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Luo Y, Leng J, Shi R, Jiang Y, Chen D, Wu Q, Tie H. Concomitant tricuspid valve surgery in patients undergoing left ventricular assist device: a systematic review and meta-analysis. Int J Surg 2024; 110:3039-3049. [PMID: 38348836 DOI: 10.1097/js9.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION This study aims to investigate the effect of concomitant tricuspid valve surgery (TVS) during left ventricular assist device (LVAD) implantation due to the controversy over the clinical outcomes of concomitant TVS in patients undergoing LVAD. METHODS A systematic literature search was performed in PubMed and EMbase from the inception to 1 August 2023. Studies comparing outcomes in adult patients undergoing concomitant TVS during LVAD implantation (TVS group) and those who did not (no-TVS group) were included. The primary outcomes were right heart failure (RHF), right ventricular assist device (RVAD) implantation, and early mortality. All meta-analyses were performed using random-effects models, and a two-tailed P <0.05 was considered significant. RESULTS Twenty-one studies were included, and 16 of them were involved in the meta-analysis, with 660 patients in the TVS group and 1291 in the no-TVS group. Patients in the TVS group suffered from increased risks of RHF [risk ratios (RR)=1.31, 95% CI: 1.01-1.70, P =0.04; I2 =38%, pH =0.13), RVAD implantation (RR=1.56, 95% CI: 1.16-2.11, P =0.003; I2 =0%, pH =0.74), and early mortality (RR=1.61, 95% CI: 1.07-2.42, P =0.02; I2 =0%, pH =0.75). Besides, the increased risk of RHF holds true in patients with moderate to severe tricuspid regurgitation (RR=1.36, 95% CI: 1.04-1.78, P =0.02). TVS was associated with a prolonged cardiopulmonary bypass time. No significant differences in acute kidney injury, reoperation requirement, hospital length of stay, or ICU stay were observed. CONCLUSIONS Concomitant TVS failed to show benefits in patients undergoing LVAD, and it was associated with increased risks of RHF, RVAD implantation, and early mortality.
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Affiliation(s)
- Yuxiang Luo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jiajie Leng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Rui Shi
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yingjiu Jiang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qingchen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
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Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, Green CL, Gross R, Bryner BS, Schroder JN, Daneshmand MA, Russell SD, DeVore AD, Patel CB, Katz JN, Milano CA, Bishawi M. Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial. J Thorac Cardiovasc Surg 2024; 167:1810-1820.e2. [PMID: 36639288 PMCID: PMC10185708 DOI: 10.1016/j.jtcvs.2022.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. METHODS Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. RESULTS This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. CONCLUSIONS The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.
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Affiliation(s)
| | - Yuting Chiang
- Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Ryan Gross
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | | | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center
| | | | - Jason N Katz
- Division of Cardiology, Duke University Medical Center
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center.
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Mitra A, Castleberry A, Urban M, Siddique A. Does concomitant tricuspid valve intervention at the time of left ventricular assist device placement for patients with significant tricuspid regurgitation lead to improved outcomes compared to isolated left ventricular assist device placement? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae005. [PMID: 38216526 PMCID: PMC10850842 DOI: 10.1093/icvts/ivae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with advanced heart failure (HF) and moderate to severe functional tricuspid regurgitation (TR) undergoing left ventricular assist device (LVAD) placement is concomitant tricuspid valve intervention (TVI) superior for the clinical outcomes of survival, right ventricular failure, rehospitalizations for HF, functional status, and quality of life?' Altogether, 56 papers were found using the reported search, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Our search found no significant clinical benefit for concomitant TVI at the time of LVAD placement. We conclude that patient with moderate-to-severe TR should not routinely undergo concomitant TVI with LVAD placement.
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Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony Castleberry
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marian Urban
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aleem Siddique
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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Mitra A, Siddique A. Tricuspid regurgitation in the setting of LVAD support. Front Cardiovasc Med 2023; 10:1090150. [PMID: 37304950 PMCID: PMC10250620 DOI: 10.3389/fcvm.2023.1090150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Tricuspid valve regurgitation (TR) is a common complication of end-stage heart failure. Increased pulmonary venous pressures caused by left ventricular (LV) dysfunction can result in a progressive dilation of the right ventricle and tricuspid valve annulus, resulting in functional TR. Here, we review what is known about TR in the setting of severe LV dysfunction necessitating long-term mechanical support with left ventricular assist devices (LVADs), including the occurrence of significant TR, its pathophysiology, and natural history. We examine the impact of uncorrected TR on LVAD outcomes and the impact of tricuspid valve interventions at the time of LVAD placement, revealing that TR frequently improves after LVAD placement with or without concomitant tricuspid valve intervention such that the benefit of concomitant intervention remains controversial. We summarize the current evidence on which to base medical decisions and provide recommendations for future directions of study to address outstanding questions in the field.
