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Tran P, Lau C, Joshi M, Kuehl M, Maddock H, Banerjee P. Exploring Changes in Myocyte Structure, Contractility, and Energetics From Mechanical Unloading in Patients With Heart Failure Undergoing Ventricular Assist Device Implantation: A Systematic Review and Meta-Analysis. Heart Lung Circ 2024:S1443-9506(24)00082-9. [PMID: 38704332 DOI: 10.1016/j.hlc.2024.01.039] [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: 09/17/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 05/06/2024]
Abstract
AIMS Recent reports of myocardial recovery after mechanical unloading with left ventricular assist devices (LVADs) have challenged the prevailing notion that end-stage heart failure (HF) is irreversible. To improve our understanding of this phenomenon, we comprehensively analysed the structural, functional, and energetic changes in failing human cardiomyocytes after LVAD implantation. METHODS Based on a prospectively registered protocol (PROSPERO-CRD42022380214), 30 eligible studies were identified from 940 records with a pooled population of 648 patients predominantly with non-ischaemic cardiomyopathy. RESULTS LVAD led to a substantial regression in myocyte size similar to that of donor hearts (standardised mean difference, -1.29; p<0.001). The meta-regression analysis revealed that HF duration was a significant modifier on the changes in myocyte size. There were some suggestions of fibrosis reversal (-5.17%; p=0.009); however, this was insignificant after sensitivity analysis. Developed force did not improve in cardiac trabeculae (n=5 studies); however, non-physiological isometric contractions were tested. At the myocyte level (n=4 studies), contractile kinetics improved where the time-to-peak force reduced by 41.7%-50.7% and time to 50% relaxation fell by 47.4%-62.1% (p<0.05). Qualitatively, LVAD enhanced substrate utilisation and mitochondrial function (n=6 studies). Most studies were at a high risk of bias. CONCLUSION The regression of maladaptive hypertrophy, partial fibrosis reversal, and normalisation in metabolic pathways after LVAD may be a testament to the heart's remarkable plasticity, even in the advanced stages of HF. However, inconsistencies exist in force-generating capabilities. Using more physiological force-length work-loop assays, addressing the high risks of bias and clinical heterogeneity are crucial to better understand the phenomenon of reverse remodelling.
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Affiliation(s)
- Patrick Tran
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Clement Lau
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mithilesh Joshi
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Kuehl
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Maddock
- Centre for Health & Life Sciences, Coventry University, Coventry, UK
| | - Prithwish Banerjee
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
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2
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Pamias-Lopez B, Ibrahim ME, Pitoulis FG. Cardiac mechanics and reverse remodelling under mechanical support from left ventricular assist devices. Front Cardiovasc Med 2023; 10:1212875. [PMID: 37600037 PMCID: PMC10433771 DOI: 10.3389/fcvm.2023.1212875] [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: 04/27/2023] [Accepted: 07/05/2023] [Indexed: 08/22/2023] Open
Abstract
In recent years, development of mechanical circulatory support devices has proved to be a new treatment modality, in addition to standard pharmacological therapy, for patients with heart failure or acutely depressed cardiac function. These include left ventricular assist devices, which mechanically unload the heart when implanted. As a result, they profoundly affect the acute cardiac mechanics, which in turn, carry long-term consequences on myocardial function and structural function. Multiple studies have shown that, when implanted, mechanical circulatory assist devices lead to reverse remodelling, a process whereby the diseased myocardium reverts to a healthier-like state. Here, we start by first providing the reader with an overview of cardiac mechanics and important hemodynamic parameters. We then introduce left ventricular assist devices and describe their mode of operation as well as their impact on the hemodynamics. Changes in cardiac mechanics caused by device implantation are then extrapolated in time, and the long-term consequences on myocardial phenotype, as well as the physiological basis for these, is investigated.
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Affiliation(s)
- Blanca Pamias-Lopez
- Department of Myocardial Function, Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Michael E. Ibrahim
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Fotios G. Pitoulis
- Department of Myocardial Function, Imperial College London, National Heart and Lung Institute, London, United Kingdom
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
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3
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Rohde S, de By TMMH, Bogers AJJC, Schweiger M. Myocardial recovery in children supported with a durable ventricular assist device-a systematic review. Eur J Cardiothorac Surg 2023; 64:ezad263. [PMID: 37498565 PMCID: PMC10560320 DOI: 10.1093/ejcts/ezad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/18/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES A small percentage of paediatric patients supported with a ventricular assist device (VAD) can have their device explanted following myocardial recovery. The goal of this systematic review is to summarize the current literature on the clinical course in these children after weaning. METHODS A systematic literature search was performed on 27 May 2022 using Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar to include all literature on paediatric patients supported by a durable VAD during the last decade. Overlapping study cohorts and registry-based studies were filtered out. RESULTS Thirty-seven articles were included. Eighteen of them reported on the incidence of recovery in cohort studies, with an overall incidence rate of 8.7% (81/928). Twenty-two of the included articles reported on clinical outcomes after VAD explantation (83 patients). The aetiologies varied widely and were not limited to diseases with a natural transient course like myocarditis. Most of the patients in the included studies (70; 84.3%) were supported by a Berlin Heart EXCOR, and in 66.3% (55/83), only the left ventricle had to be supported. The longest follow-up period was 19.1 years, and multiple studies reported on long-term myocardial recovery. Fewer than half of the reported deaths had a cardiac cause. CONCLUSIONS Myocardial recovery during VAD support is dependent on various contributing components. The interactions among patient-, device-, time- and hospital-related factors are complex and not yet fully understood. Long-term recovery after VAD support is achievable, even after a long duration of VAD support, and even in patients with aetiologies different from myocarditis or post-cardiotomy heart failure. More research is needed on this favourable outcome after VAD support.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children′s Hospital Zurich, Pediatric Heart Centre, Department for Congenital Heart Surgery, Zurich, Switzerland
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4
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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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5
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Martin TG, Juarros MA, Leinwand LA. Regression of cardiac hypertrophy in health and disease: mechanisms and therapeutic potential. Nat Rev Cardiol 2023; 20:347-363. [PMID: 36596855 PMCID: PMC10121965 DOI: 10.1038/s41569-022-00806-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 01/05/2023]
Abstract
Left ventricular hypertrophy is a leading risk factor for cardiovascular morbidity and mortality. Although reverse ventricular remodelling was long thought to be irreversible, evidence from the past three decades indicates that this process is possible with many existing heart disease therapies. The regression of pathological hypertrophy is associated with improved cardiac function, quality of life and long-term health outcomes. However, less than 50% of patients respond favourably to most therapies, and the reversibility of remodelling is influenced by many factors, including age, sex, BMI and disease aetiology. Cardiac hypertrophy also occurs in physiological settings, including pregnancy and exercise, although in these cases, hypertrophy is associated with normal or improved ventricular function and is completely reversible postpartum or with cessation of training. Studies over the past decade have identified the molecular features of hypertrophy regression in health and disease settings, which include modulation of protein synthesis, microRNAs, metabolism and protein degradation pathways. In this Review, we summarize the evidence for hypertrophy regression in patients with current first-line pharmacological and surgical interventions. We further discuss the molecular features of reverse remodelling identified in cell and animal models, highlighting remaining knowledge gaps and the essential questions for future investigation towards the goal of designing specific therapies to promote regression of pathological hypertrophy.
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Affiliation(s)
- Thomas G Martin
- Department of Molecular, Cellular and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA
| | - Miranda A Juarros
- Department of Molecular, Cellular and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA
| | - Leslie A Leinwand
- Department of Molecular, Cellular and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA.
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA.
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6
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Fresiello L, Muthiah K, Goetschalckx K, Hayward C, Rocchi M, Bezy M, Pauls JP, Meyns B, Donker DW, Zieliński K. Initial clinical validation of a hybrid in silico—in vitro cardiorespiratory simulator for comprehensive testing of mechanical circulatory support systems. Front Physiol 2022; 13:967449. [PMID: 36311247 PMCID: PMC9606213 DOI: 10.3389/fphys.2022.967449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Simulators are expected to assume a prominent role in the process of design—development and testing of cardiovascular medical devices. For this purpose, simulators should capture the complexity of human cardiorespiratory physiology in a realistic way. High fidelity simulations of pathophysiology do not only allow to test the medical device itself, but also to advance practically relevant monitoring and control features while the device acts under realistic conditions. We propose a physiologically controlled cardiorespiratory simulator developed in a mixed in silico-in vitro simulation environment. As inherent to this approach, most of the physiological model complexity is implemented in silico while the in vitro system acts as an interface to connect a medical device. As case scenarios, severe heart failure was modeled, at rest and at exercise and as medical device a left ventricular assist device (LVAD) was connected to the simulator. As initial validation, the simulator output was compared against clinical data from chronic heart failure patients supported by an LVAD, that underwent different levels of exercise tests with concomitant increase in LVAD speed. Simulations were conducted reproducing the same protocol as applied in patients, in terms of exercise intensity and related LVAD speed titration. Results show that the simulator allows to capture the principal parameters of the main adaptative cardiovascular and respiratory processes within the human body occurring from rest to exercise. The simulated functional interaction with the LVAD is comparable to the one clinically observed concerning ventricular unloading, cardiac output, and pump flow. Overall, the proposed simulation system offers a high fidelity in silico-in vitro representation of the human cardiorespiratory pathophysiology. It can be used as a test bench to comprehensively analyze the performance of physically connected medical devices simulating clinically realistic, critical scenarios, thus aiding in the future the development of physiologically responding, patient-adjustable medical devices. Further validation studies will be conducted to assess the performance of the simulator in other pathophysiological conditions.
