The Longest Living Patient Supported With Left Ventricular Assist Device (14 Years).

Left ventricular assist devices (LVADs) improve survival and reduce symptoms in patients with advanced heart failure; however, the longer-term durability of LVADs remains uncertain especially with older-generation devices. In this case report, we describe the clinical course of a patient who has been successfully treated with the same HeartMate II LVAD for 14 years, the longest published and still ongoing LVAD support with the same originally implanted device.

Multisystem inflammatory syndrome in adults with cardiac engagement: a case report and literature review.

Background: Following infection with severe acute respiratory syndrome coronavirus, a post-infectious multisystem inflammatory syndrome in adults (MIS-A) has been identified. It affects multiple organ systems and can lead to multi-organic failure. Case summary: This case report describes a patient with MIS-A with significant cardiac involvement including peri-myocarditis, pulmonary hypertension, right-sided heart failure, tricuspid regurgitation, and cardiogenic shock. After being diagnosed and treated correctly for MIS-A, the patient recovered completely, without any cardiac sequelae. Discussion: The hyperinflammation in MIS-A can have cardiac engagement. Although more research is required to further clarify the underlying mechanisms, prompt diagnosis and anti-inflammatory treatment are crucial for better outcomes and cardiac recovery.

A case report about successful treatment of refractory ventricular tachycardia with ablation under prolonged haemodynamic support with extracorporeal membrane oxygenation.

BACKGROUND: In patients with severe left ventricular dysfunction, recurrent ventricular tachycardia (VT) non-responsive to antiarrhythmic therapies may cause further deterioration of cardiac function and haemodynamic instability. The use of extracorporeal membrane oxygenation (ECMO) in the setting of haemodynamically unstable VT may allow rhythm stabilization and can be effective in providing haemodynamic stability during VT ablation procedures. CASE SUMMARY: We describe the clinical course of a patient with ischaemic cardiomyopathy and recurrent VTs in the early post-myocardial infarction (MI) period. Nineteen days after MI, the patient started to experience recurrent attacks of VT, which became more frequent and non-responsive to medical treatment including amiodarone and lidocaine. The patient developed cardiogenic shock and a decision was made to institute ECMO. The patient was supported with ECMO for 32 days because of heart failure, refractory VT, and recurrent infections. An electrophysiological study was performed 4 days after ECMO initiation, which revealed a large scar area in the left ventricle. Radiofrequency energy was applied 69 times, rendering the VT non-inducible. Subsequently, VT attacks disappeared and the patient was weaned from ECMO after 32 days. The patient received a left ventricular assist device 5 days post-ECMO weaning and was then transplanted. DISCUSSION: There is still no evidence or guidelines regarding patients with refractory VT; however, ECMO support has been successfully used during VT ablation procedures. In this case report, VT ablation had a crucial role in treating the culprit arrhythmia while the implementation of ECMO allowed a complex ablation procedure to be completed safely.

Electrostatic Discharge Causing Pump Shutdown in HeartMate 3.

Left ventricular assist devices (LVADs) improve symptoms and outcomes in advanced heart failure. Although device malfunction has decreased significantly with later generation LVADs, it has not been eliminated. We describe the clinical course of a patient with HeartMate 3 LVAD who experienced device malfunction, involving temporary pump shutdown suspected to be caused by electrostatic discharge. (Level of Difficulty: Advanced.).

The Differential Impact of the Left Atrial Pressure Components on Pulmonary Arterial Compliance-Resistance Relationship in Heart Failure.

