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The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: A 10- Year Update
... However, involvement of prosthetic material exhibits bio lm-friendly environment and treatment challenges requiring long term treatment consistent to infective endocarditis scheme. According to the International Society of Heart and Lung Transplantation (ISHLT) guidelines a minimum of 2-week therapy is indicated for super cial DLI and 6-8 weeks in case of deep DLI [4]. This poses a great logistic and economic burden mainly attributable to prolong hospital stay. ...
... vancomycin resistant enterococci (VRE), and Streptococcus spp [6]. Complex mechanism of action assures a rapid bactericidal effect and high anti-bio lm activity [4]. The latter could be crucial in case of DLI due to prosthetic material involvement along with Staphylococcus aureus a potent bio lm former. ...
... Treatment failure was de ned as presence of signs, symptoms, laboratory and /or imaging results suggesting presence of active infection despite standard antibiotic therapy in the index hospital stay. According to ISHLT guidelines standard antibiotic therapy is recommended to be continued for 42-56 days [4]. Acute kidney injury (AKI) was de ned as meeting at least stage I injury in line with recommendation by Kormos [7]. ...
Background LVAD utility in heart failure patients is growing. Despite advancement in technology rates of LVAD- related infections remain high limiting outcomes. We aimed to assess the effectiveness and safety of oritavancin for LVAD-related Gram-positive infections. Methods A retrospective study evaluating adult LVAD patients who received ≥ 1 oritavancin dose for treatment of Gram-positive LVAD-related infection between September 2022 and December 2024. Oritavancin was given at the end of shortened standard antibiotic therapy. The primary endpoint was a 90-day clinical and microbiological cure of primary or relapsing infection within 90 days from the first oritavancine dose. Secondary endpoints were adverse events. Results Overall, nine patients were included. All were male, mean age was 53± 9 years. In total they experienced 10 LVAD- related episodes. Most episodes (80%) were deep drive-line infections. Organism most commonly responsible for infection was Staphyloccocus aureus .Oritavancine was administered after a median time of 31 ±13 days of standard antibiotic therapy. In total 18 doses of oritavancine were administered with median of 2 per case separated on average by 20±4 days. Primary endpoint was achieved in 90% of cases, shortening therapy by a median time of 24 days. Serious adverse events occurred in two out of 9 patients: delirium and shiver with marked increase of inflammatory markers. Conclusion Oritavancine has a potential to shorten in hospital therapy and improve outcomes in LVAD-related Gram-positive infections in advanced heart failure patients. The study is the first to report delirium and transient increase in inflammatory biomarkes as side effects.
... In selected end-stage HF patients with infiltrative, restrictive, and hypertrophic CM, heart transplantation is recommended [60], with no significant difference in survival rates amongst patients with restrictive CM compared to non-restrictive CM. However, patients with amyloidosis and cancer-therapy-related restrictive CM showed a decreased longterm survival rate [61]. On the other hand, in specific circumstances, patients are not suitable candidates for heart transplantation or MCS therapy. ...
... Nevertheless, the In selected end-stage HF patients with infiltrative, restrictive, and hypertrophic CM, heart transplantation is recommended [60], with no significant difference in survival rates amongst patients with restrictive CM compared to non-restrictive CM. However, patients with amyloidosis and cancer-therapy-related restrictive CM showed a decreased longterm survival rate [61]. On the other hand, in specific circumstances, patients are not suitable candidates for heart transplantation or MCS therapy. ...
Citation: Baba, D.-F.; Danilesco, A.; Suciu, H.; Avram, C.; Harpa, M.M.; Stoian, M.; Moldovan, D.-A.; Huma, L.; Rusu, G.; Pal, T.; et al. The Effect of Early Spironolactone Administration on 2-Year Acute Graft Rejection in Cardiac Transplant Patients. Abstract: Background: The objective of our study was to investigate the impact of miner-alocorticoid receptor antagonists (MRAs), such as spironolactone, administrated early after cardiac transplantation on the occurrence of acute graft rejection (AGR) in the first 2 years post-transplant. Methods: This retrospective research was conducted in the Emergency Institute for Cardiovascular Diseases and Transplantation of Targu Mures, Romania. After applying the inclusion criteria, between January 2011 and December 2023, 36 patients fit the study design. Using Cox proportional hazards regression and Kaplan-Meier curves, we determined the time-to-event distribution, for which the first episode of AGR was considered an event, with a significance threshold of 0.05. Results: The 1-year rate of AGR was 38.9% and was 47.2% at 2 years, with a 2-year mortality of 11.1%. The interpretation of the Cox regression indicated that early initiation of spironolactone represents a protective factor against the 2-year AGR (HR: 0.263; 95%CI: 0.076-0.922; p = 0.037 by the log-rank test). Conclusions: These results might suggest a possible benefit of the early administration of spironolactone after a heart transplant, but further prospective studies need to be performed for the validation of our findings.
... Due to this progressive nature and significant impact on effective LVAD circulatory support, aortic regurgitation should be treated aggressively at time of LVAD implant. The 2023 ISHLT guidelines [10] recommend that (1) More than mild aortic regurgitation should be addressed at the time of LVAD implant. Aortic valve replacement using a biologic valve should be performed, if necessary and (2) Aortic valve closure techniques may be considered to address more than mild aortic regurgitation in selected patients. ...
... In situations where a significant shunt is discovered after the LVAD with associated clinical challenges as noted above, transcatheter intervention can be performed. The 2023 ISHLT guidelines [10] recommend that (1) Preoperative assessment of the presence of interatrial communication should be performed using TEE and (2) Closure of a significant interatrial shunt should be performed. ...
Left ventricular assist devices (LVADs) have changed the landscape for patients with advanced heart failure (HF). With advances in pump design and management, patients with LVADs are living longer with improved quality of life despite having more comorbidities and complex structural heart disease. As such, HF cardiologists and surgeons collaborate more frequently with structural heart interventionalists to address the complex problems of patients with LVADs who present at different points of failure in their circuits. Unlike heart transplants and total artificial heart recipients, the native heart and its components must function to maintain successful circulatory support from these assist devices. Multiple points of potential failure of the native heart and the LVAD circuit exist that can result in significant morbidity and mortality. These include regurgitant valve lesions, interatrial shunts, outflow cannula obstruction, and pump thrombosis. Transcatheter interventions can be applied and tailored specifically to the anatomy of the individual in these situations to improve the lives and outcomes of our LVAD patients. This review provides a comprehensive approach for diagnosing and treating structural heart disease associated with patients who have LVADs, focusing on multidisciplinary collaboration and individualized interventional strategies.
... Additionally, conflicting evidence surrounding pre-LVAD MR, particularly regarding the benefit of concomitant correction 1,6-12 and the risk of adverse outcomes if left untreated, 5,[13][14][15][16][17] remains to be consolidated. This is reflected in current international guidelines 18 and expert consensus, 19 where the recommendations for concomitant mitral valve surgery for MR have been modified or conditionally included as a weak recommendation. This study aimed to determine whether preexisting MR warrants corrective surgery at the time of LVAD implantation. ...
