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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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2
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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Garcia-Gonzalez MA, Vallejo-Ruiz V, Atonal-Flores F, Flores-Hernandez J, Torres-Ramírez O, Diaz-Fonsecae A, Perez Vizcaino F, Lopez-Lopez JG. Sildenafil prevents right ventricular hypertrophy and improves heart rate variability in rats with pulmonary hypertension secondary to experimental diabetes. Clin Exp Hypertens 2022; 44:355-365. [DOI: 10.1080/10641963.2022.2050743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Miguel Angel Garcia-Gonzalez
- Departamento de Farmacia, Benemerita Universidad Autonoma de Puebla, Laboratorio de Farmacia Clinica, Edificio FCQ10, Ciudad Universitaria, Col. Jardines de San Manuel, Puebla, Mexico
| | - Veronica Vallejo-Ruiz
- Instituto Mexicano del Seguro Social, Centro de Investigación Biomédica de Oriente, Laboratorio de Biología Molecular, Puebla, Mexico
| | - Fausto Atonal-Flores
- Departamento de Fisiología, Benemérita Universidad Autónoma de Puebla, Facultad de Medicina, Metepec, Mexico
| | - Jorge Flores-Hernandez
- Laboratorio de Neuromodulación, Benemerita Universidad Autonoma de Puebla, Fisiología, Puebla,Mexico
| | - Oswaldo Torres-Ramírez
- Departamento de Farmacia, Benemérita Universidad Autónoma de Puebla, Facultad de Ciencias Químicas, Puebla, Mexico
| | - Alfonso Diaz-Fonsecae
- Departamento de Farmacia, Benemérita Universidad Autónoma de Puebla, Facultad de Ciencias Químicas, Puebla, Mexico
| | - Francisco Perez Vizcaino
- Departamento de Farmacología y Toxicología, Universidad Complutense de Madrid, Escuela de Medicina, Puebla,Mexico
| | - Jose Gustavo Lopez-Lopez
- Departamento de Farmacia, Benemerita Universidad Autonoma de Puebla, Laboratorio de Farmacia Clinica, Edificio FCQ10, Ciudad Universitaria, Col. Jardines de San Manuel, Puebla, Mexico
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Jakstaite AM, Luedike P, Schmack B, Pizanis N, Riebisch M, Weymann A, Kamler M, Ruhparwar A, Rassaf T, Papathanasiou M. Increased bleeding risk with phosphodiesterase-5 inhibitors after left ventricular assist device implantation. ESC Heart Fail 2021; 8:2419-2427. [PMID: 33821578 PMCID: PMC8318463 DOI: 10.1002/ehf2.13322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/26/2022] Open
Abstract
Aims Therapy with phosphodiesterase‐5 inhibitors (PDE5Is) after left ventricular assist device (LVAD) implantation has been associated with lower mortality and device thrombosis but increased risk for post‐operative and gastrointestinal bleeding. We aimed to evaluate the impact of long‐term PDE5Is on the overall bleeding risk after LVAD implantation. Methods and results We retrospectively included patients who received a continuous‐flow LVAD at our site and were prescribed with long‐term oral PDE5Is after discharge from the index hospitalization. The primary endpoint was the occurrence of bleeding at 12 month follow‐up. Secondary endpoints were all‐cause death and the combination of bleeding and all‐cause death. Our analysis included 109 patients of whom 75 (69%) received long‐term PDE5Is. Mean age was 56 years, and 85% were male. At 12 months, 19 (17%) patients experienced at least one bleeding event. Patients on PDE5Is had higher bleeding rates (23% vs. 6%, P = 0.03) and more bleeding events per patient‐year (0.32 vs. 0.06, P = 0.03) compared with patients not on PDE5Is. While overall bleeding incidence was excessively higher in the PDE5I group, there were no significant differences in the incidence of major bleeding (19% vs. 6%, P = 0.08) and gastrointestinal bleeding (11% vs. 3%, P = 0.18). Kaplan–Meier analysis revealed higher cumulative incidence of bleeding for the PDE5I group (log rank = 0.04) with no difference on all‐cause death (log rank = 0.67) and the combination of bleeding and all‐cause death (log rank = 0.13). Hospitalizations for bleeding and their duration were numerically higher in the PDE5I group (0.28 vs. 0.03, P = 0.07 and 2.4 vs. 0.2, P = 0.07, respectively). Conclusions Phosphodiesterase‐5 inhibitor treatment after LVAD implantation is associated with increased bleeding risk after LVAD implantation. The safety of long‐term PDE5Is in LVAD patients remains unclear and needs to be further clarified in prospective studies with randomized study design.
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Affiliation(s)
- Aiste-Monika Jakstaite
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Matthias Riebisch
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
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Right Ventricular Failure Post-Implantation of Left Ventricular Assist Device: Prevalence, Pathophysiology, and Predictors. ASAIO J 2021; 66:610-619. [PMID: 31651460 DOI: 10.1097/mat.0000000000001088] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Despite advances in left ventricular assist device (LVAD) technology, right ventricular failure (RVF) continues to be a complication after implantation. Most patients undergoing LVAD implantation have underlying right ventricular (RV) dysfunction (either as a result of prolonged LV failure or systemic disorders) that becomes decompensated post-implantation. Additional insults include intra-operative factors or a sudden increase in preload in the setting of increased cardiac output. The current literature estimates post-LVAD RVF from 3.9% to 53% using a diverse set of definitions. A few of the risk factors that have been identified include markers of cardiogenic shock (e.g., dependence on inotropes and Interagency Registry for Mechanically Assisted Circulatory Support profiles) as well as evidence of cardiorenal or cardiohepatic syndromes. Several studies have devised multivariable risk scores; however, their performance has been limited. A new functional assessment of RVF and a novel hepatic marker that describe cholestatic properties of congestive hepatopathy may provide additional predictive value. Furthermore, future studies can help better understand the relationship between pulmonary hypertension and post-LVAD RVF. To achieve our ultimate goal-to prevent and effectively manage RVF post-LVAD-we must start with a better understanding of the risk factors and pathophysiology. Future research on the different etiologies of RVF-ranging from acute post-surgical complication to late-onset RV cardiomyopathy-will help standardize definitions and tailor therapies appropriately.
