Left Ventricular Device Research Articles

Tricuspid Valve Repair in Patients with Left Ventricular Assist Device Implants and Tricuspid Valve Regurgitation: Propensity Score-Adjusted Analysis of Clinical Outcome

OBJECTIVES: In end-stage heart failure patients with left-ventricular assist device implantation and tricuspid valve (TV) regurgitation grade >2, the surgical strategy for TV regurgitation is unclear at present. We aimed to compare clinical outcomes in patients receiving leftventricular assist device (LVAD) implants with or without TV repair (TVR). METHODS: We included 58 patients with TV regurgitation grade >2 in our data analysis. Thirty-two patients received TVR during LVAD implantation (TVR+ group), whereas 26 patients did not receive TVR (TVR− group). We assessed demographic and various preoperative clinical and echocardiographic parameters in both groups. The primary end-point was survival up to 1 year. Secondary end-points were the incidence of prolonged mechanical ventilatory support, rethoracotomy, early and late right heart failure and liver or kidney failure. RESULTS: Preoperatively, the two groups differed according to heart failure diagnosis, need for inotropic support and haemodynamic/ echocardiographic parameters such as transpulmonary gradient, cardiac index and the ratio of the right-ventricular end-diastolic diameter to the left-ventricular end-diastolic diameter. The survival rate up to 1 year was 53.1% in the TVR+ group and 73.1% in the TVR− group (P= 0.176). The propensity score (PS)-adjusted 1-year mortality risk with the TVR− group as a reference was 3.05 for the TVR+ group (95% confidence interval: 0.84–11.11; P= 0.091). Secondary end-points did not differ significantly between study groups. CONCLUSIONS: Data indicate that end-stage heart failure patients with TV regurgitation grade >2 undergoing LVAD implants do not benefit from concomitant TVR. Results have to be confirmed by prospective studies.

Successful Perioperative Management of a Patient with the Left Ventricular Assist Device for Brain Tumor Resection: Case Report and Review of the Literature

Heart failure is the leading cause of death in the United States. Our increasingly aged population will contribute to an increased incidence and prevalence of heart failure, thereby augmenting the need for mechanical circulatory devices. Here we present the first successful resection of a brain tumor in a left ventricular device- (LVAD-) dependent patient with increased intracranial pressure and address pertinent perioperative anesthetic considerations and management.

Case report of a patient with left ventricular assistance device undergoing chemotherapy for a new diagnosis of lung cancer.

The optimal management of cancer in patients with severe heart failure is not defined. This issue is particularly challenging when a diagnosis of limited-stage small cell lung cancer (SCLC) is made incidentally in the context of evaluating patient for candidacy for cardiac transplantation. Limited-stage SCLC is typically managed on a curative therapeutic paradigm with combined modality approach involving chemotherapy and radiation. Even with excellent performance status and good organ function, the presence of severe cardiomyopathy poses significant challenges to the delivery of even single modality approach with chemotherapy or radiotherapy, let alone the typical curative combined modality approach. With mechanical left ventricular devices to provide cardiac support, treatment options for cancer in the setting of advanced heart failure may be improved. Here we discuss the therapeutic dilemma involving a patient with severe cardiomyopathy and left ventricular assistant device (LVAD) who was found to have limited-stage SCLC during the evaluation process for cardiac transplantation.

Mechanical Circulatory Support and the Role of LVADs in Heart Failure Therapy.

Heart failure is epidemic in the United States with a prevalence of over 5 million. The diagnosis carries a mortality risk of 50% at 5 years rivaling many diagnoses of cancer. Heart transplantation, long the “gold standard” treatment for end stage heart failure unresponsive to maximal medical therapy falls way short of meeting the need with only about 2,000 transplants performed annually in the United States due to donor limitation. Left ventricular devices have emerged as a viable option for patients as both a “bridge to transplantation” and as a final “destination therapy”.

Sağ ve Sol Ventrikül Destek Cihazı Takılan Hastanın Postoperatif Dönemdeki Hemşirelik Bakımı

Sağ ve Sol Ventrikül Destek Cihazı Takılan Hastanın Postoperatif Dönemdeki Hemşirelik Bakımı

Gastrointestinal bleeding after continuous-flow left ventricular device implantation: review of pathophysiology and management.

Gastrointestinal bleeding is one of the most common complications in patients with continuous-flow left ventricular assist devices. Though the exact pathophysiology is still unclear, continuous-flow physiology, acquired Von Willebrand disease, and formation of arteriovenous malformations in the gastrointestinal tract are implicated. An individualized plan of endoscopic therapy and anticoagulation management is required when caring for these patients.

Professor I-wen Wang: better life supported through mechanical circulatory devices-a dream within reach.

