Treatment Of Terminal Heart Failure Research Articles

Cardiac Rehabilitation to Inpatient Heart Transplant-HRN4HTx Intervention Protocol.

Heart transplantation is the gold-standard treatment for terminal heart failure. Despite being successful, pre- and post-transplant limitations interfere with patients' functional capacity, self-care, and quality of life post-surgery. Rehabilitation is necessary to address these limitations, prevent complications, and promote a safe return home. This study analyzes the safety of a phase 1 cardiac rehabilitation protocol (RN4HTx) in heart transplant patients and its effects on self-care capacity. A quantitative, descriptive study was conducted with 19 heart transplant recipients. The protocol was implemented in collaboration with a rehabilitation professional, who monitored adverse events, hemodynamic variables, self-care capacity (Barthel) pre- and post-transplant, and functional capacity at discharge (6 min walk test). The results showed that 68.42% of recipients were men, with an average age of 50.21 years and 15 days of hospitalization post-transplant. Approximately 73.68% of recipients were transferred from other wards with changes in functional capacity. All patients progressed to the final stage of the program without adverse events. There was a notable improvement in self-care capacity before and after transplantation, with a measure of functional status of 310.035 m (6MWT). The study found that RN4HTx is a feasible cardiac rehabilitation program without adverse events in the immediate postoperative period following heart transplantation, positively impacting functional recovery and therapeutic self-care capacity, thus increasing the safety of returning home. This study was retrospectively registered on Clinical Trials-NCT06552390.

Heart transplantation : Current situation

Heart transplantation is the gold-standard in the treatment of terminal heart failure. The shortage of donor hearts represents the major obstacle in patient care and necessitates the creation of waiting lists and allocation algorithms. The Transplantation Act regulates donor heart allocation according to the urgency and the prospects of success. Donor hearts can be implanted following the classical biatrial or the modern bicaval valve implantation technique with a slightly lower spectrum of complications. Modern mechanical perfusion systems enable extended transport times. After heart transplantation rejection reactions must be controlled by an individually adjusted immunosuppression to guarantee long-term survival with as few complications as possible.

The results of orthotopic heart transplantation using the bicaval technique

Circulatory failure, which develops in the final stages of the course of the most heart diseases, is a link in the progressive process. This process is accompanied by a significant decrease in the quality of life, as well as high disability and mortality.
 Heart transplantation increases the survival of patients with chronic heart failure, increases tolerance to physical exertion, improves the quality of life of patients and allows most of them to return to vigorous activity.
 Aim. The work is devoted to the analysis of the results of orthotopic heart transplantation in patients with a progressive course of chronic heart failure that cannot be treated conservatively.
 Materials and methods. We analyzed the clinical course of heart transplants in 55 patients. There were 46 (83.6 %) men and 9 (16.4 %) women among the recipients. The average age was 46.0 ± 10.0 years.
 Results. The result of the conducted retrospective study revealed that in-hospital (early) and one-year (longterm) survival among patients in our study was 92.7 % and 81.8 %, respectively.
 Conclusions. Heart transplantation is the most effective method of treatment for terminal heart failure. The quality of life of heart transplant patients improves significantly after surgery and is the main factor in the development of heart transplantation nowadays.
 The main causes of death were acute graft dysfunction, rejection reactions, and coronary heart disease of the transplanted heart. Problems related to cardiac graft dysfunction and rejection in the early and long-term period still need to be definitively resolved.

Development of a bioreactor system for pre-endothelialized cardiac patch generation with enhanced viscoelastic properties by combined collagen I compression and stromal cell culture.

