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Bhatia A, Hanna J, Stuart T, Kasper KA, Clausen DM, Gutruf P. Wireless Battery-free and Fully Implantable Organ Interfaces. Chem Rev 2024; 124:2205-2280. [PMID: 38382030 DOI: 10.1021/acs.chemrev.3c00425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Advances in soft materials, miniaturized electronics, sensors, stimulators, radios, and battery-free power supplies are resulting in a new generation of fully implantable organ interfaces that leverage volumetric reduction and soft mechanics by eliminating electrochemical power storage. This device class offers the ability to provide high-fidelity readouts of physiological processes, enables stimulation, and allows control over organs to realize new therapeutic and diagnostic paradigms. Driven by seamless integration with connected infrastructure, these devices enable personalized digital medicine. Key to advances are carefully designed material, electrophysical, electrochemical, and electromagnetic systems that form implantables with mechanical properties closely matched to the target organ to deliver functionality that supports high-fidelity sensors and stimulators. The elimination of electrochemical power supplies enables control over device operation, anywhere from acute, to lifetimes matching the target subject with physical dimensions that supports imperceptible operation. This review provides a comprehensive overview of the basic building blocks of battery-free organ interfaces and related topics such as implantation, delivery, sterilization, and user acceptance. State of the art examples categorized by organ system and an outlook of interconnection and advanced strategies for computation leveraging the consistent power influx to elevate functionality of this device class over current battery-powered strategies is highlighted.
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Affiliation(s)
- Aman Bhatia
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
| | - Jessica Hanna
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
| | - Tucker Stuart
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
| | - Kevin Albert Kasper
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
| | - David Marshall Clausen
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
| | - Philipp Gutruf
- Department of Biomedical Engineering, The University of Arizona, Tucson, Arizona 85721, United States
- Department of Electrical and Computer Engineering, The University of Arizona, Tucson, Arizona 85721, United States
- Bio5 Institute, The University of Arizona, Tucson, Arizona 85721, United States
- Neuroscience Graduate Interdisciplinary Program (GIDP), The University of Arizona, Tucson, Arizona 85721, United States
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2
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Falland R, Allen S. Perioperative management of patients with a ventricular assist device undergoing non-cardiac surgery. BJA Educ 2023; 23:406-413. [PMID: 37720560 PMCID: PMC10501881 DOI: 10.1016/j.bjae.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- R. Falland
- Royal Adelaide Hospital, Adelaide, Australia
| | - S.J. Allen
- Auckland City Hospital, Auckland, New Zealand
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3
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Sohn SH, Kang Y, Hwang HY, Chee HK. Optimal timing of heart transplantation in patients with an implantable left ventricular assist device. KOREAN JOURNAL OF TRANSPLANTATION 2023; 37:79-84. [PMID: 37435145 PMCID: PMC10332290 DOI: 10.4285/kjt.23.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/28/2023] [Indexed: 07/13/2023] Open
Abstract
Heart transplantation (HTPL) has been established as the gold-standard surgical treatment for end-stage heart failure. However, the use of a left ventricular assist device (LVAD) as a bridge to HTPL has been increasing due to the limited availability of HTPL donors. Currently, more than half of HTPL patients have a durable LVAD. Advances in LVAD technology have provided many benefits for patients on the waiting list for HTPL. Despite their advantages, LVADs also have limitations such as loss of pulsatility, thromboembolism, bleeding, and infection. In this narrative review, the benefits and shortcomings of LVADs as a bridge to HTPL are summarized, and the available literature evaluating the optimal timing of HTPL after LVAD implantation is reviewed. Because only a few studies have been published on this issue in the current era of third-generation LVADs, future studies are needed to draw a definite conclusion.
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Affiliation(s)
- Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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4
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Smith PA, Wang Y, Frazier OH. The Evolution of Durable, Implantable Axial-Flow Rotary Blood Pumps. Tex Heart Inst J 2023; 50:492012. [PMID: 37011366 PMCID: PMC10178652 DOI: 10.14503/thij-22-7908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Left ventricular assist devices (LVADs) are increasingly used to treat patients with end-stage heart failure. Implantable LVADs were initially developed in the 1960s and 1970s. Because of technological constraints, early LVADs had limited durability (eg, membrane or valve failure) and poor biocompatibility (eg, driveline infections and high rates of hemolysis caused by high shear rates). As the technology has improved over the past 50 years, contemporary rotary LVADs have become smaller, more durable, and less likely to result in infection. A better understanding of hemodynamics and end-organ perfusion also has driven research into the enhanced functionality of rotary LVADs. This paper reviews from a historical perspective some of the most influential axial-flow rotary blood pumps to date, from benchtop conception to clinical implementation. The history of mechanical circulatory support devices includes improvements related to the mechanical, anatomical, and physiologic aspects of these devices. In addition, areas for further improvement are discussed, as are important future directions-such as the development of miniature and partial-support LVADs, which are less invasive because of their compact size. The ongoing development and optimization of these pumps may increase long-term LVAD use and promote early intervention in the treatment of patients with heart failure.
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Affiliation(s)
- P Alex Smith
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
| | - Yaxin Wang
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
| | - O H Frazier
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
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5
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George TJ, Aldrich A, Smith RL, Ryan WH, DiMaio JM, Kabra N, Afzal A, Rawitscher DA. Development of a non‐transplant left ventricular assist device program. J Card Surg 2022; 37:3188-3198. [DOI: 10.1111/jocs.16790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Timothy J. George
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Allison Aldrich
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Robert L. Smith
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - William H. Ryan
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - J. Michael DiMaio
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Nitin Kabra
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - Aasim Afzal
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
| | - David A. Rawitscher
- Department of Advanced Heart Failure and MCS, Baylor Scott and White The Heart Hospital Plano Texas USA
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Al-Naamani A, Fahr F, Khan A, Bireta C, Nozdrzykowski M, Feder S, Deshmukh N, Jubeh M, Eifert S, Jawad K, Schulz U, Borger MA, Saeed D. Minimally invasive ventricular assist device implantation. J Thorac Dis 2021; 13:2010-2017. [PMID: 33841987 PMCID: PMC8024790 DOI: 10.21037/jtd-20-1492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Durable mechanical circulatory support (MCS) systems are established therapy option in patients with end-stage heart failure, with increasing importance during the last years due to donor organ shortage. Left ventricular assist devices (LVADs) are traditionally implanted through median sternotomy (MS). However, improvement in the pump designs during the last years led to evolvement of new surgical approaches that aim to reduce the invasiveness of the procedure. Numerous reports and studies have shown the viability and possible advantages of less-invasive approach compared to the sternotomy approach. The less invasive implant strategies for LVADs, while vague in definition, are characterized by minimizing surgical trauma and if possible, cardio-pulmonary bypass related complications. Usually it involves minimizing or completely avoiding sternal trauma, avoiding heart luxation while simultaneously leaving the major part of pericardium intact. There is no consensus between the centers regarding the ideal approach for LVAD implantation. Some centers, like our center, perform by default VAD implantation using less invasive approach in almost all patients and some centers use only sternotomy approach. The aim of this review article is to shed light on the currently available less invasive options of LVAD implantation, with particular focus on the centrifugal pumps, and their possible advantages compared to traditional sternotomy approach.
