Clinical Challenges in Advanced Heart Failure, Heart Transplantation and Mechanical Circulatory Support

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: 30 April 2024 | Viewed by 3771

Special Issue Editor


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Guest Editor
Interdisciplinary Heart Failure Section, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
Interests: advanced heart failure; worsening heart failure; heart transplantation; left ventricular assist device; mechanical circulatory support

Special Issue Information

Dear Colleagues,

Heart failure is continuing to increase, particularly in the aging population. While the early stages of heart failure are usually well managed by medical therapy and additional supportive means, worsening or advanced heart failure may require further steps. According to American College of Cardiology (ACC), Stage D heart failure patients are at an increased risk and are characterized by refractory heart failure symptoms, despite optimized guideline-directed medical treatment. In selected cases, heart transplantation or mechanical circulatory support have to be taken into account. While heart transplantation entered the scene in the 1960s, mechanical circulatory support in terms of left ventricular assist devices have traditionally gained importance due to a shortage of donor organs. In the meantime, they have overcome the role of bridge to transplant devices. Now, left ventricular assist devices are often implanted as bridge to decision or destination therapy. This, in turn, assigns heart failure units a role in the long-term follow-up of heart transplant recipients or patients utilizing ventricular assist devices. The aim of this Special Issue is to present original scientific research addressing the identification of patients at risk of experiencing worsening or advanced heart failure, and to mirror the challenging therapeutic scenario of heart transplantation and temporary or permanent mechanical circulatory support.

Prof. Dr. Jürgen R. Sindermann
Guest Editor

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Keywords

  • advanced heart failure
  • worsening heart failure
  • heart transplantation
  • immunosuppression
  • left ventricular assist device
  • temporary mechanical circulatory support
  • risk stratification

Published Papers (5 papers)

