Driving After Left Ventricular Assist Device Implantation.

Literature on driving capacities of ventricular assist device patients is rare and driving restrictions differ from center to center. Currently, no guidelines exist on whether and when left ventricular assist device (LVAD) patients are allowed to begin driving cars after device implantation. In this study, we assess the driving abilities of patients after LVAD implantation. Three hundred and ninety LVAD patients have been surveyed in a worldwide, multicenter study. The single survey followed a multi-method design, including online, phone, and face-to-face interviews. Out of 390 patients, 72% are still driving and 28% did not continue driving after LVAD implantation. Reasons for discontinuation were capability (24%), insecurity (17%), and disapproval by family members (9%) or doctors (5%). Ninety percent of the patients describe their ability to drive as perfect or adequate. Sixty-nine percent state that they are not restricted in their general driving capacity. Forty-nine percent report not to be restricted in agility to drive by the device equipment. The majority of patients have not been involved in car accidents or major complications (94%). Eight accidents were reported (3%). Out of those, all were minor collisions. No patient reported the occurrence of a fatal accident or casualties. LVAD alarms did occur in six incidents (2%) with the majority being low battery alarms. The results of this study suggest that driving with a left ventricular assist device is safe for stable patients and driving can be resumed 3 months after LVAD implantation after careful patient assessment.

Left Ventricular Assist Devices - A State of the Art Review.

Cardiovascular diseases are the leading cause of mortality rates throughout the world. Next to an insufficient number of healthy donors, this has led to increasing numbers of patients on heart transplant waiting lists with prolonged waiting times. Innovative technological advancements have led to the production of ventricular assist devices that play an increasingly important role in end stage heart failure therapy. This review is intended to provide an overview of current implantable left ventricular assist devices, different design concepts and implantation techniques. Challenges such as infections and thromboembolic events that may occur during LVAD implantations have also been discussed.

Inert gas rebreathing - helpful tool in the management of left ventricular assist device patients.

In patients with left ventricular assist devices (LVAD), exercise capacity is a decisive factor regarding the quality of life. When evaluating exercise capacity, precise information about the total cardiac output generated is crucial. To date, complex measurements using a right-heart catheter were necessary in order to determine total cardiac output. The inert gas rebreathing method facilitates non-invasive, direct and valid measurement of total cardiac output as well as associated parameters, like the difference in arteriovenous oxygen saturation, both at rest and during exercise. It is the aim of this paper to focus on this conclusive method which is, despite its simplicity and low-risk reproducibility, rarely used within the framework of LVAD patient treatment at the present time. The test protocol used at our hospital is presented to facilitate the implementation of this helpful tool in other interested institutions.

Association of drop vertical jump displacement with select performance variables.

Drop vertical jumps (DVJs) stimulate enhanced countermovement loading as would occur with a run-up before jumping. A variety of performance variables have been associated with DVJ performance including ground contact time (GCT), reactive strength index (RSI), eccentric utilization ratio (EUR), and elasticity index (EI). This study examined the stability reliability and precision of these variables and their associations with DVJ displacement in trained men and women. The EUR and EI measures were redundant, so only EUR findings were reported. Except for EUR, data for all variables were both reliable and precise (intraclass correlation coefficient ≥ 0.70, coefficient of variation [CV%] ≤ 15.0) although EUR data were precise (CV% ≤ 15.0). Correlations with DVJ displacement were low for GCT, moderate for RSI, and negligible for EUR. Therefore, GCT and EUR likely represent unique performance characteristics not related to DVJ displacement. Furthermore, the variability in DVJ performance accounted for by RSI may primarily reflect the inclusion of displacement as the numerator in the quotient for calculating it.

Mid-term Outcome of the Edge-To-Edge Mitral Valve Repair Via Aortic Outflow Tract in High-Risk Patients.

The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high-risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace and/or none), mild (1), moderate (2) or moderate to severe (3-4). The patients were 74 ± 7.8 years old. 65% of the patients were male. Mean cardiopulmonary bypass time was 115 ± 37 minutes and mean cross-clamp time was 71 ± 23 minutes. There was a significant improvement in preoperative vs postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); P = 0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months' (range 3 - 19 months') and in 16 patients at a median of 34 months' postoperatively (range 21 - 53 months') showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months' were 88% and 81% respectively. Mitral valve reoperation was conducted in 1 patient (2%), who was suffering of endocarditis. Stroke occurred in 2 patients (7%). Cardiac arrhythmia was observed in 15 patients (35%). 8 patients (19%) suffered from atrial fibrillation and 7 patients (16%) displayed atrioventricular blockage. 10 patients (23%) could be treated conservatively and 5 patients (12%) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high-risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66% of them could be treated successfully by conservative procedures.

