2019 EACTS Expert Consensus on long-term mechanical circulatory support

Impact of concomitant aortic valve replacement in patients with mild-to-moderate aortic valve regurgitation undergoing left ventricular assist device implantation: EUROMACS analysis

INTRODUCTION

Left ventricular assist device (LVAD) therapy may lead to an aortic regurgitation, limiting left ventricular unloading and causing adverse events. Whether concomitant aortic valve replacement may improve outcomes in patients with preoperative mild-to-moderate aortic regurgitation remains unclear.

METHODS

A retrospective propensity score-matched analysis of adult patients with preoperative mild-to-moderate aortic regurgitation undergoing durable LVAD implantation between 01/01/2011 and 30/11/2021 was performed. Patients undergoing concomitant valve surgery other than biological aortic valve replacement were excluded, resulting in 77 with concomitant biological aortic valve replacement and 385 without.

RESULTS

Following 1:1 propensity score matching, two groups of 55 patients with and without biological aortic valve replacement were obtained, (mean age 59 ± 11 years, 92% male, 59.1% HeartWare). Aortic regurgitation was mild in 72.7% and 76.4% and moderate in 27.3% and 23.6% in non-replacement and replacement cohorts respectively. The 30-day survival was 89.1% vs. 85.5% (p = 0.59), 1-year survival 69.1% vs. 56.4% (p = 0.19), and 2-year survival 61.8% vs. 47.3% (p = 0.10) in the non-replacement and replacement groups, respectively. After a mean follow-up of 1.2 years, non-replacement patients had a higher incidence of pump thrombosis (11 [20%] vs. 3 [5.5%], p = 0.022) and fewer major bleedings (2 [3.6%] vs. 11 [20%], p = 0.008).

CONCLUSION

Compared with those treated conservatively, patients with mild-to-moderate aortic regurgitation undergoing concomitant aortic valve replacement during LVAD implantation have a similar survival up to 2 years on support. Patients with concomitant valve replacement had a higher risk of bleeding complications but fewer pump thromboses.

A case of truncus arteriosus with severe heart failure and pulmonary stenosis: bridge to transplant candidacy with surgical correction and a ventricular-assist device

Ventricular-assist device therapy for small patients with congenital heart disease is challenging due to its complex anatomy and hemodynamics. We describe a 3-year-old patient with heart failure with truncus arteriosus in the palliative stage. The patient underwent palliative right ventricular outflow tract reconstruction following bilateral pulmonary artery banding. At 6 months of age, the patient developed severe truncal valve regurgitation and left ventricular dysfunction. Emergent truncal valve replacement with a mechanical valve was performed, but left ventricular dysfunction persisted. At 3 years of age, the patient developed acute progression of heart failure triggered by influenza infection. The patient was intubated and transferred to our center to determine the indication for heart transplantation. On the second day after admission, signs of multiorgan failure appeared. Emergent ventricular-assist device implantation for both ventricles was performed with truncal valve closure, ventricular septal defect closure, atrial septal defect closure, and re-right ventricular outflow tract reconstruction. The right ventricular-assist device was successfully removed on the seventh postoperative day. Due to the small pulmonary arteries, severe pulmonary stenosis persisted after ventricular-assist device implantation, but it gradually improved with multiple pulmonary angioplasties. The patient was registered in the Japanese organ transplant network and is awaiting a donor organ in a stable condition.

Backwash Maneuver for HeartMate3 Inflow Thrombosis: Experience From Two Cases

The ingested pump inflow thrombus, although rare, is a potentially life-threatening complication of left ventricular assist devices. During the last years, the backwash maneuver is considered an alternative method to pump replacement for the treatment of inflow thrombosis, showing high success rate in selected patients with HeartWare HVAD devices. However, that was not the case in our present report, in which we detail the application of this method in two HeartMate3 patients with ingested pump inflow thrombus. Washing out the thrombus was not feasible in either case, possibly due to mechanical aspects of the inflow part of the HeartMate3 pump. As a result, we remain skeptical regarding the use of the method in HeartMate3 patients with inflow thrombosis.

Sex Differences in the In-Hospital Outcomes of Left Ventricular Assist Device Implantation: A Population-Based National Inpatient Sample Study From 2015 to 2021

BACKGROUND

Left ventricular assist device (LVAD) implantation can be used to manage advanced heart failure. Debates over sex differences in postoperative outcomes of LVAD implantation remain contentious; there is limited evidence available from the continuous-flow era, particularly following the introduction of third-generation devices. This study aimed to conduct a comprehensive, contemporary, and population-based analysis of the sex difference in the in-hospital outcomes following LVAD implantations.

METHODS

Patients who underwent LVAD implantation were selected from National Inpatient Sample from Q4 2015-2021. Multivariable logistic regression was used to compare in-hospital outcomes between females and males, where demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status were adjusted.

RESULTS

There were 1201 (23.6%) female and 3881 (76.4%) male patients who underwent LVAD implantation. Females and males had comparable in-hospital mortality, MACE, and stroke. However, females had higher diaphragmatic paralysis (aOR = 7.94, 95 CI = 1.46-43.48, p = 0.02). Meanwhile, females had lower cardiogenic shock (aOR = 0.85, 95 CI = 0.73-0.98, p = 0.02), renal complications (aOR = 0.72, 95 CI = 0.62-0.84, p < 0.01), and infection (aOR = 0.70, 95 CI = 0.58-0.86, p < 0.01). Females also had longer hospital length of stay (44.1 ± 40.0 vs. 38.8 ± 30.6 days, p = 0.01) and higher total hospital charges (1293779.0 ± 1182139.0 vs. 1172780.0 ± 917544.0 US dollars, p = 0.04).

CONCLUSION

In the contemporary era with the introduction of third-generation devices, in-hospital mortality and stroke after LVAD implantation continued to decrease and were comparable in both sexes. However, there are still notable sex-based differences in the complications of LVAD implantation, which underscores the need for sex-specific preoperative risk assessments and tailored perioperative management.

Aortic regurgitation in left ventricular assist device patients: Does aortic root dilatation contribute to valve incompetence?

BACKGROUND

Aortic regurgitation (AR) is a known complication after left ventricular assist device (LVAD) implantation potentially leading to recurrent heart failure. Possible pathomechanisms include valvular pathologies and aortic root dilatation. We assessed aortic root dimensions in a group of consecutive LVAD patients who received HeartMate 3.

METHODS

Since 11/2015, we identified 68 patients with no or mild AR at the time of HeartMate 3 implantation who underwent serial echocardiography to assess AR and aortic root dimensions (annulus, sinus, and sinotubular junction). Median follow-up was 40 months (2-94 months). Results were correlated with clinical outcomes.

RESULTS

Patients were 60 ± 10 years old, predominantly male (88%) and 35% presented in preoperative critical condition as defined by INTERMACS levels 1 and 2. During follow-up, 23 patients developed AR ≥ II (34%). Actuarial incidence was 8% at 1 year, 29% at 3 years and 41% at 5 years. Echocardiography revealed practically stable root dimensions at the latest follow-up compared to the preoperative state (annulus: 23 ± 3 mm vs. 23 ± 2 mm, sinus: 32 ± 4 mm vs. 33 ± 3 mm, sinotubular junction: 27 ± 3 mm vs. 28 ± 3 mm), irrespective of the development of AR. Serial CT angiograms were performed in 13 patients to confirm echocardiographic findings. Twenty-one patients died during LVAD support leading to a 5-year survival of 71%, showing no difference between patients with and without AR ≥ II (p = 0.573).

