The progress of mechanical circulatory support devices / 中国胸心血管外科临床杂志

@#As a global disease, heart failure affects at least 26 million people, and its prevalence is still rising. Besides, the mortality rate and readmission rate remain high. Advanced heart failure is the terminal stage of various heart diseases, and often requires some treatments other than drug intervention, such as heart transplantation which is the gold standard for treatment of heart failure. However, limited by the number of donors, the number of heart transplants in the world has reached a bottleneck. There is a huge gap between the number of patients who need heart transplants and patients who get hearts for survival successfully in reality. With the exploration and development of mechanical circulation support devices for more than half a century, they have become a wonderful treatment for patients with advanced heart failure. This article will introduce the latest progress of mechanical circulatory support devices at home and abroad from the aspects of temporary and long-term devices.

Dispositivos de asistencia ventricular en el shock cardiogénico posinfarto: importancia del soporte hemodinámico: reporte de caso / Ventricular assist devices in post-infarction cardiogenic shock: importance of hemodynamic support: case report / Dispositivos de assistência ventricular no choque cardiogênico pós-infarto: importância do suporte hemodinâmico: relato de caso

El shock cardiogénico posinfarto caracterizado por un estado de insuficiencia circulatoria sistémica requiere de un tratamiento precoz en vistas a restablecer la estabilidad hemodinámica y la función ventricular. Este consta de la reperfusión coronaria mediante revascularización miocárdica; en algunos casos es necesaria la utilización de dispositivos de asistencia ventricular. El ECMO venoarterial es un sistema de circulación extracorpórea que permite un soporte biventricular oxigenando la sangre y reintroduciéndola mediante un flujo continuo hacia la circulación arterial sistémica. El uso de dicho dispositivo en pacientes con shock cardiogénico ha mostrado una mejoría significativa de la sobrevida a 30 días en comparación con el uso del balón de contrapulsación intraaórtico. No obstante, sus potenciales complicaciones, como dificultad en el vaciamiento ventricular izquierdo, síndrome de Arlequín, sangrados e infecciones, hacen fundamental la formación y el trabajo en equipo del heart team. Un porcentaje no menor de estos pacientes presentarán una severa disfunción ventricular permanente, por lo que podrían ser candidatos a dispositivos de asistencia ventricular izquierda de larga duración tipo Heartmate III como puente al trasplante cardíaco, el cual ha mostrado resultados satisfactorios con una excelente sobrevida a mediano plazo.

Post-infarction cardiogenic shock characterized by a state of systemic circulatory failure requires early treatment in order to restore hemodynamic stability and ventricular function. This consists of coronary reperfusion through myocardial revascularization, requiring in some cases the use of ventricular assist devices. Veno-arterial ECMO is an extracorporeal circulation system that allows biventricular support by oxygenating the blood and reintroducing it through a continuous flow towards the systemic arterial circulation. The use of this device in patients with cardiogenic shock has shown a significant improvement in survival at 30 days compared to the use of intra-aortic balloon pump. However, its potential complications, such as difficulty in left ventricular emptying, Harlequin syndrome, bleeding and infections, make the training and teamwork of the heart team essential. A great percentage of these patients will present a severe permanent ventricular dysfunction, so they could be candidates for long-term mechanical circulatory support devices like Heartmate III as a bridge to transplant or myocardial recovery, or destination therapy, which has shown satisfactory results with excellent medium-term survival.

O choque cardiogênico pós-infarto caracterizado por um estado de insuficiência circulatória sistêmica requer tratamento precoce para restabelecer a estabilidade hemodinâmica e a função ventricular. Esta consiste na reperfusão coronariana por meio de revascularização miocárdica, necessitando, em alguns casos, do uso de dispositivos de assistência ventricular. A ECMO venoarterial é um sistema de circulação extracorpórea que permite o suporte biventricular oxigenando o sangue e reintroduzindo-o através de um fluxo contínuo para a circulação arterial sistêmica. O uso desse dispositivo em pacientes com choque cardiogênico mostrou melhora significativa na sobrevida em 30 dias em relação ao uso de contrapulsação com balão intra-aórtico. No entanto, suas potenciais complicações, como dificuldade de esvaziamento ventricular esquerdo, síndrome de Harlequin, sangramentos e infecções, tornam imprescindível o treinamento e o trabalho em equipe do time do coração. Não uma pequena porcentagem desses pacientes apresentará uma condição ventricular permanente grave, podendo ser candidatos a dispositivos de assistência ventricular esquerda de longa duração do tipo Heartmate III como ponte para o transplante cardíaco, que tem demonstrado resultados satisfatórios com excelente sobrevida em médio prazo.

