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Ondrusek M, Artemiou P, Bezak B, Gasparovic I, By TMD, Durdik S, Lesny P, Goncalvesova E, Hulman M. Temporal Analysis in Outcomes of Long-Term Mechanical Circulatory Support: Retrospective Study. Thorac Cardiovasc Surg 2024; 72:521-529. [PMID: 38641334 DOI: 10.1055/s-0044-1782600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND Mechanical assist device indications have changed in recent years. Reduced incidence of complications, better survival, and the third generation of mechanical support devices contributed to this change. In this single-center study, we focused on two time periods that are characterized by the use of different types of mechanical support devices, different patient characteristics, and change in the indications. METHODS The data were processed from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). We retrospectively defined two time intervals to reflect changes in ventricular assist device technology (period 1: 2007-2015; period 2: 2016-20222). A total of 181 patients underwent left ventricular assist device implantation. Device utilization was the following: HeartMate II = 52 (76.4%) and HeartWare = 16 (23.6%) in period 1 and HeartMate II = 2 (1.8%), HeartMate 3 = 70 (61:9%), HeartWare = 29 (25.7%), SynCardia TAH = 10 (8.8%), and BerlinHeart EXCOR = 2 (1.8%) in period 2. The outcomes of the time intervals were analyzed and evaluated. RESULTS Survival was significantly higher during the second time period. Multivariate analysis revealed that age and bypass pump time are independent predictors of mortality. Idiopathic cardiomyopathy, bypass time, and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score are independent predictors of adverse events. Furthermore, the first period was noted to be at an increased risk of the following adverse events: pump thrombosis, gastrointestinal bleeding, and bleeding events. CONCLUSION Despite the higher risk profile of the patients and persistent challenges, during the second period, there was a significant decrease in mortality and morbidity. The use of the HeartMate 3 device may have contributed to this result.
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Affiliation(s)
- Matej Ondrusek
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular diseases, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Panagiotis Artemiou
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular diseases, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Branislav Bezak
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular diseases, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Ivo Gasparovic
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular diseases, Clinic of Cardiac Surgery, Bratislava, Slovakia
| | - Theo Mmh de By
- EUROMACS, European Association for Cardio-Thoracic Surgery (EACTS), Windsor, United Kingdom
| | - Stefan Durdik
- Faculty of Medicine, Comenius University, St. Elizabeth Oncology Institute, Clinic of Surgical Oncology, Bratislava, Slovakia
| | - Peter Lesny
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular Diseases, Clinic of Heart Failure, Bratislava, Slovakia
| | - Eva Goncalvesova
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular Diseases, Clinic of Heart Failure, Bratislava, Slovakia
| | - Michal Hulman
- Faculty of Medicine of the Comenius University, National Institute of Cardiovascular diseases, Clinic of Cardiac Surgery, Bratislava, Slovakia
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2
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [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: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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3
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Wu P, Bai Y, Du G, Zhang L, Zhao X. Resistance valves in circulatory loops have a significant impact on in vitro evaluation of blood damage caused by blood pumps: a computational study. Front Physiol 2023; 14:1287207. [PMID: 38098804 PMCID: PMC10720901 DOI: 10.3389/fphys.2023.1287207] [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: 09/01/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
Background: Hemolysis and its complications are major concerns during the clinical application of blood pumps. In-vitro circulatory testing loops have been employed as the key procedure to evaluate the hemolytic and thrombogenic performance of blood pumps during the development phase and before preclinical in-vivo animal studies. Except for the blood damage induced by the pump under test, blood damage induced by loop components such as the resistance valve may affect the accuracy, reproducibility, and intercomparability of test results. Methods: This study quantitatively investigated the impact of the resistance valve on in vitro evaluation of blood damage caused by blood pumps under different operating points. A series of idealized tubing models under the resistance valve with different openings were created. Three pumps - the FDA benchmark pump, the HeartMate 3 LVAD, and the CH-VAD - were involved in hypothetical tests. Eight operating points were chosen to cover a relatively wide spectrum of testing scenarios. Computational fluid dynamics (CFD) simulations of the tubing and pump models were conducted at the same operating points. Results and Conclusion: Overall, hemolysis and platelet activation induced by a typical resistance valve are equivalent to 17%-45% and 14%-60%, respectively, of those induced by the pump itself. Both ratios varied greatly with flow rate, valve opening and pump models. Differences in blood damage levels between different blood pumps or working conditions can be attenuated by up to 45%. Thus, hemolysis and platelet activation induced by the resistance valve significantly affect the accuracy of in-vitro hemocompatibility evaluations of blood pumps. A more accurate and credible method for hemocompatibility evaluations of blood pumps will benefit from these findings.
