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Elbayomi M, Tandler R, Ebel N, Schubert DW, Werner S, Kondruweit M, Weyand M, Heim C. Patient-tailored silicone plug for HeartMate 3™ left ventricular assist device explantation. J Artif Organs 2024; 27:159-161. [PMID: 37099051 PMCID: PMC11126425 DOI: 10.1007/s10047-023-01397-w] [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: 01/26/2023] [Accepted: 04/13/2023] [Indexed: 04/27/2023]
Abstract
Patient-tailored silicone plug for HeartMate 3™ left ventricular assist device explantation in two successive males proceeded successfully. Given medical therapeutic advancements, FDA-approved plug systems designed by LVAD manufacturers themselves will be necessary for the near future to provide a safe and simple device explantation alternative that fulfills all regulatory standards.
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Affiliation(s)
- Mohamed Elbayomi
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany.
| | - Rene Tandler
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Nina Ebel
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Dirk W Schubert
- Institute for Polymer Materials, Friedrich-Alexander-University, Erlangen, Germany
| | - Siegfried Werner
- Institute for Polymer Materials, Friedrich-Alexander-University, Erlangen, Germany
| | - Markus Kondruweit
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Micheal Weyand
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Christian Heim
- Department of Cardiac Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
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Kyriakopoulos CP, Selzman CH, Giannouchos TV, Mylavarapu R, Sideris K, Elmer A, Vance N, Hanff TC, Kagawa H, Stehlik J, Drakos SG, Goodwin ML. Hospital Readmissions in Patients Supported with Durable Centrifugal-Flow Left Ventricular Assist Devices. J Clin Med 2024; 13:2869. [PMID: 38792411 PMCID: PMC11122328 DOI: 10.3390/jcm13102869] [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: 04/19/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Centrifugal-flow left ventricular assist devices (CF-LVADs) have improved morbidity and mortality for their recipients. Hospital readmissions remain common, negatively impacting quality of life and survival. We sought to identify risk factors associated with hospital readmissions among patients with CF-LVADs. Methods: Consecutive patients receiving a CF-LVAD between February 2011 and March 2021 were retrospectively evaluated using prospectively maintained institutional databases. Hospital readmissions within three years post-LVAD implantation were dichotomized into heart failure (HF)/LVAD-related or non-HF/LVAD-related readmissions. Multivariable Cox regression models augmented using a machine learning algorithm, the least absolute shrinkage and selection operator (LASSO) method, for variable selection were used to estimate associations between HF/LVAD-related readmissions and pre-, intra- and post-operative clinical variables. Results: A total of 204 CF-LVAD recipients were included, of which 138 (67.7%) had at least one HF/LVAD-related readmission. HF/LVAD-related readmissions accounted for 74.4% (436/586) of total readmissions. The main reasons for HF/LVAD-related readmissions were major bleeding, major infection, HF exacerbation, and neurological dysfunction. Using pre-LVAD variables, HF/LVAD-related readmissions were associated with substance use, previous cardiac surgery, HF duration, pre-LVAD inotrope dependence, percutaneous LVAD/VA-ECMO support, LVAD type, and the left ventricular ejection fraction in multivariable analysis (Harrell's concordance c-statistic; 0.629). After adding intra- and post-operative variables in the multivariable model, LVAD implant hospitalization length of stay was an additional predictor of readmission. Conclusions: Using machine learning-based techniques, we generated models identifying pre-, intra-, and post-operative variables associated with a higher likelihood of rehospitalizations among patients on CF-LVAD support. These models could provide guidance in identifying patients with increased readmission risk for whom clinical strategies to mitigate this risk may further improve LVAD recipient outcomes.
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Affiliation(s)
- Christos P. Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA; (C.P.K.); (K.S.); (T.C.H.); (J.S.); (S.G.D.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Craig H. Selzman
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT 84112, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
| | - Theodoros V. Giannouchos
- Department of Health Policy & Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Rohan Mylavarapu
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
| | - Konstantinos Sideris
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA; (C.P.K.); (K.S.); (T.C.H.); (J.S.); (S.G.D.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
| | - Ashley Elmer
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
| | - Nathan Vance
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
| | - Thomas C. Hanff
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA; (C.P.K.); (K.S.); (T.C.H.); (J.S.); (S.G.D.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
| | - Hiroshi Kagawa
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA; (C.P.K.); (K.S.); (T.C.H.); (J.S.); (S.G.D.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
| | - Stavros G. Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA; (C.P.K.); (K.S.); (T.C.H.); (J.S.); (S.G.D.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Matthew L. Goodwin
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA; (C.H.S.); (R.M.); (A.E.); (N.V.); (H.K.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health and School of Medicine, Salt Lake City, UT 84132, USA
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Tran P, Lau C, Joshi M, Kuehl M, Maddock H, Banerjee P. Exploring Changes in Myocyte Structure, Contractility, and Energetics From Mechanical Unloading in Patients With Heart Failure Undergoing Ventricular Assist Device Implantation: A Systematic Review and Meta-Analysis. Heart Lung Circ 2024:S1443-9506(24)00082-9. [PMID: 38704332 DOI: 10.1016/j.hlc.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 05/06/2024]
Abstract
AIMS Recent reports of myocardial recovery after mechanical unloading with left ventricular assist devices (LVADs) have challenged the prevailing notion that end-stage heart failure (HF) is irreversible. To improve our understanding of this phenomenon, we comprehensively analysed the structural, functional, and energetic changes in failing human cardiomyocytes after LVAD implantation. METHODS Based on a prospectively registered protocol (PROSPERO-CRD42022380214), 30 eligible studies were identified from 940 records with a pooled population of 648 patients predominantly with non-ischaemic cardiomyopathy. RESULTS LVAD led to a substantial regression in myocyte size similar to that of donor hearts (standardised mean difference, -1.29; p<0.001). The meta-regression analysis revealed that HF duration was a significant modifier on the changes in myocyte size. There were some suggestions of fibrosis reversal (-5.17%; p=0.009); however, this was insignificant after sensitivity analysis. Developed force did not improve in cardiac trabeculae (n=5 studies); however, non-physiological isometric contractions were tested. At the myocyte level (n=4 studies), contractile kinetics improved where the time-to-peak force reduced by 41.7%-50.7% and time to 50% relaxation fell by 47.4%-62.1% (p<0.05). Qualitatively, LVAD enhanced substrate utilisation and mitochondrial function (n=6 studies). Most studies were at a high risk of bias. CONCLUSION The regression of maladaptive hypertrophy, partial fibrosis reversal, and normalisation in metabolic pathways after LVAD may be a testament to the heart's remarkable plasticity, even in the advanced stages of HF. However, inconsistencies exist in force-generating capabilities. Using more physiological force-length work-loop assays, addressing the high risks of bias and clinical heterogeneity are crucial to better understand the phenomenon of reverse remodelling.
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Affiliation(s)
- Patrick Tran
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Clement Lau
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mithilesh Joshi
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Kuehl
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Maddock
- Centre for Health & Life Sciences, Coventry University, Coventry, UK
| | - Prithwish Banerjee
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
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Visker JR, Brintz BJ, Kyriakopoulos CP, Hillas Y, Taleb I, Badolia R, Shankar TS, Amrute JM, Ling J, Hamouche R, Tseliou E, Navankasattusas S, Wever-Pinzon O, Ducker GS, Holland WL, Summers SA, Koenig SC, Hanff TC, Lavine KJ, Murali S, Bailey S, Alharethi R, Selzman CH, Shah P, Slaughter MS, Kanwar MK, Drakos SG. Integrating molecular and clinical variables to predict myocardial recovery. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.16.589326. [PMID: 38659908 PMCID: PMC11042352 DOI: 10.1101/2024.04.16.589326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Mechanical unloading and circulatory support with left ventricular assist devices (LVADs) mediate significant myocardial improvement in a subset of advanced heart failure (HF) patients. The clinical and biological phenomena associated with cardiac recovery are under intensive investigation. Left ventricular (LV) apical tissue, alongside clinical data, were collected from HF patients at the time of LVAD implantation (n=208). RNA was isolated and mRNA transcripts were identified through RNA sequencing and confirmed with RT-qPCR. To our knowledge this is the first study to combine transcriptomic and clinical data to derive predictors of myocardial recovery. We used a bioinformatic approach to integrate 59 clinical variables and 22,373 mRNA transcripts at the time of LVAD implantation for the prediction of post-LVAD myocardial recovery defined as LV ejection fraction (LVEF) ≥40% and LV end-diastolic diameter (LVEDD) ≤5.9cm, as well as functional and structural LV improvement independently by using LVEF and LVEDD as continuous variables, respectively. To substantiate the predicted variables, we used a multi-model approach with logistic and linear regressions. Combining RNA and clinical data resulted in a gradient boosted model with 80 features achieving an AUC of 0.731±0.15 for predicting myocardial recovery. Variables associated with myocardial recovery from a clinical standpoint included HF duration, pre-LVAD LVEF, LVEDD, and HF pharmacologic therapy, and LRRN4CL (ligand binding and programmed cell death) from a biological standpoint. Our findings could have diagnostic, prognostic, and therapeutic implications for advanced HF patients, and inform the care of the broader HF population.
