, and 63% at 1, 2, and 3years after LVAD implantation, respectively. The rate of freedom from LVAD driveline infection in patients managed by the modified fixation method was 91% at 1, 2, as well as 3years after LVAD implantation. The freedom rates from LVAD driveline infection in the patients with modified fixation method was lower than in the patients with the conventional method (p = 0.04). Our study revealed that the modified fixation method may offer the possibility for preventing LVAD driveline infection.