The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review

One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.

Association of Nutritional Risk Index With Continuous Flow Left Ventricular Assist Device Complications

BACKGROUND

Studies revealing the relationship between major surgery outcomes and nutritional parameters are increasing daily. Publications demonstrating the relationship between early postoperative success and surgical complications in patients with chronic heart failure and continuous flow left ventricular assist device (cf-LVAD) are limited. The vast majority of patients with advanced chronic heart failure are cachexic, and the reason for this is multifactorial. The aim of this study is to investigate the link between the modified nutritional risk index (NRI) and 6-month survival and complication rates in patients with a cf-LVAD.

METHODS

This study included statistical analysis of NRI and postoperative parameters of 456 patients with advanced heart failure who had cf-LVAD implantation between 2010 and 2020.

RESULTS

The results of this study showed a statistically significant difference between mean NRI values and postoperative parameters such as 6-month survival (P = .001), right ventricular failure (P = .003), infection (P = .001), driveline infection (P = .000), and sepsis (P = .000).

CONCLUSIONS

This study revealed that 6-month postoperative complications and mortality rates of patients with advanced heart failure in patients with cf-LVAD are closely related to malnutrition status. In these patients, nutrition specialist use would be beneficial both preoperatively and postoperatively to increase surveillance and reduce postoperative complications.

Association of Age, Sex, and Heart Failure Etiology in Continuous Flow Left Ventricular Assist Device Patients

BACKGROUND

Advanced heart failure studies demonstrate that ischemic factors increase in prevalence with age and are more prominent in men. Ejection fraction (EF) cannot be preserved in these patients, and ischemic cardiomyopathy develops. Non-ischemic factors are more prominent in female heart failure patients, where the EF is preserved. Although an age-associated increase in the rate of heart failure is acknowledged in both sexes, etiologic classifications by sex-based age groups are still lacking. This study examined the etiology of heart failure according to age and sex in ventricular assist device patients.

METHODS

The patient population included 457 end-stage heart failure patients who received a continuous flow-left ventricular assist device at Ege University Hospital between 2010 and 2017. Age, sex, and cardiomyopathy etiology data were obtained from the hospital database. The Mann-Whitney U test was applied to test the statistical significance among subgroups (95% CI, P < .05 for statistical significance).

RESULTS

The prevalence of ischemic cardiomyopathy was significantly lower in male patients aged 18 to 39 years compared to older patients. Conversely, no difference was seen among female patients. The prevalence of dilated cardiomyopathy was higher in male patients who were 18 to 39 years of age compared to older patients, but no difference was present among the female patients.

CONCLUSIONS

Age and heart failure etiology were demonstrated to be interrelated in men but not in women. The fact that etiologic factors of advanced heart failure in women have a wider range than in men makes the current classification systems insufficient for use in female populations.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Relation Between Frailty and 1-Year Outcomes After Implantation of a Left Ventricular Assist Device

Frailty has been associated with morbidity and mortality in patients with heart failure and those who underwent cardiac surgery. We aimed to study the effect of frailty on cardiovascular outcomes and the reversibility of frailty after the left ventricular assist device (LVAD) implantation. A total of 51 consecutive patients (44 men; aged 54 ± 10 years) scheduled to undergo LVAD implantation were assessed for frailty (Fried's phenotype, frail ≥3/5), cognitive function (using Mini-Cog), and depression (utilizing Patient Health Questionnaire-9) before the surgery and 3 months afterward. Patients were observed for mortality and adverse events [all-cause readmission, bleeding, renal dysfunction, and ventricular fibrillation (VF)/sustained ventricular tachycardia (VT)] for 12 months. More than half of the patients (54%) were designated as frail. Although there was no statistical difference in mortality among frail and nonfrail patients, frail ones were more likely to have a prolonged length of stay [adjusted odds ratio (AOR) 14.9, 95% confidence interval 1.6 to 132.5, p = 0.01]. At the 3-month reassessment after operation, frailty and cognition rates were better (frailty score [lower is better]: 3 vs 1.5, p <0.0001; cognition score [higher is better]: 4.5 vs 5, p = 0.001), and patients had less depression (Patient Health Questionnaire-9 score [lower is better]: 8 vs 4, p <0.0001). Of the secondary outcomes, only postoperative VF/sustained VT reached statistical significance in being more common among frail patients than nonfrail ones (p = 0.02). Although frailty was not associated with mortality at 1 year, prolonged length of stay occurred more with frail LVAD patients. Frailty status, cognitive function, and depressive mood all improved in most patients after LVAD.

