Discontinuation of HeartWare RVAD support without device removal in chronic BIVAD patients.

During biventricular assist device (BVAD) support, right ventricular (RV) assistance may restore sufficient RV function after several weeks to months. Since November 2009, 10 patients (9 men and 1 woman; mean age, 49.7 ± 14.4 y) suffering from idiopathic dilatative cardiomyopathy received BVAD employing two implantable continuous-flow pumps of the HeartWare type. In three male patients, aged 53, 57, and 60 years, after a right ventricular assist device (RVAD) support time of 15.6, 11.2, and 3.6 months, respectively, the RVAD was stopped, and the percutaneous lead was surgically shortened in two cases. There were no differences in preoperative RV geometry and function or in severity of tricuspid valve regurgitation in patients with and without delayed RV recovery. Follow-up echocardiography revealed no regurgitation through the right pump in any patient. One patient died due to severe sepsis 63 days later; the other two patients are currently on left ventricular assist devices support at home, 120 and 236 days after RVAD deactivation with stable hemodynamic conditions and without any thromboembolic events. RV function may recover even after weeks or months on BVAD support. The HeartWare HVAD used as an RVAD may be stopped and left in place without complications.

Retrospective hemolysis comparison between patients with centrifugal biventricular assist and left ventricular assist devices.

Little is known about the hemolysis rate in the case of concomitant implantation of two continuous flow pumps for the treatment of biventricular heart failure. We present a retrospective study comparing the hemolysis parameters in patients supported with one implantable centrifugal pump of the type HeartWare HVAD used as a left ventricular assist device (LVAD) and with two pumps as a biventricular assist device (BiVAD). A total of 20 consecutive patients who received HeartWare BiVAD (n = 10) and LVAD (n = 10) support at our institution between September 2009 and September 2010 were examined. Hemolysis- and anemia-related parameters were analyzed after 2 weeks, 5 weeks, 3 months, and 6 months of support. Preoperative levels of hemoglobin, lactate dehydrogenase (LDH), and total bilirubin were similar in both groups. There were no differences in LDH, plasma-free hemoglobin (fHB), or total bilirubin levels postoperatively for up to 6 months. Only the haptoglobin level was lower in BiVAD recipients up to 3 months after surgery: 2nd week (63.5 [range: 8-237] mg/dl vs. 151 [range: 11-263] mg/dl, p = 0.05), 5th week (67 [range: 8-196] mg/dl vs. 215 [range: 56-292] mg/dl, p = 0.046), and after 3rd month (42 [range: 8-205] mg/dl vs. 220 [range: 157-256] mg/dl, p = 0.048). Our retrospective analysis of BiVAD HeartWare and LVAD HeartWare recipients showed a lack of a clinically important degree of hemolysis when two centrifugal HeartWare pumps are used for biventricular support.

Novel correlations between the genotype and the phenotype of hypertrophic and dilated cardiomyopathy: results from the German Competence Network Heart Failure.

AIMS: Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) can both be due to mutations in the genes encoding ß-myosin heavy chain (MYH7) or cardiac myosin-binding protein C (MYBPC3). The aim of the present study was to determine the prevalence and spectrum of mutations in both genes in German HCM and DCM patients and to establish novel genotype-to-phenotype correlations. METHODS AND RESULTS: Coding exons and intron flanks of the two genes MYH7 and MYBPC3 of 236 patients with HCM and 652 patients with DCM were sequenced by conventional and array-based means. Clinical records were established following standard protocols. Mutations were detected in 41 and 11% of the patients with HCM and DCM, respectively. Differences were observed in the frequency of splice site and frame-shift mutations in the gene MYBPC3, which occurred more frequently (P< 0.02, P< 0.001, respectively) in HCM than in DCM, suggesting that cardiac myosin-binding protein C haploinsufficiency predisposes to hypertrophy rather than to dilation. Additional novel genotype-to-phenotype correlations were found in HCM, among these a link between MYBPC3 mutations and a particularly large thickness of the interventricular septum (P= 0.04 vs. carriers of a mutation in MYH7). Interestingly, this correlation and a link between MYH7 mutations and a higher degree of mitral valve regurgitation held true for both HCM and DCM, indicating that the gene affected by a mutation may determine the magnitude of structural and functional alterations in both HCM and DCM. CONCLUSION: A large clinical-genetic study has unravelled novel genotype-to-phenotype correlations in HCM and DCM which warrant future investigation of both the underlying mechanisms and the prognostic use.

[Technical possibilities and limitations of mechanical circulatory support]. / Herzinsuffizienz - Technische Möglichkeiten und Grenzen der Mechanischen Kreislaufunterstützung.

