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Components of the Continuous-Flow Left Ventricular Assist Device (LVAD). The inflow cannula is inserted into the apex of the left ventricle, and the outflow cannula is anastomosed to the ascending aorta. Blood exits through the left ventricular apex and into the left ventricular assist device, which pumps throughout cardiac diastole and systole into the ascending aorta, with the rotor being the only moving part. The left ventricular assist device pump is placed within the abdominal wall or peritoneal cavity. A percutaneous lead carries the electrical cable to an electronic controller and battery packs, which are worn on a belt and shoulder holster, respectively.
Source publication
The use of left ventricular assist devices is an accepted therapy for patients with refractory heart failure, but current pulsatile volume-displacement devices have limitations (including large pump size and limited long-term mechanical durability) that have reduced widespread adoption of this technology. Continuous-flow pumps are newer types of le...
Context in source publication
Context 1
... pump used in this study was the Heartmate II LVAD (Thoratec), which is a continuous-flow de- vice consisting of an internal axial-flow blood pump with a percutaneous lead that connects the pump to an external system driver and power source (Fig. 1). 10 The pump contains an internal rotor with helical blades that curve around a cen- tral shaft. When the rotor spins on its axis, ki- netic energy is imparted to the blood, which is drawn continuously from the left ventricular apex through the pump and into the ascending aorta. The pump has an implant volume of 63 ml and generates up to 10 liters per minute of flow at a mean pressure of 100 mm Hg. Details of the de- vice's function and the approach to surgical im- plantation have been described elsewhere. 10,14 Follow-up after Device Implantation After implantation of the device, a standardized antithrombotic regimen was implemented with ini- tiation of heparin followed by transition to war- farin as well as aspirin and dipyridamole (see the Supplementary Appendix). Postoperative medical care (including inotropic, antiarrhythmic, and heart-failure therapy) was managed according to each investigator's preference and usual practice. Data on performance of the device and hemody- namics of patients were recorded every 8 hours for 3 days, daily through day 14, and weekly through day 30 while the patient was hospitalized. The re- sults of a physical assessment and laboratory tests and a list of medications were recorded on days 1, 3, 5, 7, 11, 14, 21, and 28 after implantation of the device while the patient was hospitalized. Af- ter 30 days, device measurements, laboratory eval- uations, and physical assessments were required on a monthly ...
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Insertion of a left ventricular assist device (LVAD) improves survival and quality of life (QOL) in patients with class IV heart failure failing medical management. However, QOL and survival of patients bridged to LVAD with extracorporeal membrane oxygenation (ECMO) is unknown. Between July 2008 and June 2014, 213 patients underwent insertion of He...
We report here a successful case of recovery from cardiogenic shock resulting from ischemic cardiomyopathy, treated by using a left ventricular assist device (LVAD). The LVAD was successfully explanted at the time of simultaneous coronary artery bypass grafting and left ventricular restoration after recovery from end-organ dysfunction by LVAD suppo...
We describe the insertion of a permanent implantable left ventricular assist device and intraoperative transoesophageal echocardiography
in this instance. We also review the literature on the use of intraoperative transoesophageal echocardiography.
Chronic unloading of the failing heart with a left ventricular assist device (LVAD) can decrease cardiac mass and myocyte size and has the potential to improve contractile function. To study the effect of chronic ventricular unloading on myocardial gene expression, a microarray (U133A, Affymetrix) profiling gene expression was compared before and a...
The effects of continuous flow left ventricular assist device (CF-LVAD) support on microvascular endothelial function in New York Heart Association (NYHA) class IV heart failure (HF) patients are currently unknown. Microvascular endothelial function was assessed by beat-to-beat plethysmographic measurement of finger arterial pulse wave signal chang...
Citations
... 16 The basic components of a centrifugal VAD consist of an intra-pericardial pump with an inflow cannula, an outflow graft and a percutaneous drive line that connects the pump to an external battery pack and controller ( Figure 1). 12,13,[17][18][19] VADs can be configured to support the left ventricle (LVAD), with an inflow cannula inserted into the left ventricular apex and an outflow graft usually anastomosed to the ascending aorta surgically, usually via a mid sternotomy and using cardiopulmonary bypass. Durable VAD support for the right ventricle (RVAD) is an off-label use of the pump and requires technical modifications. ...