Utilización de oxigenación por membrana extracorpórea venoarterial en el shock cardiogénico y paro cardiorrespiratorio refractarios: experiencia inicial de 7 años en un centro de cardiología de adultos / Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock and Cardiac Arrest: An Initial 7-Year Experience in an Adult Cardiology Center

RESUMEN Introducción: La oxigenación por membrana extracorpórea venoarterial (ECMO VA) es una intervención de rescate en pacientes con shock cardiogénico (SC), y paro cardiorrespiratorio (PCR) refractarios a las terapias convencionales. Objetivo: Describir las características, y resumir nuestra experiencia inicial de 7 años de pacientes que requirieron ECMO VA por SC o PCR. Material y métodos: Se realizó un estudio de cohorte unicéntrico. Se analizaron retrospectivamente los pacientes adultos consecutivos que fueron asistidos con ECMO VA por SC o PCR refractarios entre 2014 y 2020 en el ICBA Instituto Cardiovascular. Resultados: Se incluyeron 54 pacientes, (54 ± 12 años). El 36,5% presentó miocardiopatía isquémica, y el 23,1% enfermedad valvular significativa. Las indicaciones para ECMO VA fueron: poscardiotomía (43,4%), SC refractario (28,3%), y falla primaria del injerto (20,8%). La reanimación cardiopulmonar previa a la ECMO VA se realizó en el 18,5%. La canulación fue periférica en el 81,5%, el 83,3% se asistió en INTERMACS 1, y el 87% presentaba balón de contrapulsación intraaórtico. La duración de asistencia en ECMO VA fue de 5,5 días (RIC 2,8-10). La tasa de supervivencia en ECMO VA fue del 63% (37% puente a trasplante cardíaco, y 26% recuperación), y al alta del 42,6%. Las complicaciones más frecuentes fueron: sangrado (61,1%), infección (51,9%), y complicaciones tromboembólicas (46,3%). Conclusión: La ECMO VA como tratamiento del SC o PCR refractarios en nuestro centro presentó una sobrevida aceptable al alta hospitalaria. La ECMO VA es un tratamiento efectivo cuando las terapias convencionales fallan, siendo aparentemente útil y aplicable en un país donde existe acceso limitado a los dispositivos de asistencia ventricular compleja.

ABSTRACT Background: Venoarterial extra corporeal membrane oxygenation (VA-ECMO) is a rescue intervention used in patients with cardiogenic shock (CS) or cardiac arrest (CA) refractory to conventional medical therapies. Objective: The aim of the present study is to describe the characteristics and summarize our 7-year experience in patients with CS or CA supported with VA-ECMO. Methods: We conducted a single-center retrospective study analyzing consecutive adult patients requiring VA-ECMO due to refractory CS or CA at ICBA, Instituto Cardiovascular between January 2014 and December 2020. Results: A total age 54 patients were included (54 ± 12 years), 36.5% presented ischemic cardiomyopathy and 23.1% significant valvular heart disease. The indications for VA-ECMO implantation were post-cardiotomy (43.4%), refractory CS (28.3%) and primary graft dysfunction (20.8%). Cardiopulmonary resuscitation before VA-ECMO occurred in 18.5% of the cases. Peripheral cannulation was performed in 81.5% of the cases, 83.3% had INTERMACS profile 1 and 87% were on intraaortic balloon pump. Duration of ventricular assistance on VA- ECMO was 5.5 days (IQR 2.8-10). Survival rate on ECMO VA was 63% (37% as a bridge to cardiac transplantation and 26% as a bridge to recovery) and survival to discharge was 42.6%. The most common complications were hemorrhage (61.1%), infections (51.9%), and thromboembolic complications (46.3%). Conclusion: In our center, VA-ECMO as a treatment for refractory CS or CA showed acceptable survival during ventricular support and on hospital discharge. It is an effective life support treatment to rescue critically ill patients when conventional therapies fail, is apparently useful and can be implemented in a country with limited resources and access to complex ventricular assist devices.