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Affiliation(s)
- Libera Fresiello
- Cardiovascular and Respiratory Physiology, University of Twente, Enschede, Netherlands
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- *Correspondence: Libera Fresiello,
| | - Kavitha Muthiah
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
| | - Kaatje Goetschalckx
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christopher Hayward
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Maria Rocchi
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maxime Bezy
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jo P. Pauls
- School of Engineering, Griffith University, Southport, QLD, Australia
| | - Bart Meyns
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dirk W. Donker
- Cardiovascular and Respiratory Physiology, University of Twente, Enschede, Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Krzysztof Zieliński
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
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Schreiber C, Dieterlen MT, Garbade J, Borger MA, Sieg F, Spampinato R, Dobrovie M, Meyer AL. Validation of mitral regurgitation reversibility in patients with HeartMate 3 implantation. Artif Organs 2021; 46:106-116. [PMID: 34398476 DOI: 10.1111/aor.14053] [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: 01/20/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 11/27/2022]
Abstract
The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3 years. Of 135 LVAD patients (with severe MR, n = 33; with none, mild, or moderate MR, n = 102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1 month postoperatively, and at 1, 2, and 3 years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P < .001), right ventricular end-diastolic diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), and estimated pulmonary artery pressure (P < .001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2 years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P = .073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.
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Affiliation(s)
- Constantin Schreiber
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Maja-Theresa Dieterlen
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jens Garbade
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael A Borger
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Franz Sieg
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ricardo Spampinato
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Monica Dobrovie
- Heart Center, HELIOS Clinic, Clinic of Cardiac Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Anna L Meyer
- Department of Cardiac Surgery, University Hospital, Heidelberg, Germany
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8
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Shen S, Sewanan LR, Campbell SG. Evidence for synergy between sarcomeres and fibroblasts in an in vitro model of myocardial reverse remodeling. J Mol Cell Cardiol 2021; 158:11-25. [PMID: 33992697 DOI: 10.1016/j.yjmcc.2021.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 12/22/2022]
Abstract
We have created a novel in-vitro platform to study reverse remodeling of engineered heart tissue (EHT) after mechanical unloading. EHTs were created by seeding decellularized porcine myocardial sections with a mixture of primary neonatal rat ventricular myocytes and cardiac fibroblasts. Each end of the ribbon-like constructs was fixed to a plastic clip, allowing the tissues to be statically stretched or slackened. Inelastic deformation was introduced by stretching tissues by 20% of their original length. EHTs were subsequently unloaded by returning tissues to their original, shorter length. Mechanical characterization of EHTs immediately after unloading and at subsequent time points confirmed the presence of a reverse-remodeling process, through which stress-free tissue length was increased after chronic stretch but gradually decreased back to its original value within 9 days. When a cardiac myosin inhibitor was applied to tissues after unloading, EHTs failed to completely recover their passive and active mechanical properties, suggesting a role for actomyosin contraction in reverse remodeling. Selectively inhibiting cardiomyocyte contraction or fibroblast activity after mechanical unloading showed that contractile activity of both cell types was required to achieve full remodeling. Similar tests with EHTs formed from human induced pluripotent stem cell-derived cardiomyocytes also showed reverse remodeling that was enhanced when treated with omecamtiv mecarbil, a myosin activator. These experiments suggest essential roles for active sarcomeric contraction and fibroblast activity in reverse remodeling of myocardium after mechanical unloading. Our findings provide a mechanistic rationale for designing potential therapies to encourage reverse remodeling in patient hearts.
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Affiliation(s)
- Shi Shen
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Lorenzo R Sewanan
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Stuart G Campbell
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA; Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA.
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Abstract
This review provides a comprehensive overview of the past 25+ years of research into the development of left ventricular assist device (LVAD) to improve clinical outcomes in patients with severe end-stage heart failure and basic insights gained into the biology of heart failure gleaned from studies of hearts and myocardium of patients undergoing LVAD support. Clinical aspects of contemporary LVAD therapy, including evolving device technology, overall mortality, and complications, are reviewed. We explain the hemodynamic effects of LVAD support and how these lead to ventricular unloading. This includes a detailed review of the structural, cellular, and molecular aspects of LVAD-associated reverse remodeling. Synergisms between LVAD support and medical therapies for heart failure related to reverse remodeling, remission, and recovery are discussed within the context of both clinical outcomes and fundamental effects on myocardial biology. The incidence, clinical implications and factors most likely to be associated with improved ventricular function and remission of the heart failure are reviewed. Finally, we discuss recognized impediments to achieving myocardial recovery in the vast majority of LVAD-supported hearts and their implications for future research aimed at improving the overall rates of recovery.
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Affiliation(s)
| | | | - Gabriel Sayer
- Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Nir Uriel
- Cardiovascular Research Foundation, New York, NY (D.B.)
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10
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Tschöpe C, Spillmann F, Potapov E, Faragli A, Rapis K, Nelki V, Post H, Schmidt G, Alogna A. The "TIDE"-Algorithm for the Weaning of Patients With Cardiogenic Shock and Temporarily Mechanical Left Ventricular Support With Impella Devices. A Cardiovascular Physiology-Based Approach. Front Cardiovasc Med 2021; 8:563484. [PMID: 33681302 PMCID: PMC7933542 DOI: 10.3389/fcvm.2021.563484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/20/2021] [Indexed: 01/14/2023] Open
Abstract
Objectives: Mechanical circulatory support (MCS) is often required to stabilize therapy-refractory cardiogenic shock patients. Left ventricular (LV) unloading by mechanical ventricular support (MVS) via percutaneous devices, such as with Impella® axial pumps, alone or in combination with extracorporeal life support (ECLS, ECMELLA approach), has emerged as a potential clinical breakthrough in the field. While the weaning from MCS is essentially based on the evaluation of circulatory stability of patients, weaning from MVS holds a higher complexity, being dependent on bi-ventricular function and its adaption to load. As a result of this, weaning from MVS is mostly performed in the absence of established algorithms. MVS via Impella is applied in several cardiogenic shock etiologies, such as acute myocardial infarction (support over days) or acute fulminant myocarditis (prolonged support over weeks, PROPELLA). The time point of weaning from Impella in these cohorts of patients remains unclear. We here propose a novel cardiovascular physiology-based weaning algorithm for MVS. Methods: The proposed algorithm is based on the experience gathered at our center undergoing an Impella weaning between 2017 and 2020. Before undertaking a weaning process, patients must had been ECMO-free, afebrile, and euvolemic, with hemodynamic stability guaranteed in the absence of any inotropic support. The algorithm consists of 4 steps according to the acronym TIDE: (i) Transthoracic echocardiography under full Impella-unloading; (ii) Impella rate reduction in single 8–24 h-steps according to patients hemodynamics (blood pressure, heart rate, and ScVO2), including a daily echocardiographic assessment at minimal flow (P2); (iii) Dobutamine stress-echocardiography; (iv) Right heart catheterization at rest and during Exercise-testing via handgrip. We here present clinical and hemodynamic data (including LV conductance data) from paradigmatic weaning protocols of awake patients admitted to our intensive care unit with cardiogenic shock. We discuss the clinical consequences of the TIDE algorithm, leading to either a bridge-to-recovery, or to a bridge-to-permanent LV assist device (LVAD) and/or transplantation. With this protocol we were able to wean 74.2% of the investigated patients successfully. 25.8% showed a permanent weaning failure and became LVAD candidates. Conclusions: The proposed novel cardiovascular physiology-based weaning algorithm is based on the characterization of the extent and sustainment of LV unloading reached during hospitalization in patients with cardiogenic shock undergoing MVS with Impella in our center. Prospective studies are needed to validate the algorithm.