CONCLUSIONS

At least moderate AR develops over time in a substantial fraction of patients (one-third over 3 years). The mechanism does not seem to be related to dilatation of the aortic annulus or root.

The relation between socioeconomic status and invasive haemodynamics at evaluation for advanced heart failure

AIMS

Socioeconomic deprivation is a risk marker for worse prognosis in patients with heart failure (HF), and a potential barrier to referral for advanced HF evaluation. The relationship between socioeconomic status (SES) and invasive haemodynamics in patients undergoing evaluation for advanced HF therapies is unknown.

METHODS

We combined a consecutive clinical registry of patients evaluated for advanced HF with patient-level data on SES (household income, education, workforce status, cohabitant status and distance from home to tertiary HF centre) derived from nationwide registries. Using this information, the cohort was divided into groups of low-, medium- and high degree of socioeconomic deprivation. The associations between SES and invasive haemodynamics were explored with multiple linear regression adjusted for age and sex.

RESULTS

A total of 631 patients were included. The median age was 53 years, and 23% were women. Patients in the highest income quartile versus the lowest (Q4 vs. Q1) were older (median age 57 vs. 50 years) and more often male (83% vs. 67%), both P < 0.001. Increasing household income (per 100 000 Danish kroner,1 EUR = 7.4 DKK) was associated with lower pulmonary capillary wedge pressure (PCWP) [-0.18 mmHg, 95% confidence interval (CI) -0.36 to -0.01, P = 0.036] but not significantly associated with central venous pressure (CVP) (-0.07 mmHg, 95% CI -0.21 to 0.06, P = 0.27), cardiac index (-0.004 L/min/m2, 95% CI -0.02 to 0.01, P = 0.60), or pulmonary vascular resistance (PVR) (-0.003 Wood units, 95% CI -0.37 to 0.16, P = 0.84). Comparing the most deprived with the least deprived group, adjusted mean PVR was higher (0.35 Wood units, 95% CI 0.02 to 0.68, P = 0.04), but PCWP (0.66 mmHg, 95% CI -1.49 to 2.82, P = 0.55), CVP (-0.26 mmHg, 95% CI -1.76 to 1.24, P = 0.73) and cardiac index (-0.03 L/min/m2, 95% CI -0.22 to 0.17, P = 0.78) were similar.

CONCLUSIONS

Most haemodynamic measurements were similar across layers of SES. Nevertheless, there were some indications of worse haemodynamics in patients with lower household income or a high accumulated burden of socioeconomic deprivation. Particular attention may be warranted in socioeconomically deprived patients to ensure timely referral for advanced HF evaluation.

Evaluation of warfarin dose and INR time in therapeutic range in left ventricular assist device patients with sleeve gastrectomy

Sleeve gastrectomy is safe and effective in patients with left ventricular assist devices (LVADs) and morbid obesity to improve candidacy for transplantation and increase survival rates. Literature describing warfarin anticoagulation in this population is limited. A single-center, propensity score-matched, retrospective cohort study was conducted to determine if sleeve gastrectomy in LVAD-implanted patients has an effect on warfarin dose requirements in the outpatient setting. Patients were eligible for inclusion if they were 18 years of age or older, underwent LVAD implant at the study center, and were discharged from the hospital on warfarin therapy. They must have at least 8 weeks of available follow-up data post-discharge. Propensity matching was utilized to identify a non-sleeve gastrectomy LVAD-only patients for comparison. A total of 96 LVAD-only patients and 48 LVAD plus sleeve gastrectomy patients were included in the final analysis. Outpatient warfarin requirements increased from baseline over time in both groups, with no significant differences between groups except at month 12, with a mean total weekly dose of 38.1 ± 21.4 mg in the LVAD only group and 46.8 ± 18.6 mg in the LVAD with sleeve gastrectomy group (p = 0.05). The sleeve gastrectomy group had a significantly lower warfarin doses per kilogram of body weight until month 6 post-discharge. The percent time in therapeutic range was significantly lower in the SG group at the 8 week, 3 month, and 6 month interval time point. There were no significant differences in the incidence of bleeding or thromboembolic events.

Recent Developments in Ventricular Assist Device Therapy

The evolution of left ventricular assist devices (LVADs) from large, pulsatile systems to compact, continuous-flow pumps has significantly improved implantation outcomes and patient mobility. Minimally invasive surgical techniques have emerged that offer reduced morbidity and enhanced recovery for LVAD recipients. Innovations in wireless power transfer technologies aim to mitigate driveline-related complications, enhancing patient safety and quality of life. Pediatric ventricular assist devices (VADs) remain a critical unmet need; challenges in developing pediatric VADs include device sizing and managing congenital heart disease. Advances in LVAD technology adapted for use in right ventricular assist devices (RVADs) make possible the effective management of right ventricular failure in patients with acute cardiac conditions or congenital heart defects. To address disparities in mechanical circulatory support (MCS) access, cost-effective VAD designs have been developed internationally. The Vitalmex device from Mexico City combines pulsatile-flow technology with a paracorporeal design, utilizing cost-effective materials like silicone-elastic and titanium, and features a reusable pump housing to minimize manufacturing and operational costs. Romanian researchers have used advanced mathematical modeling and three-dimensional (3D) printing to produce a rim-driven, hubless axial-flow pump, achieving efficient blood flow with a compact design that includes a wireless power supply to reduce infection risk. In conclusion, MCS continues to advance with technological innovation and global collaboration. Ongoing efforts are essential to optimize outcomes, expand indications, and improve access to life-saving therapies worldwide.

Strategies in Diagnosis and Therapy of External Outflow Graft Obstruction in Patients with a Fully Magnetically Levitated Left Ventricular Assist Device: A Meta-Analysis and Systematic Review

Background: The HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD) is the only commercially available option considered suitable for long-term circulatory support. External compression of the outflow graft causing obstruction (eOGO) is a serious adverse event affecting patients on long-term support. The obstruction occurs due to the accumulation of gelatinous substance between the bend relief and outflow graft. This systematic review evaluated all available studies with regard to the diagnosis and therapy of eOGOs. Methods: A systematic literature review and analysis of individual patient data was performed using MEDLINE/PubMed following PRISMA guidelines. Original works dating up to 31 October 2024 were considered. Results: Twenty-four publications that met the inclusion criteria were identified, providing individual data from 113 patients with a median support time to eOGO diagnosis of 809 days [588, 1095] and follow-up after treatment of 365 days [33, 605]. eOGO severity classification was performed on 108 patients according to our grading system. For treatment, most patients underwent surgery (n = 38) or stenting (n = 29). A hazard ratio of 0.75 [0.28, 2.03] was calculated for the surgical group versus the stenting group (p = 0.570). Conclusions: Concerning 30-day mortality, we did not find a significant difference between the eOGO severity of survivors and non-survivors. We found no significant differences in outcome between patients with differing eOGO severity and treatment strategy, namely stenting and surgery. Due to an increase in eOGO incidence after one year of support, we propose that clinicians monitor their patients for this complication when support time surpasses one year.

