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Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Left ventricular assist device (LVAD) support is an increasingly important and successful therapeutic option for patients with end-stage heart failure. As chronic heart failure progresses, the left and right ventricles adapt by enlarging its volume and patients present for LVAD implantation with varying degrees of dilatation. By quantitatively assessing right ventricular (RV) and left ventricular (LV) volumes using 3D transoesophageal echocardiography and correlating the findings with clinical outcomes, we aim to investigate the prognostic value of LV and RV volumes for early survival after LVAD implantation., Methods: This is a single-centre, non-randomized diagnostic cohort study using prospectively collected clinical and 3D echocardiographic data from 65 patients scheduled for LVAD implantation, using centrifugal pumps for long-term support (HeartWare and HeartMate 3). The primary end-point for this study is 60-day mortality, with longer term survival as a secondary end-point., Results: We divided our cohort group into survivors and non-survivors at 60 days [49 patients (75%) and 16 patients (25%), respectively]. Right to left end-diastolic ratio assessed by 2D echocardiography was significantly higher in the 60-day non-survivors group (0.70 ± 0.09 vs 0.62 ± 0.11; P = 0.01). Indexed end-diastolic volume parameters (LV, RV and overall heart) showed significant differences among the groups and were higher in the 60-day survivors group (LV volume 154 ± 51 ml/m2 vs 110 ± 40 ml/m2, P = 0.004; RV volume 96 ± 27 ml/m2 vs 80 ± 23 ml/m2, P = 0.05; heart 250 ± 64 ml/m2 vs 190 ± 57 ml/m2, P= 0.003). To investigate haemodynamic and echocardiographic parameters, the right to left end-diastolic ratio and indexed RV end-diastolic volume were associated with 60-day mortality in the logistic regression analysis. The Kaplan-Meier survival curves for patients with indexed RV end-diastolic volume >82 ml/m2 vs indexed RV end-diastolic volume ≤82 ml/m2 showed better 1-year survival (P = 0.005) for the group with more RV dilatation., Conclusions: Patients with moderately increased end-diastolic RV volume index carry a higher postoperative risk, while severe RV dilatation seems to be protective. In future, postoperative management of patients with moderately dilated RVs should be focussed on adjusting individually appropriate LVAD flows and providing frequent follow-up.

HeartWare assist device outflow graft obstruction is an uncommon but severe complication, and it may be because of several reasons. We present a case of recurrence of heart failure in a young patient supported with left ventricular assist device and on the waiting list for heart transplantation. After a complex diagnostic workout, a stenosis of the graft anastomosis was found and successfully stented.

Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25-70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty-six patients (38 men; median age 54.5 years, range: 25-70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28-68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90-day and 6-month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1-year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction., (© 2013, Copyright the Authors. Artificial Organs © 2013, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: After left ventricular assist device (LVAD) implantation, right ventricular (RV) failure is a major cause of post-operative morbidity and mortality. Recently, in patients with similar hemodynamic challenge, but less severe RV impairment, who were undergoing surgery for mitral valve repair, concomitant tricuspid valve repair improved post-operative RV re-remodeling in patients with severely dilated tricuspid annuli without tricuspid regurgitation (TR)., Methods: Pre-operative transesophageal echocardiography and clinical data were prospectively collected from 122 patients without severe TR, who were selected for LVAD implantation. Patients were assigned to one of two groups according to pre-operative tricuspid annulus diameter <43 mm or >43 mm. Groups were compared for parameters that may impact survival after LVAD implantation. Kaplan-Meier survival curves were evaluated for the impact of tricuspid annulus size and right-to-left ventricular diameter ratio (R/L ratio) on 36-month survival. Multivariate analysis was used to identify the pre-operative parameters that independently affected survival., Results: Patients with tricuspid annulus >43 mm presented with higher R/L ratio (0.73 ± 0.21 vs 0.56 ± 0.13; p < 0.00001) and higher proBNP plasma concentration (12,872 ± 13,084 vs 8,988 ± 13,018 pg/ml; p = 0.018). Both R/L ratio >0.72 and tricuspid annulus >43 mm adversely affected survival (p = 0.003 and 0.007, respectively). In the multivariate analysis only tricuspid annulus diameter >43 mm (hazard ratio 2.16, CI 1.21 to 3.84, p = 0.009) and age (hazard ratio 1.03, CI 1.00 to 1.06, p = 0.04) were independent predictors of survival after LVAD., Conclusions: Tricuspid dilation, even without severe regurgitation, adversely affects survival after LVAD implantation. Further studies are required to determine whether concomitant tricuspid valve repair may improve survival in these patients., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Introduction: Aortic valve regurgitation or the presence of a mechanical aortic valve prosthesis is a relative contraindication for implantation of left ventricular assist devices (LVAD). However, concomitant aortic valve replacement by a biological prosthesis is one of the options in this situation. We analyzed our recent experience with left ventricular assist device implantation and concomitant aortic valve replacement., Methods: Between January 1, 2008 and January 15, 2012, 318 adult patients (>18 years old) were supported with a long-term implantable LVAD in our institution. In 19, simultaneous aortic valve replacement (6 redo and 13 primary procedures) was performed. Patients were divided into 2 groups according to INTERMACS (IM) level: Group 1 (n = 7) consisted of patients with IM level 1-2 and Group 2 (n = 12) of IM level 3-4 patients. As a control cohort we analyzed all LVAD recipients during the study period (n = 299, study group excluded). The control cohort was similarly divided into two groups according to the IM level: Group 3 (n = 162) consisted of patients with IM level 1-2 and Group 4 (n = 137) of those with IM level 3-5. Perioperative data and outcomes in all groups were retrospectively analyzed and compared (Group 1 compared to Group 3; and Group 2 to Group 4)., Results: In study Groups 1 and 2 all patients were male; in Groups 3 and 4, 80% and 88% respectively were male. Median age distribution in Groups was 55, 61, 54, and 57 years respectively. Patients from Group 2 were significantly older than those from Group 4 (p = 0.039). Body mass index was significantly lower in Group 1 than in Group 3 (p = 0.033). Cardio-pulmonary bypass time was significantly longer in Groups 1 and 2 compared with Groups 3 and 4 respectively (p=0.001). Patients from Group 1 had a trend more often to develop right ventricular failure requiring a right ventricular assist device (RVAD) than those in Group 3 (p = 0.09). Intensive care unit stay duration of mechanical ventilation and in-hospital mortality in Group 1 were significantly higher than in Group 3 (p = 0.025, p = 0.005, p = 0.038). Patients from Group 2 had similar outcomes compared to those from Group 4., Conclusions: In stable patients, simultaneous aortic valve replacement and LVAD implantation are not associated with an impaired outcome. In patients with cardiogenic shock an additional aortic valve replacement may impair outcome; therefore alternative techniques should be considered.

