UNASSIGNED: Mechanical circulatory support (MCS), temporary or durable, is essential in patients with acute heart failure presenting in cardiogenic shock (CS). MCS is fundamental in patients with advanced heart failure when used as a bridge to decision, transplant or left ventricular recovery. Limited data on acute-on-chronic heart failure (HF) patients exists in the era of axillary mechanical circulatory support with the Impella 5.5. We describe a case of chronic ischemic cardiomyopathy, HF-CS, in a patient who underwent Impella placement, medical optimization, and explant, now with sustained normalization in ejection fraction.
UNASSIGNED: A Caucasian female in her 50 s was referred to our center for evaluation for advanced therapies, including transplantation or durable left ventricular assist device placement. Her initial ejection fraction was 30% with comorbidities including multivessel coronary artery disease revascularized with 3 vessel bypass grafting ten years prior, type 2 diabetes (A1c 8.6%), and peripheral vascular disease. During her evaluation, she had acute decompensation leading to cardiogenic shock and required hospitalization with inotrope initiation, which was unable to be weaned. She was approved for organ transplant and listed; however, she required escalation of support and eventual placement of right axillary Impella 5.5. While on Impella support, her vasoactive needs reduced, and she was found to have left ventricular recovery and tolerated the initiation of guideline medical therapy. After three weeks of support, the Impella was weaned and explanted, and the patient was discharged. She remains stable with a sustained ejection fraction of greater than 50% with NYHA class 1 functional status at follow-up. One year later, the patient showed sustained myocardial recovery with guideline-directed medical therapy (GDMT).
UNASSIGNED: Our case highlights a unique approach in patients with long-standing (>5 years) heart failure who may benefit from early consideration for axillary support and concomitant optimization with guideline-directed medical therapy to assess for explant and native heart recovery.

OBJECTIVE: Historically, the perfusion-guided sequence suggests to first transplant the side with lowest lung perfusion. This sequence is thought to limit right ventricular afterload and prevent acute heart failure after first pneumonectomy. As a paradigm shift, we adopted the right-first implantation sequence, irrespective of lung perfusion. The right donor lung generally accommodates a larger proportion of the cardiac output. We hypothesized that the right-first sequence reduces the likelihood of oedema formation in the firstly transplanted graft during second-lung implantation. Our objective was to compare the perfusion-guided and right-first sequence for intraoperative extracorporeal membrane oxygenation (ECMO) need and primary graft dysfunction (PGD).
METHODS: A retrospective single-center cohort study (2008-2021) including double-lung transplant cases (N = 696) started without ECMO was performed. Primary end-points were intraoperative ECMO cannulation and PGD grade 3 (PGD3) at 72 h. Secondary end-points were patient and chronic lung allograft dysfunction (CLAD)-free survival. In cases with native left lung perfusion ≤50% propensity score adjusted comparison of the perfusion-guided and right-first sequence was performed.
RESULTS: When left lung perfusion was ≤50%, right-first implantation was done in 219 and left-first in 189 cases. Intraoperative escalation to ECMO support was observed in 10.96% of right-first vs 19.05% of left-first cases (odds ratio 0.448; 95% confidence interval 0.229-0.0.878; p = 0.0193). PGD3 at 72 h was observed in 8.02% of right-first vs 15.64% of left-first cases (0.566; 0.263-1.217; p = 0.1452). Right-first implantation did not affect patient or CLAD-free survival.
CONCLUSIONS: The right-first implantation sequence in off-pump double-lung transplantation reduces need for intraoperative ECMO cannulation with a trend towards less PGD grade 3.

Since 2022, the mechanical left ventricular support system Impella 5.5® has been used in Austria for patients with cardiogenic shock, advanced heart failure, post-cardiotomy and low output syndrome. The surgical insertion of the Impella 5.5 via the subclavian artery or alternatively via the ascending aorta has become an established procedure for medium-term treatment in patients with cardiogenic shock and bridging scenarios, such as bridge to recovery, bridge to left ventricular assist device (LVAD), bridge to decision, and bridge to heart transplant (HTx) in Austria. All Impella left ventricular heart pumps share the common feature of unloading the left ventricle, with the Impella 5.5 achieving a full cardiac output of 5.5 l/min. The stable positioning via transaxillary or transaortic insertion enables rapid extubation and mobilization of patients in the intensive care unit (ICU), leading to a significantly shorter ICU stay. The combined support of Impella 5.5 with venoarterial extracorporeal membrane oxygenation (VA-ECMO) has also proven effective in certain scenarios. Several nonrandomized studies demonstrated the effectiveness and safety of the Impella 5.5 in practice, which have been included in multiple international guidelines. The advantages of the Impella 5.5 in practice include the easy handling with high positional stability, and low complications rates. This article describes the significance of surgical Impella treatment in Austria from the perspective of Austrian clinical experts.