Left Ventricular Dimensions and Clinical Outcomes With a Fully Magnetically Levitated Left Ventricular Assist Device

BACKGROUND

Prior analyses have suggested that a smaller left ventricular end-diastolic diameter (LVEDD) is associated with reduced survival following HeartMate 3 left ventricular assist device implantation.

OBJECTIVES

In this trial-based comprehensive analysis, the authors sought to examine clinical characteristics and association with the outcome of this specific relationship.

METHODS

The authors analyzed the presence of LVEDD <55 mm among 1,921 analyzable HeartMate 3 patients within the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3) trial portfolio, on endpoints of overall survival and adverse events at 2 years. Adverse events included hemocompatibility-related (stroke, bleeding, and pump thrombosis) and non-hemocompatibility-related (right heart failure, infection) outcomes.

RESULTS

Those with a smaller LVEDD (<55 mm) (n = 108) were older (age 63 ± 11 years vs 60 ± 12 years; P = 0.005), were more often female (31% vs 20%; P = 0.096), and had more ischemic cardiomyopathy (60.2% vs 42.6%; P = 0.0004) compared with the LVEDD ≥55 mm group (n = 1,813). Death during implant hospitalization was higher (14.8 vs 5.7%; P = 0.0007) and survival at 2 years was lower (63.3% vs 81.8%; HR: 1.97 [95% CI: 1.39-2.79]; P = 0.0002) in the LVEDD <55 mm group. The LVEDD <55 mm group experienced more deaths due to hemocompatibility-related adverse events (2.8% vs 0.6%; HR: 4.61 [95% CI: 1.29-16.45]; P = 0.018) and right heart failure, both early (0-30 days; 7.4% vs 2.0%; HR: 3.70 [95% CI: 1.73-7.91]; P = 0.001) and late (>30 days; 12.0 vs 4.8%; HR: 2.58 [95% CI: 1.37-4.84]; P = 0.003). Low-flow alarms rehospitalizations were higher in the LVEDD <55 mm cohort (17.4 vs 8.3%; HR: 2.39 [95% CI: 1.59-3.59]; P < 0.001).

CONCLUSIONS

Although infrequent in occurrence, smaller LVEDD (<55 mm) is associated with increased risk for early and late mortality, a consequence of hemocompatibility-related and right heart failure-related deaths. Rehospitalizations due to low-flow alarms are also more frequent. (MOMENTUM 3 IDE Clinical Study Protocol [HM3™]; NCT02224755; MOMENTUM 3 Continued Access Protocol [MOMENTUM 3 CAP]; NCT02892955).

In Vitro Analysis of Left Ventricular Assist Device Outflow Graft Orientations and Their Effect on Aortic Hemodynamics

Continuous-flow left ventricular assist devices have become an important treatment option for patients with advanced heart failure. However, adverse hemodynamic effects as consequence of an altered blood flow within the aorta and the aortic root remain a topic of concern. In this work, we investigated the influence of the outflow graft orientation on the hemodynamic profile and flow parameters within the thoracic aorta. Aortic models with different outflow graft orientations were designed and three-dimensional (3D) printed to mimic common implantation configurations and were integrated into a pulsatile mock circulatory flow loop. Assist device function was achieved using a rotary pump, replicating nonpulsatile, continuous support flows of 1-5 L/min. Flow velocity, wall shear stress, and pressure gradients were investigated for each configuration using sonography and four-dimensional (4D) flow magnetic resonance imaging. Mean wall shear stresses measured in 4D flow software were lowest for a graft inclination angle of 45°. Streamline visualization revealed areas of nonuniform, retrograde, and vortex flow in all models but most prominent for the aortic model with an outflow graft inclination of 60°. The insights gained from this research may aid in understanding clinical outcomes following assist device implantation and long-term mechanical circulatory support.

Collaborative care models in adult congenital heart disease transplant

PURPOSE OF REVIEW

While multidisciplinary collaboration is a tenant of quality heart failure care and critical to the success of transplant programs, this essay challenges the temptation to shoehorn adult congenital heart disease (ACHD) patients into preexisting processes and paradigms. We explore the development of more relevant models, purposefully designed to improve ACHD transplant volumes and outcomes.

RECENT FINDINGS

Globally, the rapid acceleration of ACHD patients living with and dying from HF stands in stark contrast to their access to transplant. Inferior early outcomes after ACHD transplant remain an undeniable barrier. And yet while all large registry datasets attest to this statistic, a few centers have achieved results comparable to those in acquired heart disease. This despite increases in both ACHD candidate complexity and referrals for Fontan Circulatory Failure. Perhaps something in their approach to care delivery is key?.

SUMMARY

Alone, neither ACHD nor transplant programs can provide optimal management of HF in ACHD. A siloed approach is similarly inadequate. Building new ACHD-HF-Transplant teams, centered on the patient and supplemented by ad hoc expert partnerships, is an exciting approach that can improve outcomes, create a high-quality training environment, and in our experience, is a truly rewarding way of working together.

Destination Therapy Strategies of Advanced Heart Failure in Elderly Non-Heart Transplant Candidates: A Propensity Matching Analysis from the LEVO-D and REGALAD Registries

Heart transplantation (HT) is the gold standard therapy for advanced heart failure (ADHF), and LVADs as destination therapy are an option in non-HT candidates. Most patients with ADHF never receive HT or an LVAD, so alternative strategies are needed. Intermittent levosimendan can reduce HF hospitalizations in ADHF patients in the short term. It is uncertain whether the results of the comparison of inotropes with older-generation LVADs would have the same outcomes in the current era of ADHF patients treated with levosimendan, who are less sick but older. In this paper, we compare the use of two therapeutic strategies for end-stage HF in patients who are not candidates for HT: repetitive intermittent levosimendan vs. LVAD as destination therapy. To do so, we compare two multicenter cohorts of real-life patients from Spain: the LEVO-D registry and the REGALAD registry. In total, 715 patients coming from the two registries were found: 403 from LEVO-D and 312 from REGALAD. Non-adjusted median survival was shorter for LEVO-D patients, with the benefit for the LVADs seen only after the first year of therapy. The survival advantage for the LVAD cohort was also true after analysis of the matched cohort but, as in the non-matched analysis, the survival benefit was mainly shown after one year of follow-up. We conclude that in elderly ADHF non-HT candidates, LVAD therapy offers significantly better long-term outcomes when compared to intermittent levosimendan; thus, it should be considered in carefully selected candidates. On the other hand, in poor LVAD candidates or highly comorbid patients, intermittent inotropic support with levosimendan could be a reasonable alternative to LVAD, as 1-year outcomes are similar.

Prosthetic Valve Fate in Patients With Continuous-Flow Left Ventricular Assist Devices

Prosthetic valve-related morbidity and mortality in patients with left ventricular assist devices (LVADs) remain unclear. We retrospectively reviewed patients who received a HeartMate II or 3 LVAD at our center between April 2004 and December 2022. Patients with a valve prosthesis in any position were included. Of the 726 LVAD recipients, 74 (10.2%) underwent valve replacement before (n = 37, 50.0%), concomitantly with (n = 32, 43.2%), or after (n = 6, 8.1%) LVAD insertion. Prosthetic valves were implanted in the aortic (n = 32), mitral (n = 23), and tricuspid (n = 26) positions. Mechanical valves were present in eight (three aortic, five mitral) patients. At a median follow-up of 1.97 years post-VAD (interquartile range [IQR]: 0.56-4.58 years), there was one valve-related death due to severe aortic bioprosthetic insufficiency. Five of 28 (17.9%) patients with an aortic bioprosthesis had evidence of dysfunction on follow-up echocardiography. Median time to first sign of aortic bioprosthetic valve dysfunction was 1 (IQR: 0.6-5.1) year from time of LVAD with the prosthesis in place and 10.8 (IQR: 9.5-12.6) years from date of initial valve insertion. Prosthetic valve-related mortality or reinterventions are uncommon in patients with LVADs; however, bioprosthetic aortic valve dysfunction can develop less than 1 year after LVAD implantation.

