1
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Schwoerer AP, Biermann D, Ehmke H. Ventricular unloading causes prolongation of the QT interval and induces ventricular arrhythmias in rat hearts. Front Physiol 2024; 15:1346093. [PMID: 39022307 PMCID: PMC11251997 DOI: 10.3389/fphys.2024.1346093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Ventricular unloading during prolonged bed rest, mechanical circulatory support or microgravity has repeatedly been linked to potentially life-threatening arrhythmias. It is unresolved, whether this arrhythmic phenotype is caused by the reduction in cardiac workload or rather by underlying diseases or external stimuli. We hypothesized that the reduction in cardiac workload alone is sufficient to impair ventricular repolarization and to induce arrhythmias in hearts. Methods Rat hearts were unloaded using the heterotopic heart transplantation. The ECG of unloaded and of control hearts were telemetrically recorded over 56 days resulting in >5 × 106 cardiac cycles in each heart. Long-term electrical remodeling was analyzed using a novel semi-automatic arrhythmia detection algorithm. Results 56 days of unloading reduced left ventricular weight by approximately 50%. While unloading did not affect average HRs, it markedly prolonged the QT interval by approximately 66% and induced a median tenfold increase in the incidence of ventricular arrhythmias in comparison to control hearts. Conclusion The current study provides direct evidence that the previously reported hypertrophic phenotype of repolarization during cardiac unloading translates into an impaired ventricular repolarization and ventricular arrhythmias in vivo. This supports the concept that the reduction in cardiac workload is a causal driver of the development of arrhythmias during ventricular unloading.
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Affiliation(s)
- Alexander Peter Schwoerer
- Department of Cellular and Integrative Physiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Daniel Biermann
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Congenital and Pediatric Heart Surgery, Children’s Heart Clinic, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heimo Ehmke
- Department of Cellular and Integrative Physiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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2
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Kato H, Iwahana T, Ono R, Okada S, Matsumiya G, Kobayashi Y. Hemodynamic parameters at rest predicting exercise capacity in patients supported with left ventricular assist device. J Artif Organs 2024; 27:7-14. [PMID: 36933087 DOI: 10.1007/s10047-023-01388-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/26/2023] [Indexed: 03/19/2023]
Abstract
Left ventricular assist devices improve prognosis and quality of life, but exercise capacity remains limited in most patients after device implantation. Left ventricular assist device optimization through right heart catheterization reduces device-related complications. However, hemodynamic parameters associated with exercise capacity under optimized conditions. The aim of this study was to elucidate the predictors of exercise capacity from hemodynamic parameters at rest after left ventricular assist device optimization. We retrospectively reviewed 24 patients who underwent a ramp test with right heart catheterization, echocardiography and cardiopulmonary exercise testing more than 6 months after left ventricular assist device implantation. Pump speed was optimized to a lower setting that achieved right atrial pressure < 12 mmHg, pulmonary capillary wedge pressure < 18 mmHg, and cardiac index > 2.2 L/min/m2, then exercise capacity was assessed by cardiopulmonary exercise testing. After left ventricular assist device optimization, the mean right atrial pressure, pulmonary capillary wedge pressure, cardiac index, and peak oxygen consumption were 7 ± 5 mmHg, 10 ± 7 mmHg, 2.7 ± 0.5 L/min/m2, and 13.2 ± 3.0 mL/min/kg, respectively. Pulse pressure, stroke volume, right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure were significantly associated with peak oxygen consumption. Multivariate linear regression analysis of factors predicting peak oxygen consumption revealed that pulse pressure, right atrial pressure, and aortic insufficiency remained independent predictors (β = 0.401, p = 0.007; β = - 0.558, p < 0.001; β = - 0.369, p = 0.010, respectively). Our findings suggests that cardiac reserve, volume status, right ventricular function, and aortic insufficiency predict exercise capacity in patients with a left ventricular assist device.