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Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery,University of Nebraska Medical Center, Omaha, NE, United States
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Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
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Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
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Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
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Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Naganuma M, Akiyama M, Sasaki K, Maeda K, Ito K, Suzuki T, Katahira S, Suzuki Y, Saiki Y. Aortic Insufficiency Causes Symptomatic Heart Failure during Left Ventricular Assist Device Support. TOHOKU J EXP MED 2021; 255:229-237. [PMID: 34789593 DOI: 10.1620/tjem.255.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
De novo aortic insufficiency is often documented during long-term left ventricular assist device (LVAD) support, despite the absence of aortic insufficiency at the time of LVAD implantation. However, whether aortic insufficiency affects long-term mortality and symptomatic heart failure in LVAD-supported patients remains controversial. We aimed to examine whether aortic insufficiency development influenced mortality and symptomatic heart failure following LVAD implantation. Fifty-three patients who underwent durable LVAD implantation between January 1, 2008 and April 31, 2017 were retrospectively examined in a single center institute. After discharge, we performed the echocardiographic examination in accordance with the Japanese registry for the mechanically assisted circulatory support protocol. Aortic insufficiency was graded on an interval scale (severe = 4, moderate = 3, mild = 2, trivial or none = 1). Kaplan-Meier estimates for long-term mortality at the follow-up were generated. We used a logistic regression model to identify risk factors for symptomatic heart failure. The overall median duration of LVAD support was 856.3 ± 430.8 days (range, 12-1,744 days). We did not observe a significant difference in long-term mortality in patients with aortic insufficiency ≥ 3 grade compared with patients with aortic insufficiency < 3 grade (P = 0.767; log-rank). Aortic insufficiency was associated with an increased risk for heart failure event after discharge (odds ratio, 4.12; confidence interval, 1.48-16.93; P = 0.005). Aortic insufficiency was an independent risk factor for symptomatic heart failure and was not associated with long-term mortality. Aortic insufficiency progression was associated with symptomatic heart failure.
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Affiliation(s)
- Masaaki Naganuma
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Masatoshi Akiyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Konosuke Sasaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Kay Maeda
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Koki Ito
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Tomoyuki Suzuki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Shintaro Katahira
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yusuke Suzuki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
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Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020; 33:692-734. [PMID: 32503709 DOI: 10.1016/j.echo.2020.03.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
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Affiliation(s)
| | | | - Niv Ad
- White Oak Medical Center and University of Maryland, Silver Spring, Maryland
| | - Alan Finley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Bradley Taylor
- University of Maryland Medical Center, Baltimore, Maryland
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10
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Fujino T, Imamura T, Nitta D, Kim G, Smith B, Kalantari S, Nguyen A, Chung B, Narang N, Holzhauser L, Juricek C, Rodgers D, Song T, Ota T, Jeevanandam V, Burkhoff D, Sayer G, Uriel N. Effect of Concomitant Tricuspid Valve Surgery With Left Ventricular Assist Device Implantation. Ann Thorac Surg 2020; 110:918-924. [PMID: 32035052 DOI: 10.1016/j.athoracsur.2019.12.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/24/2019] [Accepted: 12/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in advanced heart failure (HF) patients. However, the effect of concomitant tricuspid valve repair or replacement (tricuspid valve intervention [TVI]) with left ventricular assist device (LVAD) implantation is controversial. The aim of this study was to investigate the longitudinal trend of TR after LVAD implantation and the effect of TVI on the TR trend and clinical outcomes. METHODS We retrospectively reviewed patients at our institution who underwent LVAD implantation between April 2014 and August 2018. We evaluated the grade of TR by echocardiography before and after LVAD implantation. Moderate or greater TR was defined as significant. RESULTS Among 199 consecutive patients, 194 had at least 2 echocardiographic TR assessments before and after LVAD implantation. Of these patients, 108 were included in the TVI-positive (TVI+) group and 86 in the TVI-negative (TVI-) group. In the TVI+ group, the prevalence of significant TR decreased from 52% to about 20% in the first 6 months after implantation (P < .01). Overall survival and HF readmission-free survival were comparable between the TVI+ and TVI- patients. In contrast, patients in both groups who had significant postoperative TR during early follow-up had worse 2-year HF readmission-free survival (36% in patients with significant postoperative TR vs 55% in those without significant postoperative TR; P = .028). CONCLUSIONS Concomitant TVI with LVAD implantation improved TR in most patients but did not have an impact on clinical outcomes. Significant postoperative TR after LVAD implantation, in patients with and without TVI, was associated with worse HF-free outcomes.
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Affiliation(s)
- Takeo Fujino
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Teruhiko Imamura
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daisuke Nitta
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Luise Holzhauser
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Departments of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Daniel Burkhoff
- Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York
| | - Gabriel Sayer
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York.
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11
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Barac YD, Nicoara A, Bishawi M, Schroder JN, Daneshmand MA, Hashmi NK, Velazquez E, Rogers JG, Patel CB, Milano CA. Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. JACC-HEART FAILURE 2019; 8:141-150. [PMID: 31838034 DOI: 10.1016/j.jchf.2019.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/03/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BACKGROUND Surgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. METHODS A retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors' institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. RESULTS A total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). CONCLUSIONS Failure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nazish K Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Eric Velazquez
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
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12
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Critsinelis A, Kurihara C, Kawabori M, Sugiura T, Loor G, Frazier OH, Morgan J. Outcomes in patients who underwent a concomitant tricuspid valve procedure during left ventricular assist device implantation. J Card Surg 2019; 34:1458-1464. [PMID: 31730728 DOI: 10.1111/jocs.14304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Study findings have been inconsistent regarding whether a concomitant tricuspid valve replacement or repair performed concurrently with continuous-flow left ventricular assist device (CF-LVAD) implantation has additive clinical benefit in patients with severe tricuspid valve regurgitation (TR). AIM OF STUDY To determine the effect of performing a concomitant tricuspid valve procedure (TVP) at the time of CF-LVAD implantation on patient outcomes. METHODS We retrospectively reviewed our single-institution experience in 526 patients who underwent primary implantation of a CF-LVAD between November 2003 and March 2016. We identified 59 (11.2%) patients who had severe TR at the time of implantation and analyzed the effect of performing a concomitant TVP at the time of CF-LVAD implantation on the rate of survival, incidence of postoperative right heart failure (RHF), recurrence of TR, and incidence of 30-day readmission. RESULTS We did not observe a significant difference in the overall survival rate (P = .51), incidence of postoperative RHF (P = .26), or recurrence of TR (P = .73) between patients with severe TR who underwent a TVP and those who did not at the time of CF-LVAD implantation. However, the incidence of 30-day readmission was significantly lower in patients who underwent a TVP than in those who did not (P = .002). CONCLUSIONS Performing a concomitant TVP at the time of CF-LVAD implantation did not improve patient outcomes but reduced the incidence of 30-day readmission.
