Changes in right ventricular two-dimensional echocardiographic speckle-tracking indices in adult LVAD population: a prospective clinical study

Objective

Preserved right ventricular (RV) function is crucial in patients supported with left ventricular assist devices (LVAD). The use of strain derived from speckle tracking echocardiography (STE) is recommended by recent guidelines to evaluate intricate RV contractility. The data regarding long-term RV observation in LVAD patients using STE are limited. Thus, the study aimed to determine RV systolic function by STE in the remote period after LVAD implantation.

Methods

Patients with implanted third-generation LVADs with hydrodynamic bearing were prospectively enrolled (NCT05063006). The RV STE indices were analyzed before and after LVAD implantation, both at rest and during the cycle ergometer exercise test.

Results

We included 22 patients, the mean age was 58.4±7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. Stress tests were conducted 7 months postoperatively. The RV strain analysis was feasible in all subjects both in rest and exercise. The RV free wall strain (RVFWS) worsened from −13% (IQR, −17.3 to −10.9) to −11.3% (IQR, −12.9 to −6; p=0.033) after LVAD implantation with the particular decline in the apical RV segment [−11.3% (IQR, −16.4 to −6.2) vs −7.8% (IQR, −11.7 to −3.9; p=0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [−8.5% (IQR, −10.8 to −6.9) vs −7.3% (IQR, −9.8 to −4.7; p=0.184)]. Neither RVFWS (−11.3% (IQR, −12.9 to −6) vs −9.9% (IQR, −13.5 to −7.5; p=0.077) nor RV4CSL [−7.3% (IQR, −9.8 to −4.7) vs −7.9% (IQR, −9.8 to −6.3; p=0.548)] changed during cycle ergometer stress test.

Conclusion

The RVFWS worsens after LVAD implantation presumably due to impaired apical contractility. In LVAD-supported patients during the cycle ergometer stress test, the detailed RV strain analysis is feasible and its indices remain unchanged.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): 1. Cor Aegrum Foundation of Cardiac Surgery Development in Cracow2. Medtronic Poland sp. z o.o.

Echo-guided LVAD speed optimization for exercise maximization

Background

Continuous-flow left ventricular assist devices (LVAD) are becoming a destination therapy in patients with end-stage left ventricular dysfunction and a competitive method for heart transplantation. Current generation pumps operate with a fixed rotation speed and do not have the automatic speed adjustment capability. However, it was shown that acceleration of the pump speed during stress test increases the maximum exercise tolerance.

Purpose

The study aimed to evaluate the concept of dynamic pump speed optimization based on the echocardiographic assessment of aortic valve opening (AVO) during the cardiopulmonary exercise test (CPET).

Methods

Patients with implanted third-generation centrifugal continuous-flow LVAD's with hydrodynamic bearing were prospectively included. Two CPET's were performed after resting speed optimization. The first one with maintained baseline pump speed settings, and the second one with gradually increased speed depending on live echocardiographic imaging. The sequence of tests was random.

Results

Exercise AVO was apparent in all 22 included patients. The resting pump speed was 2691 RPM and incremented on average by 566 RPM (20%). Pump power and flow raised from 5.6 to 9.8 Watts (p<0.0001) and from 5.8 to 7.3 l/min (p<0.0001), respectively. Peak VO2 increased from 11.1 to 12.8 ml/kg/min (p=0.0003) and maximum workload from 1.1 to 1.2 W/kg (p=0.03). The Borg scale exertion level decreased from 15.2 to 13.5 (p=0.0049). There was a visible trend towards longer exercise time (36s) but no statistical significance was achieved (p=0.1).

Conclusion

Ultrasonographic AVO analysis is possible during CPET's in patients supported with LVAD. Dynamic echo-guided pump speed adjustment based on the AVO improves exercise tolerance, augments peak VO2 consumption and maximal workload. An automatic speed adjustment in the next generations of LVAD controllers might improve functional capacity and requires further basic, technological and clinical research.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): 1. Cor Aegrum Foundation of Cardiac Surgery Development in Cracow2. Medtronic Poland Sp. z o.o.

Giant cell myocarditis--a case report

The authors described a case of giant cell myocarditis treated by heart transplantation.

