МЕХАНИКАЛЫҚ ҚАН АЙНАЛЫМЫН ҚОЛДАЙТЫН ҚҰРЫЛҒЫСЫ ИМПЛАНТАЦИЯЛАНҒАН ЖҮРЕК ЖЕТКІЛІКСІЗДІГІ БАР НАУҚАСТАРДА ВАРФАРИН ДОЗАСЫН ЕСЕПТЕУ

Left ventricular assist devices (LVADs) are frequently used as a bridge to cardiac transplantation and may be useful as long-term therapy. The purpose of this study was to compare the exercise performance of LVAD patients with that of ambulatory heart failure patients. Exercise testing with hemodynamic and respiratory gas measurements was performed in 65 congestive heart failure (CHF) patients (age 53+/-10 years) and 20 LVAD patients (age 49+/-8 years). Peak Vo2 was significantly higher in the LVAD than the CHF patients (CHF, 12+/-3; LVAD, 15. 9+/-3.8 mL . kg-1 . min-1; P<0.001), as was the Vo2 at the anaerobic threshold (CHF, 8.1+/-2.1; LVAD, 12.2+/-2.9 mL . kg-1 . min-1; P<0.001). At rest, mean arterial blood pressure (CHF, 87+/-11; LVAD, 94+/-9 mm Hg) and cardiac output (CHF, 4+/-1; LVAD, 4. 9+/-0.9 L/min) were increased, whereas mean pulmonary artery pressure (CHF, 28+/-11; LVAD, 18+/-4 mm Hg) and pulmonary artery wedge pressure (CHF, 16+/-10; LVAD 5+/-3 mm Hg) were reduced (all P<0.01). At peak exercise, heart rate (CHF,125+/-24; LVAD, 148+/-24 bpm), blood pressure (CHF, 87+/-14; LVAD,96+/-12 mm Hg), and cardiac output (CHF, 7.6+/-2.2; LVAD, 11.2+/-2.6 L/min) were higher (all P<0. 01), whereas mean pulmonary artery pressure (CHF, 48+/-12; LVAD, 30+/-5 mm Hg) and mean pulmonary capillary wedge pressure (CHF, 31+/-11; LVAD, 14+/-6 mm Hg) were lower in the LVAD group (both P<0. 001). In the LVAD patients, Fick cardiac output was higher than LVAD flow sensor value measurements (Fick, 11.6+/-2.5; LVAD, 8.1+/-1.2 L/min; P<0.001). Hemodynamic measurements at rest and during exercise are significantly improved in patients with devices compared with those in ambulatory heart failure patients awaiting cardiac transplantation. Similarly, the exercise capacity of device patients is better than that of transplant candidates and in the majority of patients is similar to that of patients with mild CHF.

Systolic Nonclosure of the Mitral Valve: Two Left Ventricular Assist Device Patients with Pan-Cardiac Cycle Mitral Valve Opening During Shock States

Background The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure. Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven. There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation. To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times. Methods We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively. Results Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p&lt;0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p&lt;0,001), PAP mean (40 vs 22 mmHg, p&lt;0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p&lt;0,001). However, there was no significant increase in peak VO2 after 6 months. 12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1). Conclusion Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.

Left ventricular assist devices (LVAD) are increasingly being used to treat patients in end-stage heart failure to facilitate survival to cardiac transplant or as a bridge to myocardial recovery. The technical innovation of the LVAD has a significant benefit on the patients' physical functioning. However, within the United Kingdom, there has been no systematic evaluation of the psychological adjustment and quality of life (QoL) of patients currently living with an LVAD, or of the differences in QoL for patients who are either explanted or transplanted. To assess the differences in QoL and psychological adjustment for current LVAD patients, patients who have been transplanted from an LVAD and patients in whom the device has been explanted. Twenty-two patients involved in an LVAD programme were recruited (18 men and four women; age range 18-60). Eight patients had an LVAD in situ, six patients had the LVAD explanted and eight had undergone transplantation. QoL and psychological functioning were assessed using previously validated measures. Although there were no significant differences between the three groups, there was a trend for the LVAD patients to have higher levels of anxiety and depression and a lower QoL compared with transplanted or explanted patients. For patients with an LVAD in situ, there was a trend for QoL and psychological functioning to be poorer than for transplanted and explanted patients. Larger studies will be needed to confirm these findings, but psychological assessment and interventions to reduce psychological morbidity and improve QoL will be important in these patients, particularly in view of the increasing numbers of LVADs being implanted and the possibility of their use for long-term "destination" therapy.