Treatment of terminal heart failure still poses a significant clinical problem. Cardiac tissue engineering could offer autologous solutions for the replacement of nonfunctional myocardial tissue. So far, soft matrix construction and missing large-scale prevascularization prevented the application of sizeable cardiac repair patches. We developed a novel bioreactor system for semi-automatic compression of a collagen I hydrogel applying 16 times higher pressure than in previous studies. Resistance towards compression stress was investigated for multiple cardiac-related cell types. For scaffold prevascuarization, a tubular cavity was imprinted during the compaction process. Primary cardiac-derived endothelial cells (ECs) were isolated from human left atrial appendages (HLAAs) and characterized by fluorescence-activated cell sorting (FACS) and immunocytology. EC were then seeded into the preformed channel with dermal fibroblasts as interstitial cell component of the fully cellularized patch. After 8 days of constant perfusion culture within the same bioreactor, scaffold dynamic modulus and cell viability were analyzed. Endothelial proliferation and vessel maturation were examined by immunohistochemistry and transmission electron microscopy. Our design allowed for scaffold production and dynamic culture in a one-stop-shop model. Enhanced compression and cell-mediated matrix remodeling induced a significant increase in scaffold stiffness while ensuring excellent cell survival. For the first time, we could isolate HLAA-derived EC with proliferative potential. ECs within the central channel proliferated during flow culture, continuously expressing endothelial markers (CD31) and displaying basal membrane synthesis (collagen IV, ultrastructural analysis). After 7 days of culture, a complete endothelial monolayer could be observed. Covering cells aligned themselves in flow direction and developed mature cell-cell contacts.

Exercise after Heart Transplantation: Typical Alterations, Diagnostics and Interventions.

For the treatment of terminal heart failure, heart transplantation is considered to be the gold standard, leading to significantly improved quality of life and long-time survival. For heart transplant recipients, the development and maintenance of good functional performance and adequate exercise capacity is crucial for renewed participation and integration in self-determined live. In this respect, typical transplant-related alterations must be noted that play a significant role, leading to restrictions both centrally and peripherally. Before patients begin intensive and structured exercise training, a comprehensive diagnosis of their exercise capacity should take place in order to stratify the risks involved and to plan the training units accordingly. Particularly endurance sports and resistance exercises are recommended to counter the effects of the underlying disease and the immunosuppressive medication. The performance level achieved can vary considerably depending on their individual condition, from gentle activity through a non-competitive-level to intensive competitive sports. This paper includes an overview of the current literature on heart transplant recipients, their specific characteristics, as well as typical cardiovascular and musculoskeletal alterations. It also discusses suitable tools for measuring exercise capacity, recommendations for exercise training, required precautions and the performance level usually achieved.

Stabilisation of a Segment of Autologous Vascularised Stomach as a Patch for Myocardial Reconstruction with Degradable Magnesium Alloy Scaffolds in a Swine Model

In patients with severe heart failure, the surgical reconstruction of the damaged myocardium with regenerative biological grafts is an innovative therapeutic option. However, natural patch materials are often too delicate for a full wall repair of the left ventricle. A degradable magnesium scaffold could provide temporary mechanical stability until the sufficient physiological remodeling of such grafts. An autologous vascularised gastric patch was employed for the reconstruction of the left ventricular myocardium in a porcine model. Magnesium alloy (LA63) scaffolds were fixed over the biological patch. The function of the implant was assessed via magnetic resonance imaging. Angiography was carried out to detect a connection between the gastric and coronary vasculature. The explants were examined via µ-computer tomography and light microscopy. All the test animals survived. The prostheses integrated biologically and functionally into the myocardium. No rupture of the prostheses occurred. An anastomosis of the gastric and coronary vasculature had developed. The magnesium scaffolds degraded, on average, to 30.9% of their original volume. This novel technique responds to the increasing demand for regenerative myocardial grafts. The magnesium scaffolds’ biocompatibility and degradation kinetics, as well as their stabilizing effects, indicate their applicability in the surgical treatment of terminal heart failure.

Driveline Wound Care: Key to the Long-Term Use of Implantable Ventricular Assist Devices

Heart failure is a complicated chronic disease. Although numerous new medications are used to treat and improve the quality of life of patients with heart failure, the final treatment for terminal heart failure still relies heavily on heart transplants. However, as the number of heart donations is limited, many health institutions implant mechanical assist devices to perform heart functions temporarily. These implanted ventricular assist devices help reduce heart failure symptoms and enhance quality of life. However, driveline infection is one of the more severe complications associated with these devices. If this infection is not controlled, another heart surgery will be necessary to replace the device. Severe driveline infection may even lead to patient death. An approach to care that includes driveline wound care standardization and immobilization of the driveline has been shown to effectively decrease the incidence of driveline infections and to increase the survival rate. As Taiwan still lacks the relevant clinical care standards for implantable ventricular assist device support and driveline wound care, this study introduces the relevant Western literature and the author's clinical experience related to driveline wound management. We hope that this article serves as a useful reference for related nursing care.