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Monzo L, Reichenbach A, Al-Hiti H, Borlaug BA, Havlenova T, Solar N, Tupy M, Ters J, Kautzner J, Melenovsky V. Acute Unloading Effects of Sildenafil Enhance Right Ventricular-Pulmonary Artery Coupling in Heart Failure. J Card Fail 2020; 27:224-232. [PMID: 33232820 DOI: 10.1016/j.cardfail.2020.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/02/2020] [Accepted: 11/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Phosphodiesterase-5A inhibitors (PDE5i) are sometimes used in patients with advanced heart failure with reduced ejection fraction before heart transplant or left ventricular assist device implantation to decrease right ventricular (RV) afterload and mitigate the risk of right heart failure. Conflicting evidence exists regarding the impact of these drugs on RV contractility. The aim of this study was to explore the acute effects of PDE5i on ventricular-vascular coupling and load-independent RV contractility. METHODS Twenty-two patients underwent right heart catheterization and gated equilibrium blood pool single photon emission computed tomography, before and after 20 mg intravenous sildenafil. Single photon emission computed tomography and right heart catheterization-derived data were used to calculate RV loading and contractility. RESULTS PDE5i induced a decrease in the right atrial pressure (-43%), pulmonary artery (PA) mean pressure (-26%), and PA wedge pressure (PAWP; -23%), with favorable reductions in pulmonary vascular resistance (-41%) and PA elastance (-40%), and increased cardiac output (+13%) (all P < 0.01). The RV ejection fraction increased with sildenafil (+20%), with no change of RV contractility (P = 0.74), indicating that the improvement in the RV ejection fraction was related to enhanced RV-PA coupling (r = 0.59, P = 0.004) by a decrease in the ventricular load. RV diastolic compliance increased with sildenafil. The decrease in the PAWP correlated with RV end-diastolic volume decrease; no relationship was observed with the change in LV transmural pressure, suggesting decreased pericardial constraint. CONCLUSIONS Acute PDE5i administration has profound RV afterload-reducing effects, improves the RVEF, decreases RV volumes, and decreases the PAWP, predominantly through relief of pericardial constraint, without effects on RV chamber contractility. These findings support further study of PDE5i in protection of RV function in advanced heart failure with reduced ejection fraction who are at risk of RV failure.
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Affiliation(s)
- Luca Monzo
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic; Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Adrian Reichenbach
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Hikmet Al-Hiti
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Tereza Havlenova
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Nevenka Solar
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Marek Tupy
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Jiri Ters
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.
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7
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Papathanasiou M, Ruhparwar A, Kamler M, Rassaf T, Luedike P. Off-label use of pulmonary vasodilators after left ventricular assist device implantation: Calling in the evidence. Pharmacol Ther 2020; 214:107619. [PMID: 32599009 DOI: 10.1016/j.pharmthera.2020.107619] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/18/2020] [Indexed: 11/26/2022]
Abstract
Left ventricular assist devices (LVAD) are increasingly implanted in advanced heart failure patients to improve survival and quality of life either as a bridge to transplant, bridge to recovery or as destination therapy. LVAD therapy is often accompanied by a profound lowering of pulmonary artery pressure due to mechanical unloading of the left ventricle. Persistent pulmonary hypertension (PH) after LVAD implantation increases the risk of right ventricular failure (RVF). In this context pulmonary vasodilators have been implemented: a) as a strategy to reduce afterload and wean patients with RVF from inotropes in the early postoperative period, b) as long-term therapy aiming to optimize right heart hemodynamics and prevent late RVF and c) in order to lower persistently elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) after LVAD and enable candidacy for heart transplantation. However, considerable uncertainty exists regarding the risks and benefits of these strategies and practices vary widely among institutions. This article provides an overview of the available evidence and existing recommendations regarding the use of pulmonary vasodilators in LVAD recipients.
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Affiliation(s)
- Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Markus Kamler
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Hamdan R, Charif F, Kadri Z. Right ventricle failure in patients treated with left ventricular assist device. Ann Cardiol Angeiol (Paris) 2020; 69:51-54. [PMID: 32127195 DOI: 10.1016/j.ancard.2020.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 01/16/2020] [Indexed: 11/28/2022]
Abstract
This review article aim to highlight the right ventricular function peri left ventricular assist device implantation, and to assess the incidence, physiopathology, predictors, management and prognosis, of right ventricular failure post-implant.
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Affiliation(s)
- R Hamdan
- Cardiology department, Beirut Cardiac Institute, Beirut, Lebanon.
| | - F Charif
- Pneumology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Z Kadri
- Cardiology department, Hôtel-Dieu de France, Beirut , Lebanon
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Shin YR, Park YH, Park HK. Pediatric Ventricular Assist Device. Korean Circ J 2019; 49:678-690. [PMID: 31347320 PMCID: PMC6675693 DOI: 10.4070/kcj.2019.0163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 06/24/2019] [Indexed: 01/11/2023] Open
Abstract
There have been great advances in ventricular assist device (VAD) treatment for pediatric patients with advanced heart failure. VAD support provides more time for the patient in the heart transplant waiting list. Augmented cardiac output improves heart failure symptoms, end-organ function, and general condition, and consequently provides beneficial effects on post-transplant outcomes. Miniaturized continuous flow devices are more widely adopted for pediatric patient with promising results. For infants and small children, still paracorporeal pulsatile device is the only option for long-term support. Younger age, congenital heart disease, biventricular support, patient's status and end-organ dysfunction at the time of implantation are risks for poor outcomes. Patient selection, timing of implantation, and selection of device for each patient are critical for optimal clinical outcomes.
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Affiliation(s)
- Yu Rim Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hwan Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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11
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Gulati G, Grandin EW, Kennedy K, Cabezas F, DeNofrio DD, Kociol R, Rame JE, Pagani FD, Kirklin JK, Kormos RL, Teuteberg J, Kiernan M. Preimplant Phosphodiesterase-5 Inhibitor Use Is Associated With Higher Rates of Severe Early Right Heart Failure After Left Ventricular Assist Device Implantation. Circ Heart Fail 2019; 12:e005537. [PMID: 31181953 DOI: 10.1161/circheartfailure.118.005537] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Early right heart failure (RHF) occurs commonly in left ventricular assist device (LVAD) recipients, and increased right ventricular (RV) afterload may contribute. Selective pulmonary vasodilators, like phosphodiesterase-5 inhibitors (PDE5i), are used off-label to reduce RV afterload before LVAD implantation, but the association between preoperative PDE5i use and early RHF after LVAD is unknown. Methods and Results We analyzed adult patients from the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) who received a continuous flow LVAD after 2012. Patients on PDE5i were propensity-matched 1:1 to controls. The primary outcome was the incidence of severe early RHF, defined as the composite of death from RHF within 30 days, need for RV assist device support within 30 days, or use of inotropes beyond 14 days. Of 11 544 continuous flow LVAD recipients, 1199 (10.4%) received preoperative PDE5i. Compared to controls, patients on PDE5i had higher pulmonary artery systolic pressure (53.4 mm Hg versus 49.5 mm Hg) and pulmonary vascular resistance (2.6 WU versus 2.3 WU; P<0.001 for both). Before propensity matching, the incidence of severe early RHF was higher among patients on PDE5i than in controls (29.4% versus 23.1%; unadjusted odds ratio (OR), 1.32; 95% CI, 1.17-1.50). This association persisted after propensity matching (PDE5i, 28.9% versus control 23.7%; OR, 1.31; 95% CI, 1.09-1.57), driven by a higher incidence of prolonged inotropic support. Similar results were observed across a wide range of subgroups stratified by markers of pulmonary vascular disease and RV dysfunction. Conclusions Patients treated with preoperative PDE5i had markers of increased RV afterload and HF severity compared to unmatched controls. Even after propensity matching, patients receiving preimplant PDE5i therapy had higher rates of post-LVAD RHF.