Breast cancer and cardiovascular health

Modern cancer therapies greatly improve clinical outcomes for both early and advanced breast cancer patients. However, these advances have raised concerns about potential short- and long-term toxicities, including cardiovascular toxicities. Therefore, understanding the common risk factors and underlying pathophysiological mechanisms contributing to cardiovascular toxicity is essential to ensure best breast cancer outcomes. While cardio-oncology has emerged as a sub-speciality to address these challenges, it is essential that all cardiologists recognize and understand the cardiovascular consequences of cancer therapy. This review aims to provide a comprehensive overview of the potential adverse cardiovascular effects associated with modern breast cancer therapies. A preventive, diagnostic, and therapeutic workflow to minimize the impact of cardiovascular toxicity on patient outcomes is presented. Key aspects of this workflow include regular monitoring of cardiovascular function, early detection and management of cancer therapy-related cardiovascular toxicities, and optimization of cardiovascular risk factor control. By highlighting the gaps in knowledge in some areas, this review aims to emphasize the critical role of cardio-oncology research in ensuring the holistic well-being of patients with breast cancer.

Left Ventricular Assist Device in Advanced Refractory Heart Failure: A Comprehensive Review of Patient Selection, Surgical Approaches, Complications and Future Perspectives

The management of advanced heart failure (HF) has long posed significant challenges due to its complex and chronic nature. Heart transplantation, while effective, is not always feasible due to the limited availability of donor organs. In this context, long term mechanical circulatory support and mainly left ventricular assist devices (LVADs) have emerged as a vital intervention to fill this gap. LVAD superiority compared to medical therapy for some patients in advanced heart failure has been demonstrated either as a bridge to transplantation or as destination therapy. This literature review provides a comprehensive overview of the effectiveness, challenges, and advancements in the use of LVADs for treating advanced heart failure. It evaluates clinical outcomes associated with LVAD therapy, focusing on survival rates and quality of life improvements. The review synthesizes findings from recent studies, highlighting both the benefits and complications of LVAD implantation, such as infectious risk, thromboembolic events, hemorrhage and device malfunction. Additionally, it explores the latest technological and biomedical advancements in LVAD design, including innovations in biocompatibility, miniaturization, and power management. By examining current research, this review aims to elucidate how LVADs are transforming heart failure treatment and to offer insights into future directions for clinical practice and research.

Prognostic Value of Frailty for Heart Failure Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review

Frailty is associated with poor clinical outcomes in heart failure patients. The impact of frailty on outcomes following left ventricular assist device (LVAD) implantation, however, is less clearly defined. We therefore sought to conduct a systematic review to evaluate current frailty assessment strategies and their significance for patients undergoing LVAD implantation. We conducted a comprehensive electronic search of PubMed, Embase, and CINAHL databases from inception until April 2021 for studies examining frailty in patients undergoing LVAD implantation. Study characteristics, patient demographics, type of frailty measurement, and outcomes were extracted. Outcomes were organized into 5 basic categories: implant length of stay (iLOS), 1-year mortality, rehospitalization, adverse events, and quality of life (QOL). Of the 260 records retrieved, 23 studies involving 4935 patients satisfied the inclusion criteria. Approaches to measuring frailty varied, with the 2 most common being sarcopenia determined by computed tomography and Fried's frailty phenotype assessment. Outcomes of interest were also widely variable, with iLOS stay and mortality being the most frequently reported, albeit with differing definitions of both between studies. The heterogeneity among included studies precluded quantitative synthesis. Narrative synthesis showed that frailty by any measure is more likely to be associated with higher mortality, longer iLOS, more adverse events and worse QOL post-LVAD implant. Frailty can be a valuable prognostic indicator in patients undergoing LVAD implantation. Further studies are needed to determine the most sensitive frailty assessment, as well as the ways in which frailty may serve as a modifiable target to improve outcomes following LVAD implantation.

Right heart failure with left ventricular assist devices: Preoperative, perioperative and postoperative management strategies. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC

Right heart failure (RHF) following implantation of a left ventricular assist device (LVAD) is a common and potentially serious condition with a wide spectrum of clinical presentations with an unfavourable effect on patient outcomes. Clinical scores that predict the occurrence of right ventricular (RV) failure have included multiple clinical, biochemical, imaging and haemodynamic parameters. However, unless the right ventricle is overtly dysfunctional with end-organ involvement, prediction of RHF post-LVAD implantation is, in most cases, difficult and inaccurate. For these reasons optimization of RV function in every patient is a reasonable practice aiming at preparing the right ventricle for a new and challenging haemodynamic environment after LVAD implantation. To this end, the institution of diuretics, inotropes and even temporary mechanical circulatory support may improve RV function, thereby preparing it for a better adaptation post-LVAD implantation. Furthermore, meticulous management of patients during the perioperative and immediate postoperative period should facilitate identification of RV failure refractory to medication. When RHF occurs late during chronic LVAD support, this is associated with worse long-term outcomes. Careful monitoring of RV function and characterization of the origination deficit should therefore continue throughout the patient's entire follow-up. Despite the useful information provided by the echocardiogram with respect to RV function, right heart catheterization frequently offers additional support for the assessment and optimization of RV function in LVAD-supported patients. In any patient candidate for LVAD therapy, evaluation and treatment of RV function and failure should be assessed in a multidimensional and multidisciplinary manner.

Complications of Left Ventricular Assist Devices: A Case Study of Recurrent Bacteremia and Implications for Infection Management

Heart failure (HF) is a complex clinical condition with symptoms that result from ineffective ejection of blood due to functional or structural impairment of the heart. The most common causes of HF include ischemic heart disease, myocardial infarction (MI), hypertension, and valvular heart disease (VHD). As HF progresses to advanced stages, interventions, like left ventricular assist devices (LVADs), become essential, especially for patients ineligible for heart transplantation. However, LVADs carry substantial infection risks, particularly for bacteremia, which complicates management, patient morbidity, and patient outcomes in some cases.  Our case involves a 61-year-old male with a medical history of American College of Cardiology (ACC)/American Heart Association (AHA) stage D heart failure secondary to non-ischemic cardiomyopathy, a history of biventricular implantable cardioverter defibrillator (ICD) implantation, and an LVAD as destination therapy who experienced recurrent episodes of LVAD-associated infection. Post-implantation, he developed repeated driveline infections with Methicillin-resistant Staphylococcus aureus (MRSA) and Corynebacterium, necessitating prolonged antibiotic courses, incision and drainage, and wound care, but no device functionality issues. The patient's non-adherence to infection control measures further complicated his clinical course, with multiple hospital admissions due to recurrent infections and associated symptoms. Psychosocial factors, including anxiety and depression, significantly impacted his adherence to driveline care, highlighting the critical role of comprehensive patient support in managing LVAD complications. This case underscores the importance of candidate selection, patient education, and stringent infection control protocols in LVAD management. Early identification of patients at high infection risk, combined with ongoing psychosocial support, can improve outcomes and reduce complications. Given the potential for recurrent infections, enhanced screening for psychosocial issues and preventive strategies are essential for patients undergoing LVAD implantation.

