Predicting Success
2016; Lippincott Williams & Wilkins; Volume: 10; Issue: 1 Linguagem: Inglês
10.1161/circheartfailure.116.003694
ISSN1941-3297
AutoresJohannes Steiner, S. Wiafe, Janice Camuso, K. Milley, Luke Wooster, Cole S. Bailey, Sunu S. Thomas, David A. D’Alessandro, José P. Garcia, Gregory D. Lewis,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoHomeCirculation: Heart FailureVol. 10, No. 1Predicting Success Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBPredicting SuccessLeft Ventricular Assist Device Explantation Evaluation Protocol Using Comprehensive Cardiopulmonary Exercise Testing Johannes Steiner, MD, Stephanie Wiafe, NP, Janice Camuso, RN, Katherine Milley, RN, Luke T. Wooster, BS, Cole S. Bailey, BA, Sunu S. Thomas, MD, David A. D'Alessandro, MD, Jose P. Garcia, MD and Gregory D. Lewis, MD Johannes SteinerJohannes Steiner From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Stephanie WiafeStephanie Wiafe From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Janice CamusoJanice Camuso From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Katherine MilleyKatherine Milley From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Luke T. WoosterLuke T. Wooster From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Cole S. BaileyCole S. Bailey From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Sunu S. ThomasSunu S. Thomas From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , David A. D'AlessandroDavid A. D'Alessandro From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. , Jose P. GarciaJose P. Garcia From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. and Gregory D. LewisGregory D. Lewis From the Division of Cardiovascular Medicine, Department of Medicine (J.S., L.T.W., C.S.B., S.S.T., G.D.L.) and Division of Cardiothoracic Surgery, Department of Surgery (S.W., J.C., K.M., D.A.D., J.P.G.), Harvard Medical School, Massachusetts General Hospital, Boston. Originally published20 Dec 2016https://doi.org/10.1161/CIRCHEARTFAILURE.116.003694Circulation: Heart Failure. 2017;10:e003694IntroductionLeft ventricular assist devices (LVADs) provide decongestion of the left ventricle (LV) with associated reversal of cardiomyocyte hypertrophy, restoration of adrenergic receptor density, and improvement in calcium handling. Unfortunately, translation of these changes into definitive functional recovery at the organ level is infrequent. Reports of LVAD explantation rates because of cardiac recovery are highly variable depending on heart failure (HF) pathogenesis and weaning criteria used, with reported rates ranging from 4.5% to 45%.1 Institution-specific LVAD explantation evaluation protocols exist that use various hemodynamic, imaging, and gas exchange measurements in any combination. However, protocols that provide comprehensive assessment of myocardial performance under dynamic loading conditions and in response to the highly relevant physiological stress of exercise are lacking. The high reported rates of HF recurrence after LVAD explantation provide further motivation to carefully assess cardiac reserve capacity before explantation. This case series describes the use of a novel protocol in 2 patients, which integrates assessments of hemodynamic, imaging, and gas exchange measures during the state of rest, LVAD speed reduction, and exercise to uniquely characterize cardiac reserve capacity and guide LVAD explantation decision making.Case ReportPatient 1A 44-year-old man underwent coronary bypass graft surgery in the setting of severe LV systolic dysfunction related to anabolic steroid use and coronary artery disease. Despite prolonged, postoperative mechanical support, there was no evidence of LV function recovery, and the patient underwent insertion of a Heartware LVAD (HVAD). Six months later, a transthoracic echo on full LVAD support revealed a low normal LV ejection fraction (LVEF), normal LV end-diastolic dimension, and aortic valve opening with each beat. These data prompted a LVAD explantation evaluation (algorithm outlined in Table and Figure 1).Table. Algorithm of Our One-Day Multimodality Assessment of Cardiac ReservePhase 0 (as part of routine post-VAD management) Noninvasive clinical (NYHA class I, optivolemia) and echocardiographic assessmentPhase 1 (wean down) Repeat echo and perform hemodynamic assessment with pulmonary artery catheter on minimal LVAD supportPhase 2 Maximum, incremental ramp, upright cycle ergometry CPET with minute-by-minute assessment of filling pressures and cardiac output with pulmonary artery catheter and arterial line in place as well as first-pass radionuclide