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Affiliation(s)
- Ameen Al-Naamani
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Florian Fahr
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Asim Khan
- Department of Cardiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Christian Bireta
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael Nozdrzykowski
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Feder
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Nikhil Deshmukh
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Manal Jubeh
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sandra Eifert
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Khalil Jawad
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany.,Cardiac Surgery, Peter Munk Cardiac Center, University of Toronto, Toronto, Canada
| | - Uwe Schulz
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Diyar Saeed
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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7
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Goldstein DJ, Naka Y, Horstmanshof D, Ravichandran AK, Schroder J, Ransom J, Itoh A, Uriel N, Cleveland JC, Raval NY, Cogswell R, Suarez EE, Lowes BD, Kim G, Bonde P, Sheikh FH, Sood P, Farrar DJ, Mehra MR. Association of Clinical Outcomes With Left Ventricular Assist Device Use by Bridge to Transplant or Destination Therapy Intent: The Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) Randomized Clinical Trial. JAMA Cardiol 2021; 5:411-419. [PMID: 31939996 PMCID: PMC6990746 DOI: 10.1001/jamacardio.2019.5323] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Question In patients with advanced heart failure, do outcomes with left ventricular assist device implantation differ by the initial intended goal of therapy as a bridge to transplant or destination therapy? Findings In this randomized clinical trial, the composite end point of survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years was significantly better with the magnetically levitated centrifugal-flow HeartMate 3 than the mechanical-bearing axial-flow HeartMate II, irrespective of preimplant therapeutic intent. Event-free survival was not different between patients in the bridge to transplant or destination therapy groups treated with the HeartMate 3 pump. Meaning Per this randomized clinical trial, use of categorizations based on current or future transplant eligibility should be abandoned in favor of a single treatment indication for use of left ventricular assist devices. Importance Left ventricular assist devices (LVADs) are well established in the treatment of advanced heart failure, but it is unclear whether outcomes are different based on the intended goal of therapy in patients who are eligible vs ineligible for heart transplant. Objective To determine whether clinical outcomes in the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) trial differed by preoperative categories of bridge to transplant (BTT) or bridge to transplant candidacy (BTC) vs destination therapy (DT). Design, Setting, and Participants This study was a prespecified secondary analysis of the MOMENTUM 3 trial, a multicenter randomized clinical trial comparing the magnetically levitated centrifugal-flow HeartMate 3 (HM3) LVAD to the axial-flow HeartMate II (HMII) pump. It was conducted in 69 centers with expertise in managing patients with advanced heart failure in the United States. Patients with advanced heart failure were randomized to an LVAD, irrespective of the intended goal of therapy (BTT/BTC or DT). Main Outcomes and Measures The primary end point was survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years. Secondary end points included adverse events, functional status, and quality of life. Results Of the 1020 patients with implants (515 with HM3 devices [50.5%] and 505 with HMII devices [49.5%]), 396 (38.8%) were in the BTT/BTC group (mean [SD] age, 55 [12] years; 310 men [78.3%]) and 624 (61.2%) in the DT group (mean [SD] age, 63 [12] years; 513 men [82.2%]). Of the patients initially deemed as transplant ineligible, 84 of 624 patients (13.5%) underwent heart transplant within 2 years of LVAD implant. In the primary end point analysis, HM3 use was superior to HMII use in patients in the BTT/BTC group (76.8% vs 67.3% for survival free of disabling stroke and reoperation; hazard ratio, 0.62 [95% CI, 0.40-0.94]; log-rank P = .02) and patients in the DT group (73.2% vs 58.7%; hazard ratio, 0.61 [95% CI, 0.46-0.81]; log-rank P < .001). For patients in both BTT/BTC and DT groups, there were not significantly different reductions in rates of pump thrombosis, stroke, and gastrointestinal bleeding with HM3 use relative to HMII use. Improvements in quality of life and functional capacity for either pump were not significantly different regardless of preimplant strategy. Conclusions and Relevance In this trial, the superior treatment effect of HM3 over HMII was similar for patients in the BTT/BTC or DT groups. It is possible that use of arbitrary categorizations based on current or future transplant eligibility should be clinically abandoned in favor of a single preimplant strategy: to extend the survival and improve the quality of life of patients with medically refractory heart failure. Trial Registration ClinicalTrials.gov identifier: NCT02224755
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Affiliation(s)
- Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Yoshifumi Naka
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | | | | | - John Ransom
- Baptist Health Medical Center, Little Rock, Arkansas
| | - Akinobu Itoh
- Washington University School of Medicine, St Louis, Missouri
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York
| | | | - Nirav Y Raval
- Advent Health Transplant Institute, Orlando, Florida
| | | | | | | | - Gene Kim
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois.,University of Chicago Medical Center, Chicago, Illinois
| | | | | | | | | | - Mandeep R Mehra
- Heart and Vascular Center, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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8
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Frech A, Tarrence J, Natale G, Tumin D. Ventricular Assist Device Technology and Black-White Disparities on the Heart Transplant Wait List. Prog Transplant 2020; 31:80-87. [DOI: 10.1177/1526924820978591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Heart transplantation is the definitive treatment for end-stage heart failure. Left ventricular assist devices (LVADs) are a continually improving technology that extends life for some candidates on the heart transplant waiting list. Research Questions: Our objective is to compare Black-White differences in LVAD implantation and heart transplant outcomes during a period of technological innovation when the pulsatile flow LVAD was largely replaced by the continuous flow LVAD between 1999-2014. Design: We used transplant registry data from the United Network for Organ Sharing (N = 5,550) to identify Black and White patients with heart failure who used an LVAD as a bridge-to-transplant (BTT). Using logistic regression, we compared Black-White differences in access to newer LVAD technology and timing of implantation relative to wait listing for heart transplantation. We used competing-risks event history models to predict transplant outcomes across race, LVAD type, and timing of LVAD implantation. Results: Black and White candidates were equally likely to receive newer continuous flow LVADs, but Black candidates received LVADs later in the disease course (i.e. after transplant listing). This later timing of technological intervention contributed to poorer wait list outcomes among black transplant candidates, including lower likelihood of receiving a heart transplant and greater likelihood of being removed from the wait list due to worsening health. Discussion: Delayed LVAD implantation is more common among Black patients and is associated with poorer transplant outcomes.
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Affiliation(s)
- Adrianne Frech
- Department of Health Sciences, University of Missouri, Columbia, MO, USA
| | - Jake Tarrence
- Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Ginny Natale
- Program on Public Health, Stony Brook University, Stony Brook, NY, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
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9
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Ather N, Roberts WC. Location of the Cannula of the Left Ventricular Assist Device in Explanted Hearts After Orthotopic Heart Transplantation. Am J Cardiol 2020; 134:91-98. [PMID: 32943194 DOI: 10.1016/j.amjcard.2020.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
Many patients having orthotopic heart transplantation (OHT) have previously had a left ventricular assist device (LVAD). Such a scenario allows the study of the position of the LVAD cannula in the explanted heart. We studied the explanted hearts in 105 patients who had had a LVAD inserted earlier and later underwent OHT at Baylor University Medical Center from January 2005 to September 2019, and compared the patients in whom the margins of the LVAD cannula contacted the mural endocardium with those in whom it did not. The margins of the orifice of the LVAD cannula contacted the left ventricular (LV) mural endocardium in 38 (36%) patients (considered potentially hazardous insertion) whereas in 67 (64%) patients there was no contact (considered "ideal" insertion). Comparison of the patients with ideal cannular insertion to those with potentially hazardous insertion disclosed insignificant differences in age at LVAD insertion or OHT; gender; interval between the LVAD insertion and OHT; body mass index; underlying cardiac disease; whether or not the heart floated in a container of formaldehyde, and the type of LVAD inserted. The margins of the LVAD cannula contacted the LV mural endocardium significantly more in patients with smaller mean heart weights than those with larger mean heart weights. In conclusion, of the 105 patients studied, the cannula of the LVAD resided in the LV cavity at an angle that allowed the margins of the orifice of the cannula to contact the mural endocardium in 38 (36%), a situation that at least potentially could cause partial obstruction of its orifice. Nevertheless, comparison of the 38 patients with nonideal cannular insertion to the 67 with ideal cannular insertion disclosed only 1 significant difference between the 2 groups.