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Affiliation(s)
- Andre Critsinelis
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Chitaru Kurihara
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Masashi Kawabori
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Tadahisa Sugiura
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - O H Frazier
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.,Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute, Houston, Texas
| | - Jeffrey Morgan
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
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Imamura T, Narang N, Nnanabu J, Rodgers D, Raikhelkar J, Kalantari S, Smith B, Nguyen A, Chung B, Ota T, Song T, Jeevanandam V, Kim G, Sayer G, Uriel N. Hemodynamics of concomitant tricuspid valve procedures at LVAD implantation. J Card Surg 2019; 34:1511-1518. [PMID: 31693250 DOI: 10.1111/jocs.14275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tricuspid regurgitation (TR) is common in patients receiving left ventricular assist device (LVAD) implantation. The current literature is conflicting regarding the effects of concomitant tricuspid valve repair (TVR) at LVAD implantation. We investigated the hemodynamic effects of concomitant TVR at LVAD implantation. METHODS Consecutive clinically stable LVAD outpatients who underwent hemodynamic ramp testings were enrolled in this study, and they were stratified by concomitant TVR. Results of hemodynamic ramp tests were compared between the TVR group and the non-TVR group. RESULTS Among 65 LVAD patients undergoing ramp tests, 34 patients had received TVR, and 31 had not. There were no significant differences in baseline characteristics between two groups except for higher degree of TR and lower pulmonary artery pulsatility index in the TVR group (P < .05 for both). Following LVAD implantation, the degree of TR improved significantly in the TVR group down to the comparable level with the non-TVR group. During ramp tests, the TVR group had steeper cardiac index slope (0.14 ± 0.12 vs 0.07 ± 0.07 L/min/m2 /step, P = .002) and higher cardiac index at set LVAD speed (2.99 ± 0.84 vs 2.52 ± 0.42 L/min/m2 , P = .007). CONCLUSIONS Concomitant TVR improves cardiac output and its response to LVAD speed change following LVAD implantation. Longitudinal clinical implications of such hemodynamic changes are unknown.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jerry Nnanabu
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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14
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Atrial Fibrillation Should Guide Prophylactic Tricuspid Procedures During Left Ventricular Assist Device Implantation. ASAIO J 2019; 64:586-593. [PMID: 29088022 DOI: 10.1097/mat.0000000000000698] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Atrial fibrillation (AF) and tricuspid regurgitation (TR) are common in patients undergoing left ventricular assist device (LVAD) implantation. TR progression is associated with the presence of AF, and questions remain as to who benefits from tricuspid valve procedures (TVPs). We examined the impact of preoperative AF on TR progression after LVAD implantation. From February 2007 to May 2014, 250 patients underwent LVAD implantation at our institution. Patients with concomitant TVP were excluded from this analysis (113 patients). The indication for LVAD was destination therapy in 80 patients (58%) and the etiology of heart failure was ischemic in 73 (53%). Follow-up was available in all early survivors for a total of 393 patient-years of support. Of the 137 non-TVP patients, 52 (38%) had AF preoperatively. Observed overall survival at 1, 3, and 5 years was 82%, 67%, and 55%, respectively. Median grade of TR increased from 2 preoperatively to 3 (p = 0.04) in the AF group and 2.2 (p = 0.75) in the non-AF group at 5 years of follow-up. We also observed a significant difference in the degree of TR between groups at 3 months (p = 0.03) and 12 months (p = 0.01) postimplantation, and a trend toward significance at 18 (p = 0.06) and 24 (p = 0.07) months. The presence of AF is associated with early progression of TR after LVAD implantation. Addition of concomitant TVP in patients with preoperative AF may be considered in patients with less than severe TR. The impact of these findings on right ventricular failure/remodeling remains to be evaluated.
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15
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Bouchez S, Van Belleghem Y, De Somer F, De Pauw M, Stroobandt R, Wouters P. Haemodynamic management of patients with left ventricular assist devices using echocardiography: the essentials. Eur Heart J Cardiovasc Imaging 2019; 20:373-382. [DOI: 10.1093/ehjci/jez003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stefaan Bouchez
- Department of Anaesthesiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Yves Van Belleghem
- Department of Cardiac Surgery, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Roland Stroobandt
- Department of Cardiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Patrick Wouters
- Department of Anaesthesiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
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17
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Kimmaliardjuk DM, Ruel M. Cardiac passive-aggressive behavior? The right ventricle in patients with a left ventricular assist device. Expert Rev Cardiovasc Ther 2017; 15:267-276. [PMID: 28306362 DOI: 10.1080/14779072.2017.1308252] [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] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Right ventricular failure (RVF) affects up to 50% of patients post-left ventricular assist device (LVAD) implantation, and carries significant morbidity and mortality. There is no widely-used long-term mechanical support option for the right ventricle, thus early identification, prevention and medical treatment of RVF is of the upmost importance. Areas covered: A PubMed search was first completed searching 'Right ventricular failure post-LVAD' which yielded 152 results, and a subsequent search was performed under 'RV mechanical support' which yielded 374 results, and was filtered to 'humans' and literature written in English, generating 219 results. We focused this research on pre-operative risk factors identified in the literature for developing RVF-post LVAD implantation, and the medical and surgical treatment options for RVF, including mechanical treatment options. Expert commentary: There is little consensus on pre-operative risk factors that reliably predict RVF post-LVAD implantation. Large prospective randomized trials would help clarify indications for specific medical and surgical therapy. We gather this knowledge in the present article and describe the main RVF remediation modalities. Surgeons and anesthesiologists should help prevent and have a low threshold for initiating supportive treatment for RVF, which may include increasingly invasive therapies up to long-term mechanical RV support.