imaging at rest and peak exercise Key advanced exercise–derived parameters include peak VO2 including relative contributions of peripheral oxygen extraction (Ca-vO2), ventilatory efficiency (VE/VCO2 slope), exercise oscillatory ventilation, and hemodynamic pressure–flow relationship (PAWP/CO slope)Phase 3 Future explantation considered if all criteria were met during wean down and maximal stress, single criteria outlined in Figure 1CPET indicates cardiopulmonary exercise test; CO, cardiac output; LVAD, left ventricular assist device; NYHA, New York Heart Association; PAWP, pulmonary artery wedge pressure; VCO2, carbon dioxide production; and VE, minute ventilation.Download figureDownload PowerPointFigure 1. Proposed criteria for proceeding to next phase of the explantation evaluation protocol; left ventricular assist device explantation considered if all criteria were met during ramp down and maximal stress. CI indicates cardiac index; CO, cardiac output; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; mPAP, mean pulmonary artery pressure; MR, mitral regurgitation; NYHA, New York Heart Association; PAWP, pulmonary artery wedge pressure; RAP, right atrial pressure; RVEF, right ventricular ejection fraction; TR, tricuspid regurgitation; VCO2, carbon dioxid production; and VE, minute ventilation.Based on this algorithm, the integrated cardiopulmonary exercise test was performed on an upright cycle ergometer with HVAD speed turned down to 2000 rpm. The decrement in speed had minimal impact on measured Fick cardiac output (CO). His LVEF by first-pass radionuclide ventriculography remained normal at rest and at peak exercise. His peak VO2 (14.5 mL/kg/min) was reduced. However, the observed increment in pulmonary artery wedge pressure (PAWP; 5 to 16 mm Hg) was only modest relative to the increment in CO (7.1 to 14.6 L/min; PAWP–CO slope, 1.2 mm Hg/L/min; Figure 2; Table I in the Data Supplement). Heart rate augmented appropriately to 91% of predicted maximum. Peripheral oxygen extraction (Ca-vO2) was impaired despite normal hemoglobin, with a CvO2 remaining >10 mL/dL throughout exercise. Taken together, these findings indicated significant cardiac reserve capacity despite his abnormal peak VO2. The patient subsequently underwent successful LVAD explantation. One year after explantation, his LV systolic function remains normal (LVEF 50%), he is working full time, and he is able to perform 60 minutes of continuous treadmill exercise at a speed of 4.5 mph.Download figureDownload PowerPointFigure 2. Hemodynamic measurements in patient 1. Upright mean pulmonary artery pressure (mPAP), right atrial pressure (RAP), and pulmonary artery wedge pressure (PAWP) measurements at rest (left) and at peak exercise (111 W and 4.1 METs; right).Patient 2In contrast, we evaluated a 61-year-old patient in whom LVEF >45%, normal LV end-diastolic dimension, and New York Heart Association class I status prompted a comprehensive LVAD explantation evaluation. This patient had experienced an acute myocardial infarction complicated by cardiogenic shock 7 months prior requiring bridge-to-transplant HVAD placement. During his HVAD explantation evaluation, patient 2 had a peak VO2 of 14.1 mL/kg/min similar to patient 1. With LVAD speed reduction, his transthoracic echo indicated normal LV end-diastolic dimension, mildly depressed LVEF, and consistent aortic valve opening. During exercise, his heart rate increased to only 69% of predicted maximum despite exceeding a respiratory exchange ratio of 1.1. In contrast to patient 1, Ca-vO2 was normal, and he was able to augment his CO to only 8.3 L/min at peak exercise. His LV function was abnormal during exercise as evidenced by a significant increment in upright PAWP (7 to 20 mm Hg) coupled with impaired CO response to exercise (PAWP–CO slope, 3.2 mm Hg/L/min; Figure 3; Table I in the Data Supplement). There was also evident exercise oscillatory ventilation characteristic of advanced HF. These exercise-based findings suggested that the patient would not to be able to tolerate LVAD explantation. Thirty days later, the patient underwent cardiac transplantation.Download figureDownload PowerPointFigure 3. Hemodynamic measurements in patient 2. Upright pulmonary artery pressure (mPAP), right atrial pressure (RAP), and pulmonary artery wedge pressure (PAWP) measurements at ramp down (left) and at peak exercise (75 W and 4 METs; right).DiscussionLVAD explantation evaluation protocols are highly variable between centers. Proposed criteria have included LVEF >45%, LV end-diastolic dimension <60 mm, PAWP 2.8 L/min/m2, and solitary exercise