Remote monitoring of left ventricular assist device parameters after HeartAssist-5 implantation.

Although several left ventricular assist devices (LVADs) have been used widely, remote monitoring of LVAD parameters has been available only recently. We present our remote monitoring experience with an axial-flow LVAD (HeartAssist-5, MicroMed Cardiovascular, Inc., Houston, TX, USA). Five consecutive patients who were implanted a HeartAssist-5 LVAD because of end-stage heart failure due to ischemic (n=4) or idiopathic (n=1) cardiomyopathy, and discharged from hospital between December 2011 and January 2013 were analyzed. The data (pump speed, pump flow, power consumption) obtained from clinical visits and remote monitoring were studied. During a median follow-up of 253 (range: 80-394) days, fine tuning of LVADs was performed at clinical visits. All patients are doing well and are in New York Heart Association Class-I/II. A total of 39 alarms were received from three patients. One patient was hospitalized for suspected thrombosis and was subjected to physical examinations as well as laboratory and echocardiographic evaluations; however, no evidence of thrombus washout or pump thrombus was found. The patient was treated conservatively. Remaining alarms were due to insufficient water intake and were resolved by increased water consumption at night and summer times, and fine tuning of pump speed. No alarms were received from the remaining two patients. We believe that remote monitoring is a useful technology for early detection and treatment of serious problems occurring out of hospital thereby improving patient care. Future developments may ease troubleshooting, provide more data from the patient and the pump, and eventually increase physician and patient satisfaction. Despite all potential clinical benefits, remote monitoring should be taken as a supplement to rather than a substitute for routine clinical visits for patient follow-up.

Comparison of early and long-term follow-up results of percutaneous mitral balloon valvuloplasty and mitral valve replacement.

BACKGROUND: Percutaneous mitral balloon valvuloplasty and mitral valve replacement have been the treatment options for mitral stenosis for several years, however, studies that compare these two modalities are very rare in the literature. OBJECTIVE: In this article, we aim to investigate the comparison of clinical results of percutaneous mitral balloon valvuloplasty and mitral valve replacement. METHODS: 527 patients with rheumatic mitral stenosis, treated with percutaneous mitral balloon valvuloplasty or mitral valve replacement (276 patients with percutaneous mitral balloon valvuloplasty and 251 patients with mitral valve replacement) from 1991 to 2012 were evaluated. The demographic characteristics, clinical, echocardiographic and catheterization data of patients were evaluated retrospectively. The results of early and late clinical follow-up of patients after percutaneous mitral balloon valvuloplasty and mitral valve replacement were also evaluated. RESULTS: The mean follow-up time of the percutaneous mitral balloon valvuloplasty group was 4.7 years and, for the mitral valve replacement-group, it was 5.45 years. The hospital stay of the percutaneous mitral balloon valvuloplasty group was shorter than that of the mitral valve replacement group (2.02 days vs 10.62 days, p<0.001). The hospital mortality rate of percutaneous mitral balloon valvuloplasty and mitral valve replacement were 0% and 2% respectively (p=0.024). In the percutaneous mitral balloon valvuloplasty group, early postprocedural success rate was 92.1%. The event-free survival of percutaneous mitral balloon valvuloplasty and mitral valve replacement was found to be similar. While reintervention was higher in percutaneous mitral balloon valvuloplasty-group (p<0.001), mortality rate was higher in mitral valve replacement-group (p<0.001). CONCLUSION: Percutaneous mitral balloon valvuloplasty seems to be more advantageous than mitral valve replacement due to low mortality rates, easy application of the procedure and no need for general anesthesia.

Immediate and follow-up results of repeat percutaneous mitral balloon commissurotomy for restenosis after a succesful first procedure.

BACKGROUND: The widespread use of percutaneous mitral commissurotomy (PMC) has led to an increase in restenosis cases. The data regarding follow-up results of repeat PMC are quite limited. The aim of this retrospective analysis is to evaluate the immediate and midterm results of the second PMC, in patients with symptomatic mitral restenosis after a succesful first procedure. METHODS: Twenty patients (95% female, mean age 37 ± 4 years) who have undergone a second PMC, 6.3 ± 2.5 years after a first successful intervention built the study group. All were in sinus rhythm, with a mean Wilkins score of 8.5 ± 1.2. RESULTS: The valve area increased from 1.2 ± 0.2 to 1.9 ± 0.2 cm(2) and mean gradient decreased from 10.5 ± 3.4 to 6.1 ± 1.1 mmHg. There were no complications except for a transient embolic event without sequela (5%) and two cases (10%) of severe mitral regurgitation. The immediate success rate was 90%. The mean follow-up was 70 ± 29 months (36-156 months). The 5-year restenosis and intervention (repeat PMC or valve replacement) rates were 9.1 ± 5.2% and 3.6 ± 3.3%, respectively. The intervention free 5-year survival in good functional capacity (New York Heart Association [NYHA] I-II) was 95.1 ± 5.5% and restenosis and intervention free 5-year survival with good functional capacity was 89.7 ± 6.8%. CONCLUSIONS: Although from a limited number of selected patients, these findings indicate that repeat PMC is a safe and effective method, with follow-up results similar to a first intervention and should be considered as the first therapeutic option in suitable patients.

