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Yahav-Shafir DD, Schmelczer AJG, Frogel J, Matskovsky I, Zabida A, Eisenberger J, Morgan JA. Quality Improvement in Anesthetic Management of Patients with Left Ventricular Assist Device Support Presenting for Non-Cardiac Surgery: A Single Center Experience. J Clin Med 2024; 13:1421. [PMID: 38592256 PMCID: PMC10933769 DOI: 10.3390/jcm13051421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/05/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
With the growing number of left ventricular assist device (LVAD) recipients requiring non-cardiac surgery and the limited availability of cardiac anesthesiologists, our study reviewed non-cardiac surgeries in HeartMate III patients with LVAD at our institution. We focused on anesthesiologist roles, detailing patient characteristics, anesthetic management, and outcomes and identifying improvement opportunities in this specialized care setting. A retrospective chart review was conducted of all patients with LVAD who underwent non-cardiac surgery at our institution between 2017 and 2022. Patient demographics, surgical characteristics, anesthetic management, and 30-day mortality rates were also assessed. A total of 23 patients were identified, with 17 (73.9%) males and a median age of 61 [53.5, 67.5] years. Cardiac anesthesiologists were present in nine (39.1%) cases. Elective surgeries were more common (73.9%), with intermediate-risk surgeries accounting for 52.2% of all surgeries. General anesthesia was administered to 18 patients (78.3%), with a median duration of 40 [24, 63.5] min. A single patient required reoperation because of bleeding, and two patients (8.7%) experienced 30-day mortality. Despite guidelines lacking detail, involving non-cardiac anesthesiologists in certain cases is essential. Sharing our experience aims to enhance the evolving discourse on non-cardiac surgeries for patients with LVAD, improving their outcomes and safety.
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Affiliation(s)
- Dana D Yahav-Shafir
- Department of Anesthesiology, Sheba Medical Centre, Ramat Gan 5262000, Israel (I.M.)
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Ascher Jekutiel Gérard Schmelczer
- Department of Anesthesiology, Sheba Medical Centre, Ramat Gan 5262000, Israel (I.M.)
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Jonathan Frogel
- Department of Anesthesiology, Sheba Medical Centre, Ramat Gan 5262000, Israel (I.M.)
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Ilya Matskovsky
- Department of Anesthesiology, Sheba Medical Centre, Ramat Gan 5262000, Israel (I.M.)
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Amir Zabida
- Department of Anesthesiology, Sheba Medical Centre, Ramat Gan 5262000, Israel (I.M.)
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Jonathan Eisenberger
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Centre, Ramat Gan 5262000, Israel;
| | - Jeffrey A. Morgan
- School of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Centre, Ramat Gan 5262000, Israel;
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Wu Y, Nam Y, Yurkova I, Rich A, Gao L. Early referrals save lives in advanced heart failure. J Am Assoc Nurse Pract 2024; 36:77-82. [PMID: 37882704 DOI: 10.1097/jxx.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/01/2023] [Indexed: 10/27/2023]
Abstract
ABSTRACT Heart failure (HF) is a chronic, progressive medical condition that can quickly cause deterioration of the patient's medical and functional status. Delay of HF diagnosis and improper treatment can lead to catastrophic patient outcomes. This case report describes a 62-year-old with HF with reduced ejection fraction secondary to nonischemic cardiomyopathy, s/p cardiac resynchronization therapy defibrillator in 2020. He presented to the emergency department for worsening shortness of breath and chest pain for 3 days and subsequently had cardiac arrest. The patient eventually underwent a successful implantation of left ventricular assist device as a bridge to transplant. Timely referral yields a better patient outcome. This case study illustrates a clinical pathway that can be used by primary care providers when considering referral of a patient with advanced HF (AHF) to an AHF center for management and possible advanced therapies.