... To adjust for confounding related to the presence of other valvular diseases, patients with greater than mild aortic regurgitation and greater than moderate tricuspid regurgitation at implantation were excluded, because these have been documented to have a significant impact on LVAD therapy. 18,19 Briefly, aortic regurgitation, due to its unique closed-loop effect, can significantly compromise LVAD performance and is often progressive, and current guidelines recommend intervention for more than mild regurgitation at implantation. The impact of tricuspid regurgitation on LVAD outcomes is less well defined, with conflicting evidence in the literature; thus, the current consensus for intervention is weak but suggested if greater than moderate. ...
Objective
Mitral regurgitation may persist or progress after left ventricular assist device implantation. However, whether preexisting mitral regurgitation should be corrected at the time of implantation remains to be determined.
Methods
A retrospective, registry-based analysis was performed on 1398 continuous-flow left ventricular assist device recipients who underwent implantation between 2010 and 2022. Patients were compared for significant mitral regurgitation, defined as moderate-to-severe or greater mitral regurgitation after implantation, and major adverse events during left ventricular assist device support. Comparisons were made between patients untreated for mitral regurgitation but who had moderate or greater preexisting mitral regurgitation (n = 414) and those who had no or mild preexisting mitral regurgitation (n = 368) (cohort 1), and between patients with moderate or greater mitral regurgitation who underwent concomitant mitral valve surgery (n = 86) and those who did not (n = 414) (cohort 2).
Results
The cumulative incidence of significant mitral regurgitation was higher in patients with untreated moderate or greater mitral regurgitation in both cohorts (P < .001 and P = .025, cohorts 1 and 2, respectively). However, the cumulative incidence of all-cause mortality and readmission, and the risk of other major left ventricular assist device complications such as stroke and right heart failure were comparable between groups in both cohorts. The results were also consistent for the propensity score–matched population created in each cohort.
Conclusions
Significant mitral regurgitation may be prevented by concomitant surgery, but late survival and the risk of other major adverse events were not significantly improved by the procedure and were similar between patients with untreated moderate or greater mitral regurgitation and those with no or untreated mild mitral regurgitation. Our results suggest that mitral regurgitation during left ventricular assist device implantation may have only limited benefits from concomitant surgery.
... Marijuana is legal in several states now, suggesting its use is more acceptable, similar to alcohol and tobacco, rather than an illegal substance. ISHLT task forces encourage the development of guidelines based on data and not subjective judgement [11]. 2023 Guidelines reference studies showing marijuana is linked to decreased adherence, increased rate of infections, and problems with drug interference, and they currently recommend continuing to use a six-month period of abstinence from cannabis prior to listing for transplantation [11]. ...
... ISHLT task forces encourage the development of guidelines based on data and not subjective judgement [11]. 2023 Guidelines reference studies showing marijuana is linked to decreased adherence, increased rate of infections, and problems with drug interference, and they currently recommend continuing to use a six-month period of abstinence from cannabis prior to listing for transplantation [11]. With only data from a single center, it was not possible to evaluate differences in outcomes by substance type. ...
Aim: Patients with active substance use are not eligible for heart transplantation and often undergo left ventricular assist device (LVAD) implantation. We define substance use as use of a substance that precludes transplant such as tobacco products, marijuana, illicit drug use, and excessive alcohol use. The purpose of this study is to describe and compare outcomes in patients with active or recent substance use undergoing LVAD implantation to those who do not use substances. Materials and Methods: We performed a single-center retrospective cohort study of all patients undergoing HeartMate3 implantation during the period from 2017 to 2023. The patients were divided into those who have a current or recent history of substance use (SUD) and those who do not. The primary outcome was survival. And the secondary outcome measures included in-hospital outcomes and readmission rate. The Kaplan Meier method was used to calculate overall survival. An unadjusted multivariate cox proportion hazards model was used to assess differences in survival. Adjusted Poisson regression models were used to determine differences in readmission rates. Results: 177 patients were included, with 55 (31%) of patients using substances at the time of implantation (mainly tobacco products and marijuana). Patients using substances were younger (p<0.001) and had a higher body mass index (p=0.012). Survival (HR 1.51, CI (0.84-2.71)) and in-hospital outcomes were not significantly different between groups (stroke, bleeding, renal failure, days in intensive care, length of stay, mortality). When adjusting for age and INTERMACS score, patients with SUD had significantly higher rates of readmissions compared to those without SUD (IRR: 1.23, 95% CI:1.02-1.50, p=0.035). Conclusions: In conclusion, in a large single-center retrospective cohort study, patients who are using substances at the time of LVAD implantation have the same survival and in-hospital complication rates as patients who are not using substances. When adjusting for age and INTERMACS score, patients who use substances have a higher readmission rate than patients who are not using substances.
... On the premise of adequate left atrial unloading and end-organ perfusion, we had set a lower pump speed to allow for LV washing via aortic valve opening at every heartbeat ( Table 1, Supplementary material online, Videos S2 and S3). 14 The pump speed was set at 4900 rpm, which generated a flow of 3.1-3.5 L/min, a pulse index of 3.5-4.0. ...
Background
A small left ventricular cavity is one of the major limitations of HeartMate 3 implantation. Therefore, innovations in implantation techniques are required to expand the use of HeartMate 3, the only durable ventricular assist device approved by the US Food and Drug Administration for use in adults.
Case summary
A 65-year-old male was diagnosed with multiple myeloma and cardiac amyloidosis. Guideline-directed medical therapy was used to treat heart failure secondary to restrictive cardiomyopathy with a small left ventricle. However, after three chemotherapy courses for multiple myeloma, the patient developed refractory acute decompensated heart failure. He underwent urgent HeartMate 3 implantation as a bridge to chemotherapy. We adopted the left atrium-to-aorta configuration for HeartMate 3 implantation and performed transseptal left atrial cannulation using a modified Intergard Woven vascular graft. After discharge, the patient resumed chemotherapy on postoperative day 172 and achieved complete response on postoperative day 259. At the time of writing this report, he has been supported with HeartMate 3 for 36 months, and no major adverse events have been recorded.
Discussion
In most reports of transseptal left atrial cannulation for durable ventricular assist device implantation, a 20-mm ringed Gore-Tex graft was used as the interposition conduit. Some technical difficulties with this graft have been described. Thus, we decided to modify the Intergard Woven graft as the interposition conduit. The favorable outcome in our patient could suggest the potential of extended support with the left atrium-to-aorta configuration of HeartMate 3 for patients with a small left ventricle.
... The annual number of bone grafting and bone replacement procedures performed globally is estimated to exceed four million, with projections indicating a significant increase in the next few decades as life expectancy rises [1]. Regrettably, despite promising advances in titanium-based implants, the 10-year failure rate of these implants stands at close to 20 %, a statistic that imposes substantial financial burdens on patients and inflicts significant physical and psychological pain [2]. The key to successful implantation lies in enhancing the functional integration between bone implants and surrounding bone tissue, or osseointegration [3][4][5]. ...
Background
Titanium-based implants have demonstrated good mechanical properties and biocompatibility in clinical applications, however, their inherent low bioactivity and complex biological behaviors during the process of osseointegration have resulted in a high rate of long-term implant failure. Although the immobilization of highly bioactive peptides on the implant surface is an effective strategy to improve osseointegration, the existing mono- and bifunctional peptide-modified implant surfaces can hardly meet the needs of cell behavior regulation and tissue regeneration during the process of osseointegration, and there is an urgent need for the development of more efficient surface modification technologies.