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Affiliation(s)
| | - Marc Ruel
- a Division of Cardiac Surgery , University of Ottawa Heart Institute , Ottawa , Canada
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18
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Hillebrand J, Hoffmeier A, Djie Tiong Tjan T, Sindermann JR, Schmidt C, Martens S, Scherer M. Minimally Invasive Implantation of HeartWare Assist Device and Simultaneous Tricuspid Valve Reconstruction Through Partial Upper Sternotomy. Artif Organs 2016; 41:418-423. [DOI: 10.1111/aor.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/03/2016] [Accepted: 05/16/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Julia Hillebrand
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Andreas Hoffmeier
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Tonny Djie Tiong Tjan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Juergen R. Sindermann
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Christoph Schmidt
- Department of Anaesthesiology, Intensive Care and Pain Medicine; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
| | - Mirela Scherer
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery; University Hospital of the Westfaelische Wilhelms-University Muenster; Muenster Germany
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19
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Ikegami H, Kurlansky P, Takeda K, Naka Y. Challenges faced in long term ventricular assist device support. Expert Rev Med Devices 2016; 13:727-40. [PMID: 27376168 DOI: 10.1080/17434440.2016.1208557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The development of ventricular assist device (VAD) has been one of the revolutionary advancements in end-stage heart failure management. Although the device has developed and improved significantly over the last few decades, we still face multiple challenges. AREAS COVERED This review will discuss quality of life, survival, and clinically encountered complications in patients with VAD support. The literature was extensively reviewed for studies describing the above topic area. We describe the impact of major challenges faced in VAD support and discuss their future and expectations. Expert commentary: The technological advancement of VADs has contributed to major improvement of overall survival, enhancement of quality of life and decrease of incidence of complications. It is expected that technologies will continue to evolve. At the same time, the indications for and timing of device implantation, and selection of device type are continuously important in clinical practice setting.
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Affiliation(s)
- Hirohisa Ikegami
- a Department of Surgery, Division of Cardiothoracic Surgery , Columbia University Medical Center , New York , NY , USA
| | - Paul Kurlansky
- a Department of Surgery, Division of Cardiothoracic Surgery , Columbia University Medical Center , New York , NY , USA
| | - Koji Takeda
- a Department of Surgery, Division of Cardiothoracic Surgery , Columbia University Medical Center , New York , NY , USA
| | - Yoshifumi Naka
- a Department of Surgery, Division of Cardiothoracic Surgery , Columbia University Medical Center , New York , NY , USA
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20
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Song HK, Gelow JM, Mudd J, Chien C, Tibayan FA, Hollifield K, Naftel D, Kirklin J. Limited Utility of Tricuspid Valve Repair at the Time of Left Ventricular Assist Device Implantation. Ann Thorac Surg 2016; 101:2168-74. [PMID: 27139368 DOI: 10.1016/j.athoracsur.2016.03.040] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 02/22/2016] [Accepted: 03/11/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal management of tricuspid regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is controversial. This study was undertaken to determine the impact of tricuspid valve repair (TVR) at the time of LVAD implantation on survival. METHODS The Interagency Registry for Mechanically Assisted Circulatory Support was used to analyze the outcomes of patients undergoing LVAD implantation as destination therapy with or without concomitant TVR. RESULTS Among 2,527 patients undergoing implant of a continuous flow LVAD as destination therapy during the study period, 989 (39%) had moderate or severe TR. The management of TR was not uniform among these patients. Patients with moderate and severe TR underwent TVR in 16.7% and 35.3% of cases, respectively. Moderate and severe TR at the time of LVAD implantation were associated with poorer survival over the entire follow-up period (p = 0.009). Interestingly, TVR at the time of LVAD implantation did not confer improved survival, even among patients with preimplant moderate or severe TR. A potential explanation for this finding is that patients with preimplant moderate or severe TR who underwent LVAD implant with concomitant TVR commonly experienced recurrent, late TR (21% to 27%). CONCLUSIONS Tricuspid valve repair is performed commonly at the time of LVAD implant despite the fact that it does not confer a clear survival benefit. For many patients, LVAD implant alone relieves preimplant TR as effectively as LVAD implant with TVR. Further study is necessary to determine what factors lead to recurrence of late TR in LVAD patients both with and without TVR.