OBJECTIVE: Since United Network for Organ Sharing (UNOS) revised their heart allocation policy in 2018, usage of veno-arterial extracorporeal life support (VA-ECLS) has dramatically increased as a bridge to transplant. This study investigated outcomes of VA-ECLS patients bridged to simultaneous heart-kidney transplant (SHK) in the new policy era.
METHODS: This study included 774 adult patients from the UNOS database who received SHK between 10/18/18 and 12/31/21 and compared patients bridged to transplant on VA-ECLS (n=50) with those not bridged (n=724).
RESULTS: At baseline, SHK recipients bridged from VA-ECLS were younger (50.5 vs. 58.0 years, p=0.007), had higher eGFR at time of transplant (47.6 vs. 30.1, p<0.001), and spent fewer days on the waitlist (7.0 vs. 33.5 days, p<0.001). In the perioperative period, VA-ECLS was associated with higher rates of temporary dialysis (56.0% vs. 28.0%, p<0.001) but similar 2-year cumulative incidence of chronic dialysis (7.5% vs 5.4%, p=0.800) and renal allograft failure (12.0% vs 8.1%, p=0.500) compared to non-ECLS cohort. However, VA-ECLS patients had decreased survival to discharge (76.0% vs 92.7%, p<0.001) and 2-year post-transplant survival (71.7% vs. 83.0%, p=0.004), as well as greater 2-year cumulative incidence of cardiac allograft failure (10.0% vs 2.7%, p=0.002). Multivariable analyses found VA-ECLS at time of transplant to be independently associated with 2-year post-transplant mortality (HR [95% CI]: 3.40 [1.66-6.96], p=0.001) and cardiac allograft failure (SHR [95% CI]: 8.51 [2.77-26.09], p<0.001).
CONCLUSIONS: Under the new allocation policy, patients bridged to SHK from VA-ECLS displayed greater early mortality and cardiac allograft failure but similar renal outcomes compared to non-ECLS counterparts.

BACKGROUND: There is an increasing prevalence of durable mechanical circulatory supported patients in both the in-and-out of hospital communities. The scientific literature regarding the approach to patients supported by durable mechanical circulatory devices who suffer acutely impaired perfusion has not been well explored.
METHODS: The International Liaison Committee on Resuscitation Advanced, Basic, and Pediatric Life Support Task Forces conducted a scoping review of the literature using a population, context, and concept framework.
RESULTS: A total of 32 publications that included patients who were receiving durable mechanical circulatory support and required acute resuscitation were identified. Most of the identified studies were case reports or small case series. Of these, 11 (34.4%) included patients who received chest compressions. A number of studies reported upon delays in the application of chest compressions resulting from complexity due to the expected pulselessness in some patients with continuous flow left-ventricular assist devices as well as from concern regarding potential dislodgement of the mechanical circulatory support device. Three observational studies identified worse outcomes in durable mechanical circulatory support receiving patients with cardiac arrest and acutely impaired perfusion who received chest compressions as compared to those who did not, however those studies were at high risk of bias. Of 226 patients across 11 studies and two published scientific abstracts who sustained cardiac arrest while supported by durable MCS and underwent chest compressions, there were no reported instances of device dislodgement and 71 (31.4%) patients had favorable outcomes.
CONCLUSIONS: There is a scarcity of evidence to inform the resuscitation of patients with durable mechanical circulatory support (MCS) experiencing acute impairment in perfusion and cardiac arrest. Reports indicate that delays in resuscitation often stem from rescuers\' uncertainty about the safety of administering chest compressions. Notably, no instances of device dislodgement have been documented following chest compressions, suggesting that the risk of harm from timely CPR in these patients is minimal.

