Research

11 pages, 775 KiB

Open AccessArticle

Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy in Cardiogenic Shock: Prophylactic Versus Bail-Out Strategy

by Darko Radakovic, Armin Zittermann, Sebastian V. Rojas, Dragan Opacic, Artyom Razumov, Emir Prashovikj, Henrik Fox, René Schramm, Michiel Morshuis, Volker Rudolph, Jan Gummert, Christian Flottmann and Marcus-André Deutsch

Life 2023, 13(2), 582; https://doi.org/10.3390/life13020582 - 19 Feb 2023

Cited by 5 | Viewed by 1975

Abstract

Background: The benefit of prophylactic left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients at risk of developing LV distension remains unclear. Methods: We enrolled 136 patients treated with Impella pump decompression during VA-ECMO therapy for refractory cardiogenic shock. [...] Read more.

Background: The benefit of prophylactic left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients at risk of developing LV distension remains unclear. Methods: We enrolled 136 patients treated with Impella pump decompression during VA-ECMO therapy for refractory cardiogenic shock. Patients were stratified by specific indication for LV unloading in the prophylactic vs. bail-out group. The bail-out unloading strategy was utilized to treat LV distension in VA-ECMO afterload-associated complications. The primary endpoint was all-cause 30-day mortality after VA-ECMO implantation. The secondary endpoint was successful myocardial recovery, transition to durable mechanical circulatory support (MCS), or heart transplantation. Results: After propensity score matching, prophylactic unloading was associated with a significantly lower 30-day mortality risk (risk ratio 0.38, 95% confidence interval 0.23–0.62, and p < 0.001) and a higher probability of myocardial recovery (risk ratio 2.9, 95% confidence interval 1.48–4.54, and p = 0.001) compared with the bail-out strategy. Heart transplantation or durable MCS did not differ significantly between groups. Conclusions: Prophylactic unloading compared with the bail-out strategy may improve clinical outcomes in selected patients on VA-ECMO. Nevertheless, randomized trials are needed to validate these results. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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11 pages, 1921 KiB

Open AccessArticle

Surgical Interventions for Late Aortic Valve Regurgitation Associated with Continuous Flow-Left Ventricular Assist Device Therapy: Experience Gained and Lessons Learned

by Takayuki Gyoten, Eisuke Amiya and Minoru Ono

Life 2023, 13(1), 94; https://doi.org/10.3390/life13010094 - 29 Dec 2022

Viewed by 1336

Abstract

This study aimed to investigate the outcomes of surgical interventions for symptomatic moderate-to-severe aortic regurgitation (AR), including aortic valve replacement (AVR) and repair (AVP), in 184 patients who underwent continuous flow-left ventricular assist device (Cf-LVAD) implantation as a bridge-to-transplant (BTT) between November 2007 [...] Read more.

This study aimed to investigate the outcomes of surgical interventions for symptomatic moderate-to-severe aortic regurgitation (AR), including aortic valve replacement (AVR) and repair (AVP), in 184 patients who underwent continuous flow-left ventricular assist device (Cf-LVAD) implantation as a bridge-to-transplant (BTT) between November 2007 and April 2020. Ten patients (median age, 34 (25–41) years; 60% men) underwent surgical interventions (AVR, n = 6; AVP, n = 4) late after cf-LVAD implantation. The median duration after the device implantation was 34 (24–44) months. Three patients required additional tricuspid valve repair. Aortic valve suturing resulted in severe recurrent AR 6 months postoperatively, due to leaflet cutting in one patient. Seven patients with AVR survived without regurgitation during the study period, except for one non-survivor complicated by liver failure due to postoperative right heart failure. Therefore, six patients after AVP (n = 4) and AVR (n = 2) underwent successful heart transplantation 7 (4–13) months after aortic intervention. Kaplan–Meier analysis showed no significant difference in overall survival through 5 years after cf-LVAD implantation, regardless of the surgical AV intervention chosen (log-rank test, p = 0.86). In conclusion, surgical interventions (AVR or AVP) for patients with an ongoing cf-LVAD are safe, effective, and viable options. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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12 pages, 1521 KiB

Open AccessArticle

The Role of Daily Implant-Based Multiparametric Telemonitoring in Patients with a Ventricular Assist Device

by Denise Guckel, Mustapha El Hamriti, Sebastian V. Rojas, Henrik Fox, Angelika Costard-Jäckle, Jan Gummert, Thomas Fink, Vanessa Sciacca, Khuraman Isgandarova, Martin Braun, Moneeb Khalaph, Guram Imnadze, René Schramm, Michiel Morshuis, Philipp Sommer and Christian Sohns

Life 2023, 13(1), 38; https://doi.org/10.3390/life13010038 - 23 Dec 2022

Viewed by 1115

Abstract

The telemonitoring of heart failure (HF) patients is becoming increasingly important. This study aimed to evaluate the benefit of telemonitoring in end-stage HF patients with a ventricular-assistance device (VAD). A total of 26 HF-patients (66 ± 11 years, 88% male) on VAD therapy [...] Read more.