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Liang LW, Ladanyi A, Kennel PJ, Axsom KM, Sayer GT, Takeda K, Sekulic M, Uriel N, Drakos S, Colombo PC, Yuzefpolskaya M. Myocardial Recovery With HeartMate 3 Left Ventricular Assist Device: An Attainable Goal That Needs Better Precision. ASAIO J 2024; 70:e65-e68. [PMID: 37963291 DOI: 10.1097/mat.0000000000002099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Despite advances in our understanding of myocardial recovery among left ventricular assist device (LVAD) patients, with 10-30% of patients achieving substantial myocardial improvement, the rates of LVAD support cessation remain extremely low (1-2%). These numbers are in stark contrast to clinical trial data where successful LVAD cessation is reported in up to 47% of patients. The majority of LVAD programs lack structured recovery programs and targeted protocols, likely underscoring the heterogeneity that exists among LVAD patients with myocardial recovery. This perspective summarizes the current medical and surgical challenges with respect to 1) identifying the appropriate candidates for LVAD cessation; 2) methods to wean LVAD support; 3) reviewing surgical techniques for cessation of current generation HeartMate 3 LVAD; and 4) approaching shared decision making for LVAD cessation between patients and providers given the uncertainties that remain in the field.
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Affiliation(s)
- Lusha W Liang
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Annamaria Ladanyi
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Peter J Kennel
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Kelly M Axsom
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Koji Takeda
- Division of Thoracic and Cardiac Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Stavros Drakos
- Department of Medicine, Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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6
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [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] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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7
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Gunawan A, Robson D, Krishnaswamy RJ, Ramanayake A, Kearney K, Muthiah K, Jain P, Adji A, Hayward CS. Longitudinal analysis left ventricular chamber responses under durable LVAD support. J Heart Lung Transplant 2024; 43:420-431. [PMID: 37844674 DOI: 10.1016/j.healun.2023.10.004] [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] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Left ventricular assist device (LVAD) support offers remodeling potential in some patients. Our goal was to use noninvasively derived pressure-volume (PV) loops to understand the effect of demographic and device variables on serial changes in cardiac function under pump support. METHODS Thirty-two consecutive Medtronic HeartWare Ventricular Assist Device (HVAD) patients (mean 55.9 ± 12.3 years, 81.3% male) were prospectively recruited. Single-cycle ventricular pressure and volume were estimated using a validated algorithm. PV loops (n = 77) and corresponding cardiac chamber dynamics were derived at predefined postimplant timepoints (1, 3, 6 months). Changes in PV loop parameters sustained across the 6-month period were characterized using mixed-effects modeling. The influence of demographic and device variables on the observed changes was assessed. RESULTS Across a 6-month period, the mean ventricular function parameters remained stable. Significant predictors of monthly improvement of stroke work include: lower pump speeds (2400 rpm vs 2500-2800 rpm) [0.0.051 mm Hg/liter/month (p = 0.001)], high pulsatility index (>1.0 vs <1.0) [0.052 mm Hg/liter/month (p = 0.012)], and ischemic cardiomyopathy indication for LVAD implantation (vs nonischemic) [0.0387 mm Hg/liter/month (p = 0.007)]. Various other cardiac chamber function parameters including cardiac power, peak systolic pressure, and LV elastance also showed improvements in these cohorts. CONCLUSIONS Factors associated with improvement in ventricular energetics and hemodynamics under LVAD support can be determined with noninvasive PV loops. Understanding the basis of increasing ventricular load to optimize myocardial remodeling may prove valuable in selecting eligible recovery candidates.
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Affiliation(s)
- Aaron Gunawan
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Desiree Robson
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Rohan J Krishnaswamy
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Anju Ramanayake
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Katherine Kearney
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Audrey Adji
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia.
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8
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Antonopoulos M, Bonios MJ, Dimopoulos S, Leontiadis E, Gouziouta A, Kogerakis N, Koliopoulou A, Elaiopoulos D, Vlahodimitris I, Chronaki M, Chamogeorgakis T, Drakos SG, Adamopoulos S. Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices. J Cardiovasc Dev Dis 2024; 11:61. [PMID: 38392275 PMCID: PMC10888700 DOI: 10.3390/jcdd11020061] [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: 01/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
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Affiliation(s)
- Michael Antonopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Michael J Bonios
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Evangelos Leontiadis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Aggeliki Gouziouta
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Nektarios Kogerakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ioannis Vlahodimitris
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Maria Chronaki
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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Itagaki S, Moss N, Toyoda N, Mancini D, Egorova N, Serrao G, Lala A, Pinney SP, Boateng P, Adams DH, Anyanwu AC. Incidence, Outcomes, and Opportunity for Left Ventricular Assist Device Weaning for Myocardial Recovery. JACC. HEART FAILURE 2024:S2213-1779(23)00841-7. [PMID: 38276935 DOI: 10.1016/j.jchf.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Myocardial recovery occurs in patients with advanced heart failure on left ventricular assist device (LVAD) support, but there is the premise that it is rare with uncertain results. OBJECTIVES The goal of this study was to investigate the incidence and consequence of LVAD explant after myocardial recovery. METHODS Using the United Network for Organ Sharing registry, LVAD implants in the United States between 2005 and 2020 were tracked until death, transplantation, or explant for myocardial recovery. The cohort undergoing explant was followed up for heart failure relapse (defined as relisting followed by delisting due to death, being too ill, or transplantation; or second durable LVAD implant). RESULTS Of 15,728 LVAD implants, 126 patients underwent explant for recovery, which only occurred in 55 (38%) of 145 implanting centers. The crude cumulative incidence was 0.7% at 2 years, whereas the incidence reached 4.7% among designated centers in the selected young nonischemic cohort. Of 126 explanted patients, 76 (60%) were subsequently delisted for sustained recovery. Heart failure relapsing had a relatively higher hazard in the early phase, with a 30-day incidence of 6% (7 of 126) but tapered following with the freedom rate of 72.5% at 4 years. CONCLUSIONS In the United States, LVAD explant for myocardial recovery was underutilized, leading to a very low incidence at the national level despite a realistic rate being achieved in designated centers for selected patients. With follow-up extending up to 4 years after explant, more than one-half were successfully removed and stayed off the waitlist, and approximately 70% were free from heart failure relapse events.
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Affiliation(s)
- Shinobu Itagaki
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA.
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nana Toyoda
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Donna Mancini
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregory Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean P Pinney
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Percy Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
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10
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Oran E, Abo-Serie E, Jewkes J, Henry M, Oran B. Design and optimisation of an Intra-Aortic Shrouded rotor axial pump. J Biomech 2024; 162:111858. [PMID: 37989028 DOI: 10.1016/j.jbiomech.2023.111858] [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] [Received: 05/05/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
Undesirable side effects in patients with a LVAD (Left Ventricular Assist Device) pump fitted include blood damage, thrombosis, blood traumatisation, and End-Organ Disfunctions. These side effects have generally been attributed to the high wall shear stresses and the induced turbulent flow. In this study, we introduce a novel design to address these effects by lowering the rotational speed and providing an optimum flow path design to minimise blood damage. We present an initial scheme for a new Intra-Aortic Shrouded Rotary Axial Pump and develop a sequence of pump geometries, for which the Taguchi Design Optimisation Method has been applied. We apply CFD tools to simulate the pressure rise, pump performance, hydraulic efficiency, wall shear stress, exposure time and mass flow rate. A prototype pump has been tested in a mock cardiovascular circuit using a water-glycerol solution. The optimum design delivered the desired pressure/mass flow rate characteristics at a significantly low rpm (2900 rpm). As a result, the estimated blood damage index is low, matching the design requirements. The theoretical performance was matched by experimental results.
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Affiliation(s)
- Elif Oran
- Coventry University, Centre for Fluid and Complex Systems, Coventry, UK
| | - Essam Abo-Serie
- University of Leicester, School of Engineering, Leicester, UK.
| | - James Jewkes
- University of Leicester, School of Engineering, Leicester, UK
| | - Manus Henry
- Coventry University, Centre for Fluid and Complex Systems, Coventry, UK; University of Oxford, Department of Engineering Science, Oxford, UK
| | - Bulent Oran
- Medicana International Hospital, Department of Pediatric Cardiology, Izmir, Turkey
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11
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Dardik G, Ning Y, Kurlansky P, Almodovar Cruz G, Vinogradsky A, Fried J, Topkara VK, Takeda K. Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support. Perfusion 2023:2676591231206524. [PMID: 37861303 DOI: 10.1177/02676591231206524] [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: 10/21/2023]
Abstract
OBJECTIVE Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS). METHODS We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality. RESULTS Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality. CONCLUSIONS Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.