Drug therapy and catheter ablation for management of arrhythmias in continuous flow left ventricular assist device's patients: a Clinical Consensus Statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common with a prevalence of 20-50% at one year after LVAD implantation. Arrhythmias predispose these patients to additional risk and are associated with considerable morbidity from recurrent implantable cardioverter-defibrillator shocks, progressive failure of the unsupported right ventricle, and herald an increased risk of mortality. Management of patients with arrhythmias and LVAD differs in many aspects from the general population heart failure patients. These include ruling out the reversible causes of arrhythmias that in LVAD patients may include mechanical irritation from the inflow cannula and suction events. For patients with symptomatic arrhythmias refractory to medical treatment, catheter ablation might be relevant. There are specific technical and procedural challenges perceived to be unique to LVAD-related ventricular tachycardia (VT) ablation such as vascular and LV access, signal filtering, catheter manoeuvrability within decompressed chambers, and electroanatomic mapping system interference. In some patients, the arrhythmogenic substrate might not be readily accessible by catheter ablation after LVAD implantation. In this regard, the peri-implantation period offers a unique opportunity to surgically address arrhythmogenic substrate and suppress future VT recurrences. This document aims to address specific aspects of the management of arrhythmias in LVAD patients focusing on anti-arrhythmic drug therapy and ablations.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Pressure-dimension index and left ventricular sphericity index following HeartMate II and HeartMate 3 implantation

AIMS

This study aimed to compare the changes in the left ventricle (LV) and right ventricle (RV) geometry and performance after the implantation of HeartMate II (HMII) and HeartMate 3 (HM3). In addition, we investigated whether the echocardiographic parameters LV sphericity index (LVSI) and the novel pressure-dimension index (PDI) can predict post-operative right ventricular failure (RVF).

METHODS AND RESULTS

Between 2012 and 2020, 46 patients [HMII (n = 22) and HM3 (n = 24)] met the study's criteria and had echocardiography tests pre-operatively, 6 and 12 months post-operatively. The LVSI and PDI were calculated together with the standard LV and RV echocardiographic parameters. The mean follow-up was 24 ± 7 months. In both groups, the LV end-diastolic diameter (LVEDD) significantly decreased 12 months post-operatively compared with the pre-operative values (HMII: 6.4 ± 1.4 cm vs. 5.7 ± 0.9 cm, P = 0.040; HM3: 6.7 ± 1.3 cm vs. 5.5 ± 0.9 cm, P < 0.01, respectively). RV function 12 months post-operatively was better in the HM3 group than in the HMII group, as indicated by a significantly higher RV fractional area change (RVFAC) in the HM3 group than in the HMII group 12 months post-operatively (35 ± 12% vs. 26 ± 16%, P = 0.039), significantly higher tricuspid annular plane systolic excursion (TAPSE) in the HM3 group 12 months post-operatively compared with the HMII group (13.9 ± 1.9 mm vs. 12.0 ± 2.1 mm, P = 0.002), and the tissue Doppler estimated tricuspid annular systolic velocity (TASV) was also significantly higher in the HM3 group 12 months post-operatively compared with the HMII group (11.5 ± 2.7 mm/s vs. 9.9 ± 1.5 mm/s, P = 0.020). The LVSI value was significantly higher 12 months post-operatively in the HMII group than in the HM3 group (1.2 ± 0.4 vs. 0.8 ± 0.2, P = 0.001, respectively), indicating worse geometric changes. The PDI decreased 12 months post-operatively in the HM3-group compared with the baseline (3.4 ± 1.4 mmHg/cm2 vs. 2.0 ± 0.8 mmHg/cm2, P < 0.001). In the univariate and multivariate analyses, only the pre-operative PDI was a predictor of post-operative RVF [odds ratio: 3.84 (95% CI: 1.53-18.16, P = 0.022)]. The area under the curve for pre-operative PDI was 0.912. The 2 year survival was significantly better in the HM3 group (log-rank, P = 0.042).

CONCLUSIONS

The design of HM3 offered better geometrical preservation of the LV and enabled normal PDI values, leading to improved RV function, as indicated by better RVFAC, TAPSE, and TASV values. The use of pre-operative PDI as an additional tool for established risk scores might offer a better pre-operative predictor of RVF.

The Longest Living Patient Supported With Left Ventricular Assist Device (14 Years)

Left ventricular assist devices (LVADs) improve survival and reduce symptoms in patients with advanced heart failure; however, the longer-term durability of LVADs remains uncertain especially with older-generation devices. In this case report, we describe the clinical course of a patient who has been successfully treated with the same HeartMate II LVAD for 14 years, the longest published and still ongoing LVAD support with the same originally implanted device.

Multimodality imaging for the evaluation and management of patients with long-term (durable) left ventricular assist devices

Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation.

Heart Transplantation and Left Ventricular Assist Devices: Long-Term Prognosis and Effects on Mental Health

Heart transplantation and left ventricular assist devices (LVADs) have emerged as crucial interventions for end-stage heart failure, dramatically improving patient outcomes. This narrative review examines their historical context, indications, procedures, and outcomes, as well as their impact on long-term survival, quality of life, functional status, and mental health. While heart transplantation remains the optimal treatment, donor scarcity limits its application. LVADs have become a viable alternative, either as a bridge to transplantation or as destination therapy. Both interventions demonstrate similar long-term survival rates and significant improvements in health-related quality of life and functional status. However, they present distinct long-term management challenges, including immunosuppression needs for transplant recipients and device-related issues for LVAD patients. Mental health effects are considerable, necessitating psychological support and adaptive coping strategies. Complications such as infection, bleeding, and thrombosis remain concerns for both interventions. Patient selection criteria, technological advancements, and long-term management strategies are critical factors in optimizing outcomes. Future research should focus on device miniaturization, enhanced biocompatibility, and less invasive insertion techniques to further advance these therapies and improve patient care in end-stage heart failure.

Association between psychosocial factors and left ventricular assist device implant outcomes: A systematic review

BACKGROUND

Psychosocial assessment is a core component of the multidisciplinary evaluation for left ventricular assist device (LVAD) implantation. The degree to which psychosocial conditions are considered a contraindication to LVAD implantation continues to be debated. This systematic review examines modifiable psychosocial factors as predictors of outcomes in patients undergoing LVAD implantation.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The search resulted in 2509 articles. After deduplication, abstract and full-text review, 20 relevant articles were identified.

RESULTS

Included studies evaluated socioeconomic status (n = 6), caregiver characteristics (n = 6), non-adherence (n = 6), substance use (n = 13), and psychiatric disorder (n = 8). The most commonly measured outcomes were all-cause death, readmission rate, and adverse events. Studies varied widely in definition of each psychosocial factor and selected outcomes. No psychosocial factor was consistently associated with a specific outcome in all studies. Socioeconomic status was generally not associated with outcomes. Non-adherence, psychiatric disorder, and substance use were associated with higher risks of mortality, adverse events, and/or readmission. Findings on caregiver characteristics were mixed.

