Objective Cardiogenic shock is associated with poor clinical outcomes. Extracorporeal life support is used in most centers for short-term circulatory support. Alternatively, the Impella LP 5.0 and ...right direct (RD) microaxial ventricular assist device (Abiomed, Danvers, Mass) can provide isolated left and right ventricular support, respectively. Methods A retrospective, single center review was performed on all patients receiving circulatory assistance with either extracorporeal life support or Impella ventricular assist device. All Impella LP 5.0 were inserted via the femoral artery, while the RD system required sternotomy. Results Twenty-nine patients received ventricular assist device support (Impella LP 5.0; n = 24; and Impella RD; n = 5), whereas 32 patients were placed on extracorporeal life support. The baseline characteristics of patients with cardiogenic shock, assisted by Impella or extracorporeal life support, were similar, but the etiology of cardiogenic shock was distributed differently in the 2 groups ( P = .008). Forty-one percent of the Impella patients and 47% of the extracorporeal life support patients were weaned from support. The 30-day mortality (44% in the extracorporeal life support vs 38% in the Impella group) and proportion of patients discharged home (41% in the extracorporeal life support vs 59% in the Impella group) were not statistically different between the 2 groups. Arterial thrombosis was less frequent in the Impella group (3.4% vs 18.8%; P = .04). Blood product transfusions were less frequent in the Impella group ( P < .001). Conclusions Both extracorporeal life support and axial flow pumps provided adequate support in patients with various etiologies of cardiogenic shock. Axial-flow pump may be an optimal type of support for patients with univentricular failure, whereas extracorporeal life support could be reserved for patients with biventricular failure or combined respiratory and circulatory failure.
Implantation of left ventricular assist devices through small incisions, avoiding cardiopulmonary bypass, may decrease the activation of the inflammatory and coagulation cascades and decrease ...bleeding and vasoplegia. One patient with severe, inotrope-dependant cardiomyopathy received the HeartWare left ventricular assist device (HeartWare Inc, Framingham, MA) through an upper ministernotomy and left minithoracotomy. The outflow graft was connected to the ascending aorta, and the inflow of the left ventricular assist device was attached through to the apex of the heart. The apical puncture was performed under rapid ventricular pacing, followed by insertion of the inflow of the pump. The patient was extubated rapidly and discharged home 14 days later.
Background
Improving patient‐reported outcomes (e.g. health status) has become an important goal in left ventricular assist device (LVAD) therapy, in addition to reducing mortality and morbidity. We ...examined predictors of changes in health status scores between and within patients 12 months post LVAD implantation.
Methods
Health status Kansas City Cardiomyopathy Questionnaire (KCCQ); Short‐Form 12 (SF‐12) were assessed at 3–4 weeks after implantation, and at 3, 6 and 12 months follow up in 54 LVAD patients (74% men; mean age 54 ± 9 years).
Results
Patients experienced significant improvements in health status between baseline and 3 months follow‐up as assessed by the KCCQ (clinical summary score: F = 33.49, P < 0.001; overall summary score: F = 31.13, P < 0.001) and the SF‐12 (physical component score: F = 31.59, P < 0.001; mental component score: F = 21.77, P < 0.001), but not between 3 months and 12 months follow‐up (P > 0.05 for all). Higher scores on anxiety and depression over time, older age, lower ejection fraction, and more co‐morbidity were associated with poorer health status scores on one or both of the KCCQ and SF‐12 subscales. The majority of the between‐patient variance of the mental component summary scores (82.6%), but not the KCCQ overall summary score (41.9%), KCCQ clinical summary score (36.2%) and physical component summary scores (23.2%), was explained by the sociodemographic, clinical and psychological factors.
Conclusion
The majority of LVAD patients show a significant improvement in health status after LVAD implantation. However, there are large differences in individual health status score trajectories which are only partly explained by measures of disease severity pre‐LVAD, co‐morbidity and psychological stress.