Reliability of surface electromyography during maximal voluntary isometric contractions, jump landings, and cutting.

The reliability of electromyographic (EMG) data has been examined for isometric and slow dynamic tasks, but little is known about the repeatability of this data for ballistic movements. The purpose of this study was to examine the within-session, trial-to-trial reliability of a variety of quadriceps and hamstrings muscles during isometric and ballistic activities. Data were analyzed by way of intraclass correlation coefficients (ICC), intersubject coefficients of variation (CVinter), and intrasubject coefficients of variation (CVintra). Twenty-four subjects performed 3 repetitions each of 2 randomly ordered test exercises, including landing from a depth jump (J) and cutting after a 10-m sprint (C). Data were acquired and processed with root mean square EMG for the muscles assessed, and data were analyzed for each exercise using a repeated measures analysis of variance. Results revealed that all ICC values were greater than 0.80, with most values greater than 0.90, CVinter values ranged from 5.4% to 148.7%, and CVintra values ranged from 11.5% to 49.3%. This study indicates that EMG is a reliable method for assessing the reproducibility of both the quadriceps and hamstrings muscle activation during either isometric or ballistic exercises.

Gender-based analysis of hamstring and quadriceps muscle activation during jump landings and cutting.

This study evaluated gender differences in the magnitude and timing of hamstring and quadriceps activation during activities that are believed to cause anterior cruciate ligament (ACL) injuries. Twelve men (age = 21.0 +/- 1.2 years; body mass = 81.61 +/- 13.3 kg; and jump height = 57.61 +/- 10.15 cm) and 12 women (age = 19.91 +/- 0.9 years; body mass = 64.36 +/- 6.14 kg; and jump height = 43.28 +/- 7.5) performed 3 repetitions each of the drop jump (jump) normalized to the subject's vertical jump height, and a sprint and cut at a 45-degree angle (cut). Electromyography (EMG) was used to quantify rectus femoris (RF), vastus lateralis (VL), vastus medialis (VM), lateral hamstring (LH), and medial hamstrings (MH) activation, timing, activation ratios, and timing ratios before and after foot contact for the jump and cut and normalized to each subject's hamstring and quadriceps maximum voluntary isometric contraction. Data were analyzed using an analysis of variance with results demonstrating that during the postcontact phase of the cut, men demonstrated greater LH and MH activation than women. In the precontact phase of the jump, men showed earlier activation of the VL and VM, than women. Women produced longer RF and VM muscle bursts during the postcontact phase of the cut. Additionally, men showed a trend toward higher hamstring to quadriceps activation ratio than women for the postcontact phase of the cut. This study provides evidence that men are LH dominant during the postcontact phase of the cut compared with women, whereas women sustain RF activation longer than men during this phase. Men activate quadriceps muscles earlier than women in the precontact phase of the jump. Training interventions may offer the potential for increasing the rate and magnitude of hamstring muscle activation. These outcomes should be evaluated using EMG during movements that are similar to those that cause ACL injuries to determine if gender differences in muscle activation can be reduced.

Periodized plyometric training is effective for women, and performance is not influenced by the length of post-training recovery.

This study evaluated the effectiveness of a periodized plyometric training program and the impact of the duration of the post-training recovery period on countermovement jump performance. Fourteen women subjects participated in a 6-week periodized plyometric training program. Ten women subjects served as non-training controls. All subjects' countermovement jump height, peak power, and body mass were assessed before and 2, 4, 6, 8, and 10 days after training. Kinetic data were obtained via a force platform using the average of 3 repetitions of the countermovement jump for each testing session. Jump height was 25.0% greater (p < or = 0.05) after training with no difference (p > 0.05) between recovery periods of 2, 4, 6, 8, or 10 days, for the training group. Peak power was 11.6-14.3% (p < or = 0.001) greater after training for the training group with no difference (p > 0.05) between recovery periods of 2, 4, 6, 8, or 10 days. Analysis revealed no significant difference (p > 0.05) for jump height or peak power from pre- to posttest for the control group. Practitioners should prescribe periodized plyometric programs with decreasing volume and increasing intensity to improve jump performance without a need for a post-training recovery period.

