Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study.

BACKGROUND: Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE). METHODS: Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOA3D). Performance indices (i.e., EOA normalized to valve size) and PPM rates were determined. TTE-based EOAs obtained within 30 days were also calculated in a subset of 170 patients. RESULTS: The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3 ± 0.5 cm2, while the average EOA was 1.6 ± 0.2 cm2 for 20-mm, 2.0 ± 0.2 cm2, for 23-mm, 2.5 ± 0.3 cm2 for 26-mm, and 3.0 ± 0.3 cm2 for 29-mm THV size (P < .001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias -0.04 ± 0.15 cm2). There were strong correlations between annular area and TEE-based EOA (R = 0.84) and GOA3D (R = 0.87). The mean performance index was 47 ± 5% and was similar for all THV sizes (P = .21). EOAs based on TTE were smaller compared with those based on TEE, while the correlation with annular area (R = 0.67) and agreement with GOA3D (bias -0.26 ± 0.43 cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort. CONCLUSIONS: EOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Contrast-Enhanced Ultrasound of Muscle Perfusion May Indicate Patient Response to Left Ventricular Assist Device Therapy.

PURPOSE: Left ventricular assist device (LVAD) support is associated with peripheral vascular abnormalities beyond those associated with heart failure (HF). These abnormalities are associated with persistent functional impairments that adversely impact quality of life (QoL). Methods for measuring peripheral vascular function in this population are needed. METHODS: This pilot study investigated the use of contrast-enhanced ultrasound (CEUS) using standardized protocols to estimate changes in peripheral (quadriceps) muscle perfusion among patients with HF (INTERMACS profile 3) undergoing LVAD implantation (n = 7). Patients were then stratified by those who did ("responders", n = 4) and did not ("nonresponders", n = 3) report QoL improvement with LVAD support. RESULTS: Serial measurements obtained preoperatively and 3 months following LVAD implantation showed no significant change (P > .23) in muscle perfusion by all CEUS-based measures at rest or with an exercise stimulus for the overall population. Responders exhibited improved muscle perfusion at rest (P = .043) and decreased time to peak contrast enhancement (P = .010) at 3 months compared with baseline, suggesting improved delivery of blood to the extremities post-LVAD. Nonresponders showed unchanged resting muscle perfusion (P > .99), time to peak contrast enhancement (P = .59), and response to exercise stimulus (P > .99) following LVAD therapy. CONCLUSION: Our findings suggest that CEUS evaluation is a promising noninvasive, quantitative modality for real-time assessment of peripheral vasculature and muscle perfusion as an indication of treatment response in LVAD recipients and that this modality may capture perfusion measures important to QoL following LVAD implantation.

Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review.

Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32-57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58-255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS.

Quality of Life and Mid-Term Survival of Patients Bridged with Extracorporeal Membrane Oxygenation to Left Ventricular Assist Device.

Insertion of a left ventricular assist device (LVAD) improves survival and quality of life (QOL) in patients with class IV heart failure failing medical management. However, QOL and survival of patients bridged to LVAD with extracorporeal membrane oxygenation (ECMO) is unknown. Between July 2008 and June 2014, 213 patients underwent insertion of HeartMate II LVAD at two VAD centers without a bridge with a temporary VAD. Extracorporeal membrane oxygenation was used as a bridge before LVAD insertion in 22 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (ECMO-VAD group). No bridge was used in 21 INTERMACS 1 patients and 170 INTERMACS 2-4 patients (primary LVAD group). Survival was compared between the ECMO-VAD group and INTERMACS 1 patients who underwent a primary LVAD insertion (INTERMACS 1 group). Quality of life was compared between the ECMO-VAD group and the primary LVAD group as a whole. The in-hospital mortality of the ECMO-VAD and INTERMACS1 groups was 23% and 14%, respectively (P = 0.38). The postimplant QOL scores of the ECMO-VAD group were not different compared with the primary LVAD group. Although the ECMO-VAD group consists of critically ill patients, the QOL and survival after discharge were not significantly different compared with patients who were not bridged with ECMO.

The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: There are various factors that can influence the survival of patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). Vascular complications from femoral cannulation are common and are potentially serious. We analyzed the impact of vascular complications on survival of patients receiving VA ECMO. METHODS: Patients supported with VA ECMO by means of femoral cannulation from October 2010 to November 2014 were enrolled in this study. Data were gathered retrospectively by reviewing our institutional database. Patients were separated into two groups depending on the presence of major vascular complications, defined as patients who required surgical intervention. We evaluated predisposing factors for vascular complications and compared survival of patients in each group. RESULTS: There were 84 patients enrolled in the study. The rates of overall ECMO survival and survival to hospital discharge were 60% and 43%, respectively. Major vascular complications requiring surgical intervention were seen in 17 (20%) patients. Ten patients (12%) had compartment syndrome requiring prophylactic fasciotomy, and 10 patients (12%) had bleeding or hematoma requiring surgical exploration. The only significant predisposing factor for vascular complications was the absence of a distal perfusion catheter (odds ratio, 14.8; p = 0.03). The rate of survival to discharge was 18% and 49% in patients with and without vascular complications, respectively (p = 0.02). Vascular complications were an independent factor of significantly worse survival in patients receiving VA ECMO by multivariate analysis (hazard ratio, 2.17; p = 0.02). CONCLUSIONS: Vascular complications negatively affect survival in patients receiving VA ECMO support by means of femoral cannulation. The utilization of a distal perfusion catheter can decrease the incidence of complications.

Massive Thrombosis of the Transplanted Heart in the Early Postoperative Period.

We experienced a case with the left atrium almost completely filled with a thrombus after orthotopic heart transplantation while the patient was supported on extracorporeal membrane oxygenation for primary graft failure. The patient had recurrent thrombosis even after successful surgical thrombectomy and appropriate anticoagulation. The cardiac thrombosis resolved only after starting plasmapheresis.

Left ventricular assist device driveline infection and the frequency of dressing change in hospitalized patients.

OBJECTIVES: To determine if driveline infection is related to dressing change frequency in hospitalized adult patients with newly implanted left ventricular assist devices (LVAD). BACKGROUND: Guidelines do not exist for the frequency of driveline exit-site dressing change in hospitalized patients resulting in wide variation in practice. METHODS: A retrospective chart review was conducted on 68 patients implanted with a HeartMate II LVAD between August 2008 and September 2013 at an urban medical center. RESULTS: No driveline infections were found. Frequency of the driveline dressing change varied from daily, three times a week, and weekly. The daily dressing change group was younger in age compared to the weekly group (p = 0.005) and three times a week group (p = 0.001). No other differences were found. CONCLUSION: Driveline infections do not appear to be related to the frequency of dressing change in this population. Our data and other studies on this topic thus far are too limited to draw definitive conclusions about optimal frequency of dressing change for infection prevention.