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Affiliation(s)
- Gaurav Gulati
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
| | - E Wilson Grandin
- Cardiovascular Institute (E.W.G., F.C.).,Smith Center for Outcomes Research in Cardiology (E.W.G., K.K.)
| | - Kevin Kennedy
- Smith Center for Outcomes Research in Cardiology (E.W.G., K.K.)
| | | | - David D DeNofrio
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
| | - Robb Kociol
- Division of Cardiology (R.K.), Beth Israel Deaconess Medical Center, Boston, MA
| | - J Eduardo Rame
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia (J.E.R.)
| | - Francis D Pagani
- Division of Cardiothoracic Surgery, University of Michigan School of Medicine, Ann Arbor (F.D.P.)
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama Birmingham School of Medicine (J.K.K.)
| | - Robert L Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (R.L.K.)
| | - Jeffrey Teuteberg
- Cardiovascular Medicine, Stanford University Medical Center, CA (J.T.)
| | - Michael Kiernan
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
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12
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Sparrow CT, LaRue SJ, Schilling JD. Intersection of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients on Left Ventricular Assist Device Support: Is There a Role for Pulmonary Vasodilators? Circ Heart Fail 2019; 11:e004255. [PMID: 29321132 DOI: 10.1161/circheartfailure.117.004255] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life in patients with advanced heart failure. Despite these benefits, combined post- and precapillary pulmonary hypertension can be particularly problematic in patients on LVAD support, often exacerbating right ventricular (RV) dysfunction. Both persistently elevated pulmonary vascular resistance and RV dysfunction are associated with adverse outcomes, including death after LVAD. These observations have led to significant interest in the use of pulmonary vasodilators to treat pulmonary hypertension and preserve RV function among LVAD-supported patients. Although pulmonary vasodilators are commonly used for the treatment of pulmonary hypertension and RV dysfunction in LVADs, the benefits of this practice remain unclear. The purpose of this review is to highlight the current challenges in managing pulmonary vascular disease and RV dysfunction in patients with heart failure on LVAD support.
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Affiliation(s)
- Christopher T Sparrow
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Shane J LaRue
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Joel D Schilling
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO.
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13
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De Lazzari C, Capoccia M, Marconi S. How can LVAD support influence ventricular energetics parameters in advanced heart failure patients? A retrospective study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 172:117-126. [PMID: 30902123 DOI: 10.1016/j.cmpb.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Here we present a retrospective analysis of six heart failure patients previously discussed at a multidisciplinary team meeting. Only three out of six patients underwent LVAD insertion as the most appropriate management option. METHODS We sought to reproduce the baseline conditions of these patients on hospital admission using our cardiovascular software simulator (CARDIOSIM©). Subsequently, we simulated the effects of LVAD support and drug administration on left and right ventricular energetics parameters. LVAD assistance was delivered by CARDIOSIM© based on the module reproducing the behaviour of the Berlin Heart INCOR pump. RESULTS The results of our simulations were in agreement with the multidisciplinary team meeting outcome. The analysis of ventricular energetics parameters based on external work and pressure volume area confirmed LVAD support as a beneficial therapeutic option for the three patients considered eligible for this type of treatment. The effects induced by LVAD support and drugs administration showed specific patterns between the two groups of patients. CONCLUSION A quantitative approach with the ability to predict outcome during patient's assessment may well be an aid and not a substitute for clinical decision-making.
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Affiliation(s)
- Claudio De Lazzari
- National Research Council, Institute of Clinical Physiology (IFC-CNR), Via Palestro, 32, 00185 Rome, Italy; National Institute for Cardiovascular Research (I.N.R.C.), Via Irnerio, 48, 40126 Bologna, Italy.
| | - Massimo Capoccia
- Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK; Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
| | - Silvia Marconi
- National Research Council, Institute of Clinical Physiology (IFC-CNR), Via Palestro, 32, 00185 Rome, Italy.
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14
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Evaluation of Clinical Outcomes with Phosphodiesterase-5 Inhibitor Therapy for Right Ventricular Dysfunction After Left Ventricular Assist Device Implantation. ASAIO J 2019; 65:264-269. [DOI: 10.1097/mat.0000000000000809] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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15
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Sherwin J, Thompson E, Hill KD, Watt K, Lodge AJ, Gonzalez D, Hornik CP. Clinical pharmacology considerations for children supported with ventricular assist devices. Cardiol Young 2018; 28:1082-1090. [PMID: 29991374 PMCID: PMC6299825 DOI: 10.1017/s1047951118001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The ventricular assist device is being increasingly used as a "bridge-to-transplant" option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
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Affiliation(s)
- Jennifer Sherwin
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D. Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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16
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Jensen CW, Goldstone AB, Woo YJ. Treatment and Prognosis of Pulmonary Hypertension in the Left Ventricular Assist Device Patient. Curr Heart Fail Rep 2017; 13:140-50. [PMID: 27241336 DOI: 10.1007/s11897-016-0288-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This review will discuss the medical management of pulmonary hypertension in patients with left ventricular assist devices. Although much has been written on the management of primary pulmonary hypertension, also called pulmonary arterial hypertension, this review will instead focus on the treatment of pulmonary hypertension secondary to left heart disease. The relevant pharmacotherapy can be divided into medications for treating heart failure, such as diuretics and β-blockers, and medications for treating pulmonary hypertension. We also discuss important preoperative considerations in patients with pulmonary hypertension; the relationships between left ventricular assist devices, pulmonary hemodynamics, and right heart failure; as well as optimal perioperative and long-term postoperative medical management of pulmonary hypertension.
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Affiliation(s)
- Christopher W Jensen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Falk Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.
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17
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Sahay S, Khirfan G, Tonelli AR. Management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction. Respir Med 2017; 131:94-100. [PMID: 28947049 DOI: 10.1016/j.rmed.2017.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/01/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
Management of pulmonary hypertension (PH) has remained an unmet need in advanced left heart failure with reduced ejection fraction. In fact, patients are frequently denied heart transplant due to untreated pulmonary hypertension. The availability of mechanically circulatory devices and PH therapies has provided a ray of hope. PH specific therapies are currently not FDA approved for patients with left heart failure with reduced ejection fraction. However, clinicians have used these medications in anecdotal manner. With this review, we want to highlight the expanding use of PH specific therapy and mechanical circulatory devices in the management of PH in the setting of advanced heart failure with reduced ejection fraction.
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Affiliation(s)
- Sandeep Sahay
- Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Lung Center, Houston Methodist Hospital, Houston, TX, USA.
| | - Ghaleb Khirfan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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18
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Koulova A, Gass AL, Patibandla S, Gupta CA, Aronow WS, Lanier GM. Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation. J Thorac Dis 2017; 9:2640-2649. [PMID: 28932571 PMCID: PMC5594194 DOI: 10.21037/jtd.2017.07.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/27/2017] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension in left heart disease (PH-LHD) commonly complicates prolonged heart failure (HF). When advanced, the PH becomes fixed or out of proportion and is associated with increased morbidity and mortality in patients undergoing orthotopic heart transplant (OHT). To date, the only recommended treatment of out of proportion PH is the treatment of the underlying HF by reducing the pulmonary capillary wedge pressure (PCWP) with medications and often along with use of mechanical circulatory support. Medical therapies typically used in the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH) have been employed off-label in the setting of PH-LHD with varying efficacy and often negative outcomes. We will discuss the current standard of care including treating HF and use of mechanical circulatory support. In addition, we will review the studies published to date assessing the efficacy and safety of PAH medications in patients with PH-LHD being considered for OHT.