Abstract Background Ventricular assist devices (VADs) are used in cases of heart failure refractory to medical therapy. Most VADs are used as a bridge to heart transplantation; however, in certain ...cases, myocardial function recovers and VADs can be explanted after the patient is weaned. The objectives of this study were to describe patients who required Heartmate II VAD insertion, followed by myocardial recovery and explanation in a quaternary heart centre. Methods Patients who had a VAD explanted were identified in the mechanical support institutional database and their outcomes were analyzed. Clinical examinations, biochemical markers, and serial echocardiograms were used to demonstrate myocardial recovery. Results Seventeen patients had a Heartmate II VAD inserted between 2008 and 2010. Four patients underwent successful weaning and subsequent VAD explantation. Etiology of decompensated heart failure was idiopathic dilated cardiomyopathy ( n = 1), ischemic ( n = 1), or myocarditis ( n = 2). Mean age was 35.3 years. Patients were supported for 213 days (range 70-293 days) and were in New York Heart Association class I in the community before explantation. The devices were explanted via a minimally invasive approach, without cardiopulmonary bypass. All patients survived explantation and were discharged alive from hospital after an average of 5.7 ± 1.5 days post pump explantation. No adverse events were reported after explantation. Only one patient required allogenic blood transfusion after the procedure. Conclusions Patients requiring VAD support for myocardial failure can undergo significant reverse remodelling. Explantation can lead to optimal outcome with minimal morbidity. Methods for assessment of reverse remodelling, weaning protocol, and optimal timing of explantation remain under evaluation.
The left ventricular assist device (LVAD) has been used successfully for bridge to transplant and destination therapy. In some cases, myocardial recovery is possible and allows LVAD explantation. We ...describe a novel explant technique for the HeartMate II LVAD using small incisions on a beating heart, without cardiopulmonary bypass.
Next-generation left ventricular assist devices such as the HeartMate II (Thoratec Corporation, Pleasanton, CA) have significantly improved patient outcomes. In particular, the incidence of ...thromboembolic events appears to be significantly reduced. Pump thrombosis has occurred, however, and is well reported in the literature. The thromboses reported with next-generation devices have generally been partial thromboses associated with significant abnormalities in the system performance data as displayed on the system monitor. We describe a case of complete thrombosis of a HeartMate II axial-flow pump resulting in cardiac arrest but in the absence of alarms or significant aberrations in the performance data.
Left ventricular assist devices (LVADs) provide short- or long-term circulatory support to improve survival and reduce morbidity in selected patients with advanced heart failure. LVADs are being used ...increasingly and now have expanded indications. Health care providers across specialties will therefore not only encounter LVAD patients but play an integral role in their care. To accomplish that, they need to understand the elements of LVAD function, physiology and clinical use. This article provides a concise overview of the medical management of LVAD patients for nonexpert clinicians. Our presentation includes the basics of LVAD physiology, design, and operation, patient selection and assessment, medical management, adverse event identification and management, multidisciplinary care, and management of special circumstances, such as noncardiac surgery, cardiac arrest, and end-of-life care. The clinical examination of LVAD patients is unique in terms of blood pressure and heart rate assessment, LVAD “hum” auscultation, driveline and insertion site inspection, and device parameter recording. Important potential device-related adverse events include stroke, gastrointestinal bleeding, hematologic disorders, device infection, LVAD dysfunction, arrhythmias, and heart failure. Special considerations include the approach to the unconscious or pulseless patient, noncardiac surgery, and palliative care. An understanding of the principles presented in this paper will enable the nonexpert clinician to be effective in collaborating with an LVAD center in the assessment, medical management, and follow-up of LVAD patients. Future opportunities and challenges include the improvement of device designs, greater application of minimally invasive surgical implantation techniques, and management of health economics in cost-constrained systems like those of Canada and many other jurisdictions.
