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Dridi NP, Vishram-Nielsen JKK, Gustafsson F. Exercise Tolerance in Patients Treated With a Durable Left Ventricular Assist Device: Importance of Myocardial Recovery. J Card Fail 2020; 27:486-493. [PMID: 33347995 DOI: 10.1016/j.cardfail.2020.12.005] [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] [Received: 06/30/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
The number of patients supported with left ventricular assist devices (LVADs) is growing and support times are increasing. This has led to a greater focus on functional capacity of these patients. LVADs greatly improve heart failure symptoms, but surprisingly, improvement in peak oxygen uptake (pVO2) is small and remains decreased at approximately 50% of normal values. Inadequate increase in cardiac output during exercise is the main responsible factor for the low pVO2 in LVAD recipients. Some patients experience LV recovery during mechanical unloading and these patients have a higher pVO2. Here we review the various components determining exercise cardiac output in LVAD recipients and discuss the potential impact of cardiac recovery on these components. LV recovery may affect several components, leading to improved hemodynamics during exercise and, in turn, physical capacity in patients with advanced heart failure undergoing LVAD implantation.
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Affiliation(s)
- Nadia Paarup Dridi
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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2
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Ferrari G, Górczyńska K, Mimmo R, De Lazzari C, Clemente F, Tosti G, Guaragno M. Mono and Bi-ventricular Assistance: Their Effect on Ventricular Energetics. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When mono- and bi-ventricular mechanical assistance is used for heart recovery, its control strategy and circulatory variables affect ventricular energetics (external work-EW, oxygen consumption-VO2, cardiac mechanical efficiency-CME). This study is based on the data obtained in vitro and presents an analysis of the effects of the mono- and bi-ventricular mechanical assistance on ventricular energetics. The assistance was conducted on the principle of counterpulsation with atrio-arterial connection. It includes the following stages: 1) the characterisation of the isolated ventricle model in terms of EW, VO2 and CME as a function of the filling pressure and peripheral resistance, 2) modelling of left ventricular and pulmonary dysfunction, followed by left ventricular and bi-ventricular assistance. Experimental data enable us to draw the following conclusions: • in general, the greatest hemodynamic improvement does not correspond to the highest energetic improvement, • LVAD assistance deteriorates left ventricular CME while its effect on right ventricular energetics depends on the value of right ventricular elastance (Emax). Right ventricular CME is deteriorated by BVAD assistance irrespective of right Emax, • the energetics optimisation in bi-ventricular assistance is closely related to the right Emax, which could probably be a deciding factor in the choice of the assistance mode.
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Affiliation(s)
- G. Ferrari
- CNR Institute for Biomedical Technology, Rome - Italy
| | - K. Górczyńska
- PAN Institute of Biocybernetics and Biomedical Engineering, Warsaw - Poland
| | - R. Mimmo
- CNR Institute for Biomedical Technology, Rome - Italy
| | - C. De Lazzari
- CNR Institute for Biomedical Technology, Rome - Italy
| | - F. Clemente
- CNR Institute for Biomedical Technology, Rome - Italy
| | - G. Tosti
- CNR Institute for Biomedical Technology, Rome - Italy
| | - M. Guaragno
- CNR Institute for Biomedical Technology, Rome - Italy
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3
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Gautier SV, Itkin GP, Shevchenko AO, Khalilulin TA, Kozlov VA. DURABLE MECHANICAL CIRCULATION SUPPORT AS AN ALTERNATIVE TO HEART TRANSPLANTATION. ACTA ACUST UNITED AC 2016. [DOI: 10.15825/1995-1191-2016-3-128-136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the review a comparative analysis of the treatment of end-stage chronic heart failure using heart transplantation and durable mechanical circulatory is conducted. It shows the main advantages and limitations of heart transplantation and the prospects of application of durable mechanical circulatory support technology. The main directions of this technology, including two-stage heart transplant (bridge to transplant – BTT), assisted circulation for myocardial recovery (bridge to recovery – BTR) and implantation of an auxiliary pump on a regular basis (destination therapy, DT).