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Affiliation(s)
- Anna Koulova
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Alan L. Gass
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | | | - Chhaya Aggarwal Gupta
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Gregg M. Lanier
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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19
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Thunberg CA, Morozowich ST, Ramakrishna H. Inhaled therapy for the management of perioperative pulmonary hypertension. Ann Card Anaesth 2016; 18:394-402. [PMID: 26139748 PMCID: PMC4881725 DOI: 10.4103/0971-9784.159811] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at high risk for complications in the perioperative setting and often receive vasodilators to control elevated pulmonary artery pressure (PAP). Administration of vasodilators via inhalation is an effective strategy for reducing PAP while avoiding systemic side effects, chiefly hypotension. The prototypical inhaled pulmonary-specific vasodilator, nitric oxide (NO), has a proven track record but is expensive and cumbersome to implement. Alternatives to NO, including prostanoids (such as epoprostenol, iloprost, and treprostinil), NO-donating drugs (sodium nitroprusside, nitroglycerin, and nitrite), and phosphodiesterase inhibitors (milrinone, sildenafil) may be given via inhalation for the purpose of treating elevated PAP. This review will focus on the perioperative therapy of PH using inhaled vasodilators.
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Affiliation(s)
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
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20
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Baker WL, Radojevic J, Gluck JA. Systematic Review of Phosphodiesterase-5 Inhibitor Use in Right Ventricular Failure Following Left Ventricular Assist Device Implantation. Artif Organs 2016; 40:123-128. [DOI: 10.1111/aor.12518] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- William L. Baker
- Department of Pharmacy Practice; School of Pharmacy; University of Connecticut; Storrs CT USA
| | - Joseph Radojevic
- Center for Advanced Heart Failure & Transplant; Department of Cardiology; Hartford Hospital; Hartford CT USA
| | - Jason A. Gluck
- Center for Advanced Heart Failure & Transplant; Department of Cardiology; Hartford Hospital; Hartford CT USA
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21
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LaRue SJ, Garcia-Cortes R, Nassif ME, Vader JM, Ray S, Ravichandran A, Rasalingham R, Silvestry SC, Ewald GA, Wang IW, Schilling JD. Treatment of secondary pulmonary hypertension with bosentan after left ventricular assist device implantation. Cardiovasc Ther 2015; 33:50-5. [PMID: 25759010 DOI: 10.1111/1755-5922.12111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Secondary pulmonary hypertension (PH) and right ventricular dysfunction are common and associated with poor prognosis in HF patients with left ventricular assist devices (LVADs). The role of pulmonary vasodilator therapy for these patients is currently unclear. AIMS We sought to evaluate the safety and clinical course of patients treated with bosentan, an endothelin receptor antagonist, after the implementation of a LVAD. RESULTS Between 10/2008 and 5/2011, 50 consecutive patients with mean PAP >25 mmHg were treated with bosentan after LVAD implantation for a mean duration of 15.7 (±12.4) months. Ten patients discontinued the drug for possible side effects, including three for LFT abnormalities. Comparison of baseline to 6-month follow-up data revealed laboratory evidence for decongestion with a decrease in bilirubin (2.3-0.6, P < 0.0001) and an improvement in pulmonary hemodynamics with echocardiographically calculated mean PVR decreasing 1.4 woods units (3.93 ± 1.53 to 2.58 ± 1.05, P < 0.0001). CONCLUSION In this single-centered retrospective case series, we provide evidence that the tolerability of bosentan in LVAD-supported patients with secondary PH is comparable to prior experience in patients with heart failure.
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Affiliation(s)
- Shane J LaRue
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
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22
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Selby VN, De Marco T. Current Treatment Strategies in Pulmonary Hypertension Associated with Left Heart Disease. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0075-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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23
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King C, May CW, Williams J, Shlobin OA. Management of right heart failure in the critically ill. Crit Care Clin 2015; 30:475-98. [PMID: 24996606 DOI: 10.1016/j.ccc.2014.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Right ventricular failure complicates several commonly encountered conditions in the intensive care unit. Right ventricular dilation and paradoxic movement of the interventricular septum on echocardiography establishes the diagnosis. Right heart catheterization is useful in establishing the specific cause and aids clinicians in management. Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload. Mechanical support with right ventricular assist device or veno-arterial extracorporeal membrane oxygenation can be used in select patients who fail to improve with optimal medical therapy.
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Affiliation(s)
- Christopher King
- Medical Critical Care Service, Inova Fairfax Hospital, 618 South Royal Street, Alexandria, VA 22314, USA.
| | - Christopher W May
- Advanced Heart Failure and Cardiac Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Jeffrey Williams
- Medical Critical Care Service, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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24
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Inhaled nitric oxide in cardiac surgery: Evidence or tradition? Nitric Oxide 2015; 49:67-79. [PMID: 26186889 DOI: 10.1016/j.niox.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/08/2015] [Accepted: 06/25/2015] [Indexed: 12/15/2022]
Abstract
Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.
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25
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Critoph C, Green G, Hayes H, Baumwol J, Lam K, Larbalestier R, Chih S. Clinical Outcomes of Patients Treated With Pulmonary Vasodilators Early and in High Dose After Left Ventricular Assist Device Implantation. Artif Organs 2015; 40:106-14. [DOI: 10.1111/aor.12502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Christopher Critoph
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Gillian Green
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Helen Hayes
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Jay Baumwol
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Kaitlyn Lam
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Robert Larbalestier
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
| | - Sharon Chih
- Advanced Heart Failure and Cardiac Transplantation; Royal Perth Hospital; Wellington Street Perth Western Australia Australia
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26
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Magee AG, Makhecha S, Bentley S. Risk-benefit considerations when prescribing phosphodiesterase-5 inhibitors in children. Expert Opin Drug Saf 2015; 14:633-42. [PMID: 25746065 DOI: 10.1517/14740338.2015.1022527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Sildenafil (Revatio®) and tadalafil (Adcirca®) are specific inhibitors of the phosphodiesterase-5 enzyme and produce pulmonary vasodilation by inhibiting the breakdown of cyclic guanosine monophosphate (cGMP) in the walls of pulmonary arterioles. AREAS COVERED We focus on the efficacy and safety of sildenafil and tadalafil in the treatment of pulmonary hypertension (PH) in children through a PubMed literature search. EXPERT OPINION Although used since 1999 in the treatment of PH in children, it is only in the past few years that robust evidence for the use of sildenafil has emerged principally in the pivotal STARTS-1 study. The open-label extension of this study, STARTS-2, has revealed safety concerns substantiated by FDA post marketing surveillance leading to recommendations to use lower doses. More recently, tadalafil has been introduced allowing once daily dosing with apparently similar efficacy to sildenafil in children. Recently there have been suggestions that sildenafil and tadalafil may have a place in treating muscular dystrophy.