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Affiliation(s)
- Howard K Song
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon.
| | - Jill M Gelow
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - James Mudd
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - Christopher Chien
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon
| | - Frederick A Tibayan
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon
| | - Kathryn Hollifield
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - David Naftel
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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21
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Taghavi S, Jayarajan SN, Komaroff E, Mangi AA. Right ventricular assist device results in worse post-transplant survival. J Heart Lung Transplant 2016; 35:236-41. [DOI: 10.1016/j.healun.2015.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 09/06/2015] [Accepted: 10/14/2015] [Indexed: 11/28/2022] Open
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22
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Oezpeker C, Zittermann A, Paluszkiewicz L, Piran M, Puehler T, Sayin AO, Ensminger S, Milting H, Morshuis M, Gummert JF. Tricuspid valve repair in patients with left-ventricular assist device implants and tricuspid valve regurgitation: propensity score-adjusted analysis of clinical outcome. Interact Cardiovasc Thorac Surg 2015; 21:741-7. [DOI: 10.1093/icvts/ivv260] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/19/2015] [Indexed: 11/14/2022] Open
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23
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Right ventricular failure after left ventricular assist devices. J Heart Lung Transplant 2015; 34:1123-30. [DOI: 10.1016/j.healun.2015.06.015] [Citation(s) in RCA: 254] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/11/2015] [Accepted: 06/24/2015] [Indexed: 01/31/2023] Open
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Kalogeropoulos AP, Al-Anbari R, Pekarek A, Wittersheim K, Pernetz MA, Hampton A, Steinberg J, Georgiopoulou VV, Butler J, Vega JD, Smith AL. The Right Ventricular Function After Left Ventricular Assist Device (RVF-LVAD) study: rationale and preliminary results. Eur Heart J Cardiovasc Imaging 2015; 17:429-37. [PMID: 26160395 DOI: 10.1093/ehjci/jev162] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/31/2015] [Indexed: 01/11/2023] Open
Abstract
AIMS Despite improved outcomes and lower right ventricular failure (RVF) rates with continuous-flow left ventricular assist devices (LVADs), RVF still occurs in 20-40% of LVAD recipients and leads to worse clinical and patient-centred outcomes and higher utilization of healthcare resources. Preoperative quantification of RV function with echocardiography has only recently been considered for RVF prediction, and RV mechanics have not been prospectively evaluated. METHODS AND RESULTS In this single-centre prospective cohort study, we plan to enroll a total of 120 LVAD candidates to evaluate standard and mechanics-based echocardiographic measures of RV function, obtained within 7 days of planned LVAD surgery, for prediction of (i) RVF within 90 days; (ii) quality of life (QoL) at 90 days; and (iii) RV function recovery at 90 days post-LVAD. Our primary hypothesis is that an RV echocardiographic score will predict RVF with clinically relevant discrimination (C >0.85) and positive and negative predictive values (>80%). Our secondary hypothesis is that the RV score will predict QoL and RV recovery by 90 days. We expect that RV mechanics will provide incremental prognostic information for these outcomes. The preliminary results of an interim analysis are encouraging. CONCLUSION The results of this study may help improve LVAD outcomes and reduce resource utilization by facilitating shared decision-making and selection for LVAD implantation, provide insights into RV function recovery, and potentially inform reassessment of LVAD timing in patients at high risk for RVF.
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Affiliation(s)
- Andreas P Kalogeropoulos
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Raghda Al-Anbari
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Ann Pekarek
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Kristin Wittersheim
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Maria A Pernetz
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Amber Hampton
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Jerilyn Steinberg
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Vasiliki V Georgiopoulou
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
| | - Javed Butler
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - J David Vega
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Andrew L Smith
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University, 1462 Clifton Road NE, Suite 535B, Atlanta, GA, USA
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Dunlay SM, Deo SV, Park SJ. Impact of tricuspid valve surgery at the time of left ventricular assist device insertion on postoperative outcomes. ASAIO J 2015; 61:15-20. [PMID: 25238498 PMCID: PMC4280315 DOI: 10.1097/mat.0000000000000145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Tricuspid regurgitation (TR) is common in patients with heart failure undergoing left ventricular assist device (LVAD) implantation. Whether the TR should be surgically managed at the time of LVAD surgery is controversial. We searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE (through May 10, 2014) for randomized controlled trials and observational studies comparing postoperative outcomes in patients treated with LVAD with concomitant tricuspid valve surgery (TVS) compared with LVAD alone. Six observational studies including 3,249 patients compared outcomes following LVAD + TVS versus LVAD. Four studies were single-center and most did not adjust for potential confounders. Addition of TVS prolonged cardiopulmonary bypass times by an average of 31 minutes (three studies, 95% CI 20-42). There was no difference in need for right ventricular assist device (six studies, HR 1.42, 95% CI 0.54-3.76), acute renal failure (four studies, HR 1.07, 95% CI 0.55-2.10), or early mortality (six studies, HR 1.28, 95% CI 0.78-2.08) in patients treated with LVAD + TVS versus LVAD alone. TVS prolongs cardiopulmonary bypass times, but available data demonstrate no significant association with early postoperative outcomes. However, differences in baseline risk of patients treated with TVS versus not limit our ability to draw conclusions.
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Affiliation(s)
- Shannon M. Dunlay
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Salil V. Deo
- Division of Cardiovascular Surgery at Case Western Reserve University, Cleveland, OH
| | - Soon J. Park
- Division of Cardiovascular Surgery at Case Western Reserve University, Cleveland, OH
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Holman WL, Acharya D, Siric F, Loyaga-Rendon RY. Assessment and Management of Right Ventricular Failure in Left Ventricular Assist Device Patients. Circ J 2015; 79:478-86. [DOI: 10.1253/circj.cj-15-0093] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- William L. Holman
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
| | - Deepak Acharya
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Franjo Siric
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
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Relationship of tricuspid repair at the time of left ventricular assist device implantation and survival. Int J Artif Organs 2014; 37:834-8. [PMID: 25450319 DOI: 10.5301/ijao.5000369] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Tricuspid regurgitation contributes to right ventricular failure (RVF) and is associated with worse clinical outcomes in patients undergoing left ventricular assist device (LVAD) treatment. However, whether tricuspid valve repair (TVR) at the time of LVAD implantation improves outcomes is not clear. METHODS We identified all patients undergoing initial implantation of a long-term continuous-flow LVAD at our institution from March 2006 to August 2011. We assessed the impact of TVR on survival and incidence of RVF using Kaplan-Meier curves and proportional hazards regression adjusted for age, gender, baseline tricuspid regurgitation, RV function, MELD score, albumin, and indication (bridge vs. destination). RESULTS A total of 101 patients were included in the analysis, of which 14 patients underwent TVR concomitant LVAD. All TVR patients had moderate or severe baseline regurgitation. Crude survival was not different between groups. In multivariable models adjusted for confounding factors, TVR showed a significant association with improved survival (HR = 0.1, p = 0.049). Adjusted models showed no difference in RVF. CONCLUSIONS In this cohort of patients, TVR at the time of LVAD implantation appears associated with better survival. Additional larger studies are needed to verify the effect of TVR at the time of LVAD implantation, and whether it should be utilized more frequently.