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Affiliation(s)
- S. V. Gautier
- V.I. Shumakov Federal Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation, Moscow
| | - G. P. Itkin
- V.I. Shumakov Federal Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation, Moscow; Moscow Institute of Physics and Technology (State University), Department of physics of living systems, Moscow
| | - A. O. Shevchenko
- V.I. Shumakov Federal Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation, Moscow; N.I. Pirogov First Moscow State Medical University, Moscow
| | - T. A. Khalilulin
- V.I. Shumakov Federal Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation, Moscow; N.I. Pirogov First Moscow State Medical University, Moscow
| | - V. A. Kozlov
- Moscow Institute of Physics and Technology (State University), Department of physics of living systems, Moscow
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4
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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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Díez-Villanueva P, Gutiérrez-Ibañes E, Cuerpo-Caballero GP, Sanz-Ruiz R, Abeytua M, Soriano J, Sarnago F, Elízaga J, González-Pinto A, Fernández-Avilés F. Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty. Ann Thorac Surg 2014; 97:1300-5. [PMID: 24529484 DOI: 10.1016/j.athoracsur.2013.12.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/27/2013] [Accepted: 12/18/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves dramatic clinical consequences. So far, only five cases have been described in the literature. METHODS We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. RESULTS We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). CONCLUSIONS Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patient's outcome, most often by means of an emergency revascularization strategy.
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Affiliation(s)
- Pablo Díez-Villanueva
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain.
| | - Enrique Gutiérrez-Ibañes
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Gregorio P Cuerpo-Caballero
- Departments of Cardiovascular Surgery and Anesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ricardo Sanz-Ruiz
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Abeytua
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Soriano
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Sarnago
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Jaime Elízaga
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Angel González-Pinto
- Departments of Cardiovascular Surgery and Anesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
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Abstract
The function of the right ventricle (RV) in heart failure (HF) has been mostly ignored until recently. A 2006 report of the National Heart, Lung, and Blood Institute identified a gap between RV research efforts and its clinical importance compared with that of the left ventricle. This recent shift in paradigm is fueled by the prognostic value ascribed to RV failure in HF and morbidity/mortality after myocardial infarction and surgery. In this review, we examine the significance of RV failure in the HF setting, its clinical presentation and pathophysiology, and ways to evaluate RV function using echocardiographic measurements. Furthermore, we discuss the medical management of RV failure including traditional therapies like beta-blockers and newer options like nitric oxide, phosphodiesterase inhibitors, and calcium sensitizers. Mechanical support is also examined. Finally, this review places an emphasis on RV failure in the setting of left ventricular assist devices and heart transplantation.
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7
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Effective ventricular unloading by left ventricular assist device varies with stage of heart failure: cardiac simulator study. ASAIO J 2012; 57:407-13. [PMID: 21817896 DOI: 10.1097/mat.0b013e318229ca8d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although the use of left ventricular assist devices (LVADs) as a bridge-to-recovery (BTR) has shown promise, clinical success has been limited due to the lack of understanding the timing of implantation, acute/chronic device setting, and explantation. This study investigated the effective ventricular unloading at different heart conditions by using a mock circulatory system (MCS) to provide a tool for pump parameter adjustments. We tested the hypothesis that effective unloading by LVAD at a given speed varies with the stage of heart failure. By using a MCS, systematic depression of cardiac performance was obtained. Five different stages of heart failure from control were achieved by adjusting the pneumatic systolic/diastolic pressure, filling pressure, and systemic resistance. The Heart Mate II® (Thoratec Corp., Pleasanton, CA) was used for volumetric and pressure unloading at different heart conditions over a given LVAD speed. The effective unloading at a given LVAD speed was greater in more depressed heart condition. The rate of unloading over LVAD speed was also greater in more depressed heart condition. In conclusion, to get continuous and optimal cardiac recovery, timely increase in LVAD speed over a period of support is needed while avoiding the akinesis of aortic valve.
