Lessons learned from catheter ablation of ventricular arrhythmias in patients with a fully magnetically levitated left ventricular assist device.

INTRODUCTION: Data on catheter ablation of ventricular arrhythmias (VA) are scarce in patients with left ventricular assist devices (LVADs) and current evidence predominantly consists of case reports with outdated LVAD. This prospective observational study reports our experience in terms of catheter ablation of VAs in patients with novel 3rd generation LVADs. METHODS AND RESULTS: Between 2018 and 2020, nine consecutive patients undergoing a total number of ten ablation procedures for VAs were analyzed. The mean duration between LVAD implantation and catheter ablation was 23 ± 16 months. Acute procedural success was achieved in all patients. VA substrates were not related to the LVAD scarring (cannula) site in the majority of patients. All procedures were conducted without any relevant procedure-related complications. In terms of follow-up, only one patient presented with a repeat episode of electrical storm requiring ICD-shocks 16 months after the initial ablation procedure. Four patients suffered of singular VA effectively treated with antitachycardia pacing via their ICD. The remainder were free of any VA relapse (n = 4). Two non-procedure-related deaths occurred during follow-up. CONCLUSIONS: Catheter ablation of VAs in patients with 3rd generation LVAD is feasible and leads to satisfying clinical results in terms of freedom from VA recurrence and quality of life. The majority of arrhythmia substrates in these patients are not directly related to the LVAD cannulation site and may represent a progress of heart failure.

Changes in Von Willebrand factor profile predicts clinical outcomes in patients on mechanical circulatory support.

BACKGROUND: The associations between mechanical circulatory support (MCS), acquired von Willebrand syndrome (AvWS), and clinical outcome are incompletely understood. METHODS: In 128 heart failure patients with pulsatile MCS implants (65 total artificial heart or biventricular assist device implants, 63 left ventricular assist device [LVAD] implants) and 76 patients with continuous flow LVAD implants, we analyzed the von Willebrand factor (vWF) profile before (≤24 h) and 17.5 (standard deviation: 5.1) days after device implant. We determined vWF concentrations, vWF activity, and vWF collagen binding capacity and calculated ratios of vWF activity/binding capacity with vWF concentration. The relation of the vWF profile with clinical outcomes such as stroke, gastrointestinal bleeding, and survival was also evaluated. Events were assessed up to 1 year of device implant. RESULTS: All entities of vWF were already significantly elevated preoperatively and remained high after MCS implantation. The ratios of vWF activity/concentration (vWF:RCo/Ag) and collagen binding capacity/concentration (vWF:CBA/Ag) were significantly reduced preoperatively and remained low postoperatively, indicating AvWS. The preoperative alterations in the vWF profile were already present in patients without intra-aortic balloon pump and/or extracorporeal circulatory membrane oxygenation implants. The vWF profile was unrelated to postoperative stroke. However, a higher postoperative ratio of vWF:CBA/Ag was independently associated with increased gastrointestinal bleeding. In addition, a postoperative increase in vWF concentrations and activity were independent predictors of increased 1-year mortality. CONCLUSIONS: Our data indicate that AvWS is present in heart failure patients before device implantation, and is independently associated with clinical outcomes, especially with 1-year mortality.

Suicide after ventricular assist device implantation.

Depression and anxiety are well documented in patients with end-stage heart failure and correlate with a higher risk of suicide. We report a 69-year-old depressed patient who committed suicide by disconnecting the driveline of his left ventricular assist device almost 3 years after implantation. We provide the medical, psychologic, and psychiatric background of this unique case. This report highlights the importance of pre-implant psychologic screening, the need for regular and long-term psychologic support for this vulnerable patient population, and the need for more qualitative research on patients' views on living with a left ventricular assist device, together with research exploring risk profiles for depression and suicide.

Prolonged transcutaneous cardiopulmonary support for postcardiotomy cardiogenic shock.

Percutaneous cardiopulmonary support can be set up quickly at the bedside and provides reliable temporary mechanical circulatory support for cardiogenic shock patients. This report includes the case of a woman, age 56 years, with postoperative cardiogenic shock due to right heart failure, secondary to severe pulmonary hypertension, after mitral and tricuspid valve replacement. This was accomplished by the use of femoro-femoral Levitronix Centrimag centrifugal pump with membrane oxygenator. Adequate cardiac function returned, and the patient could be successively weaned after 37 days of support. Nitric oxide (NO) and Epoprostenol inhalation were used to enhance weaning from cardiopulmonary support. The patient recovered with ambulatory status and acceptable cardiac performance. The patient died of septicemia on postoperative day 72. In conclusion, this case report describes the safety and reliability of the Levitronix Centrimag centrifugal pump as percutaneous cardiopulmonary support for cardiogenic shock.