Association between caregivers' coping and children's psychiatric symptoms in the heart transplantation process: A pilot study

Our aim was to investigate whether there is an association between caregivers' coping and children's psychiatric symptoms and quality of life in adolescent heart transplant (HTx) recipients and HTx candidates with left ventricular assist device (LVAD). Fourteen patients were recruited for this pilot study (HTx (n = 8), LVAD (n = 6)). Schedule for Affective Disorders and Schizophrenia for School Aged Children, Present and Lifetime Version (K-SADS) was administered to detect the psychiatric diagnosis of patients. Children's Depression Inventory (CDI), State-Trait Anxiety Inventory, and Pediatric Quality of Life Inventory (PedsQL) were completed by adolescents; Brief Coping Styles Inventory by their caregivers. Six of the participants had an internalizing disorder. Optimistic coping strategy score was significantly higher in the caregivers of adolescents without an internalizing disorder than caregivers of those with an internalizing disorder (U = 2.500, P = .005). Utilizing Spearman's correlation, caregivers' optimistic approach (rho = -0.736, P = .004), and self-confident approach (rho = -0.634, P = .020) had significant negative correlations with children's CDI scores. Moreover, caregivers' optimistic approach score had a significant positive correlation with children's PedsQL score (rho = 0.563, P = .045). According to our preliminary results, it seems that caregivers' optimistic and self-confident coping strategies may be associated with fewer internalizing symptoms and a better quality of life in adolescents in the HTx process. A future multicentered longitudinal study will be planned to assess the effect of caregivers' coping strategies on the psychological adjustment of these children.

Effect of Testosterone Level on Mortality in Patients With Left Ventricular Assist Device

BACKGROUND AND OBJECTIVES

Testosterone deficiency is associated with mortality in patients with heart failure; however, its effects on patients undergoing Left Ventricular Assist Device (LVAD) implantation are unclear. We investigated the role of total testosterone (TT) and free testosterone (FT) levels on mortality undergoing LVAD implantation.

METHODS

Between December 2010 and December 2014, 101 consecutive male patients who underwent LVAD implantation and had plasma testosterone measurement (TT and FT) in the last month before operation were included in the study. Demographics, follow-up, and mortality data were analyzed retrospectively.

RESULTS

The mean age of the patients was 51.7 ± 11 years. TT and FT levels were in the below normal range of 31.6% (n = 32) and 65.3% (n = 66) of the patients, respectively. The mean follow-up time was 355 ± 268 days, and 32 (31%) patients died during follow-up. Cumulative survival rates were significantly worse in patients with low TT and FT than patients in the normal range (P < .001 and P = .029, respectively). Multivariate analysis after adjustment for clinical variables, age, albumin, C-reactive protein, total cholesterol, chronic kidney disease, diabetes mellitus (DM), and leukocytosis showed that low TT and FT were independently associated with poor survival (HR, 3.680; 95% CI, 1.615-8.385 P = .002 and HR, 3.816; 95% CI, 1.279-11.383, P = .016, respectively).

CONCLUSION

Low TT and FT levels were independent risk factors for mortality in patients with LVAD.

Left ventricular assist device implantation with left lateral thoracotomy with anastomosis to the descending aorta

OBJECTIVES

Standard implantation of the HeartWare left ventricular assist system is performed using the full sternotomy approach. However, successful implantation of left ventricular assist devices in patients with a previous median sternotomy, especially in high-risk patients, remains challenging. Herein, we compared the HeartWare left ventricular assist system implantation by thoracotomy with anastomosis of the outflow graft to the descending aorta with the standard sternotomy approach.

METHODS

Between March 2013 and June 2016, we implanted 118 adult patients with a HeartWare left ventricular assist system, excluding implants with concurrent procedures, paediatric cases and biventricular left ventricular assist device. Of these implants, 30 implants were performed with a lateral thoracotomy with outflow graft anastomosis to the descending aorta. The remaining implants were carried out with the standard median sternotomy with outflow graft anastomosis to the ascending aorta. Propensity matching using the variables age, body mass index, right atrial pressure, blood urea nitrogen, creatinine, cardiomyopathy type and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels resulted in a comparative data set of 30 thoracotomy and 30 sternotomy patients.