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Clinical Outcomes After Implantation of a Centrifugal Flow Left Ventricular Assist Device and Concurrent Cardiac Valve Procedures. Circulation 2014; 130:S3-11. [DOI: 10.1161/circulationaha.113.007911] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Cardiac valve procedures are commonly performed concurrently during implantation of left ventricular assist devices, but the added procedural risk has not been studied in detail.
Methods and Results—
Data from patients receiving the HeartWare Ventricular Assist Device in the ADVANCE bridge to transplant (BTT) trial and continued access protocol were reviewed. Of 382 consecutive patients who completed follow-up between August 2008 and June 2013 (mean time on support 389 days, median 271 days), 262 (68.6%) underwent isolated HeartWare Ventricular Assist Device implantation, 75 (19.6%) a concurrent valve procedure, and 45 (11.8%) concurrent nonvalvular procedures. Of the concurrent valve procedures, 56 were tricuspid, 13 aortic, and 6 mitral. Survival was similar between groups (79% for concurrent valve procedures and 85% for HeartWare Ventricular Assist Device only at 1 year;
P
=0.33). Concurrent valve procedures were also associated with increased unadjusted early right heart failure (RHF). A multivariable analysis for death and RHF (121 total events) identified female sex (odds ratio=2.0 [95% confidence interval, 1.2–3.3;
P
=0.0053]) and preimplant tricuspid regurgitation severity (odds ratio=2.9 [95% confidence interval, 1.8–4.8,
P
<0.0001]) as independent predictors while concurrent tricuspid valve procedures (TVP) were not predictors. Furthermore, patients with significant preimplant tricuspid regurgitation who did not receive a TVP experienced an increased rate of late RHF compared with those who received TVP (0.19 versus 0.05 events per patient-year, respectively;
P
=0.024).
Conclusions—
Compared with HeartWare Ventricular Assist Device alone, survival was equivalent for the concurrent valve procedure group. Tricuspid regurgitation severity was the most important predictor of increased postoperative RHF, and concurrent TVP was not an independent predictor of RHF overall. Concurrent TVP may reduce the rate of late RHF for patients with significant preimplant tricuspid insufficiency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00751972.
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Ramakrishna H, Augoustides JGT, Gutsche JT, Stein E, Weiss SJ, Vernick WJ. Incidental tricuspid regurgitation in adult cardiac surgery: focus on current evidence and management options for the perioperative echocardiographer. J Cardiothorac Vasc Anesth 2014; 28:1414-20. [PMID: 25319991 DOI: 10.1053/j.jvca.2014.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Stein
- Department of Anesthesiology, Ohio State University, Columbus, OH
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William J Vernick
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Akhter SA, Salabat MR, Philip JL, Valeroso TB, Russo MJ, Rich JD, Jeevanandam V. Durability of De Vega Tricuspid Valve Annuloplasty for Severe Tricuspid Regurgitation During Left Ventricular Assist Device Implantation. Ann Thorac Surg 2014; 98:81-3. [DOI: 10.1016/j.athoracsur.2014.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 03/15/2014] [Accepted: 03/20/2014] [Indexed: 01/13/2023]
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Robertson JO, Grau-Sepulveda MV, Okada S, O’Brien SM, Matthew Brennan J, Shah AS, Itoh A, Damiano RJ, Prasad S, Silvestry SC. Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: A Society of Thoracic Surgeons database analysis. J Heart Lung Transplant 2014; 33:609-17. [DOI: 10.1016/j.healun.2014.01.861] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 12/18/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022] Open
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Bansal S, Sai-Sudhakar CB, Whitson BA. Outcomes of continuous flow ventricular assist devices. World J Surg Proced 2014; 4:1-8. [DOI: 10.5412/wjsp.v4.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
Heart transplantation is commonplace, the supply is limited. Many exciting changes in the field of mechanical circulatory support have occurred in the past few years, including the axial flow pump. Left ventricular assist device (LVAD) therapy is ever evolving. As the use of LVAD therapy increases it is important to understand the indications, surgical considerations and outcomes.