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Affiliation(s)
- Alan G Magee
- University of Southampton and Royal Brompton and Harefield NHS Foundation Trusts , Southampton and London , UK
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27
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Brunner N, de Jesus Perez VA, Richter A, Haddad F, Denault A, Rojas V, Yuan K, Orcholski M, Liao X. Perioperative pharmacological management of pulmonary hypertensive crisis during congenital heart surgery. Pulm Circ 2014; 4:10-24. [PMID: 25006417 DOI: 10.1086/674885] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 09/12/2013] [Indexed: 01/12/2023] Open
Abstract
Pulmonary hypertensive crisis is an important cause of morbidity and mortality in patients with pulmonary arterial hypertension secondary to congenital heart disease (PAH-CHD) who require cardiac surgery. At present, prevention and management of perioperative pulmonary hypertensive crisis is aimed at optimizing cardiopulmonary interactions by targeting prostacyclin, endothelin, and nitric oxide signaling pathways within the pulmonary circulation with various pharmacological agents. This review is aimed at familiarizing the practitioner with the current pharmacological treatment for dealing with perioperative pulmonary hypertensive crisis in PAH-CHD patients. Given the life-threatening complications associated with pulmonary hypertensive crisis, proper perioperative planning can help anticipate cardiopulmonary complications and optimize surgical outcomes in this patient population.
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Affiliation(s)
- Nathan Brunner
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Alice Richter
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - François Haddad
- Division of Cardiology, Stanford School of Medicine, Stanford, California, USA
| | - André Denault
- Division of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Vanessa Rojas
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Ke Yuan
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Mark Orcholski
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Xiaobo Liao
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA ; Division of Cardiothoracic Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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28
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Hamdan R, Mansour H, Nassar P, Saab M. Prevention of Right Heart Failure After Left Ventricular Assist Device Implantation by Phosphodiesterase 5 Inhibitor. Artif Organs 2014; 38:963-7. [DOI: 10.1111/aor.12277] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Righab Hamdan
- Cardiology Department; Beirut Cardiac Institute; Beirut Lebanon
| | - Hassan Mansour
- Cardiology Department; Beirut Cardiac Institute; Beirut Lebanon
| | - Pierre Nassar
- Cardiology Department; Beirut Cardiac Institute; Beirut Lebanon
| | - Mohamad Saab
- Cardiothoracic Surgery Department; Beirut Cardiac Institute; Beirut Lebanon
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29
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Kong Q, Blanton RM. Protein kinase G I and heart failure: Shifting focus from vascular unloading to direct myocardial antiremodeling effects. Circ Heart Fail 2014; 6:1268-83. [PMID: 24255056 DOI: 10.1161/circheartfailure.113.000575] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Qingwu Kong
- Tufts University School of Medicine and Division of Cardiology and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
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30
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Marzec LN, Ambardekar AV. Preoperative Evaluation and Perioperative Management of Right Ventricular Failure After Left Ventricular Assist Device Implantation. Semin Cardiothorac Vasc Anesth 2013; 17:249-61. [DOI: 10.1177/1089253213488246] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Right ventricular (RV) failure continues to be a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Preoperative evaluation of RV function with a variety of clinical, laboratory, echocardiographic, and hemodynamic variables is essential to ensure appropriate patient selection for LVAD therapy but remains imperfect. Therefore, clinicians involved in the care of these patients need to be prepared to manage RV failure after LVAD placement. Perioperative management of RV failure after LVAD implantation requires minimization of intraoperative RV ischemia, maintenance of appropriate filling pressure, supportive therapy with pulmonary vasodilators and inotropes, and surgical interventions such as RV assist devices in select cases. This article reviews the incidence of RV failure with LVAD implantation, preoperative predictors of RV failure, and perioperative management strategies.
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Blanton RM, Takimoto E, Lane AM, Aronovitz M, Piotrowski R, Karas RH, Kass DA, Mendelsohn ME. Protein kinase g iα inhibits pressure overload-induced cardiac remodeling and is required for the cardioprotective effect of sildenafil in vivo. J Am Heart Assoc 2012; 1:e003731. [PMID: 23316302 PMCID: PMC3541610 DOI: 10.1161/jaha.112.003731] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 08/20/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cyclic GMP (cGMP) signaling attenuates cardiac remodeling, but it is unclear which cGMP effectors mediate these effects and thus might serve as novel therapeutic targets. Therefore, we tested whether the cGMP downstream effector, cGMP-dependent protein kinase G Iα (PKGIα), attenuates pressure overload-induced remodeling in vivo. METHODS AND RESULTS The effect of transaortic constriction (TAC)-induced left ventricular (LV) pressure overload was examined in mice with selective mutations in the PKGIα leucine zipper interaction domain. Compared with wild-type littermate controls, in response to TAC, these Leucine Zipper Mutant (LZM) mice developed significant LV systolic and diastolic dysfunction by 48 hours (n=6 WT sham, 6 WT TAC, 5 LZM sham, 9 LZM TAC). In response to 7-day TAC, the LZM mice developed increased pathologic hypertrophy compared with controls (n=5 WT sham, 4 LZM sham, 8 WT TAC, 11 LZM TAC). In WT mice, but not in LZM mice, phosphodiesterase 5 (PDE5) inhibition with sildenafil (Sil) significantly inhibited TAC-induced cardiac hypertrophy and LV systolic dysfunction in WT mice, but this was abolished in the LZM mice (n=3 WT sham, 4 LZM sham, 3 WT TAC vehicle, 6 LZM TAC vehicle, 4 WT TAC Sil, 6 LZM TAC Sil). And in response to prolonged, 21-day TAC (n=8 WT sham, 7 LZM sham, 21 WT TAC, 15 LZM TAC), the LZM mice developed markedly accelerated mortality and congestive heart failure. TAC induced activation of JNK, which inhibits cardiac remodeling in vivo, in WT, but not in LZM, hearts, identifying a novel signaling pathway activated by PKGIα in the heart in response to LV pressure overload. CONCLUSIONS These findings reveal direct roles for PKGIα in attenuating pressure overload-induced remodeling in vivo and as a required effector for the cardioprotective effects of sildenafil.
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Affiliation(s)
- Robert M Blanton
- Molecular Cardiology Research Institute and Division of Cardiology, Tufts Medical Center, Boston, MA 02111, USA.
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Fang JC, DeMarco T, Givertz MM, Borlaug BA, Lewis GD, Rame JE, Gomberg-Maitland M, Murali S, Frantz RP, McGlothlin D, Horn EM, Benza RL. World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2012; 31:913-33. [DOI: 10.1016/j.healun.2012.06.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 01/08/2023] Open
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Postoperative care and complications after ventricular assist device implantation. Best Pract Res Clin Anaesthesiol 2012; 26:231-46. [DOI: 10.1016/j.bpa.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 03/14/2012] [Indexed: 12/27/2022]
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De Santo LS, Romano G, Maiello C, Buonocore M, Cefarelli M, Galdieri N, Nappi G, Amarelli C. Pulmonary artery hypertension in heart transplant recipients: how much is too much? Eur J Cardiothorac Surg 2012; 42:864-9; discussion 869-70. [DOI: 10.1093/ejcts/ezs102] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wever-Pinzon O, Stehlik J, Kfoury AG, Terrovitis JV, Diakos NA, Charitos C, Li DY, Drakos SG. Ventricular assist devices: pharmacological aspects of a mechanical therapy. Pharmacol Ther 2012; 134:189-99. [PMID: 22281238 DOI: 10.1016/j.pharmthera.2012.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 12/30/2011] [Indexed: 11/26/2022]
Abstract
Heart failure (HF) is a global epidemic that continues to cause significant morbidity and mortality despite advances in medical therapy. Ventricular assist device technology has emerged as a therapeutic option to bridge patients with end-stage HF to heart transplantation or as an alternative to transplantation in selected patients. In some patients, mechanical unloading induced by ventricular assist devices leads to improvement of myocardial function and a possibility of device removal. The implementation of this advanced technology requires multiple pharmacological interventions, both in the perioperative and long-term periods, in order to minimize potential complications and improve patient outcomes. We herein review the latest available evidence supporting the use of specific pharmacological interventions and current practices in the care of these patients: anticoagulation, bleeding management, pump thrombosis, infections, arrhythmias, right ventricular failure, hypertension, desensitization protocols, among others. Areas of uncertainty and ground for future research are also highlighted.