Successful surgical treatment of terminal heart failure in an adolescent - left ventricular assist device implantation and subsequent heart transplantation

Introduction. Implantation of the new-generation left ventricular assist device (LVAD) is an efficient therapeutic option as a bridge to transplantation in adults, as well as in children and adolescents with small body surface. The aim of this work was to present a case of a successful surgical treatment of terminal heart failure in a male adolescent who had an LVAD implanted as a bridge to heart transplantation. Case outline. The patient, a 17-year-old male, was admitted with the end-stage heart failure due to the dilated cardiomyopathy and implanted LVAD. Fourteen months after LVAD implantation, a successful ?second stage? surgical procedure was performed ? orthotopic heart transplantation preceded by the LVAD explantation. Conclusion. Long-term mechanical circulatory support is an effective and safe method in treatment of the end-stage heart failure as a bridge to transplantation in the adolescent period.

Effects of pump speed changes on exercise capacity in patients supported with a left ventricular assist device—an overview

The implantation of left ventricular assist devices (LVAD) has been established as a successful treatment for terminal heart failure (HF) for many years. Patient benefits include significantly improved survival, as well as improved quality of life. However, peak exercise capacity following LVAD implantation remains considerably restricted. This could be due to the predominate use of continuous-flow pumps, which operate at a fixed rotational speed and do not adapt to exercise conditions. Therefore, current research is focused on whether, and to what extent, adaptations in pump speed can influence and improve patient exercise capacity. We performed a systematic PubMed literature search on this topic, and found 11 relevant studies with 161 patients. Exercise time, peak work load, total cardiac output (TCO), peak oxygen consumption (peak VO2) and, if available, values at the anaerobic threshold (AT) were all taken into consideration. Possible complications were documented. This paper aims to compare the results from these studies in order to discuss the effects of pump speed adaptations on exercise capacity.

HEART TRANSPLANTATION WITH EXTREMELY EXTENDED COLD ISCHEMIA TIME OF THE DONOR HEART

Heart transplantation is the gold standard for the treatment of terminal heart failure. The main method of the donor heart preservation is cold perfusion. The recommended maximum time for cold ischemia of the donor heart is 240 minutes. Exceeding this safe limit increases the risk of postoperative allograft dysfunction and death. However, there are reports positing a possibility to prolong the time of ischemia of the donor heart without a signifi cant risk of complications. The article presents the experience of successful transplantation of the donor heart with the cold ischemia time was 440 minutes.

New Targets for the Prevention of Chronic Rejection after Thoracic Organ Transplantation.

The gold standard for the treatment of terminal heart failure and irreversible lung diseases includes thoracic organ transplantation. The major obstacle for long-term survival after successful transplantation is chronic rejection, an ongoing immunomodulatory disease so far without effective therapy. Therefore, the aim of this review is to elucidate scientific efforts targeting different new mechanisms of cardiac allograft vasculopathy (CAV) and chronic lung allograft dysfunction (CLAD). For this purpose, we performed a systematic review of the literature to assess recent strategies in transplant immunology research. We searched MEDLINE from 2015 up to date for articles addressing the following keywords: CAV, transplant vasculopathy, transplant arteriosclerosis, CLAD, bronchiolitis obliterans transplant, and obliterative bronchiolitis transplant. All articles including experimental models in the field of transplant immunology addressing new aspects for the prevention of chronic rejection after heart and lung transplantation were included in this review. The prevention of chronic rejection would clearly improve the survival of patients after heart and lung transplantation. Interesting targets were addressed in recent research, but further research is necessary to effectively treat this life-threatening disease in transplant recipients.

Endothelial dysfunction expressed as endothelial microparticles in patients with end-stage heart failure.

Left ventricular assist devices (LVAD), currently used in treatment of terminal heart failure, are working on principle of rotary pump, which generates continuous blood flow. Non-pulsatile flow is supposed to expose endothelial cells to high stress and potential damage. Therefore, we investigated longitudinal changes in concentration of circulating endothelial microparticles (EMP) as a possible marker of endothelial damage before and after implantation of LVAD. Study population comprised 30 patients with end-stage heart failure indicated for implantation of the Heart Mate II LVAD. Concentrations of microparticles were measured as nanomoles per liter relative to phosphatidylserine before and 3 months after implantation. At 3 months after implantation we observed significant decrease in concentration of EMP [5.89 (95 % CI 4.31-8.03) vs. 3.69 (95 % CI 2.70-5.03), p=0.03] in the whole group; there was no difference observed between patients with ischemic etiology of heart failure (n=18) and with heart failure of non-ischemic etiology (n=12). In addition, heart failure etiology had no effect on the rate of EMP concentration decrease with time. These results indicate possibility that LVAD do not cause vascular damage 3 months after implantation. Whether these results suggest improvement of vascular wall function and of endothelium is to be proved in long-term studies.