aims: The prevalence of heart failure in New Zealand is increasing. A small number of select patients with predicted poor short-term survival are candidates for advanced heart failure therapies such as transplantation and durable mechanical circulatory support (MCS). The aim of our study was to introduce left ventricular assist devices (LVADs) to the wider clinicians and highlight their role in managing patients with advanced heart failure in New Zealand. method: A retrospective audit of all ventricular assist device (VAD) recipients from January 2005 to December 2022 was conducted. Data were collated using electronic medical and paper records. The primary outcome was survival to transplantation or successful explant of VAD. results: Thirty-nine patients received VADs; 32 were male and seven female. Mean age was 45 years (range 10–64 years). Most recipients were NZ European (25), six were Māori, four were Pacific peoples and four were of other ethnicities. The majority of LVADs were implanted for those with dilated cardiomyopathy (67%). At the time of data collection, 24 (62%) had survived to heart transplantation, seven (18%) died while on VAD support, five from right ventricular failure and two from strokes, one patient had their VAD explanted due to recovery and seven (18%) VAD recipients continue on support awaiting transplant. conclusion: This audit has provided an opportunity to inform New Zealand clinicians of our durable MCS programme and the expanding role of VAD support in patients with advanced heart failure. The programme will need to continue to audit and report its practice in order to provide equitable allocation of this very limited resource to a growing population in need.
... These devices have shown effectiveness in improving outcomes for patients with cardiogenic shock and advanced heart failure [38]. Additionally, the use of continuous-flow left ventricular assist devices has demonstrated significant benefits in improving hemodynamic support and quality of life for patients awaiting heart transplantation [39]. ...
Congestive heart failure (CHF) is a multifaceted clinical syndrome characterized by the inability of the heart to pump blood effectively, leading to inadequate oxygen and nutrient delivery to the body tissues. Despite advancements in treatment strategies, including guideline-directed medical treatment (GDMT), end-stage CHF remains a significant cause of morbidity and mortality worldwide. Heart transplantation is considered to be the gold standard treatment of end stage CHF but constrained by the lack of organ donors, lengthening waitlists, and the negative side effects of lifelong immunosuppressive medications. Mechanical circulatory support (MCS) has emerged as a pivotal intervention for patients with end-stage CHF, serving as a bridge to recovery, transplantation, or destination therapy. The aim of this narrative review is to highlight the historical development of MCS, to assess the recent status of MCS device technology and discuss current challenges associated with complications of MCS that need to be solved in the future by device development. The history of MCS dates back to pioneering efforts in the 1960s, with significant progress in device development and utilization over decades. MCS devices, including left ventricular assist devices (LVADs), extracorporeal membrane oxygenation (ECMO), and artificial hearts, play a crucial role in providing circulatory support to patients with end-stage CHF. Recent advancements in MCS technology aim to decrease the device size, enhance blood compatibility, reduce thrombo-embolic complications, and prolong device durability and battery life and improve physiological performance of MCS. Continued research and innovation are essential to address these challenges and improve outcomes in patients with end-stage CHF. Artificial intelligence (AI) has emerged as a valuable tool in cardiovascular medicine to facilitate risk prediction, patient selection, and treatment optimization for MCS and heart transplantation. Despite these advancements, challenges persist in MCS device selection, resource allocation, and integration of AI into clinical practice. Continued research and innovation are essential to address these challenges and improve outcomes in patients with advanced heart failure.
... Numerous studies have been conducted to evaluate the safety and outcomes of BTT therapy. The most important results and the limitations of research in this area are presented below ( Table 1, Ref. [14][15][16][17][18][19]). While there are earlier studies evaluating LVAD as a destination therapy, we are focusing on the studies evaluating it as a BTT [20]. ...
... In a first uncontrolled, prospective, multicenter study, 133 patients with end-stage HF on the waiting list for HTx underwent implantation of the HM2, an axial continuousflow pump [14]. Within 180 days after implantation, 56 (42.1%) underwent heart transplantation, 32 (23.3%) were still on the active transplant list, while 11 (8.3%) were still eligible for HTx including 4 who preferred to continue MCS. ...
... Bridge-to-transplant left ventricular assist device therapy prior to heart transplantation has yielded positive outcomes but also requires redo-sternotomy. LVAD therapy can provide effective hemodynamic support for patients awaiting heart transplant despite a significant potential for adverse events [2,97]. One study that compared heart transplant outcomes for patients bridged to transplantation with an LVAD to primary heart transplantation patients found exceptionally high survival in LVAD patients [98], though other studies have suggested a negative influence of prolonged LVAD support on post-transplant outcomes [99,100]. ...
