Reversibility of fixed pulmonary hypertension in left ventricular assist device support recipients

Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery (Impact Factor: 3.3). 02/2011; 40(4):971-7. DOI: 10.1016/j.ejcts.2011.01.019
Source: PubMed


Conflicting data still exist concerning the reversibility of secondary severe 'fixed' pulmonary hypertension (PH) by the use of left ventricular assist device (LVAD) support in terms of time necessary to provide a bridge to 'transplantability'.
We retrospectively reviewed 145 patients with heart failure and severe PH treated by LVAD support between 2000 and 2009. There were 133 men (91.7%) and 12 women (8.3%) with a mean age of 52.95±12.01 years. Patients were divided into two groups depending on preoperative PH reversibility. Fixed PH was defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg, a pulmonary vascular resistance (PVR) >2.5 Wood Unit (WU) and a transpulmonary gradient (TPG) >12 mmHg, despite pharmacological treatment.
Fifty-six patients had fixed PH (group A) and 89 reversible PH (group B). Only 27 patients of group A underwent right heart catheterization evaluation during LVAD support; the remaining 29 patients had other contraindications to heart transplantation (HTx). The 27 patients were divided into three subgroups on the basis of examination time during LVAD support: <6 months (11 patients), between 6 and 12 months (six patients) and >12 months (10 patients). The mPAP, PVR, and TPG decreased significantly during LVAD support (mPAP, 37.26±6.35 mmHg vs 21.00±7.51 mmHg, p=0.007; PVR, 3.49±1.47 WU vs 1.53±0.66 WU, p=0.000; and TPG, 15.04±5.22 mmHg vs 7.78±3.21 mmHg, p=0.019). A significant reduction of all parameters was observed during the first 6 months and later on there was no further decrease. There were no significant differences between the three subgroups (mPAP, p=0.680; PVR, p=0.723; and TPG, p=0.679) in terms of time of reversibility. LVAD support allowed 19 patients to be transplanted.
Patients with fixed PH can be treated with LVAD support. Our data suggest that 6 months after LVAD implantation it is possible to observe an important reduction of PH and evaluate the potential transplantability of patients. Longer support does not add any effect of LVAD on PH.

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Available from: Antonio Loforte, Sep 29, 2015
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    • "A ventricular assist device effectively reverses pulmonary hypertension and offers benefits such as unloading of the failing left ventricle as well as improved functional capacity, quality of life and survival. This can allow for cardiac orthotopic transplantation (bridge to heart transplant) in patients who were not initially considered candidates (Mikus et al. 2011; Torre-Amione et al. 2010). This study has clinical relevance for these individuals, suggesting that LVAD and heart transplanted patients may suffer from a subtle and subclinical interoceptive imbalance that may impact their social cognition abilities. "
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    ABSTRACT: Recent advances in neuroscience have provided new insights into the understanding of heart-brain interaction and communication. Cardiac information to the brain relies on two pathways, terminating in the insular (IC) and anterior cingulate (ACC) cortices, along with the somatosensory cortex (S1-S2). Interoception relying on these neuroanatomical pathways has been shown to modulate social cognition. We report the case study of C.S., a patient with an “external heart” (an extracorporeal left-univentricular cardiac assist device, LVAD). The patient was assessed with neural/behavioral measures of cardiac interoception complemented by neuropsychological and social cognition measures. The patient’s performance on the interoception task (heartbeat detection) seemed to be guided by signals from the artificial LVAD, which provides a somatosensory beat, rather than by his endogenous heart. Cortical activity (heart-evoked potential, HEP) decreased in comparison to normal volunteers, particularly during interoceptive states. The patient accurately performed several cognitive tasks, expect for empathy, theory of mind and decision-making. This evidence suggests an imbalance in the patient’s cardiac interoceptive pathways that enhances sensation driven by the artificial pump over that from the cardiac vagal-ICC-ACC pathway. A patient with two hearts, one endogenous and one artificial, presents a unique opportunity to explore models of interoception and heart-brain interaction.
    Social Cognitive and Affective Neuroscience 01/2013; 24(11). DOI:10.1093/scan/nst108 · 7.37 Impact Factor
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    • "There appears to be an expanding role for the LVAD as a bridge to heart transplant in the management of patients with severe left ventricular systolic HF and PH. Several studies in patients with systolic HF and severe PH have demonstrated that an elevated PVR despite pharmacologic therapy is often reduced to <2.5 Wood units over a 6 month time period following LVAD placement [58–62]. Retrospective, observational data analysis has also established that in patients in whom the pulmonary pressure improves with LVAD therapy as bridge to transplant, there is no statistical difference in subsequent posttransplant survival compared to patients without PH [60, 61]. "
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    ABSTRACT: Pulmonary hypertension (PH) is the end result of a variety of diverse pathologic processes. The chronic elevation in pulmonary artery pressure often leads to right ventricular pressure overload and subsequent right ventricular failure. In patients with left-sided cardiac disease, PH is quite common and associated with increased morbidity and mortality. This article will review the literature as it pertains to the epidemiology, pathogenesis, and diagnosis of PH related to aortic valve disease, mitral valve disease, left ventricular systolic and diastolic dysfunction, and pulmonary veno-occlusive disease. Moreover, therapeutic strategies, which focus on treating the underlying cardiac pathology will be discussed.
    Pulmonary Medicine 05/2011; 2011(2090-1836):381787. DOI:10.1155/2011/381787
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    ABSTRACT: Congest Heart Fail. 2011;17:189–198. © 2011 Wiley Periodicals, Inc. Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequently encountered in patients with advanced heart failure (HF). Both conditions aggravate prognosis and influence clinical decisions. Echocardiography is the screening tool of choice for pulmonary pressures and RV function, although invasive assessment of PH is necessary when advanced therapies are considered. Reversibility of PH in response to short-term pharmacologic treatment or even to long-term unloading after left ventricular assist device (LVAD) implantation is a favorable prognostic sign for both medically treated patients and heart transplant candidates. Although patients with severe PH secondary to HF have not derived benefit from pulmonary arterial hypertension therapies thus far, agents that modulate the cyclic guanosine monophosphate pathway, including phosphodiesterase 5A inhibitors, hold promise and are being actively investigated in advanced HF. Therapies that lead to reduction in left-sided pressures, including cardiac resynchronization and LVAD placement, also have a favorable effect on pulmonary pressures and RV function. However, no specific medical treatment for RV dysfunction exists to date, highlighting an important gap in the management of patients with advanced HF. Congest Heart Fail.
    Congestive Heart Failure 07/2011; 17(4):189-98. DOI:10.1111/j.1751-7133.2011.00234.x
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