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Affiliation(s)
- Yu Wu
- Advanced Heart Failure Comprehensive Center, University of California San Francisco Health San Francisco, California
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Truong KP, Kirkpatrick JN. End-of-Life Planning in Patients with Mechanical Circulatory Support. Crit Care Clin 2024; 40:211-219. [PMID: 37973355 DOI: 10.1016/j.ccc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
There are a growing number of patients with mechanical circulatory support (MCS) in the setting of bridge to transplant and destination therapy and temporary support. Preparedness planning is an important aspect of care that involves device-specific Goals of Care and Advance Care Planning and should ideally be used in MCS candidates before initiation of therapy and revisited periodically. The withdrawal of both temporary and durable MCS can be complex and controversial.
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Affiliation(s)
- Katie P Truong
- Division of Cardiology, Department of Medicine, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA; Department of Bioethics and Humanities, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA.
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Amrute JM, Lai L, Ma P, Koenig AL, Kamimoto K, Bredemeyer A, Shankar TS, Kuppe C, Kadyrov FF, Schulte LJ, Stoutenburg D, Kopecky BJ, Navankasattusas S, Visker J, Morris SA, Kramann R, Leuschner F, Mann DL, Drakos SG, Lavine KJ. Defining cardiac functional recovery in end-stage heart failure at single-cell resolution. NATURE CARDIOVASCULAR RESEARCH 2023; 2:399-416. [PMID: 37583573 PMCID: PMC10426763 DOI: 10.1038/s44161-023-00260-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 03/01/2023] [Indexed: 08/17/2023]
Abstract
Recovery of cardiac function is the holy grail of heart failure therapy yet is infrequently observed and remains poorly understood. In this study, we performed single-nucleus RNA sequencing from patients with heart failure who recovered left ventricular systolic function after left ventricular assist device implantation, patients who did not recover and non-diseased donors. We identified cell-specific transcriptional signatures of recovery, most prominently in macrophages and fibroblasts. Within these cell types, inflammatory signatures were negative predictors of recovery, and downregulation of RUNX1 was associated with recovery. In silico perturbation of RUNX1 in macrophages and fibroblasts recapitulated the transcriptional state of recovery. Cardiac recovery mediated by BET inhibition in mice led to decreased macrophage and fibroblast Runx1 expression and diminished chromatin accessibility within a Runx1 intronic peak and acquisition of human recovery signatures. These findings suggest that cardiac recovery is a unique biological state and identify RUNX1 as a possible therapeutic target to facilitate cardiac recovery.
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Affiliation(s)
- Junedh M. Amrute
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- These authors contributed equally: Junedh M. Amrute, Lulu Lai
| | - Lulu Lai
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- These authors contributed equally: Junedh M. Amrute, Lulu Lai
| | - Pan Ma
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew L. Koenig
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenji Kamimoto
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- Center for Regenerative Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrea Bredemeyer
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Thirupura S. Shankar
- Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health & School of Medicine, Salt Lake City, UT, USA
| | - Christoph Kuppe
- Institute of Experimental Medicine and Systems Biology and Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Farid F. Kadyrov
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Linda J. Schulte
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Dylan Stoutenburg
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin J. Kopecky
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Sutip Navankasattusas
- Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health & School of Medicine, Salt Lake City, UT, USA
| | - Joseph Visker
- Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health & School of Medicine, Salt Lake City, UT, USA
| | - Samantha A. Morris
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- Center for Regenerative Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Rafael Kramann
- Institute of Experimental Medicine and Systems Biology and Division of Nephrology, RWTH Aachen University, Aachen, Germany
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Florian Leuschner
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Douglas L. Mann
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stavros G. Drakos
- Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health & School of Medicine, Salt Lake City, UT, USA
| | - Kory J. Lavine
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
- Center for Regenerative Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Preoperative Nutritional Optimization and Physical Exercise for Patients Scheduled for Elective Implantation for a Left-Ventricular Assist Device—The PROPER-LVAD Study. SURGERIES 2022. [DOI: 10.3390/surgeries3040031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Prehabilitation is gaining increasing interest and shows promising effects on short- and long-term outcomes among patients undergoing major surgery. The effect of multimodal, interdisciplinary prehabilitation has not yet been studied in patients with severe heart failure scheduled for the implantation of a left-ventricular assist device (LVAD). Methods: This randomized controlled multi-center study evaluates the effect of preoperative combined optimization of nutritional and functional status. Patients in the intervention group are prescribed daily in-bed cycling and oral nutrition supplements (ONS) from study inclusion until the day before LVAD-implantation. Patients in the control group receive standard of care treatment. The primary outcomes for the pilot study that involves 48 patients are safety (occurrence of adverse events), efficacy (group separation regarding the intake of macronutrients), feasibility of the trial protocol (compliance (percentage of received interventions) and confirmation of recruitment rates. Secondary outcomes include longitudinal measurements of muscle mass, muscle strength, physical function and quality of life, next to traditional clinical outcomes (30-day mortality, hospital and ICU length of stay, duration of mechanical ventilation and number of complications and infections). If the pilot study is successful, a larger confirmatory, international multicenter study is warranted.