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Affiliation(s)
- Carsten Tschöpe
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Frank Spillmann
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Evgenij Potapov
- Department of Heart Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Alessandro Faragli
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Konstantinos Rapis
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Vivian Nelki
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Heiner Post
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Department of Cardiology, Contilia Heart and Vessel Centre, St. Marien-Hospital Mülheim, Mülheim, Germany
| | - Gunther Schmidt
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Alessio Alogna
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany.,Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH), Charité-University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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11
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Miranda-Silva D, G Rodrigues P, Alves E, Rizo D, Fonseca ACRG, Lima T, Baganha F, Conceição G, Sousa C, Gonçalves A, Miranda I, Vasques-Nóvoa F, Magalhães J, Leite-Moreira A, Falcão-Pires I. Mitochondrial Reversible Changes Determine Diastolic Function Adaptations During Myocardial (Reverse) Remodeling. Circ Heart Fail 2020; 13:e006170. [PMID: 33176457 DOI: 10.1161/circheartfailure.119.006170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Often, pressure overload-induced myocardial remodeling does not undergo complete reverse remodeling after decreasing afterload. Recently, mitochondrial abnormalities and oxidative stress have been successively implicated in the pathogenesis of several chronic pressure overload cardiac diseases. Therefore, we aim to clarify the myocardial energetic dysregulation in (reverse) remodeling, mainly focusing on the mitochondria. METHODS Thirty-five Wistar Han male rats randomly underwent sham or ascending (supravalvular) aortic banding procedure. Echocardiography revealed that banding induced concentric hypertrophy and diastolic dysfunction (early diastolic transmitral flow velocity to peak early-diastolic annular velocity ratio, E/E': sham, 13.6±2.1, banding, 18.5±4.1, P=0.014) accompanied by increased oxidative stress (dihydroethidium fluorescence: sham, 1.6×108±6.1×107, banding, 2.6×108±4.5×107, P<0.001) and augmented mitochondrial function. After 8 to 9 weeks, half of the banding animals underwent overload relief by an aortic debanding surgery (n=10). RESULTS Two weeks later, hypertrophy decreased with the decline of oxidative stress (dihydroethidium fluorescence: banding, 2.6×108±4.5×107, debanding, 1.96×108±6.8×107, P<0.001) and diastolic dysfunction improved simultaneously (E/E': banding, 18.5±4.1, debanding, 15.1±1.8, P=0.029). The reduction of energetic demands imposed by overload relief allowed the mitochondria to reduce its activity and myocardial levels of phosphocreatine, phosphocreatine/ATP, and ATP/ADP to normalize in debanding towards sham values (phosphocreatine: sham, 38.4±7.4, debanding, 35.6±8.7, P=0.71; phosphocreatine/ATP: sham, 1.22±0.23 debanding, 1.11±0.24, P=0.59; ATP/ADP: sham, 6.2±0.9, debanding, 5.6±1.6, P=0.66). Despite the decreased mitochondrial area, complex III and V expression increased in debanding compared with sham or banding. Autophagy and mitophagy-related markers increased in banding and remained higher in debanding rats. CONCLUSIONS During compensatory and maladaptive hypertrophy, mitochondria become more active. However, as the disease progresses, the myocardial energetic demands increase and the myocardium becomes energy deficient. During reverse remodeling, the concomitant attenuation of cardiac hypertrophy and oxidative stress allowed myocardial energetics, left ventricle hypertrophy, and diastolic dysfunction to recover. Autophagy and mitophagy are probably involved in the myocardial adaptation to overload and to unload. We conclude that these mitochondrial reversible changes underlie diastolic function adaptations during myocardial (reverse) remodeling.
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Affiliation(s)
- Daniela Miranda-Silva
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Patrícia G Rodrigues
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Estela Alves
- LaMetEX, Laboratory of Metabolism and Exercise (E.A., D.R., J.M.).,CIAFEL, Research Centre in Physical Activity, Health and Leisure, Faculty of Sports, Portugal (E.A., D.R., J.M.)
| | - David Rizo
- LaMetEX, Laboratory of Metabolism and Exercise (E.A., D.R., J.M.).,CIAFEL, Research Centre in Physical Activity, Health and Leisure, Faculty of Sports, Portugal (E.A., D.R., J.M.)
| | - Ana Catarina R G Fonseca
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Portugal (A.C.R.G.F.)
| | - Tânia Lima
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Fabiana Baganha
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Gloria Conceição
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Cláudia Sousa
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Alexandre Gonçalves
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Isabel Miranda
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Francisco Vasques-Nóvoa
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - José Magalhães
- LaMetEX, Laboratory of Metabolism and Exercise (E.A., D.R., J.M.).,CIAFEL, Research Centre in Physical Activity, Health and Leisure, Faculty of Sports, Portugal (E.A., D.R., J.M.)
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
| | - Inês Falcão-Pires
- Department of Surgery and Physiology, Porto, Portugal (D.M.S., P.G.R., T.L., F.B., G.C., C.S., A.G., I.M., F.V.-N., A.L.-M., I.F.-P.)
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12
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Adorisio R, Mencarelli E, Cantarutti N, Calvieri C, Amato L, Cicenia M, Silvetti M, D’Amico A, Grandinetti M, Drago F, Amodeo A. Duchenne Dilated Cardiomyopathy: Cardiac Management from Prevention to Advanced Cardiovascular Therapies. J Clin Med 2020; 9:jcm9103186. [PMID: 33019553 PMCID: PMC7600130 DOI: 10.3390/jcm9103186] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) cardiomyopathy (DCM) is characterized by a hypokinetic, dilated phenotype progressively increasing with age. Regular cardiac care is crucial in DMD care. Early recognition and prophylactic use of angiotensin converting enzyme inhibitors (ACEi) are the main stay therapeutic strategy to delay incidence of DMD-DCM. Pharmacological treatment to improve symptoms and left ventricle (LV) systolic function, have been widely implemented in the past years. Because of lack of DMD specific drugs, actual indications for established DCM include current treatment for heart failure (HF). This review focuses on current HF strategies to identify, characterize, and treat DMD-DCM.
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Affiliation(s)
- Rachele Adorisio
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.M.); (L.A.); (M.G.); (A.A.)
- Correspondence: ; Tel.: +39-06-6859-2217; Fax: +39-06-6859-2607
| | - Erica Mencarelli
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.M.); (L.A.); (M.G.); (A.A.)
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (N.C.); (C.C.); (M.C.); (M.S.); (F.D.)
| | - Camilla Calvieri
- Pediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (N.C.); (C.C.); (M.C.); (M.S.); (F.D.)
| | - Liliana Amato
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.M.); (L.A.); (M.G.); (A.A.)
| | - Marianna Cicenia
- Pediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (N.C.); (C.C.); (M.C.); (M.S.); (F.D.)
| | - Massimo Silvetti
- Pediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (N.C.); (C.C.); (M.C.); (M.S.); (F.D.)
| | - Adele D’Amico
- Neuromuscolar Disease, Genetic and Rare Disease Research Area, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Maria Grandinetti
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.M.); (L.A.); (M.G.); (A.A.)
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A, Gemelli IRCCS, 20097 Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias/Syncope Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (N.C.); (C.C.); (M.C.); (M.S.); (F.D.)
| | - Antonio Amodeo
- Heart Failure Clinic-Heart Failure, Heart Transplant, Mechanical Circulatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.M.); (L.A.); (M.G.); (A.A.)
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13
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Brener MI, Uriel N, Burkhoff D. Left Ventricular Volume Reduction and Reshaping as a Treatment Option for Heart Failure. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1777359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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Yousefzai R, Brambatti M, Tran HA, Pedersen R, Braun OÖ, Baykaner T, Ghashghaei R, Sulemanjee NZ, Cheema OM, Rappelt M, Baeza C, Alkhayyat A, Shi Y, Pretorius V, Greenberg B, Adler E, Thohan V. Benefits of Neurohormonal Therapy in Patients With Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2019; 66:409-414. [PMID: 31192845 DOI: 10.1097/mat.0000000000001022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have dramatically improved short-term outcomes among patients with advanced heart failure. While neurohormonal blockade (NHB) is the cornerstone of treatment for patients with heart failure with reduced ejection fraction, its effect after LVAD placement has not been established. We reviewed medical records of 307 patients who underwent primary LVAD implantation from January 2006 to September 2015 at two institutions in the United States. Patients were followed for at least 2 years post-LVAD implantation or until explantation, heart transplantation, or death. Cox regression analysis stratifying on center was used to assess associations with mortality. Neurohormonal blockade use was treated as a time-dependent predictor. Stepwise selection indicated treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) (hazard ratio [HR] = 0.53 [0.30-0.95], p = 0.03), age at the time of implantation (HR = 1.28 [1.05-1.56] per decade, p = 0.02), length of stay postimplantation (HR = 1.16 [1.11-1.21] per week, p < 0.01) and INTERMACS profile of 1 or 2 (HR = 1.86 [1.17-2.97], p < 0.01) were independent predictors of mortality. In this large, retrospective study, treatment with ACEIs or ARBs was an independent factor associated with decreased mortality post-LVAD placement.
