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Papathanasiou M, Ruhparwar A, Kamler M, Rassaf T, Luedike P. Off-label use of pulmonary vasodilators after left ventricular assist device implantation: Calling in the evidence. Pharmacol Ther 2020; 214:107619. [PMID: 32599009 DOI: 10.1016/j.pharmthera.2020.107619] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/18/2020] [Indexed: 11/26/2022]
Abstract
Left ventricular assist devices (LVAD) are increasingly implanted in advanced heart failure patients to improve survival and quality of life either as a bridge to transplant, bridge to recovery or as destination therapy. LVAD therapy is often accompanied by a profound lowering of pulmonary artery pressure due to mechanical unloading of the left ventricle. Persistent pulmonary hypertension (PH) after LVAD implantation increases the risk of right ventricular failure (RVF). In this context pulmonary vasodilators have been implemented: a) as a strategy to reduce afterload and wean patients with RVF from inotropes in the early postoperative period, b) as long-term therapy aiming to optimize right heart hemodynamics and prevent late RVF and c) in order to lower persistently elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) after LVAD and enable candidacy for heart transplantation. However, considerable uncertainty exists regarding the risks and benefits of these strategies and practices vary widely among institutions. This article provides an overview of the available evidence and existing recommendations regarding the use of pulmonary vasodilators in LVAD recipients.
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Affiliation(s)
- Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Markus Kamler
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Sabato LA, Salerno DM, Moretz JD, Jennings DL. Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation. Pharmacotherapy 2017; 37:944-955. [DOI: 10.1002/phar.1959] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Leah A. Sabato
- Heart Failure and Cardiac Transplantation; Department of Pharmacy; UC Health-University of Cincinnati Medical Center; Cincinnati Ohio
| | - David M. Salerno
- Solid Organ Transplantation; Department of Pharmacy; NewYork-Presbyterian Hospital - Weill Cornell Medical Center; New York New York
| | - Jeremy D. Moretz
- Ventricular Assist Devices; Department of Pharmacy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Douglas L. Jennings
- Heart Transplant and Mechanical Circulatory Support; Department of Pharmacy; New York-Presbyterian Hospital - Columbia University Medical Center; New York NY
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Schmid C, Jurmann M, Birnbaum D, Colombo T, Falk V, Feltrin G, Garatti A, Genoni M, Gerosa G, Göttel P, Gummert J, Halfmann R, Hammel D, Hennig E, Kaufmann F, Lanfranconi M, Meyns B, Mohr F, Müller J, Nikolov D, Rucinskas K, Scheld HH, Schmid FX, Schneider M, Sirvydis V, Tandler R, Vitali E, Vlasselaers D, Weyand M, Wilhelm M, Hetzer R. Influence of inflow cannula length in axial-flow pumps on neurologic adverse event rate: results from a multi-center analysis. J Heart Lung Transplant 2008; 27:253-60. [PMID: 18342745 DOI: 10.1016/j.healun.2007.12.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 12/18/2007] [Accepted: 12/18/2007] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The application of axial-flow pumps in patients with end-stage heart failure reveals a significantly reduced infectious complication rate as compared with rates observed with pulsatile devices. The remaining adverse event rate relates mainly to thromboembolic complications with neurologic consequences. We investigated the dependence of the neurologic adverse event rate on the length of the inflow cannula. METHODS A total of 216 consecutive patients with an axial-flow pump (INCOR; Berlin Heart GmbH, Berlin, Germany) were included in a retrospective multi-center analysis. In 138 patients, a short inflow cannula (24-mm tip length into the left ventricle), and in 78 patients a long inflow cannula (tip length 34 mm) was applied. RESULTS Patients with a long inflow cannula (LC) demonstrated a better survival rate than those with a short inflow cannula (SC) at the end of the observation period (LC, 63.4%; SC, 52.9%; p = 0.05). The thromboembolic adverse event rate was also significantly lower. Only 3 of the 78 patients (3.8%) with an LC had a thromboembolic adverse event (thromboembolic events per patient-year = 0.11) as compared with 32 (23.2%) of SC patients (thromboembolic events per patient-year = 0.50, p < 0.001). CONCLUSIONS Patients with a long inflow cannula had a better survival rate and a lower incidence of cerebrovascular adverse events than patients with a short inflow cannula.
