RESUMO
Sodium-glucose cotransporter (SGLT) 2 inhibitors, or gliflozins, have quickly risen to prominence within the cardiovascular field due to their substantial benefit in the management of heart failure with reduced ejection fraction (HFrEF). SGLT channels are present throughout the body in various isoforms, but SGLT1 and SGLT2 have been the centre of medical investigation due to known genetic mutations. SGLT2 plays a major role in renal re-absorption of glucose, prompting the development of SGLT2 inhibitors to promote glycosuria and aid in diabetes management. The United States Food and Drug Administration requires evaluation of new antidiabetic medications for cardiovascular safety, prompting several randomized controlled trials of SGLT2 inhibitors over the past 5 years. These initial trials demonstrated superiority in cardiovascular outcomes with SGLT2 inhibitor use and suggested particular benefit in heart failure (HF) outcomes, prompting further study of their mechanisms. Subsequent SGLT2 inhibitor studies have demonstrated reductions in HF hospitalizations and cardiovascular mortality in patients with HFrEF, regardless of the presence of diabetes mellitus. In this review, we discuss the mechanism of action and major clinical trial results that have propelled SGLT2 inhibitors into a key role for patients with HFrEF.
RESUMO
BACKGROUND: Despite improvements in pump design and durability, left ventricular assist device patients still suffer from life-threatening complications such as pump thrombosis (PT) and infection, often necessitating device exchange. Surgical exchange from HeartMate II (HM2; Abbott, Pleasanton, CA) to another HM2 is safe and associated with low mortality, but recurrent device thrombosis rates are high. Switching from axial-flow to centrifugal-flow pump, such as the HeartWare ventricular assist device (HVAD; Medtronic, Framingham, MA) may offer certain advantages due to it being a smaller, newer generation device, although there are limited data to support this strategy. Herein, we aimed to assess the surgical approach and feasibility, safety, and outcomes of surgical exchange from HM2 to HVAD. METHODS: We evaluated HM2 patients who underwent device exchange to HVAD due to PT or infection at 4 large-volume left ventricular assist device implant centers. RESULTS: Twenty-four patients underwent HM2 to HVAD exchange due to PT (92%) and refractory infection (8%). Patients were male (75%), white (88%), with ischemic cardiomyopathy (54%), Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) scale level 1-3 (90%), and destination therapy (62%). The majority underwent redo-sternotomy (79%) and the remainder underwent minimally invasive thoracotomy with subcostal approach. The existing HM2 outflow graft was maintained in 79% of cases. Recurrent PT was noted in 9% of patients. Mortality was 8% at 30 days and 33% at 1 year. CONCLUSIONS: The surgical exchange from a HM2 to HVAD is safe and feasible, despite the differences in device specifications and surgical adaptation required. Newer-generation pumps are increasingly considered for exchange in the setting of HM2 device complication, and increasing experience with modified surgical approaches may be valuable in the current era.