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10
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Shaffer A, Cogswell R, John R. Future developments in left ventricular assist device therapy. J Thorac Cardiovasc Surg 2020; 162:605-611. [PMID: 33293063 DOI: 10.1016/j.jtcvs.2020.07.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn.
| | - Rebecca Cogswell
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minn
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
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11
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Papanastasiou CA, Kyriakoulis KG, Theochari CA, Kokkinidis DG, Karamitsos TD, Palaiodimos L. Comprehensive review of hemolysis in ventricular assist devices. World J Cardiol 2020; 12:334-341. [PMID: 32843935 PMCID: PMC7415236 DOI: 10.4330/wjc.v12.i7.334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/02/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023] Open
Abstract
Ventricular assist devices (VADs) have played an important role in altering the natural history of end-stage heart failure. Low-grade hemolysis has been traditionally described in patients with VADs, indicating effective device functionality. However, clinically significant hemolysis could be crucial in terms of prognosis, calling for prompt therapeutic actions. The absence of solid and widely approved diagnostic criteria for clinically significant hemolysis, render the utilization of hemolysis laboratory markers challenging. Hemolysis incidence varies (5%-18%) depending on definition and among different VAD generations, being slightly higher in continuous-flow devices than in pulsatile devices. Increased shear stress of red blood cells and underlying device thrombosis appear to be the main pathogenetic pathways. No certain algorithm is available for the management of hemolysis in patients with VADs, while close clinical and laboratory monitoring remains the cornerstone of management. Imaging examinations such as echocardiography ramp test or computed tomography scan could play a role in revealing the underlying cause. Treatment should be strictly personalized, including either pharmacological (antithrombotic treatment) or surgical interventions.
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Affiliation(s)
- Christos A Papanastasiou
- 1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki 54621, Greece
| | - Konstantinos G Kyriakoulis
- 3rd Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, United States
| | - Theodoros D Karamitsos
- 1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki 54621, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, United States
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12
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Okoh AK, Selevanny M, Singh S, Hirji S, Singh S, Al Obaidi N, Lee LY, Camacho M, Russo MJ. Racial disparities and outcomes of left ventricular assist device implantation as a bridge to heart transplantation. ESC Heart Fail 2020; 7:2744-2751. [PMID: 32627939 PMCID: PMC7524221 DOI: 10.1002/ehf2.12866] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/27/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
Aims This study investigated outcomes after continuous flow left ventricular assist device (CF‐LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race. Methods and results De‐identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF‐LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post‐transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post‐transplant survival. We used Kaplan–Meier survival curves and the log‐rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF‐LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasians, 26% (n = 3677) were AA, 7% (n = 997) were Hispanic, and 3% (n = 502) had a different race. Compared with Caucasian, AA, and Hispanic patients had higher body mass indexes and a lower level of education and are more likely to be public health insurance beneficiaries. There was a significantly lower incidence of transplantation in AAs compared with Caucasians, Hispanics, and others at 12, 24, and 60 months, respectively (Gray's test, P < 0.001). The AA race was a significant predictor of waitlist mortality or delisting owing to worsening clinical status [hazard ratio, 95% confidence interval: 1.10 (1.01 to 1.16; P < 0.001)]. Among those who were successfully BTT, risk‐adjusted post‐transplant survival was similar among the four groups (log‐rank test: P = 0.589). Conclusions Disparities exist among different races that receive a CF‐LVAD as a BTT. These disparities translate into increased waitlist morbidity and mortality but not long‐term post‐transplant survival among those who successfully reach transplant.
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Affiliation(s)
- Alexis Kofi Okoh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA.,Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mariam Selevanny
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Supreet Singh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Sameer Hirji
- Department of Surgery, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Swaiman Singh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Nawar Al Obaidi
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Margarita Camacho
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA.,Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mark J Russo
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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13
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Koycu A, Vural O, Bahcecitapar M, Jafarov S, Beyazpinar G, Beyazpinar DS. Device-related epistaxis risk: continuous-flow left ventricular assist device-supported patients. Eur Arch Otorhinolaryngol 2020; 277:2767-2773. [PMID: 32556786 DOI: 10.1007/s00405-020-06127-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to analyze the effect of device-dependent factors on epistaxis episodes comparing patients supported with a continuous-flow left ventricular assist device (CF-LVAD) to patients under the same antithrombotic therapy. METHODS Patients who underwent CF-LVAD between 2012 and 2018 were reviewed retrospectively from the institutionally adopted electronic database. Patients who underwent mitral valve replacement (MVR) surgery receiving the same anticoagulant and antiaggregant therapy were included as a control group. Demographics, epistaxis episodes, and nonepistaxis bleeding between the two groups were compared. RESULTS A total of 179 patients met the inclusion criteria (61 patients CF-LVAD group, 118 patients MVR group). The median (range) follow-up periods for the study (CF-LVAD) and control (MVR) groups were 370 (2819) and 545.70 (2356) days, respectively. There was a significant difference for frequency of bleeding episodes per month between CF-LVAD and MVR groups (p = 0.003 < 0.05). The most common site of bleeding was the anterior septum in both groups (90.9% for the CF-MVR group and 100% for the MVR group). While 14 patients (23%) had nonepistaxis bleeding in the CF-LVAD group, only two patients (1.7%) had nonepistaxis bleeding in the MVR group. There were significant differences in nonepistaxis bleeding rates between the CF-LVAD and MVR groups (χ2=19.79, p < 0.001). CONCLUSION Both epistaxis and nonepistaxis bleeding rates were higher in the CF-LVAD group than in the MVR group. This suggests that the use of CF-LVAD support could directly increase the risk of hemorrhagic complications. LEVEL OF EVIDENCE 2A (Etiology/Harm).
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Affiliation(s)
- Alper Koycu
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Omer Vural
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey.
| | - Melike Bahcecitapar
- Department of Statistics, Faculty of Science, Hacettepe University, Ankara, 06800, Turkey
| | - Sabuhi Jafarov
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Gulfem Beyazpinar
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Deniz Sarp Beyazpinar
- Department of Cardiovascular Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
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All Left Ventricular Device Bridges Can Lead to a Heart Transplant. ASAIO J 2020; 66:399-400. [PMID: 32221143 DOI: 10.1097/mat.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Yin MY, Wever-Pinzon O, Mehra MR, Selzman CH, Toll AE, Cherikh WS, Nativi-Nicolau J, Fang JC, Kfoury AG, Gilbert EM, Kemeyou L, McKellar SH, Koliopoulou A, Vaduganathan M, Drakos SG, Stehlik J. Post-transplant outcome in patients bridged to transplant with temporary mechanical circulatory support devices. J Heart Lung Transplant 2019; 38:858-869. [DOI: 10.1016/j.healun.2019.04.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/20/2019] [Accepted: 04/14/2019] [Indexed: 01/06/2023] Open
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16
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Ozbaran M, Yagdi T, Engin C, Nalbantgil S, Ozturk P. Left ventricular assist device implantation with left lateral thoracotomy with anastomosis to the descending aorta. Interact Cardiovasc Thorac Surg 2019; 27:186-190. [PMID: 29554252 DOI: 10.1093/icvts/ivy061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 02/06/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Standard implantation of the HeartWare left ventricular assist system is performed using the full sternotomy approach. However, successful implantation of left ventricular assist devices in patients with a previous median sternotomy, especially in high-risk patients, remains challenging. Herein, we compared the HeartWare left ventricular assist system implantation by thoracotomy with anastomosis of the outflow graft to the descending aorta with the standard sternotomy approach. METHODS Between March 2013 and June 2016, we implanted 118 adult patients with a HeartWare left ventricular assist system, excluding implants with concurrent procedures, paediatric cases and biventricular left ventricular assist device. Of these implants, 30 implants were performed with a lateral thoracotomy with outflow graft anastomosis to the descending aorta. The remaining implants were carried out with the standard median sternotomy with outflow graft anastomosis to the ascending aorta. Propensity matching using the variables age, body mass index, right atrial pressure, blood urea nitrogen, creatinine, cardiomyopathy type and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels resulted in a comparative data set of 30 thoracotomy and 30 sternotomy patients. RESULTS Within the first 30 days, the incidence of right heart failure (17% vs 10%, thoracotomy vs sternotomy) and bleeding (10% vs 7%, respectively) were similar between the surgical approaches. Thirty-day survival was 93.3% for both groups. Currently, 3 patients in the thoracotomy cohort have been transplanted and 17 remain on support, while in the sternotomy cohort, 1 patient has been transplanted and 21 remain on support. CONCLUSIONS In our single-centre experience, the lateral thoracotomy with outflow graft anastomosis to the descending aorta had similar early outcomes compared to the standard sternotomy.