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Affiliation(s)
- Rayan Yousefzai
- From the Lifespan Cardiovascular Institute, Rhode Island Hospital, Brown University, Providence, Rhode Island.,Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Michela Brambatti
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Hao A Tran
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Rachel Pedersen
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Oscar Ö Braun
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Tina Baykaner
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Roxana Ghashghaei
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Nasir Z Sulemanjee
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Omar M Cheema
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Matthew Rappelt
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin. Dr. Shi is now with the National Institutes of Health, Rockville, Maryland
| | - Carmela Baeza
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Abdulaziz Alkhayyat
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Yang Shi
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin. Dr. Shi is now with the National Institutes of Health, Rockville, Maryland
| | - Victor Pretorius
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Barry Greenberg
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Eric Adler
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Vinay Thohan
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
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15
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Miranda-Silva D, Gonçalves-Rodrigues P, Almeida-Coelho J, Hamdani N, Lima T, Conceição G, Sousa-Mendes C, Cláudia-Moura, González A, Díez J, Linke WA, Leite-Moreira A, Falcão-Pires I. Characterization of biventricular alterations in myocardial (reverse) remodelling in aortic banding-induced chronic pressure overload. Sci Rep 2019; 9:2956. [PMID: 30814653 PMCID: PMC6393473 DOI: 10.1038/s41598-019-39581-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/18/2019] [Indexed: 01/03/2023] Open
Abstract
Aortic Stenosis (AS) is the most frequent valvulopathy in the western world. Traditionally aortic valve replacement (AVR) has been recommended immediately after the onset of heart failure (HF) symptoms. However, recent evidence suggests that AVR outcome can be improved if performed earlier. After AVR, the process of left ventricle (LV) reverse remodelling (RR) is variable and frequently incomplete. In this study, we aimed at detecting mechanism underlying the process of LV RR regarding myocardial structural, functional and molecular changes before the onset of HF symptoms. Wistar-Han rats were subjected to 7-weeks of ascending aortic-banding followed by a 2-week period of debanding to resemble AS-induced LV remodelling and the early events of AVR-induced RR, respectively. This resulted in 3 groups: Sham (n = 10), Banding (Ba, n = 15) and Debanding (Deb, n = 10). Concentric hypertrophy and diastolic dysfunction (DD) were patent in the Ba group. Aortic-debanding induced RR, which promoted LV functional recovery, while cardiac structure did not normalise. Cardiac parameters of RV dysfunction, assessed by echocardiography and at the cardiomyocyte level prevailed altered after debanding. After debanding, these alterations were accompanied by persistent changes in pathways associated to myocardial hypertrophy, fibrosis and LV inflammation. Aortic banding induced pulmonary arterial wall thickness to increase and correlates negatively with effort intolerance and positively with E/e′ and left atrial area. We described dysregulated pathways in LV and RV remodelling and RR after AVR. Importantly we showed important RV-side effects of aortic constriction, highlighting the impact that LV-reverse remodelling has on both ventricles.
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Affiliation(s)
| | | | | | - Nazha Hamdani
- Department of Systems Physiology, Ruhr University, Bochum, Germany
| | - Tânia Lima
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | - Glória Conceição
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | | | - Cláudia-Moura
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | - Arantxa González
- Program of Cardiovascular Diseases, Centre for Applied Medical Research, University of Navarra and CIBERCV, Pamplona, Spain.,Department of Cardiology and Cardiac Surgery and Department of Nephrology, University of Navarra Clinic, Pamplona, Spain
| | - Javier Díez
- Program of Cardiovascular Diseases, Centre for Applied Medical Research, University of Navarra and CIBERCV, Pamplona, Spain.,Department of Cardiology and Cardiac Surgery and Department of Nephrology, University of Navarra Clinic, Pamplona, Spain
| | - Wolfgang A Linke
- Institute of Physiology II, University of Muenster, Muenster, Germany
| | | | - Inês Falcão-Pires
- Department of Surgery and Physiology, University of Porto, Porto, Portugal.
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16
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Postoperative B-Type Natriuretic Peptide as Predictor for Postoperative Outcomes in Patients Implanted With Left Ventricular Assist Devices. ASAIO J 2019; 65:148-151. [DOI: 10.1097/mat.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Gu K, Zhang Z, Chang Y, Gao B, Wan F. Computational analysis of the hemodynamic characteristics under interaction influence of β-blocker and LVAD. Biomed Eng Online 2018; 17:178. [PMID: 30509276 PMCID: PMC6276231 DOI: 10.1186/s12938-018-0602-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/09/2018] [Indexed: 12/12/2022] Open
Abstract
Background Hemodynamic characteristics of the interaction influence among support level and model of LVAD, and coupling β-blocker has not been reported. Methods In this study, the effect of support level and model of LVAD on cardiovascular hemodynamic characteristics is investigated. In addition, the effect of β-blocker on unloading with LVAD is analyzed to elucidate the mechanism of LVAD coupling β-blocker. A multi-scale model from cell level to system level is proposed. Moreover, LVAD coupling β-blocker has been researching to explain the hemodynamics of cardiovascular system. Results Myocardial force was decreased along with the increase of support level of LVAD, and co-pulse mode was the lowest among the three support modes. Additionally, the β-blocker combined with LVAD significantly reduced the left ventricular volume compared with LVAD support without β-blocker. However, the left ventricular pressure under both cases has no significant difference. External work of right ventricular was increased along with the growth of support level of only LVAD. The LVAD under co-pulse mode achieved the lowest right-ventricular EW among the three support modes. Conclusions Co-pulse mode with β-blocker could be an optimal strategy for promoting cardiac structure and function recovery.
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Affiliation(s)
- Kaiyun Gu
- Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Rd, Haidian District, Beijing, 100191, China
| | - Zhe Zhang
- Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Rd, Haidian District, Beijing, 100191, China.
| | - Yu Chang
- College of Life Science & Bio-Engineering, Beijing University of Technology, Beijing, 100124, China.
| | - Bin Gao
- College of Life Science & Bio-Engineering, Beijing University of Technology, Beijing, 100124, China
| | - Feng Wan
- Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Rd, Haidian District, Beijing, 100191, China
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18
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Han HC. Understanding the mechanisms of mechanical unloading to achieve myocardial recovery. Am J Physiol Heart Circ Physiol 2018; 315:H1519-H1520. [DOI: 10.1152/ajpheart.00586.2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hai-Chao Han
- Department of Mechanical Engineering, University of Texas at San Antonio, and Biomedical Engineering Program, University of Texas at San Antonio-University of Texas Health Science Center at San Antonio, San Antonio, Texas
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19
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Castillero E, Ali ZA, Akashi H, Giangreco N, Wang C, Stöhr EJ, Ji R, Zhang X, Kheysin N, Park JES, Hegde S, Patel S, Stein S, Cuenca C, Leung D, Homma S, Tatonetti NP, Topkara VK, Takeda K, Colombo PC, Naka Y, Sweeney HL, Schulze PC, George I. Structural and functional cardiac profile after prolonged duration of mechanical unloading: potential implications for myocardial recovery. Am J Physiol Heart Circ Physiol 2018; 315:H1463-H1476. [PMID: 30141986 PMCID: PMC6297806 DOI: 10.1152/ajpheart.00187.2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/18/2018] [Accepted: 08/02/2018] [Indexed: 11/22/2022]
Abstract
Clinical and experimental studies have suggested that the duration of left ventricular assist device (LVAD) support may affect remodeling of the failing heart. We aimed to 1) characterize the changes in Ca2+/calmodulin-dependent protein kinase type-IIδ (CaMKIIδ), growth signaling, structural proteins, fibrosis, apoptosis, and gene expression before and after LVAD support and 2) assess whether the duration of support correlated with improvement or worsening of reverse remodeling. Left ventricular apex tissue and serum pairs were collected in patients with dilated cardiomyopathy ( n = 25, 23 men and 2 women) at LVAD implantation and after LVAD support at cardiac transplantation/LVAD explantation. Normal cardiac tissue was obtained from healthy hearts ( n = 4) and normal serum from age-matched control hearts ( n = 4). The duration of LVAD support ranged from 48 to 1,170 days (median duration: 270 days). LVAD support was associated with CaMKIIδ activation, increased nuclear myocyte enhancer factor 2, sustained histone deacetylase-4 phosphorylation, increased circulating and cardiac myostatin (MSTN) and MSTN signaling mediated by SMAD2, ongoing structural protein dysregulation and sustained fibrosis and apoptosis (all P < 0.05). Increased CaMKIIδ phosphorylation, nuclear myocyte enhancer factor 2, and cardiac MSTN significantly correlated with the duration of support. Phosphorylation of SMAD2 and apoptosis decreased with a shorter duration of LVAD support but increased with a longer duration of LVAD support. Further study is needed to define the optimal duration of LVAD support in patients with dilated cardiomyopathy. NEW & NOTEWORTHY A long duration of left ventricular assist device support may be detrimental for myocardial recovery, based on myocardial tissue experiments in patients with prolonged support showing significantly worsened activation of Ca2+/calmodulin-dependent protein kinase-IIδ, increased nuclear myocyte enhancer factor 2, increased myostatin and its signaling by SMAD2, and apoptosis as well as sustained histone deacetylase-4 phosphorylation, structural protein dysregulation, and fibrosis.
