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The use of mechanical circulatory support and passive ventricular constraint in patients with acute and chronic heart failure
Linköping University, Department of Medicine and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Many patients are diagnosed as having chronic heart failure (CHF) and apart from the fact that daily activities are impaired, they are great consumers of health care, and the prognosis is poor. The distinction between acute heart failure (AHF) and CHF may be difficult and is more a question of time rather than severity. The “gold standard” treatment for end‐stage heart failure is heart transplantation. Due to organ shortage this is reserved for selected patients only. Since the introduction of mechanical circulatory support (MCS) more and more patients with progressive CHF have been bridged‐to‐heart‐transplantation. There are MCS systems available for both short‐ and long‐term support. Newer concepts such as ventricular constraint to prevent ventricular remodelling are on the way. We have investigated short‐ (ImpellaTM) and long‐term (HeartMateTM I and II) MCS and ventricular constraint (CorCapTM CSD) as treatment concepts for all forms of heart failure, the aims being: bridge‐to‐decision, bridge‐to‐transplant and extended therapy, called “destination therapy” (DT).

Methods and results: In Paper I, the use of HM‐ITM pulsatile MCS in bridge‐to‐transplantation patients in Sweden was retrospectively investigated regarding outcome and risk factors for mortality and morbidity. Fifty‐nine patients were treated between 1993 and 2002. The dominating diagnosis was dilated cardiomyopathy in 61%. Median support time was 99.5 days. 18.6% died before transplantation. Four patients needed RV assist due to right ventricular failure. Haemorrhage was an issue. Six patients (10%) suffered a cerebrovascular thromboembolic lesion. 15% developed driveline infection. 45% of the MCS patients were discharged home while on pump treatment. Massive blood transfusion was a predictor for mortality and morbidity, p<0.001.

In Paper II the second generation long‐term MCS, the continuous axial flow pump HM‐IITM, was prospectively evaluated for mortality and morbidity. Eleven patients, from 2005 until 2008, were consecutively included at our institution. One patient received the pump for DT. The median pump time was 155 days. Survival to transplantation was 81.8%. Ten patients could be discharged home before transplantation after a median time of 65 days.

Paper III investigated the Swedish experience and outcome of short‐term axial flow MCS, the ImpellaTM, in patients with AHF. Fifty patients were collected between 2003 and 2007 and divided into two groups: 1. Surgical group (n=33) with cardiogenic shock after cardiac surgery; and 2. Non‐surgical group (n=17), patients with AHF due to acute coronary syndromes with cardiogenic shock (53%) and myocarditis (29%). The 1‐year survival was 36% and 70%, respectively. 52% were reoperated because of bleeding. Predictors for survival at 30 days were preoperatively placed IABP (p=0.01), postoperatively cardiac output at 12 hours and Cardiac Power Output at 6 and 12 hours.

In Paper IV we evaluated the use and long term outcome of ventricular constraint CorCapTM CSD. Since 2003, 26 consecutive patients with chronic progressive heart failure were operated with CSD via sternotomy (n=25) or left mini‐thoracotomy (n=1). Seven patients were operated with CorCapTM only. Nineteen patients had concomitant cardiac surgery. There were three early and three late deaths. The remaining cohort (n=18) was investigated in a cross‐sectional study regarding QoL with SF‐36. There was no difference in QoL measured with SF‐36 after a mean 3‐years follow up period, when compared to an age‐ and sex‐matched control group from the general population. The one‐year survival was 86%, and after three years 76%. Echocardiographic dimensions had improved significantly after three years.

