Continuous-flow left ventricular assist devices (cf-LVAD) play an important role in the management of patients with advanced heart failure. De novo aortic regurgitation after cf-LVAD implantation may ...adversely impact device performance. We performed a systematic search of PubMed, SCOPUS, and Cochrane Library for articles reporting on the incidence and predictors of de novo aortic regurgitation among cf-LVAD recipients. Eight studies totaling 548 patients were identified in the meta-analysis. The pooled incidence of de novo AR across the analyzed studies was 37%. Factors influencing its development and progression are older age, persistent aortic valve closure, being female, and duration of cf-LVAD support.
The hemodynamic vascular consequences of implanting left ventricular assist devices (LVADs) have not been studied in detail. We investigated the effect of LVAD implantation compared with heart ...transplant (HTx) on microvascular and macrovascular function in patients with end-stage heart failure and evaluated whether microparticles may play a role in LVAD-related endothelial dysfunction.
Vascular function was assessed in patients with end-stage heart failure awaiting HTx, patients who had undergone implantation of a continuous-flow centrifugal LVAD, and patients who had already received a HTx. Macrovascular function was measured by flow-mediated vasodilation (FMD) using high-resolution ultrasound of the brachial artery. Microvascular function was assessed in the forearm during reactive hyperemia using laser Doppler perfusion imaging and pulsed wave Doppler. Age-matched patients without heart failure and without coronary artery disease (CAD) (healthy control subjects) and patients with stable CAD served as control subjects. Circulating red blood cell (CD253(+)), leukocyte (CD45(+)), platelet (CD31(+)/CD41(+)), and endothelial cell (CD31(+)/CD41(-), CD62e(+), CD144(+)) microparticles were determined by flow cytometry and free hemoglobin by enzyme-linked immunosorbent assay.
FMD and microvascular function were significantly impaired in patients with end-stage heart failure compared with healthy control subjects and patients with stable CAD. LVAD implantation led to recovery of microvascular function, but not FMD. In parallel, increased free hemoglobin was observed along with red and white cell microparticles and endothelial and platelet microparticles. This finding indicates destruction of blood cells with release of hemoglobin and activation of endothelial cells. HTx and LVAD implantation led to similar improvements in microvascular function. FMD increased and microparticle levels decreased in patients with HTx, whereas shear stress during reactive hyperemia was similar in patients with LVADs and patients with HTx.
Our data suggest that LVAD support leads to significant improvements in microvascular perfusion and hemodynamics. However, destruction of blood cells may contribute to residual endothelial dysfunction potentially by increasing nitric oxide scavenging capacity.
Objectives
The objective of this study was to assess the prognostic value of the Model for End‐stage Liver Disease (MELD)‐XI score in patients undergoing PMVR with the MitraClip system.
Background
...MELD‐XI score, which was originally developed for prognostic assessment in patients with advanced liver disease, has been reported as a predictor of outcome in heart failure patients.
Methods
A total of 192 consecutive patients undergoing percutaneous mitral valve repair (PMVR) were included into final analysis. MELD‐XI score was calculated on the day of the procedure and patients were categorized into three groups based on MELD‐XI score and compared with regards to clinical characteristics and outcomes following PMVR.
Results
MELD‐XI > 12 was associated with male gender, higher logistic EuroSCORE, reduced left ventricular ejection fraction, enlarged right ventricular end‐diastolic diameter, degree of mitral regurgitation, increased NT‐proBNP serum levels and elevated right atrial pressures. Youden‐Index revealed a cutoff of 16 in the MELD‐XI score as best predictor of one‐year all‐cause mortality. Kaplan–Meier analysis and the log‐rank test confirmed increased one‐year mortality in patients with critically high score above 16 (mortality MELD‐XI score > 16 vs 16–12 vs <12:39% vs 9%. vs 15%; P = 0.005). Compared to patients with lower MELD‐XI score, these patients exhibited a more than 3‐fold increased one‐year mortality after PMVR.
Conclusion
Given the high mortality in patients with a MELD‐XI score > 16, these patients require a high‐risk preoperative assessment and should undergo a careful discussion within the heart team for the best treatment option given the considerable one‐year mortality following PMVR.