Instead of the ventricles, atria may be the cardiac structures mainly compressed during cardiopulmonary resuscitation (CPR). This study aimed to assess the prevalence and the mechanical characteristics of atrial compression, named the \"atrial pump mechanism\", in patients undergoing CPR. A retrospective cohort study was conducted on patients with witnessed refractory out-of-hospital cardiac arrest who were admitted to a tertiary referral center for extracorporeal CPR. The area of maximal compression (AMC) by chest compressions was assessed by transesophageal echocardiography. Right atrial wall excursion (RAWE), left atrial fractional shortening (LAFS), right ventricular fractional area change (RVFAC), and left ventricular fractional shortening (LVFS) were measured. Common carotid and middle cerebral artery peak velocities were assessed using color-Doppler imaging as markers of cardiac outflow and cerebral perfusion. Forty patients were included in the study. Five (12.5%) had AMC over the atria. The atrial pump pattern was characterized by marked atrial compression with higher RAWE and LAFS values compared to the other patients (p < 0.001). Common carotid Doppler and transcranial Doppler-velocity patterns were detectable in all patients with open left ventricular outflow tract, without differences between patients. CPR was successful in four patients (80%) with atrial pump compared to 14 (40%) with no atrial pump mechanism (p = 0.155). In this series of selected patients with witnessed cardiac arrest, the prevalence of the atrial pump mechanism was not negligible. It may contribute to forward blood flow and the maintenance of cerebral perfusion during prolonged cardiopulmonary resuscitation.

暂无摘要。

Dilated cardiomyopathy (DCM) is a prevalent heart muscle disease characterized by ventricular dilation and systolic dysfunction, leading to severe heart failure (HF) and often requiring heart transplantation (HTx). This systematic review aimed to synthesize information regarding the role of ventricular assist devices (VADs) in managing HF patients due to DCM. A comprehensive search was conducted across PubMed, Embase, Scopus, Web of Science, and Cochrane databases for studies published between 2014 and 2024. Inclusion criteria were studies involving adult patients with HF due to DCM treated with VADs. Exclusion criteria included non-human studies, pediatric populations, and non-peer-reviewed articles. Thirty-one studies met the inclusion criteria. The included studies demonstrated that the use of VADs in patients with DCM resulted in significant improvements in left ventricular ejection fraction (LVEF), myocardial fibrosis reduction, and reverse ventricular remodeling. Studies reported enhanced survival rates, reduced symptoms, and better quality of life. VADs served as a critical bridge to HTx and, in some cases, as long-term destination therapy. However, complications such as thrombus formation, anemia, and kidney failure were noted, emphasizing the need for vigilant monitoring and management. Continuous advancements in VAD technology and patient management protocols were found to be essential for optimizing outcomes. We conclude that VADs play a crucial role in managing advanced HF due to DCM by providing mechanical circulatory support, improving cardiac function, and enhancing patient survival and quality of life. Despite associated complications, VADs are invaluable for patients with severe HF, offering both immediate and long-term therapeutic benefits. Future research should focus on minimizing complications and further improving VAD technology to enhance patient outcomes.

BACKGROUND: The left atrial assist device (LAAD) is a novel continuous-flow pump designed to treat patients with heart failure with preserved ejection fraction, a growing type of heart failure, but with limited device-treatment options. The LAAD is implanted in the mitral plane and pumps blood from the left atrium into the left ventricle. The purpose of this study was to refine the initial design of the LAAD, using results from computational fluid dynamics (CFD) analyses to inform changes that could improve hydraulic performance and flow patterns within the LAAD.
METHODS: The initial design and three variations were simulated, exploring changes to the primary impeller blades, the housing shape, and the number, size, and curvature of the diffuser vanes. Several pump rotational speeds and flow rates spanning the intended range of use were modeled.
RESULTS: Guided by the insight gained from each design iteration, the final design incorporated impeller blades with improved alignment relative to the incoming flow and wider, more curved diffuser vanes that better aligned with the approaching flow from the volute. These design adjustments reduced flow separation within the impeller and diffuser regions. In vitro testing confirmed the CFD predicted improvement in the hydraulic performance of the revised LAAD flow path design.
CONCLUSIONS: The CFD results from this study provided insight into the key pump design-related parameters that can be adjusted to improve the LAAD\'s hydraulic performance and internal flow patterns. This work also provided a foundation for future studies assessing the LAAD\'s biocompatibility under clinical conditions.

In patients with post-myocardial infarction ventricular septal defects, temporary left ventricular support using Impella 5.5 can decrease shunting, facilitate peri-infarct tissue remodeling, and allow for assessment of myocardial recovery prior to repair. When there is inadequate cardiac recovery, implantation of a durable left ventricular assist device such as HeartMate 3 at time of repair can be safely performed. A right ventriculotomy provides multiple advantages when performing VSD repair and concomitant HeartMate 3 placement.