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OBJECTIVES: Right heart failure (RHF) after the implantation of a left ventricular assist device (LVAD) remains a dreaded postoperative complication. Using 2D speckle-tracking echocardiography, it is possible to acquire right ventricular global and regional function. The aim of our study was to assess whether speckle-tracking echocardiography values will better predict the RHF post-continuous-flow LVAD implantation. METHODS: From January 2014 to January 2016, 54 patients who underwent LVAD implantation were included and retrospectively analysed. Clinical, invasive haemodynamic (right and left heart catheterization), laboratory and transthoracic echocardiography data were reviewed. Multivariable logistic regression was performed using RHF as dependent variable. RESULTS: Thirteen patients (24%) developed RHF. These patients had significantly elevated procalcitonin (P = 0.011), elevated central venous pressure (CVP) pre- and post-LVAD implantation (P = 0.002 and 0.031, respectively), higher right ventricular (RV) and pulmonary systolic pressure (P = 0.016 and 0.013, respectively), higher Michigan Risk Score (P = 0.001) and a lower peak systolic longitudinal strain of the basal RV free wall (P = 0.032). Haemoglobin, procalcitonin, RV systolic pressure, basal right ventricular free wall and pre-CVP entered the final multivariable analysis, only basal right ventricular free wall (P < 0.001) and pre-CVP (P < 0.001) remained significant predictors of RHF. The sensitivity and specificity of the final model were 85.7% and 95.4%, respectively. The negative predictive value reached 94%. CONCLUSIONS: 2D strain parameters of the RV free wall seem to be auspicious for RV function and predicting RHF. Moreover, intraoperative CVP should not be neglected since elevated values proved to be highly associated with RHF. Our results represent a valuable supplement to other scores by considering both echocardiography and intraoperative data. [ABSTRACT FROM AUTHOR]

Background: The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications.Methods: From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVAD ultra ) in 13 patients. After propensity score matching, we compared the LVAD ultra group with a matched group (LVAD match ) receiving conventional anesthesia management.Results: Patients in the LVAD ultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival.Conclusion: In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria. [ABSTRACT FROM AUTHOR]

Background Left ventricular assist devices (LVADs) are nowadays a widespread option for the effective treatment of heart failure. We hypothesized that the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) might be a superior tool in clinical decision making compared with other established score systems. Methods In this retrospective, single-center analysis, between 2008 and 2014, 40 consecutive patients were followed for up to 36 months after LVAD (Thoratec Heart- Mate II) implantation. Postoperative survival was correlated to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels, Destination Therapy Risk Score (DTRS), HeartMate II Risk Score (HMRS), and EuroSCORE II. Results Overall, a positive outcome (survival, transplantation, or weaning) was reached in 87.5% (30 days), 70% (1 year), and 60% (2 and 3 years) of cases. Patients were categorized as high, medium, and low risk by use of the different scores. With in the created subgroups, the following 1-year positive outcomes were achieved--INTERMACS: high risk 58% versus low risk 68%; EuroSCORE II: high risk 17% versus low risk 89%; DTRS: high risk 44% versus low risk 75%; and HMRS: high risk 60% versus low risk 100%. After 1 year, the EuroSCORE II classification's area under the receiver operating characteristic curve (AUC) was superior (AUC = 0.78) and Fisher exact test revealed a significant predictive value for this classification (p = 0.0037) but not for INTERMACS levels, DTRS, or HMRS classifications. Conclusion These results support the assumption that EuroSCORE II risk classification may be useful to predict survival in LVAD patients. In our observation, it proved to be superior to INTERMACS, DTRS, and HMRS after 1 year. [ABSTRACT FROM AUTHOR]

Introduction:The design of implantable blood pumps is either based on displacement pumps with membranes or rotary pumps. Both pump types have limitations to meet the clinical requirements. Rotary piston blood pumps have the potential to overcome these limitations and to merge the benefits. Compared to membrane pumps, they are smaller and with no need for wear-affected membranes and valves. Compared to rotary pumps, the blood flow is pulsatile instead of a non-physiological continuous flow. Furthermore, the risk of flow-induced blood damage and platelet activation may be reduced due to low shear stress to the blood. Areas covered:The past developments of rotary piston blood pumps are summarized and the main problem for long-term application is identified: insufficient seals. A new approach with seal-less drives is proposed and current research on a simplified rotary piston design is presented. Expert commentary:The development of blood pumps focuses mainly on the improvement of rotary pumps. However, medical complications indicate that inherent limitations of this pump type remain and restrict the next substantial step forward in the therapy of heart failure patients. Thus, research on different pump types is reasonable. If the development of reliable drives and bearings succeeds, rotary piston blood pumps become a promising alternative. [ABSTRACT FROM AUTHOR]

