Infection is the commonest adverse effect in patients implanted with contemporary continuous-flow pumps with most such events presenting as events unrelated to the pump components. Whether mechanical circulatory devices confer an immunosuppressive effect leading to propensity for infection warrants closer scrutiny to understand and ameliorate this morbidity. (Funded by Abbott; MOMENTUM 3 NCT02224755).

These findings support the feasibility, high fidelity and usefulness of a LVAD DA into busy real-world cardiovascular care. The majority of clinical providers believe the aid is relevant to clinical practice.

Background: An increasing number of continuous flow pumps are currently under clinical studies, however very little data exist on the hemodynamic and cellular responses of the failing heart to continuous flow support. The purpose of this investigation was to characterize the response of the failing myocardium to continuous flow support.Methods: We compared echocardiographic and cellular markers of failing myocardium at the time of left ventricular assist device (LVAD) implantation and explantation in 20 consecutive patients (12 pulsatile flow [Novacor] and 8 continuous flow [DeBakey-Noon]).Results: The use of mechanical support with both continuous- or pulsatile-type LVADs resulted in a reduction of left ventricular end-diastolic dimension (LVEDD), end-diastolic volume (EDV), end-systolic volume (ESV) and left atrial volume (LAV), as well as a decrease in mitral E/A ratio, tricuspid regurgitation velocity (TRV) and pulmonary valve acceleration time (PVAT). Comparative analyses for patients treated with a continuous- vs pulsatile-type LVAD support showed a greater degree of unloading with the latter type, as shown by the effect on LVEDD (-13.7% vs -33.7%, p = 0.0.004), EDV (-23.5% vs -41.2%, p = 0.015), ESV (-25.6% vs -57.6%, p = 0.001) and LAV (-25.2% vs -40.4%, p = 0.071). The hemodynamic effects of continuous vs pulsatile LVAD support were similar, as shown by their effect on mitral E/A ratio (-23.9% vs -39.9%, P = NS), TRV (-26.4% vs -23.8%, P = NS) and PVAT (28.5% vs 38.5%, P = NS). Only pulsatile support demonstrated a statistically significant percent change in mass (-6.3% vs -20.6%, p = 0.038). Continuous and pulsatile forms of mechanical support demonstrated equivalent reductions in myocardial tumor necrosis factor-alpha (TNF-alpha), total collagen and mycocyte size.Conclusions: Our findings show that, although there are differences between these 2 devices in magnitude of unloading, both forms of support effectively normalize cellular markers of the failing phenotype. J Heart Lung Transplant 2005;24:566-75. Copyright (c) 2005 by the International Society for Heart and Lung Transplantation.

Purpose of review The authors present a comprehensive analysis of the evidence in support of improvements at the cellular, structural, and hemodynamic levels after left ventricular assist device support. Recent findings The use of left ventricular assist devices as a strategy to bridge patients to cardiac transplantation and, more recently, as a form of destination therapy has provided a great opportunity to study failing myocardium at various time points. Specifically, myocardial samples can be obtained from patients at the time of left ventricular assist device implantation and again at explant, thereby allowing comparisons between paired samples of failing myocardium obtained before and after mechanical unloading. Summary A body of knowledge has been generated that illustrates the ability of the myocardium to “heal.” This information may give us better insight into cellular and molecular mechanisms of heart failure and potential new therapies for patients with end-stage heart failure.

Purpose of review More than 5 million people in the United States alone have congestive heart failure, and an estimated 40 million have established risks and warrant therapy. Mineralocorticoid antagonists have emerged as a new paradigm for the treatment of congestive heart failure. They have established benefits among patients with chronic symptomatic systolic dysfunction, and recent studies have demonstrated substantial effect on the morbidity and mortality among patients with heart failure after myocardial infarction. The exact biologic mechanism is thus far unknown. Recent findings Within the last 5 years, efforts have intensified to help define better the biologic mechanisms by which mineralocorticoid receptor antagonisms exert the observed clinical benefit. Elegant human studies have demonstrated some important observations. First, under conditions of increased plasma aldosterone concentrations, the heart will extract aldosterone. Second, aldosterone extraction in the heart stimulates increased collagen turnover culminating in ventricular remodeling. Third, among people with chronic systolic or diastolic heart failure, aldosterone is actually produced and secreted by the heart. Finally, antagonism of the mineralocorticoid receptor will attenuate or abrogate many of these deleterious effects. Summary Combined clinical and detailed mechanistic investigations have established mineralocorticoid receptor antagonism as the new treatment paradigm for congestive heart failure. Recent clinical data have demonstrated that treatment of patients with a combination of mineralocorticoid receptor antagonism (eplerenone) and angiotensin converting enzyme-inhibitor (ACE-I) results in substantial reduction in left ventricular mass. Furthermore, a federally funded initiative to treat more than 6000 patients with diastolic heart failure with spironolactone is in its final phases of planning. It is foreseeable that, along with ACE-I and β-blockers, mineralocorticoid receptor antagonism will become part of the treatment paradigm for people across the entire spectrum of cardiovascular disease.