Optimal utilization of mechanical circulatory support and transplant resources in the comprehensive treatment of terminal heart failure

In the adult group, 66% of patients were at INTERMACS level 1, critical cardiogenic shock, and 19% were at level 2, progressive decline. Indications for primary MCS included: acute exacerbation of chronic heart failure, acute cardiogenic shock and respiratory failure. Altogether, procedural success was accomplished in 49.4% of patients. MCS efficiently bridged 14 patients with heart failure to heart transplantation. In 15 patients, long term support was instituted, either as a destination therapy or as a bridge to heart transplant; 13 received HeartMate II, and 2 patients received HeartWare. One patient with respiratory failure was successfully bridged to lung transplantation. In the pediatric group, 60% patients were bridged to recovery. Postcardiotomy MCS was used in 33.7% patients. Patient outcome after 30 days was assessed as: alive (22.4%), alive on support (13.5%), dead (64.0%). The most common perioperative complication was renal failure, in 42.7% patients.

Pediatric heart transplantation: 17-year Brno experience

AimTo summarize the follow-up of children who underwent orthotopic heart transplantation (HTx) in the Center of Cardiovascular and Transplantation Surgery in Brno during the past 17 years. Patients and methodsBetween May 1995 and October 2012, 42 children aged 2 months–17.5 years were listed for HTx, of these 26 underwent HTx later. ResultsOf 42 children listed for HTx, 12 died, 26 underwent HTx, 3 were excluded because of improved clinical status, and 1 is waiting for HTx. Five children died early after the transplantation, one patient died 6.5 years after HTx. The 1-year, 5-years and 10-years post-transplantation survival rates are 81%, 81%, and 76.9%, respectively. One patient underwent re-transplantation 11.5 years after HTx because of coronary artery disease affecting the graft. Long-term follow-up data are available for 21 children surviving 1.6–17.4 years (mean 8.7±5.3 years). The most common morbidities were hypertension and mild chronic kidney disease (CKD 2). Pneumonia was the most common infectious complication requiring hospitalization. EBV infection with subsequent development of post-transplant lymphoproliferative disorder (PTLD) was a severe late complication in two patients (diagnosed 8 and 15 years after transplantation). The increase in incidence of coronary artery disease during the second decade post-HTx (affecting 7.7% patients after 5 years and 42.8% patients after 10 years) leads to a significant increase in the morbidity of pediatric patients surviving more than 10 years after transplantation. ConclusionHeart transplantation currently represents an effective treatment of terminal heart failure in children. Improving outcomes of pediatric HTx mainly reflect the drop in early mortality. The main causes of late morbidity and mortality of children after HTx are the increase in incidence of coronary artery disease and malignant diseases (PTLD). Our results of long-term follow-up of children after heart transplantation are consistent with published data from other centers.

Optimal utilization of mechanical circulatory support and transplant resources in the comprehensive treatment of terminal heart failure

Treatment of end-stage heart failure has reached new frontiers. With a scarce availability of hearts, mechanical circulatory support (MCS) has become an integral part of end-stage heart failure treatment and has improved survival. A variety of devices may be instituted either for short or long term support in different clinical indications, such as postcardiotomy circulatory failure, acute cardiogenic shock, chronic heart failure in patients not eligible for a transplant to heart transplant deterioration. Permanent or temporary MCS has emerged as an indispensible treatment for advanced stage heart failure alongside established standard medical procedures. Herein we report brief narrative review of MCS devices used for end-stage heart failure.

Ventricular assist devices for all?

In the past 5 years, the numbers of ventricular assist device (VAD) systems implanted worldwide have increased exponentially. Thus, since the introduction of the HeartMate II LVAD by Thoratec (Thoratec Inc., Pleasanton, CA, USA) over 10 000 of these pumps have been implanted. The HVAD manufactured by HeartWare (HeartWare Inc., Framingham, MA, USA) has also found widespread application in Europe, and particularly in Germany, before it has even been approved for the US market. The driving force behind the spread of this form of treatment for terminal heart failure was, in the first place, not only the increasingly good results found in studies, but also the results achieved in broad clinical routine with the application of these systems, which have been further developed since VAD use began. The 6-month survival in bridge-to-transplant patients, for example, rose to 93% [1], whereas in 2008 a rate of 82% was reported [2].