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Affiliation(s)
- Mustafa Ozbaran
- Department of Cardiovascular Surgery, Ege University Hospital, Izmir, Turkey
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University Hospital, Izmir, Turkey
| | - Cagatay Engin
- Department of Cardiovascular Surgery, Ege University Hospital, Izmir, Turkey
| | - Sanem Nalbantgil
- Department of Cardiology, Ege University Hospital, Izmir, Turkey
| | - Pelin Ozturk
- Department of Cardiovascular Surgery, Ege University Hospital, Izmir, Turkey
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Simon MA, Bachman TN, Watson J, Baldwin JT, Wagner WR, Borovetz HS. Current and Future Considerations in the Use of Mechanical Circulatory Support Devices: An Update, 2008–2018. Annu Rev Biomed Eng 2019; 21:33-60. [DOI: 10.1146/annurev-bioeng-062117-121120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our review in the 2008 volume of this journal detailed the use of mechanical circulatory support (MCS) for treatment of heart failure (HF). MCS initially utilized bladder-based blood pumps generating pulsatile flow; these pulsatile flow pumps have been supplanted by rotary blood pumps, in which cardiac support is generated via the high-speed rotation of computationally designed blading. Different rotary pump designs have been evaluated for their safety, performance, and efficacy in clinical trials both in the United States and internationally. The reduced size of the rotary pump designs has prompted research and development toward the design of MCS suitable for infants and children. The past decade has witnessed efforts focused on tissue engineering–based therapies for the treatment of HF. This review explores the current state and future opportunities of cardiac support therapies within our larger understanding of the treatment options for HF.
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Affiliation(s)
- Marc A. Simon
- Department of Medicine, Vascular Medicine Institute, and Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - Timothy N. Bachman
- Department of Medicine, Vascular Medicine Institute, and Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - John Watson
- Department of Bioengineering, University of California, San Diego, La Jolla, California 92093, USA
| | - J. Timothy Baldwin
- National Heart, Blood, and Lung Institute, Bethesda, Maryland 20892, USA
| | - William R. Wagner
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - Harvey S. Borovetz
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
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Fugar S, Okoh AK, Eshun D, Yirerong J, Appiah LT, Mbachi C, Legge T, Camacho M, Russo MJ. National Trends and Outcomes of Patients Bridged to Transplant With Continuous Flow Left Ventricular Assist Devices. Transplant Proc 2019; 51:852-858. [PMID: 30979475 DOI: 10.1016/j.transproceed.2019.01.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Continuous flow left ventricular assist devices (CF-LVAD) are widely used as a bridge to transplantation (BTT) among patients with advanced heart failure. The primary outcome of the current study was to study the incidence of waitlist mortality and morbidity of CF-LVAD patients bridged to heart transplantation in the current BTT era and to determine the factors that increased their risk of delisting. METHODS Patients who were bridged to heart transplant with a CF-LVAD between April 2008 and September 2015 were identified from the United Network for Organ Sharing heart transplant registry. They were then categorized based on the development of complications. Cox proportional hazards and Kaplan-Meier survival curves were used for time-to-event analysis for the primary outcome. RESULTS Out of 7070 patients who were bridged to heart transplant, 2510 (36%) developed device-related complications. The primary outcome was present in 1631 of 7070 patients (23%). Independent predictors of primary outcome were age, ABO blood group, etiology of cardiomyopathy, and history of diabetes mellitus. Developing one device-related complication was associated with a hazard ratio (HR) of 2.59 of having the primary outcome. The HR increased to 3.45 when ≥2 of the defined complications occurred. In patients who developed the primary outcome, they most likely had a device infection (odds ratio 2.51). CONCLUSION Findings from the current study add to the existing literature about the incidence of morbidity and mortality in the current BTT era. Development of one device-related complication increases the risk of death or delisting among patients on the heart transplant waitlist; however, this risk almost doubles when 2 or more complications occur.
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Affiliation(s)
- S Fugar
- Department of Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA.
| | - A K Okoh
- Department of Cardiothoracic Surgery, RWJ Barnabas Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - D Eshun
- Department of Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - J Yirerong
- Department of Internal Medicine, Brown University Memorial Hospital of Rhode Island, Providence, Rhode Island
| | - L T Appiah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - C Mbachi
- Department of Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - T Legge
- Boston Consulting Group, Chicago, Illinois, USA
| | - M Camacho
- Department of Cardiothoracic Surgery, RWJ Barnabas Health, Newark Beth Israel Medical Center, Newark, New Jersey
| | - M J Russo
- Department of Cardiothoracic Surgery, RWJ Barnabas Health, Newark Beth Israel Medical Center, Newark, New Jersey
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Shehab S, Rao S, Macdonald P, Newton PJ, Spratt P, Jansz P, Hayward CS. Outcomes of venopulmonary arterial extracorporeal life support as temporary right ventricular support after left ventricular assist implantation. J Thorac Cardiovasc Surg 2018; 156:2143-2152. [DOI: 10.1016/j.jtcvs.2018.05.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 01/16/2023]
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21
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Artificial Lungs for Lung Failure. J Am Coll Cardiol 2018; 72:1640-1652. [DOI: 10.1016/j.jacc.2018.07.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/13/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
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22
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Berdat PA, Gygax E, Nydegger U, Carrel T. Short- and long-term mechanical cardiac assistance. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the increase in high risk patients undergoing cardiac surgery and the substantial mortality among patients waiting for cardiac transplantation, the need for mechanical circulatory support is growing. Several devices are currently available, ranging from the intra-aortic balloon pump to fully implantable ventricular assist devices. Each system has its own features, and proper patient selection as well as the timing of implantation is sometimes difficult. Algorithms for stepwise management in subgroups of patients remain controversial and the concepts of weaning patients after myocardial recovery during mechanical circulatory support need further evaluation for their long-term effects. Future identification of valuable prognostic and risk factors may help in decision-making and allow for improved survival of these often very ill patients. In this report we review the concepts of mechanical circulatory support at our institution with emphasis on a detailed overview of technical features of extracorporeal life support.
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Affiliation(s)
- P. A. Berdat
- Department of Cardiovascular Surgery, University Hospital, Bern - Switzerland
| | - E. Gygax
- Department of Cardiovascular Surgery, University Hospital, Bern - Switzerland
| | - U. Nydegger
- Department of Cardiovascular Surgery, University Hospital, Bern - Switzerland
| | - T. Carrel
- Department of Cardiovascular Surgery, University Hospital, Bern - Switzerland
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Rao P, Smith R, Khalpey Z. Potential Impact of the Proposed Revised UNOS Thoracic Organ Allocation System. Semin Thorac Cardiovasc Surg 2018; 30:129-133. [PMID: 29409980 DOI: 10.1053/j.semtcvs.2018.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/11/2022]
Abstract
The current United States heart allocation system faces 2 main challenges: an evolving landscape of device therapy in advanced heart failure and a rapidly increasing transplant waiting list. The proposed new heart allocation system involves expansion of the 3 tiers and enables greater distinction between different types of mechanical circulatory support devices. In this review, we discuss how the proposed revision reconciles key concerns of the current system to create a more fair and equitable allocation of hearts in the United States.
