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Shih H, Mondellini GM, Kurlansky PA, Sun J, Ning Y, Feldman VR, Tiburcio M, Maguire CW, Ladanyi A, Clerkin K, Naka Y, Sayer GT, Uriel N, Colombo PC, Takeda K, Yuzefpolskaya M. Unplanned hospital readmissions following HeartMate 3 implantation: Readmission rates, causes, and impact on survival. Artif Organs 2024. [PMID: 38825957 DOI: 10.1111/aor.14763] [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: 12/12/2023] [Revised: 03/12/2024] [Accepted: 04/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Hospital readmissions following left ventricular assist device (LVAD) remain a frequent comorbidity, associated with decreased quality of life and increased resources utilization. This study sought to determine causes, predictors, and impact on survival of hospitalizations during HeartMate 3 (HM3) support. METHODS All patients implanted with HM3 between November 2014 to December 2019 at Columbia University Irving Medical Center were consecutively enrolled in the study. Demographics and clinical characteristics from the index admission and the first outpatient visit were collected and used to estimate 1-year and 900-day readmission-free survival and overall survival. Multivariable analysis was performed for subsequent readmissions. RESULTS Of 182 patients who received a HM3 LVAD, 167 (92%) were discharged after index admission and experienced 407 unplanned readmissions over the median follow up of 727 (interquartile range (IQR): 410.5, 1124.5) days. One-year and 900-day mean cumulative number of all-cause unplanned readmissions was 0.43 (95%CI, 0.36, 0.51) and 1.13 (95%CI, 0.99, 1.29). The most frequent causes of rehospitalizations included major infections (29.3%), bleeding (13.2%), device-related (12.5%), volume overload (7.1%), and other (28%). One-year and 900-day survival free from all-cause readmission was 38% (95%CI, 31-46%) and 16.6% (95%CI, 10.3-24.4%). One-year and 900-day freedom from 2, 3, and ≥4 readmissions were 60.7%, 74%, 74.5% and 26.2%, 33.3%, 41.3%. One-year and 900-day survival were unaffected by the number of readmissions and remained >90%. Male sex, ischemic etiology, diabetes, lower serum creatinine, longer duration of index hospitalization, and a history of readmission between discharge and the first outpatient visit were associated with subsequent readmissions. CONCLUSIONS Unplanned hospital readmissions after HM3 are common, with infections and bleeding accounting for the majority of readmissions. Irrespective of the number of readmissions, one-year survival remained unaffected.
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Affiliation(s)
- Hueyjong Shih
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Giulio M Mondellini
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Paul A Kurlansky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York, USA
| | - Vivian R Feldman
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Melie Tiburcio
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Conor W Maguire
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Annamaria Ladanyi
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Kevin Clerkin
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Gabriel T Sayer
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Nir Uriel
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York, USA
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Marshall V WH, Wright LK, Lampert BC, Salavitabar A, Daniels CJ, Rajpal S. Invasive Implanted Hemodynamic Monitoring in Patients With Complex Congenital Heart Disease: State-of-the-Art Review. Am J Cardiol 2024; 223:123-131. [PMID: 38761965 DOI: 10.1016/j.amjcard.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/07/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
As the number of patients with congenital heart disease (CHD) continues to increase, the burden of heart failure (HF) in this population requires innovative strategies to individualize management. Given the success of implanted invasive hemodynamic monitoring (IHM) with the CardioMEMSTM HF system in adults with acquired HF, this is often suggested for use in patients with CHD, though published data are limited to case reports and case series. Therefore, this review summarizes the available published reports on the use of IHM in patients with complex CHD, describes novel applications, and highlights future directions for study. In patients with CHD, IHM has been used across the lifespan, from age 3 years to adulthood, with minimal device-related complications reported. IHM uses include (1) prevention of HF hospitalizations; (2) reassessment of hemodynamics after titration of medical therapy without repeated cardiac catheterization; (3) serial monitoring of at-risk patients for pulmonary hypertension to optimize timing of heart transplant referral; (4) and hemodynamic assessment with exercise (5) or after ventricular assist device placement. IHM has the potential to reduce the number of cardiac catheterizations in anatomically complex patients and, in patients with Fontan circulation, IHM pressures may have prognostic implications. In conclusion, though further studies are needed, as patients with CHD age and HF is more prevalent, this tool may assist CHD physicians in caring for this complex patient population.