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Duveau D. [Circulatory assistance: point of view of surgeon]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:589-90. [PMID: 12946489 DOI: 10.1016/s0750-7658(03)00203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
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Affiliation(s)
- Paul L DiGiorgi
- Department of Surgery, Columbia University, New York, New York 10032, USA
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Endo GJ, Kojima K, Nakamura K, Matsuzaki Y, Onitsuka T. Nitric oxide inhalation prompts weaning from the right ventricular assist device: evaluation under continuous-flow biventricular assistance. J Thorac Cardiovasc Surg 2002; 124:739-49. [PMID: 12324732 DOI: 10.1067/mtc.2002.124669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the effect of nitric oxide on the recovery of right heart function under global ischemia with a continuous-flow biventricular assist device support. METHODS Fifteen piglets were divided into three groups: continuous-flow biventricular assist support only (control group), global ischemia with continuous-flow biventricular assist support (ischemia only group), and global ischemia with continuous-flow biventricular assist support plus nitric oxide inhalation (nitric oxide group). Two continuous-flow pumps were used as left and right ventricular assist devices. In the ischemic groups (ischemia only group and nitric oxide group), global ischemia was induced for 30 minutes and followed by a 6-hour reperfusion period; the nonischemic control group underwent a 6-hour perfusion period only. The left ventricular assist device was driven at a flow rate of more than 75 to 80 mL/(min. kg). The right ventricular assist device was driven so as to sustain the left ventricular assist device flow, and the animal was weaned from it in accordance with the objective of cardiac recovery. RESULTS Mean pulmonary arterial pressure remained low in the nitric oxide group (mean 23 mm Hg), whereas it rose from 19.9 mm Hg to 39.3 mm Hg in the ischemia group and to 26.2 mm Hg in the control group. Mixed venous saturation was maintained at more than 60% in all cases. Although no piglets in the ischemia group were able to survive without continuous-flow biventricular assist support, the right ventricular assist device flow ratio (device flow/total systemic flow) in the nitric oxide group could be reduced in all cases, and it was possible to wean the piglets from right ventricular assist device support in 4 of 5 cases. CONCLUSION Inhalation of 40-ppm nitric oxide enabled smoother maintenance of the left ventricular assist device flow and prompted the weaning from right ventricular assist device support on continuous-flow biventricular assist.
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Affiliation(s)
- George J Endo
- 2nd Department of Surgery, Miyazaki Medical College, 5200 Kihara, Kiyotake Miyazaki 889-1692, Japan.
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Rajek A, Pernerstorfer T, Kastner J, Mares P, Grabenwöger M, Sessler DI, Grubhofer G, Hiesmayr M. Inhaled nitric oxide reduces pulmonary vascular resistance more than prostaglandin E(1) during heart transplantation. Anesth Analg 2000; 90:523-30. [PMID: 10702430 DOI: 10.1097/00000539-200003000-00005] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Heart transplantation in patients with increased pulmonary vascular resistance is often associated with postbypass right heart failure. We therefore compared the abilities of prostaglandin E(1) (PGE(1)) and inhaled nitric oxide to reduce pulmonary vascular resistance during heart transplantation. Patients undergoing orthotopic heart transplantation for congestive heart failure were randomly assigned to either a PGE(1) infusion at a rate of 8 ng. kg. (-1)min(-1) starting 10 min before weaning from cardiopulmonary bypass (CPB) (n = 34) or inhalation of 4 ppm nitric oxide starting just before weaning from CPB (n = 34). Both treatments were increased stepwise, if necessary, and were stopped 6 h postoperatively. Hemodynamic values were recorded after the induction of anesthesia, 10 and 30 min after weaning from CPB, and 1 h and 6 h postoperatively. Immediately after weaning from CPB, pulmonary vascular resistance was nearly halved in the nitric oxide group but reduced by only 10% in the PGE(1) group. Pulmonary artery pressure was decreased approximately 30% during nitric oxide inhalation, but only approximately 16% during the PGE(1) infusion. Six hours after surgery, pulmonary vascular resistance and pulmonary artery pressure were similar in the two groups. The ratio between pulmonary vascular resistance and systemic vascular resistance was significantly less in the nitric oxide patients at all postbypass times. In contrast, the pulmonary-to-systemic vascular resistance ratio increased approximately 30% in the patients given PGE(1). Cardiac output, heart rate, mean arterial pressure, right atrial pressure, and pulmonary wedge pressure did not differ between the groups. Weaning from CPB was successful in all patients assigned to nitric oxide inhalation; in contrast, weaning failed in six patients assigned to PGE(1) (P = 0.03). IMPLICATIONS Nitric oxide inhalation selectively reduces pulmonary vascular resistance and pulmonary artery pressure immediately after heart transplantation which facilitates weaning from cardiopulmonary bypass.