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Affiliation(s)
- Gabriel Dardik
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Alice Vinogradsky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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12
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Tedford RJ, Leacche M, Lorts A, Drakos SG, Pagani FD, Cowger J. Durable Mechanical Circulatory Support: JACC Scientific Statement. J Am Coll Cardiol 2023; 82:1464-1481. [PMID: 37758441 DOI: 10.1016/j.jacc.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/01/2023] [Accepted: 07/12/2023] [Indexed: 10/03/2023]
Abstract
Despite advances in medical therapy for patients with stage C heart failure (HF), survival for patients with advanced HF is <20% at 5 years. Durable left ventricular assist device (dLVAD) support is an important treatment option for patients with advanced HF. Innovations in dLVAD technology have reduced the risk of several adverse events, including pump thrombosis, stroke, and bleeding. Average patient survival is now similar to that of heart transplantation at 2 years, with 5-year dLVAD survival now approaching 60%. Unfortunately, greater adoption of dLVAD therapy has not been realized due to delayed referral of patients to advanced HF centers, insufficient clinician knowledge of contemporary dLVAD outcomes (including gains in quality of life), and deprioritization of patients with dLVAD support waiting for heart transplantation. Despite these challenges, novel devices are on the horizon of clinical investigation, offering smaller size, permitting less invasive surgical implantation, and eliminating the percutaneous lead for power supply.
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Affiliation(s)
- Ryan J Tedford
- Medical University of South Carolina, Charleston, South Carolina, USA
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13
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Hamad EA, Byku M, Larson SB, Billia F. LVAD therapy as a catalyst to heart failure remission and myocardial recovery. Clin Cardiol 2023; 46:1154-1162. [PMID: 37526373 PMCID: PMC10577530 DOI: 10.1002/clc.24094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.
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Affiliation(s)
- Eman A. Hamad
- Lewis Katz School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Mirnela Byku
- Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Sharon B. Larson
- Baptist Heart Institute at Baptist Memorial HospitalMemphisTennesseeUSA
| | - Filio Billia
- Peter Munk Cardiac CenterUniversity Health NetworkTorontoOntarioCanada
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14
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Rohde S, de By TMMH, Bogers AJJC, Schweiger M. Myocardial recovery in children supported with a durable ventricular assist device-a systematic review. Eur J Cardiothorac Surg 2023; 64:ezad263. [PMID: 37498565 PMCID: PMC10560320 DOI: 10.1093/ejcts/ezad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/18/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES A small percentage of paediatric patients supported with a ventricular assist device (VAD) can have their device explanted following myocardial recovery. The goal of this systematic review is to summarize the current literature on the clinical course in these children after weaning. METHODS A systematic literature search was performed on 27 May 2022 using Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar to include all literature on paediatric patients supported by a durable VAD during the last decade. Overlapping study cohorts and registry-based studies were filtered out. RESULTS Thirty-seven articles were included. Eighteen of them reported on the incidence of recovery in cohort studies, with an overall incidence rate of 8.7% (81/928). Twenty-two of the included articles reported on clinical outcomes after VAD explantation (83 patients). The aetiologies varied widely and were not limited to diseases with a natural transient course like myocarditis. Most of the patients in the included studies (70; 84.3%) were supported by a Berlin Heart EXCOR, and in 66.3% (55/83), only the left ventricle had to be supported. The longest follow-up period was 19.1 years, and multiple studies reported on long-term myocardial recovery. Fewer than half of the reported deaths had a cardiac cause. CONCLUSIONS Myocardial recovery during VAD support is dependent on various contributing components. The interactions among patient-, device-, time- and hospital-related factors are complex and not yet fully understood. Long-term recovery after VAD support is achievable, even after a long duration of VAD support, and even in patients with aetiologies different from myocarditis or post-cardiotomy heart failure. More research is needed on this favourable outcome after VAD support.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children′s Hospital Zurich, Pediatric Heart Centre, Department for Congenital Heart Surgery, Zurich, Switzerland
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15
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Duggal NM, Lei I, Wu X, Aaronson KD, Pagani FD, Lam HYK, Tang PC. Mitral regurgitation severity at left ventricular assist device implantation is associated with distinct myocardial transcriptomic signatures. J Thorac Cardiovasc Surg 2023; 166:141-152.e1. [PMID: 34689984 DOI: 10.1016/j.jtcvs.2021.08.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We examined for differences in pre-left ventricular assist device (LVAD) implantation myocardial transcriptome signatures among patients with different degrees of mitral regurgitation (MR). METHODS Between January 2018 and October 2019, we collected left ventricular (LV) cores during durable LVAD implantation (n = 72). A retrospective chart review was performed. Total RNA was isolated from LV cores and used to construct cDNA sequence libraries. The libraries were sequenced with the NovaSeq system, and data were quantified using Kallisto. Gene Set Enrichment Analysis (GSEA) and Gene Ontology analyses were performed, with a false discovery rate <0.05 considered significant. RESULTS Comparing patients with preoperative mild or less MR (n = 30) and those with moderate-severe MR (n = 42), the moderate-severe MR group weighted less (P = .004) and had more tricuspid valve repairs (P = .043), without differences in demographics or comorbidities. We then compared both groups with a group of human donor hearts without heart failure (n = 8). Compared with the donor hearts, there were 3985 differentially expressed genes (DEGs) for mild or less MR and 4587 DEGs for moderate-severe MR. Specifically altered genes included 448 DEGs for specific for mild or less MR and 1050 DEGs for moderate-severe MR. On GSEA, common regulated genes showed increased immune gene expression and reduced expression of contraction and energetic genes. Of the 1050 genes specific for moderate-severe MR, there were additional up-regulated genes related to inflammation and reduced expression of genes related to cellular proliferation. CONCLUSIONS Patients undergoing durable LVAD implantation with moderate-severe MR had increased activation of genes related to inflammation and reduction of cellular proliferation genes. This may have important implications for myocardial recovery.
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Affiliation(s)
- Neal M Duggal
- Department of Anesthesiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | | | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
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16
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Bhattacharya P, Samson R, Apte N, Fu S. Myocardial recovery following left ventricular assist device implantation. Indian J Thorac Cardiovasc Surg 2023; 39:154-160. [PMID: 37525711 PMCID: PMC10386991 DOI: 10.1007/s12055-023-01543-2] [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: 02/21/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 08/02/2023] Open
Abstract
Durable left ventricular assist devices (LVADs) have consistently shown improved mortality and morbidity in patients with end-stage heart failure. Select patients with LVADs may experience significant enough myocardial recovery after device implantation to allow for explantation or decommissioning. While earlier trials suggested a high incidence of recovery, real-world clinical data have demonstrated this to be a much rarer phenomenon. Whether or not patients experience recovery, practices such as speed optimization and usage of guideline-directed medical therapy can improve patient outcomes.
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Affiliation(s)
- Priyanka Bhattacharya
- Department of Medicine, Division of Cardiology, University of Louisville, 201 Abraham Flexner Way, Ste 1001, Louisville, KY 40202 USA
| | - Rohan Samson
- Advanced Heart Failure Therapies, University of Louisville Health, Louisville, KY USA
| | - Nachiket Apte
- Department of Medicine, Division of Cardiology, University of Louisville, 201 Abraham Flexner Way, Ste 1001, Louisville, KY 40202 USA
| | - Sheng Fu
- Department of Medicine, Division of Cardiology, University of Louisville, 201 Abraham Flexner Way, Ste 1001, Louisville, KY 40202 USA
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17
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Boss LA, Lovell NH, Stevens MC. Evaluating Indices for Non-invasive Myocardial Recovery Assessment in LVAD-Supported Heart Failure Patients. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082936 DOI: 10.1109/embc40787.2023.10339995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Accurate assessment of myocardial recovery (MR) under left ventricular assist device (LVAD) support is essential for clinicians to manage heart failure patients. However, current techniques for assessing MR are time-consuming, invasive, and infrequent. Measuring MR using indices derived from LVAD operating data instead provides a potential real-time alternative. Several of these indices for assessing the MR of LVAD-supported heart failure patients were collated from the literature and subject to a comprehensive comparative analysis. The objective of this analysis was to determine the most accurate index for assessing systolic cardiac function under LVAD-support, characterized by maximal end-systolic elastance (Emax), while remaining insensitive to preload & afterload. The indices were compared in computational simulation, utilizing an LVAD + cardiovascular system model to sweep through a large array of Emax and resistance conditions. Results demonstrated the index that correlated best with Emax, showing the highest accuracy, was the ratio between maximum flow acceleration and flow pulsatility (average R2 =0.9790). The same index also exhibited the lowest % variation (sensitivity) to preload & afterload (1.32% & 13.53% respectively). However, opportunities for improvement remain among current recovery assessment indices, with this study providing a baseline of performance for potential future indices to improve upon.Clinical relevance- This study presents a potential real-time measure of native cardiac function in LVAD-supported heart failure patients to support patient management and further recovery.