Methods
In the present study, a multifunctional peptide-modified implant material, MPN@K6, was successfully prepared by linking one end of a tripeptide system (cell adhesion peptide RGD, osteogenic growth peptide OGP, and pro-angiogenic peptide ang), which possesses a specific biological function, to hexameric lysine, and constructing the tripeptide system on the surface of metal-polyphenol coatings (MPNs) by means of non-covalent interactions between the lysine and the polyphenol, and then the MPN@K6 - RGD/OGP/ang was used as a peptide modification. RGD/OGP/ang.
Results
The MPN@K6-RGD/OGP/Ang coating not only supported the early adhesion and migration, late osteogenesis and mineralization of BMSCs, but also promoted the adhesion, migration and vascularization of HUVECs. RT-qPCR results showed that the hybrid peptide up-regulated the expression of key factors in angiogenesis and osteogenesis. In vivo testing further confirmed these findings, with the functional peptide coating being 1.5 to 2 times more effective at inducing new bone formation at an early stage than the other two-peptide combinations, confirming the effectiveness and superiority of the tripeptide synergistic modification strategy.
Conclusions
The results showed that the MPN@K6 - RGD/OGP/ang-modified implant exhibited significant advantages at the cellular level compared to different combinations of bifunctional peptide-coated forms. It was able to promote early cell migration and adhesion more efficiently, significantly induced osteoblast differentiation and mineralization, and enhanced the level of local vascularization. In a rat bone defect animal model, the material demonstrated more excellent bone repair effects and achieved better bone healing results, confirming the effectiveness and superiority of the tripeptide synergistic modification strategy.
The translational potential of this article
The trifunctional peptide coating (MPN@K6 - RGD/OGP/Ang) constructed in this paper has a mild preparation process, is biologically safe, facilitates large-scale production, has a positive effect on bone tissue repair, and has a great potential for clinical application in orthopedic and dental implants.
... The copyright holder for this preprint this version posted April 28, 2025. investigator (first author) who carried out all the experiments as detailed in the supplementary pages (10)(11)(12)(13)(14)(15)(16). ...
Introduction: Percutaneous left ventricular assist devices (pLVADs) have become essential tools during coronary reperfusion in high risk PCI. Significant reduction in infarct propagation is observed when mechanical unloading is coupled with reperfusion, but little is known of the effect this reduction in wall stress and extracellular matrix with pLVADs have on the hearts regenerative capacity.
Objective: This study investigates the effect coronary reperfusion coupled with mechanical unloading has on myocardial fibrosis, and the impact these changes in extracellular matrix have on the hearts regenerative potential.
Methods: MI was induced by coronary artery ligation in Lewis rats. Hearts underwent permanent coronary ligation (AMI) or were reperfused after 90 minutes (AMI/R). In each group, hearts were either loaded (AMI-L or AMI/R-L) or unloaded (AMI-U or AMI/R-U). In the unloaded subgroup, the infarcted hearts were explanted after 90 minutes and transplanted into the abdomen of healthy recipients via heterotopic abdominal heart-lung transplantation. The recipient's heart acted as control. Hearts were analysed on day 7.
Results: 30 hearts were studied. In the permanent ligation group, fibrosis increased in both the loaded and unloaded hearts with no significant rise in cardiomyocyte proliferation. After coronary reperfusion, there was a decrease in fibrosis with mechanical unloading and cardiomyocyte proliferation rose significantly (AMI/R-L vs AMI/R-U p= 0.0001). Cardiomyocyte proliferative rate in the loaded and unloaded hearts was 0.6%, and 3.7% respectively after permanent ligation, and 0.5%, and 10.4% respectively after coronary reperfusion.
Conclusion: These data show that coronary reperfusion coupled with mechanical unloading reduces myocardial fibrosis and upregulates cardiomyocyte proliferation after myocardial infarction.
... 8 The ISHLT consensus guidelines for the management of MCS-specific/related infections recommend (a) prompt institution of empiric, systemic antimicrobial therapy, tailored to microbiologic assessments, (b) consideration for surgical drainage, with or without NPWT (negative pressure wound therapy) using VAC (vacuum-assisted closure) dressings, then (c) antibiotic therapy, pathogen specific, for 6-8 weeks followed by long-term antibiotic suppression. 13,14 For definitive cure, or for addressing recalcitrant infections, it has been recommended that transplant listing or device exchange should be considered. ...
Background
LVAD infections are associated with substantial morbidity and mortality. We explored the impact of surgical Omentoplasty (OMP) added to Incision and Debridement (I&D) plus Antibiotic therapy (AB) on survival and infection-related readmissions in patients with LVAD infections.
Methods
Thirty-three patients with deep LVAD-specific infections were studied over a period of 12 years. Survival and readmissions for recurrent infection in subjects receiving I&D and ABs alone (Group A, n = 15) were compared to those in whom OMP was added to I&D and ABs (Group B, n = 18).
Results
Baseline characteristics were similar between groups, as well as infectious organisms. Two-year survival was significantly improved in Group B (OMP + I&D + ABs) as compared to Group A (I&D + ABs without OMP) [77% vs. 7%; p < 0.001]. Recurrent infection-related readmissions were notably lower in Group B compared to Group A (0.18 vs. 0.24 admissions/patient-year), with a significant reduction within Group B following the application of OMP (0.13 to 0.06 admissions/patient-year). Following OMP, intravenous (IV) antibiotics were successfully replaced with oral long-term ABs in the 78% of patients. No long-term antibiotic-related complications were noted.
Conclusion
This report, comprising the most extensive such experience to date, indicates that combining surgical Omentoplasty (OMP) with incision and debridement (I&D) plus antibiotic (AB) treatment is remarkably effective for suppressing deep LVAD infections, improving survival and decreasing infection-related readmissions. Filling the open space around an implanted LVAD with highly vascularized omentum, as a living tissue with anti-infective properties, appears to be effective for improving outcomes with LVAD infections.
... Data from cardiac implantable devices were also included in the analysis. Indications for HTx were based on guidelines [13]. ...
Background
Several predictors of atrial fibrillation (AF) onset in patients with hypertrophic cardiomyopathy (HCM) have been proposed, however, all of them showed limited accuracy. This study aims to assess the role of new echographic parameters in predicting AF onset and major adverse cardiovascular outcomes (cardiovascular death or heart transplantation).
Methods
Clinical and imaging data from 141 patients with HCM and without a history of AF were retrospectively analyzed over a 5-year period. Patients who developed AF during the study were compared to those who did not. The analysis focused on key atrial parameters, including the Left Atrial Contraction Index (LACI) and Left Atrial Ejection Fraction (LAEF). LACI was defined as the ratio of left atrial end-diastolic volume to left ventricular end-diastolic volume. Echocardiographic measurements were standardized using cardiac magnetic resonance (CMR) as the reference. Regarding statistical analysis, each significant continuous variable was categorized by identifying a cut-off value using the Youden index. Independent associations with outcomes and cumulative survival were assessed using Cox regression analysis.
Results
Thirty-five patients developed AF, at a mean time of 4 years. The HCM-AF group had significantly higher values of LACI, left atrial diameter (LAD), and left atrial minimum volume (LAVmin). A LACI > 43% on echocardiography and LACI > 44% on CMR showed the best performance in identifying patients at risk for AF. In multivariate analysis, an echocardiographic LAEF < 43% was independently associated with the occurrence of AF (HR 2.9, 95% CI: 1.2–6.9). Additionally, a LAD > 40.5 mm was independently associated with AF onset, with a hazard ratio of 2.5 (95% CI 1.1–5.5). Eleven patients experienced the composite outcome of cardiovascular death or heart transplant, and a LACI > 60% was associated with this outcome.