Professor I-wen Wang received his medical degree from Case Western Reserve University School of Medicine, after that he has 17 years of experience and practices in thoracic surgery and cardiovascular surgery. With his rich experience, he was elected one of nine doctors at Indiana University Health Methodist Hospital of Indianapolis who specialize in Thoracic & Cardiac Surgery. Journal of Thoracic Disease (JTD) had the honor to conduct an in-depth interview with him concerning his studies in left assisted ventricular device (LVAD) and extracorporeal membrane oxygenation (ECMO) at the 2014 Chinese Heart Congress.

Aortic Valve Function Under Support of a Left Ventricular Assist Device: Continuous vs. Dynamic Speed Support.

Continuous flow left ventricular devices (CF-LVADs) support the failing heart at a constant speed and alters the loads on the aortic valve. This may cause insufficiency in the aortic valve under long-term CF-LVAD support. The aim of this study is to assess the aortic valve function under varying speed CF-LVAD support. A Medtronic freestyle valve and a Micromed DeBakey CF-LVAD were tested in a mock circulatory system. First, the CF-LVAD was operated at constant speeds between 7500 and 11,500 rpm with 1000 rpm intervals. The mean pump outputs obtained from these tests were applied in varying speed CF-LVAD support mode using a reference model for the pump flow. The peak of the instantaneous pump flow was applied at peak systole and mid-diastole, respectively. Ejection durations and in the aortic valve were the longest when the peak pump flow was applied at mid-diastole among the CF-LVAD operating modes. Furthermore, mean aortic valve area over a cardiac cycle was highest when the peak pump flow was applied at mid-diastole. The results show that changing phase of the reference flow rate signal may reduce the effects of the CF-LVADs on altered aortic valve closing behavior, without compromising the overall pump support level.

Use of left ventricular support devices during acute coronary syndrome and percutaneous coronary intervention.

In an effort to improve outcomes in percutaneous coronary intervention (PCI), percutaneous ventricular assist devices (PVADs) have been investigated in (1) high-risk PCI, (2) acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) and (3) in AMI without CS. PCI has become an increasing complex due to an ageing population with complex disease and the frequent presence of impaired LV function. Patients undergoing high-risk PCI in these circumstances are prone to acute cardiovascular collapse. Additionally, mortality in AMI complicated by CS remains high. Lastly, LV support during AMI may reduce infarct size and therefore preserve LV function. At present, four commercially available devices exist: intra-aortic balloon pump counterpulsation (IABP), Impella, TandemHeart and extracorporeal membrane oxygenation (ECMO). These devices are employed in an effort to increase cardiac output, mean arterial pressure (MAP) and coronary perfusion and to reduce pulmonary capillary wedge pressure (PCWP). The mechanism of action differs with each device, and there are advantages and disadvantages. In this update, we discuss recent data describing the use of PVADs to support patients with AMI with or without cardiogenic shock and during high-risk PCI. We focus on the unique features of each device, highlighting strengths, weaknesses and frequently encountered complications, which may be important when tailoring the most appropriate PVAD therapy to an individual patient's need.

Mechanical circulatory support devices as destination therapy-current evidence.

Advanced heart failure is an increasing problem worldwide. Nowadays, mechanical circulatory support devices (MSCD) are an established therapeutic option for terminal heart failure after exhaustion of medical and conventional surgical treatment, and are becoming a realistic alternative to heart transplantation (HTX). There are a number of different treatment options for these patients, such as bridge to transplantation (BTT), bridge to candidacy (BTC), bridge to recovery (BTR) and the destination therapy (DT) option. The latter option has become more frequent throughout the last years, due to a donor organ shortage and an increasing number of older patients with terminal heart failure who are not eligible for HTX. These factors have led to a rapidly increasing number of LVAD implantations as well as centers which perform these procedures. This has also been due to improved LVAD survival rates and quality of life following the introduction of smaller, intrapericardial and more durable continuous flow left ventricular devices. The most common complications for these patients are device-related problems, such as coagulation disorders, gastrointestinal bleeding, device related infection, pump thrombosis or cerebrovascular accidents. However, some questions still remain unanswered or under debate, such as the exact time-point for LVAD implantation. In addition, aspects such as better biocompatibility for LVADs remain a major challenge. This review will concentrate on DT for terminal heart failure and provide an overview of the current evidence for LVAD implantation in this patient group, with particular emphasis on indication and time-point of implantation, choice of LVADs, and long term outcomes and quality of life.