Dispositivos de asistencia ventricular en insuficiencia cardíaca avanzada

La insuficiencia cardíaca (IC) continúa siendo una enfermedad de alta prevalencia, afectando al 1-2% de la población en países desarrollados y constituye por ello un problema de salud por los altos costos que esto conlleva. A pesar de los avances en el tratamiento farmacológico y mediante dispositivos implantables presenta un pronóstico pobre. Aproximadamente un 5% de los pacientes con diagnóstico de IC se hallan en un estadio avanzado de la enfermedad o estadio D. En las últimas tres décadas el trasplante cardíaco (TC) se ha convertido en el tratamiento de elección para este grupo de altísimo riesgo. Desafortunadamente, un pequeño porcentaje de pacientes cumple con la edad adecuada y con la ausencia de comorbilidades necesarias para poder acceder a este tratamiento, además de la limitante de la escasez de donantes en la actualidad. Debido a ello y a las largas listas de espera a nivel mundial, cada vez es mayor el desarrollo y la utilización de dispositivos de asistencia ventricular (DAV), que han mejorado la supervivencia a corto y largo plazo, dada la calidad de vida de pacientes con esta grave afección, generando una reducción progresiva de la tasa de complicaciones. Estos beneficios no solo aportan una alternativa a pacientes que esperan un TC, sino que permiten a aquellos con contraindicaciones reversibles a disponer del tiempo y la oportunidad de convertirse en candidatos adecuados, o en caso de que esto no sea posible, su final utilización como terapia de destino. Aun así son muchas las limitaciones de estos dispositivos: su costo, su durabilidad, la tasa de complicaciones y su aplicación a un espectro limitado de pacientes. El avance tecnológico para paliar las complicaciones, la mayor experiencia en los centros de manejo y su generalización para permitir un costo más reducido son estrategias que permitirán que la utilización de DAV en los pacientes con IC avanzada se continúe afianzando.

Heart failure (HF) continues to be a highly prevalent disease, affecting 1-2% of the population in developed countries and is therefore a health problem due to the high costs that this entails. Despite advances in pharmacological treatment and implantable devices, it has a poor prognosis. Approximately 5% of patients diagnosed with HF are in an advanced stage of the disease or stage D. In the last three decades, heart transplantation (HT) has become the treatment of choice for this group of very high risk. Unfortunately, a small percentage of patients meet the appropriate age and the absence of comorbidities necessary to access this treatment, in addition to the limitation of the shortage of donors at present. Due to this and the long waiting lists worldwide, the development and use of ventricular assist devices (VAD), which have improved short and long-term survival, due to the quality of life of patients with This serious condition, generating a progressive reduction in the rate of complications. These benefits not only provide an alternative for patients waiting for a HT, but also allow those with reversible contraindications to have the time and opportunity to become suitable candidates, or in case this is not possible, their final use as therapy of destiny. Even so, there are many limitations of these devices: their cost, their durability, the rate of complications and their application to a limited spectrum of patients. The technological advance to alleviate the complications, the greater experience in the centers of management and its generalization to allow a lower cost are strategies that will allow the use of VAD in patients with advanced HF to continue strengthening.

A insuficiência cardíaca (IC) continua a ser uma doença altamente prevalente, afetando 1-2% da população nos países desenvolvidos e, portanto, é um problema de saúde devido aos altos custos que isso acarreta. Apesar dos avanços no tratamento farmacológico e dispositivos implantáveis, tem um mau prognóstico. Aproximadamente 5% dos pacientes com diagnóstico de IC estão em estágio avançado da doença ou estágio D. Nas últimas três décadas, o transplante cardíaco (TC) tornou-se o tratamento de escolha para esse grupo de risco muito alto. Infelizmente, uma pequena porcentagem de pacientes atinge a idade adequada e a ausência de comorbidades necessárias para acessar esse tratamento, além da limitação da falta de doadores no momento. Devido a isso e as longas listas de espera em todo o mundo, o desenvolvimento e uso de dispositivos de assistência ventricular (DAV), que melhoraram a sobrevivência a curto e longo prazo, devido à qualidade de vida dos pacientes com Esta condição séria, gerando uma redução progressiva na taxa de complicações. Esses benefícios não apenas fornecem uma alternativa para pacientes que aguardam um TC, mas também permitem que aqueles com contraindicações reversíveis tenham tempo e oportunidade de se tornarem candidatos adequados ou, caso isso não seja possível, seu uso final como terapia. de destino. Mesmo assim, existem muitas limitações desses dispositivos: seu custo, sua durabilidade, a taxa de complicações e sua aplicação a um espectro limitado de pacientes. O avanço tecnológico para aliviar as complicações, a maior experiência nos centros de gestão e sua generalização para permitir um menor custo são estratégias que permitirão que o uso do DAV em pacientes com IC avançada continue fortalecendo-se.