Influence of ACE-inhibition and mechanical unloading on the regulation of extracellular matrix proteins in the myocardium of heart transplantation candidates bridged by ventricular assist devices.

BACKGROUND: Whether adverse structural changes in the myocardium due to remodelling can be reversed by ventricular assist device (VAD) support in patients with end-stage heart failure is controversial. AIMS: To investigate the effect of VAD support on the extra-cellular matrix. METHODS: We analysed the collagen content in terminal failing ventricles of VAD-patients and donor hearts using 4-hydroxyproline for total collagen and real time RT-PCR for fibronectin (FN), collagen I alpha 1 (Col1A1), III alpha 1 (Col3A1) and TGF beta 1 analysis. RESULTS: Compared to donor hearts we found similar increases in Col1A1 and TGF beta1 but not Col3A1 and FN mRNAs, which were similar in the myocardium from patients receiving a VAD or heart transplant. However, patients receiving ACE-I during VAD-support had lower Col1A1 mRNA content at transplantation. The total collagen content was not influenced by mechanical unloading or by ACE-I medication. CONCLUSION: Mechanical unloading by VAD does not reduce the collagen content of the terminal failing ventricle possibly due to increased TGF beta1 levels. However, Col1A1 production may be reduced by ACE-I medication during VAD support.

CardioWest total artificial heart: Bad Oeynhausen experience.

BACKGROUND: The use of ventricular assist devices (VAD) has become a widely accepted therapeutic option. However, there are still limitations to the patient collective eligible for VAD placement, who might therefore benefit from the implantation of a total artificial heart. We present the first German single-center experience with the CardioWest total artificial heart (TAH) (SynCardia Systems, Tucson, AZ) in 42 patients. METHODS: Between February 2001 and December 2003, 42 patients (37 men, 5 women, mean age 51 +/- 13 years) received a TAH at our Center. Their body surface area ranged between 1.5 and 2.4 (mean, 1.9 +/- 0.19) m2. All patients were in persistent cardiogenic shock in spite of maximum inotropic support and had numerous preoperative risk factors (intraaortic balloon pumping, mechanical ventilation, acute renal failure, previous cardiac surgery, recent cardiopulmonary resuscitation). RESULTS: Duration of support was 1 to 291 days. Eleven patients (26%) underwent successful transplantation; 9 of them could be discharged home. Twenty-two patients died under support, 21 of them from multiple organ failure and 1 patient from a technical problem. Nine patients are still on the device, 4 of them at home after the original CardioWest console was replaced by the Berlin Heart EXCOR driver (Berlin Heart, Berlin, Germany). Exceptional results were achieved in patients with cardiogenic shock after cardiac surgery or after acute myocardial infarction. CONCLUSIONS: Against the background of the extremely poor preoperative situation of our patients, the overall survival rate of 48% can be considered as favorable. A prospective, randomized study is planned to find out whether patients with idiopathic dilated or ischemic cardiomyopathy are more likely to benefit from a biventricular assist device or a total artificial heart.

The structural examination of myocardial samples from patients with end-stage heart failure supported by ventricular assist devices using electron microscopy and amino acid analysis reveals low degree of reverse remodeling.

BACKGROUND: Chronic heart failure is a multifactorial, progressive disease of many causes and is associated with complex ventricular remodeling. Deposition of extracellular matrix proteins and sarcomeric disarray of the myocytes occur in end-stage heart failure. Ventricular assist devices (VAD), implanted as bridge to transplantation, may reverse ventricular remodeling. Although successfully weaning patients from VAD support has been reported, it is not clear to what degree reversal of remodeling occurs in unloaded failing hearts. Because collagen deposition and ultrastructural disarray are hallmarks of myocardial remodeling, we analyzed the myocardial ultrastructure and collagen content of VAD-supported hearts before and after mechanical unloading. METHODS: We used amino acid analysis to measure collagen content (4-hydroxyproline content) in 24 transplant candidates receiving VAD support. We used transmission electron microscopy to examine the ultrastructure in 6 patients receiving VAD support. RESULTS: The 4-hydroxyproline content increased significantly at VAD implantation and was not altered by mechanical unloading. The ultrastructure showed signs of persisting cardiomyopathy. CONCLUSION: Mechanical unloading does not alter the total collagen content of the supported, failing heart. Thus, structural reversal of the remodeling process associated with heart failure is not a general phenomenon in mechanically unloaded hearts.