Conclusion
In patients with HCM, both LACI and LAEF were significantly associated with the occurrence of AF over a 4-year period, demonstrating higher sensitivity and specificity compared to other parameters. A LACI > 60% was also found to be associated with cardiovascular death or heart transplant in this population.
Graphical Abstract
Evaluation of left atrial morpho-functionl parameter using multimodality imaging, and their association with atrial fibrillation in HCM patients. The figure summarizes the main findings of the present article. AF: atrial fibrillation; CMR: cardiac magnetic resonance; HCM: hypertrophic cardiomyopathy; TTE: transthoracic echocardiography; LACI: left atrioventricular coupling index; LAEF: left atrium ejection fraction.
... Echocardiography remains the primary imaging modality for routine assessment in this cohort of patients due to its accessibility, low cost, and the inherent MRI-incompatibility of many D-LVADs. Despite its widespread use, echocardiography currently has a minimal role in the 2023 INTERMACS guidelines [4] for the monitoring and diagnosis of RVF in patients outside the peri-operative period. Current guidelines recommend hemodynamic assessment via right heart catheterization as the gold standard for assessing pressures; repeated and routine invasive assessments are impractical in this largely outpatient population. ...
Background
Late‐onset Right Ventricular (RV) failure is an established complication of Durable Left‐Ventricular Assist Device (D‐LVAD) implantation. Transthoracic echocardiography (TTE) remains the primary imaging modality for serial monitoring in this population, but its interpretation remains challenging due to device‐related changes in RV size and function and a lack of guidelines addressing this impact. This study aims to examine the diagnostic and prognostic utility of TTE parameters of RV size and function in the detection of late‐onset RV failure post‐implantation.
Methods and Results
A systematic literature search of medical databases was performed to identify all relevant studies assessing TTE parameters in adult patients with D‐LVADs (January 2003–August 2023; English only). Of the 350 studies identified, nine studies with a pooled cohort of 627 patients and three studies with a pooled cohort of 175 patients (40 Cases and 135 controls) were meta‐analyzed across a range of structural and functional TTE parameters. Compared to World Alliance Societies of Echocardiography (WASE) reference values, this population had dilated RV size (as quantified by RVEDD) and reduced systolic function (as quantified by TAPSE, RVFAC, and RVEF). TAPSE was positively associated with the non‐RVF group, while RVEDD was negatively associated with the non‐RVF group.
Conclusions
Based on the available studies, there was baseline RV dilatation and reduced systolic function in patients with D‐LVADs. Additionally, TAPSE and RVEDD demonstrated a statistically significant association with the development of RVF post‐implantation, indicating a potential role as prognostic markers. Further studies should also be conducted to establish post‐implantation TTE reference values.
... Although renal dysfunction is not listed as a contraindication for LVAD therapy in the guidelines, some centers still consider severe renal dysfunction (eGFR <40 mL/min/1.73 m 2 ) as a relative contraindication, mainly because of the increased mortality risk after LVAD implantation in these patients (11)(12)(13)(14). Moreover, current guidelines lack recommendations for selecting between heart transplantation or LVAD implantation in patients with end-stage HF combined with renal dysfunction (eGFR <90 mL/min/1.73 ...
Background:
Renal function is a crucial factor affecting the prognosis of patients with end-stage heart failure (HF). The differential impacts of heart transplantation and left ventricular assist device (LVAD) implantation on renal function are unclear. Therefore, we compared the perioperative renal function changes in patients who underwent heart transplantation with that of patients who underwent LVAD implantation.
Methods:
This study included 77 patients who underwent heart transplantation and 59 patients who underwent LVAD implantation at five hospitals between January 2019 and December 2023. These patients were divided into two groups based on surgery type: heart transplantation or LVAD implantation. The estimated glomerular filtration rates (eGFRs) before surgery and on postoperative days (PODs) 1, 7, and 30 were compared. A subgroup analysis was conducted for patients with preoperative renal dysfunction, and paired-samples t-tests were used to compare renal function changes before and one month after surgery.
Results:
Patients in the LVAD group were older (56.4 vs. 44.4 years, P<0.001) and had lower preoperative eGFRs (72.5 vs. 91.3 mL/min/1.73 m2, P=0.001) than patients in the heart transplantation group did. On POD 1 and POD 7, the LVAD group continued to have a lower eGFR than the heart transplantation group. The baseline eGFRs were not significantly different (63.3 vs. 60.4 mL/min/1.73 m2, P=0.44) in patients with preoperative renal dysfunction (eGFR <90 mL/min/1.73 m2). However, on PODs 1, 7, and 30, the eGFR in the LVAD group was significantly greater than that in the heart transplantation group. By POD 30, renal function in the LVAD group had recovered to near-normal levels (60.4-87.6 mL/min/1.73 m2), whereas in the heart transplantation group, the eGFR remained close to the preoperative level (63.3-63.4 mL/min/1.73 m2). In the LVAD group, the eGFR significantly increased on POD 30, with 84.7% (50/59) of the LVAD patients showing varying degrees of improvement in renal function. In the heart transplantation group, patients' eGFRs on POD 30 were comparable to their preoperative values, with more than half of them showing a decreased eGFR. Among the patients with preoperative renal dysfunction, 10 without a history of preoperative continuous renal replacement therapy (CRRT) underwent postoperative CRRT in the heart transplantation group; nine of them died within three months of transplantation. In the LVAD group, three patients without preoperative CRRT support required CRRT postoperatively, with one case of early mortality.
Conclusions:
For patients with end-stage HF and concurrent renal dysfunction, compared to heart transplantation, LVAD implantation with this new device resulted in significantly improved renal function. With no malfunctions, the device operated in a safe and effective manner and was successfully managed to improve renal function.
... The intersection of obesity and heart failure, particularly heart failure with reduced ejection fraction (HFrEF), is an ongoing challenge in contemporary cardiology. 1 Obesity is an independent risk factor for the development of heart failure, worsens the course of HFrEF and limits access to life-saving interventions like cardiac transplantation. 2,3 Recent evidence indicates that greater adiposity increases HFrEF related morbidity and mortality, contrasting earlier studies suggesting a protective effect of obesity on mortality in advanced heart failure. [4][5][6][7] The International Society of Heart Lung Transplantation eligibility guidelines for cardiac transplant recommend a body mass index (BMI) less than 35 kg/m 2 due to higher perioperative complications and poorer outcomes with obesity. ...
Background
Obesity in patients with heart failure with reduced ejection fraction (HFrEF) increases morbidity and may preclude them from accessing advanced heart failure therapies. Bariatric surgery, specifically sleeve gastrectomy (SG), may improve eligibility for cardiac transplant; however, its impact on heart failure outcomes is not well defined.
Methods
We conducted a retrospective cohort study of patients with obesity (body mass index [BMI] ≥35 kg/m²) and (left ventricular ejection fraction [LVEF] ≤40%) who underwent SG at a tertiary heart transplant center. Outcomes were compared with controls matched for age, sex, LVEF, and BMI receiving standard care. We evaluated BMI, New York Heart Association (NYHA) functional class, medications, echocardiographic parameters, time to advanced heart failure therapies, and survival.