[Risk of hypertension after heart transplantation in the follow-up period]

From October 1988 to March 2000, 58 patients underwent orthotopic heart transplantation (HTX). Data of 220 heart recipients with the follow up > or = 3 months after HTX were analyzed using the average values of blood pressure measured with the sphigmo-manometer. 65% of patients were diagnosed with the hypertension (HA). 39.9% of those patients (NTA group) had the systolic blood pressure < or = 140 mmHg and diastolic blood pressure < or = 90 mmHg during pharmacotherapy. 60.1% of hypertensive patients (NTB group) had the systolic pressure > 140 mmHg and/or diastolic pressure > 90 mmHg despite pharmacotherapy. 35% of all patients had normal blood pressure after HTX (HNA group). Patients with hypertension were older and the end stage ischemic cardiomyopathy was more frequently indication for HTX. Significantly more females were in NTA group. We observed no influence of the daily dose of cyclosporine or other immunosuppressive drugs on HA. The average blood concentration of cyclosporine A and mycophenolate mofetil was similar in all groups. The calcium channel blockers and inhibitors of angiotensin converting enzyme were main tool of pharmacotherapy used. In NTA group calcium channels blockers were used more frequently. In NTB group there was a statistically significant higher blood level of creatinine. After HTX there is a high risk of HA, which: increases with age, with the ischemic cardiomyopathy as indication to HTX, is significantly higher in males, there is no correlation between HA and the dosage and blood level of cyclosporine, increases with kidney insufficiency. In monotherapy calcium channel blockers seem to be especially effective.

The incidence of malignancy in heart transplant recipients

OBJECTIVES AND METHODS

219 heart transplant recipients with survival over 3 months were retro- and prospectively analysed for the incidence of primary neoplasms. Patients received immunosuppressive drugs (cyclosporine A, azathioprine, steroids) with a 4-5 days induction course of Rabbit Anti-Thymocyte Immunoglobulin (RATG) or monoclonal antibodies induction /OKT3/ in some cases. Anti-rejection treatment consisted of pulse doses of methyloprednisolon or RATG.

RESULTS

9 cases of malignancy (4.1%) with one case of pre-malignant liver condition (dysplasia gigantocellulare, 0.45%) were found (8M; 1F; age: 45-67 y.o., x57.7). Symptoms of neoplasms occurred 7-79 months (x31.4) postoperatively. Skin carcinomas: planoepitheliale, spinocellulare, soft tissue neoplasms/mesenchymal sarcoma, larynx Ca planoepitheliale, lung: adenocarcinoma and Ca microcellulare, kidney Ca clarocellulare and post transplant non-Hodgkin lymphoma were diagnosed. Chemo- and radiotherapy, surgery and reduction of immunosuppression did not change the outcome of malignancy in 6 pts.; (regression-1 pt was., remission-2 pts). Patients died 7-86 months after Htx (x41), 4-25 mos. (x12.5) after suffering from first symptoms and 0-10 months (x4.9) after pathology-based diagnosis of neoplasm.

CONCLUSIONS

Heart transplant recipients have an increased risk of carcinogenesis. The incidence of malignancies in the studied group is similar or even lower than in other reports.

The quality of life after aortic valve replacement with homografts or prosthetic valves

BACKGROUND AND AIM OF THE STUDY

The study aim was to evaluate the quality of life in patients after homograft or prosthetic aortic valve implantation. Evaluation was based on clinical and echocardiographic examinations, and on analysis of data from patient questionnaires.

METHODS

Patients undergoing either homograft (HV, n = 220) or prosthetic (PV, n = 220) aortic valve replacement were investigated. The patients groups were similar in age, sex, follow up period, risk factors and type of heart defect, and did not demonstrate any dysfunction of the replacement valve.

RESULTS

During both pre- and postoperative periods, no significant inter-group differences were identified with regard to the occurrence of retrosternal pain, dyspnea, palpitation, fear reaction and circulatory efficiency based on NYHA classification, and self-evaluation of physical activity assessed by patient questionnaires. The majority of patients in both groups noticed on increase in their quality of life and physical activity. The reduced sexual activity (50%) and fear reaction (30%) in both groups did not correlate with their improved sense of well-being. Up to 14.6% of PV patients did not accept the implanted valve, and 65 (29.5%) would have preferred an HV, despite the need for reoperation. Following surgery, 21% of HV patients resumed work, compared with only 7.7% of PV patients. The frequency of claims for disability pension after surgery did not correlate with the considerate clinical and subjective improvement.

CONCLUSIONS

In patients receiving either homograft or prosthetic valves, the subjective evaluation of life quality is comparable with the clinical evaluation, though the homograft valve was better accepted than its prosthetic counterpart.