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Affiliation(s)
- Prashant Rao
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Richard Smith
- Department of Perfusion and Artificial Heart Programs, University of Arizona, Tucson, Arizona
| | - Zain Khalpey
- Department of Cardiothoracic Surgery, University of Arizona, Tucson, Arizona.
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24
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Jensen CW, Goldstone AB, Woo YJ. Treatment and Prognosis of Pulmonary Hypertension in the Left Ventricular Assist Device Patient. Curr Heart Fail Rep 2017; 13:140-50. [PMID: 27241336 DOI: 10.1007/s11897-016-0288-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This review will discuss the medical management of pulmonary hypertension in patients with left ventricular assist devices. Although much has been written on the management of primary pulmonary hypertension, also called pulmonary arterial hypertension, this review will instead focus on the treatment of pulmonary hypertension secondary to left heart disease. The relevant pharmacotherapy can be divided into medications for treating heart failure, such as diuretics and β-blockers, and medications for treating pulmonary hypertension. We also discuss important preoperative considerations in patients with pulmonary hypertension; the relationships between left ventricular assist devices, pulmonary hemodynamics, and right heart failure; as well as optimal perioperative and long-term postoperative medical management of pulmonary hypertension.
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Affiliation(s)
- Christopher W Jensen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Falk Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.
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25
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Sehatbakhsh S, Kushnir A, Kabach M, Kolek M, Chait R, Ghumman W. A case of electromagnetic interference between HeartMate 3 LVAD and implantable cardioverter defibrillator. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:218-220. [PMID: 28976004 DOI: 10.1111/pace.13210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 09/12/2017] [Accepted: 09/22/2017] [Indexed: 12/14/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) have been shown to have a significant benefit in reducing sudden cardiac death (SCD) in patients with systolic heart failure. Additionally, cardiac devices as a bridge to transplant or destination therapy are often used in patients with end-stage systolic heart failure. As a result, most patients with left ventricular assist devices (LVADs) also have an ICD. Here, we present an electromagnetic interference (EMI) between HeartMate 3 LVAD and ICD. This issue might be critical for both electrophysiologists and advanced heart failure cardiologists to understand prior to implantation of ICD/LVADs in these patients.
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26
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Moss JD, Flatley EE, Beaser AD, Shin JH, Nayak HM, Upadhyay GA, Burke MC, Jeevanandam V, Uriel N, Tung R. Characterization of Ventricular Tachycardia After Left Ventricular Assist Device Implantation as Destination Therapy: A Single-Center Ablation Experience. JACC Clin Electrophysiol 2017; 3:1412-1424. [PMID: 29759673 DOI: 10.1016/j.jacep.2017.05.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to report mechanisms of ventricular tachycardia (VT) and outcomes of VT ablation in patients with a left ventricular assist device (LVAD) as destination therapy. BACKGROUND Continuous flow LVAD implantation plays a growing role in the management of end-stage heart failure, and VT is common. There are limited reports of VT ablation in patients with a destination LVAD. METHODS Patients with a continuous-flow LVAD referred for VT ablation from 2010 to 2016 were analyzed retrospectively. Baseline patient characteristics, procedural data, and clinical follow-up were evaluated. Arrhythmia-free survival was assessed. RESULTS Twenty-one patients (90% male, 62 ± 10 years) underwent catheter ablation of VT at a median of 191 days (interquartile range: 55 to 403 days) after LVAD implantation (15 HeartMate II, 6 HeartWare HVAD). Five patients (24%) had termination (n = 4) or slowing (n = 1) of VT with ablation near the apical inflow cannula, and 3 (14%) had bundle-branch re-entry. Freedom from recurrent VT among surviving patients was 64% at 1 year, with overall survival 67% at 1 year for patients without arrhythmia recurrence and 29% for patients with recurrence (p = 0.049). One patient had suspected pump thrombosis within 30 days of the ablation procedure, with no other major acute complications. CONCLUSIONS In this relatively large, single-center experience of VT ablation in destination LVAD, freedom from recurrent VT and implantable cardioverter-defibrillator shocks was associated with improved 1-year survival. Bundle branch re-entry was more prevalent than anticipated, and cannula-adjacent VT was less common. This challenging population remains at risk for late pump thrombosis and mortality.
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Affiliation(s)
- Joshua D Moss
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco, San Francisco, California.
| | - Erin E Flatley
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
| | - John H Shin
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Hemal M Nayak
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
| | | | | | - Nir Uriel
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Heart and Vascular Center, University of Chicago Medicine, Chicago, Illinois
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Sunagawa G, Koprivanac M, Karimov JH, Moazami N, Fukamachi K. Current status of mechanical circulatory support for treatment of advanced end-stage heart failure: successes, shortcomings and needs. Expert Rev Cardiovasc Ther 2017; 15:377-387. [PMID: 28351172 DOI: 10.1080/14779072.2017.1313114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Heart failure (HF) remains a major global burden in terms of morbidity and mortality. Despite advances in pharmacological and resynchronization device therapy, many patients worsen to end-stage HF. Although the gold-standard treatment for such patients is heart transplantation, there will always be a shortage of donor hearts. Areas covered: A left ventricular assist device (LVAD) is a valuable option for these patients as a bridge measure (to recovery, to candidacy for transplant, or to transplant itself) or as destination therapy. This review describes the current indications for and complications of the most commonly implanted LVADs. In addition, we review the potential and promising new LVADs, including the HeartMate 3, MVAD, and other LVADs. Studies investigating each were identified through a combination of online database and direct extraction of studies cited in previously identified articles. Expert commentary: The goal of LVADs has been to fill the gap between patients with end-stage HF who would likely not benefit from heart transplantation and those who could benefit from a donor heart. As of now, the use of LVADs has been limited to patients with end-stage HF, but next-generation LVAD therapy may improve both survival and quality of life in less sick patients.
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Affiliation(s)
- Gengo Sunagawa
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Marijan Koprivanac
- b Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure , Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Jamshid H Karimov
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Nader Moazami
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA.,b Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure , Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Kiyotaka Fukamachi
- a Department of Biomedical Engineering , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
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Suarez-Barrientos A. Asistencia mecánica circulatoria como puente al trasplante. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2016.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ensminger SM, Gerosa G, Gummert JF, Falk V. Mechanical Circulatory Support: Heart Failure Therapy “in Motion”. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Stephan M. Ensminger
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetescenter NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Gino Gerosa
- Department of Cardiac Surgery, Padova University Hospital, Padova, Italy
| | - Jan F. Gummert
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetescenter NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
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Mechanical Circulatory Support: Heart Failure Therapy “in Motion”. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:305-314. [DOI: 10.1097/imi.0000000000000305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Because the first generation of pulsatile-flow devices was primarily used to bridge the sickest patients to transplantation (bridge-to-transplant therapy), the current generation of continuous-flow ventricular assist devices qualifies for destination therapy for patients with advanced heart failure who are ineligible for transplantation. The first-generation devices were associated with frequent adverse events, limited mechanical durability, and patient discomfort due device size. In contrast, second-generation continuous-flow devices are smaller, more quiet, and durable, thus resulting in less complications and significantly improved survival rates. Heart transplantation remains an option for a limited number of patients only, and this fact has also triggered the discussion about the optimal timing for device implantation. The increasing use of continuous-flow devices has resulted in new challenges, such as adverse events during long-term support, and high hospital readmission rates. In addition, there are a number of device-related complications including mechanical problems such as device thrombosis, percutaneous driveline damage, as well as conditions such as hemolysis, infection, and cerebrovascular accidents. This review provides an overview of the evolution of mechanical circulatory support systems from bridge to transplantation to destination therapy including technological advances and clinical improvements in long-term patient survival and quality of life. In addition, recent changes in device implant strategies and current trials are reviewed and discussed. A brief glimpse into the future of mechanical circulatory support therapy will summarize the innovations that may soon enter clinical practice.