Mobile extracorporeal life support (ECLS) may soon be on the verge to become a fundamental part of emergency medicine. Here, we report on our four-year experience of providing advanced mechanical ...circulatory support for out-of-center patients within the Düsseldorf ECLS Network (DELSN).
This retrospective cohort study analyses the outcome of 160 patients with refractory circulatory failure consecutively treated with mobile veno-arterial extracorporeal membrane oxygenation (vaECMO) between July 2011 and October 2015 within the DELSN.
Out of the 160 patients (56±16years, vaECMO initiation under CPR 68%), 59 patients (36%) survived to primary discharge, with 50 patients (31%) still alive after a median follow-up of 1.74 years. Time-discrete mortality was highest during the first 24h. There was no difference between survivors and non-survivors regarding age, etiology of circulatory failure, presence of CPR during implantation or distance to implantation site. Incidence of kidney injury requiring dialysis (61% vs. 24%, p<0.0001), shock liver (27% vs. 12%, p=0.031) and visceral ischemia (19% vs. 3%, p=0.013) were the only complications increased in non-survivors. Subgroup analysis showed no significant outcome difference for ECPR vs. non-ECPR patients. Outcome was significantly impaired with initial neuron-specific enolase ≥45.4μg/L (AUC 0.75, p<0.0001) and lactate ≥5.5mmol/L (AUC 0.70, p<0.0001). Program-year-dependent in-center mortality showed an increasing trend, while program-year-dependent follow-up mortality decreased over time.
This study illustrates that regional mobile ECLS rescue therapy can be provided with encouraging outcomes, although patient selection criteria and early outcome parameters reflecting on therapy success or futility still need to be refined.
Objectives
This study sought to validate the performance of the VT‐LVAD risk model in predicting late ventricular arrhythmias (VAs) in patients after left ventricular assist device (LVAD) ...implantation.
Background
The need for implantable cardioverter‐defibrillator (ICD)‐implantation in LVAD recipients is not well studied. A better selection of the patients with high risk for late VAs could lead to a more targeted ICD‐implantation or replacement.
Methods
The study evaluated the performance of the VT‐LVAD prognostic score (VAs prior LVAD, no ACE‐inhibitor in medication, heart failure duration > 12 months, early VAs post‐LVAD implantation, atrial fibrillation prior LVAD, idiopathic dilated cardiomyopathy) for the endpoint of the occurrence of late VAs in 357 LVAD patients in Heart Centre of Leipzig.
Results
From the initial 460 patients, 357 (age: 58 ± 10 years; left ventricular ejection fraction: 20 ± 6%; HeartWare: 50%; HeartMate III: 42%) were assigned to four risk groups according to their VT‐LVAD score varying from low risk to very high risk. After 25 months, late VAs occurred in 130 patients. The VT‐LVAD score was an independent predictor of late VAs (multivariate analysis; p = < .001; goodness‐of‐tip p = .347; odds ratio: 4.8). While there was no statistically significant difference between the low‐ and intermediate‐risk group, risk stratification for patients with high risk and very high risk performed more accurately (pairwise comparison p = .005 and p < .001, respectively).
Conclusions
The VT‐LVAD score predicted accurately the occurrence of late VAs in high‐risk LVAD recipients in a large external cohort of LVAD recipients supporting its utility for more targeted ICD implantations.
The optimal surgical approach in patients with pectus excavatum (PEx) who need cardiac surgery remains uncertain. The challenge is even greater, if it is already foreseeable that the patient will be ...needed further procedure in the next future. We describe a novel sternotomy-sparing approach for minimal-invasive biventricular assist device (BiVAD) implantation in a patient with an acute heart failure (HF) due to dilated cardiomyopathy and severe PEx. Moreover, alternative approaches for ventricular assist device (VAD) implantation and timing of the repair of PEx will be discussed.