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Fujita T, Kobayashi J, Hata H, Seguchi O, Murata Y, Yanase M, Nakatani T. Right heart failure and benefits of adjuvant tricuspid valve repair in patients undergoing left ventricular assist device implantation. Eur J Cardiothorac Surg 2014; 46:802-7. [PMID: 24574450 DOI: 10.1093/ejcts/ezu040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although right heart failure (RVF) is an important issue in the management of patients with left ventricular assist devices (LVADs), the benefits of performing tricuspid valve repair in conjunction with LVAD implantation have not been demonstrated. METHODS We retrospectively reviewed the records of 141 patients who received LVAD implantation as a bridge to transplant from May 1999 to January 2013. We assessed short- and long-term right heart function in 69 of these patients who underwent tricuspid valve repair because of moderate-to-severe tricuspid regurgitation (TR) or severe dilatation of the tricuspid annulus. RVF was defined as the need for a right ventricular assist device or >30 days of intravenous inotropic support. TR was graded from 0 to 4, while fibrosis in myocardial biopsy samples was graded pathologically from 0 to 3. RESULTS The average duration of LVAD support was 595 days. Twenty-seven patients developed RVF and their survival rate was significantly worse than that of patients who did not develop RVF (65 vs 91% at 1 year). RVF was significantly related to high preoperative ratio of central venous pressure (CVP) to pulmonary capillary wedge pressure, high total bilirubin, high fibrosis score and high TR grade. In patients who underwent tricuspid valve repair, the TR grade was significantly reduced from 2.6 to 1.0, and this decrease was maintained for 2 years. Although patients who underwent tricuspid valve repair had significantly higher TR grades, ratios of CVP to pulmonary capillary wedge pressure and fibrosis scores preoperatively, no survival impairment was seen. CONCLUSIONS Tricuspid valve repair is a useful and durable adjuvant procedure for restoring deteriorated right ventricular function in patients requiring LVAD implantation.
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Affiliation(s)
- Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Osamu Seguchi
- Department of Transplantation, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Yoshihiro Murata
- Department of Transplantation, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplantation, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Takeshi Nakatani
- Department of Transplantation, National Cerebral and Cardiovascular Centre, Osaka, Japan
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Bartels K, Karhausen J, Sullivan BL, Mackensen GB. Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography. Semin Cardiothorac Vasc Anesth 2014; 18:341-51. [DOI: 10.1177/1089253214522326] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose of the review. This review aims to summarize recent findings relevant for perioperative 2- and 3-dimensional imaging of the right heart with transesophageal echocardiography. Special attention is given to developments that are likely to affect future approaches for prevention and therapy of perioperative right heart failure. Recent findings. Three-dimensional transesophageal echocardiography techniques are becoming more common for the evaluation of anatomy, volumes, and functional indices. Summary. Right heart failure continues to contribute to morbidity and mortality in the context of cardiothoracic surgery. The advent and widespread clinical use of innovative tools permitting more accurate echocardiographic assessment of the right heart will open the door to renewed interest in novel therapeutic strategies.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Jörn Karhausen
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - G. Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
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John R, Naka Y, Park SJ, Sai-Sudhakar C, Salerno C, Sundareswaran KS, Farrar DJ, Milano CA. Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices. J Thorac Cardiovasc Surg 2014; 147:581-9; discussion 589. [DOI: 10.1016/j.jtcvs.2013.10.024] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/16/2013] [Accepted: 10/12/2013] [Indexed: 11/28/2022]
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Wang TS, Hernandez AF, Felker GM, Milano CA, Rogers JG, Patel CB. Valvular Heart Disease in Patients Supported With Left Ventricular Assist Devices. Circ Heart Fail 2014; 7:215-22. [DOI: 10.1161/circheartfailure.113.000473] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Teresa S. Wang
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
| | - Adrian F. Hernandez
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
| | - G. Michael Felker
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
| | - Carmelo A. Milano
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
| | - Joseph G. Rogers
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
| | - Chetan B. Patel
- From the School of Medicine (T.S.W.), Division of Cardiology (A.F.H., G.M.F., J.G.R., C.B.P.), and Division of Cardiothoracic Surgery (C.A.M.), Duke University Medical Center, Durham, NC
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Morgan JA, Tsiouris A, Nemeh HW, Hodari A, Karam J, Brewer RJ, Paone G. Impact of concomitant cardiac procedures performed during implantation of long-term left ventricular assist devices. J Heart Lung Transplant 2013; 32:1255-61. [DOI: 10.1016/j.healun.2013.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 07/12/2013] [Accepted: 09/17/2013] [Indexed: 11/24/2022] Open
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Atluri P, Fairman AS, MacArthur JW, Goldstone AB, Cohen JE, Howard JL, Zalewski CM, Shudo Y, Woo YJ. Continuous flow left ventricular assist device implant significantly improves pulmonary hypertension, right ventricular contractility, and tricuspid valve competence. J Card Surg 2013; 28:770-5. [PMID: 24118109 DOI: 10.1111/jocs.12214] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous flow left ventricular assist devices (CF LVAD) are being implanted with increasing frequency for end-stage heart failure. At the time of LVAD implant, a large proportion of patients have pulmonary hypertension, right ventricular (RV) dysfunction, and tricuspid regurgitation (TR). RV dysfunction and TR can exacerbate renal dysfunction, hepatic dysfunction, coagulopathy, edema, and even prohibit isolated LVAD implant. Repairing TR mandates increased cardiopulmonary bypass time and bicaval cannulation, which should be reserved for the time of orthotopic heart transplantation. We hypothesized that CF LVAD implant would improve pulmonary artery pressures, enhance RV function, and minimize TR, obviating need for surgical tricuspid repair. METHODS One hundred fourteen continuous flow LVADs implanted from 2005 through 2011 at a single center, with medical management of functional TR, were retrospectively analyzed. Pulmonary artery pressures were measured immediately prior to and following LVAD implant. RV function and TR were graded according to standard echocardiographic criteria, prior to, immediately following, and long-term following LVAD. RESULTS There was a significant improvement in post-VAD mean pulmonary arterial pressures (26.6 ± 4.9 vs. 30.2 ± 7.4 mmHg, p = 0.008) with equivalent loading pressures (CVP = 12.0 ± 4.0 vs. 12.1 ± 5.1 p = NS). RV function significantly improved, as noted by right ventricular stroke work index (7.04 ± 2.60 vs. 6.05 ± 2.54, p = 0.02). There was an immediate improvement in TR grade and RV function following LVAD implant, which was sustained long term. CONCLUSION Continuous flow LVAD implant improves pulmonary hypertension, RV function, and tricuspid regurgitation. TR may be managed nonoperatively during CF LVAD implant.