Treatment of Terminal Heart Failure and Cardiogenic Shock in 36 Children Less than 10 Kg Body Weight Assisted by Berlin Heart Excor Device

Treatment of Terminal Heart Failure and Cardiogenic Shock in 36 Children Less than 10 Kg Body Weight Assisted by Berlin Heart Excor Device

Outcomes after Implantation of Left Ventricular Assist Devices in Patients with Terminal Heart Failure Complicated by Cardiogenic Shock at Time of Device Placement

Background: Presence of cardiogenic shock at time of left ventricular assist device (LVAD) placement for treatment of terminal heart failure diminishes the therapy success. We studied the impact of cardiogenic shock on survival in recipients of new miniaturized rotary blood pumps. Methods: Between 08/2009 and 07/2011 a total of 116 patients with terminal heart failure were treated with the centrifugal blood pump HeartWare HVAD. We divided patients as follows: Group 1, those suffering from cardiogenic shock, n=22; Group 2, those without shock at time of device placement, n=96. Survival rate and clinical course in both groups were analyzed. Results: Cumulative survival rate at 90 days and 1 year was 86% for group 1 and 83% and 81% for group 2, respectively (p=0.7). In Group 1 median support time and cumulative follow-up were 215 days (range 6-665 days) and 15.5 pt./y., with 14 patients with ongoing support and 2 transplanted compared to those in group 2: 234 days (range 1-682 days) and 64.4 pt./y., with 65 patients with ongoing support, 3 transplanted and 1 weaned from the device. Conclusion: A HeartWare HVAD provides good hemodynamic support and end-organ recovery in heart failure patients with and without onset of cardiogenic shock at time of device insertion. After hospital discharge both groups presented good outcomes of longterm circulatory support.

Treatment of Terminal Heart Failure and Cardiogenic Shock in 36 Children Less than 10 Kg Body Weight Assisted by Berlin Heart Excor Device

Background: Since the first implantation of a pulsatile paediatric ventricular assist device (VAD, Berlin Heart) in a child in 1990 at our institution outcome has significantly improved, with the implementation of optimized cannulas, modified anticoagulation and optimized surgical and intensive care management since 1999. We present our clinical experience with the Berlin Heart Excor device since 1999 in children with a body weight less than 10 kg. Methods: We performed a retrospective case analysis of all children less than 10 kg body weight who were treated with the Berlin Heart Excor since January 1st 1999 until February 5th 2012. Results: Thirty-six infants, age 0 - 27 months (median 6 mo), weight 3.2 - 9.9 kg (median 6.1 kg), were treated with VAD. Median time on support was 35 days (1 - 418 d). Twenty-nine children had left VAD and seven children biventricular VAD support systems. All children suffered from terminal heart failure with multiorgan failure or cardiogenic shock. Twenty-two had cardiomyopathy, five suffered from fulminant myocarditis and nine had a preceding operation on cardiopulmonary bypass. Procedural success was achieved in 72 % of children: 10 could be weaned from the system, another 15 patients received successful heart transplantation, 10 infants died and one is still on mechanical support. All patients with fulminant myocarditis were weaned from the assist system. At follow-up 1 year after explantation (n=24) the statomotoric development was normal or near normal in 21 of the 24 surviving children. In the seven children in whom thromboembolic events occurred two had mild to moderate hemiparesis, two severe statomotoric retardation and two recovered completely at follow-up examination. One child died 11 months after successful heart transplantation due to pneumonia. Conclusion: With a total survival rate of 72% the outcome of VAD support in small children is comparable to that in older children. The Berlin Heart Excor device is now a well-established treatment for small children suffering from cardiogenic shock of any aetiology.

Postoperative ICU care of patients suffering from cardiogenic shock at time of left ventricular device placement

Aims: Cardiogenic shock at time of left ventricular assist device (LVAD) placement for treatment of terminal heart failure is related to high incidence of biventricular failure and its sequellae. We studied the catecholamine therapy and ICU complication profile of this specific patient cohort.