Results
Twenty patients (median BMI 42.8 kg/m², LVEF 25%) underwent SG compared to 40 matched patients. Both groups demonstrated reductions in BMI; however, weight loss was significantly greater in the treatment group (−9.9 [95% CI −12.2, −7.6] vs. −2.7 [−4.3, −1.1] kg/m², p < 0.05). Despite this, improvements in LVEF (+16.6% [10.2, 23.0] vs. +0.1% [−4.4, 4.7], p < 0.05) along with NYHA class (−0.8 [95% CI: −1.3, −0.3] vs. +0.4 [0.1, 0.7], p < 0.05) were only observed in those receiving SG. Overall survival was significantly higher in the treatment group [HR: 0.2 (0.07, 0.62), p < 0.01], which had no deaths compared to 35% in the comparison group.
Conclusion
In patients with HFrEF and obesity, SG is associated with significant improvements in cardiac function and survival compared to standard care, supporting its role as a safe and effective bridge to recovery or candidacy.
... The indication for LVAD implantation followed established international guidelines. [20][21][22] Besides, the selection of candidates for CH-VAD implantation was conducted by a multidisciplinary heart failure team, ensuring a comprehensive evaluation of patient suitability. Patients were all diagnosed with end-stage heart failure refractory to optimal medical therapy (NYHA Class IIIb or IV), and reduced left ventricular ejection fraction (LVEF < 30%). ...
The CH-VAD is a fully magnetically levitated left ventricular assist device (LVAD) designed for optimized hemocompatibility. This study evaluates the clinical outcomes of 77 patients implanted with the CH-VAD across seven centers in China from June 2022 to June 2024. Patients had a mean age of 57.5 years, primarily classified as INTERMACS 2 or 3, with dilated and ischemic cardiomyopathy as the main causes of heart failure (HF). The study reported a 91.6% survival rate at both 6-month and 1-year follow-ups, aligning with international LVAD outcomes. Key adverse events were infrequent, including low rates of right HF, reoperation for bleeding, and driveline infection. Importantly, no pump thrombosis or device failures were noted. The results suggest that the CH-VAD is a reliable and effective long-term mechanical circulatory support option for end-stage HF patients in China, warranting further studies for long-term efficacy evaluation.
... Furthermore, routine replacement of a well-functioning mechanic mitral valve was not recommended. 17 The current study documents similar overall survival, but important differences in the morbidity associated with the presence of a mechV in patients with congenital heart disease. In particular, there was an increase in hemorrhagic stroke and major bleeding among patients with a mechV. ...
... 92 LVAD implantation could also be contraindicated in irreversible severe chronic kidney disease (CKD): patients with CKD Stage IV and V are associated with increased morbidity and mortality in the postoperative period, hence they should be carefully selected for LVAD and an initial support with a temporary device to evaluate a potential renal recovery before implanting can be considered. 93,94 Other absolute contraindications include severe hepatic or neurological disease (i.e. recent stroke), systemic illness with a life expectancy of <2 years or malignancy within 5 years. ...
With the increasing prevalence of mitral transcatheter edge-to-edge repair (mTEER), there is higher likelihood that patients with end-stage heart failure will present for left ventricular assist device (LVAD) with a mTEER device in place. The decision to remove a mTEER device or leave it will likely be guided by intraoperative echocardiography performed and interpreted by the cardiac anesthesiologist. Interpretation of intraoperative echocardiographic findings in these cases can be erroneous if specific attention is not given to important caveats.
Background: The novel method of non-invasive right ventricular (RV) myocardial work (MW) analysis provides a load-independent assessment of RV function by combining myocardial strain with loading conditions. However, its use has not been well described in the perioperative setting to date. We aimed to evaluate the feasibility of assessing RV MW, and to describe the perioperative course of this new technique. Methods: In this retrospective study, patients scheduled for LVAD surgery were evaluated for feasibility of RV MW analysis. Preoperative (T1) and postoperative (T2) transthoracic echocardiography (TTE) included the assessment of conventional echocardiographic measurements, myocardial strain, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) for the evaluation of RV function. Results: Ten patients had complete TTE data available for RV MW analysis, which indicated significant reduction of effective and ineffective RV MW (GWI, 212 mmHg% (IQR 128; 266) v 96 mmHg% (IQR 63; 150), P = 0.02; GCW, 331 mmHg% (IQR 263; 476) v 198 mmHg% (IQR 136; 274), P < 0.01; GWW, 171 mmHg% (IQR 102; 243) v 98 mmHg% (IQR 48; 153), P = 0.04), while GWE remained stable (69% (IQR 37; 78) v 64% (IQR 61; 78), P = 0.26) after LVAD implantation. Conventional parameters were not able to detect these changes. Moreover, there were different trends of RV MW indices in patients with and without postimplant RV failure. Conclusion: This study demonstrates that non-invasive RV MW assessment is feasible in the perioperative setting of LVAD implantation and provides valuable insights into RV function that are not captured by conventional echocardiographic methods. Further research is warranted to validate these findings.
The impact of hemolysis during microaxial flow pump (mAFP; Impella, Danvers, Massachusetts, US) support on early outcomes after durable left ventricular assist device (d-LVAD) implantation is unknown. Three hundred and eleven consecutive patients undergoing d-LVAD implantation after mAFP support (Impella 5.0/5.5 72.3%) were retrospectively included. The incidence and predictors of hemolysis (plasma-free hemoglobin >20 mg/dl or lactic dehydrogenase (LDH) >2.5-fold the upper reference limit) before d-LVAD implantation were assessed, along with its impact on early post-d-LVAD outcomes. The primary outcome was a composite of hemocompatibility-related adverse events (HRAEs: stroke/gastrointestinal bleeding/pump thrombosis). Hemolysis occurred in 40.8%. Impella 2.5/CP versus 5.0/5.5 was the single independent predictor of hemolysis (adj-hazard ratio [HR] = 2.68, 95% confidence interval [CI] = 1.04–6.94, p = 0.031). Post-d-LVAD HRAEs occurred more frequently among patients with hemolysis (31.9% vs. 20.6%; p = 0.041), mainly driven by hemorrhagic stroke and gastrointestinal bleeding. At multivariate analysis, hemolysis remained independently associated with HRAEs (adj-HR = 1.62, 95% CI = 1.02–2.58; p = 0.041). Patients with hemolysis were more likely to need a temporary right ventricular assist device following d-LVAD implantation (28.3% vs. 16.8%; p = 0.012), with no difference in mortality (23.6% vs . 21.2%; p = 0.355). In conclusion, among patients undergoing d-LVAD implantation with mAFP bridge, hemolysis is common, occurs more frequently among patients supported with Impella 2.5/CP, and is an independent predictor of post-d-LVAD HRAEs.
