Mechanical Circulatory Support in Patients with End-Stage Heart Failure

Abstract

Objective. The aim of the study is to establish the effectiveness of mechanical support of blood circulation of patients with end-stage heart failure depending on the method of surgical correction.
 Materials and methods. The results of the study are based on the data of examination and dynamic observation of 73 patients (median age 44 (16-69) years, 68 men, 5 women) who were treated from 2008-2019 іn the following medical institutions: Republican Scientific and Practical Center «Cardiology» (Minsk, Republic of Belarus) and Center of cardiac surgery on the basis of Hospital «Feofania». Patients were examined during the initial examination, after 3 months and after 1 year.
 Results and discussion. As a result of the study found, indications for surgical treatment of patients with end-stage heart failure those are the following criteria: left ventricular ejection fraction (LV EF) <20%, (p < .0001). Pulmonary artery occlusion pressure (PAL) from 25 mm Hg up to 35 mm Hg (p < .0001). Peak myocardial oxygen consumption <14 ml/kg/min on the background of maximum drug therapy (p < .0001). Pulmonary vascular resistance (PVR) <5 units by Wood, (p < .0001). Transpulmonary gradient up to 15 mm Hg (p < .0001). Indications for LVAD therapy are the following criteria: left ventricular ejection fraction (LV EF) <20%, (p <0001). Pulmonary artery occlusion pressure > 35 mm Hg (p < .0001). Pulmonary vascular resistance (PVR) >5 units by Wood, (p < .0001). Transpulmonary gradient >15 mm Hg (p < .0001). Against the background of work LVAD after 3 months there was a decrease in the left ventricular cavity by 30%, (p < .0001), decrease in the pancreatic cavity by 25.5%, (p < .0001), increase in fraction LV emission by 21%, (p < .0001). According to direct pulmonary arterial tonometry with LVAD therapy, there was a decrease in pulmonary vascular resistance «Wood» by 34%, (p < .0001), reduction in pulmonary arterial pressure by 24%, (p < .0001), a decrease of transpulmonary gradient by 21%, (p < .0001). The results of the change in functional indicators in patients on LVAD therapy after 3 months: increase maximum myocardial oxygen consumption by 6% (p < .0001), increase exercise tolerance by 15% (p < .0001). Indications for BiVAD-therapy are the following criteria: biventricular insufficiency, (p < .0001). Pulmonary artery occlusion pressure >35 mm Hg, (p < .0001). Pulmonary vascular resistance >5 units by Wood, (p < .0001). Transpulmonary gradient >15 mm Hg, (p < .0001). Against the background of BiVAD work in 3 months was noted reduction of the right ventricular (RV) enddiastolic volume (EDV) by 6% (p <0001), reduction of the RV end-systolic volume (ESV) by 10%, (p < .0001), increase in LV EF by 33%, (p < .0001), decrease in left ventricular (LV) ESV (M-mode) by 36.3%, (p < .0001), a decrease in LV EDV (M-mode) by 30%, (p < .0001), a decrease in LV ESV (B-mode) by 22.5%, (p < .0001), increase in tricuspid systolic excursion (TAPSE) by 21.4%, (p < .0001). According to the direct pulmonary arterial tonometry during use BiVAD-therapy: reduction of pulmonary vascular resistance «Wood» by 22%, (p < .0001), reduction of pulmonary arterial pressure by 15%, (p <0001), reduction of transpulmonary gradient by 14%, (p <0001). The results of surgical treatment of patients with critical heart failure: after direct orthotopic heart transplantation (OHT): 24 patients were treated with positive result (92%), 2 patients died (8%). There were 18 patients performed secondary OHT, patients who were on LVAD therapy (46%). 18 patients (46%) continue LVAD-therapy. On LVAD-therapy 3 patients died (8%). The cause of death is purulent-septic lesions. Which patients were on BiVAD-therapy: secondary OHT performed 4 patients (50%). 4 patients (50%) died on BIVAD-therapy. The cause of death in 2 cases was purulent-septic lesions (50%), and in 2 other cases it was multisystem organ failure (50%)
 Conclusions. Analysis of the results of the differential approach to surgical treatment patients with heart failure NYHA functional class III-IV: patients with critical heart failure in the presence of contraindications to direct heart transplantation, it is advisable to consider the use of long-term mechanical circulatory support based on LVAD therapy (p < .0001) and BiVAD-therapy (p < .0001) as a mechanical bridge to heart transplantation. Applied long-term mechanical support of blood circulation in patients with high indicators of pulmonary hypertension (p < .0001), allows in a short time (4-6 weeks) to normalize pulmonary artery pressure and consider performing a secondary heart transplant.