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
... The implantation rate of left ventricular assist devices (LVADs) has increased widely over the previous decade, largely driven by the improved reliability, design, and experience of LVAD support. 1,2 These improvements led to more considerate clinical management, less morbidity and mortality, and a higher quality of life. 3,4 Interestingly, despite the advances in LVAD design and medical management of these patients, the implantation technique remained generally unchanged. ...
This study aimed to explore the potential impact of the angular position of the outflow graft on thromboembolic events and aortic valve regurgitation in people with a left ventricular assist device (LVAD). We analyzed contrast computed tomography (CT) data of patients with LVAD implantation between 2016 and 2021. Three-dimensional reconstructions of the outflow graft and aortic arch were performed to calculate the horizontal (azimuth) angle and vertical (polar) angle, as well as the relative distance between the outflow graft, aortic valve, and brachiocephalic artery. Among 59 patients (median age 57, 68% male), a vertical angle ≥107° correlated significantly with increased cerebrovascular accidents (hazard ratio [HR]: 5.8, 95% confidence interval [CI]: 1.3–26.3, p = 0.022) and gastrointestinal bleeding (HR: 3.4, 95% CI: 1.0–11.2, p = 0.049) during a median 25 month follow-up. No significant differences were found between the vertical angle and aortic valve regurgitation or survival. The horizontal angle and relative distance did not show differences regarding clinical adverse events. This study emphasizes the importance of the LVAD outflow graft angular position to prevent life-threatening thromboembolic events. This study suggests the need for prospective research to further validate these findings.
... Postoperatively after LVAD implantation, the right (unsupported) heart is faced with the "hemodynamic challenge" of managing the normalized cardiac output provided by the LVAD and therefore requires special attention to prevent RHF. RHF is a common complication with reported rates of 4-50% and associated with increased morbidity and mortality [7][8][9][10][11]. RHF is still a leading cause of death, especially in the early postoperative phase [12] with a 6-month mortality up to 29% [13]. 2 of 10 However, the pathophysiology of RHF in LVAD patients is not yet fully understood [14,15], but the role of the tricuspid valve is increasingly recognized and TR has been discussed as a root cause or symptom of RHF [16,17]. ...
Objectives: Benefits of tricuspid valve repair (TVR) in left ventricular assist device (LVAD) patients have been questioned. High TVR failure rates have been reported. Remaining or recurring TR was found to be a risk factor for right heart failure (RHF). Therefore, we assessed our experience. Methods: Since 12/2010, 195 patients have undergone LVAD implantation in our center. Almost half (n = 94, 48%) received concomitant TVR (LVAD+TVR). These patients were included in our analysis. Echocardiographic and clinical data were assessed. Median follow-up was 2.8 years (7 days–0.6 years). Results were correlated with clinical outcomes. Results: LVAD+TVR patients were 59.8 ± 11.4 years old (89.4% male) and 37.3% were INTERMACS level 1 and 2. Preoperative TR was moderate in 28 and severe in 66 patients. RV function was severely impaired in 61 patients reflected by TAPSE-values of 11.2 ± 2.9 mm (vs. 15.7 ± 3.8 mm in n = 33; p < 0.001). Risk for RHF according to EUROMACS-RHF risk score was high (>4 points) in 60 patients, intermediate (>2–4 points) in 19 and low (0–2 points) in 15. RHF occurred in four patients (4.3%). Mean duration of echocardiographic follow-up was 2.8 ± 2.3 years. None of the patients presented with severe and only five (5.3%) with moderate TR. The vast majority (n = 63) had mild TR, and 26 patients had no/trace TR. Survival at 1, 3 and 5 years was 77.4%, 68.1% and 55.6%, 30-day mortality was 11.7% (n = 11). Heart transplantation was performed in 12 patients (12.8%). Conclusions: Contrary to expectations, concomitant TVR during LVAD implantation may result in excellent repair durability, which appears to be associated with low risk for RHF.
... Moreover, placement in patients with smaller bodies or left ventricular sizes and even right-sided support became feasible [19][20][21]. CF-LVADs have also demonstrated improved durability (>10 years in some cases), they produce less noise and they are user-friendly [22,23]. Furthermore, the cost effectiveness of LVAD therapy is continuously improving, irrespective of the pre-implant strategy (bridge to transplant or destination therapy), especially with new-generation devices, and this can promote LVAD utilization in more patients and in weaker healthcare systems [24]. ...
