Despite improvements in pharmacological therapy and pacing, prognosis in advanced heart failure (HF) remains poor, with a 1‐year mortality of 25–50%. While heart transplantation provides excellent ...survival and quality of life for eligible patients, only a few can be offered this treatment due to shortage of donor organs. Implantable left ventricular assist device (LVAD) technology has improved considerably, and the currently used continuous flow devices may last >10 years in a patient. LVADs are being used increasingly both as bridge‐to‐transplantation and as destination therapy. Current studies report 1‐ and 2‐year survival after LVAD implantation of 80% and 70%, respectively. Outcome after LVAD implantation in stable patients is superior to that of ‘crash and burn’ patients or patients sliding on inotropes, favouring early referral and implantation. This review summarizes factors to consider when deciding on LVAD implantation such as age, co‐morbidity, and cardiac pathophysiology. Complications to LVAD therapy are reviewed. It is concluded that while complications with LVAD therapy are not uncommon, most are manageable, and current outcomes clearly justify use of LVADs in advanced HF.
Molecular understanding of neutralizing antibody responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could accelerate vaccine design and drug discovery. We analyzed 294 ...anti-SARS-CoV-2 antibodies and found that immunoglobulin G heavy-chain variable region 3-53 (IGHV3-53) is the most frequently used IGHV gene for targeting the receptor-binding domain (RBD) of the spike protein. Co-crystal structures of two IGHV3-53-neutralizing antibodies with RBD, with or without Fab CR3022, at 2.33- to 3.20-angstrom resolution revealed that the germline-encoded residues dominate recognition of the angiotensin I converting enzyme 2 (ACE2)-binding site. This binding mode limits the IGHV3-53 antibodies to short complementarity-determining region H3 loops but accommodates light-chain diversity. These IGHV3-53 antibodies show minimal affinity maturation and high potency, which is promising for vaccine design. Knowledge of these structural motifs and binding mode should facilitate the design of antigens that elicit this type of neutralizing response.
In broad terms, "advanced" heart failure describes a clinical syndrome characterized by persistent or progressive symptoms and ventricular dysfunction despite guideline-directed medical therapy. ...Clinically the definition is often dependent upon iterative and integrated clinical assessments to identify patients with worsening status and reliance on specific therapies. This review examines current consensus definitions, highlights strategies for risk stratification and prognostication, and examines short- and long-term treatment strategies. Lastly, this paper explores future directions of research and development for the field.
In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We ...analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1 year before (pre: October 18, 2017‐October 17, 2018) and following (post: October 18, 2018‐October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre‐ to 3032 postimplementation. Seventy‐eight percent of transplants in the post era were for the most medically urgent (statuses 1‐3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4 hours (all P < .001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient‐years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.
This article compares timeframes before and after implementation of a revised heart allocation policy, showing increased travel distance, more transplants for the most medically urgent, and similar waitlist and posttransplant mortality rates.
The HeartMate II left ventricular assist device is widely used to support failing myocardium. In early 2011, one large center noticed an increasing frequency of thrombosis with this LVAD. It was ...confirmed at three other centers, but the cause has not been identified.
The HeartMate II (Thoratec), a small, axial-flow left ventricular assist device (LVAD), rapidly became integral to the treatment of patients with advanced heart failure.
1
Pivotal trials and postmarketing approval studies of the HeartMate II provide a reference occurrence of thrombosis of 2 to 4%
2
–
4
; however, an unexpected abrupt increase in the incidence of pump thrombosis was observed in a single-center quality review. To confirm that this finding was not an isolated phenomenon, two additional experienced centers pooled data to investigate the incidence of pump thrombosis and of elevated lactate dehydrogenase (LDH) levels as its clinical biomarker (indicating hemolysis), . . .
Changes in United States heart allocation: A community energized to improve policy Rogers, Joseph G.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
December 2016, 2016-12-00, 20161201, Letnik:
152, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Donor heart allocation in the United States has not evolved in concert with changes in the characteristics of patients on the waiting list or evolution in technology. Data showing the growing ...population of patients with advanced heart failure coupled with the relatively fixed number of cardiac donors and regional access disparities motivated the United Network for Organ Sharing (UNOS) Thoracic Committee to reexamine candidate prioritization and broader organ sharing. The resultant proposed policy change stratifies patients in a more granular manner based primarily on wait-list mortality and is designed to expand the geographic boundaries to permit greater access to donor hearts for the most critically ill patients awaiting transplant.
Objectives This study sought to assess the impact of continuous flow left ventricular assist devices (LVADs) on functional capacity and heart failure-related quality of life. Background Newer ...continuous-flow LVAD are smaller and quieter than pulsatile-flow LVADs. Methods Data from advanced heart failure patients enrolled in the HeartMate II LVAD (Thoratec Corporation, Pleasanton, California) bridge to transplantation (BTT) (n = 281) and destination therapy (DT) (n = 374) trials were analyzed. Functional status (New York Heart Association NYHA functional class, 6-min walk distance, patient activity scores), and quality of life (Minnesota Living With Heart Failure MLWHF and Kansas City Cardiomyopathy Questionnaires KCCQ) were collected before and after LVAD implantation. Results Compared with baseline, LVAD patients demonstrated early and sustained improvements in functional status and quality of life. Most patients had NYHA functional class IV symptoms at baseline. Following implant, 82% (BTT) and 80% (DT) of patients at 6 months and 79% (DT) at 24 months improved to NYHA functional class I or II. Mean 6-min walk distance in DT patients was 204 m in patients able to ambulate at baseline, which improved to 350 and 360 m at 6 and 24 months. There were also significant and sustained improvements from baseline in both BTT and DT patients in median MLWHF scores (by 40 and 42 U in DT patients, or 52% and 55%, at 6 and 24 months, respectively), and KCCQ overall summary scores (by 39 and 41 U, or 170% and 178%). Conclusions Use of a continuous flow LVAD in advanced heart failure patients results in clinically relevant improvements in functional capacity and heart failure-related quality of life.
Highlights • We performed an analysis using ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) data of patients with invasive hemodynamic data. • ...We examined outcomes of patients with heart failure and with persistent hemodynamic abnormalities. • Final pulmonary capillary wedge pressure was associated with adverse outcomes, but final cardiac index was not.
Felker and Rogers express insights about mechanical cardiac support. The development of durable mechanical circulatory support devices as long-term therapy has been a major advance in the treatment ...of patients with late-stage heart failure. Sequential improvements in device engineering led to more effective pump designs, resulting in progressive improvements in device durability, reduced adverse events, and better long-term patient outcomes. The Antiplatelet Removal and Hemocompatibility Events With the HeartMate 3 Pump (ARIES-HM3) study was designed and conducted to test the safety of aspirin therapy (100 mg daily) in patients with the LVAD treated with vitamin k antagonists to a target international normalized ratio goal of 2.0 to 3.0. The primary findings demonstrated that avoiding aspirin therapy was noninferior to low-dose aspirin with regard to the primary composite end point of survival free of nonsurgical hemocompatibility adverse events, which included stroke, pump thrombosis, major nonsurgical bleeding, and arterial peripheral thromboembolism.
PDF