The telemonitoring of heart failure (HF) patients is becoming increasingly important. This study aimed to evaluate the benefit of telemonitoring in end-stage HF patients with a ventricular-assistance device (VAD). A total of 26 HF-patients (66 ± 11 years, 88% male) on VAD therapy with an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization defibrillator (CRT-D) including telemonitoring function were enrolled. The long-term follow-up data (4.10 ± 2.58 years) were assessed. All the patients (n = 26, 100%) received daily ICD/CRT-D telemonitoring. In most of the patients (73%, n = 19), the telemedical center had to take action for a mean of three times. An acute alert due to sustained ventricular arrhythmias (VAs) occurred in 12 patients (63%) with 50% of them (n = 6) requiring ICD shock delivery. Eight patients (67%) were hospitalized due to symptomatic VAs. In 11 patients (92%), immediate medication adjustments were recommended. Relevant lead issues were revealed in thirteen patients (50%), with six patients (46%) undergoing consecutive lead revisions. Most of the events (83%) were detected within 24 h. Daily telemonitoring significantly reduced the number of in-hospital device controls by 44% (p < 0.01). The telemonitoring ensured that cardiac arrhythmias and device/lead problems were identified early, allowing pre-emptive and prompt interventions. In addition, the telemonitoring significantly reduced the number of in-hospital device controls in this cohort of HF patients. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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10 pages, 814 KiB

Open AccessArticle

Impact of Left Ventricular Assist Devices on Days Alive and Out of Hospital in Hemodynamically Stable Patients with End-Stage Heart Failure: A Propensity Score Matched Study

by Theresa Tenge, Sebastian Roth, René M‘Pembele, Giovanna Lurati Buse, Florian Boenner, Christina Ballázs, Igor Tudorache, Udo Boeken, Artur Lichtenberg, Martin Neukirchen, Ragnar Huhn and Hug Aubin

Life 2022, 12(12), 1966; https://doi.org/10.3390/life12121966 - 24 Nov 2022

Cited by 1 | Viewed by 1243

Abstract

The two main surgical options to treat end-stage heart failure are heart transplantation (HTx) or left ventricular assist device (LVAD) implantation. In hemodynamically stable patients, the decision for HTx listing with or without LVADs is challenging. We analyzed the impact of both options [...] Read more.

The two main surgical options to treat end-stage heart failure are heart transplantation (HTx) or left ventricular assist device (LVAD) implantation. In hemodynamically stable patients, the decision for HTx listing with or without LVADs is challenging. We analyzed the impact of both options on days alive and out of hospital (DAOH) and survival. This retrospective study screened all patients with HTx or LVAD implantation between 2010 and 2020. The main inclusion criterion was hemodynamic stability defined as independence of intravenous inotropic/vasoactive support at decision. Propensity score matching (PSM) was performed. The primary endpoint was DAOH within one year after the decision. Secondary endpoints included survival, duration until HTx, and hospitalizations. In total, 187 patients received HTx and 227 patients underwent LVAD implantation. There were 21 bridge-to-transplant (BTT)-LVAD patients (implantation less than a month after HTx listing or listing after implantation) and 44 HTx-waiting patients included. PSM identified 17 matched pairs. Median DAOH at one year was not significantly different between the groups (BTT-LVAD: median 281, IQR 89; HTx waiting: median 329, IQR 74; p = 0.448). Secondary endpoints did not differ significantly. Our data suggest that BTT-LVAD implantation may not be favorable in terms of DAOH within one year for hemodynamically stable patients compared to waiting for HTx. Further investigations on quality of life and long-term outcomes are warranted. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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13 pages, 1315 KiB

Open AccessArticle

Improving Survival in Cardiogenic Shock—A Propensity Score-Matched Analysis of the Impact of an Institutional Allocation Protocol to Short-Term Mechanical Circulatory Support

by Sascha Ott, Daniel Lewin, Gaik Nersesian, Julia Stein, Isabell A. Just, Matthias Hommel, Felix Schoenrath, Christoph T. Starck, Benjamin O’Brien, Volkmar Falk, Evgenij Potapov and Pia Lanmueller

Life 2022, 12(11), 1931; https://doi.org/10.3390/life12111931 - 19 Nov 2022

Cited by 8 | Viewed by 3849

Abstract

Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for [...] Read more.

Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for CS patients and presents outcome data before and after implementation. Data from 421 patients treated for CS with tMCS between 2018 and 2021 were analyzed. In 2019, we implemented a new SOP for allocating CS patients to tMCS modalities. The association between the time of SOP implementation and the 30-day and 1-year survival as well as hospital discharge was evaluated. Of the 421 patients included, 189 were treated before (pre-SOP group) and 232 after implementation of the new SOP (SOP group). Causes of CS included acute myocardial infarction (n = 80, 19.0%), acute-on-chronic heart failure in patients with dilated or chronic ischemic heart failure (n = 139, 33.0%), valvular cardiomyopathy (n = 14, 3.3%) and myocarditis (n = 5, 1.2%); 102 patients suffered from postcardiotomy CS (24.2%). The SOP group was further divided into an SOP-adherent (SOP-A) and a non-SOP-adherent group (SOP-NA). The hospital discharge rate was higher in the SOP group (41.7% vs. 29.7%), and treating patients according to the SOP was associated with an improved 30-day survival (56.9% vs. 38.9%, OR 2.21, 95% CI 1.01–4.80, p = 0.044). Patient allocation according to the presented SOP significantly improved 30-day survival. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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8 pages, 397 KiB

Open AccessCommunication

Left Ventricular Assist Device Implantation in Cancer-Therapy-Related Heart Failure

by Johanna Mulzer, Marcus Müller, Felix Schoenrath, Volkmar Falk, Evgenij Potapov and Jan Knierim

Life 2022, 12(10), 1485; https://doi.org/10.3390/life12101485 - 24 Sep 2022

Cited by 3 | Viewed by 1419

Abstract

Objectives: Cancer-therapy-related heart failure (CTrHF) due to cardiotoxic drugs or radiation is a growing cause of end-stage heart failure. Limited knowledge is available concerning the use of continuous-flow left-ventricular-assist devices (cfLVAD) in this setting. Methods: The files of all 1334 patients who underwent [...] Read more.

Objectives: Cancer-therapy-related heart failure (CTrHF) due to cardiotoxic drugs or radiation is a growing cause of end-stage heart failure. Limited knowledge is available concerning the use of continuous-flow left-ventricular-assist devices (cfLVAD) in this setting. Methods: The files of all 1334 patients who underwent cfLVAD implantation between December 2008 and December 2020 were screened for the cause of heart failure. All patients with CTrHF were included in the analysis. Results: A total of 32 patients with a median age of 58 years (IQR: 46–65) were included in the study; 15 (47%) were male. The median time from the first diagnosis of heart failure (HF) to cfLVAD implantation was 6 months (IQR 2–24), and from cancer treatment to cfLVAD implantation 40 months (IQR 5–144). Malignancies comprised non-Hodgkin lymphoma (n = 12, 37%), breast cancer (n = 9, 28%), sarcoma (n = 5, 16%), leukemia (n = 5, 16%), and others (n = 1, 3%). In 24 patients, chemotherapy included anthracyclines (others n = 2, unknown n = 6). Chest radiation was performed in 13 patients (39%). Moreover, 71% were classified as INTERMACS profile 1 or 2. The 30-day survival rate after LVAD implantation was 88%. Rethoracotomy was necessary in nine (29%), and a temporary right ventricular assist device in seven (21%) patients. The median survival was 29 months. There was no significant difference in survival or right HF between patients with CTrHF and a matched control group. Conclusions: CfLVAD implantation is feasible in high-risk patients with CTrHF with or without prior chest radiation. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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10 pages, 495 KiB

Open AccessArticle

Bridging with Veno-Arterial Extracorporeal Membrane Oxygenation in Children: A 10-Year Single-Center Experience

by Antonio Amodeo, Milena Stojanovic, Hitendu Dave, Robert Cesnjevar, Alexander Konetzka, Tugba Erdil, Oliver Kretschmar and Martin Schweiger

Life 2022, 12(9), 1398; https://doi.org/10.3390/life12091398 - 08 Sep 2022

Cited by 1 | Viewed by 1152

Abstract

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is frequently used in children with and without congenital heart disease (CHD). This study, of a single-center and retrospective design, evaluated the use and timing of V-A ECMO in a pediatric cohort who underwent V-A ECMO implantation [...] Read more.