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8
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Scherer M, Sirat AS, Moritz A, Martens S. Extracorporeal membrane oxygenation as perioperative right ventricular support in patients with biventricular failure undergoing left ventricular assist device implantation. Eur J Cardiothorac Surg 2011; 39:939-44; discussion 944. [DOI: 10.1016/j.ejcts.2010.09.044] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 09/22/2010] [Accepted: 09/29/2010] [Indexed: 11/15/2022] Open
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9
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Kirkpatrick JN. Using Echo to Evaluate Patients With Left Ventricular Assist Devices (LVADs): Adding Non-Invasive PVR Into the Diagnostic Toolbox. J Am Soc Echocardiogr 2009; 22:1063-6. [DOI: 10.1016/j.echo.2009.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Fitzpatrick JR, Frederick JR, Hsu VM, Kozin ED, O'Hara ML, Howell E, Dougherty D, McCormick RC, Laporte CA, Cohen JE, Southerland KW, Howard JL, Jessup ML, Morris RJ, Acker MA, Woo YJ. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant 2009; 27:1286-92. [PMID: 19059108 DOI: 10.1016/j.healun.2008.09.006] [Citation(s) in RCA: 298] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 07/09/2008] [Accepted: 09/03/2008] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Right ventricular (RV) failure after left ventricular assist device (LVAD) placement is a serious complication and is difficult to predict. In the era of destination therapy and the total artificial heart, predicting post-LVAD RV failure requiring mechanical support is extremely important. METHODS We reviewed patient characteristics, laboratory values and hemodynamic data from 266 patients who underwent LVAD placement at the University of Pennsylvania from April 1995 to June 2007. RESULTS Of 266 LVAD recipients, 99 required RV assist device (BiVAD) placement (37%). We compared 36 parameters between LVAD (n = 167) and BiVAD patients (n = 99) to determine pre-operative risk factors for RV assist device (RVAD) need. By univariate analysis, 23 variables showed statistically significant differences between the two groups (p < or = 0.05). By multivariate logistic regression, cardiac index < or =2.2 liters/min/m(2) (odds ratio [OR] 5.7), RV stroke work index < or =0.25 mm Hg . liter/m(2) (OR 5.1), severe pre-operative RV dysfunction (OR 5.0), pre-operative creatinine > or =1.9 mg/dl (OR 4.8), previous cardiac surgery (OR 4.5) and systolic blood pressure < or =96 mm Hg (OR 2.9) were the best predictors of RVAD need. CONCLUSIONS The most significant predictors for RVAD need were cardiac index, RV stroke work index, severe pre-operative RV dysfunction, creatinine, previous cardiac surgery and systolic blood pressure. Using these data, we constructed an algorithm that can predict which LVAD patients will require RVAD with >80% sensitivity and specificity.
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Affiliation(s)
- J Raymond Fitzpatrick
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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11
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Catena E, Paino R, Milazzo F, Colombo T, Marianeschi S, Lanfranconi M, Aresta F, Bruschi G, Russo C, Vitali E. Mechanical Circulatory Support for Patients With Fulminant Myocarditis: The Role of Echocardiography To Address Diagnosis, Choice of Device, Management, and Recovery. J Cardiothorac Vasc Anesth 2009; 23:87-94. [DOI: 10.1053/j.jvca.2008.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Indexed: 11/11/2022]
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12
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Maybaum S, Kamalakannan G, Murthy S. Cardiac Recovery During Mechanical Assist Device Support. Semin Thorac Cardiovasc Surg 2008; 20:234-46. [DOI: 10.1053/j.semtcvs.2008.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2008] [Indexed: 11/11/2022]
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13
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Postcardiotomy Cardiogenic Shock: The Role of Ventricular Assist Devices. Crit Care Nurs Clin North Am 2007; 19:427-43, vi-vii. [DOI: 10.1016/j.ccell.2007.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Mahmud M, Champion HC. Right ventricular failure complicating heart failure: pathophysiology, significance, and management strategies. Curr Cardiol Rep 2007; 9:200-8. [PMID: 17470333 DOI: 10.1007/bf02938351] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Right heart failure most commonly results from the complication of left heart failure (systolic or nonsystolic dysfunction) or pulmonary hypertension. Over the past decade, greater attention has been paid to the role of right ventricular failure in the morbidity and mortality associated with cardiomyopathy and pulmonary hypertension. The right ventricle is distinct from the left ventricle not only in its spatial localization, but also in its response to increased afterload and signaling mechanisms. This article discusses the role of right ventricular failure in the setting of heart failure as well as the clinical diagnosis and management of right ventricular failure.
