Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect
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Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect. / Pahuja, Mohit; Schrage, Benedikt; Westermann, Dirk; Basir, Mir B; Garan, Arthur Reshad; Burkhoff, Daniel.
In: CIRC-HEART FAIL, Vol. 12, No. 7, 07.2019, p. e005981.Research output: SCORING: Contribution to journal › SCORING: Journal article › Research › peer-review
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TY - JOUR
T1 - Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect
AU - Pahuja, Mohit
AU - Schrage, Benedikt
AU - Westermann, Dirk
AU - Basir, Mir B
AU - Garan, Arthur Reshad
AU - Burkhoff, Daniel
PY - 2019/7
Y1 - 2019/7
N2 - BACKGROUND: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown.METHODS AND RESULTS: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS.CONCLUSIONS: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.
AB - BACKGROUND: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown.METHODS AND RESULTS: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS.CONCLUSIONS: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.
KW - Adult
KW - Aged
KW - Aged, 80 and over
KW - Extracorporeal Membrane Oxygenation/instrumentation
KW - Female
KW - Heart Failure/physiopathology
KW - Heart Septal Defects, Ventricular/physiopathology
KW - Heart Ventricles/physiopathology
KW - Heart-Assist Devices/adverse effects
KW - Hemodynamics/physiology
KW - Humans
KW - Intra-Aortic Balloon Pumping/adverse effects
KW - Male
KW - Middle Aged
KW - Myocardial Infarction/physiopathology
KW - Risk Factors
KW - Shock, Cardiogenic/physiopathology
U2 - 10.1161/CIRCHEARTFAILURE.119.005981
DO - 10.1161/CIRCHEARTFAILURE.119.005981
M3 - SCORING: Journal article
C2 - 31296094
VL - 12
SP - e005981
JO - CIRC-HEART FAIL
JF - CIRC-HEART FAIL
SN - 1941-3289
IS - 7
ER -