Abstract Objectives Temporary right ventricular assist devices (RVADs) may be required to support patients with perioperative refractory right ventricular failure (RVF). We report on our experience ...using a different technique of RVAD implantation that does not necessitate resternotomy at the time of RVAD removal. Methods Patients with perioperative RVF who underwent temporary RVAD implantation between January 2010 and February 2014 were reviewed. A dacron graft was attached to the pulmonary artery and passed through a subxiphoid exit, where the RVAD outflow cannula was inserted. The inflow cannula was percutaneously cannulated in the femoral vein, and the sternum was primarily closed. On the day of RVAD explantation, the outflow graft of the RVAD was pulled and ligated, and the insertion site was secondarily closed. The RVAD inflow cannula was removed, and direct pressure was applied. Results Twenty-one patients (age 58 ± 14 years) were supported. Seventeen patients (81%) had RVF after left ventricular assist device implantation, and 4 patients developed postcardiotomy RVF. The median duration of RVAD support was 9 days (range: 2-88 days). Eleven patients (52%) were successfully weaned from the RVAD. Two patients were bridged to transplantation. Eight patients died on left ventricular assist device and/or RVAD support. The survival rates to discharge or heart transplantation, and to 1-year, were 62% and 52%, respectively. Conclusions No technical issues were encountered in this large series of RVAD implantations using the described technique for various forms of postoperative RVF. Extended support duration and reduction of resternotomy risks may be the main advantages of this technique compared with conventional RVAD implantation methods.
The lifetime risk of developing heart failure is approximately 20%, and survival rates remain poor. Myocardial mitochondrial function has been suggested to play a pivotal role in heart failure ...pathophysiology. Human studies on ex vivo mitochondrial function have mostly been limited to atrial tissue obtained during open heart surgery and have provided contradictory results. This study aimed at measuring myocardial mitochondrial function in transcatheter ventricular endomyocardial biopsies and assessing the relationship between oxidative capacity and heart function. We enrolled 40 heart failure patients undergoing ventricular assist device surgery or heart transplantation (34 males, age 57 ± 11 years, body mass index 26.6 ± 4.8 kg/m
) and 29 heart transplant recipients of comparable age and body mass index with normal left ventricular function undergoing surveillance biopsies (23 males, 57 ± 12 years, body mass index 26.2 ± 4.1 kg/m
). High-resolution respirometry was established in the myocardium to measure oxidative capacity ex vivo. The mitochondrial oxidative capacity was 90% higher in ventricular compared to atrial tissues (n = 11, p < 0.01) of explanted hearts. Respiration rates were comparable in ventricular samples of heart failure patients obtained during open heart surgery by standard tissue preparation or ex vivo endomyocardial biopsy (r = 0.9988, p < 0.0001, n = 8), and the mitochondrial oxidative capacity in samples from these patients remained stable for 8 h when stored in either of two common preservation buffers. The oxidative capacity was 44% lower in heart failure than in transplant recipients (67 ± 3 vs. 97 ± 5 pmol/s mg, p < 0.0001) and correlated positively with heart function (r = 0.49, p < 0.01). High-resolution respirometry of ventricular tissue is feasible in transcatheter biopsies, facilitating clinical studies on myocardial mitochondrial function in patients not undergoing heart surgery.
Non-surgical bleeding (NSB) remains the most critical complication in patients under left ventricular assist device (LVAD) support. It is well known that blood exposed to high shear stress results in ...platelet dysfunction. Compared to patients without NSB, decreased surface expression of platelet receptor GPIbα was observed in LVAD patients with NSB. In this study, we aimed to compare the expression level of glycoprotein (GP)Ib-IX-V platelet receptor complex in HeartMate 3 (HM 3) patients with and without bleeding complications to investigate the alterations of the platelet transcriptomic profile on platelet damage and increased bleeding risk. Blood samples were obtained from HM 3 patients with NSB (bleeder group,
= 27) and without NSB (non-bleeder group,
= 55). The bleeder group was further divided into patients with early NSB (bleeder ≤ 3 mo,
= 19) and patients with late NSB (bleeder > 3 mo,
= 8). The mRNA and protein expression of GPIbα, GPIX and GPV were quantified for each patient. Non-bleeder, bleeder ≤ 3 mo and bleeder > 3 mo were comparable regarding the mRNA expression of GPIbα, GPIX and GPV (
> 0.05). The protein analysis revealed a significantly reduced expression level of the main receptor subunit GPIbα in bleeders ≤ 3 mo (
= 0.04). We suggest that the observed reduction of platelet receptor GPIbα protein expression in patients who experienced their first bleeding event within 3 months after LVAD implantation may influence platelet physiology. The alterations of functional GPIbα potentially reduce the platelet adhesion capacities, which may lead to an impaired hemostatic process and the elevated propensity of bleeding in HM 3 patients.
PDF