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18
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Chrysakis N, Xanthopoulos A, Magouliotis D, Starling RC, Drakos SG, Triposkiadis F, Skoularigis J. Myocardial Recovery. Diagnostics (Basel) 2023; 13:diagnostics13081504. [PMID: 37189604 DOI: 10.3390/diagnostics13081504] [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: 03/20/2023] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
In this paper, the feasibility of myocardial recovery is analyzed through a literature review. First, the phenomena of remodeling and reverse remodeling are analyzed, approached through the physics of elastic bodies, and the terms myocardial depression and myocardial recovery are defined. Continuing, potential biochemical, molecular, and imaging markers of myocardial recovery are reviewed. Then, the work focuses on therapeutic techniques that can facilitate the reverse remodeling of the myocardium. Left ventricular assist device (LVAD) systems are one of the main ways to promote cardiac recovery. The changes that take place in cardiac hypertrophy, extracellular matrix, cell populations and their structural elements, β-receptors, energetics, and several biological processes, are reviewed. The attempt to wean the patients who experienced cardiac recovery from cardiac assist device systems is also discussed. The characteristics of the patients who will benefit from LVAD are presented and the heterogeneity of the studies performed in terms of patient populations included, diagnostic tests performed, and their results are addressed. The experience with cardiac resynchronization therapy (CRT) as another way to promote reverse remodeling is also reviewed. Myocardial recovery is a phenomenon that presents with a continuous spectrum of phenotypes. There is a need for algorithms to screen suitable patients who may benefit and identify specific ways to enhance this phenomenon in order to help combat the heart failure epidemic.
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Affiliation(s)
- Nikolaos Chrysakis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Dimitrios Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Filippos Triposkiadis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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19
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Macera F, Dewachter C, Stefanidis C, Vanden Eynden F, Bondue A, Vachiéry J, Roussoulières A. Lung diffusion capacity correlates with pre-implant pulmonary hypertension and predicts outcome after LVAD implantation. ESC Heart Fail 2023; 10:1043-1053. [PMID: 36546904 PMCID: PMC10053279 DOI: 10.1002/ehf2.14256] [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] [Received: 07/14/2022] [Revised: 10/26/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Diffusing capacity of the lung for carbon monoxide (DLCO ) reduction is common in heart failure (HF) and is associated with a worse prognosis. Correlations between DLCO and pulmonary hypertension (PH) are unclear, and published data are conflicting; it has been shown that DLCO impairment may persist or even worsen after normalization of pulmonary pressures following left ventricle assist device (LVAD) implantation, maybe reflecting persistent pulmonary damage. We aimed to investigate the impact of pre-implant DLCO and central haemodynamics on outcome in patients with advanced HF implanted with a LVAD. METHODS AND RESULTS We retrospectively analysed pre-implant and post-implant data from 42 patients implanted with a LVAD at our institution. Out of 42 patients, 35 had post-capillary PH before implantation, including 17 with combined post- and pre-capillary PH (Cpc-PH). Median DLCO was 59% (IQR 47-68%), and it inversely correlated with pulmonary vascular resistance (PVR) (P 0.037) and diastolic pulmonary gradient (DPG) (P 0.042). Compared with baseline, LVAD resulted in improvement in LV diameter (LVDd, P < 0.001), mitral regurgitation (P 0.022), and PH (mPAP 24 vs. 36 mmHg, P < 0.001; PAWP 12 vs. 23 mmHg, P 0.001; pulmonary artery compliance, CPA 3.1 vs. 1.9 mL/mmHg, P 0.021). Lower DLCO and Cpc-PH at baseline were associated with a better LV reverse remodelling post-implantation (P 0.027 for LVDd) but also with a smaller gain in CPA (P 0.049). CONCLUSIONS Before LVAD implantation, DLCO impairment is associated with higher PVR and DPG, suggesting that it might be an expression of persistent pulmonary damage occurring in Cpc-PH. After LVAD implantation, both LV dimension and haemodynamics improve. Lower pre-implant DLCO is associated with better LV reverse remodelling.
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Affiliation(s)
- Francesca Macera
- Department of CardiologyHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
- Department of CardiologyNiguarda Ca' Granda HospitalMilanItaly
| | - Céline Dewachter
- Department of CardiologyHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
| | - Constantin Stefanidis
- Department of Cardiac SurgeryHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
| | - Frédéric Vanden Eynden
- Department of Cardiac SurgeryHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
| | - Antoine Bondue
- Department of CardiologyHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
| | - Jean‐Luc Vachiéry
- Department of CardiologyHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
| | - Ana Roussoulières
- Department of CardiologyHôpital Universitaire de Bruxelles – Hôpital ErasmeBrusselsBelgium
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20
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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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21
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Liao X, Kennel PJ, Liu B, Nash TR, Zhuang RZ, Godier-Furnemont AF, Xue C, Lu R, Colombo PC, Uriel N, Reilly MP, Marx SO, Vunjak-Novakovic G, Topkara VK. Effect of mechanical unloading on genome-wide DNA methylation profile of the failing human heart. JCI Insight 2023; 8:161788. [PMID: 36656640 PMCID: PMC9977498 DOI: 10.1172/jci.insight.161788] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Heart failure (HF) is characterized by global alterations in myocardial DNA methylation, yet little is known about the epigenetic regulation of the noncoding genome and potential reversibility of DNA methylation with left ventricular assist device (LVAD) therapy. Genome-wide mapping of myocardial DNA methylation in 36 patients with HF at LVAD implantation, 8 patients at LVAD explantation, and 7 nonfailing (NF) donors using a high-density bead array platform identified 2,079 differentially methylated positions (DMPs) in ischemic cardiomyopathy (ICM) and 261 DMPs in nonischemic cardiomyopathy (NICM). LVAD support resulted in normalization of 3.2% of HF-associated DMPs. Methylation-expression correlation analysis yielded several protein-coding genes that are hypomethylated and upregulated (HTRA1, FBXO16, EFCAB13, and AKAP13) or hypermethylated and downregulated (TBX3) in HF. A potentially novel cardiac-specific super-enhancer long noncoding RNA (lncRNA) (LINC00881) is hypermethylated and downregulated in human HF. LINC00881 is an upstream regulator of sarcomere and calcium channel gene expression including MYH6, CACNA1C, and RYR2. LINC00881 knockdown reduces peak calcium amplitude in the beating human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). These data suggest that HF-associated changes in myocardial DNA methylation within coding and noncoding genomes are minimally reversible with mechanical unloading. Epigenetic reprogramming strategies may be necessary to achieve sustained clinical recovery from heart failure.
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Affiliation(s)
- Xianghai Liao
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Peter J Kennel
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Bohao Liu
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Trevor R Nash
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Richard Z Zhuang
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | | | - Chenyi Xue
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Rong Lu
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Muredach P Reilly
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Steven O Marx
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | | | - Veli K Topkara
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
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22
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Drakos SG, Badolia R, Makaju A, Kyriakopoulos CP, Wever-Pinzon O, Tracy CM, Bakhtina A, Bia R, Parnell T, Taleb I, Ramadurai DKA, Navankasattusas S, Dranow E, Hanff TC, Tseliou E, Shankar TS, Visker J, Hamouche R, Stauder EL, Caine WT, Alharethi R, Selzman CH, Franklin S. Distinct Transcriptomic and Proteomic Profile Specifies Patients Who Have Heart Failure With Potential of Myocardial Recovery on Mechanical Unloading and Circulatory Support. Circulation 2023; 147:409-424. [PMID: 36448446 PMCID: PMC10062458 DOI: 10.1161/circulationaha.121.056600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/25/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Extensive evidence from single-center studies indicates that a subset of patients with chronic advanced heart failure (HF) undergoing left ventricular assist device (LVAD) support show significantly improved heart function and reverse structural remodeling (ie, termed "responders"). Furthermore, we recently published a multicenter prospective study, RESTAGE-HF (Remission from Stage D Heart Failure), demonstrating that LVAD support combined with standard HF medications induced remarkable cardiac structural and functional improvement, leading to high rates of LVAD weaning and excellent long-term outcomes. This intriguing phenomenon provides great translational and clinical promise, although the underlying molecular mechanisms driving this recovery are largely unknown. METHODS To identify changes in signaling pathways operative in the normal and failing human heart and to molecularly characterize patients who respond favorably to LVAD unloading, we performed global RNA sequencing and phosphopeptide profiling of left ventricular tissue from 93 patients with HF undergoing LVAD implantation (25 responders and 68 nonresponders) and 12 nonfailing donor hearts. Patients were prospectively monitored through echocardiography to characterize their myocardial structure and function and identify responders and nonresponders. RESULTS These analyses identified 1341 transcripts and 288 phosphopeptides that are differentially regulated in cardiac tissue from nonfailing control samples and patients with HF. In addition, these unbiased molecular profiles identified a unique signature of 29 transcripts and 93 phosphopeptides in patients with HF that distinguished responders after LVAD unloading. Further analyses of these macromolecules highlighted differential regulation in 2 key pathways: cell cycle regulation and extracellular matrix/focal adhesions. CONCLUSIONS This is the first study to characterize changes in the nonfailing and failing human heart by integrating multiple -omics platforms to identify molecular indices defining patients capable of myocardial recovery. These findings may guide patient selection for advanced HF therapies and identify new HF therapeutic targets.