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Akhtar W, Gamble B, Kiff K, Wypych-Zych A, Raj B, Takata J, Gil FR, Hurtado A, Rosenberg A, Bowles CT. Mechanical life support algorithm developed by simulation for inpatient emergency management of recipients of implantable left ventricular assist devices. Resusc Plus 2022; 10:100254. [PMID: 35669526 PMCID: PMC9162943 DOI: 10.1016/j.resplu.2022.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/23/2022] [Accepted: 05/16/2022] [Indexed: 12/01/2022] Open
Abstract
Background Published guidance concerning emergency management of left ventricular assist device (LVAD) recipients is both limited and lacking in consensus which increases the risk of delayed and/or inappropriate actions. Methods In our specialist tertiary referral centre we developed, by iteration, a novel in-hospital resuscitation algorithm for LVAD emergencies which we validated through simulation and assessment of our multi-disciplinary team. A Mechanical Life Support course was established to provide theoretical and practical education combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to restart LVAD function) and a multiple-choice question (MCQ) examination. Results The mean baseline staff confidence score in management of LVAD emergencies was 2.4 ± 1.2 out of a maximum of 5 (n = 29). After training with simulation, mean confidence score increased to 3.5 ± 0.8 (n = 13). Clinical personnel who were provided with the novel resuscitation algorithm were able to reduce time taken to restart LVAD function from a mean value of 49 ± 8.2 seconds (pre-training) to 20.4 ± 5 seconds (post-training) (n = 42, p < 0.0001). The Mechanical Life Support course increased mean confidence from 2.5 ± 1.2 to 4 ± 0.6 (n = 44, p < 0.0001) and mean MCQ score from 18.7 ± 3.4 to 22.8 ± 2.6, out of a maximum of 28 (n = 44, p < 0.0001). Conclusion We present a simplified LVAD Advanced Life Support algorithm to aid the crucial first minutes of resuscitation where basic interventions are likely to be critical in assuring good patient outcomes.
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Key Words
- ALS, Advanced Life Support
- Advanced life support
- CALS, Cardiac Advanced Life Support
- CPR, Cardio-Pulmonary Resuscitation
- Cardiac arrest
- DNAR, do not attempt resuscitation order
- ECMO, Extracorporeal Membrane Oxygenation
- ETCO2, End Tidal Carbon Dioxide, kPa Kilopascal
- LVAD
- LVAD, Left Ventricular Assist Device
- Left ventricular assist device
- MAP, Mean Arterial Pressure
- MCQ, multiple-choice exam
- MDT, multi-disciplinary team
- MLS, Mechanical Life Support
- Mechanical circulatory support
- Resuscitation
- VF, Ventricular Fibrillation
- VT, Ventricular Tachycardia
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Affiliation(s)
- Waqas Akhtar
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Brigitte Gamble
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Kristine Kiff
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | | | - Binu Raj
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Junko Takata
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Fernando Riesgo Gil
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Ana Hurtado
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
| | - Alex Rosenberg
- Harefield Hospital, Hill End Road, Harefield, Uxbridge UB96JH, United Kingdom
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