Conclusion: In our unit, a non‐transplanting medium‐sized cardiothoracic department, short‐ and long‐term MCS (ImpellaTM resp. HMTM) in patients with acute or chronic HF have been used with good results. The use of ventricular constraint early in the course of the disease is a good adjunct to other treatment options in progressive chronic HF patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2010. , 68 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1178
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-56424ISBN: 978‐91‐7393‐414‐5 OAI: oai:DiVA.org:liu-56424DiVA: diva2:318896
Public defence
2010-06-12, Elsa Brändströmsalen, Universitetssjukhuset, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2010-05-11 Created: 2010-05-11 Last updated: 2010-05-11Bibliographically approved
List of papers
1. Risk Factor Analysis of Swedish Left Ventricular Assist Device (LVAD) Patients
Open this publication in new window or tab >>Risk Factor Analysis of Swedish Left Ventricular Assist Device (LVAD) Patients
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2003 (English)In: Annals of Thoracic Surgery, ISSN 0003-4975, E-ISSN 1552-6259, Vol. 76, no 6, 1993-1998 p.Article in journal (Refereed) Published
Abstract [en]

Background. The use of left ventricular assist devices (LVADs) is established as a bridge to heart transplantation. Methods. All Swedish patients on the waiting list for heart transplantation, treated with LVAD since 1993 were retrospectively collected into a database and analyzed in regards to risk factors for mortality and morbidity. Results. Fifty-nine patients (46 men) with a median age of 49 years (range, 14 to 69 years), Higgins score median of 9 (range, 3 to 15), EuroScore median of 10 (range, 5 to 17) were investigated. Dominating diagnoses were dilated cardiomyopathy in 61% (n = 36) and ischemic cardiomyopathy in 18.6% (n = 11). The patients were supported with LVAD for a median time of 99.5 days (range, 1 to 873 days). Forty-five (76%) patients received transplants, and 3 (5.1%) patients were weaned from the device. Eleven patients (18.6%) died during LVAD treatment. Risk factor analysis for mortality before heart transplantation showed significance for a high total amount of autologous blood transfusions (p < 0.001), days on mechanical ventilation postoperatively (p < 0.001), prolonged postoperative intensive care unit stay (p = 0.007), and high central venous pressure 24 hours postoperatively and at the final measurement (p = 0.03 and 0.01, respectively). Mortality with LVAD treatment was 18.6% (n = 11). High C-reactive protein (p = 0.001), low mean arterial pressure (p = 0.03), and high cardiac index (p = 0.03) preoperatively were risk factors for development of right ventricular failure during LVAD treatment. Conclusions. The Swedish experience with LVAD as a bridge to heart transplantation was retrospectively collected into a database. This included data from transplant and nontransplant centers. Figures of mortality and morbidity in the database were comparable to international experience. Specific risk factors were difficult to define retrospectively as a result of different protocols for follow-up among participating centers. © 2003 by The Society of Thoracic Surgeons.

Place, publisher, year, edition, pages
Elsevier, 2003
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-46398 (URN)10.1016/S0003-4975(03)01016-6 (DOI)000186986500046 ()
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved
2. A single center experience with the HeartMate II (TM) Left Ventricular Assist Device (LVAD)
Open this publication in new window or tab >>A single center experience with the HeartMate II (TM) Left Ventricular Assist Device (LVAD)
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2009 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 43, no 6, 360-365 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. Left ventricular assist devices (LVAD), used in the setting bridge-to-transplantation and destination therapy, for patients with deteriorating severe heart failure are continuously developing. The second generation, the axial flow pumps, have been introduced since some years. Design. Eleven consecutive patients, seven male, with severe heart failure due to ischemic cardiomyopathy (n = 5), dilated cardiomyopathy (n = 5) and cytotoxic ethiology (n = 1) were implanted with the HeartMate-II (TM). They were preoperatively treated with inotropic support (n = 9), ventricular assist device (n = 2) and mechanical ventilation (n = 4). Results. Eight patients were bridged to transplant after median 155 days (range, 65 to 316 days). One patient is ongoing for 748 days, intended for destination therapy. Ten of eleven patients were discharged after median 64 days (range, 40 to 105 days). Four patients were reoperated due to bleeding. Two embolic events were recorded. One perioperative death. Conclusion. Eleven HM-II (TM) LVADs have been implanted in our institution with good early results. Eight patients were successfully bridged to heart transplantation. One patient is intended for destination therapy and is ongoing since November 2006. In these severely ill patients, this technique offers a good chance surviving until heart transplantation. In selected cases the technique also offers the possibility of a permanent support and longevity.