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Affiliation(s)
- Mobusher Mahmud
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 720 Rutland Avenue, Ross 850, Baltimore, MD 21205, USA
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15
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Hetzer R, Alexi-Meskishvili V, Weng Y, Hübler M, Potapov E, Drews T, Hennig E, Kaufmann F, Stiller B. Mechanical cardiac support in the young with the Berlin Heart EXCOR pulsatile ventricular assist device: 15 years' experience. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006:99-108. [PMID: 16638554 DOI: 10.1053/j.pcsu.2006.02.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The pediatric-size pneumatically driven pulsatile extracorporeal ventricular assist device (VAD) Berlin Heart EXCOR (Berlin Heart Mediprodukt GmbH, Berlin, Germany) was introduced into clinical practice by the German Heart Institute Berlin in 1992. Until July 1, 2005, Berlin Heart EXCOR systems have been used for circulatory support in 68 children up to 18 years of age with severe circulatory failure resistant to pharmacologic therapy. These were patients suffering from cardiomyopathy, fulminant myocarditis, end-stage congenital cardiac defects, and acute heart failure following congenital heart surgery. Mean VAD support time was 35 days (range, 0 to 420 days). Forty-two patients (62%) survived to transplantation or after weaning; 37 patients (54%), including eight infants, were discharged home. These results in patients with very advanced disease have improved significantly in recent years because of technical developments and growing experience in the treatment of patients on the device, in postoperative care and optimal timing for VAD implantation. Timely implantation of the Berlin Heart EXCOR in the course of progressive heart failure now appears to be justified because the system has undergone the necessary modifications and the accumulation of clinical knowledge has made its use highly reliable and safe.
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16
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Radovancevic B, Gregoric ID, Tamez D, Vrtovec B, Tuzun E, Chee HK, Moore S, Jarvik RK, Frazier OH. Biventricular Support with the Jarvik 2000 Axial Flow Pump: A Feasibility Study. ASAIO J 2003; 49:604-7. [PMID: 14524573 DOI: 10.1097/01.mat.0000084109.47034.8a] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with congestive heart failure who are supported with a left ventricular assist device (LVAD) may experience right ventricular dysfunction or failure that requires support with a right ventricular assist device (RVAD). To determine the feasibility of using a clinically available axial flow ventricular assist device as an RVAD, we implanted Jarvik 2000 pumps in the left ventricle and right atrium of two Corriente crossbred calves (approximately 100 kg each) by way of a left thoracotomy and then analyzed the hemodynamic effects in the mechanically fibrillated heart at various LVAD and RVAD speeds. Right atrial implantation of the device required no modification of either the device or the surgical technique used for left ventricular implantation. Satisfactory biventricular support was achieved during fibrillation as evidenced by an increase in mean aortic pressure from 34 mm Hg with the pumps off to 78 mm Hg with the pumps generating a flow rate of 4.8 L/min. These results indicate that the Jarvik 2000 pump, which can provide chronic circulatory support and can be powered by external batteries, is a feasible option for right ventricular support after LVAD implantation and is capable of completely supporting the circulation in patients with global heart failure.
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Affiliation(s)
- Branislav Radovancevic
- Cardiopulmonary Transplantation Service and Cullen Cardiovascular Research Laboratories, Texas Heart Institute at St. Luke's Episcopal Hospital, PO Box 20345, Houston, TX 77225-0345, USA
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17
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Abstract
Patient selection for left ventricular assist device (LVAD) therapy is the most important process in obtaining a successful outcome. Evaluation requires assessing the appropriateness for device implantation based on need and risk of LVAD implant to the patient. Appropriate patients can be selected without the need for invasive hemodynamic measurements and selection can be based on symptoms, appropriateness of medical therapy, and on the need for inotropic therapy. Assessing the risk of LVAD therapy to the patient requires evaluating the degree of organ dysfunction and technical factors. Patients should be offered the option of LVAD therapy if they meet criteria for need, possess the potential for organ recovery, and have appropriate operative risk.