RESULTS

Within the first 30 days, the incidence of right heart failure (17% vs 10%, thoracotomy vs sternotomy) and bleeding (10% vs 7%, respectively) were similar between the surgical approaches. Thirty-day survival was 93.3% for both groups. Currently, 3 patients in the thoracotomy cohort have been transplanted and 17 remain on support, while in the sternotomy cohort, 1 patient has been transplanted and 21 remain on support.

CONCLUSIONS

In our single-centre experience, the lateral thoracotomy with outflow graft anastomosis to the descending aorta had similar early outcomes compared to the standard sternotomy.

Short-term Results of Heartmate 3 Ventricular Assist Device Implantation for End-Stage Heart Failure

OBJECTIVE

To report our initial experience with Heartmate 3 ventricular assist device (HM3) in cases with end-stage heart failure (ESHF).

METHODS

Charts of 8 ESHF patients who underwent HM3 implantation in our clinic from January to June 2016 (group 1) and 16 patients who underwent HM2 implantation during 2015 (group 2) were reviewed retrospectively. Demographics as well as pre- and early postoperative medical data were noted and statistically analyzed between the 2 groups.

RESULTS

No statistical difference was found in age or sex distribution between groups (P > .05). Mean Interagency Registry for Mechanically Assisted Circulatory Support scores were 2.13 ± 0.99 and 3.38 ± 0.72 in groups 1 and 2, respectively (P = .020). Mean cardiopulmonary bypass time, and chest tube drainage fluid volume and blood product requirement during intensive care unit (ICU) stay were 64.0 ± 13.9 minutes, 1,112.5 ± 516.7 mL, and 318.8 ± 271.2 mL, respectively, in group 1 and 89.0 ± 33.3 minutes, 2,081.3 ± 1,696.0 mL, and 1,118.8 ± 1,010.8 mL in group 2 (P = .027, P = .019, and P = .040, respectively). Need for surgical revision and early mortality were not evident for group 1, although 4 cases (25.0%) required revision surgery, and early mortality was seen in 3 cases (18.8%) in group 2 (P = .121 and P = .190, respectively). Mean durations of ICU stay and total postoperative hospitalization were 5.9 ± 2.0 and 18.3 ± 5.5 days, respectively in group 1 and 6.2 ± 4.3 and 18.0 ± 6.9 days in the surviving 13 patients of the group 2 (P = .645 and P = .697, respectively).

CONCLUSIONS

With its shorter implantation time and reduced blood product requirement in the early postoperative period, the HM3 system was found to be safe and effective in ESHF treatment.

Anesthetic Management for Left Ventricular Assist Device Implantation Through Left Thoracotomy: Evaluation of On-Pump Versus Off-Pump

BACKGROUND

Ventricular assist devices (VADs) are alternative approaches to medical treatment in patients with acute or chronic heart failure. The goal of this study was to compare an anesthetic approach in patients undergoing implantation of a VAD with (on-pump) or without (off-pump) cardiopulmonary bypass (CPB) through left thoracotomy.

METHODS

A total of 32 patients were divided into 2 groups: on-pump (group 1) and off-pump (group 2). A standard anesthesia protocol was used in all patients. Baseline characteristics of the patients, intraoperative hemodynamic and respiratory variables, anesthetic agents and vasoactive drugs administered, the amount of blood products, extubation, length of hospital stay and intensive care unit stay, and postoperative complications were recorded.

RESULTS

Patients' mean age was 54.7 ± 13.3 years (range, 18-74 years). Eighteen patients underwent surgery with CPB. Demographic data of the patients, preoperative characteristics, intraoperative use of blood products, intraoperative complications, and anesthetic drugs used were similar between groups (P > .05). The duration of surgery (219 ± 23 vs 273 ± 56 minutes) and anesthesia (274 ± 38 vs 323 ± 57 minutes) were shorter in group 2; there was no difference between the 2 groups in terms of mechanical ventilation time, length of stay in the intensive care unit, and length of hospital stay. There was no decrease in postoperative oxygen parameters and an increase in patient lactate levels with the use of CPB. The use of fresh frozen plasma and platelet suspension in the postoperative period was significantly higher in group 1 (P < .05). The rate of complications and mortality rate were comparable between the 2 groups (P > .05).