Bridging with low-molecular-weight heparin (LMWH) is recommended in continuous-flow left ventricular assist device (CF-LVAD) patients during subtherapeutic international normalized ratios (INRs). We aimed to assess the risk of adverse events during bridging in patients implanted at Leiden University Medical Center between 2010 and 2024. Incidence rates and hazard ratios of major bleeding, thromboembolic events, neurologic complications, and death with 95% confidence intervals (95% CI) were estimated by time-dependent Cox regression. Using a regression discontinuity design, we mimicked a trial by comparing patients during LMWH treatment due to a subtherapeutic INR to patients during INRs just in target range and no LMWH, considering INRs ±0.1, ±0.2, ±0.3, ±0.4, and ±0.5 around the lower INR target range. Ninety-two patients were included, with a median age of 63 years, 73 (79%) were male and 43 (47%) had Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 3. Major bleeding rates were increased during bridging in all analyses. Bridging had 3.7-fold (95% CI, 1.6–8.7) increased major bleeding risk compared with no bridging considering INRs ±0.1, and 2.8-fold (95% CI, 1.4–5.5) considering INRs ±0.5. Thromboembolic events were infrequent and not different between the two groups. Neurologic complications occurred more frequently during bridging. Moreover, the risk of mortality was 25.0-fold (95% CI, 3.6–173.1) increased during versus no bridging. Therefore, bridging should be considered with caution in CF-LVAD patients.
Cardiovascular disease remains a leading cause of morbidity and mortality in adults despite recent scientific advancements. Although people are living longer lives, there may be an adverse impact on quality of life, necessitating a greater need for palliative care services and support. Palliative care for adults with advanced cardiovascular disease has the potential to significantly improve quality of life for individuals living with cardiovascular disease and their informal care partners. Effective communication, shared decision-making, age-friendly care principles, and advance care planning are vital components of palliative care and support comprehensive and holistic care throughout the advanced cardiovascular disease trajectory and across care settings. Current evidence highlights the benefits of palliative care in managing symptoms, reducing psychological distress, and supporting both people with cardiovascular disease and their care partners. However, significant gaps exist in palliative care research related to non–heart failure populations, care partner outcomes, and palliative care implementation in diverse populations. This scientific statement (1) discusses the application of effective communication, shared decision-making, age-friendly care, and advance care planning in advanced cardiovascular disease palliative care; (2) provides a summary of recent evidence related to palliative care and symptom management, quality of life, spiritual and psychological support, and bereavement support in individuals with advanced cardiovascular disease and their care partners; (3) discusses issues involving diversity, equity, and inclusion in cardiovascular disease palliative care; (4) highlights the ethical and legal concerns surrounding palliative care and implanted cardiac devices; and (5) provides strategies for palliative care engagement in adults with advanced cardiovascular disease for the care team.
Heart transplant remains the treatment of choice for patients with advanced heart failure (HF). However, due to a lack of donor organs, left ventricular assist devices (LVADs) have been used as a bridge until donor organs become available. Recently, we have observed more patients with advanced HF being placed on LVAD as destination therapies, particularly in patients with contraindications to heart transplantation. Acute kidney injury (AKI) post‐LVAD implantation is common. Even with renal recovery, these patients are surviving longer and hence it is not uncommon for them to eventually develop chronic kidney disease (CKD), potentially progressing to end‐stage kidney disease (ESKD) requiring kidney replacement therapy (KRT). There remains a paucity of published literature to guide prescription and management of LVAD recipients on long‐term maintenance KRT, particularly in the community setting. Even the latest international guidelines on mechanical circulatory support (MCS) fail to provide adequate guidance for the management of such patients. We present a case of a patient who was on LVAD for 2 years prior to developing ESKD and share our experience of transitioning her from an inpatient hospital setting to the community haemodialysis centre with the help of a multi‐disciplinary care team consisting of the cardiothoracic surgeon, cardiologist, nephrologist, LVAD coordinators, and the community haemodialysis centre nursing team. We aim to share the considerations in management of LVAD recipients on maintenance haemodialysis in a community dialysis centre and how we cared for such a patient. With an increasing prevalence of LVAD patients with renal impairment potentially requiring KRT, a standardised multidisciplinary team approach will be essential to ensure better care for these patients in the immediate post‐operative setting and offer these patients the option of eventual discharge to the community.
As left ventricular assist device (LVAD) use expands to include more critically ill patients, identifying and mitigating preoperative risk factors, such as peripheral arterial disease (PAD) and use of temporary mechanical circulatory support (tMCS) essential. This retrospective cohort study included patients who underwent HeartMate 3 (HM3) implantation from 2015 to 2023. Patients were divided into those with severe PAD and those without as well as the use of tMCS. The primary outcome was the incidence of vascular complications, defined as the development of dry gangrene, need for lower extremity amputation, or revascularization. Secondary outcomes included stroke, renal failure, death during implant hospitalization, and overall survival. Of the 197 patients who underwent HM3 implantation, 22 (11%) were identified as having severe PAD sonographically. Vascular complications were significantly more common in patients with severe PAD (23% vs. 4%, p = 0.005). There were no significant differences in other complications such as renal failure, stroke, or death during implant hospitalization. Multivariable unadjusted analysis revealed that both PAD, postoperative tMCS, and femoral cannulation site independently increased the odds of vascular complications, whereas in the adjusted model preoperative tMCS was associated with vascular complications. These findings underscore the importance of preoperative risk stratification and tailored perioperative management.
Introduction
Durable left ventricular assist devices (LVADs) improve outcomes for advanced heart failure (HF) patients. Vericiguat, which enhances HF outcomes by affecting systemic and pulmonary vasculature, may benefit LVAD patients as well.
Methods
The study aimed to investigate the safety and efficacy of Vericiguat in patient on LVAD support. This retrospective analysis included patients supported with LVAD who were treated with Vericiguat. Safety outcomes comprised LVAD‐related hemocompatibility‐related adverse events (HRAE) and Vericiguat adverse events. Efficacy outcomes included changes in NYHA functional class and NT‐proBNP levels.
Results
We identified eight HeartMate3 patients treated with Vericiguat. Median age was 65 years‐old, 87.5% were men, and median duration on Vericiguat therapy was 254 days (161–272). None of the patients had experienced HRAE, adverse events related to Vericiguat or died. A reduction in pulmonary capillary wedge pressure was observed (17 [16–23.5] vs. 9 [6.5–11] mmHg, p = 0.06), along with an increase in cardiac index (from 1.9 [1.5–2.6] to 2.1 [1.8–3.2] L/min/m ² , p = 0.12) and right ventricle stroke work index (5.4 [4.1, 7.0] vs. 7.5 [6.9, 9.2] g/m/beat/m ² , p = 0.043). NT‐proBNP levels (2171 [779–3366] vs. 1677 [406–2490] pg/mL, p = 0.438) decreased but did not reach statistical significance.
Conclusions
Preliminary results suggests that Vericiguat therapy in LVADs is safe and indicates a trend toward improved efficacy.
Objective
The HeartMate 3(HM3) has become among the most widely utilized durable left ventricular(LV) assist devices(LVAD) owing to reduced rates of pump thrombosis, bleeding, and stroke. One limitation of the HM3 is its large size which poses a challenge for implantation in smaller LVs. Herein, we describe a novel technique for durable LVAD implantation in patients with a small LV.
Methods
Patients who underwent durable LVAD implantation from 01/2020–08/2024 were included in this study. The modified technique involved excision of the mitral valve and associated apparatus to create room for the LVAD inflow. The primary outcome was mortality and secondary outcomes included rates of postoperative complications and hemodynamic parameters. Patient follow-up was until September 2024.