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Affiliation(s)
- O Wever-Pinzon
- Divisions of Cardiology & Molecular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Aggarwal S, Gross CM, Kumar S, Datar S, Oishi P, Kalkan G, Schreiber C, Fratz S, Fineman JR, Black SM. Attenuated vasodilatation in lambs with endogenous and exogenous activation of cGMP signaling: role of protein kinase G nitration. J Cell Physiol 2011; 226:3104-13. [PMID: 21351102 DOI: 10.1002/jcp.22692] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pulmonary vasodilation is mediated through the activation of protein kinase G (PKG) via a signaling pathway involving nitric oxide (NO), natriuretic peptides (NP), and cyclic guanosine monophosphate (cGMP). In pulmonary hypertension secondary to congenital heart disease, this pathway is endogenously activated by an early vascular upregulation of NO and increased myocardial B-type NP expression and release. In the treatment of pulmonary hypertension, this pathway is exogenously activated using inhaled NO or other pharmacological agents. Despite this activation of cGMP, vascular dysfunction is present, suggesting that NO-cGMP independent mechanisms are involved and were the focus of this study. Exposure of pulmonary artery endothelial or smooth muscle cells to the NO donor, Spermine NONOate (SpNONOate), increased peroxynitrite (ONOO(-) ) generation and PKG-1α nitration, while PKG-1α activity was decreased. These changes were prevented by superoxide dismutase (SOD) or manganese(III)tetrakis(1-methyl-4-pyridyl)porphyrin (MnTMPyP) and mimicked by the ONOO(-) donor, 3-morpholinosydnonimine N-ethylcarbamide (SIN-1). Peripheral lung extracts from 4-week old lambs with increased pulmonary blood flow and pulmonary hypertension (Shunt lambs with endogenous activation of cGMP) or juvenile lambs treated with inhaled NO for 24 h (with exogenous activation of cGMP) revealed increased ONOO(-) levels, elevated PKG-1α nitration, and decreased kinase activity without changes in PKG-1α protein levels. However, in Shunt lambs treated with L-arginine or lambs administered polyethylene glycol conjugated-SOD (PEG-SOD) during inhaled NO exposure, ONOO(-) and PKG-1α nitration were diminished and kinase activity was preserved. Together our data reveal that vascular dysfunction can occur, despite elevated levels of cGMP, due to PKG-1α nitration and subsequent attenuation of activity.
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Affiliation(s)
- Saurabh Aggarwal
- Pulmonary Disease Program, Vascular Biology Center, Georgia Health Sciences University, Augusta, Georgia 30912, USA
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Matamis D, Pampori S, Papathanasiou A, Papakonstantinou P, Tsagourias M, Galiatsou E, Koulouras V, Nakos G. Inhaled NO and sildenafil combination in cardiac surgery patients with out-of-proportion pulmonary hypertension: acute effects on postoperative gas exchange and hemodynamics. Circ Heart Fail 2011; 5:47-53. [PMID: 22057829 DOI: 10.1161/circheartfailure.111.963314] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The goal of this study was to examine the effects of coadministration of sildenafil and inhaled nitric oxide (iNO) in patients with out-of-proportion pulmonary hypertension who underwent cardiac valve replacement surgery. METHODS AND RESULTS Twenty consecutive cardiac surgery patients with out-of-proportion pulmonary hypertension were randomly assigned postoperatively into 2 groups: group A received 10 ppm of iNO followed by sildenafil (100 mg) orally 30 minutes later, and group B initially received sildenafil (100 mg) orally followed by 10 ppm of iNO 60 minutes later. Hemodynamic and gas exchange data were obtained at baseline, after administration of either iNO or sildenafil alone, and at 90 minutes from baseline. In group A, iNO resulted in a significant reduction in mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) (by 9.6% and 20.8%, respectively). In group B, sildenafil administration also resulted in a significant decrease in mean arterial pressure, MPAP, pulmonary artery occlusive pressure, PVRI, and systemic vascular resistance index but also in the PaO(2)/inspired fraction of oxygen ratio (by 18.7%, 22.0%, 15.7%, 31.6%, 21.3%, and 14%, respectively). In both groups, the coadministration of the 2 drugs resulted in a significant further reduction of mean arterial pressure, MPAP, pulmonary artery occlusive pressure, systemic vascular resistance index, and PVRI, whereas cardiac index and mixed venous oxygen saturation remained unchanged. The hypoxemia after sildenafil administration in group B improved after the coadministration of iNO, and thus PaO(2)/inspired fraction of oxygen returned to values near baseline. CONCLUSION In this study, the postoperative coadministration of iNO and oral sildenafil in patients with out-of-proportion pulmonary hypertension undergoing cardiac surgery is safe and results in an additive favorable effect on pulmonary arterial pressure and pulmonary vascular resistance, without systemic hypotension and ventilation/perfusion mismatch.
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Affiliation(s)
- Dimitrios Matamis
- Intensive Care Unit, Papageorgiou General Hospital, Thessalonica, Greece
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Melby SJ, Moon MR, Lindman BR, Bailey MS, Hill LL, Damiano RJ. Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic valve stenosis. J Thorac Cardiovasc Surg 2011; 141:1424-30. [PMID: 21596173 DOI: 10.1016/j.jtcvs.2011.02.028] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 02/03/2011] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The presence of pulmonary hypertension historically has been considered a significant risk factor affecting early and late outcomes after valve replacement. Given the number of recent advances in the management of pulmonary hypertension after cardiac surgery, a better understanding of its impact on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine whether pulmonary hypertension remains a risk factor in the modern era for adverse outcomes after aortic valve replacement for aortic valve stenosis. METHODS From January 1996 to June 2009, a total of 1080 patients underwent aortic valve replacement for primary aortic valve stenosis, of whom 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had pulmonary hypertension. Pulmonary hypertension was defined as mild (sPAP 35-44 mm Hg), moderate (45-59 mm Hg), or severe (≥ 60 mm Hg). In the group of patients with pulmonary hypertension, 204 had postoperative echocardiograms. RESULTS Operative mortality was significantly higher in patients with pulmonary hypertension (47/506, 9%, vs 31/574, 5%, P = .02). The incidence of postoperative stroke was similar (P = .14), but patients with pulmonary hypertension had an increased median hospital length of stay (8 vs 7 days, P = .001) and an increased incidence of prolonged ventilation (26% vs 17%, P < .001). Preoperative pulmonary hypertension was an independent risk factor for decreased long-term survival (relative risk 1.7, P = .02). Those with persistent pulmonary hypertension postoperatively had decreased survival. Five-year survival (Kaplan-Meier) was 78% ± 6% with normal sPAP and 77% ± 7% with mild pulmonary hypertension postoperatively, compared with 64% ± 8% with moderate and 45% ± 12% with severe pulmonary hypertension (P < .001). CONCLUSIONS In patients undergoing aortic valve replacement, preoperative pulmonary hypertension increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe pulmonary hypertension after aortic valve replacement had decreased long-term survival. These data suggest that pulmonary hypertension had a significant impact on outcomes in patients undergoing aortic valve replacement and should be considered in preoperative risk assessment.