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is frequently used in children with and without congenital heart disease (CHD). This study, of a single-center and retrospective design, evaluated the use and timing of V-A ECMO in a pediatric cohort who underwent V-A ECMO implantation between January 2009 and December 2019. The patients were divided into a pre-/non-surgical group and a post-surgical group. Among the investigated variables were age, gender, weight, duration of ECMO, ECMO indication, and ventricular physiology, with only the latter being statistically relevant between the two groups. A total of 111 children (58 male/53 female), with a median age of 87 days (IQR: 7–623) were supported using V-A ECMO. The pre-/non-surgical group consisted of 59 patients and the post-surgical group of 52 patients. Survival at discharge was 49% for the pre-/non-surgical group and 21% for the surgical group (p = 0.04). Single-ventricle physiology was significant for a worse outcome (p = 0.0193). Heart anatomy still has the biggest role in the outcomes of children on ECMO. Nevertheless, children with CHD can be successfully bridged with ECMO to cardiac operation. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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11 pages, 1368 KiB

Open AccessArticle

Benefits of Intra-Aortic Balloon Pump Support in Patients with Postcardiotomy Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation

by Dejan Radakovic, Kiril Penov, Khaled Hamouda, Nodir Madrahimov, Darko Radakovic, Constanze Bening, Rainer G. Leyh and Ivan Aleksic

Life 2022, 12(8), 1195; https://doi.org/10.3390/life12081195 - 05 Aug 2022

Cited by 4 | Viewed by 1757

Abstract

Background: The benefit of the combined use of an intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy shock remains unclear. We aimed to analyse the potential benefits and safety of combining these two devices. Methods: We enrolled 200 patients [...] Read more.

Background: The benefit of the combined use of an intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy shock remains unclear. We aimed to analyse the potential benefits and safety of combining these two devices. Methods: We enrolled 200 patients treated with either VA-ECMO only or in combination with IABP (ECMO-I group) between January 2012 and January 2021. To adjust the patients’ backgrounds, we used propensity score matching for additional analyses, resulting in 57 pairs. The primary endpoint was 30-day survival. Secondary endpoints included successful weaning and complication rates. We also analysed hemodynamic parameters in both groups. Results: After propensity score matching, 30-day survival was better in the ECMO-I group (log-rank p = 0.004). The ECMO-I and ECMO-only groups differed regarding the secondary endpoints, including successful weaning (50.9% and 26.3%, respectively; p = 0.012) and the need for continuous renal replacement therapy (28.1% and 50.9%, p = 0.021). Complication rates were not statistically different between the two groups. Conclusion: Compared to VA-ECMO alone, the combined use of VA-ECMO and IABP is beneficial regarding 30-day survival in selected patients with postcardiotomy shock; successful ECMO weaning and freedom from renal replacement therapy is more common in patients supported with VA-ECMO plus IABP. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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Review

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20 pages, 1775 KiB

Open AccessEditor’s ChoiceReview

Left Ventricular Assist Device as a Destination Therapy: Current Situation and the Importance of Patient Selection

by María Melendo-Viu, David Dobarro, Sergio Raposeiras Roubin, Carmen Llamas Pernas, Candela Moliz Cordón, Miriam Vazquez Lamas, Miguel Piñón Esteban, Maria Ángela Varela Martínez, Emad Abu Assi, Rafael Pita Romero, Juan José Legarra Calderón and Andrés Íñiguez Romo

Life 2023, 13(4), 1065; https://doi.org/10.3390/life13041065 - 21 Apr 2023

Cited by 3 | Viewed by 5528

Abstract

Advanced heart failure is a growing problem for which the best treatment is cardiac transplantation. However, the shortage of donors’ hearts made left ventricular assist devices as destination therapy (DT-LVAD) a highly recommended alternative: they improved mid-term prognosis as well as patients’ quality [...] Read more.

Advanced heart failure is a growing problem for which the best treatment is cardiac transplantation. However, the shortage of donors’ hearts made left ventricular assist devices as destination therapy (DT-LVAD) a highly recommended alternative: they improved mid-term prognosis as well as patients’ quality of life. Current intracorporeal pumps with a centrifugal continuous flow evolved in the last few years. Since 2003, when first LVAD was approved for long-term support, smaller device sizes with better survival and hemocompatibility profile were reached. The most important difficulty lies in the moment of the implant. Recent indications range from INTERMACS class 2 to 4, with close monitoring in intermediate cases. Moreover, a large multiparametric study is needed for considering the candidacy: basal situation, with a special interest in frailty, comorbidities, including renal and hepatic dysfunction, and medical background, considering every prior cardiac condition, must be evaluated. In addition, some clinical risk scores can be helpful to measure the possibility of right heart failure or morbi-mortality. With this review, we sought to summarize all the device improvements, with their updated clinical results, as well as to focus on all the patient selection criteria. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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Other

Jump to: Research, Review

13 pages, 2916 KiB

Open AccessCase Report

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

by Anca Racolta, Jae-Hyun Johannes Ahn, Marinos Kantzis, Hendrik Milting, Volker Lauenroth, Hermann Körperich, Eugen Sandica, Stephan Schubert and Kai Thorsten Laser

Life 2022, 12(11), 1681; https://doi.org/10.3390/life12111681 - 22 Oct 2022

Viewed by 1263

Abstract

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 [...] Read more.

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. Full article

(This article belongs to the Special Issue Advanced Heart Failure Therapy and Mechanical Circulatory Support)

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