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Affiliation(s)
- A Rajek
- Departments of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Cardiology, and Cardiothoracic Surgery, University of Vienna, Vienna, Austria.
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Affiliation(s)
- D J Goldstein
- Department of Surgery, Columbia-Presbyterian Medical Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Abstract
Inhaled nitric oxide (iNO) is a pulmonary-selective vaso dilator with minimal bronchodilator activity in humans. NO also inhibits platelet and neutrophil activation and adhesion and inhibits ischemia-reperfusion injury. The pulmonary vasodilatory property of iNO causes a reduc tion in pulmonary vascular resistance and improvement in arterial oxygenation in a wide spectrum of diseases characterized by pulmonary hypertension and hypox emia. Promising examples of diseases for which NO may provide beneficial physiologic effects are primary and secondary pulmonary hypertension, right ventricu lar failure, cardiac transplantation, pulmonary embo lism, protamine reactions, acute respiratory distress syndrome, lung transplantation and, perhaps, chronic obstructive airways disease. The usefulness of iNO may be improved by concomitant therapy with pulmonary- selective intravenous vasoconstrictors (eg, Almitrine; Vectarian, Neuilly, France) and cGMP phosphodiester ase V inhibitors (eg, Zaprinast; Research Biochemicals International, Natick, MA). Almitrine improves oxygen ation, synergistically with iNO, and may be useful in disease states characterized primarily by hypoxemia. Zaprinast may be useful for weaning iNO and avoidance of rebound pulmonary hypertension.
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Affiliation(s)
- Simon C. Body
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stanton K. Shernan
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Goldstein DJ, Dean DA, Smerling A, Oz MC, Burkhoff D, Dickstein ML. Inhaled nitric oxide is not a negative inotropic agent in a porcine model of pulmonary hypertension. J Thorac Cardiovasc Surg 1997; 114:461-6. [PMID: 9305200 DOI: 10.1016/s0022-5223(97)70194-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Reports of pulmonary edema complicating inhaled nitric oxide therapy in patients with chronic heart failure and pulmonary hypertension have raised the concern that inhaled nitric oxide may have negative inotropic effects. METHODS AND RESULTS We investigated the effect of multiple doses of inhaled nitric oxide (20, 40 and 80 ppm) on left ventricular contractile state in 10 open-chest pigs. Pressure-volume loops were generated during transient preload reduction to determine the end-systolic pressure-volume relationship and the stroke work-end-diastolic volume relation. Inhaled nitric oxide had no effect on systemic vascular resistance, cardiac output, end-systolic pressure volume relationship or stroke work-end-diastolic volume relation under normal conditions. After induction of pulmonary hypertension (intravenous thromboxane A2 analog), inhalation of nitric oxide (80 ppm) resulted in a reduction in pulmonary vascular resistance (mean +/- standard error of the mean) from 10.4 +/- 3 to 6.5 +/- 2 Wood units (p < 0.001) and in pulmonary artery pressure from 44 +/- 4 to 33 +/- 4 mm Hg (p < 0.05). Left ventricular end-diastolic volume rose from 53 +/- 9 ml to 57 +/- 10 ml (p = 0.02). No statistically significant change in cardiac output or systemic vascular resistance was observed. Inhaled nitric oxide had no effect on end-systolic pressure-volume relationship or stroke work-end-diastolic volume relation. CONCLUSIONS In a porcine model of pulmonary hypertension, inhaled nitric oxide does not impair left ventricular contractile function. Therefore the cause of pulmonary edema observed in some patients receiving inhaled nitric oxide is not due to a negative inotropic action of this therapy.
