Gastrointestinal Angiodysplasia in Heart Failure and during CF LVAD Support

Introduction: Left ventricular assist devices (LVADs) are increasingly implanted for advanced heart failure either as a bridge to transplantation (BTT) or destination therapy (DT). The reported incidence of cerebrovascular events (CVE) following LVAD is 8-25%. The effects of medical comorbidities and perioperative events on the development of CVE are unclear. Methods: CVEs were retrospectively identified from the Barnes-Jewish Hospital LVAD database consisting of 373 patients with mean LVAD support of 13.5 months (range 0 days-8.2 years); Heartmate II 87%, Heartware 13%. Demographic, clinical, and outcome data were collected and analyzed in patients with and without CVE using standard statistical methods. Results: CVE occurred in 71 patients (19%) at a rate of 0.17 per patient-year 24.5±30.7 months after implantation. Coronary artery disease (P=0.007), diabetes mellitus (P=0.02) and LVAD indication of DT (P=0.04) were more common in patients with CVEs. Duration of cardiopulmonary bypass, hospital length of stay and incidence of bacteremia were not different between those with early CVE (within 30 days of implantation, 35%) and without CVE. CVEs were ischemic (ICVE) in 35 (49%), hemorrhagic (HCVE, including intracerebral, subarachnoid, and subdural) in 26 (37%), and both in 10 (14%). Patients with ICVE and HCVE did not differ in demographic variables, pre-LVAD co-morbidities, post-LVAD complications, NIH Stroke Scale at time of event, or anti-thrombotic regimen (ATR), except that events in those on no ATR were only ischemic. Patients with HCVEs were more likely to be discharged with no ATR (P=0.015). Mortality was significantly higher in patients with CVE (59.1% vs. 29.2% in those without CVE) but did not differ by CVE type. In patients with CVE, 57.1% of deaths were secondary to the CVE (ICVE 25%, HCVE 93.7%, P<0.001). Among BTT patients, only 14.6% with CVE underwent transplantation vs. 39.8% without CVE (P =0.002). Conclusions: CVE remains a serious complication of LVAD support for advanced heart failure and is associated with increased mortality and lower rates of heart transplantation. Further investigations to identify risk factors for CVEs in LVAD patients and potential preventive measures including optimal ATRs are warranted.

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Abstract 2585: Continuous Flow Left Ventricular Assist Devices (LVADs) Effectively Improve Pulmonary Hemodynamics in Bridge-to-Transplant Patients with End-Stage Heart Failure

Circulation ◽

10.1161/circ.116.suppl_16.ii_572-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Forum Kamdar ◽

Andrew Boyle ◽

Monica Colvin-Adams ◽

Kenneth Liao ◽

Lyle Joyce ◽

...

Keyword(s):

Heart Failure ◽

Pulmonary Hypertension ◽

Continuous Flow ◽

Left Ventricular ◽

Pulmonary Hemodynamics ◽

Bridge To Transplant ◽

Transplant Patients ◽

End Stage Heart Failure ◽

End Stage ◽

Lvad Support

Introduction : Pulmonary hypertension is a frequent sequelae of end-stage heart failure and remains a contraindication for cardiac transplantation. Pulsatile LVADs have been shown to effectively reduce pulmonary hypertension in these patients. However, it remains to be seen if newer continuous flow LVADs have a similar effect on pulmonary hypertension. The objective of this study was to determine if the Heartmate (HM) II, a continuous flow LVAD is effective in improving pulmonary hemodynamics in bridge-to-transplant patients. Methods : 30 patients with end-stage heart failure underwent placement of HM II LVAD as a bridge-to-transplant (BTT) at a single center. Pulmonary hemodynamics were evaluated with right heart catheterization at baseline, after placement of an intra-aortic balloon pump (IABP), and post-LVAD (prior to heart transplant). Results : Demographic data of these patients were as follows: mean age 51.6 ± 13.3 years, 70% male, LVEF 14.7 ± 5.11%, 56.6% ischemic etiology and 83.3% received IABP prior to LVAD. Following LVAD support (mean duration of 146. 41 ± 73.83 days), systolic and diastolic pulmonary artery pressures (SPAP and DPAP) decreased significantly (SPAP 56.8 ± 13.55 mmHg, DPAP 28.27 ± 6.23 mmHg to SPAP 35.38 ± 10.23 mmHg, DPAP 15.71 ± 5.36 mmHg; p < 0.001). Similarly, pulmonary vascular resistance (PVR) decreased significantly from 3.69 ± 2.02 to 2.00 ± 0.85 Woods units (p = 0.004). Transpulmonary gradient (TPG) also declined significantly post-LVAD from 13.3 ± 5.6 to 9.35 ± 2.98 mmHg (p = 0.02). Conclusion : Continuous flow LVADs effectively improve pulmonary hemodynamics associated with end-stage heart failure. Therefore, adequate left ventricular decompression achieved with continuous flow LVAD support can reverse significant pulmonary hypertension in end-stage heart failure patients making them eligible for cardiac transplantation.