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Affiliation(s)
- William H Marshall V
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio.
| | - Lydia K Wright
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Brent C Lampert
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio
| | | | - Curt J Daniels
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Saurabh Rajpal
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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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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Tedeschi A, Palazzini M, Trimarchi G, Conti N, Di Spigno F, Gentile P, D’Angelo L, Garascia A, Ammirati E, Morici N, Aschieri D. Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts. J Clin Med 2024; 13:2592. [PMID: 38731120 PMCID: PMC11084728 DOI: 10.3390/jcm13092592] [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: 03/28/2024] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Heart failure (HF) is a leading cause of morbidity worldwide, imposing a significant burden on deaths, hospitalizations, and health costs. Anticipating patients' deterioration is a cornerstone of HF treatment: preventing congestion and end organ damage while titrating HF therapies is the aim of the majority of clinical trials. Anyway, real-life medicine struggles with resource optimization, often reducing the chances of providing a patient-tailored follow-up. Telehealth holds the potential to drive substantial qualitative improvement in clinical practice through the development of patient-centered care, facilitating resource optimization, leading to decreased outpatient visits, hospitalizations, and lengths of hospital stays. Different technologies are rising to offer the best possible care to many subsets of patients, facing any stage of HF, and challenging extreme scenarios such as heart transplantation and ventricular assist devices. This article aims to thoroughly examine the potential advantages and obstacles presented by both existing and emerging telehealth technologies, including artificial intelligence.
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Affiliation(s)
- Andrea Tedeschi
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
| | - Matteo Palazzini
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy;
| | - Nicolina Conti
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Francesco Di Spigno
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
| | - Piero Gentile
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Luciana D’Angelo
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Andrea Garascia
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Enrico Ammirati
- “De Gasperis” Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (M.P.); (N.C.); (P.G.); (L.D.); (A.G.); (E.A.)
| | - Nuccia Morici
- IRCCS Fondazione Don Carlo Gnocchi, 20148 Milan, Italy;
| | - Daniela Aschieri
- Cardiology Unit of Emergency Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy; (F.D.S.); (D.A.)
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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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Fu D, Ramakrishna H, Stawiarski KM. Remote Pulmonary Artery Pressure Monitoring Systems: Analysis of Evolving Data. J Cardiothorac Vasc Anesth 2024; 38:839-842. [PMID: 38195274 DOI: 10.1053/j.jvca.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Danni Fu
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | - Harish Ramakrishna
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY.
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Rodenas-Alesina E, Brahmbhatt DH, Mak S, Ross HJ, Luk A, Rao V, Billia F. Value of Invasive Hemodynamic Assessments in Patients Supported by Continuous-Flow Left Ventricular Assist Devices. JACC. HEART FAILURE 2024; 12:16-27. [PMID: 37804313 DOI: 10.1016/j.jchf.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 10/09/2023]
Abstract
Left ventricular assist devices (LVADs) are increasingly used in patients with end-stage heart failure (HF). There is a significant risk of HF admissions and hemocompatibility-related adverse events that can be minimized by optimizing the LVAD support. Invasive hemodynamic assessment, which is currently underutilized, allows personalization of care for patients with LVAD, and may decrease the need for recurrent hospitalizations. It also aids in triaging patients with persistent low-flow alarms, evaluating reversal of pulmonary vasculature remodeling, and assessing right ventricular function. In addition, it can assist in determining the precipitant for residual HF symptoms and physical limitation during exercise and is the cornerstone of the assessment of myocardial recovery. This review provides a comprehensive approach to the use of invasive hemodynamic assessments in patients supported with LVADs.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Cardiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Mount Sinai Hospital, Toronto Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Mount Sinai Hospital, Toronto Ontario, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adriana Luk
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiac Surgery, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Filio Billia
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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