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Affiliation(s)
- Hirotoshi Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan.
| | - Togo Iwahana
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
| | - Ryohei Ono
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sho Okada
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
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3
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Shi J, Yu X, Liu Z. A review of new-onset ventricular arrhythmia after left ventricular assist device implantation. Cardiology 2022; 147:315-327. [PMID: 35483328 PMCID: PMC9393833 DOI: 10.1159/000524779] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/24/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Heart failure (HF) is a severe and terminal stage of various heart diseases. Left ventricular assist devices (LVADs) are relatively mature and have contributed to the treatment of end-stage HF. Ventricular arrhythmia (VA) is a common complication after LVAD implantation, including ventricular tachycardia and ventricular fibrillation, both of which may cause abnormal circulation in the body. METHODS A literature search was conducted in the PubMed database, "Ventricular Arrhythmia" OR "VA" OR "Arrhythmia" OR "Ventricular Tachycardia," OR "Ventricular Fibrillation" AND "LVAD" OR "Left Ventricular Assist Device" OR "Heart Assist Device" as either keywords or MeSH terms, the authors screened the titles and abstracts of the articles. Eventually, 12 original research articles were retrieved. RESULTS The 0.83 [95%CI: 0.77, 0.89] of patients were male. A whole of 53% [95%CI:0.25, 0.81] of VA patients had a history of atrial fibrillation and 61% [95%CI:0.52, 0.69] had a history of VA. 39% [95%CI:0.29, 0.49] of the participants had no prior history of VA and experienced new VA following CF-LVAD implantation. Following CF-LVAD implantation, 59% [95%CI:0.51, 0.67] of patients developed the early VA (VA ≤ 30 days). The 30-day mortality of patients was 4% [95%CI:0.01, 0.07]. And overall mortality was 28% [95%CI:0.15, 0.41] The reported incidence of VA after LVAD implantation is not identical in different medical centers and ranges from 20% to 60%. The mechanism of VA after LVAD implantation is summarized as primary cardiomyopathy-related, device mechanical stimulation, myocardial scarring, ventricular displacement, electrolyte regulation, and other processes. CONCLUSIONS A preoperative VA history is considered a predictor of VA following LVAD implantation in most studies. Multiple mechanisms and factors, such as prevention of "suction events", ablation, and ICD, should be considered for the prevention and treatment of postoperative VA in patients requiring long-term VAD treatment. This study provides a reference for the clinical application of LAVD and the prevention of postoperative VA after LVAD implantation. Future multicenter prospective studies with uniform patient follow-up are needed to screen for additional potential risk factors and predictors. These studies will help to define the incidence rate of VA after LAVD implantation. As a result, we provide guidance for the selection of preventive intervention.
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4
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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5
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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6
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Abstract
PURPOSE OF REVIEW Left ventricular assist devices (LVADs) have extended the life expectancy of patients with heart failure. The hemodynamic support afforded by LVADs in this population has also resulted in patients having prolonged ventricular arrhythmias. The purpose of this article is to review the mechanisms of ventricular arrhythmias in LVADs and the available management strategies. RECENT FINDINGS Recent evidence suggests that prolonged ventricular arrhythmias may result in increased mortality in patients with LVADs. SUMMARY Successful management of ventricular arrhythmias in patients with LVAD requires interdisciplinary collaboration between electrophysiology and heart failure specialists. Medical management, including changes to LVAD changes, heart failure medication management, and antiarrhythmics constitute the initial treatment for ventricular arrhythmias. Surgical or endocardial ablation are reasonable options if VAs are refractory.
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7
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Correale M, Monaco I, Tricarico L, Bottigliero D, Sicuranza M, Del Forno B, Godeas G, Teri A, Maiorano A, Perulli R, Centola A, De Bonis M, Di Biase M, Brunetti ND. Advanced heart failure: non-pharmacological approach. Heart Fail Rev 2020; 24:779-791. [PMID: 30972521 DOI: 10.1007/s10741-019-09786-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with advanced heart failure have poor prognosis despite traditional pharmacological therapies. The early identification of these subjects would allow them to be addressed on time in dedicated centers to select patients eligible for heart transplantation or ventricular assistance. In this article we will report the current management of these patients based on latest international guidelines, underlining some critical aspects, with reference to future perspectives.