CONCLUSIONS

Our study results show that the use of CPB during VAD implantation via left thoracotomy increases operation time and use of blood products, while causing no change in the rate of complications.

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow-up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3-6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right-sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support.

Building 3D anatomical model of coiling of the internal carotid artery derived from CT angiographic data

The purpose of this study is to recreate live patient arterial anomalies using new recent application of three-dimensional (3D) printed anatomical models. Another purpose of building such models is to evaluate the effectiveness of angiographic data. With the help of the DICOM files from computed tomographic angiography (CT-A), we were able to build a printed model of variant course of the internal carotid artery (ICA). Images of coiling of the ICA taken by CT-A, were then converted into 3D images using Google SketchUp free software, and the images were saved in stereolithography format. Imaging helped us conduct the examination in details with reference to geometrical features of ICA, degree of curve, its extension, location and presence of loop. Challenging vascular anatomy was exposed with models of adverse curve of carotid anatomy, including highly angulated necks, conical necks, short necks, tortuous carotid arteries, and narrowed carotid lumens. It assisted us to comprehend spatial anatomy configuration of life-like models. 3D model can be very effective in cases when anatomical difficulties are detected through the CT-A, and therefore, a tactile approach is demanded preoperatively. 3D life-like models serve as an essential office-based tool in vascular surgery as they assist surgeons in preoperative planning, develop intraoperative guidance, teach both the patients and the surgical trainees, and simulate to show patient-specific procedures in medical field.

Left Ventricular Aneurysm Repair with Endoaneurysmorrhaphy Technique: An Assessment of Two Different Ventriculotomy Closure Methods

BACKGROUND

Left ventricular aneurysm is a serious mechanical complication of myocardial infarction and has an incidence of 10-35% after myocardial infarction. Ventricular aneurysm in patients with angina, heart failure, and ventricular arrhythmia should be surgically treated. Endoaneurysmorrhaphy is one of the repair techniques that results in better left ventricular geometry and function. After this surgical procedure the ventriculotomy is repaired either with Teflon felt strips or by direct suture of the epicardium.

METHODS

In this study, we described the postoperative early outcomes of two ventriculotomy closing techniques such as Teflon felt versus direct closure after aneurysm repair. This retrospective study included a total of 73 patients (mean age &gt; 70 years) with left ventricular aneurysm, who underwent endoaneurysmorrhaphy repair between 1997 and 2009. All selected patients were divided into two groups according to the ventriculotomy closure technique either by Teflon felt or direct by epicardial closure. The pre-, intra-, and postoperative results of these patients were analyzed accordingly.

RESULTS

The postoperative early mortality rate and postoperative bleeding were not significantly different between the Teflon felt and primary closure groups (P = .246 and P = .371 respectively), but postoperative arrhythmias were significantly higher in the Teflon felt repair group (P = .049).

CONCLUSION

Endoaneurysmorrhaphy is a better surgical technique in left ventricle aneurysm to restore the internal contour and preserve the surface anatomy of the ventricle. The ventriculotomy closure can be performed with two different approaches, including Teflon felt strips or by direct suture of the epicardium. Based on this study's findings, two repair techniques have similar impact on the early outcomes. However, with overall outcomes with respect to Teflon felt repair, direct closure of the ventriculotomy after endoaneurysmorrhaphy was superior.

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey

INTRODUCTION

HeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center.

METHODS

Twenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation.

RESULTS

Mean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus.

