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Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation. [ABSTRACT FROM AUTHOR]

Background: Left ventricular assist device (LVAD) recipients report symptom improvement but find adjusting to life with the LVAD challenging. These challenges are unique, and existing patient‐reported outcome measures (PROMs) do not reflect their experiences. This study aimed to develop a culturally relevant quality of life PROM for use with LVAD recipients in future research, design evolutions and clinical practice. Methods: A three‐stage mixed‐methods approach was used to develop a PROM: stage 1 included group concept mapping (GCM); stage 2 semi‐structured qualitative interviews were conducted with 11 LVAD recipients and 10 clinicians, and a questionnaire was developed using a conceptual framework; and stage 3 used exploratory psychometric analysis of the PROM data using Rasch measurement theory. This paper presents stages 2 and 3. Results: The conceptual framework consisted of four key concepts, including general health, life with the LVAD, equipment and clothing and emotional impact. Statements from interviews and GCM were used to create items for the LVAD quality of life (LVAD‐QoL). Cognitive interviews tested face validity and participant comprehension. Forty‐nine participants were recruited from three UK transplant centres. PROM data were collected and analysed using Rasch analysis. Four items displayed misfit; dependency between item sets was the biggest issue (57/485 pairwise differences). After restructuring and dealing with item misfit, the LVAD‐QoL conformed to the Rasch model, supporting the psychometric properties and quality of the LVAD‐QoL. Conclusions: Using a mixed‐methods approach ensured the development of a robust and psychometrically sound tool for research, design evolution and clinical practice with LVAD recipients. [ABSTRACT FROM AUTHOR]

Background: Based on theoretical physiology, the ratio of pulmonary artery pulse pressure to mean pulmonary pressure (PP-MPAP), termed proportional pulmonary pulse pressure, provides a measure of coupling between the right ventricle and the pulmonary circulation. This study tested the hypothesis that lower PP-MPAP ratio was associated with left ventricular (LV) distension in patients with cardiogenic shock who underwent extracorporeal life support (ECLS). Methods: This is a retrospective observational single-centre study of 22 patients with cardiogenic shock who underwent ECLS as the primary support modality without and with LV distension and Impella unloading. The relationship between post-support PP-MPAP and 12-hour lactate clearance was also assessed. Results: Of the 22 patients: 10 patients underwent additional Impella unloading due to LV distension (Group 1) and 12 patients on ECLS only without LV distension (Group 2). As predicted by the theoretical model, PP-MPAP on ECLS dropped in Group 1 (pre-Impella) from 0.473 ± 0.067 to 0.372 ± 0.087, p < 0.001; but increased in Group 2 patients without LV distension (0.518 ± 0.070 to 0.549 ± 0.072, p = 0.002). Impella support in Group 1 increased PP-MPAP (0.372 ± 0.087 to 0.615 ± 0.094, p < 0.001). On multiple regression analysis, post-support PP-MPAP was significantly associated with 12-hour lactate clearance. Conclusion: Changes in PP-MPAP is associated hemodynamic response to ECLS and 12-hour lactate clearance. This simple parameter may guide therapeutic optimization in cardiogenic shock and ECLS. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"—Dr. Robert Bartlett, describe the history and advances of ECMO. [ABSTRACT FROM AUTHOR]

The Fick principle is an established method to quantify intracardiac shunts. The Fick principle has also found utility in the practice of extracorporeal membrane oxygenation (ECMO). This report describes a novel 'shunt fraction' method to calculate intrinsic cardiac output in central (right atrial‐to‐aorta) ECMO. The physiological basis of this 'shunt fraction' method is described, followed by the case presentation that details the clinical application of this method of quantifying intrinsic cardiac output to guide weaning and liberation from central VA ECMO. [ABSTRACT FROM AUTHOR]

Wave intensity analysis (WIA) uses simultaneous changes in pressure and flow velocity to determine wave energy, type, and timing of traveling waves in the circulation. In this study, we characterized wave propagation in the pulmonary artery in patients with pulmonary hypertension associated with left‐sided heart disease (PHLHD) and the effects of dobutamine. During right heart catheterization, pressure and velocity data were acquired using a dual‐tipped pressure and Doppler flow sensor wire (Combowire; Phillips Volcano), and processed offline using customized Matlab software (MathWorks). Patients with low cardiac output underwent dobutamine challenge. Twenty patients with PHLHD (all heart failure with reduced left ventricular ejection fraction) were studied. Right ventricular systole produced a forward compression wave (FCW), followed by a forward decompression wave (FDW) during diastole. Wave reflection manifesting as backward compression wave (BCW) following the FCW was observed in 14 patients. Compared to patients without BCW, patients with BCW had higher mean pulmonary artery pressure (28.7 ± 6.12 vs. 38.6 ± 6.5 mmHg, p = 0.005), and lower pulmonary arterial capacitance (PAC: 2.88 ± 1.75 vs. 1.73 ± 1.16, p = 0.002). Pulmonary vascular resistance was comparable. Mean pulmonary artery pressure of 34.5 mmHg (area under the curve [AUC]: 0.881) and PAC of 2.29 mL/mmHg (AUC: 0.833) predicted BCW. The magnitude of the FCW increased with dobutamine (n = 11) and correlated with pulmonary artery wedge pressure. Wave reflection in PHLHD is more likely at higher pulmonary artery pressures and lower PAC and the magnitude of reflected waves correlated with pulmonary artery wedge pressure. Dobutamine increased FCW but did not affect wave reflection. [ABSTRACT FROM AUTHOR]