Background: The Masimo Pronto-7® calculates hemoglobin (Hb) values using the pulsoximetry technique and a variety of mathematical algorithms analyzing the pulse waveform. Although this system has demonstrated a high level of accuracy in average patients, the performance might be altered in special patient populations. Regarding patients with left ventricular cardiac failure, a rotary blood pump generates a constant, continuous, non-pulsatile flow to improve effective cardiac output. Due to this alteration in both, blood flow and arterial blood pressure we hypothesized a reduced accuracy of the Masimo Pronto-7® to detect Hb in patients with left ventricular cardiac failure. To test our hypothesis, we evaluated the Pronto-7®SpHb system in outpatients after continuous-flow-left ventricular assist device (cf-LVAD) implantation (HEARTMATE II, Thoratec). Methods: 21 cf-LVAD outpatients from the Clinic for Cardiac, Thoracic and Vascular Surgery were investigated during routine follow up examinations. After venous blood samples were drawn, the Pronto-7® sensor was attached to one randomly selected finger of one hand. The collected SpHb data were compared with Hb values measured by our central laboratory. The difference between the methods was determined using Bland - Altman analysis. The study was registered in the DRKS (DRKS00004415). Results: In all cf-LVAD patients evaluated, the Pronto-7® successfully detected SpHb values. Using Bland - Altman analysis, a bias of 0.14 g/dl (95% upper and lower limits of agreement ± 2.76 g/dl) was calculated. Conclusion: The Pronto-7® overestimated the actual Hb value in cf-LVAD outpatients with the HEARTMate II. Due to this, we conclude that the system is suitable for screening in routine examinations and further analysis can be performed if needed. However, its use as an emergency tool is questionable because of the increased inaccuracy when Hb values are critically low. [ABSTRACT FROM AUTHOR]

Introduction: Despite the improvements in standardized cardiopulmonary resuscitation, survival remains low, mainly due to initial myocardial dysfunction and hemodynamic instability. Our goal was to compare the efficacy of two left ventricular assist devices on resuscitation and hemodynamic supply in a porcine model of ventricular fibrillation (VF) cardiac arrest. Methods: Seventeen anaesthetized pigs had 12 min of untreated VF followed by 6 min of chest compression and boluses of epinephrine. Next, a first defibrillation was attempted and pigs were randomized to any of the three groups: control (n = 5), implantation of an percutaneous left ventricular assist device (Impella, n = 5) or extracorporeal membrane oxygenation (ECMO, n = 7). Hemodynamic and myocardial functions were evaluated invasively at baseline, at return of spontaneous circulation (ROSC), after 10–30–60–120–240 min post-resuscitation. The primary endpoint was the rate of ROSC. Results: Only one of 5 pigs in the control group, 5 of 5 pigs in the Impella group, and 5 of 7 pigs in the ECMO group had ROSC (p < 0.05). Left ventricular ejection fraction at 240 min post-resuscitation was 37.5 ± 6.2% in the ECMO group vs. 23 ± 3% in the Impella group (p = 0.06). No significant difference in hemodynamic parameters was observed between the two ventricular assist devices. Conclusion: Early mechanical circulatory support appeared to improve resuscitation rates in a shockable rhythm model of cardiac arrest. This approach appears promising and should be further evaluated. [ABSTRACT FROM AUTHOR]

Introduction: An increasing number of patients require implantation of left ventricular assist device (LVAD) for the management of their end-stage heart failure. Organ dysfunctions and infectious complications belong to the most common adverse events, resulting from inflammation and oxidative stress. The essential trace element selenium is considered as cornerstone of the antioxidant defense mechanisms, which may offer therapeutic benefits. Hypothesis: Selenium supplementation provides beneficial effects after LVAD implantation. Methods: Adult patients scheduled to undergo LVAD implantation (destination therapy) were randomized to receive 300μg of sodium-selenite the evening before surgery, followed by high dose IV selenium supplementation (3000μg after induction, 1000μg on ICU admission, and 1000μg daily in ICU) or placebo. Patients with known severe renal dysfunction & chronic liver disease were excluded. The main outcomes of the pilot study were to determine its efficacy, feasibility (recruitment rates) and monitoring of adherence to the protocol. In an explorative approach, we evaluated major clinical endpoints, for the following confirmatory study. Results: In total, 20 patients met the inclusion criteria. The average recruitment rate was 1.5 patients/month (0-3). The average duration of the study intervention was 12.6 days (7-14) and there was a 97.7% compliance with dose administration. During the postoperative course, the inflammatory response, assessed by IL6 was similar between the groups. The number and duration of organ dysfunctions, requiring the need for ICU support was comparable. The placebo group showed a no significant faster recovery in this small cohort 12.5h (0.1-29.4) vs 20.5h (0.2-28.2). The intervention group presented a higher cardiac output, higher systolic and mean blood pressures, as well as lower pulmonary and central venous blood pressures on the 1. day of surgery. Conclusions: Selenium supplementation in patients receiving LVAD implantation was feasible and showed efficacy on patients' outcomes. A larger, more definitive trial is currently being planed. [ABSTRACT FROM AUTHOR]