Biventricular Pacing Versus RightVentricular Pacing in Patients Supported With LVAD.

Use of CoSeal in a Patient With a Left Ventricular Assist Device

Background: Intracerebral hemorrhage (ICH) in left ventricular assist device (LVAD) patients is a devastating complication. Hematoma expansion (HE) is associated with poor outcomes in ICH patients, but the impact of HE on LVAD patients is not known. Prevention of HE includes rapid and complete coagulopathy reversal, adding further potential complications in LVAD patients given the inherent risk of hardware thrombosis. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality in this population. Methods: We performed a retrospective cohort study of ICH patients with preceding LVAD implantation admitted to Columbia University Irving Medical Center between Jan 2008 and April 2019. Intentionally matched ICH controls without LVADs were identified to compare rate of HE in LVAD and non LVAD patients. ICH volume was measured using ABC/2 method.We defined HE as an increase in hematoma volume of 6 ml or 33% comparing the first and last scan in 24 hours. Demographic data was compared using Pearson’s χ2 test for categorical variables and students T test and Wilcoxon rank sum test for normal and non-parametric continuous variables. The association between HE and hospital mortality in LVAD patients was examined using regression modeling after adjusting for Glasgow coma scale, age, hematoma size and location and admission INR. Results: Of605 LVAD patients, we identified 40 patients with ICH. Of these, 28 patients met the inclusion criteria. Mean (SD) age of LVAD patients was 56 (10), 29% of patients were female and the majority (81%) of LVAD patients were supported by Heartmate II. The median (interquartile range [IQR]) baseline hematoma size was 20.1 ml (8.6-46.9), median (IQR) ICH score was 1 (1-2). HE occurred in 16 (57%) patients supported by LVAD, and in 50% of patients without LVAD with no difference (p=0.6).There was an association between HE and in-hospital mortality in LVAD patients after adjusting for admission ICH score and INR (OR of 20.5, 95% CI: 1.8-232.8). Conclusions: HE is a potentially modifiable risk factor for mortality. We demonstrate that LVAD patients experience HE at a similar rate to matched controls. We show that prevention of HE with anticoagulation reversal does not increase mortality.

Functional Status, Quality of Life and Ventricular Tachyarrhythmias Improve with Right Ventricular Pacing Compared to Biventricular Pacing in LVAD Patients

Micro RNA Expression of Heart Failure Patients and Responses to Left Ventricular Assistant Device Support

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

Introduction: Left ventricular assist device (LVAD) therapy aims to improve LV reverse remodeling, but still &gt;50% of chronic heart failure (CHF) patients show ‘no’ recovery. The current clinical paradigm to assess post-LVAD myocardial recovery relies on ventricular rotational and deformational mechanics. Investigating the role of a pre-LVAD QRS as a potential indicator for post-LVAD LV recovery in CHF patients may help clinicians develop optimal care plans for LVAD patients. Hypothesis: Pre-LVAD short QRS has potential value to be useful as an independent predictor for early myocardial recovery following LVAD implantation. Methods: Chronic and dilated cardiomyopathy patients (n=315) undergoing LVAD implantation were retrospectively studied. Acute HF etiology and post-LVAD follow up (&lt;3 months) were exclusion criteria. Post-LVAD myocardial recovery criteria for responders (R) is defined as post-LVAD implant follow-up LVEF ≥40% and LVIDd ≤6 cm. Non-recovery (NR) criteria is defined as follow-up LVEF &lt;40% and LVIDd &lt; or &gt;6 cm. From 315 LVAD patients, 39 fulfilled the criteria of myocardial recovery as ‘R’. Results: Based on univariate logistic regression, pre-LVAD QRS duration is found to be a predictor of myocardial recovery following LVAD implantation (OR:0.986, 95% CI:0.976-0.996, p=0.005) in LVAD patients. QRS duration is 14.5% longer in the ‘NR’ group as compared with the ‘R’ group (145±36 ms vs 124±37 ms). In multivariate logistic regression, after adjusting for previous thoracotomy, beta-blockers, and a previously evaluated composite score (UCARS) including age, HF duration, and LVEDD, pre-LVAD QRS remains a significant predictor of ‘R’ status (OR:0.983, 95% CL:0.973-0.994, p=0.003). The model shows an accuracy of 0.74 with a p-value of &lt;0.001. Conclusions: Pre-LVAD short QRS interval is associated with post-LVAD LV reverse remodeling in the ‘R’ group, and thus could be of use in a clinical setting for predicting post-LVAD early myocardial recovery.