Impact of right ventricular stroke work index on predicting hospital readmission and functional status of patients with advanced heart failure.

INTRODUCTION AND AIMS: The prognosis of chronic heart failure with reduced ejection fraction (HFrEF) has been studied extensively, but factors predicting cardiac decompensation are poorly defined. Right ventricular stroke work index (RVSWI), an invasive measure of right ventricular (RV) systolic function, is a well-known prognostic marker of RV failure after left ventricular assist device insertion and after lung transplantation. Thus, the aim of this study was to assess whether there is a relationship between RVSWI, HFrEF hospital readmission due to cardiac decompensation, and prognosis. METHODS: We prospectively enrolled 132 consecutive patients with HFrEF. Right heart catheterization was performed and RVSWI values were calculated in all patients. The relationship between RVSWI values and readmission and prognosis was analyzed. RESULTS: During a median follow-up of 20±7 months, 33 patients were readmitted due to cardiac decompensation in the survivor group, and 18 patients died due to cardiac causes. There was no difference between patients who died and survived in terms of RVSWI values. Among patients with decompensation, mean RVSWI was significantly lower than in patients with stable HFrEF (6.0±2.2 g/m2/beat vs. 8.8±3.5 g/m2/beat, p<0.001). On correlation analysis, RVSWI was negatively correlated with NYHA functional class. RVSWI was also identified as an independent risk factor for cardiac decompensation in Cox regression survival analysis. CONCLUSIONS: We showed that RVSWI predicts cardiac decompensation and correlates with functional class in advanced stage HFrEF. Our data suggest the value of combining information on right heart hemodynamics with assessment of RV function when defining the risk of patients with advanced HFrEF.

Right atrial pacemaker lead thrombosis causing tricuspid inflow obstruction.

A 75-year-old man was admitted to our hospital with a complaint of progressive dyspnea with effort. The patient had a permanent pacemaker that was implanted 16 years ago. Transesophageal echocardiography revealed a large, mobile mass in the right atrium attaching to the insertion site of the atrial lead at the tricuspid valve level. Because of the size, mobility, and location of the mass, urgent surgical removal was considered. The mass was successfully removed. Histologic examination of the mass demonstrated a partially organized thrombus. The postoperative course was uneventful and the patient's symptoms improved remarkably after operation.

Evaluation of Resting Cardiac Power Output as a Prognostic Factor in Patients with Advanced Heart Failure.

If the heart is represented by a hydraulic pump, cardiac power represents the hydraulic function of the heart. Cardiac pump function is frequently determined through left ventricular ejection fraction using imaging. This study aims to validate resting cardiac power output (CPO) as a predictive biomarker in patients with advanced heart failure (HF). One hundred and seventy-two patients with HF severe enough to warrant cardiac transplantation were retrospectively reviewed at a single tertiary care institution between September 2010 and July 2013. Patients were initially evaluated with simultaneous right-sided and left-sided cardiac catheter-based hemodynamic measurements, followed by longitudinal follow-up (median of 52 months) for adverse events (cardiac mortality, cardiac transplantation, or ventricular assist device placement). Median resting CPO was 0.54 W (long rank chi-square = 33.6; p < 0.0001). Decreased resting CPO (<0.54 W) predicted increased risk for adverse outcomes. Fifty cardiac deaths, 10 cardiac transplants, and 12 ventricular assist device placements were documented. The prognostic relevance of resting CPO remained significant after adjustment for age, gender, left ventricular ejection fraction, mean arterial pressure, pulmonary vascular resistance, right atrial pressure, and estimated glomerular filtration rate (HR, 3.53; 95% confidence interval, 1.66 to 6.77; p = 0.0007). In conclusion, lower resting CPO supplies independent prediction of adverse outcomes. Thus, it could be effectively used for risk stratification in patients with advanced HF.

Surgical placement of left ventricular lead for cardiac resynchronisation therapy after failure of percutaneous attempt.

OBJECTIVE: Cardiac resynchronisation therapy has been shown to be an effective treatment to improve functional status and prolong survival of patients in advanced chronic heart failure. This study assessed the surgical outcomes of left anterior mini-thoracotomy for the implantation of left ventricular epicardial pacing leads in cardiac resynchronisation therapy. METHODS: Our study consisted of 30 consecutive patients who underwent cardiac resynchronisation therapy with a left thoracotomy between November 2010 and April 2012 in our clinic. Postoperative follow up included the assessment of New York Heart Association (NYHA) functional class, electrocardiography and echocardiography. RESULTS: There were 22 male and eight female patients with a mean age of 68 ± 5.04 years. All patients were in NYHA class III or IV. Pre-procedure mean left ventricular ejection fraction was 28.1 ± 4.5% and post-procedural ejection fraction improved to 31.7 ± 5.1%. The pre-operative QRS duration changed from 171.7 ± 10.8 to 156.2 ± 4.4 ms after the operation. Also there was a significant reduction in left ventricular end-diastolic dimension from 6.98 ± 0.8 to 6.72 ± 0.8 mm (p < 0 .05), but no change in left ventricular end-systolic dimension and severity of mitral regurgitation. All patients had successful surgical left ventricular lead placement. There was no procedure-related mortality. The mean follow-up time was 40.4 months. CONCLUSION: Surgical epicardial left ventricular lead placement procedure is a safe and effective technique in patients with a failed percutaneous attempt.

