Hand assistive device with suction cup (HADS) technology for poststroke patients

A stroke is a neurological disease that primarily causes paralysis. Besides paraplegia, all other types of paralysis affect the upper extremity. Advanced technologies, such as wearable devices and rehabilitation regimens, are also being developed to enhance the functional ability of a stroke person to grasp and release daily living objects. In this research, we developed a rehabilitation functional assist device combining a flexion and extension mechanism with suction cup technology (hybrid technology) to help post-stroke patients improve their hand grip strength in day-to-day grasping activities. Ten poststroke hemiplegia patients were studied to test the functional ability of the impaired hand by wearing and not wearing the device. The outcomes were validated by three standard clinical tests, such as the Toronto Rehabilitation Institute - Hand Functional Test (TRI-HFT), the Chedoke Arm Hand Activity Inventory (CAHAI-9), and the Fugl-Meyer Assessment (FMA) with overall score improvements of 14.5 ± 3.8-25 ± 2.2 (p = 0.005), 5.4 ± 2.8-10 ± 1.6 (p = 0.008), and 9.6 ± 2.6-17 ± 2.4 (p = 0.005) respectively. The p-value for each of the three evaluations was less than 0.05, indicating significantly improved results and the average feedback score of the participants was 3.8 out of 5. The proposed device significantly increased impaired hand functionality in post-stroke patients. The subjects could complete some of the grasping tasks that they could not grasp without the device.Clinical trial registrationThe Clinical Trial Registry of India approved the work CTRI/2022/02/040495 described in this manuscript.

Cardiac Muscle Training-A New Way of Recognizing and Supporting Recovery for LVAD Patients in the Pediatric Population

Patients with refractory heart failure due to chronic progressive cardiac myopathy (CM) may require mechanical circulatory support as a bridge to transplantation. A few patients can be weaned from support devices if recovery can be achieved. The identification of these patients is of great importance as recovery may be missed if the heart is unloaded by the ventricular assist device (VAD). Testing the load-bearing capacity of the supported left ventricle (LV) by temporarily and gradually reducing mechanical support during cardiac exercise can help identify responders and potentially aid the recovery process. An exercise training protocol was used in 3 patients (8 months, 18 months and 8 years old) with histological CM findings and myocarditis. They were monitored regularly using clinical information and functional imaging with VAD support. Echocardiographic examination included both conventional real-time 3D echocardiography (RT3DE) and speckle tracking (ST). A daily temporary reduction in pump rate (phase A) was followed by a permanent reduction in rate (phase B). Finally, pump stops of up to 30 min were performed once a week (phase C). The final decision on explantation was based on at least three pump stops. Two patients were weaned and successfully removed from the VAD. One of them was diagnosed with acute viral myocarditis. The other had chronic myocarditis with dilated myopathy and mild interstitial fibrosis. The noninvasive assessment of cardiac output and strain under different loading conditions during VAD therapy is feasible and helps identify candidates for weaning despite severe histological findings. The presented protocol, which incorporates new echocardiographic techniques for determining volume and deformation, can be of great help in positively guiding the process of individual recovery, which may be essential for selecting and increasing the number of patients to be weaned from VAD.

Prolonged Use of an Impella Assist Device in a Sepsis-Induced Cardiomyopathy: A Case Report

The inflammatory response triggered by sepsis can frequently cause reversible myocardial depression termed sepsis-induced cardiomyopathy. The resulting pathologic changes are often self-limiting and cardiac function returns to baseline following resolution of the underlying exacerbating factors. The following case examines a patient with septic shock and sepsis-induced cardiomyopathy that, despite maximal medical therapy, required mechanical support with an Impella assist device for seven days. To the best of our knowledge and research, this represents the longest documented use of an Impella heart pump in septic shock and associated sepsis-induced cardiomyopathy. Utilization of mechanical support in the setting of septic shock has seen growing interest in recent years, but more structured studies need to be conducted for better understanding of their overall effect on morbidity and mortality.

Impact of left ventricular unloading using a peripheral Impella®-pump in eCPR patients

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to increasing survival rates in selected patients. Additional left ventricular mechanical unloading, using a transfemoral micro-axial blood pump (Impella® Denver, Massachusetts, USA), might improve patients' outcomes. In this regard, we sought to investigate patients who suffered OHCA (out-of hospital cardiac arrest) or IHCA (in-hospital cardiac arrest) with subsequent eCPR via VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and concomitant Impella® implantation based on survival and feasibility of ECMO weaning.