Emergent Reconnection of a Transected Left Ventricular Assist Device Driveline

BackgroundRecent clinical advances with new mechanical circulatory systems have led to additional strategies in the treatment of end-stage heart failure. The third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a blood pump and a driveline (cable) that exits the patient's skin connecting the implanted pump to an externally worn controller. We report a rare case of a HeartWare LVAD driveline rewiring after accidental (presumed) transection of the driveline system. Case ReportA 67-year-old male with a medical history of ischemic cardiomyopathy status post HeartWare LVAD implantation presented to the emergency department (ED) after acute LVAD failure. On the morning of presentation, he attempted to cut the paper tape off of his adult diaper with scissors and accidentally (presumed) and unwitnessed severed the driveline system. The patient immediately went into cardiac arrest and was transported to a regional medical center. On arrival, he exhibited no appreciable vital signs and was subsequently intubated, vascular access was placed, and inotropic support initiated. The emergency physician individually stripped and reconnected the color-coded driveline wires using multiple hemostats, electrical tape, and cardboard, which resulted in regeneration of positive LVAD flows. Why Should an Emergency Physician Be Aware of This?VAD patients will present in extremis typically to the ED with manifestations of pump dysfunction ranging from diminished flows needing fluid management or pump adjustments to full pump failure manifesting as cardiogenic shock, needing rapid resuscitation and transfer to a cardiothoracic surgical unit with on-site VAD-perfusion specialists.

Advances in clinical cardiology.

Multiple, potentially practice-changing cardiology trials have been presented or published over the past year. In this paper, we summarize and place in clinical context, new data regarding management of acute coronary syndrome and ST-elevation myocardial infarction (copeptin assessment, otamixaban, cangrelor, prasugrel, sodium nitrite, inclacumab, ranolazine, preventive coronary intervention of non-culprit lesions, immediate thrombolytic therapy versus transfer for primary intervention), new coronary intervention data (thrombectomy, radial access, pressure wire fractional flow reserve, antiplatelet therapy duration and gene-guidance, permanent and biodegradable polymers, coronary bifurcation and strategies), and coronary artery bypass data (off pump vs. on pump). Latest trials in trans-aortic valve implantation, heart failure (eplerenone, aliskiren, spironolactone, sildenafil, dopamine, nesiritide, omecamtiv mecarbil, the algisyl left ventricular augmentation device, and echo-guided cardiac resynchronization), atrial fibrillation (edoxaban, dabigatran, and ablation), cardiac arrest (hypothermia, LUCAS™ mechanical chest compression), and cardiovascular prevention (vitamins, renal denervation for resistant hypertension, renal artery stenting, saxagliptin, alogliptin, and gastric banding) are also discussed.

Does Renal Dysfunction and Method of Bridging Support Influence Heart Transplant Graft Survival?

Renal insufficiency is common in status 1B patients supported with inotropes or a continuous flow left ventricular device (CF-LVAD) as a bridge to heart transplantation. We evaluated the association of renal function and inotrope versus CF-LVAD support on posttransplant graft survival in status 1B patients. The Scientific Registry for Transplant Recipients database was analyzed for posttransplant survival in status 1B patients bridged with inotropes or CF-LVAD who underwent transplantation between 2003 and 2012. Pretransplant renal function was measured by estimating glomerular filtration rate (GFR) and was stratified as less than 45 mL · min(-1) · 1.73 m(-2), 45 to 59, and 60 or greater. Univariate Kaplan-Meier and multivariate Cox regression models were used to evaluate the main effects of GFR strata and inotropes versus CF-LVAD, and the interaction effect of GFR strata by CF-LVAD, on graft survival. This study included 4,158 status 1B patients (74% male, aged 53 ± 12 years). Of those, 659 patients had a CF-LVAD (HeartMate-II [Thoratec, Pleasanton, CA], n = 638; HVAD [HeartWare, Framingham, MA], n = 21), and 3,530 were receiving inotropes (31 CF-LVAD patients were also receiving inotropes). Kaplan-Meier analyses demonstrated reduced graft survival (p = 0.022) in patients with pretransplant GFR less than 45 versus GFR 45 to 59 (p = 0.062) and versus GFR 60 or greater (p = 0.007), and no effect of inotrope versus CF-LVAD support on graft survival (p = 0.402). Multivariate analysis demonstrated that, after adjusting for the main effects of GFR stratum, CF-LVAD, and inotropes, status 1B patients bridged with a CF-LVAD and GFR in the lowest stratum had reduced graft survival (interaction effect p = 0.040). Pretransplant renal insufficiency was associated with reduced posttransplant graft survival in status 1B patients. This risk is increased for patients bridged with a CF-LVAD (versus inotropes) who have GFR in the lowest stratum.