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Affiliation(s)
- Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Viale Pinto 1, 71122, Foggia, Italy
| | - Ilenia Monaco
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Dario Bottigliero
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Monica Sicuranza
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Benedetto Del Forno
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Giulia Godeas
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Antonino Teri
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Annamaria Maiorano
- Nephrology Dialysis and Transplantation Unit, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Rossella Perulli
- Nephrology Dialysis and Transplantation Unit, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Antonio Centola
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Matteo Di Biase
- Santa Maria Hospital, Gruppo Villa Maria Research and Care, Bari, Italy
| | - Natale Daniele Brunetti
- Cardiology Department, Ospedali Riuniti University Hospital, Viale Pinto 1, 71122, Foggia, Italy.
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8
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Santangeli P, Marchlinski FE. Ablation Therapy for Refractory Ventricular Arrhythmias. Annu Rev Med 2020; 71:177-190. [PMID: 31747356 DOI: 10.1146/annurev-med-041818-020033] [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: 11/09/2022]
Abstract
Recurrent ventricular arrhythmias (VAs) are a leading cause of cardiovascular morbidity and mortality. In the last three decades, important advancements have occurred in the understanding of the mechanisms of recurrent VAs, their prognostic implications in different clinical contexts, and their treatment options. VAs occur in structurally normal hearts as well as in patients with underlying heart disease, but the latter group has a particularly high risk of recurrent VAs. Catheter ablation offers the possibility of cure for a substantial proportion of patients. Research has focused on identifying optimal targets for ablation, correlating the underlying structural abnormalities with the site of origin of VAs, and determining the optimal procedural approach. Ablation therapy can be life-saving in select patients with high burden of repetitive VAs or advanced heart failure syndromes. This article focuses on clinical aspects of catheter ablation of VAs, particularly the selection and clinical management of patients undergoing catheter ablation procedures and expected outcomes.
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Affiliation(s)
- Pasquale Santangeli
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; ,
| | - Francis E Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; ,
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9
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Boulet J, Massie E, Mondésert B, Lamarche Y, Carrier M, Ducharme A. Current Review of Implantable Cardioverter Defibrillator Use in Patients With Left Ventricular Assist Device. Curr Heart Fail Rep 2019; 16:229-239. [DOI: 10.1007/s11897-019-00449-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Eisen HJ. Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications. Korean Circ J 2019; 49:568-585. [PMID: 31243930 PMCID: PMC6597447 DOI: 10.4070/kcj.2019.0161] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Congestive heart failure is a major cause of morbidity and mortality as well as a major health care cost in the developed world. Despite the introduction of highly effective heart failure medical therapies and simple devices such as cardiac resynchronization therapy that reduce mortality, improve cardiac function and quality of life, there remains a large number of patients who do not respond to these therapies or whose heart failure progresses despite optimal therapy. For these patients, cardiac transplantation is an option but is limited by donor availability as well as co-morbidities which may limit survival post-transplant. For these patients, left ventricular assist devices (LVADs) offer an alternative that can improve survival as well as exercise tolerance and quality of life. These devices have continued to improve as technology has improved with substantially improved durability of the devices and fewer post-implant complications. Pump thrombosis, stroke, gastrointestinal bleeding and arrhythmias post-implant have become less common with the newest devices, making destination therapy where ventricular assist device are implanted permanently in patients with advanced heart failure, a reality and an appropriate option for many patients. This may offer an opportunity for long term survival in many patients. As the first of the totally implantable devices are introduced and go to clinical trials, LVADs may be introduced that may truly be alternatives to cardiac transplantation in selected patients. Post-implant right ventricular failure remains a significant complication and better ways to identify patients at risk as well as to manage this complication must be developed.
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Affiliation(s)
- Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
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11
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Gopinathannair R, Cornwell WK, Dukes JW, Ellis CR, Hickey KT, Joglar JA, Pagani FD, Roukoz H, Slaughter MS, Patton KK. Device Therapy and Arrhythmia Management in Left Ventricular Assist Device Recipients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e967-e989. [DOI: 10.1161/cir.0000000000000673] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.