CONCLUSION

Of the psychosocial factors studied, non-adherence, psychiatric disorder, and substance use were the most consistently associated with an increased risk of mortality, readmission, and/or adverse events. Heterogeneity in research methodology and study quality across studies precludes firm conclusions regarding the impact of psychosocial factors on long-term patient outcomes. The results of this review reveal a need for adequately powered studies that use uniform definitions of psychosocial factors to clarify relationships between these factors and outcomes after LVAD implantation.

Durable left ventricular assist devices as a bridge to transplantation: what to expect along the way?

INTRODUCTION

The scarcity of donors coupled with the improvements in left ventricular assist devices (LVAD) technology has led to the use of LVAD as a bridge to transplantation (BTT).

AREAS COVERED

The authors provide an overview of the current status of LVAD BTT implantation with special focus ranging from patient selection and pre-implantation optimization to post-transplant outcomes.

EXPERT OPINION

The United Network for Organ Sharing 2018 policy amendment resulted in a significant reduction in the number of LVADs used for BTT in the US. To overcome this issue, modifications in the US allocation policy to consider factors such as days on device support, age, and type of complications may be necessary to potentially increase implantation rates.

Apixaban in bridge to transplant and destination LVAD - rationale and study design: the ApixiVAD trial

AIMS

Use of novel anticoagulation in mechanical circulatory support is controversial. We report the rationale and design of the ApixiVad pilot trial, a pilot study testing the safety of apixaban as an anticoagulant in patients bridged to transplant (BTT) or for destination (DT) with Heartmate 3 (HM3) left ventricular assist device (LVAD).

METHODS AND RESULTS

Apixaban has been used in small non-randomized cohorts in LVAD patients and shown to be effective in ex vivo studies. The ApixiVAD study examines apixaban use in a multicentre, international, open-label, randomized, controlled trial aiming to include 50 BTT or DT HM3 patients with a 1:1 randomization ratio. This event-driven study has a maximum follow-up period of 24 months with interim analysis at 6 months. The primary outcome is death, thromboembolic events and major bleeding, including operative bleeding and immediate transplant outcomes. The secondary outcome focuses on patients' quality of life related to anticoagulation. This investigator-driven pilot study is not powered to determine the non-inferiority of apixaban. An increase in primary outcome in the apixaban group of 20% will be considered a signal of harm.

CONCLUSIONS

A positive outcome in the ApixiVAD study would provide the basis for future, larger, pivotal anticoagulation trials in LVAD patients.

Echocardiographic haemodynamic monitoring in the context of HeartMate 3™ therapy: a systematic review

AIMS

While echocardiography remains essential within haemodynamic monitoring of durable mechanical circulatory support, previous echocardiographic guidelines are missing scientific evidence for the novel HeartMate 3™ (HM3) system. Accordingly, this review aims to summarize available echocardiographic evidence including HM3.

METHODS AND RESULTS

This systematic review adhered to the PRISMA 2020 guidelines. Searches were conducted during August 2023 across PubMed, Embase, and Google Scholar using specific echocardiographic terms combined with system identifiers. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies and Critical Appraisal Instrument (PCAI) for cross-sectional studies. Nine studies met the inclusion criteria, of which eight cohort studies and one cross-sectional study. Aortic regurgitation (AR) prevalence at approximately 12 months of support exhibited heterogenicity (33.5% (Δ 33%)) in a limited number of studies (n = 3). Several studies (n = 5) demonstrated an increasing prevalence and severity of AR during HM3 support, generating moderate to high level of evidence. One AR study showed a higher cumulative incidence of death and heart failure (HF) readmission compared with those without significant AR, hazard ratio 3.42 (95% CI 1.48-8.76). A second study showed that a worsening AR group had significantly lower survival-free from HF readmission (59% vs. 89%, P = 0.023) with a hazard ratio of 5.18 (95% CI 1.07-25.0), while a third study did not reveal any differences in cardiac-related hospitalizations in the 12 months follow-up or non-cardiac-related hospitalization. Mitral regurgitation (MR) prevalence at approximately 12 months of support exhibited good consistency 15.0% (Δ 0.8%) in both included studies, which did not reveal any significant pattern of changing prevalence over time. Tricuspid regurgitation (TR) prevalence at approximately 12 months of support exhibited fair consistency 28.5% (Δ 8.3%) in a limited number of studies (n = 2); both studies showed a statistically un-confirmed trend of increased TR prevalence over time. The evidence of general prevalence of right ventricular dysfunction (RVD) was insufficient due to lack of studies.

CONCLUSIONS

There are few methodologically consistent studies with focus on long-term haemodynamic effects. Aortic regurgitation still seems to be a prevalent and potentially significant finding. The available evidence concerning right heart function is limited despite clinical relevance and potential prognostic value. Potential interventricular and haemodynamic interplay are identified as a white field for future research.

Platelet reactivity is associated with pump thrombosis in patients with left ventricular assist devices

Background

Patients with left ventricular assist devices (LVADs) are treated with a potent antithrombotic regimen to prevent pump thrombosis and thromboembolism. High on-treatment residual platelet reactivity (HRPR) is associated with ischemic outcomes in cardiovascular disease.

Objectives

In the current study, we investigated the prevalence and clinical impact of HRPR in stable LVAD patients.

Methods

Pump thrombosis, bleeding events, and death were assessed in 62 LVAD patients (19 HeartWare HVAD [Medtronic] and 43 HeartMate 3 [Abbott]) during a 2-year follow-up. Platelet aggregation was measured by multiple electrode aggregometry, and HRPR was defined as arachidonic acid (AA)-inducible platelet aggregation of ≥21 aggregation units. Soluble P-selectin was determined by enzyme-linked immunosorbent assay.

Results

Three patients (4.8%) had pump thrombosis and 10 patients (16.1%) suffered a bleeding complication. AA-inducible platelet aggregation was significantly higher in patients with pump thrombosis (P = .01), whereas platelet aggregation in response to adenosine diphosphate (ADP) and thrombin receptor-activating peptide (TRAP) was comparable between patients without and those with pump thrombosis (both P > .05). Platelet aggregation in response to AA, ADP, and TRAP was similar in patients without and with a bleeding event (all P > .05). HRPR was detected in 29 patients (46.8%) and was associated with significantly higher platelet aggregation in response to AA, ADP, and TRAP as well as higher levels of soluble P-selectin compared with patients without HRPR (all P < .05). All pump thromboses occurred in patients with HRPR (3 vs 0; P = .06) and HVAD.

Conclusion

Platelet reactivity is associated with pump thrombosis in LVAD patients. HRPR may represent a risk marker for pump thrombosis, particularly in HVAD patients.

An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device

Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.

Fibrinolytic Agents in Thromboembolic Diseases: Historical Perspectives and Approved Indications

Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients with pulmonary embolism with hemodynamic compromise, ST-segment elevation myocardial infarction (STEMI), acute ischemic stroke, and central venous access device occlusion. Reteplase and tenecteplase have also received FDA approval for treating patients with STEMI. This review provides an overview of the historical background related to fibrinolytic agents and briefly summarizes their approved indications across various thromboembolic diseases.

Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival

Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 ( p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.