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Fox AA, Nussmeier NA. Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery? Semin Cardiothorac Vasc Anesth 2016; 8:283-95. [PMID: 15583790 DOI: 10.1177/108925320400800403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over 410,000 cardiac surgeries are performed in American women each year. Women having coronary artery bypass graft (CABG) and valve surgery do so at an older age and with more cardiovascular risk factors than men. Women's smaller body size may also increase risk by increasing the technical difficulty of surgical procedures. Female CABG patients appear to have higher perioperative mortality and cardiac morbidity, although studies of neurologic outcomes in female CABG patients have produced equivocal findings. Women undergoing CABG tend to consume more hospital resources than men do in terms of blood transfusion, mechanical ventilation, and length of intensive care unit and overall hospital stay. With regard to valve surgery, women appear to have worse outcomes than men if the surgery is combined with a CABG operation. Women and men undergoing isolated aortic valve surgery have similar mortality, but little is known about gender differences in mitral and tricuspid valve surgery outcomes. Women who require heart transplantation tend to have idiopathic cardiomyopathy rather than the ischemic cardiomyopathy that is more common in male heart transplant candidates. Although female heart transplant recipients seem to have a stronger immunologic response after transplantation, which manifests in more frequent acute rejection episodes, it is not clear whether this increases women's mortality risk. Men appear to have a greater incidence of posttransplant vasculopathy than women. Further research is needed to identify risk factors for perioperative morbidity and mortality in women undergoing cardiac surgery and to develop medical interventions to mitigate these risks.
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Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Acquired von Willebrand syndrome associated with left ventricular assist device. Blood 2016; 127:3133-41. [PMID: 27143258 DOI: 10.1182/blood-2015-10-636480] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 04/24/2016] [Indexed: 12/14/2022] Open
Abstract
Left ventricular assist devices (LVAD) provide cardiac support for patients with end-stage heart disease as either bridge or destination therapy, and have significantly improved the survival of these patients. Whereas earlier models were designed to mimic the human heart by producing a pulsatile flow in parallel with the patient's heart, newer devices, which are smaller and more durable, provide continuous blood flow along an axial path using an internal rotor in the blood. However, device-related hemostatic complications remain common and have negatively affected patients' recovery and quality of life. In most patients, the von Willebrand factor (VWF) rapidly loses large multimers and binds poorly to platelets and subendothelial collagen upon LVAD implantation, leading to the term acquired von Willebrand syndrome (AVWS). These changes in VWF structure and adhesive activity recover quickly upon LVAD explantation and are not observed in patients with heart transplant. The VWF defects are believed to be caused by excessive cleavage of large VWF multimers by the metalloprotease ADAMTS-13 in an LVAD-driven circulation. However, evidence that this mechanism could be the primary cause for the loss of large VWF multimers and LVAD-associated bleeding remains circumstantial. This review discusses changes in VWF reactivity found in patients on LVAD support. It specifically focuses on impacts of LVAD-related mechanical stress on VWF structural stability and adhesive reactivity in exploring multiple causes of AVWS and LVAD-associated hemostatic complications.
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Patel S, Nicholson L, Cassidy CJ, Wong KYK. Left ventricular assist device: a bridge to transplant or destination therapy? Postgrad Med J 2016; 92:271-81. [PMID: 26969730 DOI: 10.1136/postgradmedj-2015-133718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/18/2016] [Indexed: 12/18/2022]
Abstract
Heart failure is a major problem worldwide; it is the leading cause of hospitalisation and is posing a huge financial burden. Advances in healthcare have contributed to increased life expectancy, with a resultant increase in the number of patients with chronic heart failure. For many patients who are still severely symptomatic despite optimal medical therapy and cardiac resynchronisation therapy, cardiac transplantation would be the preferred treatment option. However, hopes are cut short with a limited donor pool of hearts for the increasing number of patients requiring cardiac transplantation. One uprising method to fill this treatment void for patients with advanced end-stage heart failure (ESHF) is the Left Ventricular Assist Device (LVAD). Although traditionally used as a bridge to transplantation, owing to limitation of suitable donors, evidence suggests increasing potential for the use of LVAD as destination therapy (DT), that is, lifelong permanent support. Exploration of DT is a promising avenue to many patients suffering with ESHF who may never be fortunate enough to receive a heart transplant, but not without reservations of its efficacy, safety, effects on quality-adjusted life years and cost-effectiveness, especially in comparison to heart transplantation.
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Affiliation(s)
| | | | | | - Kenneth Y-K Wong
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
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Heatley G, Sood P, Goldstein D, Uriel N, Cleveland J, Middlebrook D, Mehra MR. Clinical trial design and rationale of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) investigational device exemption clinical study protocol. J Heart Lung Transplant 2016; 35:528-36. [PMID: 27044532 DOI: 10.1016/j.healun.2016.01.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 01/14/2023] Open
Abstract
The HeartMate 3 left ventricular assist system (LVAS; St. Jude Medical, Inc., formerly Thoratec Corporation, Pleasanton, CA) was recently introduced into clinical trials for durable circulatory support in patients with medically refractory advanced-stage heart failure. This centrifugal, fully magnetically levitated, continuous-flow pump is engineered with the intent to enhance hemocompatibility and reduce shear stress on blood elements, while also possessing intrinsic pulsatility. Although bridge-to-transplant (BTT) and destination therapy (DT) are established dichotomous indications for durable left ventricular assist device (LVAD) support, clinical practice has challenged the appropriateness of these designations. The introduction of novel LVAD technology allows for the development of clinical trial designs to keep pace with current practices. The prospective, randomized Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) clinical trial aims to evaluate the safety and effectiveness of the HeartMate 3 LVAS by demonstrating non-inferiority to the HeartMate II LVAS (also St. Jude Medical, Inc.). The innovative trial design includes patients enrolled under a single inclusion and exclusion criteria , regardless of the intended use of the device, with outcomes ascertained in the short term (ST, at 6 months) and long term (LT, at 2 years). This adaptive trial design includes a pre-specified safety phase (n = 30) analysis. The ST cohort includes the first 294 patients and the LT cohort includes the first 366 patients for evaluation of the composite primary end-point of survival to transplant, recovery or LVAD support free of debilitating stroke (modified Rankin score >3), or re-operation to replace the pump. As part of the adaptive design, an analysis by an independent statistician will determine whether sample size adjustment is required at pre-specified times during the study. A further 662 patients will be enrolled to reach a total of 1,028 patients for evaluation of the secondary end-point of pump replacement at 2 years.