measurement variables in the form of peak VO2 >16 mL/kg/min or an increase in minute ventilation relative to the production of carbon dioxide (VE/VCO2 slope) of 14 L/min in the setting of derived LVAD flows of only 2.4 to 3 L/min. In this patient's case, a normal PAWP–CO slope and lack of exercise oscillatory ventilation, coupled with appropriate heart rate response, normal exercise LVEF, and a significant estimated intrinsic cardiac contribution to directly measure CO of >10 L/min at peak exercise, indicated robust cardiac reserve that prompted successful LVAD explantation.ConclusionsLVAD explantation evaluation protocols remain heterogeneous across institutions. The use of a peak VO2 cut point in isolation may not adequately reflect cardiac reserve capacity. Consideration should be given to performing comprehensive exercise-based evaluations that permit ascertainment of filling pressures, CO, and variance in Ca-vO2 in evaluating LVAD explanation candidacy.Sources of FundingThis article is supported by National Health Institutes and National Heart, Lung, and Blood Institute funding (1R01HL131029).DisclosuresNone.FootnotesThe Data Supplement is available at http://circheartfailure.ahajournals.org/lookup/suppl/doi:10.1161/CIRCHEARTFAILURE.116.003694/-/DC1.Correspondence to Gregory D. Lewis, MD, Division of Cardiovascular Medicine, Department of Internal Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. E-mail [email protected]References1. Ibrahim M, Yacoub MH.Bridge to recovery and weaning protocols.Heart Fail Clin. 2014; 10(suppl 1):S47–S55. doi: 10.1016/j.hfc.2013.08.004.CrossrefMedlineGoogle Scholar2. Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M, Banner NR, Khaghani A, Yacoub MH.Left ventricular assist device and drug therapy for the reversal of heart failure.N Engl J Med. 2006; 355:1873–1884. doi: 10.1056/NEJMoa053063.CrossrefMedlineGoogle Scholar3. Malhotra R, Bakken K, D'Elia E, Lewis GD.Cardiopulmonary exercise testing in heart failure.JACC Heart Fail. 2016; 4:607–616. doi: 10.1016/j.jchf.2016.03.022.CrossrefMedlineGoogle Scholar4. Dhakal BP, Malhotra R, Murphy RM, Pappagianopoulos PP, Baggish AL, Weiner RB, Houstis NE, Eisman AS, Hough SS, Lewis GD.Mechanisms of exercise intolerance in heart failure with preserved ejection fraction: the role of abnormal peripheral oxygen extraction.Circ Heart Fail. 2015; 8:286–294. doi: 10.1161/CIRCHEARTFAILURE.114.001825.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kanwar M, Selzman C, Ton V, Miera O, CornwellIII W, Antaki J, Drakos S and Shah P (2022) Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support, The Journal of Heart and Lung Transplantation, 10.1016/j.healun.2022.05.015, Online publication date: 1-May-2022. Kára T and Aschermann M (2022) (Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology), Cor et Vasa, 10.33678/cor.2022.040, 64:Suppl.2, (89-132), Online publication date: 26-Apr-2022. Rosenbaum A, Antaki J, Behfar A, Villavicencio M, Stulak J and Kushwaha S (2021) Physiology of Continuous‐Flow Left Ventricular Assist Device Therapy Comprehensive Physiology, 10.1002/cphy.c210016, (2731-2767) Ton V, Thomas S, Coglianese E, D'Alessandro D and Lewis G (2021) Left Ventricular Assist Device Explant and Mitral Valve Replacement for Myocardial Recovery, Circulation: Heart Failure, 14:8, Online publication date: 1-Aug-2021. Liu X, Kimmelstiel C, Couper G and Brovman E (2021) Echocardiographic Assessment of Left Ventricular Assist Device Outflow Velocity During Percutaneous Decommissioning, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2020.12.043, 35:5, (1534-1538), Online publication date: 1-May-2021. Albulushi A, Goldsweig A, Stoller D, Delaney J, Um J, Lowes B and Zolty R (2020) Percutaneous Deactivation of Left Ventricular Assist Devices, Seminars in Thoracic and Cardiovascular Surgery, 10.1053/j.semtcvs.2020.01.012, 32:3, (467-472), Online publication date: 1-Nov-2021. Koshy A, Green T, Toms A, Cassidy S, Schueler S, Jakovljevic D and MacGowan G (2019) The role of exercise hemodynamics in assessing patients with chronic heart failure and left ventricular assist devices, Expert Review of Medical Devices, 10.1080/17434440.2019.1675506, 16:10, (891-898), Online publication date: 3-Oct-2019. January 2017Vol 10, Issue 1 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.116.003694PMID: 27998882 Originally publishedDecember 20, 2016 Keywordscardiopulmonary exercise testmechanical assist devicecardiomyopathyPDF download Advertisement SubjectsCardiomyopathyCardiovascular SurgeryExercise TestingRemodeling
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