MY APPROACH to evaluation of patients prior to high-risk PCI with left ventricular support devices

With the aging population and more extensive and complex coronary disease seen in the elderly population, there are times when interventional cardiologists are asked to perform high-risk percutaneous coronary intervention (PCI) among patients who have previously been considered for coronary artery bypass grafting, but where this strategy is not felt to be the best approach for the patient based on the heart team's review of the information. Performing high-risk PCI is fairly complex and straddles the area between bypass surgery and more routine mediumor low-risk PCI. In this scenario, the cardiologist needs to assess the patient more as a surgeon would approach a patient for bypass surgery. The areas to consider from a risk perspective are the types of vessels that are being approached, the number of vessels to be approached, left ventricular (LV) function, and the amount and area of ischemia vs vessels treated. Generally speaking, stress as well as functional MRI can be very helpful in sorting out the ejection fraction, areas that are ischemic, and areas that are viable or not viable. This would allow the physician to better pinpoint the amount of ischemia that might occur in the setting of high-risk PCI of left main vessels, last conduit, or other areas that contain a large amount of ischemia potentially present.

MECHANISMS OF RIGHT VENTRICULAR FAILURE AND BIVENTRICULAR MECHANICAL CIRCULATORY SUPPORT

The paper presents a review of the problems of mechanical circulatory support with left ventricular bypass in total cardiac failure. Dysfunction of right ventricular de fi nes the high mortality on left ventricular device. One of the effective methods for solving this problem is the use of right ventricular assisted devices. There are considered of the basic physiological mechanisms of interaction between the right and left ventricles of the heart, affecting on the function of the right heart. Shows the need to assess right ventricular function before deciding on mechanical circulatory support. Provides examples of the estimation the predictors of the right ventricular failure. The basic methods and devices of biventricular circulatory support were con- sidered.

(533) - Reducing 30 Day Hospital Readmissions for Patients with Left Ventricular Support Devices

Reducing 30 Day Hospital Readmissions for Patients with Left Ventricular Support Devices R.C. Starling ,1 T.J. Myers,2 R.R. Bostic,2 J.B. O’Connell,2 N.A. Mokadam,3 C.T. Salerno,4 R.L. Kormos.5 1Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH; 2Thoratec Corporation, Pleasanton, CA; 3Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA; 4Heart Transplant and Mechanical Assist Device Program, St. Vincent Heart Center of Indiana, Indianapolis, IN; 5Cardiothoracic Surgery, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA.

(47) - Increased Sensitization To HLA and To Cardiac Self-Antigens (Myosin and Vimentin) in Patients Waiting for Cardiac Transplantation With Left Ventricular Assisting Device (LVAD)

LVAD patients have higher incidence of Antibody Mediated Rejection (AMR) and Cardiac Allograft Vasculopathy (CAV) in post-transplant period. In this study we tested the hypothesis that antibodies to HLA developed due to LVAD may also induce immune responses to Cardiac Cryptic Antigens: Vimentin, Cardiac Myosin (SAgs) which may adversely affect the cardiac allograft survival.

(647) - Pulmonary Vasodilators Early and in High Dose Improve Outcomes and Reduce Right Ventricular Failure After Left Ventricular Device Implantation

(647) - Pulmonary Vasodilators Early and in High Dose Improve Outcomes and Reduce Right Ventricular Failure After Left Ventricular Device Implantation

Sex-Specific Outcomes in Patients Receiving Continuous-Flow Left Ventricular Devices as a Bridge to Transplantation or Destination Therapy

Reports on sex-related outcomes in left ventricular assist device (LVAD) patients are conflicting. In addition, females have been underrepresented in most multicenter randomized controlled trials for mechanical circulatory support (MCS). The objective of our study was to analyze our experience implanting 130 continuous-flow LVADs and to determine the impact of sex on survival. We identified 130 patients who underwent implantation of a continuous-flow LVAD at our institution. Patients were stratified into two groups based on sex. Variables were compared using two-sided t-tests, χ2 tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the two groups and if sex was a significant independent predictor of outcome. Of the 130 patients, 35 were females and 95 were males. Female patients had worse pre-LVAD cardiac output and cardiac index and were more likely to be on MCS at the time of implantation. Male patients had worse renal function. Survival was analogous for both cohorts with 30 day, 6 month, 1 year, and 2 year survivals of 97%, 90.8%, 90.8%, and 84.3%, respectively, for female patients versus 94.7%, 87.9%, 78.4%, and 72.8%, respectively, for male patients. The incidence of other LVAD-related complications was also similar in both groups. Gender did not predict postoperative mortality on univariate analysis. Contrary to most published reports, female and male LVAD patients have similar postoperative and midterm survival, length of hospital stay, readmission rates, and postoperative complications. It appears that females have gained more benefit from newer generation devices compared to males.

CRT-162 Impella® and Tandem Heart® for Circulatory Support in Refractory Cardiogenic Shock

Previous studies demonstrate that in patients with cardiogenic shock the Impella® (Abiomed, Danvers, MA) and Tandem Heart® (CardiacAssist, Pittsburg, PA) percutaneous left ventricular hemodynamic support devices improve cardiac index, systemic blood pressure and mixed venous oxygen saturation.