Objectives: Transapical aortic valve implantation significantly reduces operative risk in elderly patients with aortic valve stenosis and comorbidities. However, it is unknown whether this procedure is feasible in patients with advanced heart failure., Methods: Between April 2008 and July 2010, 258 patients underwent transapical aortic valve implantation. Twenty-one patients had advanced heart failure with decompensation and a left ventricular ejection fraction of 10% to 25%. The mean age of these patients was 74 ± 11 years (range, 36-88 years). The mean left ventricular ejection fraction was 20% ± 5% (range, 10%-25%). Mean logistic EuroSCORE was 66% ± 21% (range, 27%-97%) and mean Society of Thoracic Surgeons score 33% ± 25% (range, 4%-90%). Nine patients were operated on using femorofemoral cardiopulmonary bypass and 12 without., Results: Technical success of the procedure was 100% with no conversion to conventional surgery. The mean time of cardiopulmonary bypass was 27 ± 25 minutes (range, 6-81 minutes). Postoperatively, the left ventricular ejection fraction increased to 38% ± 12% (range, 20%-60%). There were no postoperative neurologic complications. A new pacemaker implantation was needed in 2 (10%) patients. The 30-day mortality was 4.8%. Survival at 1, 3, 12, and 24 months was 95%, 81%, 76%, and 62%, respectively., Conclusions: Transapical aortic valve implantation can be performed safely in patients with decompensated heart failure or even in the presence of cardiogenic shock., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Up to 30% of patients with end-stage heart failure experience biventricular failure that requires biventricular mechanical support. For these patients, only bulky extracorporeal or implantable displacement pumps or the total artificial heart have been available to date, which enables only limited quality of life for the patients. It was our goal to evaluate a method that would allow the use of 2 implantable centrifugal left ventricular assist devices as a biventricular assist system., Methods and Results: Seventeen patients have been implanted with 2 HeartWare HVAD pumps, 1 as a left ventricular assist device and 1 as a right ventricular assist device. Seventy-seven percent of the patients had idiopathic dilated or ischemic cardiomyopathy. Their age ranged from 29 to 73 years (mean 51.8 ± 14.5 years), and 11 (64.7%) received intravenous catecholamine support preoperatively. The right ventricular assist device pump was implanted into the right ventricular free wall. The afterload of this pump was artificially increased by local reduction of the outflow graft diameter, and the effective length of its inflow cannula was reduced by the addition of two 5-mm silicon suture rings to the original HVAD implantation ring. All right ventricular assist device devices could be operated in appropriate speed ranges and delivered a flow of between 3.0 and 5.5 L/min. Thirty-day survival was 82%, and 59% of the patients could be discharged home after recovering from the operation. There was no clinically relevant hemolysis in any of the patients., Conclusions: Two HeartWare HVAD pumps can be used as a biventricular assist system. This implantable biventricular support gives the patients more comfort and mobility than usual biventricular ventricular assist devices with large and noisy displacement pumps.