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12
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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13
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Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider. J Emerg Med 2019; 56:611-623. [PMID: 31003823 DOI: 10.1016/j.jemermed.2019.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs). OBJECTIVE This review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context. DISCUSSION With a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population. CONCLUSIONS The cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.
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Arkles JS, Marchlinski F. When Should the Electrophysiologist Be Involved in Managing Patients with Ventricular Assist Devices and Ventricular Arrhythmias? J Innov Card Rhythm Manag 2019; 10:3605-3610. [PMID: 32494416 PMCID: PMC7252896 DOI: 10.19102/icrm.2019.100407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/18/2018] [Indexed: 11/06/2022] Open
Abstract
The successful management of ventricular arrhythmias (VAs) in people with left ventricular assist devices (LVADs) is often complex. The need for and the role of defibrillator therapy is continually evolving in this group. VAs occur frequently and significantly impact the clinical course of patients with LVADs. The management of VAs begins prior to LVAD implantation and typically involves appropriate implantable cardioverter-defibrillator use and programming after the fact. Surgical ablation during LVAD implantation and supplementary catheter ablation performed as needed are attractive options for the management of VAs in this population. The performance of catheter ablation is generally safe and feasible after LVAD implantation with a team approach.
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Affiliation(s)
- Jeffrey S Arkles
- Electrophysiology Section, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Francis Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Tan NY, Sangaralingham LR, Schilz SR, Dunlay SM. Longitudinal Heart Failure Medication Use and Adherence Following Left Ventricular Assist Device Implantation in Privately Insured Patients. J Am Heart Assoc 2017; 6:e005776. [PMID: 28974501 PMCID: PMC5721829 DOI: 10.1161/jaha.117.005776] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/07/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are few data describing the longitudinal use of and adherence to heart failure medications following left ventricular assist device (LVAD) implantation. METHODS AND RESULTS Using a large US commercial insurance database, patients who received an LVAD (International Classification of Diseases, 9th Revision, Clinical Modification code 37.66) and survived to hospital discharge without heart transplantation between January 1, 2006, and March 31, 2015, were identified. Heart failure medication use from 3 months before 1-year post-LVAD was examined using linked pharmacy claims. Differences in the proportion of patients taking heart failure medications post LVAD compared with pre LVAD were examined using McNemar test. Predictors of post-LVAD medication use and poor medication adherence (proportion of days covered <0.8) were identified via logistic regression. Among 362 patients (mean age, 57.4 years; 75.1% men), compared with pre LVAD, the proportion of patients taking anticoagulants and antiarrhythmics following LVAD increased; mineralocorticoid receptor antagonists, thiazide diuretics, and digoxin decreased; and β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and loop diuretics did not change. Pre-LVAD medication use was associated with post-LVAD use across all medication classes. The proportion of patients with poor medication adherence was 28.8%, 39.0%, and 36.0% for β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and anticoagulants, respectively. Many patients with poor adherence completely discontinued use of the medication. CONCLUSIONS Neurohormonal antagonist use after LVAD was inconsistent, perhaps reflecting uncertainty of therapeutic benefit in this population. Medication adherence post-LVAD was poor in many patients. Further work is needed to delineate the reasons for nonadherence after LVAD.
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Affiliation(s)
- Nicholas Y Tan
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- OptumLabs, Cambridge, MA
| | - Stephanie R Schilz
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Shannon M Dunlay
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Santangeli P, Rame JE, Birati EY, Marchlinski FE. Management of Ventricular Arrhythmias in Patients With Advanced Heart Failure. J Am Coll Cardiol 2017; 69:1842-1860. [DOI: 10.1016/j.jacc.2017.01.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
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Butterfield M, Derr C, Keffeler J, Jelic T. Organized cardiac activity in an awake LVAD patient during ventricular fibrillation. Am J Emerg Med 2017; 35:1041.e1-1041.e3. [PMID: 28291704 DOI: 10.1016/j.ajem.2017.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mike Butterfield
- Tampa General Hospital, University of South Florida, Emergency Medicine Residency Program, Tampa, FL, United States.