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Affiliation(s)
| | | | - Daniel Goldstein
- Department of Cardiothoracic Surgery, Montefiore Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - Joseph Cleveland
- Department of Surgery, University of Colorado Anschutz Medical Center, Denver, Colorado, USA
| | | | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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Pre-Operative Right Ventricular Dysfunction Is Associated With Gastrointestinal Bleeding in Patients Supported With Continuous-Flow Left Ventricular Assist Devices. JACC-HEART FAILURE 2015; 3:956-64. [PMID: 26577618 DOI: 10.1016/j.jchf.2015.09.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 08/28/2015] [Accepted: 09/11/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study sought to determine whether severe right ventricular (RV) dysfunction in the pre-operative setting is associated with an increased risk of gastrointestinal bleeding (GIB) post-left ventricular assist device (LVAD). BACKGROUND GIB is a significant complication in patients supported with continuous-flow LVADs. The impact of RV dysfunction on the risk of GIB has not been investigated. METHODS We retrospectively identified 212 patients who survived index hospitalization after implantation of HeartMate II (Thoratec Corp., Pleasanton, California) or Heartware HVAD (HeartWare Corp., Framingham, Massachusetts) from June 2009 to April 2013. Patients with severe RV dysfunction on pre-LVAD echocardiogram (n = 37) were compared to patients without severe RV dysfunction (n = 175). The primary outcome was freedom from GIB. RESULTS The majority of patients were male (79%) with a median INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of 2 at LVAD implantation. There were no significant differences between cohorts with respect to demographics, comorbidities, device type, international normalization ratio, or aspirin strategy. During follow-up, 81 patients had GIB events: 23 of 37 (62%) in the severe RV dysfunction group versus 58 of 175 (33%) in the control group (p = 0.001). After adjustment for age and ischemic cardiomyopathy, severe RV dysfunction was associated with increased risk of GIB (hazard ratio: 1.799, 95% confidence interval: 1.089 to 2.973, p = 0.022). CONCLUSIONS In this single-center sample of patients supported with continuous-flow LVADs, severe RV dysfunction on pre-LVAD echocardiogram was associated with an increased risk of GIB. Further studies are needed to investigate possible mechanisms by which RV dysfunction increases the risk of GIB and to identify patient populations who may benefit from alterations in antithrombotic strategies.
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Schumer EM, Ising MS, Slaughter MS. The current state of left ventricular assist devices: challenges facing further development. Expert Rev Cardiovasc Ther 2015; 13:1185-93. [DOI: 10.1586/14779072.2015.1098534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Petukhov DS, Selishchev SV, Telyshev DV. Development of Left Ventricular Assist Devices as the Most Effective Acute Heart Failure Therapy. BIOMEDICAL ENGINEERING-MEDITSINSKAYA TEKNIKA 2015. [DOI: 10.1007/s10527-015-9480-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stey AM, Russell MM, Zingmond DS, Gibbons MM, Hall BL, Needleman J, Lawson EH, Liu N, Ko CY. Using Merged Clinical and Claims Registry Data to Identify High Utilizers of Surgical Inpatient Care 1 Year after Colectomy. J Am Coll Surg 2015; 221:441-51.e1. [PMID: 26141469 DOI: 10.1016/j.jamcollsurg.2015.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/05/2015] [Accepted: 03/08/2015] [Indexed: 11/13/2022]
Abstract
BACKGROUND Under bundled payment initiatives, providers will be held financially responsible for patients' acute and post-acute care costs. Certain patients, termed high utilizers, use disproportionate shares of resources during 1 year. The aim of this study was to identify high utilizers, describe their costs, and determine whether preoperative characteristics predict high utilizer status. STUDY DESIGN Colectomy patients with 1-year follow-up were identified in a linked clinical (American College of Surgeons NSQIP) and administrative (Medicare inpatient claims) dataset (2005 to 2008). Cost of inpatient care was calculated by multiplying patient Medicare charges in each cost center by cost-to-charge ratios from the Medicare cost reports. A mixed-effects logistic model quantified the association between preoperative characteristics and being a high utilizer after elective and emergent colectomies. RESULTS One thousand and fifty-five of 10,561 colectomy patients accounted for >50% of the inpatient care cost of the entire cohort during 1 year postoperatively. This top decile of patients were labeled high utilizers and had substantially greater costs in the following cost centers: intensive care ($36,322 vs $0), respiratory ($2,875 vs $22), radiology ($649 vs $29), and cardiology ($5,057 vs $166) (all p < 0.001). High utilizers more frequently had emergent index colectomies (43% vs 17%; p < 0.001). Patients with American Society of Anesthesiologists class IV and V had 2-fold increased odds of being high utilizers after both elective (odds ratio = 2.72; 95% CI, 1.89-3.90) and emergent colectomies (odds ratio = 2.09; 95% CI, 1.23-3.55). CONCLUSIONS Patients in the top cost decile account for the majority of costs in the year after colectomy, disproportionately accumulate those costs in particular cost centers, and can be identified preoperatively.
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Affiliation(s)
- Anne M Stey
- Icahn School of Medicine at Mount Sinai Medical Center, New York, NY; David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Marcia M Russell
- David Geffen School of Medicine, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - David S Zingmond
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Melinda M Gibbons
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Bruce L Hall
- American College of Surgeons, Chicago, IL; Department of Surgery, Olin Business School, and Center for Health Policy, Washington University in Saint Louis, St Louis VA Medical Center, BJC Healthcare Saint Louis, St Louis, MO
| | - Jack Needleman
- Fielding School of Public Health, University of California, Los Angeles, CA
| | - Elise H Lawson
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Nancy Liu
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Clifford Y Ko
- David Geffen School of Medicine, University of California, Los Angeles, CA; American College of Surgeons, Chicago, IL
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Krim SR, Vivo RP, Campbell P, Estep JD, Fonarow GC, Naftel DC, Ventura HO. Regional differences in use and outcomes of left ventricular assist devices: Insights from the Interagency Registry for Mechanically Assisted Circulatory Support Registry. J Heart Lung Transplant 2015; 34:912-20. [PMID: 25824553 DOI: 10.1016/j.healun.2015.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/23/2014] [Accepted: 01/13/2015] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND We examined whether characteristics, implant strategy, and outcomes in patients who receive continuous-flow left ventricular assist devices (CF-LVAD) differ across geographic regions in the United States. METHODS A total of 7,404 CF-LVAD patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 134 participating institutions were analyzed from 4 distinct regions: Northeast, 2,605 (35%); Midwest, 2,210 (30%); West, 973 (13%); and South, 1,616 (22%). RESULTS At baseline, patients in the Northeast and South were more likely to have INTERMACS risk profiles 1 and 2. A bridge-to-transplant (BTT) strategy was more common in the Northeast (31.7%; West, 18.5%; South, 26.9%; Midwest, 25.5%; p < 0.0001). In contrast, destination therapy (DT) was more likely in the South (40.6%; Northeast, 32.3%; Midwest, 27.3%; West, 27.3%; p < 0.0001). Although all regions showed a high 1-year survival rate, some regional differences in long-term mortality were observed. Notably, survival beyond 1 year after LVAD implant was significantly lower in the South. However, when stratified by device strategy, no significant differences in survival for BTT or DT patients were found among the regions. Finally, with the exception of right ventricular failure, which was more common in the South, no other significant differences in causes of death were observed among the regions. CONCLUSIONS Regional differences in clinical profile and LVAD strategy exist in the United States. Despite an overall high survival rate at 1 year, differences in mortality among the regions were noted. The lower survival rate in the South may be attributed to patient characteristics and higher use of LVAD as DT.
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Affiliation(s)
- Selim R Krim
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana.
| | - Rey P Vivo
- Ahmanson-University of California, Los Angeles (UCLA) Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - Patrick Campbell
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Jerry D Estep
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles (UCLA) Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - David C Naftel
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hector O Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
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Surgical Treatment of Advanced Heart Failure. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_21] [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: 10/23/2022]
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Rose EA. Understanding translational research: a play in four acts. J Pediatr Surg 2015; 50:37-43. [PMID: 25598090 DOI: 10.1016/j.jpedsurg.2014.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
Translational research (TR) bridges discovery to clinical delivery. All TR also requires the development of an intervention. Classical 'bench to bedside' TR is responsible for many important advances, but cannot account for many others, which begin with clinical observations. My personal involvement in TR has ranged from exploration of long-term mechanical circulatory support devices to amelioration of the progression of Alzheimer's disease to the pharmacologic cure of smallpox. This experience suggests that most TR is opportunistic and inefficient. A strategic approach to TR based on a better understanding of the processes it entails could enhance progress in TR despite its increasing complexity.
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Affiliation(s)
- Eric A Rose
- Population Science and Health Policy, Surgery, Cardiovascular Surgery, and Medicine, Mount Sinai School of Medicine, New York, NY, United States.