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Affiliation(s)
- Peng Wu
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing, China
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Yuqiao Bai
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Guanting Du
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Liudi Zhang
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Xiangyu Zhao
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
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4
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Wu P, Wu ZJ, Chen H, Chen Z, Zhang X, Yang M. Editorial: Recent advances in the design and preclinical evaluation of ventricular assist devices. Front Physiol 2023; 14:1322077. [PMID: 38028772 PMCID: PMC10680364 DOI: 10.3389/fphys.2023.1322077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Peng Wu
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing, China
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Zhongjun J. Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Haibo Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xiwen Zhang
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
| | - Ming Yang
- Department of Instrument Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
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5
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Ammann KR, Outridge CE, Roka-Moiia Y, Muslmani S, Ding J, Italiano JE, Tomat E, Corbett S, Slepian MJ. Sodium bicarbonate as a local adjunctive agent for limiting platelet activation, aggregation, and adhesion within cardiovascular therapeutic devices. J Thromb Thrombolysis 2023; 56:398-410. [PMID: 37432612 PMCID: PMC10439054 DOI: 10.1007/s11239-023-02852-4] [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] [Accepted: 06/12/2023] [Indexed: 07/12/2023]
Abstract
Cardiovascular therapeutic devices (CTDs) remain limited by thrombotic adverse events. Current antithrombotic agents limit thrombosis partially, often adding to bleeding. The Impella® blood pump utilizes heparin in 5% dextrose (D5W) as an internal purge to limit thrombosis. While effective, exogenous heparin often complicates overall anticoagulation management, increasing bleeding tendency. Recent clinical studies suggest sodium bicarbonate (bicarb) may be an effective alternative to heparin for local anti-thrombosis. We examined the effect of sodium bicarbonate on human platelet morphology and function to better understand its translational utility. Human platelets were incubated (60:40) with D5W + 25 mEq/L, 50 mEq/L, or 100 mEq/L sodium bicarbonate versus D5W or D5W + Heparin 50 U/mL as controls. pH of platelet-bicarbonate solutions mixtures was measured. Platelet morphology was examined via transmission electron microscopy; activation assessed via P-selectin expression, phosphatidylserine exposure and thrombin generation; and aggregation with TRAP-6, calcium ionophore, ADP and collagen quantified; adhesion to glass measured via fluorescence microscopy. Sodium bicarbonate did not alter platelet morphology but did significantly inhibit activation, aggregation, and adhesion. Phosphatidylserine exposure and thrombin generation were both reduced in a concentration-dependent manner-between 26.6 ± 8.2% (p = 0.01) and 70.7 ± 5.6% (p < 0.0001); and 14.0 ± 6.2% (p = 0.15) and 41.7 ± 6.8% (p = 0.03), respectively, compared to D5W control. Platelet aggregation via all agonists was also reduced, particularly at higher concentrations of bicarb. Platelet adhesion to glass was similarly reduced, between 0.04 ± 0.03% (p = 0.61) and 0.11 ± 0.04% (p = 0.05). Sodium bicarbonate has direct, local, dose-dependent effects limiting platelet activation and adhesion. Our results highlight the potential utility of sodium bicarbonate as a locally acting agent to limit device thrombosis.
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Affiliation(s)
- Kaitlyn R Ammann
- Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA
- Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ, USA
- Sarver Heart Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA
| | - Christine E Outridge
- Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ, USA
| | - Yana Roka-Moiia
- Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA
- Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ, USA
- Sarver Heart Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA
| | - Sami Muslmani
- Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ, USA
| | | | - Joseph E Italiano
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisa Tomat
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, AZ, USA
| | | | - Marvin J Slepian
- Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA.
- Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ, USA.
- Sarver Heart Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA.
- Department of Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724, USA.
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6
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Hayward C, Adachi I, Baudart S, Davis E, Feller ED, Kinugawa K, Klein L, Li S, Lorts A, Mahr C, Mathew J, Morshuis M, Müller M, Ono M, Pagani FD, Pappalardo F, Rich J, Robson D, Rosenthal DN, Saeed D, Salerno C, Sauer AJ, Schlöglhofer T, Tops L, VanderPluym C. Global Best Practices Consensus: Long-term Management of HeartWare Ventricular Assist Device Patients. J Thorac Cardiovasc Surg 2022; 164:1120-1137.e2. [DOI: 10.1016/j.jtcvs.2022.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
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7
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McMullen L, Barker K, Fried J, Wagener G. Clinical considerations for the evaluation of patients with left ventricular assist devices. JAAPA 2022; 35:37-42. [PMID: 34939589 DOI: 10.1097/01.jaa.0000803636.43190.eb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A left ventricular assist device (LVAD) provides mechanical circulatory support for patients with end-stage heart failure. As these devices become more prevalent, clinicians must be familiar with the device's function, common complications, and management strategies when evaluating this patient population.
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Affiliation(s)
- Leah McMullen
- At Columbia University Medical Center in New York, N.Y., Leah McMullen and Kelly Barker practice in the cardiothoracic ICU. Justin Fried is an assistant professor of medicine in the division of cardiology at Columbia University Medical Center. Gebhard Wagener is a professor of anesthesiology at Columbia University Medical Center and chief of the division of vascular anesthesiology. The authors have disclosed no potential conflicts of interest, financial or otherwise
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8
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Doğan Ö, Arslan Ş, Özyıldırım S, Abacı O. A stable patient with a left ventricular assist device was admitted to the outpatient clinic with ventricular fibrillation. Anatol J Cardiol 2021; 25:595-597. [PMID: 34369890 DOI: 10.5152/anatoljcardiol.2021.02009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ömer Doğan
- İstanbul University-Cerrahpaşa, Institute of Cardiology; İstanbul-Turkey
| | - Şükrü Arslan
- İstanbul University-Cerrahpaşa, Institute of Cardiology; İstanbul-Turkey
| | - Serhan Özyıldırım
- İstanbul University-Cerrahpaşa, Institute of Cardiology; İstanbul-Turkey
| | - Okay Abacı
- İstanbul University-Cerrahpaşa, Institute of Cardiology; İstanbul-Turkey
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9
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Santos CD, Matos NL, Asleh R, Dawit S, Rabinstein AA, O'Carroll CB, Li Z, Freeman WD. The Dilemma of Resuming Antithrombotic Therapy After Intracranial Hemorrhage in Patients With Left Ventricular Assist Devices. Neurocrit Care 2021; 32:822-827. [PMID: 31531758 DOI: 10.1007/s12028-019-00836-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND/OBJECTIVE Antithrombotic therapy is administered after left ventricular assist device (LVAD) implantation to prevent thromboembolic events. Intracranial hemorrhage (ICH) is a life-threatening adverse event requiring immediate discontinuation of antithrombotics. We investigated the timing of antithrombotic resumption after ICH in patients with LVADs and the association between timing and risk of recurrent hemorrhage and thrombotic events. METHODS We performed a multicenter, retrospective analysis of patients with ICH occurrence during LVAD antithrombotic regimen with subsequent resumption of antithrombotics from January 1, 2010, to December 31, 2017. Covariates included age, international normalized ratio, antithrombotic dosing, timing of resumption, modified Rankin score, and subsequent hemorrhagic and thrombotic events within 1 year post-ICH. Patients who did not resume anticoagulation were excluded. RESULTS Of 673 patients with LVADs, 85 (12.6%) developed ICH while being treated with antithrombotics. Forty-three were excluded due to death prior to resumption and one due to lack of resumption. The remaining 41 patients were on antithrombotics with a median (interquartile range [IQR]) international normalized ratio at ICH onset of 2.6 (1.8-3.6). Aspirin and warfarin were resumed at a median (IQR) of 5.5 (1.3-8.8) and 6.5 (4.0-15.5) days post-ICH, respectively. A continuous unfractionated heparin infusion was initiated in 16 (39.0%) patients at a median (IQR) of 2.5 (1.0-7.8) days post-ICH. During the 1-year follow-up after anticoagulation resumption, 11 (26.8%) patients suffered secondary hemorrhages and two (4.9%) suffered secondary thrombotic events. Using Kaplan-Meier method and log-rank test, we compared all patients who resumed anticoagulation by 6 days post-ICH to those who resumed after 6 days. There was no difference in freedom from secondary hemorrhagic event between the two groups (P = 0.75). CONCLUSION Despite timing of resumption of antithrombotic therapy after ICH, recurrent hemorrhagic events can be expected in one-quarter of these patients over the subsequent year.