| | - Charlotte Derr
- Tampa General Hospital, University of South Florida, Emergency Medicine Residency Program, Tampa, FL, United States
| | - Jotham Keffeler
- Aeromed Transport, Tampa General Hospital, Tampa, FL, United States
| | - Tom Jelic
- Tampa General Hospital, University of South Florida, Emergency Medicine Residency Program, Tampa, FL, United States
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Lvad pump speed increase is associated with increased peak exercise cardiac output and vo2, postponed anaerobic threshold and improved ventilatory efficiency. Int J Cardiol 2017; 230:28-32. [DOI: 10.1016/j.ijcard.2016.12.112] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/11/2016] [Accepted: 12/17/2016] [Indexed: 11/22/2022]
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Agrawal S, Garg L, Nanda S, Sharma A, Bhatia N, Manda Y, Singh A, Fegley M, Shirani J. The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices - A meta-analysis. Int J Cardiol 2016; 222:379-384. [PMID: 27505320 DOI: 10.1016/j.ijcard.2016.07.257] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/12/2016] [Accepted: 07/30/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) and implantable cardioverter defibrillators (ICD) are each known to improve mortality in patients with advanced congestive heart failure (CHF). If ICDs contribute to improved survival specifically in recipients of LVADs is currently unknown. AIM To evaluate the impact of presence of ICD on mortality in continuous flow LVAD recipients. METHODS A meta- analysis of available literature was performed. PubMed, Embase and Google Scholar databases were searched for studies that compared mortality in continuous flow LVAD patients with ICDs (new implantation or no de-activation) and without ICDs (including de-activation of existing implant). Pooled analysis using a fixed effects model was used for outcomes of interest. RESULTS We included 3 observational studies for a total of 292 patients (203 (69.5%) with ICD versus 89 (30.5%) without ICD). The presence of an active ICD was not associated with improved survival [OR 0.63, 95% CI 0.33-1.18; p=0.15]. In bridge to transplantation [BT] patients (224 patients, 149 with ICD versus 75 without ICD), an active ICD was not associated with a higher probability of survivzal [OR 1.47, 95% CI 0.78-2.76; p=0.23]. There was no difference in the occurrence of severe right ventricular dysfunction or failure between two groups [OR 0.78, 95% CI 0.42-1.47; p=0.45]. The risk of LVAD related complications were similar [OR 0.68, 95% CI 0.35-1.31; P=0.25]. CONCLUSION This meta-analysis demonstrates that there is no survival benefit with ICD in heart failure patients supported with continuous flow LVAD. There is an urgent need of large-scale randomized trials to specifically address this issue.
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Affiliation(s)
- Sahil Agrawal
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA.
| | - Lohit Garg
- Department of Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Sudip Nanda
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA
| | - Abhishek Sharma
- Division of Cardiology, Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Nirmanmoh Bhatia
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Yugandhar Manda
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA
| | - Amitoj Singh
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA
| | - Mark Fegley
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA
| | - Jamshid Shirani
- Division of Cardiology, Department of Medicine, St. Luke's University Health Network, Bethlehem, PA 18015, USA
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Abstract
Patients on long-term left ventricular assist device (LVAD) support present unique challenges in the intensive care unit. It is crucial to know the status of end-organ perfusion, which may require invasive hemodynamic monitoring with a systemic arterial and pulmonary artery catheter. Depending on the indication for LVAD support (bridge to decision or cardiac transplantation vs destination therapy), it is important to readdress goals of care with the patient (if possible) and their family after major events have occurred that challenge the survival of the patient.