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Affiliation(s)
- Estibaliz Castillero
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Ziad A Ali
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Hirokazu Akashi
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Nicholas Giangreco
- Department of Biomedical Informatics, Systems Biology, Institute for Genomic Medicine, Data Science Institute, Columbia University , New York, New York
| | - Catherine Wang
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Eric J Stöhr
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
- School of Sport and Health Sciences, Cardiff Metropolitan University , Cardiff , United Kingdom
| | - Ruping Ji
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Xiaokan Zhang
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Nathaniel Kheysin
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Joo-Eun S Park
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Sheetal Hegde
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Sanatkumar Patel
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Samantha Stein
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Carlos Cuenca
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Diana Leung
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Shunichi Homma
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Nicholas P Tatonetti
- Department of Biomedical Informatics, Systems Biology, Institute for Genomic Medicine, Data Science Institute, Columbia University , New York, New York
| | - Veli K Topkara
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Paolo C Colombo
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
| | - H Lee Sweeney
- Department of Pharmacology, University of Florida , Gainesville, Florida
| | - P Christian Schulze
- Division of Cardiology, College of Physicians and Surgeons of Columbia University , New York, New York
| | - Isaac George
- Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University , New York, New York
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Sustained Cardiac Recovery Hinges on Timing and Natural History of Underlying Condition. Am J Med Sci 2018; 356:47-55. [DOI: 10.1016/j.amjms.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 01/12/2023]
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Takami Y, Hoshino N, Kato Y, Sakurai Y, Amano K, Higuchi Y, Tochii M, Ishida M, Ishikawa H, Takagi Y, Ozaki Y. Recovery from anthracycline-induced cardiomyopathy with biventricular assist and valve repairs: A case report and literature review. Int J Artif Organs 2018; 41:413-417. [PMID: 29806528 DOI: 10.1177/0391398818772497] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Ventricular assist device is used in the patients with severe heart failure due to cardiotoxicity of anthracyclines, which are widely used chemotherapeutic agents for a wide range of malignant tumors. However, recovery of cardiac function is rare. METHODS We present the clinical course of a 43-year-old woman in remission from diffuse large B-cell lymphoma after the chemotherapy including anthracyclines, who presented in cardiogenic shock 8 months after the end of chemotherapy. RESULTS The patient was initially treated with intra-aortic balloon pumping, followed by conversion to left ventricular assist device with an Abiomed AB5000 (Abiomed, Inc, Danvers, MA) and right ventricular assist device with a centrifugal pump and a membrane oxygenator, in addition to tricuspid annuloplasty, due to rapid deterioration to cardiogenic shock. With intensive medical treatments during biventricular support, her cardiac and respiratory functions gradually improved, although moderate mitral regurgitation persisted despite of left ventricular unloading. At 64 days of biventricular support, she underwent mitral valve annuloplasty to correct regurgitation under cardiopulmonary bypass. She was consequently weaned from biventricular assist successfully 8 days after mitral surgery (72 days of biventricular support). The patient discharged uneventfully from our hospital and survives at home 12 months after weaning from the ventricular assist devices. CONCLUSION Our case and the literature review highlight potential usefulness of aggressive mechanical biventricular support for cardiac recovery in patients with anthracycline-induced cardiomyopathy. Additional valve surgery and neurohormonal medications may be also promising in such patients with cancer, who are contraindicated for heart transplantation.
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Affiliation(s)
- Yoshiyuki Takami
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naoki Hoshino
- 2 Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasuchika Kato
- 2 Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yusuke Sakurai
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kentaro Amano
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshiro Higuchi
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masato Tochii
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Michiko Ishida
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Ishikawa
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasushi Takagi
- 1 Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yukio Ozaki
- 2 Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
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Abstract
Advances in medical and device therapies have demonstrated the capacity of the heart to reverse the failing phenotype. The development of normative changes to ventricular size and function led to the concept of reverse remodelling. Among heart failure therapies, durable mechanical circulatory support is most consistently associated with the largest degree of reverse remodelling. Accordingly, research to analyse human tissue after a period of mechanical circulatory support continues to yield a wealth of information. In this Review, we summarize the latest findings on reverse remodelling and myocardial recovery. Accumulating evidence shows that the molecular changes associated with heart failure, in particular in the transcriptome, metabalome, and extracellular matrix, persist in the reverse-remodelled myocardium despite apparent normalization of macrolevel properties. Therefore, reverse remodelling should be distinguished from true myocardial recovery, in which a failing heart regains both normal function and molecular makeup. These findings have implications for future research to develop therapies to repair fully the failing myocardium. Meanwhile, recognition by society guidelines of this new clinical phenotype, which is coming to be known as a state of heart failure remission, underscores the need to accurately define and identify reverse modelled myocardium for the establishment of appropriate therapies.
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Fresiello L, Rademakers F, Claus P, Ferrari G, Di Molfetta A, Meyns B. Exercise physiology with a left ventricular assist device: Analysis of heart-pump interaction with a computational simulator. PLoS One 2017; 12:e0181879. [PMID: 28738087 PMCID: PMC5524292 DOI: 10.1371/journal.pone.0181879] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 07/07/2017] [Indexed: 12/02/2022] Open
Abstract
Patients with a Ventricular Assist Device (VAD) are hemodynamically stable but show an impaired exercise capacity. Aim of this work is to identify and to describe the limiting factors of exercise physiology with a VAD. We searched for data concerning exercise in heart failure condition and after VAD implantation from the literature. Data were analyzed by using a cardiorespiratory simulator that worked as a collector of inputs coming from different papers. As a preliminary step the simulator was used to reproduce the evolution of hemodynamics from rest to peak exercise (ergometer cycling) in heart failure condition. Results evidence an increase of cardiac output of +2.8 l/min and a heart rate increase to 67% of the expected value. Then, we simulated the effect of a continuous-flow VAD at both rest and exercise. Total cardiac output increases of +3.0 l/min (+0.9 l/min due to the VAD and +2.1 l/min to the native ventricle). Since the left ventricle works in a non-linear portion of the diastolic stiffness line, we observed a consistent increase of pulmonary capillary wedge pressure (from 14 to 20 mmHg) for a relatively small increase of end-diastolic volume (from 182 to 189 cm3). We finally increased VAD speed during exercise to the maximum possible value and we observed a reduction of wedge pressure (-4.5 mmHg), a slight improvement of cardiac output (8.0 l/min) and a complete unloading of the native ventricle. The VAD can assure a proper hemodynamics at rest, but provides an insufficient unloading of the left ventricle and does not prevent wedge pressure from rising during exercise. Neither the VAD provides major benefits during exercise in terms of total cardiac output, which increases to a similar extend to an unassisted heart failure condition. VAD speed modulation can contribute to better unload the ventricle but the maximal flow reachable with the current devices is below the cardiac output observed in a healthy heart.
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Affiliation(s)
- Libera Fresiello
- KU Leuven, Department of Cardiac Surgery, Leuven, Belgium
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
- * E-mail:
| | - Frank Rademakers
- KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Piet Claus
- KU Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Gianfranco Ferrari
- Nałecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Arianna Di Molfetta
- Medical and Surgical Department of Pediatric Cardiology, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Bart Meyns
- KU Leuven, Department of Cardiac Surgery, Leuven, Belgium
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Wever-Pinzon J, Selzman CH, Stoddard G, Wever-Pinzon O, Catino A, Kfoury AG, Diakos NA, Reid BB, McKellar S, Bonios M, Koliopoulou A, Budge D, Kelkhoff A, Stehlik J, Fang JC, Drakos SG. Impact of Ischemic Heart Failure Etiology on Cardiac Recovery During Mechanical Unloading. J Am Coll Cardiol 2017; 68:1741-1752. [PMID: 27737740 DOI: 10.1016/j.jacc.2016.07.756] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/07/2016] [Accepted: 07/12/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Small-scale studies focused mainly on nonischemic cardiomyopathy (NICM) have shown that a subset of left ventricular assist device (LVAD) patients can achieve significant improvement of their native heart function, but the impact of ischemic cardiomyopathy (ICM) has not been specifically investigated. Many patients with acute myocardial infarction are discharged from their index hospitalization without heart failure (HF), only to return much later with overt HF syndrome, mainly caused by chronic remodeling of the noninfarcted region of the myocardium. OBJECTIVES This study sought to prospectively investigate the effect of ICM HF etiology on LVAD-associated improvement of cardiac structure and function using NICM as control. METHODS Consecutive patients (n = 154) with documented chronic and dilated cardiomyopathy (ICM, n = 61; NICM, n = 93) requiring durable support with continuous-flow LVAD were prospectively evaluated with serial echocardiograms and right heart catheterizations. RESULTS In patients supported with LVAD for at least 6 months, we found that 5% of subjects with ICM and 21% of subjects with NICM achieved left ventricular ejection fraction ≥40% (p = 0.034). LV end-diastolic and end-systolic volumes and diastolic function were significantly and similarly improved in patients with ICM and NICM. CONCLUSIONS LVAD-associated unloading for 6 months resulted in a substantial improvement in myocardial structure, and systolic and diastolic function in 1 in 20 ICM and 1 in 5 NICM patients. These specific incidence and timeline findings may provide guidance in clinical practice and research design for sequencing and prioritizing advanced HF and heart transplantation therapeutic options in patients with ICM and NICM.
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Affiliation(s)
- James Wever-Pinzon
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Craig H Selzman
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Greg Stoddard
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Omar Wever-Pinzon
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Anna Catino
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Abdallah G Kfoury
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Nikolaos A Diakos
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Bruce B Reid
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Stephen McKellar
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Michael Bonios
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Antigone Koliopoulou
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Deborah Budge
- University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Aaron Kelkhoff
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Josef Stehlik
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - James C Fang
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Stavros G Drakos
- Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, University of Utah Health Sciences Center, Intermountain Medical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; University of Utah Molecular Medicine Program, Salt Lake City, Utah.
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25
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Heterotopic Abdominal Rat Heart Transplantation as a Model to Investigate Volume Dependency of Myocardial Remodeling. Transplantation 2017; 101:498-505. [PMID: 27906830 DOI: 10.1097/tp.0000000000001585] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Heterotopic abdominal rat heart transplantation has been extensively used to investigate ischemic-reperfusion injury, immunological consequences during heart transplantations and also to study remodeling of the myocardium due to volume unloading. We provide a unique review on the latter and present a summary of the experimental studies on rat heart transplantation to illustrate changes that occur to the myocardium due to volume unloading. We divided the literature based on whether normal or failing rat heart models were used. This analysis may provide a basis to understand the physiological effects of mechanical circulatory support therapy.
