The Inflammatory Response to Ventricular Assist Devices

Abstract

The therapeutic use of ventricular assist devices (VADs) for end-stage heart failure (HF) patients who are ineligible for transplant has increased steadily in the last decade. In parallel, improvements in VAD design have reduced device size, cost, and device-related complications. These complications include infection and thrombosis which share underpinning contribution from the inflammatory response and remain common risks from VAD implantation. An added and underappreciated difficulty in designing a VAD that supports heart function and aids the repair of damaged myocardium is that different types of HF are accompanied by different inflammatory profiles that can affect the response to the implanted device. Circulating inflammatory markers and changes in leukocyte phenotypes receive much attention as biomarkers for mortality and disease progression. However, they are seldom used to monitor progress during and outcomes from VAD therapy or during the design phase for new devices. Even the partial reversal of heart damage associated with heart failure is a desirable outcome from VAD use. Therefore, improved understanding of the interplay between VADs and the recipient's inflammatory response would potentially increase their uptake, improve patient lives, and fuel research related to other blood-contacting medical devices. Here we provide a review of what is currently known about inflammation in heart failure and how this inflammatory profile is altered in heart failure patients receiving VAD therapy.

Heart failure and COVID-19

“…Although cellular immunity was reported to be compromised among long-term LVAD recipients, [ 71 , 72 ] there is no clear evidence suggesting that they are at increased risk of acquiring the virus. It is also known that the inflammatory profile is significantly altered in HF patients supported by LVAD therapy, who generally have elevated cytokines [ 73 ]. This should be taken into consideration when clinically evaluating LVAD patients presenting with COVID-19 or utilizing their inflammatory and cardiac biomarkers for treatment or prognosis.…”

Thrombogenic and Inflammatory Reactions to Biomaterials in Medical Devices

“…Overtime, the ventricular assist device reduced size, cost, and complications, but thrombosis remains a common risk; elevation of lactic dehydrogenase is a useful biomarker of pump thrombosis. Thrombosis incidence in continuous-flow devices (HeartMate II R , Thoratec Corp., Pleasanton, CA) increased substantially from 2.2 to 8.4% from March 2011 to January 2013 (Starling et al, 2014), and pump rotational blood flow seems to play a pivotal role (Radley et al, 2018). Inflammation is a contributing factor to thrombus formation and progression (Radley et al, 2018).…”

The Imperfect Cytokine Storm

“…Inflammation and myocardial injury from COVID-19 must be differentiated from baseline inflammation often encountered during LVAD support [5]. In our LVAD patient, several biomarkers including LDH, absolute lymphocyte count, brain natriuretic peptide (BNP) and troponin have previously been obtained.…”

“…Still, caution is warranted as major adverse effects of tocilizumab include infection, infusion reactions, dyslipidemia, neutropenia, and potential malignancy [6]. Patients on LVAD support are particularly vulnerable to infectious complications due to the inherent presence of hardware and driveline exposure as well as the fact that prolonged support has been associated with immune dysregulation [5].…”