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Carr MJ, Smith SA, Slaughter MS, Pahwa S. Managing valvular pathology during LVAD implantation. Indian J Thorac Cardiovasc Surg 2023; 39:101-113. [PMID: 37525709 PMCID: PMC10387021 DOI: 10.1007/s12055-023-01567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
Since the time of their invention, implantable continuous flow left ventricular assist devices (LVADs) have improved the quality of life and extended survival for patients with advanced heart failure. The decision surgeons and their physician colleagues make with these patients to undergo implantation must come with full understanding of the immediate, short-term, and long-term implications of such a life-changing procedure. The presence of pathology regarding the aortic, mitral, and tricuspid valves introduces particularly complex problems for the surgical treatment strategy. Concomitant valve repair or replacement increases cardiopulmonary bypass and cross clamp times, and could potentially lead to worse outcomes in the perioperative setting. Following perioperative recovery, valvular pathology may worsen or arise de novo given the often drastic immediate physiologic changes in blood flow, septal function, and, over time, ventricular remodeling. Over the past two decades, there has been vast improvement in the device manufacturing, surgical techniques, and medical management surrounding LVAD implantation. Yet, addressing concomitant valvular pathology remains a complex question with no perfect solutions. This review aims to briefly describe the evolution of approach to valvular pathology in the LVAD patient and offer our opinion and treatment rationale.
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Affiliation(s)
- Michael J. Carr
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Susan Ansley Smith
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
| | - Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY USA
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Siems C, Aggarwal R, Shaffer A, John R. Right heart failure after left ventricular assist device implantation: a persistent problem. Indian J Thorac Cardiovasc Surg 2023; 39:161-169. [PMID: 37525713 PMCID: PMC10387018 DOI: 10.1007/s12055-023-01481-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/09/2022] [Accepted: 01/17/2023] [Indexed: 02/24/2023] Open
Abstract
Left ventricular assist device (LVAD) is an option for bridge-to-transplant or destination therapy for patients with end-stage heart failure. Right heart failure (RHF) remains a complication after LVAD implantation that portends high morbidity and mortality, despite advances in LVAD technology. Definitions of RHF vary, but generally include the need for inotropic or pulmonary vasodilator support, or potential right ventricular (RV) mechanical circulatory support. This review covers the complex pathophysiology of RHF related to underlying myocardial dysfunction, interventricular dependence, and RV afterload, as well as treatment strategies to curtail this challenging problem.
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Affiliation(s)
- Chesney Siems
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455 USA
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Calin E, Ducharme A, Carrier M, Lamarche Y, Ben Ali W, Noly PE. Key questions about aortic insufficiency in patients with durable left ventricular assist devices. Front Cardiovasc Med 2022; 9:1068707. [PMID: 36505355 PMCID: PMC9729243 DOI: 10.3389/fcvm.2022.1068707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
The development of the latest generation of durable left ventricular assist devices (LVAD) drastically decreased adverse events such as pump thrombosis or disabling strokes. However, time-related complications such as aortic insufficiency (AI) continue to impair outcomes following durable LVAD implantation, especially in the context of long-term therapy. Up to one-quarter of patients with durable LVAD develop moderate or severe AI at 1 year and its incidence increases with the duration of support. The continuous regurgitant flow within the left ventricle can compromise left ventricular unloading, increase filling pressures, decrease forward flow and can thus lead to organ hypoperfusion and heart failure. This review aims to give an overview of the epidemiology, pathophysiology, and clinical consequences of AI in patients with durable LVAD.
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Affiliation(s)
- Eliza Calin
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Pierre-Emmanuel Noly
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada,*Correspondence: Pierre-Emmanuel Noly,
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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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