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
... Left ventricular assist device (LVAD) implantation is generally recommended as a therapeutic option for patients with advanced left ventricular heart failure and shows improved survival rates, better quality of life, and increased functional capacity compared to medical therapy alone [1][2][3][4]. Although the operative risks of LVAD are well established, prognostic factors that influence long-term postoperative outcome are less well understood. ...
... Not applicable. 1 ...
Background
Left ventricular assist devices (LVAD) are an established treatment for end-stage left ventricular heart failure. Parameters are needed to identify the most appropriate patients for LVADs. This study aimed to evaluate pectoral muscle mass and density as prognostic parameters.
Methods
This single-center study included all patients with LVAD implantation between January 2010 and October 2017 and a preoperative chest CT scan. Pectoral muscle mass was assessed using the Pectoralis Muscle Index (PMI, surface area indexed to height, cm²/m²) and pectoral muscle density by Hounsfield Units (HU). Overall mortality was analyzed with Kaplan–Meier survival analysis and 1-year and 3-year mortality with receiver operating characteristic (ROC) curves and Cox regression models.
Results
57 patients (89.5% male, mean age 57.8 years) were included. 64.9% of patients had end-stage left ventricular failure due to ischemic heart disease and 35.1% due to dilated cardiomyopathy. 49.2% of patients had preoperative INTERMACS profile of 1 or 2 and 33.3% received mechanical circulatory support prior to LVAD implantation. Total mean PMI was 4.7 cm²/m² (± 1.6), overall HU of the major pectoral muscle was 39.0 (± 14.9) and of the minor pectoral muscle 37.1 (± 16.6). Mean follow-up was 2.8 years (± 0.2). Mortality rates were 37.5% at 1 year and 48.0% at 3 years. Neither PMI nor HU were significantly associated with overall mortality at 1-year or 3-year.
Conclusions
The results of our study do not confirm the association between higher pectoral muscle mass and better survival after LVAD implantation previously described in the literature.
... Ventricular arrhythmias (VAS) is defined as episodes of sustained (>30 s) ventricular tachycardia (VT) or any episode of ventricular fibrillation (VF). Ventricular arrhythmias occur in from 20 to 50% of LVAD recipients and are the most significant cause of mortality [6,7]. The majority of ventricular arrhythmias in patients with LVADs are monomorphic, sustained ventricular tachycardia episodes with a re-entrant mechanism related to scar tissue (discussed further later in the article), accounting for up to 80% of cases. ...
Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.
... Originally utilized as a bridge to transplantation (BTT), their usage has evolved to include destination therapy (DT) [1]. Remarkable advancements in LVAD technology have significantly improved the functional status, as well as the quality and duration of life for patients [2]. However, one common complication observed in LVAD patients is gastrointestinal bleeding (GIB), with a meta-analysis reporting a pooled prevalence of 23% (95% confidence interval (CI): 20.5% -27%) [3]. ...
... A history of GIB may also be a confounding factor as it increases the risk of recurrent bleeding in this population [2]. Morgan et al [11] reported that a history of GIB prior to LVAD implantation was the only independent predictor of GIB and was the only significant variable between patients with and without GIB after implantation (21.1% vs. 10.4%, ...
Background
Gastrointestinal bleeding (GIB) is common in left ventricular assist devices (LVADs) patients, but the optimal screening approach before LVAD implantation is still unclear. The aim of the study was to describe our experience with pre- and post-LVAD implantation endoscopic screening and subsequent GI bleeding in this cohort.
Methods
A retrospective review was conducted among all patients who underwent LVAD implantation at Saint Luke’s Hospital, between 2010 and 2020. The data were reviewed to determine the yield and safety of endoscopic procedures performed within 1 month before LVAD placement and the incidence of GIB within 1 year after implantation.
Results
A total of 167 LVAD patients met the inclusion criteria, and 23 underwent pre-implantation endoscopic evaluation. Angiodysplasia had a significantly higher odds ratio (OR) of 9.41 (95% confidence interval (CI): 2.01 - 44.09) in post-LVAD endoscopy, while there was no significant difference in bleeding from other sources such as peptic ulcer disease or diverticular bleeding. There was no difference in the incidence of GIB in patients who underwent endoscopic evaluation pre-LVAD compared to post-LVAD GIB (32.6% vs. 39.1%, P = 0.64). Endoscopy was well-tolerated in this cohort, and argon plasma coagulation was the most commonly used intervention to achieve hemostasis.
Conclusions
According to our results, we recommend against routine pre-LVAD endoscopic screening. Instead, we suggest an individualized approach, where decisions are made on a case-by-case basis.
