Post Left Ventricular Assist Device Research Articles

Impact of Diabetes Mellitus on Outcomes in Patients with Left Ventricular Assist Devices.

Heart failure (HF) represents a significant health burden in the United States, resulting in substantial mortality and healthcare costs. Through the array of treatment options available, including lifestyle modifications, medications, and implantable devices, HF management has evolved. Left ventricular assist devices (LVADs) have emerged as a crucial intervention, particularly in patients with advanced HF. However, the prevalence of comorbidities such as diabetes mellitus (DM) complicates treatment outcomes. By elucidating the impact of DM on LVAD outcomes, this review aims to inform clinical practice and enhance patient care strategies for individuals undergoing LVAD therapy. Patients with DM have higher rates of hypertension, dyslipidemia, peripheral vascular disease, and renal dysfunction, posing challenges to LVAD management. The macro/microvascular changes that occur in DM can lead to cardiomyopathy and HF. Glycemic control post LVAD implantation is a critical factor affecting patient outcomes. The recent literature has shown significant decreases in hemoglobin A1c following LVAD implantation, representing a possible bidirectional relationship between DM and LVADs; however, the clinical significance of this decrease is unclear. Furthermore, while some studies show increased short- and long-term mortality in patients with DM after LVAD implantation, there still is no literature consensus regarding either mortality or major adverse outcomes in DM patients.

(837) - Trending Renal Function Pre- and Post-Left Ventricular Assist Device (LVAD) Implantation

(837) - Trending Renal Function Pre- and Post-Left Ventricular Assist Device (LVAD) Implantation

Abstract P103: Alterations in Sarcopenia Index Are Associated With Inflammation, Gut and Oral Microbiota Among Heart Failure, Left Ventricular Assist Device and Heart Transplant Patients

Introduction: Sarcopenia, characterized by loss of muscle mass and function, is prevalent in heart failure (HF) and associated with poor outcomes. We investigated alterations in sarcopenia index (SI), a surrogate marker of skeletal muscle mass, in HF, left ventricular assist device (LVAD) and heart transplant (HT) and assessed its relationship with inflammation and digestive tract (gut and oral) microbiota. Hypothesis: Sarcopenia will be associated with increased inflammation, dysbiotic microbial signatures, higher HF class, and earlier time post-HT or post LVAD. Methods: We enrolled 460 HF, LVAD and HT patients. Repeated measures pre and post procedures were obtained in a subset of LVAD and HT patients. Sarcopenia index (serum Creatinine/Cystatin C) and inflammatory biomarkers (C-reactive protein, interleukin-6, tumor necrosis factor-alpha) were measured in 271 and 622 blood samples, respectively. Gut and saliva microbiota were assessed via 16S rRNA sequencing among 335 stool and 341 saliva samples. Multivariable regression models were used to assess the relationship between SI and i) New York Heart Association class; ii) pre- vs. post-LVAD or HT; iii) biomarkers of inflammation and microbial diversity. Results: Median (interquartile range) ln-SI was -0.13(-0.32,0.05). Ln-SI decreased across worsening HF class, further declined within the 1-month after LVAD and HT and rebounded over time to the levels of symptomatic HF. Ln-SI demonstrated an inverse correlation with inflammation (r=-0.28, p<0.0001), and a positive correlation with gut (r=0.26, p<0.0001) and oral microbial diversity (r=0.24, p<0.0001). Presence of the gut taxa Roseburia inulinivorans was associated with increased SI. Conclusions: SI levels decreased in symptomatic HF and remained decreased long-term after LVAD and HT. SI levels covaried with inflammation, gut and oral microbiota in a similar fashion.

The lived experience of patients with left ventricular assist devices: a systematic review of qualitative studies