Evaluation of Intraoperative Right Ventricular Myocardial Work Indices in Left Ventricular Assist Device Implantation: A Case Report

Right ventricular myocardial work is an echocardiographic technique yielding significant insights into cardiac mechanics, energetics, and efficiency. Combining right ventricular myocardial strain with loading conditions correlates with invasively measured myocardial work and myocardial oxygen consumption. This method has not yet been described intraoperatively by transesophageal echocardiography. We describe this technique during a left ventricular assist device implantation. This case demonstrates that right ventricular myocardial work indices can be monitored intraoperatively and might assist decisions during left ventricular assist device implantation.

Antithrombotic therapy for durable left ventricular assist devices: protocol for a living systematic review with indirect comparison/network meta-analysis

BACKGROUND

Left ventricular assist devices (LVADs) have emerged as a successful treatment option for patients with end-stage heart failure. Compared with the best medical therapy, LVADs improve survival and enhance functional capacity and quality of life. However, two major complications compromise this patient population's outcomes: thrombosis and bleeding. Despite technological innovations and better hemocompatibility, these devices alter the rheology, triggering the coagulation cascade and, therefore, require antithrombotic therapy. Anticoagulation and antiplatelet therapies represent the current standard of care. Still, inconsistency in the literature exists, especially whether antiplatelet therapy is required, whether direct oral anticoagulants can replace vitamin K antagonists and even whether phosphodiesterase type 5 inhibitors with their antithrombotic effects could be added to the regimen of anticoagulation.

METHODS AND ANALYSIS

We will perform a living systematic review with network meta-analysis and indirect comparison between current antithrombotic therapies, which have and have not been directly compared within clinical trials and observational studies. We will systematically search the following electronic sources: Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica Database (EMBASE). We will exclusively examine studies published in English from 2016 to the present. Studies conducted before 2016 will be omitted since our primary focus is evaluating continuous flow devices. Two independent reviewers will assess the articles by title, abstract and full text; any disagreement will be resolved through discussion, and a third reviewer will be involved if necessary. The Cochrane Risk of Bias tool will be used to assess the risk of bias. We will then conduct a pairwise meta-analysis; if the assumption of transitivity is satisfied, we will proceed with network meta-analysis using Bayesian methodology.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as no primary data are collected. This systematic review and network meta-analysis will delineate the risks of stroke, thromboembolic events, pump thrombosis, gastrointestinal bleeding and mortality in patients equipped with LVADs who are subjected to various antithrombotic regimens. The findings will be disseminated via a peer-reviewed publication and presented at conference meetings. This will enhance clinical practice and guide future research on anticoagulation strategies within this distinct patient cohort.

PROSPERO REGISTRATION NUMBER

CRD42023465288.

HeartMate 3 implantation with an emphasis on the biventricular configuration

OBJECTIVES

Right ventricular failure following implantation of a durable left ventricular assist device (LVAD) is a major driver of mortality. Reported survival following biventricular (BiVAD) or total artificial heart (TAH) implantation remains substantially inferior to LVAD alone. We report our outcomes with LVAD and BiVAD HeartMate 3 (HM3).

METHODS

Consecutive patients undergoing implantation of an HM3 LVAD between November 2014 and December 2021, at The Alfred, Australia were included in the study. Comparison was made between the BiVAD and LVAD alone groups.

RESULTS

A total of 86 patients, 65 patients with LVAD alone and 21 in a BiVAD configuration underwent implantation. The median age of the LVAD and BiVAD groups was 56 years (Interquartile range 46-62) and 49 years (Interquartile range 37-55), respectively. By 4 years after implantation, 54% of LVAD patients and 43% of BiVAD patients had undergone cardiac transplantation. The incidence of stroke in the entire experience was 3.5% and pump thrombosis 5% (all in the RVAD). There were 14 deaths in the LVAD group and 1 in the BiVAD group. The actuarial survival for LVAD patients at 1 year was 85% and BiVAD patients at 1 year was 95%.

CONCLUSIONS

The application of HM 3 BiVAD support in selected patients appears to offer a satisfactory solution to patients requiring biventricular support.

Medium-term outcomes of concomitant aortic valve repair in patients with continuous-flow left ventricular assist device

OBJECTIVE

To analyze the development of aortic insufficiency in patients who received central aortic valve repair when undergoing continuous-flow left ventricular assist device implantation.

METHODS

We conducted a retrospective review of patients who underwent implantation with HeartMate II or 3 (Abbott Laboratories) between 2004 and 2022. Ninety-four patients were excluded from analysis for history of aortic valve procedures, a bicuspid aortic valve, baseline trace aortic insufficiency, or other concomitant aortic valve procedure. Patients who had mild or greater aortic insufficiency had concomitant aortic valve repair. Clinical characteristics, serial echocardiograms, and outcomes were determined.

RESULTS

Of the 656 patients who underwent HeartMate II or 3 implantation, 105 patients (59 HeartMate II and 46 HeartMate 3) met study criteria. Median age was 68 years (60-74 years), 91.4% (n = 96) were male, 54.4% (n = 56) were White, and 68.6% (n = 72) received support as destination therapy. Preoperative aortic insufficiency degree was 54.3% (n = 57) mild, 23.8% (n = 25) mild-to-moderate, 20.0% (n = 21) moderate, 1.0% (n = 1) moderate-to-severe, and 1.0% (n = 1) severe. In hospital mortality was 5.7% (n = 6). Freedom from moderate or greater aortic insufficiency was 96.4% (95% confidence interval [CI], 92.5%-100%), 93.3% (95% CI, 87.6%-99.2%), and 91.0% (95% CI, 84.1%-98.5%) at 1-year, 2-year, and 3-year postimplantation, respectively. One patient who received a HeartMate II experienced severe aortic insufficiency and was treated with a heart transplant. Three-year survival was 63.4% (95% CI, 52.9%-75.9%).

CONCLUSIONS

Central aortic valve repair may be an effective technique to mitigate aortic insufficiency in HeartMate II and 3. A larger cohort study with longer duration of follow-up is warranted to further investigate the clinical effect.

Outcomes of left ventricular assist device implantations at Karolinska University Hospital: A retrospective study

Background

To descriptively present data and outcomes of left ventricular assist device (LVAD) implantations at Karolinska University Hospital.

Methods

Data were collected from consecutive patients (n = 44) who were implanted with HeartMate 3 (HM3) at Karolinska University Hospital between 2017 and 2022. The study presents baseline characteristics, clinical course during the inpatient hospital care after implantation, adverse events, and clinical outcomes.

Results

Median intensive care unit stay and hospital stay after HM3 implantation was 8 (interquartile range [IQR] 6; 15) and 28 days (IQR 22; 36), respectively. In total, 73% underwent ramp test at some point after the implantation. Death from all causes within 30 days postimplantation was 5%. A total of 21 patients (48%) underwent right heart catheterization, at a median of 0.5 years (IQR 0.3; 0.7) after implantation, and all exhibited optimally unloaded left ventricles. During the study period, 34% of the patients were transplanted, 5% were explanted, and 16% died with LVAD. In total, 11% and 5% suffered from early and late right ventricle failures, respectively. Acute renal failure affected 46% and 18% had driveline infection. Spontaneous cerebral hemorrhage and cerebral infarction affected 5% and 7% of the study population, respectively. Gastrointestinal bleeding affected 16%. The median LVAD duration was 10 months (IQR 5; 22). The 1-year survival rate with LVAD was 85%, and the 2-year survival rate was 80%.