DISCUSSION

Mechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Effects of levosimendan on isolated human internal mammary artery and saphenous vein: concurrent use with conventional vasodilators

Graft spasm is a common problem in coronary artery bypass grafting (CABG). In this study, we aimed to investigate the interaction of levosimendan, a novel inodilator, with vasodilator agents that are clinically used for the treatment of graft spasm and with endogenous vasoconstrictors that are thought to play a role in graft vasospasm, in human internal mammary artery (IMA) and saphenous vein (SV). Isolated human IMA and SV segments derived from patients undergoing CABG were suspended in an organ bath. Responses to cumulative concentrations of noradrenaline (NA), serotonin (5-HT), papaverine, nitroglycerin (NG), and diltiazem were recorded before and after 10(-5) m levosimendan incubation (30 min). In addition, cumulative levosimendan responses were taken in vessels precontracted with NA or 5-HT. 10(-5) m levosimendan reduced NA Emax and sensitivity in IMA and SV, and 5-HT Emax responses in IMA. Moreover, levosimendan caused concentration-dependent relaxation in both grafts. Papaverine Emax or sensitivity was not altered by levosimendan neither in IMA nor in SV. Levosimendan diminished NG sensitivity in IMA and Emax responses in SV and decreased diltiazem Emax responses both in IMA and SV. Our results suggest that levosimendan may be used alone for prevention or treatment of graft spasm in IMA or in combination with papaverine in IMA and SV grafts. However, as concurrent administration with diltiazem or NG causes a reduction in relaxation in vitro, we suggest caution should be exercised when using levosimendan in combination with these agents.

New era of pediatric ventricular assist devices: let us go to school

As there is still a shortage of pediatric donor hearts, several techniques have been used to assist pediatric patients to survive until transplantation. VADs provide long-term support and ability of mobilization for children before a suitable heart becomes available. Several devices such as paracorporeal pumps have been used for this purpose, with acceptable morbidity and mortality rates. However, discharge is not possible, as there is no mobile drive unit for these small-sized pumps. The possible negative psychosocial impact of long-term hospitalization, away from home and school, may cause some adjustment problems in the future. In this case series, three pediatric patients that underwent intracorporeal LVAD implantation and returned to school are presented to share clinical experience and also to attract attention to the potential social and psychiatric implications.

Long-term paracorporeal ventricular support systems: a single-center experience

BACKGROUND

The Berlin Heart EXCOR is a first-generation paracorporeal, pneumatic ventricular assist device that creates pulsatile flow. It can be used for long-term support of the left and/or right ventricule during end-stage heart failure. The aim of this study was to share our clinical experience in 54 patients.

METHODS

Between April 2007 and August 2012, 54 patients with end-stage heart failure underwent Berlin Heart EXCOR ventricular assist device implantation, including 5 females and 9 children. Twenty-four patients (44%) were in Intermacs level 1, 11 (21%) in level 2, and 19 (35%) in level 3. Biventricular support was applied to 13 patients. Device implantation was performed with an "on pump" beating heart technique while 6 other patients underwent intervention operations while the aortic valve has under cross-clamp. Tricuspid annuloplasty was performed in 6 patients.

RESULTS

There was no peroperative death. Nine patients (17%) underwent re-exploration because of hemorrhage in the early postoperative period. Heart transplantation was performed in 32 patients (59%), while 10 (19%) are still under pump support with a mean follow-up of 13 months. Although 1 was successfully weaned from the system, 11 patients (20%) died during the support. Pump-head exchange was required 19 times in 17 patients because of visible thrombus or fibrin deposit in the pump head or due to membrane rupture.

DISCUSSION

The use of long-term paracorporeal assist devices has decreased in recent years because of the increased popularity of implantable devices that permit longer survival and a better quality of life. We believe that the Berlin Heart EXCOR has a special role because it can be used in pediatric patients and especially in critical conditions like Intermacs levels 1 and 2.

Fundus fluorescein angiographic findings in patients who underwent ventricular assist device implantation