Abstract Background although the utilization of left ventricular assist devices (LVADs) in heart failure (HF) patients has been increasing, little is known about the patients’ experience of living and managing daily life post LVAD implantation. Knowing more about the patients’ experience would help LVAD nurses establish a less hierarchical and more meaningful therapeutic relationship with their patients, and anticipate the patients’ physical, emotional and social needs post LVAD implantation. Purpose to identify the themes and patterns amongst individuals with HF who have opted for LVAD implantation, as very few studies have looked at the needs of this patient group. Methods a systematic search of PubMed, Scopus, ScienceDirect and Google Scholar in November 2022 yielded 530 research papers from 2011-2022 with keywords: LVAD, left-assist, patient, qualitative. All studies were imported into Covidence, 24 duplicates were removed, and 506 papers were subjected to abstract, title and full-text screening by three researchers independently. Screening resulted in the inclusion of 15 qualitative studies on the experiences of adult patients with implanted LVAD. All studies that were included had conducted qualitative interviews. Each study was scored according to CASP criteria, and no distinction was made between Bridge-To-Transplantation Therapy and Destination Therapy. Results Fifteen [n=15] studies in 7 countries involving 296 individuals (232 patients and 64 informal caregivers) were reviewed. The review of the literature revealed a variety of findings. Data analysis identified seven themes pertaining to the experience of living with LVAD: a) physical and functional dimensions of life [n=7 studies], b) emotional – psychological dimensions [n=10 studies], c) hope and optimism [n=5 studies] d) social aspects and relations to others [n=6 studies], e) adaptation and coping mechanisms [n=6 studies], f) receiving support from others as part of holistic care [n=3 studies], and g) liminality and ambivalence [n=3 studies]. Conclusions LVAD patients experience a life with functional limitations, fear, lifestyle changes, frustration, with "up and down-ness", that requires them to resort to a repertoire of adaptation and coping mechanisms, hope, and support from family and services. LVAD implantation introduces them to a new embodied experience of living with stigma, but also to a feeling that they have been "saved". Somewhere along their "LVAD trajectory", they experience loss of identity and "liminality", and they go through what is also known as "biographical disruption". Professionals in LVAD and Heart Failure services would be better suited to support patients and their caregivers through this journey of life transformation and ambivalence, if they were more aware of the aforementioned findings. This review sheds light on the experience of a very unique group of patients, who need specialist and needs-specific care in this post-modernism biotechnical era.PRISMA Flow DiagramTable of the included studies

PO-04-192 RISK FACTORS AND OUTCOMES OF ELECTRICAL STORM AFTER LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION

Electrical storm after Left Ventricular Assist Device (LVAD) is a recognized complication. The risk factors associated with electrical storm, impact on survival is less studied. The aim of this study is to study the incidence, risk factors of electrical storm after LVAD implantation and the impact of electrical storm on survival in patients undergoing LVAD. We performed a retrospective cohort study of all patients who underwent the LVAD implantation from January 1, 2001, to December 31, 2020, at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). The incidence and outcomes of electrical storm (≥3 sustained [>30 seconds] ventricular arrhythmia episodes over a 24-hour period) were identified. Among 886 patients who underwent LVAD implantation, electrical storm occurred in 61 (7%) patients after median of 13 days (interquartile range [IQR] 4.5- 302) post LVAD implantation. Thirty-five patients (57.3%) developed electrical storm within 30 days, while 26 patients (42.6%) developed ES at a median of 689 days (IQR of 228-1171) after LVAD. Pre LVAD history of ventricular arrhythmias (43% vs 25%, p-value=0.002) and implantable cardioverter-defibrillator (ICD) shock (34% vs 22%, p-value=0.024) and history of were significantly associated with electrical storm after LVAD implantation. The 1-year mortality rate after first occurrence of electrical storm was 38%. Following LVAD implantation, the rate of electrical storm was 7% with majority of electrical storm occurring within 30-days of LVAD. Risk factors for electrical storm included pre-implant history of ventricular arrhythmias and ICD shock.

PO-04-191 RISK FACTORS AND OUTCOMES OF EARLY VENTRICULAR ARRHYTHMIAS AFTER LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION

Ventricular arrhythmias (VAs) may occur during the early post-operative period after the implantation of left ventricular assist device (LVAD). The factors associated with its development and the long-term clinical outcome are unclear. This study aimed to evaluate the risk factors and outcomes of early ventricular arrhythmias <30 days after LVAD implantation. We performed a retrospective cohort study on all patients who underwent LVAD implantation at the Mayo Clinic (Rochester, Phoenix, and Jacksonville) from January 1, 2001, to December 31, 2020. Early VAs were defined as sustained (>30 seconds) ventricular tachycardia or ventricular fibrillation occurring less than 30 days after the LVAD implantation. Detailed review of the electronic health records within the Mayo Clinic and outside medical records were performed. A total of 886 patients were included in the study, with a median age of 60 years (interquartile range [IQR]: 50-67), and 78.9% were male. A total of 195 (22.1%) patients had early VAs after LVAD implant. Pre-implant characteristics associated with early VAs were history of VAs (32.8% vs 23.9% p=0.012), history of ventricular tachycardia ablation (5.6% vs 2.0%, p=0.007), history of ICD shocks (32.3% vs 20.1%, p<0.001) and the use of mexiletine (16.4% vs 5.9%, p<0.001) and sotalol (8.2% vs 3.6% p=0.007) before LVAD. There was no difference in the subsequent risk of late VAs in patients with or without early VAs (27.7% vs. 25.8%, p=0.29). The 1-year post LVAD mortality rate was higher in patients with early VAs compared to patients without early VAs (32% vs 18%, P<0.01). Early VAs occur in 22.1% of patients undergoing LVAD implant and is associated with increased 1-year post LVAD mortality. Significant pre-implant risk factors include a history of VAs, ICD shocks, and anti-arrhythmic drug use before the procedure.

Association Of The Stanford Integrated Psychosocial Assessment Score With Short-term Post-left Ventricular Assist Device Outcomes

Association Of The Stanford Integrated Psychosocial Assessment Score With Short-term Post-left Ventricular Assist Device Outcomes

Body mass index and natriuretic peptides trends before and after left ventricular assist device

AbstractBackgroundIt is unknown to what degree of sarcopenia related to heart failure (HF) is reversible with resolution of the HF syndrome. We evaluated whether (1) weight loss prior to left ventricular assist device (LVAD) is associated with pre‐operative sarcopenia as quantified on pre‐operative chest CTs and (2) determine the relationship between weight recovery (increase) after LVAD implantation and reduction of NT‐proBNP levels.MethodsIn a large single‐centre cohort (n = 502), CT measures of sarcopenia (pectoralis muscle mass indexed to body surface area and tissue attenuation) were correlated with pre‐LVAD BMI trend (n = 190). BMI and NT‐proBNP trends before and after LVAD implantation were evaluated (n = 403). Linear effects modelling was performed to test the association between NT‐proBNP and BMI trends.ResultsA downtrending BMI prior to LVAD was associated with pectoralis muscle tissue attenuation (P &lt; 0.05). BMI declined prior to LVAD, declined further early post‐implant, and then increased between 100 and 300 days post‐implant (average per cent change in BMI in Year 1, 7.6%, 95% CI: 6.3–8.8%). NT‐proBNP decreased during the first 100 post LVAD days (−5.4%, 95% CI: −6.6 to −4.2%). Post‐LVAD NT‐proBNP and BMI trends were significantly associated, with a decrease of 1 unit log NT‐proBNP associated with an increase in BMI of 0.81 kg/m2 (CI: 0.53–1.09, P &lt; .001). The rise in post‐LVAD BMI occurred after the reduction in NT‐proBNP levels. Patients who failed to gain weight post‐LVAD had the highest 6‐month post‐LVAD natriuretic peptides (lowest per cent BMI gain tertile NT‐proBNP: 2208 vs. highest 1635 pg/mL, P &lt; 0.001).ConclusionsWeight recovery during LVAD support occurs after the reduction in natriuretic peptide levels. Failure to gain weight during LVAD support was associated with persistently elevated natriuretic peptide levels. These data collectively suggest that recovery of body mass may be dependent upon recovery of the HF syndrome.

Abstract 15585: Myocardial Reserve After Milrinone to Predict Right Ventricular Failure After LVAD Implantation