Background: Used frequently for right ventricular dysfunction (RVD), the clinical benefit of inhaled nitric oxide (iNO) is still unclear. We conducted a randomized, double-blind, controlled trial to determine the effect of iNO on post-operative outcomes in the setting of left ventricular assist device (LVAD) placement., Methods: Included were 150 patients undergoing LVAD placement with pulmonary vascular resistance ≥ 200 dyne/sec/cm(-5). Patients received iNO (40 ppm) or placebo (an equivalent concentration of nitrogen) until 48 hours after separation from cardiopulmonary bypass, extubation, or upon meeting study-defined RVD. For ethical reasons, crossover to open-label iNO was allowed during the 48-hour treatment period if RVD criteria were met., Results: RVD criteria were met by 7 of 73 patients (9.6%; 95% confidence interval, 2.8-16.3) in the iNO group compared with 12 of 77 (15.6%; 95% confidence interval, 7.5-23.7) who received placebo (p = 0.330). Time on mechanical ventilation decreased in the iNO group (median days, 2.0 vs 3.0; p = 0.077), and fewer patients in the iNO group required an RVAD (5.6% vs 10%; p = 0.468); however, these trends did not meet statistical boundaries of significance. Hospital stay, intensive care unit stay, and 28-day mortality rates were similar between groups, as were adverse events. Thirty-five patients crossed over to open-label iNO (iNO, n = 15; placebo, n = 20). Eighteen patients (iNO, n = 9; placebo, n = 9) crossed over before RVD criteria were met., Conclusions: Use of iNO at 40 ppm in the perioperative phase of LVAD implantation did not achieve significance for the primary end point of reduction in RVD. Similarly, secondary end points of time on mechanical ventilation, hospital or intensive care unit stay, and the need for RVAD support after LVAD placement were not significantly improved., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

The implantation of ventricular assist devices (VADs) is a valuable option in patients with end-stage heart failure. The number of VAD implantations is growing worldwide. Between July 1987 and July 2010, we implanted 1,598 VADs in 1,455 patients. The majority were male (81.0%), and their mean age was 49.4 years (range 0.3-82 years). Indications for implantation were: cardiomyopathy (n = 1,074), post-cardiotomy heart failure (n = 282), acute myocardial infarction (n = 83), graft failure after heart transplantation (n = 64), and others (n = 61). In 55.5%, the VAD implanted was left ventricular, in 39.5% biventricular, and in 4.8% right ventricular. Until 1995, the implanted pumps were mostly pulsatile. Today, however, more than 95% of the implanted VADs are continuous-flow rotary pumps. The average support time was 148.6 days (range 0-1,836 days). The percentage of biventricular VADs has dropped over the years to 20% in 2009. Three hundred forty-seven patients could be successfully bridged to heart transplantation. In 122 patients (8.3%), the device could be explanted after myocardial recovery. In 2009, 31.4% of the patients were implanted for permanent support. During the study period, 521 patients could be discharged home or to a rehabilitation center. Implantation of ventricular assist devices is now an established treatment for patients with both acute and chronic end-stage heart failure. Small implantable left ventricular assist devices of the second and third generation are now broadly employed worldwide, with growing acceptance and decreasing complications. The percentage of biventricular support has dropped over the years to 20%.