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Affiliation(s)
- Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Palmer B, Lampert B, Mathier MA. Management of Right Ventricular Failure in Pulmonary Hypertension (and After LVAD Implantation). CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:533-43. [DOI: 10.1007/s11936-013-0267-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Systolic heart failure is a problem of substantial magnitude worldwide. Over the last 25 years great progress has been made in the medical management of heart failure with the recognition of the benefits of beta-adrenergic blockade, modulation of the renin-angiotensin and mineralocorticoid axes and judicious diuretic therapy. In addition, cardiac resynchronization therapy and prophylactic implantation of cardiac defibrillators have been responsible for measurable benefits in terms of functional status and dysrhythmia-related mortality, respectively. Unfortunately, progressive cardiac dysfunction often results in activity limitation, symptoms at rest, hospital admission, end-organ dysfunction and death despite maximal implementation of standard therapies. Heart transplantation has been a dramatic and effective therapy for end-stage heart failure, but it remains limited by a shortage of donor organs, strict criteria defining acceptable recipients and often unsatisfactory long-term success. Mechanical alternatives to support the failing circulation have been sought for the last 50 years. The history of device development has been marked in general by the slow progress achieved by a few dedicated and persevering pioneers. In the past decade, however, evolving technology has dramatically changed the field and broadened the options for the treatment of advanced heart failure. This review will detail the important milestones and the current state of the art, with an emphasis on implantable devices for intermediate to long term support.
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Piacentino V, Ganapathi AM, Stafford-Smith M, Hsieh MK, Patel CB, Simeone AA, Rogers JG, Milano CA. Utility of concomitant tricuspid valve procedures for patients undergoing implantation of a continuous-flow left ventricular device. J Thorac Cardiovasc Surg 2012; 144:1217-21. [DOI: 10.1016/j.jtcvs.2012.07.064] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/02/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
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Deo SV, Hasin T, Altarabsheh SE, McKellar SH, Shah IK, Durham L, Stulak JM, Daly RC, Park SJ, Joyce LD. Concomitant tricuspid valve repair or replacement during left ventricular assist device implant demonstrates comparable outcomes in the long term. J Card Surg 2012; 27:760-6. [PMID: 23173864 DOI: 10.1111/jocs.12020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Severe tricuspid regurgitation (TR) is present in nearly half the patients undergoing implant of a left ventricular assist device (LVAD) and its correction confers better long-term outcome. AIM To compare the early and late results of tricuspid valve repair (TVrpr) or replacement (TVR) with LVAD implant. PATIENT AND METHODS Sixty-four from a cohort of 126 patients had a concomitant tricuspid valve procedure; 48 (75%) underwent a TVrpr whereas 16 (25%) had TVR. All preoperative hemodynamic parameters including the mean TR grade (TVrpr; 3.6 vs. TVR; 3.7) were comparable (p = 0.7). The mean TR grade was 1.6 ± 1.5 for the remaining 62 patients who did not have a concomitant tricuspid valve procedure, with 4/62 (6%) having severe TR (p < 0.0001). RESULTS Cardiopulmonary bypass time was longer for patients undergoing TVR (p = 0.01). There was a significant reduction in right atrial pressure for the entire cohort (p < 0.01) and the postoperative right atrial pressure was not statistically different between TVrpr (13.6 ± 4.6) and TVR (11.6 ± 4.3; p = 0.6. Postoperative intensive care unit stay was comparable as was the duration of inotropic support (p = 0.5) or need for temporary right ventricular mechanical support. In-hospital mortality (12%) was not different between groups. The mean time for LVAD support was 12.3 ± 9.71 months and the last transthoracic echocardiographic examination was performed at mean intervals of 13.8 ± 10.8 months (TVrpr) and 11.8 ± 7.6 months (TVR; p = 0.47). Reduction in TR grade was similar between groups (p = 0.27). Late mortality (p = 1.00) was comparable in both groups. Using log-rank analysis, there was no significant difference in the estimated survival between TVrpr and TVR (p = 0.88). CONCLUSION TVrpr repair at the time of LVAD implant is effective in correcting TR even at the end of one year of follow-up. The choice to repair or replace does not affect the clinical outcome.
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Affiliation(s)
- Salil V Deo
- Department of Cardiovascular Surgery Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota 55901, USA
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Ozbaran M, Yagdi T, Engin C, Nalbantgil S, Ayik F, Oguz E, Engin Y, Özturk P. New Circulatory Support System: Heartware. Transplant Proc 2012; 44:1726-8. [DOI: 10.1016/j.transproceed.2012.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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44
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Right ventricular failure after LVAD implantation: Prevention and treatment. Best Pract Res Clin Anaesthesiol 2012; 26:217-29. [DOI: 10.1016/j.bpa.2012.03.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/14/2012] [Indexed: 11/22/2022]
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45
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Krishan K, Nair A, Pinney S, Adams D, Anyanwu AC. Low Incidence of Bleeding-Related Morbidity With Left Ventricular Assist Device Implantation in the Current Era. Artif Organs 2012; 36:746-51. [DOI: 10.1111/j.1525-1594.2012.01465.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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