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26
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Tenorio C, González N, Jaramillo JS, Ong G, Burkhoff D, Kronzon I, Perier P, Kleber F. Device-based Therapy for Mitral Regurgitation and Ventricular Reshaping. STRUCTURAL HEART 2017. [DOI: 10.1080/24748706.2017.1362608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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27
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The Physiology of Continuous-Flow Left Ventricular Assist Devices. J Card Fail 2017; 23:169-180. [DOI: 10.1016/j.cardfail.2016.10.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/13/2016] [Accepted: 10/25/2016] [Indexed: 11/21/2022]
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Marinescu KK, Uriel N, Mann DL, Burkhoff D. Left ventricular assist device-induced reverse remodeling: it's not just about myocardial recovery. Expert Rev Med Devices 2016; 14:15-26. [PMID: 27871197 DOI: 10.1080/17434440.2017.1262762] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The abnormal structure, function and molecular makeup of dilated cardiomyopathic hearts can be partially normalized in patients supported by a left ventricular assist device (LVAD), a process called reverse remodeling. This leads to recovery of function in many patients, though the rate of full recovery is low and in many cases is temporary, leading to the concept of heart failure remission, rather than recovery. Areas covered: We summarize data indicative of ventricular reverse remodeling, recovery and remission during LVAD support. These terms were used in searches performed in Pubmed. Duplication of topics covered in depth in prior review articles were avoided. Expert commentary: Although most patients undergoing mechanical circulatory support (MCS) show a significant degree of reverse remodeling, very few exhibit sufficiently improved function to justify device explantation, and many from whom LVADs have been explanted have relapsed back to the original heart failure phenotype. Future research has the potential to clarify the ideal combination of pharmacological, cell, gene, and mechanical therapies that would maximize recovery of function which has the potential to improve exercise tolerance of patients while on support, and to achieve a higher degree of myocardial recovery that is more likely to persist after device removal.
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Affiliation(s)
- Karolina K Marinescu
- a Department of Medicine, Division of Cardiology, Advanced Heart Failure , Rush University Medical Center , Chicago , IL , USA
| | - Nir Uriel
- b Department of Medicine, Division of Cardiology , University of Chicago , Chicago , IL , USA
| | - Douglas L Mann
- c Department of Medicine, Division of Cardiology , Washington University School of Medicine/Barnes Jewish Hospital , St. Louis , MO , USA
| | - Daniel Burkhoff
- d Department of Medicine, Division of Cardiology , Columbia University Medical Center/New York-Presbyterian Hospital , New York , NY , USA
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29
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Grupper A, Zhao YM, Sajgalik P, Joyce LD, Park SJ, Pereira NL, Stulak JM, Burnett JC, Edwards BS, Daly RC, Kushwaha SS, Schirger JA. Effect of Neurohormonal Blockade Drug Therapy on Outcomes and Left Ventricular Function and Structure After Left Ventricular Assist Device Implantation. Am J Cardiol 2016; 117:1765-70. [PMID: 27079215 DOI: 10.1016/j.amjcard.2016.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 11/27/2022]
Abstract
Neurohormonal blockade drug therapy (NHBDT) is the cornerstone therapy in heart failure (HF) management for promoting reverse cardiac remodeling and improving outcomes. It's utility in left ventricular assist device (LVAD) supported patients remains undefined. Sixty-four patients who received continuous flow LVAD at our institution were retrospectively reviewed and divided into 2 groups: no-NHBDT group (n = 33) received LVAD support only and NHBDT group (n = 31) received concurrent NHBDT based on the clinical judgment of the attending physicians. Cardiac remodeling (echocardiographic parameters and biomarkers) and clinical outcome (functional status, HF-related hospital readmissions, and mortality) data were collected. A statistically significant increase in ejection fraction, decrease in LV end-diastolic diameter index and LV mass index, and a sustained reduction in N-terminal pro B-type natriuretic peptide (NTproBNP) were observed in the NHBDT group at 6 months after LVAD implant (p <0.05). NHBDT-treated patients experienced significantly greater improvement in New York Heart Association functional classification and 6-minute-walk distance throughout the study. The combined end point of cardiovascular death or HF hospitalization was significantly reduced in patients receiving NHBDT (p = 0.013) associated primarily with a 12.1% absolute reduction in HF-related hospitalizations (p = 0.046). In conclusion, NHBDT in LVAD-supported patients is associated with a significant reversal in adverse cardiac remodeling and a reduction in morbidity and mortality compared with LVAD support alone.
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Sakamuri SSVP, Takawale A, Basu R, Fedak PWM, Freed D, Sergi C, Oudit GY, Kassiri Z. Differential impact of mechanical unloading on structural and nonstructural components of the extracellular matrix in advanced human heart failure. Transl Res 2016; 172:30-44. [PMID: 26963743 DOI: 10.1016/j.trsl.2016.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/05/2016] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
Abstract
Adverse remodeling of the extracellular matrix (ECM) is a significant characteristic of heart failure. Reverse remodeling of the fibrillar ECM secondary to mechanical unloading of the left ventricle (LV) by left ventricular assist device (LVAD) has been subject of intense investigation; however, little is known about the impacts on nonfibrillar ECM and matricellular proteins that also contribute to disease progression. Explanted failing hearts were procured from patients with nonischemic dilated cardiomyopathy (DCM) with or without LVAD support, and compared to nonfailing control hearts. LV free wall specimens were formalin-fixed, flash-frozen or optimum cutting temperature-mount frozen. Histologic and biochemical assessment of fibrillar ECM showed that LVAD support was associated with lower levels of insoluble collagen, collagen type I mRNA, and collagen I/III ratio compared with no-LVAD hearts. A disintegrin and Metalloproteinase with Thrombospondin Motifs-2 (ADAM-TS2), a procollagen endopeptidase, was reduced in no-LVAD but not in LVAD hearts. The rise in ECM proteolytic activities was significantly lower in LVAD hearts. Matrix metalloproteinases (MMP1, MMP2, MMP8, MMP13, and MT1-MMP/MMP14) were comparable between DCM hearts. Tissue inhibitor of metalloproteinase (TIMP)3 and TIMP4 messenger RNA and protein showed the greatest reduction in no-LVAD hearts. Basement membrane proteins exhibited less severe disarray of laminin and fibronectin-1 in LVAD-supported hearts. The rise in matricellular protein, osteopontin, was suppressed in LVAD hearts, whereas secreted protein, acidic, cysteine-rich (SPARC) levels was unaffected by LVAD. Mechanical unloading of the failing DCM hearts can restore the fibrillar ECM and the basement membrane, contributing toward improved clinical outcomes. However, persistent elevation of matricellular proteins such as SPARC could contribute to the relapse of failing hearts on removal of LVAD support.
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Affiliation(s)
- Siva S V P Sakamuri
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Abhijit Takawale
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Ratnadeep Basu
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute of Alberta, C880, 1403 29 Street NW, Calgary, Alberta
| | - Darren Freed
- Department of Cardiovascular Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Consolato Sergi
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Gavin Y Oudit
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Zamaneh Kassiri
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta.
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Ventricular Recovery and Pump Explantation in Patients Supported by Left Ventricular Assist Devices: A Systematic Review. ASAIO J 2016; 62:219-31. [DOI: 10.1097/mat.0000000000000328] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Serum Brain Natriuretic Peptide Concentration 60 Days After Surgery as a Predictor of Long-Term Prognosis in Patients Implanted With a Left Ventricular Assist Device. ASAIO J 2016; 61:e36-9. [PMID: 26120957 PMCID: PMC4487874 DOI: 10.1097/mat.0000000000000237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mechanical circulatory support by a left ventricular assist device (LVAD) is used to bridge patients with advanced heart failure to transplant or as a definitive treatment. We retrospectively sought predictors of long-term outcome in a cohort of 83 patients who had undergone LVAD treatment. We subjected perioperative clinical data of patients to statistical analysis to establish parameters associated with all-cause mortality, and the cutoff values, sensitivity, and specificity of those that had a statistically significant relation with survival. Mean follow-up was 717 days (standard deviation, 334 days; range, 17-1,592 days). Fourteen patients (16.8%) died, but nine (10.8%) were weaned from support. Serum brain natriuretic peptide (BNP) concentration measured 60 days after implantation was significantly associated with all-cause mortality. The optimal BNP cutoff value to predict death during LVAD support was 322 pg/ml, with a sensitivity of 71.4% and specificity of 79.8%. Two-year survival was 92.0% in those with 60 days serum BNP concentration <322 pg/ml compared with 70.5% in those in whom it was ≥322 pg/ml (p = 0.003). The relation between BNP and survival likely reflects recovery of native myocardial function and improvements in global health and should assist clinicians in the on-going management of long-term LVAD therapy.