Conclusions

The results of this low-volume single-center retrospective study on LVAD implantations align with the results of other studies and international registries.

LVAD as a Bridge to Transplantation-Current Status and Future Perspectives

Heart failure (HF) is a common disease associated with high morbidity and mortality rates despite advanced pharmacological therapies. Heart transplantation remains the gold standard therapy for end-stage heart failure; however, its application is curtailed by the persistent shortage of donor organs. Over the past two decades, mechanical circulatory support, notably Left Ventricular Assist Devices (LVADs), have been established as an option for patients waiting for a donor organ. This comprehensive review focuses on elucidating the benefits and barriers associated with this application. We provide an overview of landmark clinical trials that have evaluated the use of LVADs as a bridge to transplantation therapy, with a particular focus on post-transplant outcomes. We discuss the benefits of stabilizing patients with these systems, weighing associated complications and limitations. Further technical advancements and research on optimal implantation timing are critical to ultimately improve outcomes and securing quality of life. In a world where the availability of donor organs remains constrained, LVADs are an increasingly important piece of patient care, bridging the critical gap to transplantation in advanced heart failure management.

A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device

BACKGROUND

The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study.

METHODS

A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases.

RESULTS

Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%).

CONCLUSIONS

Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.

Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.

Back to the basics: The need for an etiological classification of chronic heart failure

The left ventricular (LV) ejection fraction (LVEF), despite its severe limitations, has had an epicentral role in heart failure (HF) classification, management, and risk stratification for decades. The major argument favoring the LVEF based HF classification has been that it defines groups of patients in which treatment is effective. However, this reasoning has recently collapsed, since medical treatment with neurohormonal inhibitors, has proved beneficial in most HF patients regardless of the LVEF. In addition, there has been compelling evidence, that the LVEF provides poor guidance for device treatment of chronic HF (implantation of cardioverter defibrillator, cardiac resynchronization therapy) since sudden cardiac death may occur and cardiac dyssynchronization may be disastrous in all HF patients. The same holds true for LV assist device implantation, in which the LVEF has been used as a surrogate for LV size. In this review article we update the evidence questioning the use of LVEF-based HF classification and argue that guidance of chronic HF treatment should transition to more contemporary concepts. Specifically, we propose an etiologic chronic HF classification predominantly based on epidemiological data, which will be foundational for further higher resolution phenotyping in the emerging era of precision medicine.

Durability of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation

Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days-0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2-4 points) in 19 and low (0-2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF.

Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices

Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.

Ventricular Arrhythmias in Left Ventricular Assist Device Patients-Current Diagnostic and Therapeutic Considerations

Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.

Driveline infection according to driveline positioning in left ventricular assist device implant recipients

We conducted a prospective, open-labeled, clinical trial, with a two-by-two factorial design, of argon cold plasma application and two different types of driveline positioning for the prevention of driveline infection (DLI) in 80 patients with a left ventricular assist device (LVAD) implant. Here, we present the results of intracorporeal loop positioning (n = 40) versus no intracorporeal loop positioning (n = 40). Patients were followed up for 1 year. According to the Driveline Expert STagINg and carE grading (DESTINE) system, a DLI was considered in case of a stage 2 or higher graded infection. During follow-up, 29 (36%) patients experienced a DLI, 16 in the group with intracorporeal loop positioning and 13 in the group with no intracorporeal loop positioning. Kaplan-Meier estimates of freedom from DLI showed no statistically significant difference between study groups during follow-up (p = 0.33). In detail, 30-day freedom from DLI was for the groups with and without intracorporeal loop positioning 92 and 92%, respectively, and 1-year freedom from DLI was 51 and 62%, respectively. In conclusion, this controlled clinical trial was unable to show a statistically significant difference in freedom from DLI during one year of follow-up in groups with or without intracorporeal loop positioning. However, larger trials have to confirm these results.

[Heart transplantation : Current situation]

Heart transplantation is the gold-standard in the treatment of terminal heart failure. The shortage of donor hearts represents the major obstacle in patient care and necessitates the creation of waiting lists and allocation algorithms. The Transplantation Act regulates donor heart allocation according to the urgency and the prospects of success. Donor hearts can be implanted following the classical biatrial or the modern bicaval valve implantation technique with a slightly lower spectrum of complications. Modern mechanical perfusion systems enable extended transport times. After heart transplantation rejection reactions must be controlled by an individually adjusted immunosuppression to guarantee long-term survival with as few complications as possible.

Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation

Background

The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA.

Methods and results

This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner.

Conclusion

This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.

In Search of the Holy Grail of Artificial Hearts: Are We There Yet?

The total artificial heart (TAH) has a long and rich history, being the product of decades of innovation, hard work, and dedication. This review examines the history of the TAH, a device that has revolutionized the treatment of end-stage biventricular heart failure. It reviews the development of the device from early concepts to the current state-of-the-art device, the SynCardia TAH, which has been implanted in over 2,000 patients worldwide. The article also discusses the challenges and successes experienced by researchers, clinicians, and patients throughout the development of TAH devices. Our focus will also be on discussing the hemostatic alterations in patients implanted with TAH and anticoagulation strategies to decrease associated thromboembolic risks. The article concludes with a look at other novel TAH devices and the future of TAH as an increasingly viable treatment for end-stage heart failure.

Pre-Implant Immune Status is Associated with Infection Risk After Left Ventricular Assist Device Implantation

Purpose

Infection is the most common complication after left ventricular assist device (LVAD) implantation. The immune status of LVAD patients is relevant for the incidence and severity of infection, but it is unknown if there is a predisposing immune status prior to LVAD implantation that contributes to an increased risk for infection in the post-implant period. We analyzed the pre-LVAD immune status in patients with infection within 3 months after LVAD implantation in comparison to infection-free patients.

Patients and Methods

Fifty-four consecutive LVAD patients were included in this study. According to their infectious history in the first 3 months after LVAD implantation, these patients were grouped into an infection (n=23) and an infection-free group (n=31). Pre-LVAD blood samples were obtained for flow cytometric analysis of immunological parameters including B cells, subsets of T, dendritic and natural killer cells. Patient-specific, clinical and laboratory data were recorded.

Results

Blood count analysis prior to LVAD implantation showed comparable counts of erythrocytes (p=0.19), platelets (p=0.33) and leukocytes (p=0.50) between patients with infection and infection-free patients in the post-implant period. Patients with infection in the first 3 months after LVAD implantation had lower concentrations of lymphocytes (p=0.02). Forty percent of the patients with infection showed more often pre-LVAD neutrophil-to-lymphocyte ratios (NLR) >7 than patients without infection in the first 3 months after LVAD implantation (14%, p=0.05). Patients with infection already had lower percentages of CD3+ T cells (p=0.03), CD19+ B cells (p<0.01), BDCA2+ pDCs (p=0.03) and BDCA4+ plasmacytoid DCs (pDCs) (p=0.05) prior to LVAD implantation than infection-free patients.

Conclusion

Our results demonstrated that patients with infection in the early post-implant period showed lower concentrations of lymphocytes, especially of CD3+ T cells and CD19+ B cells, decreased percentages of BDCA2+ and BDCA4+ pDCs, and had more often NLRs >7 indicating moderate-to-severe inflammation. Thus, we identified specific immunological changes pre-LVAD that could help to identify patients at risk for infection in the early post-implant period.