Pulmonary Hypertension in the Era of Mechanical Circulatory Support

Krishnamurthy, Yamini; Cooper, Lauren B.; Parikh, Kishan S.; Felker, G. Michael; Milano, Carmelo A.; Rogers, Joseph G.; Hernandez, Adrian F.; Patel, Chetan B.

doi:10.1097/mat.0000000000000408

Cited by 19 publications

(8 citation statements)

References 49 publications

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“…For others, for example, those with “fixed” pulmonary hypertension, durable LVAD support acts as a “bridge to candidacy” as it may allow reversal of the pulmonary hypertension to a level that is considered safe for heart transplantation. 56…”

Section: Impact Of Frailty On Vad Outcomesmentioning

confidence: 99%

Frailty of the Heart Recipient

Macdonald

2021

Transplantation

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Frailty has been defined as a state of increased vulnerability due to a decline in the reserve and function of multiple physiological systems. Initially conceived as a geriatric syndrome indicative of physiological aging, it is now apparent that frailty can also be observed as a manifestation of chronic disease states including heart failure. Estimates of the prevalence of frailty in heart failure vary according to the age of the study population and the frailty instrument used; however, multiple studies have identified frailty to be prevalent in patients with advanced heart failure including those who are referred for heart transplantation. Frailty is emerging as an independent predictor of mortality both before and after bridge-to-transplant ventricular assist device implantation and heart transplantation. Frailty is also predictive of prolonged hospitalization following these procedures. Heart failure–associated frailty is a dynamic state. While reversibility of frailty can be anticipated in younger heart failure patients, predicting the reversibility of frailty is more challenging in older patients who often have multiple comorbidities that may contribute to the frailty syndrome. Prehabilitation is a promising approach to both preventing and reversing frailty however more research is urgently needed to establish its effectiveness in mitigating the adverse impacts of frailty on postventricular assist device and posttransplant morbidity and mortality.

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Section: Impact Of Frailty On Vad Outcomesmentioning

confidence: 99%

Frailty of the Heart Recipient

Macdonald

2021

Transplantation

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“…Concerning diastole, the left ventricle is stiffer than a failed unassisted ventricle, due to the "reverse-remodelling" operated by the LVAD (47). The systemic and pulmonary circulation are adjusted to reproduce a relatively lower peripheral resistance [due to pharmacological treatment (48)] and a slightly higher pulmonary resistance, observed in some LVAD patients (49). In addition, some tuning of the control mechanisms that drive the adaptation of the cardiovascular system to exercise are also performed (44).…”

Section: Description Of the Cardiorespiratory Simulatormentioning

confidence: 99%

Exercise physiology in left ventricular assist device patients: insights from hemodynamic simulations

Fresiello

Gross

Jacobs

2021

Ann Cardiothorac Surg

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Left ventricular assist devices (LVADs) assure longer survival to patients, but exercise capacity is limited compared to normal values. Overall, LVAD patients show high wedge pressure and low cardiac output during maximal exercise, a phenomenon hinting at the need for increased LVAD support. Clinical studies investigating the hemodynamic benefits of an LVAD speed increase during exercise, ended in inhomogeneous and sometimes contradictory results. The native ventricle-LVAD interaction changes between rest and exercise, and this evolution is complex, multifactorial and patient-specific. The aim of this paper is to provide a comprehensive overview on the patient-LVAD interaction during exercise and to delineate possible therapeutic strategies for the future. A computational cardiorespiratory model was used to simulate the hemodynamics of peak bicycle exercise in LVAD patients. The simulator included the main cardiovascular and respiratory impairments commonly observed in LVAD patients, so as to represent an average hemodynamic response to exercise. In addition, other exercise responses were simulated, by tuning the chronotropic, inotropic and vascular functions, and implementing aortic regurgitation and stenosis in the simulator. These profiles were tested under different LVAD speeds and LVAD pressure-flow characteristics.Simulations output showed consistency with clinical data from the literature. The simulator allowed the working condition of the assisted ventricle at exercise to be investigated, clarifying the reasons behind the high wedge pressure and poor cardiac output observed in the clinics. Patients with poorer inotropic, chronotropic and vascular functions, are likely to benefit more from an LVAD speed increase during exercise.Similarly, for these patients, a flatter LVAD pressure-flow characteristic can assure better hemodynamic support under physical exertion. Overall, the study evidenced the need for a patient-specific approach on supporting exercise hemodynamics. In this frame, a complex simulator can constitute a valuable tool to define and test personalized speed control algorithms and strategies.

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“…22 If medical therapy fails to achieve acceptable pulmonary hemodynamics and primary pulmonary causes of PH have been excluded, an LVAD should be considered to maximize left ventricular unloading and pulmonary vascular remodelling. 23 Most studies have shown significant reduction in pulmonary pressures post LVAD placement. 23,24 Hemodynamic reevaluation is performed at 3-6 months after LVAD placement to ascertain PH reversibility.…”

Section: Pulmonary Hypertensionmentioning

confidence: 99%

“…23 Most studies have shown significant reduction in pulmonary pressures post LVAD placement. 23,24 Hemodynamic reevaluation is performed at 3-6 months after LVAD placement to ascertain PH reversibility. A small number of single-centre studies have successfully used phosphodiesterase-5 inhibitors to reduce PH and facilitate candidacy for HTx without LVAD placement.…”

Section: Pulmonary Hypertensionmentioning

confidence: 99%

Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care

Chih

McDonald

Dipchand

et al. 2020

Canadian Journal of Cardiology

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Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recom-R ESUM E Les pratiques relatives aux soins prodigu es aux candidats à une transplantation cardiaque et aux receveurs d'un nouveau coeur ont beaucoup evolu e depuis dix ans. Le pr esent enonc e de position conjoint de la Soci et e canadienne de cardiologie et du Canadian Cardiac Transplant Network fait etat des recommandations d'un groupe d'experts fond ees sur des donn ees probantes, et comprend des valeurs et des pr ef erences ainsi que des conseils pratiques concernant

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Pulmonary Hypertension in the Era of Mechanical Circulatory Support

Cited by 19 publications

References 49 publications

Frailty of the Heart Recipient

Frailty of the Heart Recipient

Exercise physiology in left ventricular assist device patients: insights from hemodynamic simulations

Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care

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