METHODS

From January 2016 until December 2020, 108 patients underwent eCPR at our institution. Data prior to eCPR and early outcome parameters were analyzed comparing patients who were supported with an additional Impella® (2.5 or CP) (ECMO+Impella®, n = 18) and patients without additional (ECMO, n = 90) support during V-A ECMO therapy. The primary endpoint was in-hospital mortality; secondary endpoints were, among others: ECMO explantation, need for hemodialysis, stroke, and need for blood transfusions.

RESULTS

Low-flow time was significantly lower in the ECMO+Impella group (60 min vs. 55 min, p = .01). All-cause mortality was significantly lower in the ECMO+Impella® group (82% vs. 56%, p = .01). The time of circulatory support was shorter in the ECMO cohort (2.0 ± 1.73 vs. 4.76 ± 2.88 p = .05). ECMO decannulation was significantly more feasible in patients with ECMO+Impella® (72% vs. 32%, p = .01). Patients treated with additional Impella® showed significantly more acute kidney injury with the need for dialysis (72% vs. 18%, p ≤ .01).

CONCLUSION

Concomitant Impella® support might positively influence survival and ECMO weaning in eCPR patients. Treatment-associated complications such as the need for dialysis were more common in this highly selected patient group. Further studies with larger numbers are necessary to evaluate the clinical relevance of concomitant LV-unloading in eCPR patients using an Impella® device.

Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation

BACKGROUND

Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice.

METHODS

Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality.

RESULTS

The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2  = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12).

CONCLUSION

High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.

Presence of Intracardiac Thrombus at the Time of Left Ventricular Assist Device Implantation Is Associated With an Increased Risk of Stroke and Death

BACKGROUND

Heart failure predisposes to intracardiac thrombus (ICT) formation. There are limited data on the prevalence and impact of preexisting ICT on postoperative outcomes in left ventricular assist device patients. We examined the risk for stroke and death in this patient population.

METHODS AND RESULTS

We retrospectively studied patients who were implanted with HeartMate (HM) II or HM3 between February 2009 and March 2019. Preoperative transthoracic echocardiograms, intraoperative transesophageal echocardiograms and operative reports were reviewed to identify ICT. There were 525 patients with a left ventricular assist device (median age 60.6 years, 81.8% male, 372 HMII and 151 HM3) included in this analysis. An ICT was identified in 44 patients (8.4%). During the follow-up, 43 patients experienced a stroke and 55 died. After multivariable adjustment, presence of ICT increased the risk for the composite of stroke or death at 6-month (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.00-3.33, P = .049). Patients with ICT were also at higher risk for stroke (HR 2.45, 95% CI 1.14-5.28, P = .021) and death (HR 2.36, 95% CI 1.17-4.79 P = .016) at 6 months of follow-up.

CONCLUSIONS

The presence of ICT is an independent predictor of stroke and death at 6 months after left ventricular assist device implantation. Additional studies are needed to help risk stratify and optimize the perioperative management of this patient population.

Experience with a standardized protocol to predict successful explantation of left ventricular assist devices

OBJECTIVE

Patients with a continuous-flow left ventricular assist device may show recovery of myocardial function with unloading. Identifying candidates for and predicting clinical and hemodynamic stability after left ventricular assist device explantation remain challenging.

METHODS

Retrospective analysis of patients who underwent evaluation for left ventricular assist device explantation following a standardized protocol from January 2016 to March 2020. Patients who met screening criteria underwent echocardiography under "baseline," "minimal net flow," and "pump stop" conditions. If the protocol criteria were met, right heart catheterization with left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter were performed. In patients with pulmonary capillary wedge pressure less than 16 mm Hg, explantation was performed under "pump stop" conditions.

RESULTS

A total of 544 patients were screened. Of these, 57 (10.5%) underwent a total of 73 echocardiography under "baseline" "minimal net flow" and "pump stop" conditions and 46 underwent left ventricular assist device stoppage and occlusion of the outflow graft with balloon catheter maneuvers. Complications during the procedure were rare. Ultimately, 21 patients (3.9%) underwent explantation. The left ventricular ejection fraction at baseline was 55.5% ± 6.5%. The mean pulmonary capillary wedge pressure was 8.1 ± 2.6 mm Hg and increased to 10.7 ± 2.9 mm Hg under left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter. A nonischemic cause of cardiomyopathy was more likely to be found in patients who underwent explantation (20/21 patients [95%], P = .020). The survival 1 year after explantation was 95.2%, with 1 death occurring 222 days after left ventricular assist device explantation. At follow-up (median 24.9 months [interquartile range, 16.4-43.1 months]), patients were in New York Heart Association class 1 (61.9%), 2 (28.6%), and 3 (9.5%).