BACKGROUND: An increase in the pulmonary capillary wedge pressure (PAWP) has been shown to impact on the inherent relationship between the pulmonary arterial compliance (PAC) and pulmonary vascular resistance (PVR), thus augmenting the pulsatile relative to the resistive load of the right ventricle. However, the PAWP comprises the integration of both the steady and the pulsatile pressure components. We sought to address the differential impact of the these distinct PAWP components on the PAC-PVR relationship in a cohort of patients with heart failure. METHODS AND RESULTS: The study population consisted of 192 patients with hemodynamic findings diagnostic for heart failure. Off-line analysis was performed using the MATLAB software. The steady and pulsatile PAWP components were calculated as mid-A pressure and mean pressure during the V-wave oscillation, respectively. The PAC and PVR were hyperbolically and inversely associated and the subgroup of patients with PAWP above the median (>18 mm Hg) displayed a significant left and downward shift of the curve fit (P < .001). The shift in the PAC-PVR fit between patients with higher versus low steady PAWP was not significant (P = .43). In contrast, there was a significant downward and leftward shift of the PVR-PAC curve fit for the subgroup with a higher pulsatile PAWP (P < .001). Furthermore, only the pulsatile PAWP was significantly associated with the time-constant of the pulmonary circulation, assessed as the PAC × PVR product (P < .001). CONCLUSIONS: In patients with heart failure, the pulsatile rather than the steady PAWP component stands for the previously documented shift of the PAC-PVR relationship occurring at an elevated PAWP.

Validation of non-invasive ramp testing for HeartMate 3.

AIMS: Ramp testing in the postoperative period can be used to optimize left ventricular assist device (LVAD) speed for optimal left ventricular (LV) unloading. We tested the hypothesis that a non-invasive echocardiographic ramp test post-HeartMate 3 implantation improves LV unloading immediately after and 1-3 months after as compared with before the test. We also tested a secondary hypothesis that speed adjustments during echocardiography-guided ramp testing do not worsen right ventricular (RV) function immediately after and 1-3 months after. METHODS AND RESULTS: We retrospectively reviewed data from patients who underwent an echocardiographic ramp test. A total of 14 out of 19 patients were clinically stable and were enrolled. Adequate LV unloading was defined as no more than mild mitral regurgitation, and intermittent aortic valve (AV) opening or closed AV, and reduction of left ventricular end-diastolic diameter (LVEDD); and for the follow-up measurement, decreased NT-proBNP. Median (interquartile range) time from implantation to ramp test was 27 (16; 56) days, and median time from ramp test to follow-up echocardiography was 55 (47; 102) days. Median LVAD speed achieved during ramp testing was 5550 (5375; 6025) revolutions per minute (rpm), and median final LVAD speed was 5200 (5000; 5425) rpm. Ramp testing resulted in final LVAD speed increase in 11 (79%) patients and a median net change of 200 (200; 300) rpm. Speed adjustments after ramp testing resulted in improved LVAD unloading that was achieved in additional 3 (21%) patients who were not originally optimized. RV function did not worsen significantly during ramp testing or at final LVAD speed. CONCLUSIONS: The echocardiographic ramp test allowed LVAD speed adjustment and optimization and improved LV unloading during ramp testing and at final speed with no evidence of worsening of RV function.

ST2 in heart failure with preserved and reduced ejection fraction.

OBJECTIVES: Soluble suppression of tumorigenecity 2 (sST2) is prognostic in acute and chronic heart failure with reduced ejection fraction (HFrEF) but less studied in HF with preserved EF (HFpEF). We evaluated sST2 concentrations, correlations with biomarkers and echocardiographic measures of diastolic and systolic function, and associations with outcomes in HFpEF and HFrEF. DESIGN AND RESULTS: A total of 193 subjects from three different cohorts were included. Eighty-six HFpEF patients were obtained from the Karolinska Rennes (KaRen) study, 86 patients with HFrEF were recruited from referrals to Karolinska University Hospital for advanced assessment of HF, and 21 controls were included (ClinicalTrials.gov Identifier for KaRen: NCT01091467). HFrEF and controls cohorts did not have ClinicalTrials.gov registrations. sST2 was lower in HFpEF, median (interquartile range); 23 (17-31) compared to HFrEF; 35 (23-52) µg/L, p < .001. In both HFpEF and HFrEF, sST2 correlated positively with NT-proBNP (HFpEF rs=0.392, p < .001 and HFrEF rs=0.466, p < .001). In HFpEF, sST2 correlated to left atrial volume index (rs=0.276, p = .019) but not to E/E´, nor to left ventricular mass index. sST2 was in HFpEF associated with the composite endpoint of death or HF hospitalization, adjusted hazard ratio (HR) per log increase in sST2 6.62, 95% confidence interval (CI) 1.04-42.28, p = .046, and in HFrEF death, heart transplant or left ventricular assist systems; 3.51, 95% CI 1.05-11.69, p = .041. CONCLUSIONS: In patients with HFpEF compared to HFrEF, crude levels of sST2 were lower but potentially more strongly associated with outcomes. The lower levels of sST2 in HFpEF than in HFrEF may reflect lower degrees of fibrosis, but the potentially stronger association with outcomes may reflect a greater prognostic importance of progressive fibrosis and as such a greater potential for intervention. In conclusion; this study adds to the evidence of sST2 as prognostic marker in both HFpEF and HFrEF.