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Research

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14 pages, 1913 KiB  
Article
BMI-Stratified Exploration of the ‘Obesity Paradox’: Heart Failure Perspectives from a Large German Insurance Database
by Anastasia J. Hobbach, Jannik Feld, Wolfgang A. Linke, Jürgen R. Sindermann, Patrik Dröge, Thomas Ruhnke, Christian Günster and Holger Reinecke
J. Clin. Med. 2024, 13(7), 2086; https://doi.org/10.3390/jcm13072086 - 03 Apr 2024
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Abstract
Background: The global rise of obesity and its association with cardiovascular risk factors (CVRF) have highlighted its connection to chronic heart failure (CHF). Paradoxically, obese CHF patients often experience better outcomes, a phenomenon known as the ‘obesity paradox’. This study evaluated the ‘obesity [...] Read more.
Background: The global rise of obesity and its association with cardiovascular risk factors (CVRF) have highlighted its connection to chronic heart failure (CHF). Paradoxically, obese CHF patients often experience better outcomes, a phenomenon known as the ‘obesity paradox’. This study evaluated the ‘obesity paradox’ within a large cohort in Germany and explored how varying degrees of obesity affect HF outcome. Methods: Anonymized health claims data from the largest German insurer (AOK) for the years 2014–2015 were utilized to analyze 88,247 patients hospitalized for myocardial infarction. This analysis encompassed baseline characteristics, comorbidities, interventions, complications, and long-term outcomes, including overall survival, freedom from CHF, and CHF-related rehospitalization. Patients were categorized based on body mass index. Results: Obese patients encompassed 21.3% of our cohort (median age 68.69 years); they exhibited a higher prevalence of CVRF (p < 0.001) and comorbidities than non-obese patients (median age 70.69 years). Short-term outcomes revealed lower complication rates and mortality (p < 0.001) in obese compared to non-obese patients. Kaplan–Meier estimations for long-term analysis illustrated increased incidences of CHF and rehospitalization rates among the obese, yet with lower overall mortality. Multivariable Cox regression analysis indicated that obese individuals faced a higher risk of developing CHF and being rehospitalized due to CHF but demonstrated better overall survival for those classified as having low-level obesity (p < 0.001). Conclusions: This study underscores favorable short-term outcomes among obese individuals. The ‘obesity paradox’ was confirmed, with more frequent CHF cases and rehospitalizations in the long term, alongside better overall survival for certain degrees of obesity. Full article
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10 pages, 1155 KiB  
Article
Durability of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation
by Gloria Färber, Imke Schwan, Hristo Kirov, Marcel Rose, Sophie Tkebuchava, Ulrich Schneider, Tulio Caldonazo, Mahmoud Diab and Torsten Doenst
J. Clin. Med. 2024, 13(5), 1411; https://doi.org/10.3390/jcm13051411 - 29 Feb 2024
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Abstract
Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed [...] Read more.
Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days–0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2–4 points) in 19 and low (0–2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF. Full article
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13 pages, 818 KiB  
Article
Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock
by Jan-Sören Padberg, Jannik Feld, Leonie Padberg, Jeanette Köppe, Lena Makowski, Joachim Gerß, Patrik Dröge, Thomas Ruhnke, Christian Günster, Stefan Andreas Lange and Holger Reinecke
J. Clin. Med. 2024, 13(4), 1167; https://doi.org/10.3390/jcm13041167 - 19 Feb 2024
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Abstract
Background: Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no [...] Read more.
Background: Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes. Methods: Using health claim data from AOK—Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017. Results: A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan–Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups. Conclusions: Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit. Full article
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11 pages, 883 KiB  
Article
Pulmonary Vascular Resistance to Predict Right Heart Failure in Patients Undergoing Left Ventricular Assist Device Implantation
by René Schramm, Johannes Kirchner, Mohamad Ibrahim, Sebastian V. Rojas, Michiel Morshuis, Volker Rudolph, Jan F. Gummert and Henrik Fox
J. Clin. Med. 2024, 13(2), 462; https://doi.org/10.3390/jcm13020462 - 14 Jan 2024
Viewed by 591
Abstract
Right heart failure (RHF) is associated with poor outcomes, especially in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to identify predictors of RHF after LVAD implantation. Of 129 consecutive patients (mean age 56 ± 11 years, [...] Read more.
Right heart failure (RHF) is associated with poor outcomes, especially in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to identify predictors of RHF after LVAD implantation. Of 129 consecutive patients (mean age 56 ± 11 years, 89% male) undergoing LVAD implantation, 34 developed RHF. Compared to patients without RHF, those with RHF required longer invasive mechanical ventilation and had longer intensive care unit and hospital stays (p < 0.01). One-year all-cause mortality was significantly higher in patients with versus without RHF after LVAD implantation (29.4% vs. 1.2%; hazard ratio 35.4; 95% confidence interval 4.5–277; p < 0.001). Mortality was highest in patients with delayed RHF after initial LVAD-only implantation (66.7%). Patients who did versus did not develop RHF had significantly higher baseline pulmonary vascular resistance (PVR; 404 ± 375 vs. 234 ± 162 dyn/s/cm5; p = 0.01). PVR > 250 dyn/s/cm5 was a significant predictor of survival in patients with RHF after LVAD implantation. These data confirm the negative impact of RHF on morbidity and mortality after LVAD implantation. Preoperative PVR > 250 dyn/s/cm5 determined using invasive right heart catheterization was an independent predictor of developing RHF after LVAD implantation, and of subsequent mortality, and could be used for risk stratification in the setting for deciding between single or biventricular support strategy. Full article
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Review

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18 pages, 1049 KiB  
Review
De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians
by Irene Marco, Juan Carlos López-Azor García, Javier González Martín, Andrea Severo Sánchez, María Dolores García-Cosío Carmena, Esther Mancebo Sierra, Javier de Juan Bagudá, Javier Castrodeza Calvo, Francisco José Hernández Pérez and Juan Francisco Delgado
J. Clin. Med. 2023, 12(23), 7474; https://doi.org/10.3390/jcm12237474 - 02 Dec 2023
Cited by 1 | Viewed by 1166
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection [...] Read more.
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients. Full article
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