Infrastructural needs and expected benefits of telemonitoring in left ventricular assist device therapy: Results of a qualitative study using expert interviews and focus group discussions with patients.

BACKGROUND: Heart failure is one of the most expensive chronic diseases, as it leads to considerable expenses due to increasing hospitalisation rates. In addition to the implications of the demographic transition and the lack of available organs for transplantation, a major challenge in this context is that conservative treatment options are limited. This has led to the research and development of mechanical circulatory assist systems. Telemonitoring is anticipated to be an effective tool in outpatient management, which may be a key to improved outcomes of left ventricular assist devices therapy. In patients with chronic cardiac diseases, telemedicine is already used and has been shown to reduce premature mortality. This study aims to provide insights into the left ventricular assist device-specific requirements for telemonitoring and infrastructural translation from caregivers' and patients' points of view. METHOD: A qualitative investigation based on guided interview and focus group techniques was conducted at two German heart centres. The study included 15 patients and 7 caregivers (4 cardiac surgeons, 3 ventricular assist device coordinators). Qualitative content analysis was used for data analysis. The categories for analysis were (1) benefits for patients, (2) benefits for hospitals and the healthcare system, (3) acceptance and causative factors and (4) infrastructural implementation. RESULTS: Patients and experts expect the following benefits for telemonitored patients: added safety, early detection of complications, rapid intervention in case of emergency, regular inspection of pump parameters, fewer outpatient clinic visits and the ability to provide more informed feedback and instructions to the family members who take care of the patient. However, the expected acceptance of telemonitoring in left ventricular assist device therapy differed among the interviewed groups. Alongside the aforementioned expected benefits, patients and clinical experts criticised the reduced self-determination for the patient, probable large amounts of time/effort required of the patient and caregiver and data protection/integrity issues (data misuse, device manipulation and mistransfer). Interviewees expected easy handling, proper education and safe data transmission to be necessary factors leading to acceptance. Complication rate reduction, fewer hospitalisations and cost reductions were benefits recorded for the healthcare system and clinics. Clinical experts preferred a telemonitoring centre run by ventricular assist device coordinators. CONCLUSION: Although positive expectations are associated with the use of telemonitoring in left ventricular assist device therapy, further action is needed. For example, software and infrastructure developers will need to address issues such as variations among patients and may need to find a balance between designing individualised solutions for compliant patients and a safe and easy-to-handle set-up. In addition, proper elucidation of users will contribute to the successful implementation of a left ventricular assist device telemonitoring programme among patients and caregivers.

Strength and conditioning practices of United States high school strength and conditioning coaches.

This study describes the results of a survey of the practices of high school strength and conditioning (HS S&C) coaches. Thirty-eight of 128 (29.7%) HS S&C coaches, who were surveyed, responded. This survey examines background information, physical testing, flexibility development, speed development, agility development, plyometrics, strength/power development and program design, nutrition, and injury frequency. High school strength and conditioning coaches average 14.78 years in the profession, and 89% of the survey respondents were certified by the National Strength and Conditioning Association. Coaches assess an average of 5.83 different parameters of fitness, with strength as well as power being the most common parameters assessed. Coaches tested an average of 3.86 times a year with an average of 8.51 specific tests per testing session. All HS S&C coaches used a variety of flexibility development strategies using dynamic stretching more frequently than static. Thirty-six of 38 (95%) coaches follow a periodization model, 37 of 38 (97.4%) coaches indicated that their athletes used Olympic-style lifts, and 37 of 37 (100%) coaches responding to this question used plyometric training with their athletes. The squat and its variations, as well as the Olympic-style lifts and its variations, were most frequently identified as the most important exercises prescribed. All coaches use speed development and agility training strategies with their athletes. This survey examined a variety of other practices and provides detailed information about these practices at the high school level. Coaches are encouraged to review the strength and conditioning practices described in this survey and identify and implement the ideas that may improve their practices.

Photographic LVAD Driveline Wound Infection Recognition Using Deep Learning.