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Affiliation(s)
- Edo Y Birati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Salamonsen RF, Lim E, Moloney J, Lovell NH, Rosenfeldt FL. Anatomy and Physiology of Left Ventricular Suction Induced by Rotary Blood Pumps. Artif Organs 2015; 39:681-90. [PMID: 26146861 DOI: 10.1111/aor.12550] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study in five large greyhound dogs implanted with a VentrAssist left ventricular assist device focused on identification of the precise site and physiological changes induced by or underlying the complication of left ventricular suction. Pressure sensors were placed in left and right atria, proximal and distal left ventricle, and proximal aorta while dual perivascular and tubing ultrasonic flow meters measured blood flow in the aortic root and pump outlet cannula. When suction occurred, end-systolic pressure gradients between proximal and distal regions of the left ventricle on the order of 40-160 mm Hg indicated an occlusive process of variable intensity in the distal ventricle. A variable negative flow difference between end systole and end diastole (0.5-3.4 L/min) was observed. This was presumably mediated by variable apposition of the free and septal walls of the ventricle at the pump inlet cannula orifice which lasted approximately 100 ms. This apposition, by inducing an end-systolic flow deficit, terminated the suction process by relieving the imbalance between pump requirement and delivery from the right ventricle. Immediately preceding this event, however, unnaturally low end-systolic pressures occurred in the left atrium and proximal left ventricle which in four dogs lasted for 80-120 ms. In one dog, however, this collapse progressed to a new level and remained at approximately -5 mm Hg across four heart beats at which point suction was relieved by manual reduction in pump speed. Because these pressures were associated with a pulmonary capillary wedge pressure of -5 mm Hg as well, they indicate total collapse of the entire pulmonary venous system, left atrium, and left ventricle which persisted until pump flow requirement was relieved by reducing pump speed. We suggest that this collapse caused the whole vascular region from pulmonary capillaries to distal left ventricle to behave as a Starling resistance which further reduced right ventricular output thus contributing to a major reduction in pump flow. We contend that similar complications of manual speed control also occur in the human subject and remain a major unsolved problem in the clinical management of patients implanted with rotary blood pumps.
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Affiliation(s)
- Robert Francis Salamonsen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Einly Lim
- Department of Biomedical Engineering, University of Maya, Kuala Lumpur, Malaysia
| | - John Moloney
- Department of Anesthesia, Monash University, Melbourne, Victoria, Australia.,Department of Anesthesia and Peri-operative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Nigel Hamilton Lovell
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Franklin L Rosenfeldt
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
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Szegedi N, Szeplaki G, Merkely B, Geller L. Successful emergency ablation of ventricular tachycardia in the early postoperative period after left ventricular assist device implantation. Clin Res Cardiol 2015; 104:450-2. [DOI: 10.1007/s00392-015-0813-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 01/13/2015] [Indexed: 11/29/2022]
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Abstract
The role for temporary and durable mechanical circulatory support is rapidly expanding. As the use of these technologies continues to grow, the emergency physician has an increasing opportunity to participate in the advancement of these potentially life-saving technologies. This review discusses the current role of the intra-aortic balloon pump in cardiogenic shock, describes the complications and management strategies for the critically ill patient with a left ventricular assist device, and explores the emerging role of ECMO in the emergency department for patients presenting in refractory cardiogenic shock and cardiac arrest.
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Affiliation(s)
- John C Greenwood
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA.
| | - Daniel L Herr
- Critical Care Service, Cardiac Surgery ICU, Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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Hessel EA. Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review. Semin Cardiothorac Vasc Anesth 2013; 18:57-70. [PMID: 24132353 DOI: 10.1177/1089253213506788] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
While originally primarily used as bridge to cardiac transplantation and bridge to recovery, more commonly ventricular assist devices (VADs) are being inserted as destination therapy. These patients are being discharged from transplant and mechanical assist centers, living as outpatients, and thus the pool of community-dwelling patients with VADs continues to expand. Not infrequently they present for surgical procedures either directly related to the device itself or more often incidental to the fact that they have a VAD. This scenario may be more common in patients with VADs placed for destination therapy because these patients tend to be older and have more comorbidities and are living longer with their device. Thus, it is important for all anesthesiologists to be aware of the special anesthesia needs of patients with VADs requiring noncardiac surgery.
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Affiliation(s)
- Eugene A Hessel
- 1University of Kentucky College of Medicine, Lexington, KY, USA
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