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Affiliation(s)
- Spencer J Melby
- Department of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
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Kalogeropoulos AP, Vega JD, Smith AL, Georgiopoulou VV. Pulmonary Hypertension and Right Ventricular Function in Advanced Heart Failure. ACTA ACUST UNITED AC 2011; 17:189-98. [DOI: 10.1111/j.1751-7133.2011.00234.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ensor CR, Paciullo CA, Cahoon WD, Nolan PE. Pharmacotherapy for Mechanical Circulatory Support: A Comprehensive Review. Ann Pharmacother 2011; 45:60-77. [DOI: 10.1345/aph.1p459] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To provide a comprehensive review of the pharmacotherapy associated with the provision of mechanical circulatory support (MCS) to patients with end-stage heart failure and guidance regarding the selection, assessment, and optimization of drug therapy for this population. Data Sources: The MEDLINE/PubMed, EMBASE, and Cochrane databases were searched from 1960 to July 2010 for articles published in English using the search terms mechanical circulatory support, ventricular assist system, ventricular assist device, left ventricular assist device, right ventricular assist device, biventricular assist device, total artificial heart, pulsatile, positive displacement, axial, centrifugal, hemostasis, bleeding, hemodynamic, blood pressure, thrombosis, antithrombotic therapy, anticoagulant, antiplatelet, right ventricular failure, ventricular arrhythmia, anemia, arteriovenous malformation, stroke, infection, and clinical pharmacist. Study Selection And Data Extraction: All relevant original studies, metaanalyses, systematic reviews, guidelines, and reviews were assessed for inclusion. References from pertinent articles were examined for content not found during the initial search. Data Synthesis: MCS has advanced significantly since the first left ventricular assist device was implanted in 1966. Further advancements in MCS technology that occurred in the tatter decade are changing the overall management of end-stage heart failure care and cardiac transplantation. These pumps allow for improved bridge-to-transplant rates, enhanced survival, and quality of life. Pharmacotherapy associated with MCS devices may optimize the performance of the pumps and improve patient outcomes, as well as minimize morbidity related to their adverse effects. This review highlights the knowledge needed to provide appropriate clinical pharmacy services for patients supported by MCS devices. Conclusions: The HeartMate II clinical investigators called for the involvement of pharmacists in MCS patient assessment and optimization. Pharmacotherapeutic management of patients supported with MCS devices requires individualized care, with pharmacists as part of the team, based on the characteristics of each pump and recipient.
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Affiliation(s)
- Christopher R Ensor
- Cardiothoracic Transplantation and Mechanical Circulatory Support; Clinical Assistant Professor, School of Pharmacy, University of Maryland; Department of Pharmacy, Comprehensive Transplant Center, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher A Paciullo
- Cardiothoracic Surgery Critical Care, Department of Pharmacy, Emory University Hospital, Atlanta, GA
| | - William D Cahoon
- Cardiology; Clinical Assistant Professor, School of Pharmacy, Virginia Commonwealth University, Virginia Commonwealth University Health System; Department of Pharmacy, Medical College of Virginia Hospitals, Richmond, VA
| | - Paul E Nolan
- College of Pharmacy, University of Arizona; Senior Clinical Scientist, The University Medical Center, Tucson, AZ
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Lahm T, McCaslin CA, Wozniak TC, Ghumman W, Fadl YY, Obeidat OS, Schwab K, Meldrum DR. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol 2010; 56:1435-46. [PMID: 20951319 DOI: 10.1016/j.jacc.2010.05.046] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 04/20/2010] [Accepted: 05/17/2010] [Indexed: 12/22/2022]
Abstract
Acute right ventricular (RV) failure is a frequent and serious clinical challenge in the intensive care unit. It is usually seen as a consequence of left ventricular failure, pulmonary embolism, pulmonary hypertension, sepsis, acute lung injury or after cardiothoracic surgery. The presence of acute RV failure not only carries substantial morbidity and mortality, but also complicates the use of commonly used treatment strategies in critically ill patients. In contrast to the left ventricle, the RV remains relatively understudied, and investigations of the treatment of isolated RV failure are rare and usually limited to nonrandomized observations. We searched PubMed for papers in the English language by using the search words right ventricle, right ventricular failure, pulmonary hypertension, sepsis, shock, acute lung injury, cardiothoracic surgery, mechanical ventilation, vasopressors, inotropes, and pulmonary vasodilators. These were used in various combinations. We read the abstracts of the relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for any additional relevant papers. This review summarizes the general measures, ventilation strategies, vasoactive substances, and surgical as well as mechanical approaches that are currently used or actively investigated in the treatment of the acutely failing RV.
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Affiliation(s)
- Tim Lahm
- Clarian Cardiovascular Surgery, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Banerjee D, Haddad F, Zamanian RT, Nagendran J. Right Ventricular Failure: A Novel Era of Targeted Therapy. Curr Heart Fail Rep 2010; 7:202-11. [DOI: 10.1007/s11897-010-0031-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Crit Care 2010; 14:R169. [PMID: 20858239 PMCID: PMC3219266 DOI: 10.1186/cc9264] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 05/30/2010] [Accepted: 09/21/2010] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care. METHODS A systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method. RESULTS Clinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy. CONCLUSIONS This systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.
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Affiliation(s)
- Laura C Price
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Wort
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Simon J Finney
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Philip S Marino
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Right Ventricular Failure—A Continuing Problem in Patients with Left Ventricular Assist Device Support. J Cardiovasc Transl Res 2010; 3:604-11. [DOI: 10.1007/s12265-010-9216-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 08/11/2010] [Indexed: 01/23/2023]
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Cadeiras M, von Bayern M, Deng MC. Managing drugs and devices in patients with permanent ventricular assist devices. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 9:318-31. [PMID: 17761117 DOI: 10.1007/s11936-007-0027-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients will be considered for destination mechanical circulatory support device (MCSD) implantation when all other organ-saving treatment options have failed and they are not eligible for heart transplantation. Current medical evidence suggests that only for those patients who are inotrope-dependent and therefore likely have a 1-year survival probability without MCSD implantation of less than 50%, MCSD intervention will add to survival and quality-of-life benefit. Suitable candidates for MCSD are those patients who have a high risk of dying from heart failure but acceptable noncardiac risk. Evaluation of patients for MCSD requires a systematic and critical review of all organ systems and of the psychosocial situation. Specifically, right ventricular function and risk of right ventricular failure should be evaluated before planning destination MCSD implantation. Treatment will focus on prompt recovery from MCSD implantation, maintaining optimal treatment for heart failure, and preventing/treating MCSD complications, including infection, bleeding, coagulopathy, right heart failure, and device dysfunction. MCSD programs should be organized as an advanced heart failure center directed by specialized heart failure cardiologists, surgeons expert at implant and management of MCSD, specialized nurses, social workers, psychologists, financial experts, and physical therapists. MCSD practice is based on a patient-centered theory, with an appropriate understanding of the respective roles of the physician and the patient during their iterative encounters in which the patient is an autonomous person making responsible personal health decisions while the health care team is providing continued expert and empathic counseling about various options, based on systematic outcomes research (eg, by participation in the Interagency Registry for Mechanically Assisted Circulatory Support - MCSD database ).