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Stone ML, LaPar DJ, Benrashid E, Scalzo DC, Ailawadi G, Kron IL, Bergin JD, Blank RS, Kern JA. Ventricular assist devices and increased blood product utilization for cardiac transplantation. J Card Surg 2014; 30:194-200. [PMID: 25529999 DOI: 10.1111/jocs.12474] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIM OF STUDY The purpose of this study was to examine whether blood product utilization, one-year cell-mediated rejection rates, and mid-term survival significantly differ for ventricular assist device (VAD patients compared to non-VAD (NVAD) patients following cardiac transplantation. METHODS From July 2004 to August 2011, 79 patients underwent cardiac transplantation at a single institution. Following exclusion of patients bridged to transplantation with VADs other than the HeartMate II® LVAD (n = 10), patients were stratified by VAD presence at transplantation: VAD patients (n = 35, age: 54.0 [48.0-59.0] years) vs. NVAD patients (n = 34, age: 52.5 [42.8-59.3] years). The primary outcomes of interest were blood product transfusion requirements, one-year cell-mediated rejection rates, and mid-term survival post-transplantation. RESULTS Preoperative patient characteristics were similar for VAD and NVAD patients. NVAD patients presented with higher median preoperative creatinine levels compared to VAD patients (1.3 [1.1-1.6] vs. 1.1 [0.9-1.4], p = 0.004). VAD patients accrued higher intraoperative transfusion of all blood products (all p ≤ 0.001) compared to NVAD patients. The incidence of clinically significant cell-mediated rejection within the first posttransplant year was higher in VAD compared to NVAD patients (66.7% vs. 33.3%, p = 0.02). During a median follow-up period of 3.2 (2.0, 6.3) years, VAD patients demonstrated an increased postoperative mortality that did not reach statistical significance (20.0% vs. 8.8%, p = 0.20). CONCLUSIONS During the initial era as a bridge to transplantation, the HeartMate II® LVAD significantly increased blood product utilization and one-year cell-mediated rejection rates for cardiac transplantation. Further study is warranted to optimize anticoagulation strategies and to define causal relationships between these factors for the current era of cardiac transplantation.
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Affiliation(s)
- Matthew L Stone
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia
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An insight into short- and long-term mechanical circulatory support systems. Clin Res Cardiol 2014; 104:95-111. [PMID: 25349064 DOI: 10.1007/s00392-014-0771-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
Abstract
Cardiogenic shock due to acute myocardial infarction, postcardiotomy syndrome following cardiac surgery, or manifestation of heart failure remains a clinical challenge with high mortality rates, despite ongoing advances in surgical techniques, widespread use of primary percutaneous interventions, and medical treatment. Clinicians have, therefore, turned to mechanical means of circulatory support. At present, a broad range of devices are available, which may be extracorporeal, implantable, or percutaneous; temporary or long term. Although counter pulsation provided by intra-aortic balloon pump (IABP) and comprehensive mechanical support for both the systemic and the pulmonary circulation through extracorporeal membrane oxygenation (ECMO) remain a major tool of acute care in patients with cardiogenic shock, both before and after surgical or percutaneous intervention, the development of devices such as the Impella or the Tandemheart allows less invasive forms of temporary support. On the other hand, concerning mid-, or long-term support, left ventricular assist devices have evolved from a last resort life-saving therapy to a well-established viable alternative for thousands of heart failure patients caused by the shortage of donor organs available for transplantation. The optimal selection of the assist device is based on the initial consideration according to hemodynamic situation, comorbidities, intended time of use and therapeutic options. The present article offers an update on currently available mechanical circulatory support systems (MCSS) for short and long-term use as well as an insight into future perspectives.
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Holley CT, Harvey L, John R. Left ventricular assist devices as a bridge to cardiac transplantation. J Thorac Dis 2014; 6:1110-9. [PMID: 25132978 DOI: 10.3978/j.issn.2072-1439.2014.06.46] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 06/30/2014] [Indexed: 11/14/2022]
Abstract
Heart failure remains a significant cause of morbidity and mortality, affecting over five million patients in the United States. Continuous-flow left ventricular assist devices (LVAD) have become the standard of care for patients with end stage heart failure. This review highlights the current state of LVAD as a bridge to transplant (BTT) in patients requiring mechanical circulatory support (MCS).
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Affiliation(s)
| | - Laura Harvey
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
| | - Ranjit John
- University of Minnesota Department of Surgery, Minneapolis, MN 55455, USA
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Outcomes in Patients Receiving HeartMate II Versus HVAD Left Ventricular Assist Device as a Bridge to Transplantation. Transplant Proc 2014; 46:1469-75. [DOI: 10.1016/j.transproceed.2013.12.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 12/19/2013] [Indexed: 11/23/2022]
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Slaughter MS. Bud Frazier's 1,000 th implantation of a ventricular assist device. Tex Heart Inst J 2014; 41:110-1. [PMID: 24808765 DOI: 10.14503/thij-14-4113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky 40202
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Mechanical circulatory assist device development at the Texas Heart Institute: a personal perspective. J Thorac Cardiovasc Surg 2014; 147:1738-44. [PMID: 24837720 DOI: 10.1016/j.jtcvs.2014.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In December 2013, we performed our 1000th ventricular assist device implantation at the Texas Heart Institute. In my professional career, I have been fortunate to see the development of numerous mechanical circulatory support devices for the treatment of patients with advanced heart failure. In fact, most of the cardiac pumps in wide use today were developed in the Texas Heart Institute research laboratories in cooperation with the National Heart, Lung and Blood Institute or device innovators and manufacturers and implanted clinically at our partner St. Luke's Episcopal Hospital. My early involvement in this field was guided by my mentors, Dr Michael E. DeBakey and, especially, Dr Denton A. Cooley. Also, many of the advances are directly attributable to my ongoing clinical experience. What I learned daily in my surgical practice allowed me to bring insights to the development of this technology that a laboratory researcher alone might not have had. Young academic surgeons interested in this field might be well served to be active not only in laboratory research but also in clinical practice.
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Alba AC, McDonald M, Rao V, Ross HJ, Delgado DH. The effect of ventricular assist devices on long-term post-transplant outcomes: a systematic review of observational studies. Eur J Heart Fail 2014; 13:785-95. [DOI: 10.1093/eurjhf/hfr050] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ana C. Alba
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Michael McDonald
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery; Toronto General Hospital; Toronto Ontario Canada
| | - Heather J. Ross
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
| | - Diego H. Delgado
- Division of Cardiology and Heart Transplantation; Toronto General Hospital; 585 University Ave., 11c-1207 Toronto Ontario M5G 2N2 Canada
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50
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Drakos SG, Charitos EI, Nanas SN, Nanas JN. Ventricular-assist devices for the treatment of chronic heart failure. Expert Rev Cardiovasc Ther 2014; 5:571-84. [PMID: 17489679 DOI: 10.1586/14779072.5.3.571] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The role of ventricular-assist devices in the management of end-stage heart failure is growing. Initially developed as a 'bridge to transplantation', they are now implanted permanently in patients who need cardiac replacement but are not candidates for cardiac transplantation ('destination therapy'). Furthermore, observations from expert centers indicate that a significant proportion of patients under long-term mechanical assistance can be weaned from mechanical circulatory support after significant functional recovery of their native heart ('bridge to recovery'). This review discusses the emerging roles of mechanical circulatory support and their direct implications in clinical practice. Evolution of devices, important aspects of candidate selection, challenging issues in the management of ventricular-assist device patients (infection, device malfunction, anticoagulation-thromboembolic complications, psychosocial issues and cost) and ongoing research targeting sustained myocardial recovery are discussed.
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Affiliation(s)
- Stavros G Drakos
- University of Athens Medical School, 3rd Department of Cardiology, Laiko Hospital, Athens, Greece.
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