Objective: Left ventricular assist device (LVAD) implantation is an established option for treatment of patients with end-stage heart failure, but outcome may be worsened by right ventricular failure. The aim of this study was to evaluate the acute effect of LVAD on right ventricular geometry and function and the pulmonary circulation. The effect of inhaled nitric oxide (iNO) was assessed., Methods: We evaluated pre- and postoperatively obtained transesophageal echocardiography images and hemodynamics of patients participating in a randomized trial on the effect of inhaled nitric oxide during LVAD implantation. Twenty-four patients were randomized to the iNO group and 23 to the placebo group., Results: After LVAD implantation marked decreases in pulmonary capillary wedge pressure (P < .01) and mean pulmonary artery pressure (P < .01) were observed in both groups. Pulmonary vascular resistance decreased only in the iNO group (311 ± 35 to 225 ± 17, P < .01). Transesophageal echocardiography measurements show significant improvement of right ventricular geometry (right ventricular end-diastolic diameter: 50 ± 2 to 45 ± 2, P < .01 and 48 ± 2 to 44 ± 2 mm, P < .05 in iNO and placebo groups) and function (right ventricular fractional area change: 24% ± 2% to 31% ± 2%, P < .05 and 23% ± 2% to 29% ± 2%, P < .05 in iNO and placebo groups) without any difference between the iNO and placebo groups. The overall incidence of postoperative right ventricular failure was 4 of 47 (8.5%)., Conclusions: LVAD implantation markedly improved right ventricular geometry and function in most of the patients, probably by resolving left ventricular congestion and thus reducing right ventricular afterload. Beneficial effects of iNO may have been masked by more pronounced consequences of left ventricular unloading on right ventricular function., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: Implantation of a left ventricular assist device (LVAD) is an established treatment for end-stage heart failure. Right ventricular dysfunction develops in 20%-50% of patients after device implantation, leading to prolonged hospital stays and elevated mortality rates. However, prediction of right ventricular failure remains difficult., Methods: A total of 40 patients who received an LVAD for chronic end-stage heart failure between May 2001 and December 2002 were evaluated. The patients were divided retrospectively into two groups: group I (n = 26), with no apparent postoperative right ventricular failure; and group II (n = 14), with right ventricular failure after implantation defined by the presence of two of the following criteria during the first week after surgery: mean arterial pressure ≤ 55 mmHg, central venous pressure ≥ 16 mmHg, mixed venous saturation ≤ 55%, cardiac index <2 l/min/m(2), inotropic support score >20 units or an apparent need for mechanical right ventricular support. Hemodynamic, echocardiographic, neurohumoral, and inflammatory parameters were evaluated 24 h before implantation of the LVAD., Results: Levels of procalcitonin, neopterin, n-terminalpro-brain natriuretic peptide, and big endothelin-1 were significantly lower in group I: 0.106 vs. 0.322 ng/ml, P = 0.048; 10.5 vs. 20.7 ng/ml, P = 0.018; 6322 vs. 17174 pg/ml, P = 0.032; 1.6 vs. 19.5 pg/ml, P = 0.02, respectively. Levels of creatinine kinase and creatinine were significantly lower in group I than in group II: 24 vs. 40 U/l, P = 0.034; 1.3 vs. 2.3 mg/dl, P = 0.008, respectively., Conclusion: Preoperative evaluation of markers of inflammation and neurohumoral activation may provide additional information for predicting right ventricular failure after implantation of an LVAD.

In end-stage heart failure, mechanical ventricular assist devices (VAD) are being used as bridge-to-transplantation, as a bridge-to-recovery, or as the definitive therapy. We tested the hypothesis that myocardial implantation of autologous bone marrow mononuclear cells (BMNC) increases the likelihood of successful weaning from left VAD (LVAD) support. Ten patients (aged 14-60 years) with deteriorating heart function underwent LVAD implantation and concomitant implantation of autologous BMNC. Bone marrow was harvested prior to VAD implantation and BMNC were prepared by density centrifugation. Two patients received a pulsatile, extracorporeal LVAD and eight a nonpulsatile implantable device. Between 52 and 164 x 10(7) BMNC containing between 1 and 12 x 10(6) CD34+ cells were injected into the LV myocardium. There was one early and one late death. The median time on LVAD support was 243 days (range 24-498 days). Repeated echocardiographic examinations under increased hemodynamic load revealed a significant improvement of LV function in one patient. Three patients underwent heart transplantation, and four patients remain on LVAD support >1 year without evidence of recovery. Only one patient was successfully weaned from LVAD support after 4 months, and LV function has remained stable ever since. In patients with endstage cardiomyopathy, intramyocardial injection of BMNC at the time of LVAD implantation does not seem to increase the likelihood of successful weaning from VAD support. Other cell-based strategies should be pursued to harness the potential of cell therapy in LVAD patients.

Mechanical ventricular assist devices (VAD) have become an accepted therapy for the support of patients in severe heart failure. With the devices presently available, the incidence of thromboembolic complications is high. Since November 1998, we have used the DeBakey VAD (MicroMed, Inc., Woodlands, TX). To detect the effect of this VAD on the appearance of microthrombi or bubbles from cavitation, we measured Microembolic Signals (MES) with transcranial Doppler in patients after the implantation of the DeBakey VAD. Transcranial Doppler studies were performed with the MULTI-DOP X4 device with two 2 MHz probes (for the left and right middle cranial arteries [MCA]) in five patients preoperatively and during 10 weeks after VAD implantation. Both MCAs were monitored simultaneously for 60 minutes in 10 sessions in each patient. The detection and analysis of MES was performed in accordance with the technique and criteria described by the international consensus group. No MES were noted during the study period in four patients. In one patient with preoperatively noted MES the prevalence of MES postoperatively was 50%. The high speed rotating impeller of the DeBakey VAD did not produce any detectable microthrombi or bubbles from cavitation effects.