Introduction: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a common complication associated with increased morbidity and mortality. Identifying patients at risk for RVF remains challenging. We sought to assess pre-operative right ventricular myocardial reserve after milrinone loading as a risk predictor for post-LVAD RVF. Methods: Adult patients implanted with LVADs from 2013-2019 at a single center who had right heart catherization with milrinone drug study within 30-days preoperatively were included. In addition to standard hemodynamic variables, pulmonary artery pulsatility index (PAPI), right atrial to pulmonary capillary wedge pressure ratio (RA/PCWP), right ventricular stroke work index (RVSWI), pulmonary vascular resistance index (PVRi), and stroke volume index (SVI) were recorded before and after milrinone bolus (50 mcg/kg over ten minutes). Incidence of RVF defined by MCS-ARC criteria within one-year post LVAD were recorded. Student’s unpaired t-tests were used to compare mean of hemodynamic markers to RVF outcome. Results: A total 34 patients were included; 38% women, 50% African American, 68% had non-ischemic cardiomyopathy, 47% implanted with HeartMate 3 LVAD, 20.5% with HeartMate 2, and 32% with HeartWare HVAD. Final right atrial pressure (RAP) after milrinone was higher in those with post-LVAD RVF (15.5 + 7.8mmHg vs 9.2 + 3.9mmHg, p=0.005), as was final diastolic PA pressure (34.3 + 9.2mmHg vs 25.6 + 7.7mmHg, p=0.006). SVI post-milrinone was numerically higher in those without post-LVAD RVF (32.3 + 9.2 vs 26.0 + 7.9mL/m 2 , p=0.06). Percent change in PAPI (p=0.26), RA/PCWP (p=0.35), RVSWI (p=0.10), or PVRi (p=0.92) after milrinone were not associated with RVF. Conclusions: Persistently elevated RAP and diastolic PA pressure, despite milrinone infusion, are associated with RVF after LVAD implantation. Continued reduction in SVI post milrinone may also identify patients at risk for post-LVAD RVF.

Right heart failure after left ventricular assist device: From mechanisms to treatments.

Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5-44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.

Impact of Pre-Operative Right Ventricular Response to Hemodynamic Optimization on Outcomes in Patients with LVADs.

Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ± 12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14–16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24–13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6–25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation.

Artificial intelligence-based body composition predicts postoperative complications and mortality in advanced heart failure patients receiving long-term mechanical circulatory support

Abstract Background Obesity is an independent cardiovascular risk factor and is associated with higher postoperative infection rates in patients after cardiac surgery. However, in heart failure, obesity has been described as beneficial in terms of survival (“obesity paradox”); whereas sarcopenia is associated with poor prognosis. An increasing number of advanced heart failure patients requires surgical treatment in terms of left ventricular assist device (LVAD) implantation. The postoperative in-hospital survival has improved in recent years but is still relatively high (11.1%). The impact of body composition on outcome in this population remains unclear. Purpose The aim of this investigation was to examine the preoperative computed tomography (CT) body composition based on artificial intelligence (AI) analysis as a predictor of the postoperative outcome in advanced heart failure patients, who underwent LVAD implantation. Methods Preoperative CT scans of 137 patients who received LVAD implantations between 2015 and 2020 were retrospectively analyzed using an AI-powered automated software tool based on a convolutional neural network, U-net, developed for image segmentation (Visage version 7.1., Visage Imaging GmbH, Berlin, Germany; Figure 1). Assessment of body composition included visceral and subcutaneous adipose tissue areas (VAT, SAT), psoas and total abdominal muscle areas (PMA, TAMA) and sarcopenia (defined as lumbal skeletal muscle index ≤38.5 cm2/m2 in women and ≤54.4 cm2/m2 in men). The body composition parameters were correlated with postoperative major complication rates and survival. Results The mean age of patients was 58.21±11.9 years; 122 (89.1%) were male. Most patients had severe heart failure requiring inotropes (INTERMACS profile I-III, 71.9%) secondary to coronary artery diseases or dilated cardiomyopathy (96.4%). 44 (32.1%) patients were obese (BMI ≥30 kg/m2), 96 (70.1%) were sarcopene and 19 (13.9%) were sarcopene obese. Adipose tissue was associated with a significantly higher risk of overall postoperative complications (SAT 158.22 cm2 [63.09, 256.78 cm2] vs. 124.04 cm2 [42.86, 187.68 cm2], p=0.049) and in-hospital mortality (VAT 168.11 cm2 [134.19, 285.27 cm2] vs. 135.42 cm2 [49.44, 227.91 cm2], p=0.033; SAT 227.28 cm2 [139.38, 304.35 cm2] vs. 173.81 cm2 [97.65, 254.16 cm2], p=0.009). Sarcopenia did not influence the postoperative outcome and survival within 1 year post LVAD implantation. Conclusions Preoperative AI-based CT body composition identifies patients with poor prognosis after LVAD implantation. Adipose tissue areas predict in-hospital mortality, thus, obesity as a perioperative risk factor outweighs the protective effect known in heart failure patients when undergoing LVAD implantation. Funding Acknowledgement Type of funding sources: None.