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Opening of Aortic Valve During Exercise Is Key to Preventing Development of Aortic Insufficiency During Ventricular Assist Device Treatment. ASAIO J 2015; 61:514-9. [DOI: 10.1097/mat.0000000000000247] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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34
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Serum Brain Natriuretic Peptide Concentration 60 Days After Surgery as a Predictor of Long-Term Prognosis in Patients Implanted With a Left Ventricular Assist Device. ASAIO J 2015. [DOI: 10.1097/mat.0000000000000234] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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35
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36
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Imamura T, Kinugawa K, Nitta D, Hatano M, Kinoshita O, Nawata K, Ono M. Advantage of Pulsatility in Left Ventricular Reverse Remodeling and Aortic Insufficiency Prevention During Left Ventricular Assist Device Treatment. Circ J 2015; 79:1994-9. [DOI: 10.1253/circj.cj-15-0419] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Koichiro Kinugawa
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | - Daisuke Nitta
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Kan Nawata
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
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Cavigelli-Brunner A, Schweiger M, Knirsch W, Stiasny B, Klingel K, Kretschmar O, Hübler M. VAD as bridge to recovery in anthracycline-induced cardiomyopathy and HHV6 myocarditis. Pediatrics 2014; 134:e894-9. [PMID: 25092940 DOI: 10.1542/peds.2013-2272] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This report describes an 8-year-old child with acute anthracycline-induced cardiomyopathy triggered by human herpesvirus 6 and the subsequent implantation of an intracorporeal continuous-flow left ventricular assist device (LVAD) and the process to discharge the child from the hospital. After barely 3 months on mechanical support, the device was explanted after thorough examination. Experiences regarding LVAD removal are limited, and no guidelines for echocardiographic and hemodynamic criteria for LVAD removal in children have been published thus far. We present our institutional algorithm for device selection, surveillance in an ambulatory setting, and testing for myocardial recovery, as well as our criteria for LVAD explantation in children.
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Affiliation(s)
- Anna Cavigelli-Brunner
- Divisions of Pediatric Cardiology and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and
| | - Martin Schweiger
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and Congenital Cardiovascular Surgery, and
| | - Walter Knirsch
- Divisions of Pediatric Cardiology and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and
| | - Brian Stiasny
- Divisions of Pediatric Cardiology and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and
| | - Karin Klingel
- Department of Molecular Pathology, University of Tübingen, Tübingen, Germany
| | - Oliver Kretschmar
- Divisions of Pediatric Cardiology and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and
| | - Michael Hübler
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland; and Congenital Cardiovascular Surgery, and
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Segura AM, Dris L, Massin EK, Clubb FJ, Buja LM, Frazier OH, Taegtmeyer H. Heart failure in remission for more than 13 years after removal of a left ventricular assist device. Tex Heart Inst J 2014; 41:389-94. [PMID: 25120391 DOI: 10.14503/thij-13-4029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanical cardiac unloading with use of a left ventricular assist device (LVAD) is associated with substantial improvements in left ventricular function and enables subsequent LVAD explantation in some patients. We describe the case of a 35-year-old man with dilated nonischemic cardiomyopathy who was supported with an LVAD for 9 months. After the device was removed, he led a normal life for 13 years and 4 months. However, at 49 years of age, he presented with new signs and symptoms of heart failure, necessitating implantation of a 2nd LVAD. Afterwards, he has remained asymptomatic. This case is unique in that the patient lived a normal life for longer than a decade before renewed left ventricular decompensation necessitated repeat LVAD therapy. Histologic examination revealed few changes between the first device's removal in 1999 and the 2nd device's implantation in 2012.
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Affiliation(s)
- Ana Maria Segura
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - Lamia Dris
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - Edward K Massin
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - Fred J Clubb
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - L Maximilian Buja
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - O H Frazier
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
| | - Heinrich Taegtmeyer
- Departments of Cardiovascular Pathology (Drs. Buja, Clubb, and Segura) and Cardiopulmonary Transplantation (Drs. Frazier, Massin, and Taegtmeyer), Texas Heart Institute; and Departments of Internal Medicine (Drs. Dris and Taegtmeyer) and Pathology and Laboratory Medicine (Dr. Buja), The University of Texas Medical School at Houston; Houston, Texas 77030
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Lee LC, Genet M, Acevedo-Bolton G, Ordovas K, Guccione JM, Kuhl E. A computational model that predicts reverse growth in response to mechanical unloading. Biomech Model Mechanobiol 2014; 14:217-29. [PMID: 24888270 DOI: 10.1007/s10237-014-0598-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 05/21/2014] [Indexed: 01/15/2023]
Abstract
Ventricular growth is widely considered to be an important feature in the adverse progression of heart diseases, whereas reverse ventricular growth (or reverse remodeling) is often considered to be a favorable response to clinical intervention. In recent years, a number of theoretical models have been proposed to model the process of ventricular growth while little has been done to model its reverse. Based on the framework of volumetric strain-driven finite growth with a homeostatic equilibrium range for the elastic myofiber stretch, we propose here a reversible growth model capable of describing both ventricular growth and its reversal. We used this model to construct a semi-analytical solution based on an idealized cylindrical tube model, as well as numerical solutions based on a truncated ellipsoidal model and a human left ventricular model that was reconstructed from magnetic resonance images. We show that our model is able to predict key features in the end-diastolic pressure-volume relationship that were observed experimentally and clinically during ventricular growth and reverse growth. We also show that the residual stress fields generated as a result of differential growth in the cylindrical tube model are similar to those in other nonidentical models utilizing the same geometry.
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Affiliation(s)
- L C Lee
- Department of Surgery, School of Medicine, University of California at San Francisco, San Francisco, CA, 94143, USA,
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Imamura T, Kinugawa K, Hatano M, Fujino T, Muraoka H, Inaba T, Maki H, Kagami Y, Endo M, Kinoshita O, Nawata K, Kyo S, Ono M. Preoperative beta-blocker treatment is a key for deciding left ventricular assist device implantation strategy as a bridge to recovery. J Artif Organs 2013; 17:23-32. [PMID: 24337665 DOI: 10.1007/s10047-013-0748-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 11/24/2013] [Indexed: 11/29/2022]
Abstract
To date, there have been few reports demonstrating preoperative predictors for left ventricular reverse remodeling (LVRR) after LV assist device (LVAD) implantation, especially among patients with dilated cardiomyopathy (DCM). We retrospectively analyzed 60 patients with stage D heart failure due to DCM who had received LVAD treatment [pulsatile flow (PF) type, 26; continuous flow type, 34]. Data were evaluated at 6 months or just before explantation of the LVAD. We defined "LV reverse remodeling" (LVRR) by the achievement of an LV ejection fraction (LVEF) of ≥ 35 % after 6 months of LVAD support or explantation of LVAD within 6 months. LVRR occurred in 16 of our patients (26.7 %). Uni/multivariate logistic regression analyses for LVRR demonstrated that of the preoperative variables evaluated, PF LVAD usage and insufficient preoperative β-blocker treatment were independent predictors for LVRR. Patients who accomplished LVRR had a better clinical course, including lower levels of aortic valve insufficiency and lower levels of plasma B-type natriuretic peptide. Of the six patients (10.0 %) in whom LVADs were eventually explanted, all had an LVEF of ≥ 35 % before explantation or at 6 months. Based on these results, we conclude that DCM patients with insufficient preoperative β-blocker treatment have a chance to achieve LVRR under LVAD support as a bridge to recovery.
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Affiliation(s)
- Teruhiko Imamura
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan,
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41
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Wilmot I, Lorts A, Morales D. Pediatric mechanical circulatory support. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:391-401. [PMID: 24368965 PMCID: PMC3868686 DOI: 10.5090/kjtcs.2013.46.6.391] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 10/29/2013] [Accepted: 10/29/2013] [Indexed: 11/16/2022]
Abstract
Mechanical circulatory support (MCS) in the pediatric heart failure population has a limited history especially for infants, and neonates. It has been increasingly recognized that there is a rapidly expanding population of children diagnosed and living with heart failure. This expanding population has resulted in increasing numbers of children with medically resistant end-stage heart failure. The traditional therapy for these children has been heart transplantation. However, children with heart failure unlike adults do not have symptoms until they present with end-stage heart failure and therefore, cannot safely wait for transplantation. Many of these children were bridged to heart transplantation utilizing extracorporeal membranous oxygenation as a bridge to transplant which has yielded poor results. As such, industry, clinicians, and the government have refocused interest in developing increasing numbers of MCS options for children living with heart failure as a bridge to transplantation and as a chronic therapy. In this review, we discuss MCS options for short and long-term support that are currently available for infants and children with end-stage heart failure.
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Affiliation(s)
- Ivan Wilmot
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, USA
| | - Angela Lorts
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, USA
| | - David Morales
- Department of Congenital Heart Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, USA
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Jacobs S, Geens J, Rega F, Burkhoff D, Meyns B. Continuous-flow left ventricular assist devices induce left ventricular reverse remodeling. J Heart Lung Transplant 2013; 32:466-8. [PMID: 23498166 DOI: 10.1016/j.healun.2013.01.1045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/20/2013] [Accepted: 01/25/2013] [Indexed: 11/29/2022] Open
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Abstract
Heart failure is associated with remodeling that consists of adverse cellular, structural, and functional changes in the myocardium. Until recently, this was thought to be unidirectional, progressive, and irreversible. However, irreversibility has been shown to be incorrect because complete or partial reversal can occur that can be marked after myocardial unloading with a left ventricular assist device (LVAD). Patients with chronic advanced heart failure can show near-normalization of nearly all structural abnormalities of the myocardium or reverse remodeling after LVAD support. However, reverse remodeling does not always equate with clinical recovery. The molecular changes occurring after LVAD support are reviewed, both those demonstrated with LVAD unloading alone in patients bridged to transplantation and those occurring in the myocardium of patients who have recovered enough myocardial function to have the device removed. Reverse remodeling may be attributable to a reversal of the pathological mechanisms that occur in remodeling or the generation of new pathways. A reduction in cell size occurs after LVAD unloading, which does not necessarily correlate with improved cardiac function. However, some of the changes in both the cardiac myocyte and the matrix after LVAD support are specific to myocardial recovery. In the myocyte, increases in the cytoskeletal proteins and improvements in the Ca²⁺ handling pathway seem to be specifically associated with myocardial recovery. Changes in the matrix are complex, but excessive scarring appears to limit the ability for recovery, and the degree of fibrosis in the myocardium at the time of implantation may predict the ability to recover.