Disruption of microcirculation in various tissues as a result of deformed blood rheology due to ventricular assist device (VAD) implantation causes novel arteriovenous malformations. Capillary disturbances and related vascular leakage in the retina and choroidea may also be seen in patients supported by VADs. We aimed to evaluate retinal vasculature deteriorations after VAD implantation. The charts of 17 patients who underwent VAD implantation surgery for the treatment of end-stage heart failure were retrospectively reviewed. Eight cases (47.1%) underwent pulsatile pump implantation (Berlin Heart EXCOR, Berlin Heart Mediprodukt GmbH, Berlin, Germany); however, nine cases (52.9%) had continuous-flow pump using centrifugal design (HeartWare, HeartWare Inc., Miramar, FL, USA). Study participants were selected among the patients who had survived with a VAD for at least 6 months, and results of detailed ophthalmologic examinations including optic coherence tomography (OCT) and fundus fluorescein angiography (FA) were documented. All of the 17 patients were male, with a mean age of 48.5 ± 14.8 years (15-67 years). Detailed ophthalmologic examinations including the evaluation of retinal vascular deteriorations via FA were performed at a mean of 11.8 ± 3.7 months of follow-up (6-18 months). Mean best-corrected visual acuity and intraocular pressure were found as logMAR 0.02 ± 0.08 and 14.6 ± 1.9 mm Hg, respectively in the study population. Dilated fundoscopy revealed severe focal arteriolar narrowing in two patients (11.8%), and arteriovenous crossing changes in four patients (23.5%); however, no pathological alteration was present in macular OCT scans. In patients with continuous-flow blood pumps, mean arm-retina circulation time (ARCT) and arteriovenous transit time (AVTT) were found to be 16.8 ± 3.0 and 12.4 ± 6.2 s, respectively; whereas those with pulsatile-flow blood pumps were found to be 17.4 ± 3.6 and 14.0 ± 2.1 s in patients (P=0.526 and P=0.356, respectively). FA also revealed a tendency for increased frequency of dye leakage from the optic disc in our study population. Except for remarkable delays in both ARCT and AVTT as well as a tendency for increased frequency of dye leakage from the optic disc, ophthalmologic evaluations revealed no other significant pathology or vascular deterioration in the retina that could be attributed to artificial heart systems.

Valvular procedures during ventricular assist device implantation

BACKGROUND

Increased experience and success with ventricular assist devices (VAD) has permitted more aggressive use in patients formerly believed to be inappropriate for mechanical circulatory support (MCS). There is no clearly proven policy to manage end-stage heart failure patients with valvular pathologies. The aim of this report was to analysis our experience with combined approach of VAD implantation and valvular procedures among patients with valvular heart disease and end-stage heart failure.

METHODS

We evaluated the clinical records of 67 patients who underwent MCS from April 2007 to September 2011. We identified 12 patients (17.9%) who received concomitant valvular procedures, four of whom had significant aortic insufficiency and received a simple coaptation stitch at the center to approximate the fibrous nodules of Arantius. The mechanical aortic valve was replaced with a stentless bioprosthesis in three patients. Mitral valve commissurotomy was performed in one patient with mitral stenosis and seven patients underwent tricuspit valve repair using an annuloplasty ring.

RESULTS

All 12 patients were males, of mean age 50.3 ± 11.5 years (range = 25-66). Eleven of them (91.6%) survived the early and late postoperative periods. Ten subjects (83.3%) continue to be supported with VAD; 1 (8.3%) was successfully bridged to transplantation. Each study participant regression of the valvular pathologies by early echocardiography demonstrated.

CONCLUSION

Concomitant valve surgery during VAD implantation appeared to be a reasonable option in end-stage heart failure patients with valvular heart disease.

Depression and anxiety levels of the mothers of children and adolescents with left ventricular assist devices

VADs have been used to provide treatment for end-stage heart failure. Parents may feel overwhelmed with the VAD regimes responsibility and be affected from this process beside children. In this study, we aimed to evaluate the depressive and anxiety symptoms of mothers of the first eight children equipped with a VAD in Turkey. The mothers of eight pediatric patients living with VADs were filled BDI and STAI at first month of VAD implantation (E.I) and secondly six months after their first evaluation (E.II). In E.I, the BDI mean score of mothers was 20.87, in E.II 14.37. STAI-S mean score was 53.37 in E.I and 43.62 in E.II. The Wilcoxon nonparametric-paired t-test revealed significant difference between baseline and end-point STAI-S scores (Z: -2.035; p: 0.042), and for BDI scores (Z, -1.965; p, 0.049). Prolonged usage of VAD may increase distress in parents. Psychiatric evaluation and support of the primary caregiver is important for the well-being of the pediatric patients.

To bridge or not to bridge?

OBJECTIVE

Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs.

METHODS

Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support.

RESULTS

Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥ 130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar.

CONCLUSION

Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation

BACKGROUND

Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure.

METHODS

Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL).

RESULTS

Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000).

CONCLUSION

The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.