S2155 Utilizing the Pure-Vu EVS for Inpatient Colonoscopy for Patients With an LVAD: A Case Report

Introduction: Colonoscopy is considered the standard for colon cancer screening. A key factor in ensuring high quality colonoscopy is adequate colon cleansing. In hospitalized patients, bowel preparation is often challenging and inadequate cleansing is often due to patient’s inability to tolerate the preparation, slow bowel transit in the setting of immobilization and acute illnesses, and the use of motility-altering medications. Poor bowel preparation limits visualization of the colonic mucosa and can lead to incomplete colonoscopies, missed pathology, adverse events, prolonged hospital stays and increased costs. New technologies have been developed to improve bowel preparations intra-procedurally. The Pure-Vu EVS system, which is an over-the-scope irrigation and cleansing device. This case report describes a novel use of the Pure-Vu EVS system to improve inpatient colonoscopy prep. Case Description/Methods: A 58-year-old female with past medical history significant for chronic systolic heart failure, ischemic cardiomyopathy status post Left Ventricular Assist Device (LVAD) one year prior. End stage heart failure patients requiring LVAD placement routinely undergo screening colonoscopy as part of their pre-transplant evaluation, as the presence of colon cancer or advanced neoplasia could preclude heart transplantation. As part of orthotopic heart transplant evaluation she was admitted to the hospital for IV heparin bridging for screening colonoscopy. After admission, the patient was started on standard bowel prep consisting of 4L of Golytely and Dulcolax suppository. Despite completion of prep, she continued to pass sediments and prep was deemed inadequate. The patients LVAD anticoagulation had been held for the procedure and the decision was made to proceed with colonoscopy utilizing the Pure-Vu EVS device. During the procedure the clinical team utilized the Pure-Vu EVS device and performed the procedure with cardiovascular anesthesia. The Pure-Vu EVS system effectively irrigated and suctioned areas of inadequate bowel prep with sediment larger than 3.8 mm, allowing for improved visualization of the colonic mucosa. Discussion: Pure-Vu EVS allowed for us to perform a screening colonoscopy as part of orthotopic heart transplant evaluation in a patient with LVAD admitted a hospital inpatient service for heparin bridge. This case report describes one of the first cases of the utilization of this unique technology in a patient requiring inpatient screening colonoscopy with advanced heart failure.

Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support.

Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.

Incremental Value of Global Longitudinal Strain to Michigan Risk Score and Pulmonary Artery Pulsatility Index in Predicting Right Ventricular Failure Following Left Ventricular Assist Devices.

The incremental utility of right ventricular (RV) strain on predicting right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation, beyond clinical and haemodynamic indices, is not clear. Two hundred and forty-six (246) patients undergoing LVAD implantation, who had transthoracic echocardiograms pre and post LVAD, pulmonary artery pulsatility index (PAPI) measurements and Michigan risk score, were included. We analysed RV global longitudinal strain (GLS) using speckle tracking echocardiography. RVF following LVAD implantation was defined as the need for medical support for >14 days, or unplanned RV assist device insertion after LVAD implantation. Mean preoperative RV-GLS was -7.8±2.8%. Among all, 27% developed postoperative RVF. A classification and regression tree analysis identified preoperative Michigan risk score, PAPI and RV-GLS as important parameters in predicting postoperative RVF. Eighty per cent (80%) of patients with PAPI <2.1 developed postoperative RVF, while only 4% of patients with PAPI >6.8 developed RVF. For patients with a PAPI of 2.1-3.2, having baseline Michigan risk score >2 points conferred an 81% probability of subsequent RVF. For patients with a PAPI of 3.3-6.8, having baseline RV-GLS of -4.9% or better conferred an 86% probability of no subsequent RVF. The sensitivity and specificity of this algorithm for predicting postoperative RVF were 67% and 93%, respectively, with an area under the curve of 0.87. RV-GLS has an incremental role in predicting the development of RVF post-LVAD implantation, even after controlling for clinical and haemodynamic parameters.

Reduction of Adverse Events With Phosphodiesterase 5 Inhibitors Post LVAD Implantation: Is It Time for a Randomized Trial?