Implantation of short-term and long-term right ventricular assist devices

Abstract The last decade has seen considerable growth in the use of left ventricular assist devices (LVAD), in end-phase heart failure treatment. The indications, contraindications and implantation techniques are well-defined. However, information about mechanical support for right ventricular failure is lacking. The aim of this communication is to present alternative techniques for implantation of short- and longterm right ventricular assist devices. Implanting the device in the right atrium has certain advantages when compared with the right ventricle. It is an easier surgical technique that preserves the tricuspid valve and it can potentially reduce the risk of pump thrombosis.

Perioperative management of left ventricular assist devices.

The use of mechanical circulatory support for patients with severe heart failure is on the rist. The poeoperative, intraoperative and postoperative challenges the anaesthesiologists skills. These are discussed in this review

Intravenous thrombolytic therapy for patients with ventricular assist device thrombosis: An attempt to avoid reoperation.

A growing number of patients are undergoing prolonged management of advanced heart failure with the use of continuous flow left ventricular assist devices (LVADs). Subsequently, an increasing number of patients are presenting with complications associated with these devices. Based on an analysis of three major LVAD institutions, the number of patients developing LVAD pump thrombosis may be much higher than originally projected.[1,2] The management of this highly feared complication continues to be challenging, as the population of LVAD patients is very heterogeneous and heavily burdened with comorbidities. The standard protocol of increasing anticoagulation may fail to achieve successful resolution of thrombus. Difficulty and poor prognosis may make reoperation less than desirable. Here, we present a case of successful thrombolysis following intravenous administration of tissue plasminogen activator in the Intensive Care Unit setting.

The Effect of Individualized Exercise Parameters Applied to Two Patients Recovering from Implanted Left Ventricular Assist Devices in Korea / 대한스포츠의학회지

Left ventricular assist devices (LVADs) are a treatment option for patients with severe chronic heart failure. These patients are referred to an inpatient cardiac rehabilitation after implantation to improve an aerobic capacity and quality of life (QOL). Several studies have reported that an exercise therapy, which is a component of cardiac rehabilitation, improves exercise capacity and QOL. The LVADs were implanted successfully in a destination therapy in two Korean patients, and these patients were enrolled in the cardiac rehabilitation. After an individualized intervention, they were discharged from improved exercise functional capacity and QOL. This is the first report showing a benefit of the individualized exercise therapy using different parameters after LVADs implantation in Korea.

Association of Blood Group O with Gastrointestinal Bleeding in Continuous-Flow LVAD Patients.

Background: Increasing use of mechanical circulatory devices for advanced heart failure therapy has led to challenges in managing complications that arise from device implantation for long term support either as a bridge to transplant or as destination therapy. Patients with continuous flow left ventricular assist devices (CF-LVADS) show increasing incidence of gastrointestinal (GI) bleeds. Lack of pulsatality and narrow pulse pressure result in initiation and progression of arteriovenous malformations. High shear forces generated lead to destruction of von Willebrand factor (vWF) making it functionally inactive predisposing patients to increasing bleeding. Literature suggests that patients with blood type O have lower baseline levels of von Willebrand factor. It therefore seemed relevant to study the role of blood groups in this population. Methodology: Retrospective data analysis of 119 CF-LVADS patients discharged between 01/2005 and 07/2014. This study was approved by the Institutional Review Board on 08/01/2014. Results: Blood type (p=0.23), gender (p=0.16) and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile (p=0.86) were not associated with significant incidence of GI bleeding. Blood group O was not associated with a higher incidence of GI bleeding (correlation coefficient =0.07) Patients supported on the HeartMate II (HMII) LVAD experienced more GI bleeding than patients supported on the HeartWare LVAD (HVAD) (p=0.009). HMII LVAD patients who experienced GI bleeding had a mean age of 59.8 years vs. 55.7 years for HMII LVAD patients in the Non-GI bleed group. Age was a significant factor for GI bleeding (p=0.016). Conclusion: Blood group and GI bleeding did not show any significant association in our study. Patients with blood group O did not show increased incidence of GI bleeding despite reported lower baseline levels of von Willebrand factor suggesting contribution of additional factors leading to this complication. The HVAD had a decreased incidence of GI bleeding as compared to Heartmate II. This study is limited by the fact that it was a retrospective analysis in a small population.