Purpose:Patients who require mechanical circulatory support are often severely deconditioned. They may require extended ventilatory support after device implantation. During this time, full body rehabilitation improves the outlook for successful transplantation. The purpose of this study is to illustrate that a physical therapy (PT) program with focus on early mobilization and ambulation can improve functional mobility in LVAD patients requiring prolonged mechanical ventilation. Methods This study describes the PT intervention used in two LVAD pa=. The devices used were Micromed Debakey LVAD and Thoratec LVAD. Special emphasis was placed on early mobilization and ambulation. The use of appropriate ventilatory support and a portable ventilator was imperative so patients could tolerate increased levels of exertion. Results:Both patiens showed significant functional gains during the period of prolonged mechanical ventilation and bed rest. The patient on the Thorated LVAD stayed in ICU for 71 days and was able to ambulate up to 360 feet when transferred out of ICU. He is currently waiting for a transplant. The patient on the Micromed DeBakey LVAD stayed in ICU for 49 days and was able to ambulate up to 600 feet. He subsequently had a heart transplant and was discharged home. Early PT intervention enhances functional outcomes by optimizing cardiopulmonay and neuromuscular status. Improving mobility of LVAD patients has the potential to reduce length of ICU stay by facilitating ventilator weaning as general strength and endurance improves.

Purpose of review The growing epidemic of systolic congestive heart failure mandates strategies to identify accurately people with high morbidity and mortality. Echocardiography remains the most widely available noninvasive tool for the assessment of cardiac structure, function, and hemodynamics. Clinical data paired with echocardiographic analysis in patients with systolic heart failure obtained from a variety of investigations have allowed for the evaluation of this modality as a prognostic tool. Recent findings Detailed appraisal of the literature has revealed five distinct, easy-to-evaluate echocardiographic parameters that may assist clinicians to segregate high-risk patients. The presence of or the inability to modify a left ventricular ejection fraction less than 25%, impaired right ventricular function (assessed by any of four methods), left ventricular end-diastolic dimension greater than 6.5 to 7 cm, a restrictive mitral inflow, or pulmonary hypertension (peak tricuspid regurgitant velocity >2.5 m/s) should alert clinicians of patients with high morbidity (recurrent congestive heart failure admission, arrhythmia, impaired functional capacity) and mortality. Particularly important among these variables is the presence of a restrictive mitral inflow pattern. Summary Detailed analysis of two-dimensional and Doppler data routinely obtained from echocardiograms has established prognostic implications among patients with systolic heart failure. Although prospective clinical trials are lacking, the use of echocardiography to segregate risk should be incorporated into current strategies to treat congestive heart failure and influence clinical listing for cardiac transplantation.

Background: Humoral rejection in heart transplant recipients (HTR) is characterized by more severe left ventricular dysfunction and hemodynamic compromise than caused by cellular rejection. Humoral rejection responds less favorably to conventional immunosuppressive treatment. There is data that humoral rejection responds to plasmapheresis treatment in HTR.

Background: Routine surveillance biopsies are used in the post-heart transplant setting to detect and treat sub-clinical acute rejection. No outcome data exists to establish that this identification and treatment improves transplant survival. Preliminary data suggested that frequent biopsies were unnecessary; based on these data we modified our biopsy regimen in 1999. We then sought to determine whether decreasing the frequency of post-transplant surveillance biopsies affected the survival of our heart transplant patients.

A growing number of patients present with heart failure. Some of them may qualify for surgical correction of their cardiac condition. Since heart transplantation will always be available to only a small number of patients, several new surgical techniques have been developed for approval in heart failure patients. Classic interventions such as revascularization, valve repair, or valve replacement have been improved and modified to meet the need of heart failure patients. Several of these techniques are currently under investigation in large clinical trials. These trials will definitely have an impact on the development of surgical treatment of patients with heart failure.

Objective: Certain neurohormones (e.g., brain natriuretic peptide (BNP), endothelin-1 (ET-1)) have demonstrated reliability as clinical markers of left ventricular (LV) function. The aim of this study was to examine the relationship between plasma levels of these neurohormones, LV function and histological evidence of morphological improvement in left ventricular assist device (LVAD) recipients to determine whether serial hormonal expression may be used to assess cardiac status in the LVAD setting. Methods: Plasma levels of BNP and ET-1 were measured in 19 end-stage congestive heart failure patients directly before and up to 18 weeks after implantation with various devices (DeBakeyVAD, Novacor, TCI HeartMate). Echocardiographic indices corresponding to the time-points of serial hormonal measurement were evaluated. Immunohistochemical collagen staining of LV tissue samples derived from LVAD patients at the time of device insertion and removal were then contrasted. Patients were grouped according to device employed and etiology (ischemic/dilated cardiomyopathy, ICMP/DCMP). Results: LVAD therapy significantly enhanced LV ejection fraction (EF%: 21% ± 3.8% to 37% ± 11.39%) and cardiac output (CO: 3.49 ± 1.3 to 7.3 ± 0.2 l/m) in all patients; other parameters were not appreciably altered. Absolute BNP and ET-1 plasma levels remained significantly lower in all patients after LVAD implantation (both: p < 0.001). The NOV group exhibited the most BNP reduction and EF% increase (p < 0.0004 and p < 0.038, respectively), whereas ET-1 was lower in the DVAD group (p < 0.06). In all categories, the ICMP group experienced more significant change when compared to those in the DCMP grouping. Collagen levels were sharply reduced in all patients (p < 0.0005); however, while those in the DVAD demonstrated the most evident change (p < 0.0036), there was little difference between the DCMP/ICMP groups (p < 0.012 vs p < 0.022). Both BNP and ET-1 manifested bi-phasic tendencies and an inverse proportionality to EF% measurements. Conclusions: Plasma BNP and ET-1 levels appear to correlate both with device-related LV functional and myocardial morphological improvement and may be of potential use as therapeutic indicators.