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Affiliation(s)
- Keith D Aaronson
- Division of Cardiology, Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
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18
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Abstract
There are currently several safe and effective options to provide temporary MCS for patients presenting with cardiogenic shock or refractory heart failure. Newer device designs are currently being developed that will increase the options available to patients. Due to the technological advancements, it will be difficult to predict what devices will ultimately prove to be the most efficacious. It is likely that a variety of devices will be necessary, depending on clinical circumstances and patient characteristics.
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Affiliation(s)
- Himanshu Patel
- University of Michigan Medical Center, 2120 Taubman Center, Box 0348, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0348, USA
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19
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Abstract
Heart failure is a particularly complex disorder with etiology that is primary in nature or secondary to other systemic diseases, including hypertension, diabetes, and atherosclerosis. The pathogenesis appears to result, in part, from extensive abnormal interactions among tissues, such as the heart, vasculature, kidney, lungs, and sympathetic nervous system. Improvements in understanding this complex disorder, particularly factors that contribute to cardiac cell cycle alterations, gene activation and re-expression resulting in cardiac remodeling and, eventually, maladaption are paramount. Clinical experience with the current generation of mechanical blood pumps continues to be promising; nonetheless, these devices are not the definitive therapy for all patients with heart failure. The next generation of devices capable of mimicking many of the native heart pump attributes, such as responsiveness to preload, afterload, contractility, and beat rate, will broaden the use of this technology. In addition to solving the fundamental engineering challenges (size, energy supply, biocompatibility, durability, and portability), implantable heart pumps that are physiologically adaptive would enhance the treatment strategies for prolonged chronic support. The ultimate measure of device mediated success is to show improvements that extend beyond a favorable hemodynamic profile and include nutritional status and metabolic and neurohormonal levels and must demonstrate improved exercise tolerance and a better quality of life.
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Affiliation(s)
- Paul B Bolno
- Hahnemann University Hospital, Broad & Vine Streets, Philadelphia, PA 19102-1192, USA
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20
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Abstract
Right heart failure continues to affect our clinical success with left ventricular assist device support. The inability to consistently predict the probability of the onset of right heart dysfunction contributes to this problem. We have developed an aggressive approach to the management of these patients in an attempt to decrease the incidence of this condition, which continues to carry a very high operative mortality.
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Affiliation(s)
- C H Van Meter
- Division of Cardiothoracic Surgery and Transplantation, Alton Ochsner Medical Foundation, New Orleans, Louisiana, USA
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21
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Piccione W. Left ventricular assist device implantation: short and long-term surgical complications. J Heart Lung Transplant 2000; 19:S89-94. [PMID: 11016495 DOI: 10.1016/s1053-2498(99)00110-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Long-term implanted left ventricular assist devices (LVADs) have significantly improved the care of patients awaiting heart transplantation and will provide an alternative therapy to select patients with heart failure. However, although the technology and clinical results continue to improve, LVAD implantation is still associated with a significant level of complications. Left ventricular assist device-associated complications can be broadly divided by their temporal occurrence. Early complications include perioperative hemorrhage, air embolism, and right ventricular failure. Beyond the perioperative period, late complications consist primarily of infection, thromboembolism, and primary device failure. An improved understanding of the mechanisms involved should aid the clinician in further reducing the incidence of these occurrences.
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Affiliation(s)
- W Piccione
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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Noirhomme P, Jacquet L, d'Udekem d'Acoz Y, Goenen M, Dion R. Ischemic right heart failure following LVAD implantation. J Heart Lung Transplant 2000; 19:619-20. [PMID: 10939792 DOI: 10.1016/s1053-2498(00)00097-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
During the latter half of the twentieth century, physicians have had the capability to support the circulation with mechanical devices. This article gives an historical overview of those devices. Various devices and their complications are described and evaluated. Patient selection and clinical results also are discussed.
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Affiliation(s)
- D G Pennington
- Department of Cardiothoracic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
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