Results
Eleven patients were included in this study. All patients received a HM3. The median preoperative LV end-diastolic diameter was 5.1cm. The median total time on LVAD was 149 days, and overall mortality was 27.2% occurring a median of 204 days post-LVAD implantation. Four patients (36.4%) underwent heart transplantation and four (36.4%) were alive on LVAD at last follow-up. Proportions of morbidity including readmission for heart failure (n=2, 18.2%), cerebrovascular accident (n=2, 18.2%), and pump thrombosis (n=0).
Conclusions
The small LV has been a significant challenge for durable LVAD insertion and is often considered a contraindication. A modified approach to LVAD insertion including excision of the MV and associated apparatus and alignment of the LVAD inflow cannula with the MV orifice allows for LVAD implantation in patients with a small LV.
Left ventricular assist device (LVAD) outflow graft obstruction (OGO) is a serious complication that often requires surgical intervention. Standard approaches involve cardiopulmonary bypass (CPB) or veno-arterial extracorporeal membrane oxygenation (vaECMO) to facilitate outflow graft clamping and shortening. We present a surgical approach to reduce the need for CPB or vaECMO for outflow graft shortening. A 25-year-old female presented for routine LVAD follow-up with reduced device flow. Computed tomography angiography (CTA) revealed OGO due to external compression from accumulated material between the outflow graft and bend relief, along with graft elongation. To correct this, we performed outflow graft revision and shortening using a Dacron prosthesis as a bypass from the proximal to the distal outflow graft, avoiding CPB or vaECMO. LVAD flow was immediately restored postoperatively, and the patient recovered without complications. Follow-up CTA confirmed full resolution of the obstruction with no recurrence. Managing LVAD outflow graft obstruction is particularly challenging when accompanied by elongation. The basket-handle technique offers a safe and effective alternative to traditional methods, allowing for outflow graft shortening without CPB or vaECMO, thereby reducing procedural risks and promoting faster patient recovery.
Background
Prior studies of anticoagulation bridging during periods of low International Normalized Ratio (INR) in outpatients with a durable, continuous flow left ventricular assist device (CF‐LVAD) have shown a variable impact on thrombotic and bleeding events. These studies include predominantly older devices such as the HeartMate 2 (HM2) and HeartWare HVAD, which are known to experience more overall thrombotic events than the HeartMate 3 (HM3) device. The majority of these patients also received concomitant aspirin.
Methods
The primary objective of this study was to compare hemocompatibility‐related adverse events (HRAEs) occurring while bridging subtherapeutic (≤ 1.7) INRs with therapeutic low‐molecular weight heparin (LMWH) versus not bridging in outpatients with an HM3 CF‐LVAD, many of whom were not receiving concomitant aspirin.
Results
Of the 79 patients eligible for inclusion in this study, 64 were not bridged and 15 were bridged at least once during the study period. In the non‐bridged group, there were a total of 12 HRAEs of 997 bridging opportunities (BOs) (1.20%) versus 0 of 39 BOs in the bridged group. Of the 12 HRAEs in the non‐bridged group, 10 were bleeding events; the 2 thrombotic events were minor venous thromboembolisms.
Conclusion
Omission of LMWH bridging in HM3 CF‐LVAD patients with a subtherapeutic INR and low rates of background aspirin use did not result in a statistically significant or clinically relevant increase in the rate of HRAEs.
Purpose
Reoperative durable left ventricular assist device (LVAD) insertion after coronary artery bypass grafting (CABG) is challenging due to potential injury to bypass grafts, great vessels, or the right ventricle (RV). We sought to compare the less invasive (LI) approach to the full sternotomy (FS) technique for LVAD implantation in patients with a prior history of CABG.
Methods
From March 2012 to April 2023, 29 patients with a history of CABG underwent reoperative LVAD implantation: Group FS, N = 16, and Group LI, N = 13. The LI approach includes an upper hemisternotomy and left thoracotomy without dissecting around the RV and bypass grafts.
Results
The median age was 68 years in Group FS and 70 years in Group LI ( p = 0.83). HeartMate II was only used in group FS (FS: 56.3% [ N = 9] vs. LI: 0%), whereas HeartWare (FS: 31.3% [ N = 5] vs. LI: 53.8% [ N = 7]) and Heartmate 3 (FS: 12.5% [ N = 2] vs. LI: 46.2% [ N = 6]) were used in both groups. None of the patients experienced intraoperative injury of bypass grafts. In isolated LVAD implantation, cardiopulmonary bypass time was comparable between groups (FS: 92 [68, 96] min vs. LI: 82 [61, 96] min, p = 0.33). The incidence of severe RV failure requiring mechanical support was lower in Group LI (FS: 43.8% [ N = 7] vs. LI: 0%, p = 0.02). Hospital mortality was numerically lower in the LI group (FS: 31.3% [ N = 5] vs. LI: 9.1% [ N = 1], p = 0.35). One‐year estimated survival rates were not significantly different (FS: 68.8% ± 11.6% vs. LI: 81.8% ± 11.6%, p = 0.85).
Conclusions
The less invasive technique for reoperative LVAD insertion after CABG may improve outcomes by reducing RV failure.
As the prevalence of heart failure is increasing globally, left ventricular assist devices (LVADs) have become essential therapeutic options in managing advanced heart failure. This review explores the development of LVAD technology, with a focus on the shift from pulsatile to continuous-flow devices, particularly the HeartMate 3, the most advanced generation of LVADs. The evolution in design has significantly enhanced patient survival and quality of life. However, hemocompatibility-related adverse events (HRAEs)—such as pump thrombosis, ischemic and hemorrhagic strokes, and gastrointestinal bleeding—remain major clinical challenges. Striking the delicate balance between preventing thromboembolic events and minimizing hemorrhagic risks remains critical in LVAD patient management. Current therapeutic strategies typically involve long-term anticoagulation with vitamin K antagonists and antiplatelet therapy, though optimal management must be individualized based on patient-specific factors and device characteristics. Emerging alternatives, including low-dose anticoagulation, direct oral anticoagulants such as apixaban, and aspirin-free regimens, offer promising potential to reduce adverse outcomes. This review also highlights the role of innovative mechanical designs in minimizing shear stress and alternative treatments in preventing complications like gastrointestinal bleeding. Despite these advancements, personalized treatment strategies are critical, as no single therapeutic regimen fits all LVAD recipients. Ongoing research into both device technology and pharmacological therapies is essential to further reduce HRAEs and improve long-term outcomes for LVAD patients.
Background
There is a rising number of patients with left ventricular assist devices (LVADs) undergoing non-cardiac procedures, both emergent and elective. Historically, anesthetic options for these patients have been limited to general anesthesia. Limited data exists for the use of neuraxial anesthesia in patients with LVADs despite its common use in orthopedic procedures for non-LVAD patients. Given the benefits of neuraxial anesthesia and the rising population of LVAD patients undergoing elective procedures, a better understanding of LVAD patients’ candidacy for neuraxial anesthesia needs further investigation.
Case presentation
We report the case of a patient with an LVAD who successfully underwent a total knee arthroplasty with neuraxial anesthesia at a tertiary academic center. Preoperative transthoracic echo demonstrated stable cardiac function and an ejection fraction of 10–15% with a HeartMate 3 LVAD. The primary anesthetic was a lumbar epidural that was slowly titrated to a surgical anesthetic level and an adductor canal peripheral nerve catheter was placed preoperatively for postoperative analgesia. The patient remained hemodynamically stable throughout the case, with a perfusionist monitoring the LVAD’s function intraoperatively, and tolerated the anesthetic well. His postoperative course was uneventful.