The improved survival of patients with advanced heart failure after left ventricular assist device (LVAD) implantation together with the scarcity of donor hearts has significantly increased the population of LVAD-supported patients. However, despite the improvement in LVAD technology and the advent of third-generation continuous flow LVADs, complications such as those related to hemocompatibility and stroke rates remain ongoing clinical challenges. Thus, improvement in LVAD technology should be coupled with innovative medical management to further reduce adverse events. We have previously shown a strong association between post LVAD implant phosphodiesterase-5 inhibitors (PDE-5i) use and fewer thrombotic events, as well as improved survival in 2 observational studies. We caution, nevertheless, the use of PDE-5i based on these observations and encourage clinicians to support enrollment in a randomized control trial. A randomized control trial will determine the efficacy and safety of PDE-5i use after implantation in patients with a centrifugal flow LVAD.

Pre-operative sarcopenia is predictive of recurrent gastrointestinal bleeding on left ventricular assist device support: A multicenter analysis.

Whether pre left ventricular assist device (LVAD) sarcopenia is associated with higher incidence of gastrointestinal bleeding (GIB) on LVAD support remains unknown. To study the association between preoperative sarcopenia and post LVAD GIB events, we performed a retrospective, multi-centered study including patients with chest CTs performed ≤ 3 months prior to LVAD implantation at the University of Minnesota (n=143) and Houston Methodist Hospital (n=133). To quantify sarcopenia, unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHUm) were measured on pre-operative chest CT scans. Negative binomial regression analyses were performed to determine the association between pectoralis muscle measures and number of GIB events to 2 years of LVAD support. The study cohort included 276 LVAD recipients with 43 % designated as bridge to transplant at the time of LVAD implantation. High pectoralis muscle mass and tissue attenuation were both protective against GIB events. Each 5 unit increase in PHUm was associated with an adjusted 19 % reduction in the incidence rate of GIB (95 % CI 7-29 %, p=0.002). Each unit increase in PMI was associated with an adjusted 17 % reduction in the incidence of GIB (95 % CI 1- 29 %, p=0.04). The models were adjusted for age, sex, INTERMACS profile, bridge to transplant status, creatinine, albumin and implanting center. Preoperative sarcopenia, as quantified by pectoralis muscle size and attenuation, was associated with the development of recurrent GI bleeding after LVAD implantation. These CT quantitative measures appear to predict not only early mortality but morbidity on LVAD as well.

Perioperative Levosimendan Infusion in Patients With End-Stage Heart Failure Undergoing Left Ventricular Assist Device Implantation.

Left ventricular assist device (LVAD) therapy has been instrumental in saving lives of patients with end-stage heart failure (HF). Recent generation devices have short-to-mid-term survival rates close to heart transplantation. Unfortunately, up to 1 in 4 patients develop a life-threatening right-sided HF (RHF) early post LVAD implantation, with high morbidity and mortality rate, necessitating prolonged ICU stay, prolonged inotropic support, and implantation of a right-ventricular assist device. Pre-operative optimization of HF therapy could help in prevention, and/or mitigation of RHF. Levosimendan (LEVO) is a non-conventional inotropic agent that works by amplifying calcium sensitivity of troponin C in cardiac myocytes, without increasing the intra-cellular calcium or exacerbating ischemia. LEVO acts as an inodilator, which reduces the cardiac pre-, and after-load. LEVO administration is associated with hemodynamic improvements. Despite decades long of the use of LVAD and more than two decades of the use of LEVO for HF, the literature on LEVO use in LVAD is very limited. In this paper, we sought to conduct a systematic review to synthesize evidence related to the use of LEVO for the mitigation and/or prevention of RHF in patients undergoing LVAD implantation.

Therapeutic augmentation of NO-sGC-cGMP signalling: lessons learned from pulmonary arterial hypertension and heart failure.