CONCLUSIONS

Our 4-year experience with a standardized protocol for left ventricular assist device explantation showed a low rate of adverse events. If all criteria are met, explantation can be performed safely and with an excellent survival and functional class.

Japanese registry for Mechanically Assisted Circulatory Support: First report

BACKGROUND

In Japan, ventricular assist devices (VADs) have been used for patients with severe heart failure as a bridge to transplantation (BTT) since 1992. However, it was not until 1997, when the Organ Transplant Law was enacted, that medical devices received approval by the national health insurance system for that use. To encourage research and development of innovative medical devices, the Pharmaceuticals and Medical Devices Agency has established a public-private partnership in collaboration with academic societies, hospitals and manufacturers.

METHODS

The Japanese registry for Mechanically Assisted Circulatory Support (J-MACS) is a prospective registry designed to be harmonized with the Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS). Participation in J-MACS is mandatory for device manufacturers to meet the conditions of approval as well as for hospitals to obtain authorization for reimbursement from the national health insurance system.

RESULTS

From June 2010 to April 2015, 476 patients were registered at 31 hospitals. Of these, analysis of primary VAD patients (n = 332) revealed that their overall 360-day survival was 91% (implantable 93%, extracorporeal 84%).

CONCLUSIONS

This initial report from J-MACS focuses on patients' demographics, device types, survival, competing outcomes, adverse events and successful examples of system failure detection.

Parametrization of an in-silico circulatory simulation by clinical datasets - towards prediction of ventricular function following assist device implantation

BACKGROUND

Left ventricular assist device (LVAD) therapy has revolutionized the way end stage heart failure is treated today. Analysis of LVAD interaction with the whole cardiovascular system and its biological feedback loops is often conducted by means of computer models. Generating real time pressure volume loops (PV-loops) in patients, not using conductance catheters but routine diagnostics to feed an in-silico model could help to predict postoperative complications.

METHODS

Routinely obtained hemodynamic measurements to evaluate myocardial function prior to LVAD implantation like pressure readings in the aorta, the left atrium and the left ventricle and simultaneous three-dimensional (3D) echocardiography recordings were assessed to parametrize a reduced computational model of the cardiovascular system. An automatic parameter identification procedure has been developed.

RESULTS

The results constitute a patient-individual computational simulation model. An exemplary in-silico study focusing on the effect of different ventricular assist device (VAD) speeds has been conducted. Results allow for estimation of the resulting hemodynamic parameters and changes of the PV-loops.

CONCLUSION

The model improves understanding and prediction of the interaction between pump and ventricles. Future modifications in exporting and merging routinely assessed real time hemodynamic patient data are necessary to investigate various clinical and pathological conditions of LVAD recipients.

VAD as bridge to recovery in anthracycline-induced cardiomyopathy and HHV6 myocarditis

This report describes an 8-year-old child with acute anthracycline-induced cardiomyopathy triggered by human herpesvirus 6 and the subsequent implantation of an intracorporeal continuous-flow left ventricular assist device (LVAD) and the process to discharge the child from the hospital. After barely 3 months on mechanical support, the device was explanted after thorough examination. Experiences regarding LVAD removal are limited, and no guidelines for echocardiographic and hemodynamic criteria for LVAD removal in children have been published thus far. We present our institutional algorithm for device selection, surveillance in an ambulatory setting, and testing for myocardial recovery, as well as our criteria for LVAD explantation in children.

Right heart failure post left ventricular assist device implantation

Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation. The incidence of RHF complicates 20-50% (range, 9-44%) of cases and is a major factor of postoperative morbidity and mortality. Unfortunately, despite the fact that many risk factors contributing to the development of RHF after LVAD implantation have been identified, it seems to be extremely difficult to avoid them. Prevention of RHF consists of the management of the preload and the afterload of the right ventricle with optimum inotropic support. The administration of vasodilators designed to reduce pulmonary vascular resistance is standard practice in most centers. The surgical attempt of implantation of a right ventricular assist device does not always resolve the problem and is not available in all cardiac surgery centers.