Les dispositifs d’assistance ventriculaire gauche (DAVG) permettent d’offrir à certains patients atteints d’une insuffisance cardiaque avancée une assistance circulatoire à court ou à long terme afin d’améliorer la survie et de réduire la morbidité. Les DAVG sont de plus en plus souvent utilisés et sont maintenant indiqués dans un plus grand nombre de cas. Les dispensateurs de soins de santé de différentes spécialités seront donc appelés non seulement à traiter des patients porteurs d’un DAVG, mais aussi à jouer un rôle de premier plan dans les soins qui leur sont prodigués. Pour bien jouer ce rôle, ils doivent comprendre les différents aspects de la fonction, de la physiologie et de l’utilisation clinique des DAVG. Nous présentons donc un aperçu de la prise en charge médicale des patients porteurs d’un DAVG à l’intention des cliniciens non experts. Nous abordons notamment les notions fondamentales de la physiologie, de la conception et du fonctionnement des DAVG, de la sélection et de l’évaluation des patients, de la prise en charge médicale, de la détection et de la prise en charge des événements indésirables, des soins multidisciplinaires et de la prise en charge des cas particuliers, par exemple lorsqu’un patient doit subir une intervention chirurgicale non cardiaque, subit un arrêt cardiaque ou reçoit des soins de fin de vie. L’examen clinique des patients porteurs d’un DAVG présente des particularités à différents égards : mesure de la pression artérielle et de la fréquence cardiaque, auscultation du bruit du DAVG, inspection du câble percutané et du point d’insertion, et consignation des paramètres du dispositif. Les événements indésirables graves pouvant survenir chez un patient porteur d’un DAVG sont l’accident vasculaire cérébral, l’hémorragie gastro-intestinale, les troubles hématologiques, l’infection du dispositif, le mauvais fonctionnement du DAVG, les arythmies et l’insuffisance cardiaque. Parmi les considérations particulières, citons l’approche à adopter en présence d’un patient inconscient ou sans pouls, les interventions chirurgicales non cardiaques et les soins palliatifs. Le clinicien non expert qui comprend bien les principes présentés dans le présent article pourra collaborer efficacement avec un centre spécialisé dans les DAVG pour l’évaluation, la prise en charge médicale et le suivi des patients porteurs d’un DAVG. Les possibilités à exploiter et les défis à relever comprennent l’amélioration de la conception des dispositifs, l’adoption élargie de techniques chirurgicales d’implantation minimalement invasives et la gestion des paramètres de l’économie de la santé dans des systèmes où les budgets sont limités, comme c’est le cas au Canada et dans de nombreux autres pays.
Acute rejection in cardiac transplant patients remains a contributory factor to limited survival of implanted hearts. Currently, there are no biomarkers in clinical use that can predict, at the time ...of transplantation, the likelihood of post-transplant acute cellular rejection. Such a development would be of great value in personalizing immunosuppressive treatment.
Recipient age, donor age, cold ischemic time, warm ischemic time, panel-reactive antibody, gender mismatch, blood type mismatch and human leukocyte antigens (HLA-A, -B and -DR) mismatch between recipients and donors were tested in 53 heart transplant patients for their power to predict post-transplant acute cellular rejection. Donor transplant biopsy and recipient pre-transplant blood were also examined for the presence of genomic biomarkers in 7 rejection and 11 non-rejection patients, using non-targeted data mining techniques.
The biomarker based on the 8 clinical variables had an area under the receiver operating characteristic curve (AUC) of 0.53. The pre-transplant recipient blood gene-based panel did not yield better performance, but the donor heart tissue gene-based panel had an AUC = 0.78. A combination of 25 probe sets from the transplant donor biopsy and 18 probe sets from the pre-transplant recipient whole blood had an AUC = 0.90. Biologic pathways implicated include VEGF- and EGFR-signaling, and MAPK.
Based on this study, the best predictive biomarker panel contains genes from recipient whole blood and donor myocardial tissue. This panel provides clinically relevant prediction power and, if validated, may personalize immunosuppressive treatment and rejection monitoring.
Abstract Background Impella microaxial devices provide circulatory assistance for patients with acute decompensated heart failure. This study reviews the population-based provincial experience in ...British Columbia. Methods We performed a retrospective review of the prospectively maintained database. Impella devices were inserted for acute cardiogenic shock refractory to maximal therapy, as a bridge to decision or to long-term mechanical support. Results Between August 2007 and September 2009, 35 patients received 37 Impella devices (Impella LP 2,5, n = 2; Impella LP 5,0, n = 29; and Impella RD 5.0, n = 6) (Abiomed Inc, Danvers, MA). Devices were inserted in the setting of dilated cardiomyopathy (n = 13), acute myocardial infarction (n = 6), postcardiotomy shock (n = 6), and other etiologies (n = 12). Mean age was 53.0 ± 13.7 years. Mean left ventricular ejection fraction was 19 ± 9% at the time of insertion. Nineteen patients required aggressive resuscitation, all patients were on inotropic support, 97% of patients were intubated, and 46% of patients received mechanical circulatory support prior to insertion of the Impella devices. Mean duration of support was 3.7 ± 3.0 days. In all, 49% were successfully weaned, and 22% were transferred to long-term mechanical support. Four patients have subsequently undergone successful cardiac transplantation. The 30-day mortality was 40%, and 6-month mortality was 49%. Complications included gastrointestinal bleeding (n = 1), hemoptysis (n = 1), and thrombocytopenia (n = 4). There were no cardiovascular or cerebrovascular events. Conclusion Temporary support with Impella microaxial ventricular assist devices adds a valuable therapeutic option in selected patients with acute decompensated heart failure.
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