The steady increase in the number of patients equipped with mechanical heart support implants, such as left ventricular assist devices (LVAD), along with virtually ubiquitous 24/7 internet connectivity coverage is motive to investigate and develop remote patient monitoring. In this study we explore machine learning approaches to infection severity recognition on driveline exit site images. We apply a U-net convolutional neural network (CNN) for driveline tube segmentation, resulting in a Dice score coefficient of 0.95. A classification CNN is trained to predict the membership of one out of three infection classes in photographs. The resulting accuracy of 67% in total is close to the measured expert level performance, which indicates that also for human experts there may not be enough information present in the photographs for accurate assessment. We suggest the inclusion of thermographic image data in order to better resolve mild and severe infections.

Initial experience with telemonitoring in left ventricular assist device patients.

BACKGROUND: Left ventricular assist devices (LVAD) are increasingly used in patients with end stage heart failure. The HeartAssist 5 and aVAD LVADs offer telemetric monitoring capabilities. Here we report our initial single centre experience with the largest telemonitoring cohort of LVAD patients. METHODS: Eleven patients (9 males) received a telemonitoring-capable LVAD and were included in our telemonitoring cohort. Waveforms and alarm data were obtained from the telemonitoring system and hospital records were reviewed for clinical data. RESULTS: Mean age at LVAD implantation was 59±5.1 years (mean ± standard deviation). Seven patients had non-ischemic cardiomyopathy and 4 patients had ischemic cardiomyopathy. Median LVEF at implant was 16% (IQR, 15-20%). The total follow-up time was 2,438 patient-days. A total of 6,216 alarm messages were generated in 11 patients. Most common were low flow alarms due to hypovolemia, followed by low flow alarms because of suspected pump thrombosis. One patient died during follow-up, one received a cardiac transplant and one had the LVAD explanted because of pump thrombosis. Pump thrombosis was suspected in 5 patients with 8 episodes of sudden flow decreases and laboratory signs of haemolysis. CONCLUSIONS: Real-time telemonitoring of LVAD pump flow, motor speed and power consumption is a promising tool in the follow-up of LVAD recipients. Trending pump flow over hours or days can assist in the early detection of complications, especially flow reductions due to hypovolemia and LVAD thrombosis. Further studies are warranted to delineate the impact of remote monitoring on patients' prognosis.

Using squat testing to predict training loads for the deadlift, lunge, step-up, and leg extension exercises.

The purpose of this study was to determine whether there is a linear relationship between the squat and a variety of quadriceps resistance training exercises for the purpose of creating prediction equations for the determination of quadriceps exercise loads based on the squat load. Six-repetition maximums (RMs) of the squat, as well as four common resistance training exercises that activate the quadriceps including the deadlift, lunge, step-up, and leg extension, were determined for each subject. Subjects included 21 college students. Data were evaluated using linear regression analysis to predict quadriceps exercise loads from 6RM squat data and were cross-validated with the prediction of sum of squares statistic. Analysis of the data revealed that the squat is a significant predictor of loads for the dead lift (R2 = 0.81, standard error of the estimate [SEE] = 12.50 kg), lunge (R2 = 0.62, SEE = 12.57 kg), step-up (R2 = 0.71, SEE = 9.58 kg), and leg extension (R2=0.67, SEE = 10.26 kg) exercises. Based on the analysis of the data, the following 6RM prediction equations were devised for each exercise: (a) deadlift load = squat load (0.83) + 14.92 kg, (b) lunge load = squat load (0.52) + 14.82 kg, (c) step-up load = squat load (0.50) + 3.32 kg, and (d) leg extension load = squat load (0.48) + 9.58 kg. Results from testing core exercises such as the squat can provide useful data for the assignment of loads for other exercises.

Clinical overview of the HVAD: a centrifugal continuous-flow ventricular assist device with magnetic and hydrodynamic bearings including lateral implantation strategies.

Growing worldwide incidences of end-stage heart failure and declining rates of cardiac transplants have given rise to the need for alternative treatment options, based on mechanical circulatory support (MCS) devices such as left ventricular assist devices (LVADs). Technologically advanced LVADs such as the HVAD® (HeartWare®, Medtronic) facilitate safe and efficient treatment of heart failure patients with reduced post-operative complications, which is attributed to their considerably miniaturized size. This also facilitates the development and implementation of novel, minimally-invasive surgical techniques. The HVAD is a centrifugal pump, manufactured by HeartWare Inc., (Framingham, MA, USA) and subsequently by Medtronic Inc., (Minnesota, MN, USA), and has been approved for clinical application after receiving the CE Mark approval in 2008 and the FDA approval in 2012. Current research efforts are focused on further miniaturization alongside optimization of electronic and software controllers as well as implementation of the transcutaneous energy transfer (TET) technology. Salient features of the HVAD pump technology, clinical applications and future optimization strategies have been discussed in this article.

