Percutaneous Mechanical Circulatory Support Devices: Systems and Clinical Options

Cardiogenic shock (CS) still remains a leading cause of hospital death. The adoption of percutaneous ventricular assist devices (pVADs) as treatment of CS is an option which continues to rise. Several types of pVADs have been developed by time to provide full cardiac support with few related complications and easy implantation settings. pVADs are used to support the failing heart as a bridge to recovery, decision, durable device or heart transplantation. None of these devices adopted in the clinical practice is ideal for all patients. Disadvantages may be related to the risk of limb/arm ischaemia or cerebral stroke or haemolysis. The most important choice is to identify the best device for each patient depending on haemodynamics, clinical scenario and patient anatomical/pathological issues. This chapter discusses the current pVAD options to treat CS patients

Orthotopic Heart Transplantation: Bicaval Versus Biatrial Surgical Technique

In 1967, the first cardiac transplantation was performed in South Africa by Christiaan Barnard, becoming one of the most pioneering events of the human history, comparable to the first step on the moon, 2 years later. Even if Barnard became extremely famous because of this outstanding operation, behind this event there were years and years of studies, experimentations and hard work done by others, in particular by Lower and Shumway. The initial technique, still called ‘standard technique’ is the biatrial one. In the late 1980s, alternatives like the ‘bicaval technique’ were developed in order to get a more anatomical result. In the present chapter, we will throw the reader into the early years of the cardiac transplantation era, describing all the efforts made by the “fathers” of the cardiac surgery in order to standardize techniques inherited by the modern surgeons. Afterwards, we will present a review of the literature to answer the question if the biatrial technique should still be called “standard technique”

Postoperative outcomes following rehabilitation in patients with left ventricular assist devices

Postoperative rehabilitation is a cornerstone of the recovery pathway following left ventricular assist device implantation (LVAD), and patients are expected to conduct an autonomous life thanks to improved technology and increased knowledge of mechanical circulatory support. The primary purpose of the present study was to quantify clinical changes related to rehabilitation, in patients with LVAD: functional capacity, disability, and quality of life were identified as reliable outcomes to detect such changes. The current study was a scoping review conducted searching three primary databases, namely PubMed, Scopus, and Cochrane Library, from their inception until January 2020. After the selection process was completed, 12 citations were included in the present study. Three hundred eight three patients were included in the current analysis. Functional capacity, disability, and quality of life were investigated in 157, 215, 18 patients, respectively. Significant differences were found before and after rehabilitation. The mean walked distance at 6-Minute Walk Test improved from 319±96 to 412.8±86.2 metres (p<0.001), the mean score of the Functional Independence Measure from 68.4±11.8 to 92.5±10.8 points (p<0.001), the mean score of the Short Form-36 physical component from 32.7±29.9 to 55.5±24.7 points (p=0.009) and the mental component from 55.8±19.8 to 75.4±21.4 points (p=0.002). Postoperative rehabilitation is effective at improving functional capacity, disability, and quality of life in patients with left ventricular assist device; all these three domains are particularly expressive of the entity of patients' functional recovery

Hybrid transcatheter left ventricular reconstruction for the treatment of ischemic cardiomyopathy

Left ventricular (LV) enlargement is a mechanical adaptation to accommodate LV systolic inefficiency following an acute damage or a progressive functional deterioration, which fails to correct the decline of stroke volume in the long term, leading to progressive heart failure (HF). Surgical ventricular reconstruction (SVR) is a treatment for patients with severe ischemic HF aiming to restore LV efficiency by volume reduction and LV re-shaping. Recently, a new minimally-invasive hybrid technique for ventricular reconstruction has been developed by means of the Revivent (TM) system (BioVentrix Inc., San Ramon, CA, USA). The device for ventricular reconstruction consists of anchor pairs that enable plication of the anterior and free wall LV scar against the right ventricular (RV) septal scar of anteroseptal infarctions to decrease cardiac volume without ventriculotomy in a beating-heart minimally-invasive procedure, consisting of a transjugular and left thoracotomy approach. Patients with severe (Grade 4) functional mitral regurgitation (FMR) or with previous cardiac surgery procedures were excluded. Outcome of the reconstruction procedure: from 2012 until 2019, it has been applied to 203 patients, with 5 (2.5%) in-hospital deaths. LV volume reduction varied according to experience gained along years: LV end-systolic volume index decreased from baseline 43% (post-market registry) vs. 27% (CE-mark study); left ventricular ejection fraction (LVEF) increased from baseline 25% (post-market registry) vs. 16% (CE-mark study). Clinical status (NYHA class, HF questionnaire, 6-minute walking test) improved significantly compared to baseline, and re-hospitalization rate was only 13% at 6-month follow-up (60% of patients in NYHA =3). FMR grade decreased at follow-up in 63%, while it was unchanged in 37% of patients. The hybrid ventricular reconstruction (HVR) seems a promising treatment for HF patients who may benefit from LV volume reduction, with reasonable mortality and good results at follow-up. A baseline less severe clinical profile was not associated to better outcome at follow-up, which makes the procedure feasible in patients with very large ventricles and depressed ejection fraction (EF). LV reshaping has no detrimental effect on FMR, that may, on the contrary, benefit owing to less papillary muscle displacement, partial recovery of torsion dynamics and of myofibers re-orientation. A controlled study on top of optimal medical treatment is warranted to confirm its role in the management of HF patients

Extracorporeal Membrane Oxygenation Support as Treatment for Early Graft Failure After Heart Transplantation

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx) accounting for >40% of deaths within 30 days postoperatively. According to the last International Society for Heart and Lung Transplantation (ISHLT) consensus statement, the graft dysfunction (GD) is to be classified into primary (PGD), in case of an unknown triggering factor or secondary (SGD) where there is a discernible cause such as acute rejection, pulmonary hypertension, or known surgical complications. The diagnosis of GD is to be made within 24 h after completion of Htx surgery and a severity scale for GD should include mild, moderate, or severe grades based on specified criteria. Mechanical circulatory support (MCS) for GD should be considered when medical management is not sufficient to support the newly transplanted graft. Currently, extra‐corporeal membrane oxygenation (ECMO) is widely accepted as treatment of severe EGF, given its easy and quick setup, the system versatility, the optimal end‐organ perfusion provided, and the possibility of both biventricular and lung assistance by usage of a low‐cost single pump

The Role of Extracorporeal Membrane Oxygenation Support after Pulmonary Thrombo-Endarterectomy

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare consequence of acute or chronic pulmonary embolism. Pulmonary endarterectomy (PEA) is the gold standard treatment: expert centers are able to offer this challenging procedure with low in-hospital mortality, excellent hemodynamic results, and significant improvement in exercise tolerance and quality of life. Despite careful preoperative selection and increasing technical experience in PEA, some patients may suffer from life-threatening complications requiring extracorporeal life support (ECLS). ECLS is necessary in case of heart failure, respiratory failure, or both. According to different indications and timing, cardiopulmonary failure after PEA should be managed with a tailored approach: veno-venous or veno-arterial support, and central or peripheral cannulation. In the present chapter, causes, management strategies, and outcomes of perioperative ECLS for PEA are discussed