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Affiliation(s)
- Christan D Santos
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| | - Nikki L Matos
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara Dawit
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | | | | | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - William D Freeman
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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10
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Michelhaugh SA, Camacho A, Ibrahim NE, Gaggin H, D’Alessandro D, Coglianese E, Lewis GD, Januzzi JL. Proteomic Signatures During Treatment in Different Stages of Heart Failure. Circ Heart Fail 2020; 13:e006794. [DOI: 10.1161/circheartfailure.119.006794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
Proteomics have already provided novel insights into the pathophysiology of heart failure (HF) with reduced ejection fraction. Previous studies have evaluated cross-sectional protein signatures of HF, but few have characterized proteomic changes following HF with reduced ejection fraction treatment with ARNI (angiotensin receptor/neprilysin inhibitor) therapy or left ventricular assist devices.
Methods:
In this retrospective omics study, we performed targeted proteomics (N=625) of whole blood sera from patients with American College of Cardiology/American Heart Association stage D (N=29) and stage C (N=12) HF using proximity extension assays. Samples were obtained before and after (median=82 days) left ventricular assist device implantation (stage D; primary analysis) and ARNI therapy initiation (stage C; matched reference). Oblique principal component analysis and point biserial correlations were used for feature extraction and selection; standardized mean differences were used to assess within and between-group differences; and enrichment analysis was used to generate and cluster Gene Ontology terms.
Results:
Core sets of proteins were identified for stage C (N=9 proteins) and stage D (N=18) HF; additionally, a core set of 5 shared HF proteins (NT-proBNP [N-terminal pro-B type natriuretic peptide], ESM [endothelial cell-specific molecule]-1, cathepsin L1, osteopontin, and MCSF-1) was also identified. For patients with stage D HF, moderate (δ, 0.40–0.60) and moderate-to-large (δ, 0.60–0.80) sized differences were observed in 8 of their 18 core proteins after left ventricular assist devices implantation. Additionally, specific protein groups reached concentration levels equivalent (
g
<0.10) to stage C HF after initiation on ARNI therapy.
Conclusions:
HF with reduced ejection fraction severity associates with distinct proteomic signatures that reflect underlying disease attributes; these core signatures may be useful for monitoring changes in cardiac function following initiation on ARNI or left ventricular assist device implantation.
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Affiliation(s)
- Sam A. Michelhaugh
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Alexander Camacho
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Nasrien E. Ibrahim
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - Hanna Gaggin
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - David D’Alessandro
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Erin Coglianese
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - Gregory D. Lewis
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - James L. Januzzi
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
- Baim Institute for Clinical Research, Boston, MA (J.L.J.)