The momentum of HeartMate 3: a novel active magnetically levitated centrifugal left ventricular assist device (LVAD).

Left ventricular assist devices (LVADs) are emerging as the treatment of choice for advanced heart failure due to the dearth of healthy donor hearts for cardiac transplantation. The HeartMate 3 LVAD is a novel centrifugal pump which was developed to provide hemodynamic support in heart failure patients, either as a bridge to transplant (BTT), myocardial recovery, or as destination therapy (DT). Technological and clinical advancements have led to optimized hemocompatibility and development of less invasive surgical procedures for the implantation of this pump. The worldwide first implantation of the HeartMate 3 was performed by Prof. Schmitto and his team at Hannover Medical School, Germany in 2014, paving the way for subsequent surgical developments. This article summarizes the advanced technological and clinical aspects of the HeartMate 3 and outlines future technical developments for safe and effective treatment of advanced heart failure.

Telemonitoring of left-ventricular assist device patients-current status and future challenges.

E-health, especially telemedicine, has undergone a remarkably dynamic development over the past few years. Most experience is currently in the field of telemedical care for heart failure (HF) patients. However, HF patients with an implanted left-ventricular assist device (LVAD) have been more or less excluded from consistent telemonitoring until now. And yet, continual monitoring would be very significant for this patient group because of the complexity of its aftercare, requiring steady control of various parameters (device-related parameters, vital parameters, coagulation parameters, etc.). With timely action, severe and costly complications like pump thromboses and driveline infections could be detected early on or even avoided completely. This paper describes the potential of telemonitoring in LVAD patients, as well as its first clinical implementation according to the available literature. It also describes the requirements for a complete telemonitoring of LVAD patients, facilitating the advancement of this form of continual monitoring to a clinical standard which would increase the quality of aftercare for this very special patient collective enormously.

Less Invasive Surgical Approaches for Left Ventricular Assist Device Implantation.

For several years, the standard implantation strategy of ventricular assist devices has involved a full sternotomy approach. However, less invasive implantation techniques are now becoming increasingly popular as they are associated with reduction of trauma, blood loss, and arrhythmogenic complications, as well as a decreased duration of intensive care unit and in-hospital stay. Thus, due to miniaturization and increasing technical improvement of ventricular assist devices, less invasive strategies for implantation, explantation, exchange, and concomitant cardiac procedures are on the rise. In this review article, we report on the state of the art of less invasive techniques for implantation, explantation, exchange, and combined cardiac procedures of ventricular assist devices.

Five-year results of patients supported by HeartMate II: outcomes and adverse events.

OBJECTIVES: Improved outcomes over the past decade have increased confidence of physicians and patients in extended duration of left ventricular assist device (LVAD) support. This single-centre cohort study reports 5-year outcomes with the HeartMate II (HMII) LVAD. METHODS: We describe a cohort of 89 patients who received a HMII LVAD between February 2004 and December 2010. The causes of death and adverse events were assessed by examination of medical records. A total of 202.74 patient-years were analysed. RESULTS: After 5 years, of the 89 patients, 15 patients remained on device therapy, 39 patients died, 28 patients underwent heart transplantation and 7 patients underwent explantation of the HMII for recovery. One year after the HMII implantation, there was a survival of 71% in the study cohort. In the following years, the survival rate was 65% in the 2nd year, 63% in the 3rd year, 56% in the 4th year and 54% after 5 years of LVAD support. Ten LVAD exchanges were performed in 8 (11%) patients. Currently (March 2017), 12 patients still remain on their original device. The longest ongoing patient on the HMII has been supported for over 11 years (4097 days). The most common adverse events were bleeding (68%; 1.5837 events per patient-year) and LVAD infection [49%; 1.0666 events per patient-year]. Seven cases of pump thrombosis were described (8%; 0.1131 events per patient-year). CONCLUSIONS: This is the first single-cohort study to describe a 5-year survival of HMII patients on extended duration of support. A 5-year survival of 54% was observed in this single-centre cohort.