The nitric oxide (NO)-guanylate cyclase (GC)-cyclic guanosine monophosphate (cGMP) pathway plays an important role in cardiovascular, pulmonary and renal function. Phosphodiesterase-5 inhibitors (PDE-5i) inhibit cGMP degradation, whereas both soluble guanylate cyclase (sGC) stimulators and sGC activators directly increase sGC. PDE-5i (e.g. sildenafil, tadalafil) and sGC stimulators (e.g. riociguat, vericiguat) have been extensively used in pulmonary artery hypertension (PAH) and heart failure (HF). PDE-5i have also been used in end-stage HF before and after left ventricular (LV) assist device (LVAD) implantation. Augmentation of NO-GC-cGMP signalling with PDE-5i causes selective pulmonary vasodilation, which is highly effective in PAH but may have controversial, potentially adverse effects in HF, including pre-LVAD implant due to device unmasking of PDE-5i-induced RV dysfunction. In contrast, retrospective analyses have demonstrated that PDE-5i have beneficial effects when initiated post LVAD implant due to the improved haemodynamics of the supported LV and the pleiotropic actions of these compounds. sGC stimulators, in turn, are effective both in PAH and in HF due to their balanced pulmonary and systemic vasodilation, and as such they are preferable to PDE-5i if the use of a pulmonary vasodilator is needed in HF patients, including those listed for LVAD implantation. Regarding the effectiveness of PDE-5i and sGC stimulators when initiated post LVAD implant, these two groups of compounds should be tested in a randomized control trial.

Body Mass Index And Natriuretic Peptides Trends Before And After Left Ventricular Assist Device: Evidence That Gains In Body Mass Follow On Resolution Of Heart Failure

Purpose To evaluate the hypothesis that weight gain after left ventricular assist device (LVAD) occurs after the nadir of natriuretic peptides (nt-proBNP), and that persistently elevated natriuretic peptides is associated with failure to gain weight after LVAD implantation. Methods Body mass index (BMI) and nt-proBNP trends before and after LVAD in a single center continuous flow cohort (n=505) were computed and plotted using Locally Estimated Scatterplot Smoothing (LOESS). Linear mixed effects modeling was performed to test the association between nt-proBNP and BMI. CT measures of sarcopenia (pectoralis muscle mass index to body surface area and tissue attenuation, n=194) was correlated with pre-LVAD BMI trend. Results The plots of BMI and log nt-proBNP for the entire cohort before and after LVAD are demonstrated (Figure). The rise in BMI did not occur until after the nadir of post implant nt-proBNP. Downward slope of BMI prior to LVAD was associated with lower pectoralis muscle measures prior to implantation. Patients who failed to gain weight post LVAD had the highest 6 month post LVAD natuetic peptides (lowest pecent BMI gain tertile nt-proBNP: 2,208 vs. highest 1,635 pg/mL, p <0.001). Post LVAD nt-pro BNP and BMI trends were significantly associated (a decrease of 1 unit log nt-proBNP was associated with an increase in 0.81 BMI, 95 % CI: 0.53-1.09, p < 0.001). Conclusions Weight gain post LVAD did not occur until the nadir of natriuretic peptides. Failure to gain weight post LVAD was associated with persistently elevated natriuretic peptides. These data collectively suggest that gains in body mass may be dependent on resolution of heart failure. To evaluate the hypothesis that weight gain after left ventricular assist device (LVAD) occurs after the nadir of natriuretic peptides (nt-proBNP), and that persistently elevated natriuretic peptides is associated with failure to gain weight after LVAD implantation. Body mass index (BMI) and nt-proBNP trends before and after LVAD in a single center continuous flow cohort (n=505) were computed and plotted using Locally Estimated Scatterplot Smoothing (LOESS). Linear mixed effects modeling was performed to test the association between nt-proBNP and BMI. CT measures of sarcopenia (pectoralis muscle mass index to body surface area and tissue attenuation, n=194) was correlated with pre-LVAD BMI trend. The plots of BMI and log nt-proBNP for the entire cohort before and after LVAD are demonstrated (Figure). The rise in BMI did not occur until after the nadir of post implant nt-proBNP. Downward slope of BMI prior to LVAD was associated with lower pectoralis muscle measures prior to implantation. Patients who failed to gain weight post LVAD had the highest 6 month post LVAD natuetic peptides (lowest pecent BMI gain tertile nt-proBNP: 2,208 vs. highest 1,635 pg/mL, p <0.001). Post LVAD nt-pro BNP and BMI trends were significantly associated (a decrease of 1 unit log nt-proBNP was associated with an increase in 0.81 BMI, 95 % CI: 0.53-1.09, p < 0.001). Weight gain post LVAD did not occur until the nadir of natriuretic peptides. Failure to gain weight post LVAD was associated with persistently elevated natriuretic peptides. These data collectively suggest that gains in body mass may be dependent on resolution of heart failure.