Author + information
- Received July 7, 2014
- Revision received September 26, 2014
- Accepted October 3, 2014
- Published online April 1, 2015.
- Daniel Burkhoff, MD, PhD∗,†∗ (, )
- Mathew S. Maurer, MD†,
- Susan M. Joseph, MD‡,
- Joseph G. Rogers, MD§,
- Edo Y. Birati, MD‖,
- J. Eduardo Rame, MD, MPhil‖ and
- Sanjiv J. Shah, MD¶
- ∗HeartWare International, Framingham, Massachusetts
- †Division of Cardiology, Columbia University, New York, New York
- ‡Division of Cardiology, Washington University, St. Louis, Missouri
- §Division of Cardiology, Duke University, Durham, North Carolina
- ‖Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
- ¶Division of Cardiology, Northwestern University, Chicago, Illinois
- ↵∗Reprint requests and correspondence:
Dr. Daniel Burkhoff, Division of Cardiology, Columbia University, 177 Fort Washington Avenue, New York City, New York 10032.
Objectives The purpose of this study was to provide insight into the potential for left atrium (LA) to aortic mechanical circulatory support as a treatment for patients with heart failure with preserved ejection fraction (HFpEF).
Background Although HFpEF arises from different etiologies, 1 hallmark of all forms of this syndrome is a small or minimally-dilated left ventricle (LV). Consequently, the use of traditional mechanical circulatory support in end-stage patients has been difficult. In contrast, HFpEF is also characterized by a large LA.
Methods Hemodynamic characteristics of 4 distinct HFpEF phenotypes were characterized from the published data: 1) hypertrophic cardiomyopathies; 2) infiltrative diseases; 3) nonhypertrophic HFpEF; and 4) HFpEF with common cardiovascular comorbidities (e.g., hypertension). Employing a previously-described cardiovascular simulation, the effects of a low-flow, micropump-based LA decompression device were modeled. The effect of sourcing blood from the LV versus the LA was compared.
Results For all HFpEF phenotypes, mechanical circulatory support significantly increased cardiac output, provided a mild increase in blood pressure, and markedly reduced pulmonary and LA pressures. LV sourcing of blood reduced LV end-systolic volume into a range likely to induce suction. With LA sourcing, however, LV end-systolic volume increased compared with baseline. Due to pre-existing LA enlargement, LA volumes remained sufficiently elevated, thus minimizing the risk of suction.
Conclusions This theoretical analysis suggests that a strategy involving pumping blood from the LA to the arterial system may provide a viable option for end-stage HFpEF. Special considerations apply to each of the 4 types of HFpEF phenotypes described. Finally, an HFpEF-specific clinical profile scoring system (such as that of INTERMACS [Interagency Registry for Mechanically Assisted Circulatory Support]) would aid in the selection of patients with the appropriate risk–benefit ratio for implantation of an active pump.
Dr. Burkhoff is an employee of HeartWare International; is a consultant to DC Devices; and receives speaking honoraria from Abiomed. Dr. Birati has received training and research grants from Thoratec Corporation and HeartWare Inc. Dr. Rame has served as a primary investigator for Thoratec Corporation and HeartWare Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 7, 2014.
- Revision received September 26, 2014.
- Accepted October 3, 2014.
- American College of Cardiology Foundation