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Affiliation(s)
- Emma J Birks
- Department of Cardiovascular Medicine, University of Louisville, Louisville, KY, USA.
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Control of ventricular unloading using an electrocardiogram-synchronized Thoratec paracorporeal ventricular assist device. J Thorac Cardiovasc Surg 2013; 146:710-7. [DOI: 10.1016/j.jtcvs.2012.12.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 11/15/2012] [Accepted: 12/11/2012] [Indexed: 11/18/2022]
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45
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Didié M, Biermann D, Buchert R, Hess A, Wittköpper K, Christalla P, Döker S, Jebran F, Schöndube F, Reichenspurner H, El-Armouche A, Zimmermann WH. Preservation of left ventricular function and morphology in volume-loaded versus volume-unloaded heterotopic heart transplants. Am J Physiol Heart Circ Physiol 2013; 305:H533-41. [PMID: 23771692 DOI: 10.1152/ajpheart.00218.2013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Total mechanical unloading of the heart in classical models of heterotopic heart transplantation leads to cardiac atrophy and functional deterioration. In contrast, partial unloading of failing human hearts with left ventricular (LV) assist devices (LVADs) can in some patients ameliorate heart failure symptoms. Here we tested in heterotopic rat heart transplant models whether partial volume-loading (VL; anastomoses: aorta of donor to aorta of recipient, pulmonary artery of donor to left atrium of donor, superior vena cava of donor to inferior vena cava of recipient; n = 27) is superior to the classical model of myocardial unloading (UL; anastomoses: aorta of donor to aorta of recipient, pulmonary artery of donor to inferior vena cava of recipient; n = 14) with respect to preservation of ventricular morphology and function. Echocardiography, magnetic resonance imaging, and LV-pressure-volume catheter revealed attenuated myocardial atrophy with ~30% higher LV weight and better systolic contractile function in VL compared with UL (fractional area shortening, 34% vs. 18%; maximal change in pressure over time, 2,986 ± 252 vs. 2,032 ± 193 mmHg/s). Interestingly, no differences in fibrosis (Picrosirus red staining) or glucose metabolism (2-[18F]-fluoro-2-deoxy-D-glucose-PET) between VL and UL were observed. We conclude that the rat model of partial VL attenuates atrophic remodelling and shows superior morphological as well as functional preservation, and thus should be considered more widely as a research model.
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Affiliation(s)
- Michael Didié
- Institute of Pharmacology, University Medical Center Göttingen and Deutsches Zentrum für Herz-Kreislauf-Forschung, partner site Göttingen, Germany
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46
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Wang L, Xu YX, Du XJ, Sun QG, Tian YJ. Dynamic expression profiles of MMPs/TIMPs and collagen deposition in mechanically unloaded rat heart: implications for left ventricular assist device support-induced cardiac alterations. J Physiol Biochem 2013; 69:477-85. [PMID: 23315238 DOI: 10.1007/s13105-013-0235-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 01/02/2013] [Indexed: 11/25/2022]
Abstract
Left ventricular assist devices (LVADs) ameliorate heart failure by reducing preload and afterload. However, extracellular matrix (ECM) deposition after application of LVADs is not clearly defined. The purpose of the present study was to investigate ECM remodeling after mechanical unloading in a rat heart transplant model. Sixty male Lewis rats were subjected to abdominal heterotopic heart transplantation, and the transplanted hearts were pressure- and volume-unloaded. The age- and weight- matched male Lewis rats who had undergone open thoracic surgeries were used as the control. Left ventricle ECM accumulation and the expression/activity of matrix metalloproteinases (MMPs) and tissue inhibitor of matrix metalloproteinases (TIMPs) were measured on the third, seventh, and fourteenth days after transplantation/sham surgery. Compared with the control group, myocardial ECM deposition significantly increased on the seventh and fourteenth days after heart transplantation (P < 0.05) and peaked on the 14th day. The gelatinase activity as well as mRNA expression of MMP-2 and MMP-9 significantly increased after transplantation (P < 0.05). Both mRNA and protein levels of TIMP-1 and TIMP-2 significantly increased compared with those of the control group. Mechanical unloading may lead to adverse remodeling of the ECM of the left ventricle. The underlying mechanism may due to the imbalance of the MMP/TIMP system, especially the remarkable upregulation of TIMPs in the pressure and volume unloaded heart.
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Affiliation(s)
- Lu Wang
- Division of Cardiology, Shandong Corps Hospital of Chinese People's Armed Police Forces, Jinan, Shandong, People's Republic of China
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47
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Effects of Left Ventricular Assist Device (LVAD) Placement on Myocardial Oxidative Stress Markers. Heart Lung Circ 2012; 21:586-97. [DOI: 10.1016/j.hlc.2012.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 11/18/2022]
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Drakos SG, Kfoury AG, Stehlik J, Selzman CH, Reid BB, Terrovitis JV, Nanas JN, Li DY. Bridge to recovery: understanding the disconnect between clinical and biological outcomes. Circulation 2012; 126:230-41. [PMID: 22777666 PMCID: PMC3714227 DOI: 10.1161/circulationaha.111.040261] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Stavros G Drakos
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA.
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Hou J, Kang YJ. Regression of pathological cardiac hypertrophy: signaling pathways and therapeutic targets. Pharmacol Ther 2012; 135:337-54. [PMID: 22750195 DOI: 10.1016/j.pharmthera.2012.06.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 02/05/2023]
Abstract
Pathological cardiac hypertrophy is a key risk factor for heart failure. It is associated with increased interstitial fibrosis, cell death and cardiac dysfunction. The progression of pathological cardiac hypertrophy has long been considered as irreversible. However, recent clinical observations and experimental studies have produced evidence showing the reversal of pathological cardiac hypertrophy. Left ventricle assist devices used in heart failure patients for bridging to transplantation not only improve peripheral circulation but also often cause reverse remodeling of the geometry and recovery of the function of the heart. Dietary supplementation with physiologically relevant levels of copper can reverse pathological cardiac hypertrophy in mice. Angiogenesis is essential and vascular endothelial growth factor (VEGF) is a constitutive factor for the regression. The action of VEGF is mediated by VEGF receptor-1, whose activation is linked to cyclic GMP-dependent protein kinase-1 (PKG-1) signaling pathways, and inhibition of cyclic GMP degradation leads to regression of pathological cardiac hypertrophy. Most of these pathways are regulated by hypoxia-inducible factor. Potential therapeutic targets for promoting the regression include: promotion of angiogenesis, selective enhancement of VEGF receptor-1 signaling pathways, stimulation of PKG-1 pathways, and sustention of hypoxia-inducible factor transcriptional activity. More exciting insights into the regression of pathological cardiac hypertrophy are emerging. The time of translating the concept of regression of pathological cardiac hypertrophy to clinical practice is coming.
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Affiliation(s)
- Jianglong Hou
- Regenerative Medicine Research Center, West China Hospital, Sichuan University, Chengdu, China
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50
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Abstract
Ventricular assist devices (VADs) have been used successfully as a bridge to transplant in heart failure patients by unloading ventricular volume and restoring the circulation. An artificial vasculature device (AVD) is being developed that may better facilitate myocardial recovery than VAD by controlling the afterload experienced by the native heart and controlling the pulsatile energy entering into the arterial system from the device, potentially reconditioning the arterial system properties. The AVD is a valveless, 80 ml blood chamber with a servo-controlled pusher plate connected to the ascending aorta by a vascular graft. Control algorithms for the AVD were developed to maintain any user-defined systemic input impedance (IM) including resistance, elastance, and inertial components. Computer simulation and mock circulation models of the cardiovascular system were used to test the efficacy of two control strategies for the AVD: 1) average impedance position control (AIPC)-to maintain an average value of resistance during left ventricular (LV) systole and 2) instantaneous impedance force feedback (IIFF) and position control (IIPC)-to maintain a desired value or profile of resistance and compliance. Computer simulations and mock loop tests were performed to predict resulting cardiovascular pressures, volumes, flows, and the resistance and compliance experienced by the native LV during ejection for simulated normal, failing, and recovering LV. These results indicate that the LV volume and pressure decreased, and the LV stroke volume increased with decreasing IM, resulting in an increased ejection fraction. Although the AIPC algorithm is more stable and can tolerate higher levels of sensor errors and noise, the IIFF and IIPC control algorithms are better suited to maintain any instantaneous IM or an IM profile. The developed AVD impedance control algorithms may be implemented with current VADs to promote myocardial recovery and facilitate weaning.
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