Keyword
Left ventricular assist; terminal heart failure; bridge to transplantation
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-52868 (URN)10.1080/14017430903019553 (DOI)
Available from: 2010-01-13 Created: 2010-01-12 Last updated: 2017-12-12
3. Experience with the Impella® recovery axial-flow system for acute heart failure at three cardiothoracic centers in Sweden
Open this publication in new window or tab >>Experience with the Impella® recovery axial-flow system for acute heart failure at three cardiothoracic centers in Sweden
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2009 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 43, no 4, 233-239 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. The Impella (R) recovery axial-flow system is a mechanical assist system for use in acute heart failure. This retrospective study reports the use of the device at three cardiothoracic units in Sweden. Design. Fifty patients (35 men, mean age 55.8 years, range 26 to 84 years) underwent implantation of 26 Impella (R) LP 2.5/5.0 (support-time 0.1 to 14 days), 16 Impella (R) LD (support-time 1 to 7 days) and 8 Impella (R) RD (support-time 0.1 to 8 days) between 2003 and 2007. Implantation was performed because of postcardiotomy heart failure (surgical group, n=33) or for various states of heart failure in cardiological patients (non-surgical group, n=17). The intention for the treatments was mainly to use the pump as a obridge-to-recoveryo. Results. Early mortality in the surgical and non-surgical groups was 45% and 23%, respectively. Complications included infection, 36% and right ventricular failure, 28%. Cardiac output and cardiac power output postoperatively were significantly higher among survivors than non-survivors. Conclusions. The Impella (R) recovery axial-flow system facilitates treatment in acute heart failure. Early intervention in patients with acute heart failure and optimized hemodynamics in the post-implantation period seem to be of importance for long-term survival. Insufficient early response to therapy should urge to consider further treatment options.

Keyword
Left ventricular assist device (LVAD), heart failure, temporary circulatory assistance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-19792 (URN)10.1080/14017430802715954 (DOI)
Available from: 2009-08-10 Created: 2009-08-10 Last updated: 2017-12-13
4. Long-term Quality-of-Life (QoL) in patients with progressive chronic heart failure after surgical ventricular restoration with passive ventricular constraint (CorCap-CSDTM): Comparison with a patient-matched reference group from the general population
Open this publication in new window or tab >>Long-term Quality-of-Life (QoL) in patients with progressive chronic heart failure after surgical ventricular restoration with passive ventricular constraint (CorCap-CSDTM): Comparison with a patient-matched reference group from the general population
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Chronic heart failure have a poor prognosis with high morbidity and reduced quality of life. Ventricular constraint, the CorCap Cardiac Support Device (CSD) has been introduced with the intention of inducing reverse remodeling. Studies have shown sustained improvement in left ventricular dimensions and function after three years, but quality-of-life (QoL) has been poorly studied.

Methods and Results: Since 2003, 26 patients with chronic progressive heart failure met the inclusion criteria for CSD. They were prospectively followed each year for five years postoperatively. Nineteen patients were scheduled for concomitant cardiac surgery.

In a cross-sectional study, 18 patients were investigated regarding QoL using SF-36. A reference group was randomly selected from the Swedish SF-36 general population reference group.

One-year survival for CSD-patients was 86%, three-year survival was 76%. After a mean follow-up time after surgery of 3.9 years (range; 0.9 to 7 years), no difference in QoL measured with SF-36 was found. Echocardiographic dimensions and QoL improved significantly after three years for isolated CSD patients.

Conclusions: QoL in patients operated with CSD, measured with SF-36-questionnaire, more than three years after implantation, is comparable to a matched general population reference group. In the CSD group alone, QoL improved significantly after three years.

Keyword
Ventricular constraint, Quality of Life, chronic heart failure, SF-36
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-56423 (URN)
Available from: 2010-05-11 Created: 2010-05-11 Last updated: 2010-05-11

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