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Affiliation(s)
- Stavros G. Drakos
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Rachit Badolia
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Aman Makaju
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Christos P. Kyriakopoulos
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Omar Wever-Pinzon
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Christopher M. Tracy
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Anna Bakhtina
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Ryan Bia
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Timothy Parnell
- Bioinformatics Core, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, United States
| | - Iosif Taleb
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Dinesh K. A. Ramadurai
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Sutip Navankasattusas
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Elizabeth Dranow
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Thomas C. Hanff
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Eleni Tseliou
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Thirupura S. Shankar
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Joseph Visker
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Rana Hamouche
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
| | - Elizabeth L. Stauder
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
| | - William T. Caine
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
| | - Rami Alharethi
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
| | - Craig H. Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Utah Transplantation Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program (University of Utah, Intermountain Medical Center, Salt Lake VA Medical Center), Salt Lake City, Utah, United States
| | - Sarah Franklin
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States
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23
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Schmitto JD, Kuuva A, Kronström K, Hanke JS, Kankuri E. Use of left atrial appendage as an autologous tissue source for epicardial micrograft transplantation during LVAD implantation. Front Cardiovasc Med 2023; 10:1143886. [PMID: 37187792 PMCID: PMC10176448 DOI: 10.3389/fcvm.2023.1143886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
We report here the first clinical use of the left atrial appendage (LAA) for epicardial micrograft transplantation during left ventricular assist device (LVAD) implantation. Previously, a sample from the right atrial appendage (RAA) has been available for processing and administering micrograft therapy in cardiac surgery. Both LAA and RAA are rich sources of various types of myocardial cells and are capable of providing both paracrine and cellular support to the failing myocardium. The surgical approach of LAA micrografting facilitates epicardial micrograft therapy dose escalation and treatment of larger myocardial areas than done previously. Moreover, as collection of treated vs. untreated tissues from the recipient heart is possible following LVAD implantation at the time of heart transplantation, the evaluation of the therapy's mechanism of action can be further deciphered at cellular and molecular levels. This LAA modification of the epicardial micrografting technique has the overall potential to facilitate the adoption of cardiac cell therapy during heart surgery.
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Affiliation(s)
- Jan D. Schmitto
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Kai Kronström
- EpiHeart Oy, Helsinki, Finland
- Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Jasmin S. Hanke
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Esko Kankuri
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Correspondence: Esko Kankuri
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24
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Muhammed A, Abdelazeem M, Elewa MG, Sharief M, Ammar A. Primary prevention implantable cardioverter-defibrillator use in non-ischemic dilated cardiomyopathy based on arrhythmic risk stratification and left ventricular reverse remodeling prediction. Heart Fail Rev 2023; 28:229-240. [PMID: 35587303 PMCID: PMC9902308 DOI: 10.1007/s10741-022-10246-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 02/07/2023]
Abstract
Sudden cardiac death (SCD) and significant ventricular arrhythmias in patients with dilated cardiomyopathy (DCM) have been markedly reduced over the last couple of decades as a result of the advances in pharmacological and non-pharmacological treatment. Primary prevention implantable cardioverter-defibrillator (ICD) plays an important role in the treatment of patients at risk of SCD caused by ventricular arrhythmias. However, the arrhythmic risk stratification in patients with DCM remains extremely challenging, and the decision for primary prevention ICD implantation based on left ventricular ejection fraction (LVEF) solely appears to be insufficient. This review provides an update on current evidence for primary prevention ICD implantation, arrhythmic risk stratification, and left ventricular reverse remodeling (LVRR) prediction in patients with DCM in addition to most recent guideline recommendations for primary prevention ICD implantation in DCM patients and a proposed multiparametric algorithm based on arrhythmic risk stratification and left ventricular reverse remodeling (LVRR) prediction to better identify patients who are likely to benefit from primary prevention ICD.
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Affiliation(s)
- Ahmed Muhammed
- Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Mohamed Abdelazeem
- grid.7269.a0000 0004 0621 1570Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt ,grid.240845.f0000 0004 0380 0425Department of Medicine, St. Elizabeth’s Medical Center, Boston, MA USA ,grid.67033.310000 0000 8934 4045Department of Medicine, Tufts University School of Medicine, Boston, MA USA
| | - Mohamed Gamaleldin Elewa
- grid.7269.a0000 0004 0621 1570Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Sharief
- grid.469958.fCardiology Department, Mansoura University Hospital, El Mansoura, Egypt ,grid.440181.80000 0004 0456 4815Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ahmed Ammar
- grid.7269.a0000 0004 0621 1570Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt ,grid.430729.b0000 0004 0486 7170Cardiology Department, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
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25
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Arshad S, Cutting RD, Stephens DJ, Goldberg YH, Mahr C, Vyasabattu M, Abdelfattah AH, Vaidya GN. A Peek at LVADs Pumping to Recovery. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221144352. [PMID: 36601071 PMCID: PMC9806425 DOI: 10.1177/11795468221144352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/23/2022] [Indexed: 12/27/2022]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the management of patients with advanced heart failure refractory to medical therapy. Current indications of LVADs include Bridge to Transplantation (BTT), Destination Therapy (DT) for long-term use, Bridge to the Decision (BTD) used as a temporary measure, and lastly Bridge to Recovery (BTR). Here, we briefly review the clinical evidence and the molecular mechanisms behind myocardial recovery following LVAD placement. We also share institutional protocols used at 2 major medical centers in the USA.
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Affiliation(s)
- Samiullah Arshad
- Internal Medicine, University of
Kentucky, Lexington, KY, USA,Samiullah Arshad, University of Kentucky,
2151 Meeting Street, Apt 5208, Lexington, KY 40509, USA.
| | - Rachel D Cutting
- Medical Student, University of New
England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Daniel J Stephens
- Medical Student, University of
Washington School of Medicine, Seattle, WA, USA
| | | | - Claudius Mahr
- Advanced Heart Failure and Transplant,
University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Gaurang N Vaidya
- Advanced Heart Failure and Transplant,
University of Kentucky, Lexington, KY, USA
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26
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Alotaibi K, Bakhsh A, Alkhaf F, Amro A, Albarrak M, Tantawy T, Arafat AA, Adam AI. Myocardial recovery in a patient with dilated cardiomyopathy after short-term biventricular assist device support. J Card Surg 2022; 37:5591-5594. [PMID: 36378911 DOI: 10.1111/jocs.17148] [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: 07/18/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Management of patients with end-stage heart failure is still challenging. We report a case of idiopathic dilated cardiomyopathy who went through a challenging course. The case was presented as acute heart failure syndrome, which rapidly declined into cardiogenic shock and cardiac arrest that required an extracorporeal membrane oxygenator, then biventricular assist device implantation for circulatory support. The course was complicated with severe gastrointestinal bleeding and multiorgan failure until achieving full cardiac and organ recovery. The left ventricle ejection fraction improved from 10% to 50% at discharge.
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Affiliation(s)
- Khaled Alotaibi
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Abeer Bakhsh
- Adult Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Fahmi Alkhaf
- Adult Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Ahmed Amro
- Adult Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Mohammad Albarrak
- Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Tarek Tantawy
- Cardiac Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Adam I Adam
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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27
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Elbayomi M, Weyand M, Seitz T, Heim C, Steger K, Tandler R. Recovery of a dilated left ventricle after cessation of cocaine and HVAD™ explantation using a titanium plug. J Card Surg 2022; 37:5551-5555. [PMID: 36345682 DOI: 10.1111/jocs.17135] [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: 08/10/2022] [Revised: 10/01/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
The ultimate goal in the treatment of end-stage heart failure is the recovery of cardiac function following mechanical assistance of the left ventricle. The HVAD™ pump (HeartWare Inc.) left ventricular assist device (LVAD) can be explanted without resternotomy. This article demonstrates that the use of a custom-made mechanical plug (manufactured by INNOVO Solutions GmbH), which can be inserted into the LVAD's sewing ring, is feasible. This mechanical plug explicitly designed for device explantation is a viable alternative to the current standard of care. This article adopts a less invasive technique to explant the pump. The following case illustrates this technique.
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Affiliation(s)
- Mohamed Elbayomi
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Michael Weyand
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Timo Seitz
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Heim
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Katrin Steger
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Rene Tandler
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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28
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Ruge M, Marek-Iannucci S, Massey HT, Ruggiero NJ, Lawrence J, Mehrotra P, Rame JE, Alvarez R, Rajapreyar I, Brailovsky Y. Percutaneous Decommissioning 11 Years After Initial CF-LVAD Placement. JACC: CASE REPORTS 2022; 4:101682. [PMID: 36438893 PMCID: PMC9685357 DOI: 10.1016/j.jaccas.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/24/2022]
Abstract
An 80-year-old man with severe nonischemic cardiomyopathy status post left ventricular assist device (LVAD) placement 11 years prior presented for recurrent LVAD alarms from internal driveline fracture. Given his partial myocardial recovery and his preference to avoid surgical procedures, percutaneous LVAD decommissioning was performed by occlusion of the outflow graft and subsequently driveline removal. (Level of Difficulty: Advanced.)