Controller and battery changes due to technical problems related to the HVAD® left ventricular assist device - a single center experience.

BACKGROUND: The use of left ventricular assist devices (LVADs) has increased in the last decade. Major complications have been well described, but there is no data on device alarms and actual or threatening malfunction which impair quality of life and may impair outcomes. This study describes the technical problems related to the use of the HVAD® left ventricular assist device in a single center. METHODS: We retrospectively reviewed device malfunctions and outcomes in 22 patients with HVAD® left ventricular assist device followed at Karolinska University Hospital between 2011 and 2016. Device malfunction was defined by INTERMACS as a failure of one or more of the components of the LVAD system. The primary outcome was defined as death or hospitalization or unplanned urgent clinic visit due to device alarm of unknown significance or actual or threatening malfunction. Separate secondary outcomes were malfunction resulting in controller exchange and malfunction resulting in battery change. Exploratory outcomes were death, transplantation, or explantation because of recovery. RESULTS: Median age was 59 years and 19% were women. Over a mean follow-up time of 1.7 years (37 patient-years), the primary outcome occurred 30 times (0.8 events per patient-year; 0 deaths, 2 hospitalizations and 28 un-planned clinic visits). Secondary outcomes were 41 device malfunctions for 14 patients requiring 45 controller exchanges in 12 patients (1.1 events per patient-year) and 128 battery changes in 12 patients (3.5 events per patient-year). Exploratory outcomes were 8 deaths (36.4%), 7 transplantations (31.8%) and 2 explants due to recovery (9.1%). CONCLUSION: The use of HVAD® was associated with technical problems requiring frequent un-planned clinic visits and changes of controller and/or batteries. There were no deaths due to device malfunction. Further studies are warranted to evaluate the risk of device malfunction and associated reductions in quality of life and cost.

Haemodynamic effects of levosimendan in advanced but stable chronic heart failure.

AIMS: Levosimendan improves haemodynamics in acute decompensated heart failure (HF). However, it is increasingly used for repetitive or intermittent infusions in advanced but stable chronic HF, without clear indication, selection criteria, or effect. We tested the hypotheses that (1) levosimendan improves haemodynamics in stable chronic HF and (2) that the response is dependent on baseline clinical and haemodynamic factors. METHODS AND RESULTS: Twenty-three patients [median age 56 (49-64) years, four (17%) women] with stable New York Heart Association (NYHA) III and IV HF received a single 24 h levosimendan infusion. Non-invasive haemodynamics (inert gas re-breathing technique), estimated glomerular filtration rate, and N-terminal pro-brain natriuretic peptide were assessed before and after infusion. Levosimendan had the following effects (median change): a significant increase in cardiac output (+9.8 ± 21.6%; P = 0.026) and decrease in N-terminal pro-brain natriuretic peptide (-28.1 ± 16.3%, P < 0.001), estimated total peripheral resistance (-16.9 ± 18.3%, P = 0.005), and mean arterial pressure (-5.9 ± 8.2%, P = 0.007), but no change in estimated glomerular filtration rate (+0.89 ± 14.0%, P = 0.955). There were no significant associations between baseline clinical and/or haemodynamic factors and the levosimendan effect on cardiac output. CONCLUSIONS: Levosimendan was associated with improved haemodynamics in patients with stable chronic HF, but we could not identify any predictors of the magnitude of haemodynamic response.