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94: Diminished left ventricular contractility overtime during LVAD support in ischemic heart failure

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2006.11.109 ◽

2007 ◽

Vol 26 (2) ◽

pp. S93

Author(s):

P.I. McConnell ◽

C.L. Del Rio ◽

P. Kwiatkowski ◽

D.J. Farrar ◽

B.C. Sun

Keyword(s):

Heart Failure ◽

Left Ventricular ◽

Ischemic Heart ◽

Ischemic Heart Failure ◽

Ventricular Contractility ◽

Left Ventricular Contractility ◽

Lvad Support

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Computational Simulation of Cardiac Function and Blood Flow in the Circulatory System under Continuous Flow Left Ventricular Assist Device Support during Atrial Fibrillation

Applied Sciences ◽

10.3390/app10030876 ◽

2020 ◽

Vol 10 (3) ◽

pp. 876 ◽

Cited By ~ 1

Author(s):

Selim Bozkurt

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Continuous Flow ◽

Left Ventricular ◽

Assist Device ◽

Ventricular Assist ◽

Rr Interval ◽

Left Ventricular Assist ◽

Lvad Support ◽

Interval Distribution

Prevalence of atrial fibrillation (AF) is high in heart failure patients supported by a continuous flow left ventricular assist device (CF-LVAD); however, the long term effects remain unclear. In this study, a computational model simulating effects of AF on cardiac function and blood flow for heart failure and CF-LVAD support is presented. The computational model describes left and right heart, systemic and pulmonary circulations and cerebral circulation, and utilises patient-derived RR interval series for normal sinus rhythm (SR). Moreover, AF was simulated using patient-derived unimodal and bimodal distributed RR interval series and patient specific left ventricular systolic functions. The cardiovascular system model simulated clinically-observed haemodynamic outcomes under CF-LVAD support during AF, such as reduced right ventricular ejection fraction and elevated systolic pulmonary arterial pressure. Moreover, relatively high aortic peak pressures and middle arterial peak flow rates during AF with bimodal RR interval distribution, reduced to similar levels as during normal SR and AF with unimodal RR interval distribution under CF-LVAD support. The simulation results suggest that factors such as distribution of RR intervals and systolic left ventricular function may influence haemodynamic outcome of CF-LVAD support during AF.

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Myocardial Fas and Cytokine Expression in End-Stage Heart Failure: Impact of LVAD Support

Clinical and Translational Science ◽

10.1111/j.1752-8062.2008.00056.x ◽

2008 ◽

Vol 1 (3) ◽

pp. 245-248 ◽

Cited By ~ 8

Author(s):

Maninder S. Bedi ◽

Rene J. Alvarez Jr ◽

Toru Kubota ◽

Richard Sheppard ◽

Robert L. Kormos ◽

...

Keyword(s):

Heart Failure ◽

Cytokine Expression ◽

End Stage Heart Failure ◽

End Stage ◽

Lvad Support

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ASSESSMENT OF RECURRENT HEART FAILURE DURING LVAD SUPPORT DUE TO INFLOW CANNULA DYSFUNCTION

ASAIO Journal ◽

10.1097/00002480-200503000-00121 ◽

2005 ◽

Vol 51 (2) ◽

pp. 31A

Author(s):

Brian E Jaski ◽

David A Miller ◽

Sam Baradarian ◽

Robert Adamson ◽

Walter P Dembitsky

Keyword(s):

Heart Failure ◽

Inflow Cannula ◽

Lvad Support

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Impact of heart failure drug therapy on rates of gastrointestinal bleeding in LVAD recipients: An INTERMACS analysis

The International Journal of Artificial Organs ◽

10.1177/03913988211013366 ◽

2021 ◽

pp. 039139882110133

Author(s):

Douglas L Jennings ◽

Lauren K Truby ◽

Audrey J Littlefield ◽

Alana M Ciolek ◽

Dylan Marshall ◽

...

Keyword(s):

Heart Failure ◽

Gastrointestinal Bleeding ◽

Cox Regression ◽

Angiotensin Receptor Blockers ◽

Left Ventricular ◽

Loop Diuretics ◽

Mineralocorticoid Receptor Antagonist ◽

Clinical Variables ◽

Increased Risk ◽

Lvad Support

Introduction: Gastrointestinal bleeding (GIB) remains a common and vexing complication of left ventricular assist device (LVAD) support. Recent single-center analyses suggest that ACE inhibitors (ACEi)/angiotensin receptor blockers (ARB) and digoxin may prevent GIB in LVAD patients. Here we evaluate the effect of guideline-directed medical therapies (GDMT) for heart failure (HF) on rates of GIB through analysis of the INTERMACS registry database. Methods: Thirteen thousand seven hundred thirty-two patients who received a continuous-flow LVAD and were on antiplatelet therapy and anticoagulation with warfarin after 3 months of pump support were included in the analysis. GIB events following implant were assessed based on receipt of ACEi/ARB, beta-blockers (BB), mineralocorticoid receptor antagonist (MRA), amiodarone, digoxin, loop diuretics, and phosphiesterase-5 inhibitors (PDE5). Backwards stepwise cox regression was used to control for confounding of each drug class on each other, as well as for clinical variables like age, gender, renal function, HF etiology, and device strategy. Results: After 3 months of pump support medications used in LVAD patients were BB (65.0%), ACEi/ARB (51.7%), Amio (43.7%), MRA (37.9%), and loop diuretics (70.1%). In patients with available data, PDE and digoxin use were 18.2% and 16.9%, respectively. The overall incidence of GIB was 19.5% at 2 years of support. After adjustment for other clinical variables, loop diuretics (HR 1.274, p < 0.001) and PDE5 (HR 1.241, p < 0.001) use were associated with increased risk of GIB, while use of BB (HR 0.871, p = 0.006) was associated with lower risk of GIB. ACEi/ARB (HR 1.002, p = 0.971), Amio (HR 1.083, p = 0.106), AA (HR 0.967, p = 0.522) or digoxin (HR 1.087, p = 0.169) did not affect GIB rates on LVAD support (Figure). Conclusion: Despite recent reports, ACEi/ARB, MRA, Amio, and digoxin use does not appear to be associated with GIB during LVAD support. The heightened risk seen in those on loop diuretics may reflect venous congestion in these patients, while antiplatelet effects of PDE5 could drive the higher risk of GIB.

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