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29
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Noly PE, Duggal N, Jiang M, Nordsletten D, Bonini M, Lei I, Ela AAE, Haft JW, Pagani FD, Cascino TM, Tang PC. Role of the mitral valve in left ventricular assist device pathophysiology. Front Cardiovasc Med 2022; 9:1018295. [PMID: 36386343 PMCID: PMC9649705 DOI: 10.3389/fcvm.2022.1018295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/29/2022] [Indexed: 08/27/2023] Open
Abstract
Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Neal Duggal
- Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mulan Jiang
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | - David Nordsletten
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Mia Bonini
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Ienglam Lei
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan W. Haft
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D. Pagani
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Paul C. Tang
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
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Kanwar MK, Selzman CH, Ton VK, Miera O, Cornwell WK, Antaki J, Drakos S, Shah P. Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support. J Heart Lung Transplant 2022; 41:1324-1334. [PMID: 35835680 PMCID: PMC10257189 DOI: 10.1016/j.healun.2022.05.015] [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: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022] Open
Abstract
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Massachusetts General Hospital, Harvard Medical School, Boston, Maryland
| | - Oliver Miera
- Department of Congenital Heart Disease, Pediatric Cardiology, German Heart Center, Berlin, Germany
| | - William K Cornwell
- Department of Medicine Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Stavros Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
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Tseliou E, Lavine KJ, Wever-Pinzon O, Topkara VK, Meyns B, Adachi I, Zimpfer D, Birks EJ, Burkhoff D, Drakos SG. Biology of myocardial recovery in advanced heart failure with long-term mechanical support. J Heart Lung Transplant 2022; 41:1309-1323. [PMID: 35965183 DOI: 10.1016/j.healun.2022.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022] Open
Abstract
Cardiac remodeling is an adaptive, compensatory biological process following an initial insult to the myocardium that gradually becomes maladaptive and causes clinical deterioration and chronic heart failure (HF). This biological process involves several pathophysiological adaptations at the genetic, molecular, cellular, and tissue levels. A growing body of clinical and translational investigations demonstrated that cardiac remodeling and chronic HF does not invariably result in a static, end-stage phenotype but can be at least partially reversed. One of the paradigms which shed some additional light on the breadth and limits of myocardial elasticity and plasticity is long term mechanical circulatory support (MCS) in advanced HF pediatric and adult patients. MCS by providing (a) ventricular mechanical unloading and (b) effective hemodynamic support to the periphery results in functional, structural, cellular and molecular changes, known as cardiac reverse remodeling. Herein, we analyze and synthesize the advances in our understanding of the biology of MCS-mediated reverse remodeling and myocardial recovery. The MCS investigational setting offers access to human tissue, providing an unparalleled opportunity in cardiovascular medicine to perform in-depth characterizations of myocardial biology and the associated molecular, cellular, and structural recovery signatures. These human tissue findings have triggered and effectively fueled a "bedside to bench and back" approach through a variety of knockout, inhibition or overexpression mechanistic investigations in vitro and in vivo using small animal models. These follow-up translational and basic science studies leveraging human tissue findings have unveiled mechanistic myocardial recovery pathways which are currently undergoing further testing for potential therapeutic drug development. Essentially, the field is advancing by extending the lessons learned from the MCS cardiac recovery investigational setting to develop therapies applicable to the greater, not end-stage, HF population. This review article focuses on the biological aspects of the MCS-mediated myocardial recovery and together with its companion review article, focused on the clinical aspects, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Eleni Tseliou
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Kory J Lavine
- Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart Meyns
- Department of Cardiology and Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, TX
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY; Cardiovascular Research Foundation (CRF), New York, NY
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT.
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Myostatin/AKT/FOXO Signaling Is Altered in Human Non-Ischemic Dilated Cardiomyopathy. Life (Basel) 2022; 12:life12091418. [PMID: 36143454 PMCID: PMC9506454 DOI: 10.3390/life12091418] [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: 08/08/2022] [Revised: 09/04/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Disturbances in the ubiquitin proteasome system, and especially changes of the E3 ligases, are subjects of interest when searching for causes and therapies for cardiomyopathies. The aim of this study was to clarify whether the myostatin/AKT/forkhead box O (FOXO) pathway, which regulates the expression of the E3 ligases muscle atrophy F-box gene (MAFbx) and muscle ring-finger protein-1 (MuRF1), is changed in dilated cardiomyopathy of ischemic origin (IDCM) and dilated cardiomyopathy of non-ischemic origin (NIDCM). The mRNA and protein expression of myostatin, AKT, FOXO1, FOXO3, MAFbx and MuRF1 were quantified by real-time polymerase chain reaction and ELISA, respectively, in myocardial tissue from 26 IDCM and 23 NIDCM patients. Septal tissue from 17 patients undergoing Morrow resection served as a control. MAFbx and FOXO1 mRNA and protein expression (all p < 0.05), AKT mRNA (p < 0.01) and myostatin protein expression (p = 0.02) were decreased in NIDCM patients compared to the control group. Apart from decreases of AKT and MAFbx mRNA expression (both p < 0.01), no significant differences were detected in IDCM patients compared to the control group. Our results demonstrate that the myostatin/AKT/FOXO pathway is altered in NIDCM but not in IDCM patients. FOXO1 seems to be an important drug target for regulating the expression of MAFbx in NIDCM patients.
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A Holistic View of Advanced Heart Failure. Life (Basel) 2022; 12:life12091298. [PMID: 36143336 PMCID: PMC9501910 DOI: 10.3390/life12091298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023] Open
Abstract
Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.
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Kyriakopoulos CP, Taleb I, Drakos SG. Does cardiac recovery favorably impact adverse events and outcomes of LVAD patients? J Heart Lung Transplant 2022; 41:1029-1031. [PMID: 35878939 PMCID: PMC9990470 DOI: 10.1016/j.healun.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Christos P Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health & School of Medicine, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA.
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LVAD as a Bridge to Remission from Advanced Heart Failure: Current Data and Opportunities for Improvement. J Clin Med 2022; 11:jcm11123542. [PMID: 35743611 PMCID: PMC9225013 DOI: 10.3390/jcm11123542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Left ventricular assist devices (LVADs) are an established treatment modality for advanced heart failure (HF). It has been shown that through volume and pressure unloading they can lead to significant functional and structural cardiac improvement, allowing LVAD support withdrawal in a subset of patients. In the first part of this review, we discuss the historical background, current evidence on the incidence and assessment of LVAD-mediated cardiac recovery, and out-comes including quality of life after LVAD support withdrawal. In the second part, we discuss current and future opportunities to promote LVAD-mediated reverse remodeling and improve our pathophysiological understanding of HF and recovery for the benefit of the greater HF population.
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Smith NJ, Collar N, Duvvuri P, Miles B, Wu R, Szabo A, Gaglianello N, Joyce LD, Joyce DL. Protocolized screening effectively identifies myocardial recovery following destination therapy left ventricular assist device implantation. Artif Organs 2022; 46:1636-1648. [PMID: 35319785 DOI: 10.1111/aor.14238] [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: 07/12/2021] [Revised: 02/23/2022] [Accepted: 03/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Myocardial recovery following left ventricular assist device (LVAD) implantation has been of interest in transplant candidates with non-ischemic cardiomyopathy but is rare. Evidence suggests that a combination of left ventricular unloading and pharmacologic reverse remodeling is beneficial. Recovery in non-transplant candidates (i.e., destination therapy [DT]) patients is believed to be even rarer. METHODS All DT LVADs between January 1, 2017 and November 23, 2020 were reviewed. All patients were subjected to an institutional protocol consisting of combined pharmacologic remodeling and mechanical unloading with proactive screening for recovery. The primary outcome of interest was the cumulative incidence of myocardial recovery. Baseline characteristics and operative outcomes were compared between recovered and non-recovered DT patients using non-parametric tests to identify predictive factors. RESULTS A total of 49 patients received DT LVADs. Nine patients were identified as myocardial recovery candidates using the protocol screening criteria. Overall, 11 patients underwent formal confirmatory testing for recovery, of which 10 were deemed recovered and underwent LVAD explant, defunctionalization, or transplantation. 37.5% of patients that had a concomitant coronary artery bypass during LVAD implantation achieved recovery. An equal proportion of ischemic and non-ischemic cardiomyopathy patients achieved recovery. The cumulative incidence of myocardial recovery was 25.1% at 36 months. No factors were identified as being predictive of recovery. CONCLUSION Myocardial recovery in DT LVAD patients can be achieved at a higher rate than previously reported. Revascularization at the time of LVAD is safe and may be beneficial. LVAD therapy may not be the final destination in these patients.
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Affiliation(s)
- Nathan J Smith
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Padmaraj Duvvuri
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bryan Miles
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ruizhe Wu
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nunzio Gaglianello
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David L Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Varshney AS, DeFilippis EM, Cowger JA, Netuka I, Pinney SP, Givertz MM. Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1092-1107. [PMID: 35300822 DOI: 10.1016/j.jacc.2022.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 12/27/2022]
Abstract
As the prevalence of advanced heart failure continues to rise, treatment strategies for select patients include heart transplantation or durable left ventricular assist device (LVAD) support, both of which improve quality of life and extend survival. Recently, the HeartMate 3 has been incorporated into clinical practice, the United Network for Organ Sharing donor heart allocation system was revised, and the management of LVAD-related complications has evolved. Contemporary LVAD recipients have greater preoperative illness severity, but survival is higher and adverse event rates are lower compared with prior eras. This is driven by advances in device design, patient selection, surgical techniques, and long-term management. However, bleeding, infection, neurologic events, and right ventricular failure continue to limit broader implementation of LVAD support. Ongoing efforts to optimize management of patients implanted with current devices and parallel development of next-generation devices are likely to further improve outcomes for patients with advanced heart failure.