Heart failure has become one of the fastest growing cardiovascular diagnoses, with estimates as high as 500 000 new cases per year.1,2 This growth is in part a result of the reductions in death from acute coronary syndromes, increased use of implantable cardioverter defibrillators, and improved survival with most cardiovascular interventions, which have led to this continued increase in the number of patients who develop progressive heart failure (HF). The estimated number of people in the United States with the diagnosis of HF may exceed 7 million, based on the estimated average prevalence of 2.6%,3,4 and a census of >300 million population (Figure 1).5,6 HF is clearly age related,1,–,4 with prevalence as low as 0.5% in those 65 years of age.2 This is an important demographic, because it is estimated that the number of people >65 years of age will double in the next 20 to 30 years.4,–,7 HF is not a homogeneous condition. Based primarily on data from recent hospital registries8,9 and other studies,10 nearly half of all patients have HF with preserved systolic function, and the other half have varying degrees of severity of HF with reduced systolic function. Although the prevalence of HF is higher in males at <70 years of age, overall HF is equally common in men and women. Unfortunately, the average survival of patients with either preserved or reduced systolic function is only 40% at 5 years after diagnosis,10,11 and may be as high as 80% when it reaches a refractory stage.12 One study of 3500 patients in Minnesota suggested that there is …

Timing of left ventricular assist device (LVAD) implantation in advanced heart failure patients not on inotropes is unclear. Relevant prediction models exist (SHFM [Seattle Heart Failure Model] and HMRS [HeartMate II Risk Score]), but use in this group is not established. ROADMAP (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients) is a prospective, multicenter, nonrandomized study of 200 advanced heart failure patients not on inotropes who met indications for LVAD implantation, comparing the effectiveness of HeartMate II support versus optimal medical management. We compared SHFM-predicted versus observed survival (overall survival and LVAD-free survival) in the optimal medical management arm (n=103) and HMRS-predicted versus observed survival in all LVAD patients (n=111) using Cox modeling, receiver-operator characteristic (ROC) curves, and calibration plots. In the optimal medical management cohort, the SHFM was a significant predictor of survival (hazard ratio=2.98; P<0.001; ROC area under the curve=0.71; P<0.001) but not LVAD-free survival (hazard ratio=1.41; P=0.097; ROC area under the curve=0.56; P=0.314). SHFM showed adequate calibration for survival but overestimated LVAD-free survival. In the LVAD cohort, the HMRS had marginal discrimination at 3 (Cox P=0.23; ROC area under the curve=0.71; P=0.026) and 12 months (Cox P=0.036; ROC area under the curve=0.62; P=0.122), but calibration was poor, underestimating survival across time and risk subgroups. In non-inotrope-dependent advanced heart failure patients receiving optimal medical management, the SHFM was predictive of overall survival but underestimated the risk of clinical worsening and LVAD implantation. Among LVAD patients, the HMRS had marginal discrimination and underestimated survival post-LVAD implantation. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01452802.

Chronic Mechanical Circulatory Support for Inotrope-Dependent Heart Failure Patients Who Are Not Transplant Candidates: Results of the INTrEPID Trial

Associations of Gene Polymorphism in Kazakhstani Patients with Implanted LVAD