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Affiliation(s)
- Martin Cadeiras
- Cardiac Transplantation Research, Division of Cardiology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York Presbyterian Hospital, PH Room 1291, 622 W. 168th Street, New York, NY 10032, USA
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Uhm JY, Jhang WK, Park JJ, Seo DM, Yun SC, Yun TJ. Postoperative use of oral sildenafil in pediatric patients with congenital heart disease. Pediatr Cardiol 2010; 31:515-20. [PMID: 20054528 DOI: 10.1007/s00246-009-9632-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 12/15/2009] [Indexed: 10/20/2022]
Abstract
We sought to determine the efficacy of postoperative oral sildenafil therapy (OST) in pediatric patients with congenital heart disease (CHD). A retrospective review of 45 postoperative patients with CHD who received OST was performed. Patients were categorized into three groups according to clinical indications: (1) to stabilize pulmonary vascular reactivity after biventricular repair (group 1 [n = 15]), (2) to lower pulmonary vascular resistance after bidirectional cavopulmonary shunt (group 2 [n = 12]), and (3) to improve post-Fontan hemodynamics (group 3 [n = 18]). Thirty-four patients (34 of 45 [75.6%]) had received inhaled nitric oxide (iNO) while on OST. Mean pulmonary arterial pressure (mPAP), mean systemic blood pressure (mSBP), and peripheral oxygen saturation (SpO(2)) were recorded during the first 24 hours after the initiation of OST. In group 1, the baseline mPAP/mSBP ratio (0.60 +/- 0.17) decreased significantly after the second (0.46 +/- 0.14, p = 0.004) and fourth (0.50 +/- 0.18, p = 0.025) doses of OST. In group 2, baseline SpO(2) (71.0 +/- 12.3%) increased after the fourth dose (75.1 +/- 12.3%, p = 0.04) of OST, without significant changes in mPAP. In group 3, baseline mPAP (14.8 +/- 3.3 mmHg) decreased significantly after the first (13.9 +/- 2.8 mmHg, p = 0.025) and second (13.3 +/- 1.9 mmHg, p = 0.016) doses of OST, without changes in SpO(2). In thirty-one (31 of 34 [92%]) subjects, iNO was discontinued within a median of 2 days after the initiation of OST, without rebound phenomena. There were no OST-related complications. Sildenafil citrate can be used safely in postoperative pediatric patients with CHD. Benefits from OST may be manifested differently in various clinical settings.
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Affiliation(s)
- Ju Yeon Uhm
- Division of Pediatric Cardiac Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 388-1 Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea
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Guglin M, Khan H. Pulmonary hypertension in heart failure. J Card Fail 2010; 16:461-74. [PMID: 20610227 DOI: 10.1016/j.cardfail.2010.01.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 01/14/2010] [Accepted: 01/19/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary hypertension occurs in 60% to 80% of patients with heart failure and is associated with high morbidity and mortality. METHODS AND RESULTS Pulmonary artery pressure correlates with increased left ventricular end-diastolic pressure. Therefore, pulmonary hypertension is a common feature of heart failure with preserved as well as reduced systolic function. Pulmonary hypertension is partially reversible with normalization of cardiac filling pressures. Pulmonary vasculature remodeling and vasoconstriction create a second component, which does not reverse immediately, but has been shown to improve with vasoactive drugs and especially with left ventricular assist devices. CONCLUSION Many drugs used for idiopathic pulmonary arterial hypertension are being considered as treatment options for heart failure-related pulmonary hypertension. This is of particular significance in the heart transplant population. Randomized clinical trials with interventions targeting heart failure patients with elevated pulmonary artery pressure would be justified.
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Affiliation(s)
- Maya Guglin
- Department of Cardiology, University of South Florida, Tampa, Florida 33618, USA.
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Loforte A, Montalto A, Lilla Della Monica P, Musumeci F. Simultaneous temporary CentriMag right ventricular assist device placement in HeartMate II left ventricular assist system recipients at high risk of right ventricular failure. Interact Cardiovasc Thorac Surg 2010; 10:847-50. [PMID: 20231307 DOI: 10.1510/icvts.2009.230706] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
An approach is reported for right ventricle temporary mechanical support in long-term axial left ventricular assist device (LVAD) patients preoperatively judged at high risk of right ventricular (RV) failure. The timing for RV assist device (RVAD) weaning and the technique for its removal through a right mini-thoracotomy are described. This strategy provides a good outcome in LVAD recipients avoiding the risk of immediate postoperative RV failure.
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Affiliation(s)
- Antonino Loforte
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, P.za C. Forlanini n.1, Rome 00151, Italy.
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Slaughter MS, Pagani FD, Rogers JG, Miller LW, Sun B, Russell SD, Starling RC, Chen L, Boyle AJ, Chillcott S, Adamson RM, Blood MS, Camacho MT, Idrissi KA, Petty M, Sobieski M, Wright S, Myers TJ, Farrar DJ. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010; 29:S1-39. [PMID: 20181499 DOI: 10.1016/j.healun.2010.01.011] [Citation(s) in RCA: 631] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 01/17/2010] [Indexed: 02/06/2023] Open
Abstract
Continuous-flow left ventricular assist devices (LVAD) have emerged as the standard of care for advanced heart failure patients requiring long-term mechanical circulatory support. Evidence-based clinical management of LVAD-supported patients is becoming increasingly important for optimizing outcomes. In this state-of-art review, we propose key elements in managing patients supported with the new continuous-flow LVADs. Although most of the presented information is largely based on investigator experience during the 1,300-patient HeartMate II clinical trial, many of the discussed principles can be applied to other emerging devices as well. Patient selection, pre-operative preparation, and the timing of LVAD implant are some of the most important elements critical to successful circulatory support and are principles universal to all devices. In addition, proper nutrition management and avoidance of infectious complications can significantly affect morbidity and mortality during LVAD support. Optimizing intraoperative and peri-operative care, and the monitoring and treatment of other organ system dysfunction as it relates to LVAD support, are discussed. A multidisciplinary heart failure team must be organized and charged with providing comprehensive care from initial referral until support is terminated. Preparing for hospital discharge requires detailed education for the patient and family or friends, with provisions for emergencies and routine care. Implantation techniques, troubleshooting device problems, and algorithms for outpatient management, including the diagnosis and treatment of related problems associated with the HeartMate II, are discussed as an example of a specific continuous-flow LVAD. Ongoing trials with other continuous-flow devices may produce additional information in the future for improving clinical management of patients with these devices.
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