Comparison of early and long-term follow-up results of percutaneous mitral balloon valvuloplasty and mitral valve replacement

SUMMARY BACKGROUND: Percutaneous mitral balloon valvuloplasty and mitral valve replacement have been the treatment options for mitral stenosis for several years, however, studies that compare these two modalities are very rare in the literature. ObjectIve: In this article, we aim to investigate the comparison of clinical results of percutaneous mitral balloon valvuloplasty and mitral valve replacement. Methods: 527 patients with rheumatic mitral stenosis, treated with percutaneous mitral balloon valvuloplasty or mitral valve replacement (276 patients with percutaneous mitral balloon valvuloplasty and 251 patients with mitral valve replacement) from 1991 to 2012 were evaluated. The demographic characteristics, clinical, echocardiographic and catheterization data of patients were evaluated retrospectively. The results of early and late clinical follow-up of patients after percutaneous mitral balloon valvuloplasty and mitral valve replacement were also evaluated. Results: The mean follow-up time of the percutaneous mitral balloon valvuloplasty group was 4.7 years and, for the mitral valve replacement-group, it was 5.45 years. The hospital stay of the percutaneous mitral balloon valvuloplasty group was shorter than that of the mitral valve replacement group (2.02 days vs 10.62 days, p<0.001). The hospital mortality rate of percutaneous mitral balloon valvuloplasty and mitral valve replacement were 0% and 2% respectively (p=0.024). In the percutaneous mitral balloon valvuloplasty group, early postprocedural success rate was 92.1%. The event-free survival of percutaneous mitral balloon valvuloplasty and mitral valve replacement was found to be similar. While reintervention was higher in percutaneous mitral balloon valvuloplasty-group (p<0.001), mortality rate was higher in mitral valve replacement-group (p<0.001). Conclusion: Percutaneous mitral balloon valvuloplasty seems to be more advantageous than mitral valve replacement due to low mortality rates, easy application of the procedure and no need for general anesthesia.

Serum N-terminal pro-BNP levels correlate with symptoms and echocardiographic findings in patients with mitral stenosis.

This study is designed to evaluate the N-terminal pro-BNP (NTproBNP) levels in patients with mitral stenosis (MS) and its possible correlation with clinical and echocardiographic parameters of the disease. The study group consisted of 29 patients with isolated MS (patients with greater mild regurgitation were excluded) and 20 normal control subjects of similar age and gender distribution. Blood samples for NTproBNP were collected at the time of clinical and echocardiographic examination. NTproBNP levels were elevated in patients with MS compared to controls (325 +/- 249 pg/dL [19.9-890] versus 43 +/- 36 pg/dL [5.76-193.3], P < 0.001). Patients with atrial fibrillation had significantly higher NTproBNP levels compared to those with sinus rhythm (561 +/- 281 pg/dL versus 254 +/- 194 pg/dL, P = 0.044). MS patients with sinus rhythm also had higher NTproBNP levels compared to controls (254 +/- 194 pg/dL versus 43 +/- 36 pg/dL, P = 0.00011). NT pro BNP levels correlated to the LA (R = 0.73, P < 0.0001) and RV (R = 0.41, P = 0.042) diameters, mitral valve area (R =-0.45, P = 0.025), mean mitral gradient (R = 0.57, P = 0.003), peak PAP (R = 0.7, P = 0.03), and NYHA functional class (R = 0.61, P = 0.007). In conclusion, serum NTproBNP levels correlate well with echocardiographic findings and functional class in patients with MS and can be used as a marker of disease severity. Additionally, it may have a potential use as an additional noninvasive and relatively cheap method in monitoring disease progression especially in patients with poor echocardiographic windows.

Right ventricular and tricuspid valve function in patients with two ventricular pacemaker leads.

UNLABELLED: Existing data on the effect of retained pacemaker leads on right ventricular (RV) and tricuspid valve function is limited. OBJECTIVE: In this echocardiographic study we investigated the long-term effect of retained ventricular leads on RV and tricuspid valve function in patients with permanent pacemakers. Forty patients, 18 with two (group I) and 22 with one (group II) ventricular lead were assessed echocardiographically at an average of 39 months after the second lead implantation in group I and 80 months after the lead implantation in group II. The sum of the lead body diameter in group I was significantly greater than the body diameter in group II (P < 0.000). There was no significant difference between the groups with respect to chamber diameters and ventricular or valvular functions. The distributions of the different tricuspid regurgitation (TR) grades were similar, with the majority of patients in both groups having mild TR. Retained second pacemaker leads do not have an additional negative effect on right ventricular and tricuspid valve function.