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11
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Li M, Walk R, Roka-Moiia Y, Sheriff J, Bluestein D, Barth EJ, Slepian MJ. Circulatory loop design and components introduce artifacts impacting in vitro evaluation of ventricular assist device thrombogenicity: A call for caution. Artif Organs 2019; 44:E226-E237. [PMID: 31876310 DOI: 10.1111/aor.13626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/20/2019] [Accepted: 12/16/2019] [Indexed: 12/28/2022]
Abstract
Mechanical circulatory support (MCS) devices continue to be hampered by thrombotic adverse events (AEs), a consequence of device-imparted supraphysiologic shear stresses, leading to shear-mediated platelet activation (SMPA). In advancing MCS devices from design to clinical use, in vitro circulatory loops containing the device under development and testing are utilized as a means of assessing device thrombogenicity. Physical characteristics of these test circulatory loops may also contribute to inadvertent platelet activation through imparted shear stress, adding inadvertent error in evaluating MCS device thrombogenicity. While investigators normally control for the effect of a loop, inadvertent addition of what are considered innocuous connectors may impact test results. Here, we tested the effect of common, additive components of in vitro circulatory test loops, that is, connectors and loop geometry, as to their additive contribution to shear stress via both in silico and in vitro models. A series of test circulatory loops containing a ventricular assist device (VAD) with differing constituent components, were established in silico including: loops with 0~5 Luer connectors, a loop with a T-connector creating 90° angulation, and a loop with 90° angulation. Computational fluid dynamics (CFD) simulations were performed using a k - ω shear stress transport turbulence model to platelet activation index (PAI) based on a power law model. VAD-operated loops replicating in silico designs were assembled in vitro and gel-filtered human platelets were recirculated within (1 hour) and SMPA was determined. CFD simulations demonstrated high shear being introduced at non-smooth regions such as edge-connector boundaries, tubing, and at Luer holes. Noticeable peaks' shifts of scalar shear stress (sss) distributions toward high shear-region existed with increasing loop complexity. Platelet activation also increased with increasing shear exposure time, being statistically higher when platelets were exposed to connector-employed loop designs. The extent of platelet activation in vitro could be successfully predicted by CFD simulations. Loops employing additional components (non-physiological flow pattern connectors) resulted in higher PAI. Loops with more components (5-connector loop and 90° T-connector) showed 63% and 128% higher platelet activation levels, respectively, versus those with fewer (0-connector (P = .023) and a 90° heat-bend loop (P = .0041). Our results underscore the importance of careful consideration of all component elements, and suggest the need for standardization in designing in vitro circulatory loops for MCS device evaluation to avoid inadvertent additive SMPA during device evaluation, confounding overall results. Specifically, we caution on the use and inadvertent introduction of additional connectors, ports, and other shear-generating elements which introduce artifact, clouding primary device evaluation via introduction of additive SMPA.
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Affiliation(s)
- Mengtang Li
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Ryan Walk
- Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Yana Roka-Moiia
- Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Eric J Barth
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Marvin J Slepian
- Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA.,Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.,Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA
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Left ventricular assist devices and their complications: A review for emergency clinicians. Am J Emerg Med 2019; 37:1562-1570. [PMID: 31072684 DOI: 10.1016/j.ajem.2019.04.050] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION End stage heart failure is associated with high mortality. However, recent developments such as the ventricular assist device (VAD) have improved patient outcomes, with left ventricular assist devices (LVAD) most commonly implanted. OBJECTIVE This narrative review evaluates LVAD epidemiology, indications, normal function and components, and the assessment and management of complications in the emergency department (ED). DISCUSSION The LVAD is a life-saving device in patients with severe heart failure. While first generation devices provided pulsatile flow, current LVAD devices produce continuous flow. Normal components include the pump, inflow and outflow cannulas, driveline, and external controller. Complications related to the LVAD can be divided into those that are LVAD-specific and LVAD-associated, and many of these complications can result in severe patient morbidity and mortality. LVAD-specific complications include device malfunction/failure, pump thrombosis, and suction event, while LVAD-associated complications include bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation. Assessment of LVAD function, patient perfusion, and mean arterial pressure is needed upon presentation. Electrocardiogram and bedside ultrasound are key evaluations in the ED. LVAD evaluation and management require a team-based approach, and consultation with the LVAD specialist is recommended. CONCLUSION Emergency clinician knowledge of LVAD function, components, and complications is integral in optimizing care of these patients.
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