Hallazgos clínicos asociados con una descarga hemodinámica del ventrículo izquierdo incompleta en pacientes con asistencia ventricular izquierda / Clinical findings associated with incomplete hemodynamic left ventricular unloading in patients with a left ventricular assist device

Introducción y objetivos Los efectos hemodinámicos del dispositivo de asistencia ventricular izquierda de flujo continuo (DAVI-fc) en la descarga hemodinámica del ventrículo izquierdo (DHVI) y los factores clínicos que interfieren en su optimización no están bien definidos. Métodos Se estudió de manera retrospectiva la prevalencia de altas presiones capilares enclavadas (hPCWP) del ventrículo izquierdo en 104 pacientes cuyos parámetros del DAVI-fc se optimizaron siguiendo las actuales recomendaciones clínicas. Asimismo se analizó el valor de diferentes variables clínicas, hemodinámicas y ecocardiográficas para predecir el grado de DHVI en pacientes ambulatorios portadores de un DAVI-fc. Resultados El 28% de los pacientes presentaron hPCWP. La edad, la presión venosa central y la ausencia de tratamiento con inhibidores del sistema renina-angiotesiona-aldosterona y péptido natriurético cerebral se asociaron con mayor riesgo de hPCWP. Los pacientes con DHVI óptima presentaron una disminución del diámetro indexado del ventrículo izquierdo del 15,2±14,7% en comparación con el 8,9±11,8% del grupo con hPCWP (p=0,041). El péptido natriurético cerebral <300 pg/ml predijo la ausencia de hPCWP con un valor predictivo negativo del 86% (p <0,0001). Conclusiones Una DHVI óptima es posible hasta en el 72% de los pacientes portadores de DAVI-fc cuando se siguen las actuales recomendaciones para la optimización de los parámetros del DAVI-fc. La edad, la presión venosa central y el tratamiento con inhibidores del sistema renina-angiotesiona-aldosterona tienen un efecto importante a la hora de lograr este objetivo. La concentración de péptido natriurético cerebral y la magnitud del remodelado inverso del ventrículo izquierdo son métodos no invasivos útiles para evaluar la DHVI (AU)

Introduction and objectives The effect of a centrifugal continuous-flow left ventricular assist device (cfLVAD) on hemodynamic left ventricular unloading (HLVU) and the clinical conditions that interfere with hemodynamic optimization are not well defined. Methods We retrospectively evaluated the likelihood of incomplete HLVU, defined as high pulmonary capillary wedge pressure (hPCWP)> 15mmHg in 104 ambulatory cfLVAD patients when the current standard recommendations for cfLVAD rotor speed setting were applied. We also evaluated the ability of clinical, hemodynamic and echocardiographic variables to predict hPCWP in ambulatory cfLVAD patients. Results Twenty-eight percent of the patients showed hPCWP. The variables associated with a higher risk of hPCWP were age, central venous pressure, absence of treatment with renin-angiotensin-aldosterone system inhibitors, and brain natriuretic peptide levels. Patients with optimal HLVU had a 15.2±14.7% decrease in postoperative indexed left ventricular end-diastolic diameter compared with 8.9±11.8% in the group with hPCWP (P=.041). Independent predictors of hPCWP included brain natriuretic peptide and age. Brain natriuretic peptide <300 pg/mL predicted freedom from hPCWP with a negative predictive value of 86% (P <.0001). Conclusions An optimal HLVU can be achieved in up to 72% of the ambulatory cfLVAD patients when the current standard recommendations for rotor speed setting are applied. Age, central venous pressure and therapy with renin-angiotensin-aldosteron system inhibitors had a substantial effect on achieving this goal. Brain natriuretic peptide levels and the magnitude of reverse left ventricular remodeling seem to be useful noninvasive tools to evaluate HLVU in patients with functioning cfLVAD (AU)

[Heart failure: ventricular assist devices and cardiac transplantation : A review of current surgical innovations]. / Kardiales Pumpversagen: Herzunterstützungssysteme und Herztransplantation : Eine Übersicht aktueller chirurgischer Innovationen.

BACKGROUND: End-stage heart failure is one of the leading causes of death in Germany. Cardiac transplantation is still considered the gold standard for the treatment of terminal heart failure; however, there is a discrepancy between patients on the waiting list and yearly performed transplantations. As an alternative, ventricular assist devices have achieved a high level of importance but treatment is still associated with challenges. Novel systems as well as innovative surgical techniques contribute to improving the safety and effectiveness of the treatment. OBJECTIVE: To generate an overview of current surgical innovations in cardiac transplantation and mechanical circulatory support. MATERIAL AND METHODS: A Medline search was conducted regarding innovations in cardiac transplantation and mechanical circulatory support. RESULTS AND CONCLUSION: Not only the number of yearly performed cardiac transplantations has changed but also recipient profiles. While in the pioneering era of transplantation the typical candidate was young, not previously operated on and with lower levels of comorbidities, today's patients are significantly older, have been fitted with ventricular assist devices and have increased operative risk profiles. Modern methods of organ preservation enable longer transportation and operation times as well as an improved assessment of graft function and perspectives for graft optimization in the future. In the area of ventricular assist devices, advances in the reduction of the stroke rate seem to have been achieved by the latest generation devices. From a surgical perspective, less invasive surgical techniques with promising initial results have been established at numerous centers.

A new era of ventricular assist device surgery: less invasive procedures.

As the number of patients suffering of congestive heart failure is rising worldwide, the use of mechanical circulatory support to treat these patients has also grown enormously, surpassing the number of annual heart transplants. Moreover latest generation of left ventricular assist devices (LVADs) is characterized by improved technologies. Moreover the size of new LVAD systems is considerably reduced when compared to older generation devices. Therefore, less invasive surgery is now possible for the implantation, explantation, and exchange of LVADs. Although experience with these new techniques is still limited, minimally invasive procedures are thought to improve surgical outcomes by declining the rates of operative complications such as bleeding or wound infection. The miniaturization of LVADs will continue, so that minimally invasive techniques will be used for most LVAD-related procedures in the future. In this article, we summarize and describe minimally invasive surgical techniques, with a focus on the most common LVAD systems in adults.