Ventricular assist devices (VAD) to support the left (LVAD), the right (RVAD) or both ventricles (BVAD) have emerged as one standard of care for advanced heart failure patients. Initially used to bridge patients to transplantation (BTT) they are now more frequently implanted as permanent support (destination therapy, DT). Bridge to recovery (BTR) is a valid option for only a small number of patients. Although there are different devices available, patient selection, preoperative and intraoperative management, and the timing of VAD implantation are the elements critical to successful circulatory support.

Portable mechanical circulatory support: human experience with the LIFEBRIDGE system.

PURPOSE: This study was designed to demonstrate the safety and functional performance of the LIFEBRIDGE B2T system (Medizintechnik GmbH, Ampfing, Germany), a novel portable life support system, during human applications under controlled conditions. DESCRIPTION: The LIFEBRIDGE system was used as a modular closed-circuit miniaturized cardiopulmonary bypass system for total support of circulation and gas exchange in a series of 8 elective coronary artery bypass grafting procedures using normothermic cardioplegic arrest. EVALUATION: Mean blood flow rates provided by the LIFEBRIDGE system were 4.82±0.47 L/min throughout the procedures (ie, 100% of calculated normal blood flow). Adequate gas exchange and arterial oxygenation were provided at all times. All patients survived the operations with no neurologic sequelae. CONCLUSIONS: The LIFEBRIDGE system provides sufficient circulatory support and gas exchange during cardiac arrest and apnea, which are the maximum stress conditions for a life support system. It is anticipated that the system will be widely used as a circulatory support system in future applications that require portability and rapid delivery of short-term mechanical circulatory support, such as with cardiogenic shock.

Outcomes of elective versus emergent permanent mechanical circulatory support in the elderly: a single-center experience.

BACKGROUND: Advanced age is considered a relative contraindication to heart transplantation, but there is no published consensus on critical age in the case of mechanical circulatory support (MCS). This single-center study investigated outcomes of elective versus emergent implementation of permanent MCS in the elderly. METHODS: Between January 1, 2006 and April 1, 2009, 31 patients, >65 years of age, were supported with a ventricular assist device (VAD), intended for permanent support, at our institution. The 28 left VAD (LVAD) recipients were divided into two groups: a survival group, n = 13 (ongoing MCS at 180 days or weaned); and a non-survival group, n = 15 (death on device within 180 days). In addition, the survival rate of LVAD recipients according to pre-operative INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) status was analyzed. RESULTS: The cumulative survival rates for the LVAD patients were 75% at 30 days, 46% at 180 days and 39% at 1 year after VAD implantation. The cumulative survival rates at 30 days, 180 days and 1 year were 71%, 47% and 35% for INTERMACS Level I to III (n = 17) patients vs 81%, 45% and 45% for INTERMACS Level IV to V (n = 11) patients (p = 0.9), respectively. Median age of LVAD recipients was 69 (range 66 to 80) years; 4 were women. Median support time was 565 (range 228 to 1,257) days. In 9 recipients support is ongoing. Both complications profiles and causes of death are reported. CONCLUSIONS: Our experience indicates that permanent MCS may be successful in highly selected elderly patients with terminal heart failure, especially when elective implantation is performed before development of inotropic dependency or cardiogenic shock. However, outcomes at 12 months in this selective elderly population remain uniformly poor.

Heart transplantation in women with dilated cardiomyopathy.

BACKGROUND: Dilated cardiomyopathy (DCM) is responsible for over half of all heart transplants. Fewer women with DCM undergo heart transplants than men with DCM; the reasons for this state of affairs are unclear. METHODS AND RESULTS: We analyzed prospectively a cohort of 698 DCM patients who were referred to our heart transplant center. Only 15.5% of them were women. Women and men did not differ in age or ejection fraction (24%). Women were more frequently in New York Heart Association class III-IV, had lower exercise tolerance, worse pulmonary function, and poorer kidney function (all P<0.05) than men. Women were less commonly diabetic (14% vs. 23%; P<0.05). Similar percentages of women and men who were referred were transplanted; the women spent less time on the waiting list (153+/-37 days for women and 314+/-29 days for men; P<0.05). The 10-year survival rate of women and men after transplantation was similar (57% and 45%, respectively; P<0.203). We compared our current data to our overall experience from 1985 till date (n=972), and also with the Eurotransplant heart dataset. Similar to our current findings, far lower percentages of DCM patients in both cohorts were women, although the 10-year survival of female and male DCM patients after transplantation was not different. CONCLUSIONS: Because women were referred with more severe heart failure but fewer relative contraindications, it seems that the option of transplantation is less intensely considered for women, particularly for those with comorbidities, by the referring physicians. Because women with DCM do as well as men after transplantation, efforts should be undertaken to improve referral of women.