Historia del trasplante cardíaco: "El triunfo del ingenio"

El vertiginoso avance de la medicina lleva no pocas veces a asumir con naturalidad procedimientos que resultaban impensables hasta hace pocas décadas. Quizá un ejemplo paradigmático de ello sea el trasplante cardíaco en humanos que, en poco más de 40 años, pasó de ser una entelequia a transformarse en una práctica casi rutinaria. Si bien muchos de los protagonistas más ilustres de este proceso son acreedores de editoriales, monografías y hasta extensas biografías, el presente intenta resumir los hitos más destacados de este camino, tanto a nivel nacional como internacional, enfatizando no sólo los logros; sino también, las vicisitudes que debieran atravesar hasta llegar a la práctica del trasplante cardíaco con los estándares que se conocen actualmente. Finalmente, se delinean algunos de los múltiples interrogantes y dilemas que rodean esta práctica, los cuales generarán que invariablemente en los años venideros se continúen sucediendo múltiples avances en la materia.

History of heart transplantation "The triumph of wit" The rapid advance of medicine leads frequently to naturally assume procedures that were unthinkable a few decades ago. Perhaps a paradigmatic example of this is heart transplantation in humans, which in little more than 40 years went from an entelechy to become an almost routine practice. While many of the most illustrious actors in this process are creditors of editorials, essays and extensive biographies, this attempts to summarize the most important milestones of this course, both nationally and internationally, emphasizing not only the achievements, but also the vicissitudes that should defeat to reach the practice of heart transplantation with the standards that are currently known. Finally outline some of the many questions and dilemmas surrounding this practice, which invariably will generate many advances in the field in coming years.

História do transplante de coração. "O triunfo da sagacidade" O rápido avanço da medicina não leva raramente supor naturalmente que os procedimentos eram impensáveis há algumas décadas atrás. Talvez um exemplo paradigmático disso é o transplante de coração em humanos, em pouco mais de 40 anos passou de um sonho a tornar-se uma prática quase rotineira. Enquanto muitos dos atores mais ilustres neste processo são credores de editoriais, ensaios e biografias para grande, esta tenta resumir os marcos mais importantes desta jornada, tanto nacional como internacionalmente, enfatizando não só as realizações, mas também o vicissitudes que deve percorrer para chegar à prática de transplante cardíaco com as normas que são atualmente conhecidos. Finalmente delinear algumas das muitas questões e dilemas que cercam essa prática, que, invariavelmente, geram em próximos anos muitos avanços continuam a ocorrer no campo.

Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures.

Aims and Objectives: Continuous flow left ventricular assist devices (LVAD) have emerged as a reliable treatment option for heart failure. Because of bleeding secondary to anticoagulation, these patients present frequently for gastrointestinal (GI) endoscopy. The presently available literature on perioperative management of these patients is extremely limited and is primarily based upon theoretical principles. Materials and Methods: Perioperative records of patients with LVAD undergoing (GI) endoscopy between 2008 and 2012 were reviewed. Patient, device and procedure specific information was analyzed. Results: A total of 105 LVADs were implanted, and 68 procedures were performed in 39 patients. The most common indication was GI bleed (48/68), with yearly risk of 8.57% per patient. A total of 63 procedures were performed under deep sedation, with five procedures requiring general anesthesia. Intra‑procedure hypotension was managed by fluids and (or) vasopressors/inotropes (phenylephrine, ephedrine or milrinone) guided by plethysmographic waveform, non‑invasive blood pressure (NIBP) and LVADs pulsatility index (for HeartMate II)/flow pulsatility (for HeartWare). No patient required invasive monitoring and both NIBP and pulse oximeter could be reliably used for monitoring (and guided management) in all patients due to the presence of native heart’s pulsatile output. Conclusion: In the presence of residual heart function, with optimal device settings, non‑invasive hemodynamic monitoring can be reliably used in these patients while undergoing GI endoscopy under general anesthesia or monitored anesthesia care. Transient hypotensive episodes respond well to fluids/vasopressors without the need of increasing device speed that can be detrimental.