Conclusion
Patients with LVADs should be considered candidates for neuraxial anesthesia with appropriate preoperative planning and perioperative management.
In an ever-evolving landscape of cardiovascular medicine, staying at the forefront of clinical excellence is paramount. These comprehensive guidelines serve as a guide in the pursuit of the highest standards of patient care. Developed through the collaborative efforts of leading experts, these guidelines provide a roadmap for healthcare professionals, offering evidence-based recommendations, best practices, and innovative approaches to address the diverse spectrum of cardiac conditions. Within these pages, you will find a wealth of knowledge to inform your decision-making, enhance patient outcomes, and ultimately, contribute to the well-being of individuals with end-stage heart disease who require durable mechanical support. In the rapidly advancing realm of cardiovascular medicine, the need for precise guidance in mechanical circulatory support has never been greater. We proudly present a summary of the updated Cardiac Clinical Guidelines for Mechanical Circulatory Support, a definitive resource that stands at the forefront of innovation in advanced cardiac care. Crafted by a distinguished panel of experts, these guidelines encapsulate the latest evidence-based recommendations, cutting-edge technologies, and best practices in the field of mechanical circulatory support.
Objectives
The mortality rate of acute myocardial infarction (AMI)‐related refractory cardiogenic shock (rCS) remains high, particularly in patients experiencing cardiac arrest with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to evaluate the outcomes of early escalation to CentriMag for AMI‐induced out‐of‐hospital cardiac arrest (OHCA) with ECPR.
Methods
Patients with AMI‐induced OHCA with refractory to ECMO support after ECPR were enrolled. Clinical data were analyzed to identify predictive factors for mortality and survival benefits.
Results
Eighty‐nine patients were enrolled, of whom 26 underwent CentriMag implantation. The 1‐year survival rate for those with the implantation was 34.6%. In contrast, those without implantation showed a survival rate of 7.9%. The average time from the initiation of ECPR to CentriMag implantation was 22.5 ± 14.6 h. The surgical mortality group exhibited a larger body surface area, longer intervals from CPR to ECPR, shorter duration of CentriMag support, and higher preoperative serum creatinine and postoperative day 1 serum aspartate aminotransferase levels. A prolonged interval from CPR to ECPR was identified as an independent risk factor for mortality. Extended duration of CentriMag support was associated with improved survival outcomes.
Conclusions
Early CentriMag implantation rescues patients experiencing AMI‐related OHCA with rCS and refractory to ECMO support after ECPR. This intervention provides a critical time window, serving as a safe bridge to decision.
OBJECTIVES
This fourth report aimed to provide insights into patient characteristics, outcomes, and standardized outcome ratios of patients implanted with durable Mechanical Circulatory Support across participating centers in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) registry.
METHODS
All registered patients receiving durable mechanical circulatory support up to August 2024 were included. Expected number of events were predicted using penalized logistic regression. Standardized outcome ratios (Observed/Expected events) were presented in plots to assess 30-day and 1-year mortality, ischaemic stroke, and major bleeding outcomes. Expected events were estimated using penalized logistic regression using demographics and comorbidities as predictors. Centers with <90% follow-up completeness were excluded from standardized outcome ratio assessment.
RESULTS
Analysis included 6962 implants in 6408 patients (457 patients underwent repeated implants) registered in EUROMACS from 17 countries (32 centres) (median age: 58 years, 83% males, 17% INTERMACS class 1). Thirty-day mortality, major bleeding and ischaemic stroke probabilities were 9.6, 12.6%, and 2.1%, respectively. Standardized mortality ratios showed variability between centres, ranging from 0 (95% CI : 0–0) to 1.4 (95% CI : 1.2–1.7). Higher standardized bleeding outcome ratios correlated with higher standardized ischaemic stroke ratio’s (Spearman r: 0.56, P = 0.008).
CONCLUSIONS
Most included centers perform as expected given the demographics and comorbidities of patients. A positive correlation was found between standardized bleeding and ischaemic stroke ratios, reflecting the need of continuously monitoring of adverse events by quality improvement programs.
For many decades, heart transplantation has been the “gold standard” for terminal chronic heart failure resistant to medical therapy treatment. However, there is a significant number of patients with contraindications to orthotopic heart transplantation. The only effective treatment method for these patients may be the implantation of long-term mechanical circulatory support systems. This article provides information for practicing physicians on the evolution of long-term mechanical circulatory support systems, the main criteria for selecting patients for implantation, and the specifics of their subsequent outpatient monitoring.
BACKGROUND
Patients with end-stage heart failure and low pulmonary capillary wedge pressure are referred to as cold and dry and represent an understudied minority in whom the benefit of left ventricular assist device (LVAD) therapy is unclear.
METHODS
Adults receiving LVADs between 2006 and 2017 in the Interagency Registry for Mechanically Assisted Circulatory Support database were classified as cold and wet (pulmonary capillary wedge pressure >15 mm Hg) and cold and dry (pulmonary capillary wedge pressure ≤15 mm Hg) based on pre-LVAD hemodynamics obtained via right heart catheterization. The primary outcome was 1-year survival. Secondary outcomes were rehospitalizations, change in 6-minute walk test distance, change in Kansas City Cardiomyopathy Questionnaire, and change in EuroQol questionnaire scores 1 year after LVAD.
RESULTS
Our study included 10 310 patients with complete clinical, echocardiographic, and functional capacity profiles. The median follow-up was 364 days (interquartile range, 326–381 days). Overall, the mean pulmonary capillary wedge pressure before LVAD implantation was 25±9 mm Hg. Cold and dry patients comprised 15% of the cohort and were more frequently female, had smaller mean body size, smaller mean left ventricular size, and better mean baseline renal function. Compared with cold and wet patients, cold and dry patients also had better baseline functional capacity and quality of life and experienced milder improvements after LVAD: EuroQol (+0.11 versus +0.17; P =0.001), Kansas City Cardiomyopathy Questionnaire (+26 versus +31; P =0.031), and 6-minute walk test distance (+194 feet versus +340 feet; P =0.026). There was no statistically significant difference between the rate of hospitalizations ( P =0.76), adverse events, and mortality (log-rank P =0.81) at 1 year between the 2 groups.
CONCLUSIONS
In cold and dry patients with end-stage heart failure, LVADs are associated with milder but significant improvements in functional capacity and quality of life with a similar incidence of adverse events and survival at 1 year.
A distinction between infections of left ventricular assist devices (LVADs) and cardiac implantable electronic devices (CIEDs) is warranted as they differ markedly in incidence, microbiologic profiles, clinical presentations, and extraction feasibility. These differences necessitate tailored suppressive antibiotic therapy (SAT) strategies. This commentary highlights the need for device-specific SAT approaches.
Cardiogenic shock (CS) is associated with significant mortality. Advances in pharmacological therapies and mechanical circulatory support (MCS) devices have markedly improved the therapeutic approach to CS, though treatment efficacy and safety vary. The recent DanGer shock trial showed a significant reduction in 6-month mortality for CS patients due to acute myocardial infarction. Future randomised trials should evaluate a phenotype-guided pharmaco-MCS approach to the management of CS. This paper summarises contemporary pharmacological and MCS treatments for patients with CS.
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