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Affiliation(s)
- Anubodh S Varshney
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | | | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic. https://twitter.com/netuka_ivan
| | - Sean P Pinney
- University of Chicago Medicine, Chicago, Illinois, USA. https://twitter.com/spinneymd
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Topkara VK, Sayer GT, Clerkin KJ, Wever-Pinzon O, Takeda K, Takayama H, Selzman CH, Naka Y, Burkhoff D, Stehlik J, Farr MA, Fang JC, Uriel N, Drakos SG. Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation. J Am Coll Cardiol 2022; 79:900-913. [PMID: 35241224 PMCID: PMC8928585 DOI: 10.1016/j.jacc.2021.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients. OBJECTIVES This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery. METHODS Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system. RESULTS A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05). CONCLUSIONS Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
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Affiliation(s)
- Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
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Maukel L, Weidner G, Beyersmann J, Spaderna H. Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy. J Am Heart Assoc 2022; 11:e023294. [PMID: 35191318 PMCID: PMC9075087 DOI: 10.1161/jaha.121.023294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The relevance of sex and preimplant factors for clinical outcomes among patients with left ventricular assist devices intended for destination therapy is unclear. Methods and Results INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) data (2006-2017) from 6771 men and 1690 women with left ventricular assist devices as destination therapy were analyzed to evaluate the contribution of preimplant clinical, demographic, and clinically judged psychosocial characteristics to time until death, heart transplant, device explant due to recovery, or complication-related device replacement. Associations of sex with time until each competing outcome were evaluated using cumulative incidence functions and event-specific Cox proportional hazards models. Women were younger, more likely to have nonischemic diagnoses, and reported less substance abuse but were more likely to be unmarried, not working for an income, overweight, and depressed than men. After 2 years, women had higher probabilities for recovery (3.7% versus 1.6%, P<0.001) and device replacement (12.1% versus 10%, P=0.019) than men but not for death and transplant (P>0.12). The sex differences remained after controlling for covariates (adjusted hazard ratio [HRadj] recovery, 1.85; 95% CI, 1.30-2.70; P<0.001; HRadj device replacement, 1.22; 95% CI, 1.04-1.33; P=0.015). Female-specific diagnoses (eg, postpartum heart failure) contributed to women's enhanced rate of recovery. Demographic and psychosocial factors were unrelated to women's increased event rates. Conclusions In destination therapy, women have higher rates of device replacement and recovery than men. The latter was partly explained by female-specific diagnoses. Standardized assessments of psychosocial characteristics are needed to elucidate their association with sex differences in outcomes.
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Affiliation(s)
| | - Gerdi Weidner
- Biology, San Francisco State UniversitySan FranciscoCA
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Kanelidis AJ, Grinstein J. Left Ventricular Hemodynamics: Can a Direct Assessment of Left Ventricular Performance Help Guide Myocardial Recovery in LVAD Recipients? J Card Fail 2022; 28:807-809. [PMID: 35114383 DOI: 10.1016/j.cardfail.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
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Topkara VK, Elias P, Jain R, Sayer G, Burkhoff D, Uriel N. Machine Learning-Based Prediction of Myocardial Recovery in Patients With Left Ventricular Assist Device Support. Circ Heart Fail 2022; 15:e008711. [PMID: 34949101 PMCID: PMC8766904 DOI: 10.1161/circheartfailure.121.008711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prospective studies demonstrate that aggressive pharmacological therapy combined with pump speed optimization may result in myocardial recovery in larger numbers of patients supported with left ventricular assist device (LVAD). This study sought to determine whether the use of machine learning (ML) based models predict LVAD patients with myocardial recovery resulting in pump explant. METHODS A total of 20 270 adult patients with a durable continuous-flow LVAD in the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) were included in the study. Ninety-eight raw clinical variables were screened using the least absolute shrinkage and selection operator for selection of features associated with LVAD-induced myocardial recovery. ML models were developed in the training data set (70%) and were assessed in the validation data set (30%) by receiver operating curve and Kaplan-Meier analysis. RESULTS Least absolute shrinkage and selection operator identified 28 unique clinical features associated with LVAD-induced myocardial recovery, including age, cause of heart failure, psychosocial risk factors, laboratory values, cardiac rate and rhythm, and echocardiographic indices. ML models achieved area under the receiver operating curve of 0.813 to 0.824 in the validation data set outperforming logistic regression-based new INTERMACS recovery risk score (area under the receiver operating curve of 0.796) and previously established LVAD recovery risk scores (INTERMACS Cardiac Recovery Score and INTERMACS Recovery Score by Topkara et al) with area under the receiver operating curve of 0.744 and 0.748 (P<0.05). Patients who were predicted to recover by ML models demonstrated a significantly higher incidence of myocardial recovery resulting in LVAD explant in the validation cohort compared with those who were not predicted to recover (18.8% versus 2.6% at 4 years of pump support). CONCLUSIONS ML can be a valuable tool to identify subsets of LVAD patients who may be more likely to respond to myocardial recovery protocols.
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Affiliation(s)
- Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Pierre Elias
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Rashmi Jain
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6545817. [DOI: 10.1093/ejcts/ezac173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
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Physiology and Clinical Utility of HeartMate Pump Parameters. J Card Fail 2021; 28:845-862. [PMID: 34980564 DOI: 10.1016/j.cardfail.2021.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/10/2021] [Accepted: 11/01/2021] [Indexed: 11/23/2022]
Abstract
The HeartMate 3 left ventricular assist device (LVAD) is now the only centrifugal pump intended for durable support being actively manufactured and implanted for adults in the United States. The changes in preload and afterload that accompany common clinical scenarios experienced by patients with an LVAD will cause specific changes to the LVAD pump parameters, namely, the pump power, pulsatility index, and flow. Appropriate care of this unique, and growing, population requires a full understanding of these variables as well as the underlying physiologic principles governing their derivation. The aim of this review is to focus on the updated functionality of the HeartMate 3, specifically in comparison to the HeartMate II, as well as the application of pump parameter interpretation to common clinical scenarios.
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Wehbe RM. Unleashing the Power of Machine Learning to Predict Myocardial Recovery After Left Ventricular Assist Device: A Call for the Inclusion of Unstructured Data Sources in Heart Failure Registries. Circ Heart Fail 2021; 15:e009278. [PMID: 34949097 DOI: 10.1161/circheartfailure.121.009278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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45
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Mariani S, Li T, Hegermann J, Bounader K, Hanke J, Meyer T, Jannsen-Peters H, Haverich A, Schmitto JD, Dogan G. Biocompatibility of an apical ring plug for left ventricular assist device explantation: Results of a feasibility pre-clinical study. Artif Organs 2021; 46:827-837. [PMID: 34904254 DOI: 10.1111/aor.14149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients receiving left ventricle assist devices (LVADs) as bridge to recovery remain a minority with 1%-5% of LVADs explanted after improvement of myocardial function. Nevertheless, considering the growing population of patients supported with LVADs, an increasing demand of new explantation strategies is expected in the near future. A novel plug for LVAD explantation has been developed and its biocompatibility profile needs to be proved. This study tested the biocompatibility of this novel plug in an in vivo ovine model. METHODS Six adult Blackhead Persian female sheep received plug implantation on the cardiac apex via minimally invasive approach and were clinically observed up to 90 days. Echocardiography was performed to detect thrombus formation or further plug-related complications. After the observation period, euthanasia was performed and samples including the plug and the surrounding tissues were obtained to be analyzed with correlative light and electron microscopy. Organ necrosis, ischemia and peripheral embolism were investigated. RESULTS Three animals survived surgery and completed the follow-up time without experiencing clinical complications. Echocardiographic controls excluded the presence of an intracavitary thrombus in the left ventricle (LV). Autopsy confirmed no signs of local infection, LV thrombus or peripheral embolism. Light and electron microscopy revealed an intact epithelium covering a layer of connective tissue on the plug surface facing the heart lumen. CONCLUSIONS This novel apical plug for LVAD explantation allows for endothelial and connective tissue growth on its ventricular side within 90 days from surgery. Further studies are required to fully demonstrate the biocompatibility of this apical plug and investigate the optimal anticoagulation regimen to be applied after implantation.
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Affiliation(s)
- Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Hegermann
- Institute of Functional and Applied Anatomy, Research Core Unit Electron Microscopy, Hannover Medical School, Hannover, Germany
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Jasmin Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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46
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Gerhard EF, Wang L, Singh R, Schueler S, Genovese LD, Woods A, Tang D, Smith NR, Psotka MA, Tovey S, Desai SS, Jakovljevic DG, MacGowan GA, Shah P. LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events. J Heart Lung Transplant 2021; 40:1560-1570. [PMID: 34479776 PMCID: PMC8627486 DOI: 10.1016/j.healun.2021.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown. METHODS This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant. RESULTS During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years. CONCLUSIONS LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.