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Affiliation(s)
- D J Goldstein
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, N.Y., USA
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Abstract
A great number of patients suffer and die of the sequelae of acute and chronic heart failure each year. Although advances in medical and surgical therapy have benefited many of these patients, most have disease that is refractory to any definitive therapy. For these patients cardiac transplantation is the only remaining hope. Unfortunately, because of the increasing demand for donor organs in the face of a fixed and limited supply, this option is available to only a small percentage of these patients. Even in patients accepted for transplantation, a significant waiting list mortality has been observed. A variety of VADs have been developed since the first successful case of mechanical cardiac assistance more than 30 years ago. These devices differ in basic mechanical function, method of insertion, and degree of implantability and thus have different indications and potential applications. Whereas the intraaortic balloon pump and centrifugal pumps are effective short-term support modalities, extracorporeal and implantable pulsatile devices have been used successfully for long-term support of patients with reversible and nonreversible cardiac failure. Although these pumps have most commonly been used as bridges to transplantation, increasing clinical experience has supported the notion of long-term mechanical assistance as a definitive therapy for patients with end-stage heart disease. Although complications, particularly infection and thromboembolism, pose significant challenges and long-term device reliability remains to be fully determined, available implantable devices appear to be capable of providing effective long-term support. As data are obtained from currently ongoing trials comparing VAD support with medical therapy for end-stage heart failure, ethical and economic issues will assume increasing importance.
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Affiliation(s)
- M Argenziano
- Division of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, Columbia University College of Physicians and Surgeons New York, New York, USA
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Farrar DJ, Hill JD, Pennington DG, McBride LR, Holman WL, Kormos RL, Esmore D, Gray LA, Seifert PE, Schoettle GP, Moore CH, Hendry PJ, Bhayana JN. Preoperative and postoperative comparison of patients with univentricular and biventricular support with the thoratec ventricular assist device as a bridge to cardiac transplantation. J Thorac Cardiovasc Surg 1997; 113:202-9. [PMID: 9011691 DOI: 10.1016/s0022-5223(97)70416-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The goal of this study was to determine whether there are differences in populations of patients with heart failure who require univentricular or biventricular circulatory support. METHODS Two hundred thirteen patients who were in imminent risk of dying before donor heart procurement and who received Thoratec left (LVAD) and right (RVAD) ventricular assist devices at 35 hospitals were divided into three groups: group 1 (n = 74), patients adequately supported with isolated LVADs; group 2 (n = 37), patients initially receiving an LVAD and later requiring an RVAD; and group 3 (n = 102), patients who received biventricular assistance (BiVAD) from the beginning. RESULTS There were no significant differences in any preoperative factors between the two BiVAD groups. In the combined BiVAD groups, pre-VAD cardiac index (BiVAD, 1.4 +/- 0.6 L/min per square meter, vs LVAD, 1.6 +/- 0.6 L/min per square meter) and pulmonary capillary wedge pressure (BiVAD, 27 +/- 8 mm Hg, vs LVAD, 30 +/- 8 mm Hg) were significantly lower than those in the LVAD group, and pre-VAD creatinine levels were significantly higher (BiVAD, 1.9 +/- 1.1 mg/dl, vs LVAD, 1.4 +/- 0.6 mg/dl). In addition, greater proportions of patients in the BiVAD groups required mechanical ventilation before VAD placement (60% vs 35%) and were implanted under emergency conditions than in the LVAD group (22% vs 9%). The survival of patients through heart transplantation was significantly better in patients who had an LVAD (74%) than in those who had BiVADs (58%). However, there were no significant differences in posttransplantation survival through hospital discharge (LVAD, 89%; BiVAD, 81%). CONCLUSION Patients who received LVADs were less severely ill before the operation and consequently were more likely to survive after the operation. As the severity of illness increases, patients are more likely to require biventricular support.
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Affiliation(s)
- D J Farrar
- California Pacific Medical Center, San Francisco 94115, USA
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Myles PS, Venema HR. Avoidance of cardiopulmonary bypass during bilateral sequential lung transplantation using inhaled nitric oxide. J Cardiothorac Vasc Anesth 1995; 9:571-4. [PMID: 8547562 DOI: 10.1016/s1053-0770(05)80144-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- P S Myles
- Department of Anesthesia, Alfred Hospital, Prahran, Victoria, Australia
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