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Affiliation(s)
- Eleanor F Gerhard
- Heart Failure, Mechanical Circulatory Support and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia; George Washington University School of Medicine, Washington DC, Washington DC
| | - Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ramesh Singh
- Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Stephan Schueler
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Leonard D Genovese
- Heart Failure, Mechanical Circulatory Support and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Andrew Woods
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Daniel Tang
- Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Mitchell A Psotka
- Heart Failure, Mechanical Circulatory Support and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Sian Tovey
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Shashank S Desai
- Heart Failure, Mechanical Circulatory Support and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Guy A MacGowan
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Palak Shah
- Heart Failure, Mechanical Circulatory Support and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia.
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47
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Diakos NA, Taleb I, Kyriakopoulos CP, Shah KS, Javan H, Richins TJ, Yin MY, Yen C, Dranow E, Bonios MJ, Alharethi R, Koliopoulou AG, Taleb M, Fang JC, Selzman CH, Stellos K, Drakos SG. Circulating and Myocardial Cytokines Predict Cardiac Structural and Functional Improvement in Patients With Heart Failure Undergoing Mechanical Circulatory Support. J Am Heart Assoc 2021; 10:e020238. [PMID: 34595931 PMCID: PMC8751895 DOI: 10.1161/jaha.120.020238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Recent prospective multicenter data from patients with advanced heart failure demonstrated that left ventricular assist device (LVAD) support combined with standard heart failure medications, induced significant cardiac structural and functional improvement, leading to high rates of LVAD weaning in selected patients. We investigated whether preintervention myocardial and systemic inflammatory burden could help identify the subset of patients with advanced heart failure prone to LVAD-mediated cardiac improvement to guide patient selection, treatment, and monitoring. Methods and Results Ninety-three patients requiring durable LVAD were prospectively enrolled. Myocardial tissue and blood were acquired during LVAD implantation, for measurement of inflammatory markers. Cardiac structural and functional improvement was prospectively assessed via serial echocardiography. Eleven percent of the patients showed significant reverse remodeling following LVAD support (ie, responders). Circulating tumor necrosis factor alpha, interleukin (IL)-4, IL-5, IL-6, IL-7, IL-13, and interferon gamma were lower in responders, compared with nonresponders (P<0.05, all comparisons). The myocardial tissue signal transducer and activator of transcription-3, an inflammatory response regulator, was less activated in responders (P=0.037). Guided by our tissue studies and a multivariable dichotomous regression analysis, we identified that low levels of circulating interferon gamma (odds ratio [OR], 0.06; 95% CI, 0.01-0.35) and tumor necrosis factor alpha (OR, 0.05; 95% CI, 0.00-0.43), independently predict cardiac improvement, creating a 2-cytokine model effectively predicting responders (area under the curve, 0.903; P<0.0001). Conclusions Baseline myocardial and systemic inflammatory burden inversely correlates with cardiac improvement following LVAD support. A circulating 2-cytokine model predicting significant reverse remodeling was identified, warranting further investigation as a practical preintervention tool in identifying patients prone to LVAD-mediated cardiac improvement and device weaning.
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Affiliation(s)
- Nikolaos A. Diakos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,Present address:
Division of CardiologyColumbia University Medical CenterNew YorkNY
| | - Iosif Taleb
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Christos P. Kyriakopoulos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Kevin S. Shah
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Hadi Javan
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Tyler J. Richins
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT
| | - Michael Y. Yin
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Chi‐Gang Yen
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Elizabeth Dranow
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Michael J. Bonios
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT,Present address:
Onassis Cardiac Surgery CenterAthensGreece
| | - Rami Alharethi
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Antigone G. Koliopoulou
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT,Present address:
Onassis Cardiac Surgery CenterAthensGreece
| | - Mariam Taleb
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT
| | - James C. Fang
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Craig H. Selzman
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Konstantinos Stellos
- Cardiovascular Research CentreNewcastle University & Cardiothoracic CentreNewcastle upon Tyne HospitalsNewcastleUK
| | - Stavros G. Drakos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
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48
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Sheikh FH, Craig PE, Ahmed S, Torguson R, Kolm P, Weintraub WS, Molina EJ, Najjar SS, Mohammed SF. Characteristics and Outcomes of Patients with Inflammatory Cardiomyopathies Receiving Mechanical Circulatory Support: An STS-INTERMACS Registry Analysis. J Card Fail 2021; 28:71-82. [PMID: 34474157 DOI: 10.1016/j.cardfail.2021.07.025] [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: 04/29/2021] [Revised: 07/03/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Durable mechanical circulatory support (MCS) therapy improves survival in patients with advanced heart failure. Knowledge regarding the outcomes experienced by patients with inflammatory cardiomyopathy (CM) who receive durable MCS therapy is limited. METHODS AND RESULTS We compared patients with inflammatory CM with patients with idiopathic dilated CM enrolled in the STS-INTERMACS registry. Among 19,012 patients, 329 (1.7%) had inflammatory CM and 5978 had idiopathic dilated CM (31.4%). The patients with inflammatory CM were younger, more likely to be White, and women. These patients experienced more preoperative arrhythmias and higher use of temporary MCS. Patients with inflammatory CM had a higher rate of early adverse events (<3 months after device implant), including bleeding, arrhythmias, non-device-related infections, neurologic dysfunction, and respiratory failure. The rate of late adverse events (≥3 months) was similar in the 2 groups. Patients with inflammatory CM had a similar 1-year (80% vs 84%) and 2-year (72% vs 76%, P = .15) survival. Myocardial recovery resulting in device explant was more common among patients with inflammatory CM (5.5% vs 2.3%, P < .001). CONCLUSIONS Patients with inflammatory CM who received durable MCS appear to have a similar survival compared with patients with idiopathic dilated CM despite a higher early adverse event burden. Our findings support the use of durable MCS in an inflammatory CM population.
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Affiliation(s)
- Farooq H Sheikh
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC.
| | - Paige E Craig
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Sara Ahmed
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | | | - Paul Kolm
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - William S Weintraub
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Ezequiel J Molina
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Samer S Najjar
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
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49
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Janssen E, Jukema JW, Beeres SLMA, Schalij MJ, Tops LF. Prognostic Value of Natriuretic Peptides for All-Cause Mortality, Right Ventricular Failure, Major Adverse Events, and Myocardial Recovery in Advanced Heart Failure Patients Receiving a Left Ventricular Assist Device: A Systematic Review. Front Cardiovasc Med 2021; 8:699492. [PMID: 34307507 PMCID: PMC8292668 DOI: 10.3389/fcvm.2021.699492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/01/2021] [Indexed: 12/04/2022] Open
Abstract
Aims: Major adverse event (MAE) rates during left ventricular assist device (LVAD) therapy in advanced heart failure (HF) patients are high, and impair quality of life and survival. Prediction and risk stratification of MAEs in order to improve patient selection and thereby outcome during LVAD therapy is therefore warranted. Circulating natriuretic peptides (NPs) are strong predictors of MAEs and mortality in chronic HF patients. However, whether NPs can identify patients who are at risk of MAEs and mortality or tend toward myocardial recovery after LVAD implantation is unclear. The aim of this systematic review is to analyze the prognostic value of circulating NP levels before LVAD implantation for all-cause mortality, MAEs and myocardial recovery after LVAD implantation. Methods and Results: Electronic databases were searched for studies analyzing circulating NP in adults with advanced HF before LVAD implantation in relation to mortality, MAEs, or myocardial recovery after LVAD implantation. Twenty-four studies published between 2008 and 2021 were included. Follow-up duration ranged from 48 hours to 5 years. Study sample size ranged from 14 to 15,138 patients. Natriuretic peptide levels were not predictive of all-cause mortality. However, NPs were predictive of right ventricular failure (RVF) and MAEs such as ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization. No relation between NPs and myocardial recovery was found. Conclusion: This systematic review found that NP levels before LVAD implantation are not predictive of all-cause mortality after LVAD implantation. Thus, NP levels may be of limited value in patient selection for LVAD therapy. However, NPs help in risk stratification of MAEs and may be used to identify patients who are at risk for RVF, ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization after LVAD implantation.
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Affiliation(s)
- Eva Janssen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
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50
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Birks EJ, Rame JE, Cunningham C, Drakos SG. Response by Birks et al to Letters Regarding Article, "Prospective Multicenter Study of Myocardial Recovery Using Left Ventricular Assist Devices (RESTAGE-HF [Remission from Stage D Heart Failure]): Medium-Term and Primary End Point Results". Circulation 2021; 143:e1017-e1018. [PMID: 34061583 DOI: 10.1161/circulationaha.121.053990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emma J Birks
- Division of Cardiovascular Medicine, University of Kentucky, Lexington (E.J.B.).,Division of Cardiovascular Medicine, University of Louisville, KY (E.J.B.)
| | - Jesus E Rame
- Department of Medicine, Jefferson University Hospital, Philadelphia, PA (J.E.R.)
| | | | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City (S.G.D.)
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