Effect of Pulsatile and Non-pulsatile Left Ventricular Assist Devices on the Renin-Angiotensin System in Patients with End-Stage Heart Failure

Abstract

Introduction: Left ventricular assist devices have been successfully used as a bridge to cardiac transplantation. Because many patients exhibit marked clinical improvement of their heart failure after LVAD implantation, we studied the physiological effect of pulsatile and non-pulsatile devices on the neurohormonal axis and exercise capacity. Methods: We prospectively included 20 patients (17 men, 3 women) undergoing LVAD implantation between November 2001 and January 2004. Ten patients (1 woman and 9 men) were treated with the non-pulsatile INCOR-LVAD (Berlin Heart©) and ten patients received the pulsatile EXCOR LVAD (Berlin Heart©). Blood samples for plasma renin activity (PRA) were taken once a week over a period of ten weeks. All blood samples were collected in the morning before mobilization. Blood pressure, body weight, fluid intake and urine production were measured once a day. All patients received standard hospital diet with no limitation in fluid intake. Results: Body weight remained constant in both groups throughout the ten weeks' examination, and fluid intake and urine production were balanced in all patients. Although there was no significant difference in mean blood pressure (INCOR: 70 ± 10 mmHg; EXCOR: 73 ± 10 mmHg), plasma renin activity was substantially elevated in patients with non-pulsatile left ventricular support (INCOR: 94.68 ± 33.97 µU/ml; EXCOR: 17.06 ± 15.94 µU/ml; p < 0.05). Furthermore plasma aldosterone levels were significantly higher in patients supported by non-pulsatile INCOR LVAD (INCOR: 73.4 ± 9.6 µg/ml; EXCOR: 20.6 ± 4.6 µg/ml; p < 0.05). Conclusions: Our data suggest that pulsatile as well as non-pulsatile left ventricular assist devices are equally able to treat chronic heart failure. However pulsatile devices seem to have a greater impact on reversing the changes in plasma renin activity and might thus offer a greater advantage when recovery of left ventricular function is expected.

plasma renin activity - cardiogenic shock - left ventricular assist device

References

• 1 Francis G S, Cohn J N, Johnson G, Rector T S, Goldman S, Simon A. Plasma norepinephrine, plasma renin activity, and congestive heart failure. relations to survival and the effects of therapy in V-HeFT II. The V-HeFT VA Cooperative Studies Group.  Circulation. 1993;  87 VI40-VI48
• 2 Francis G S, Rector T S, Cohn J N. Sequential neurohumoral measurements in patients with congestive heart failure.  Am Heart J. 1988;  116 1464-1468
• 3 Covit A B, Schaer G L, Sealey J E, Laragh J H, Cody R J. Suppression of the renin-angiotensin system by intravenous digoxin in chronic congestive heart failure.  Am J Med. 1983;  75 445-447
• 4 Hillege H L, Girbes A R, de Kam P J et al. Renal function, neurohormonal activation, and survival in patients with chronic heart failure.  Circulation. 2000;  102 203-210
• 5 Cohn J N, Johnson G, Ziesche S et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure.  N Engl J Med. 1991;  325 303-310
• 6 Alicandri C, Fariello R, Boni E et al. Captopril versus digoxin in mild-moderate chronic heart failure: A crossover study.  J Cardiovasc Pharmacol. 1987;  9 (Suppl. 2) S61-S67
• 7 Koul B, Solem J O, Steen S, Casimir-Ahn H, Granfeldt H, Lonn U J. HeartMate left ventricular assist device as bridge to heart transplantation.  Ann Thorac Surg. 1998;  65 1625-1630
• 8 Piccione Jr W. Mechanical circulatory assistance: changing indications and options.  J Heart Lung Transplant. 1997;  16 S25-S28
• 9 Noirhomme P, Jacquet L, Underwood M, El Khoury G, Goenen M, Dion R. The effect of chronic mechanical circulatory support on neuroendocrine activation in patients with end-stage heart failure.  Eur J Cardiothorac Surg. 1999;  16 63-67
• 10 Goldstein D J. Worldwide experience with the MicroMed DeBakey ventricular assist device as a bridge to transplantation.  Circulation. 2003;  108 (Suppl. 1) II272-II277
• 11 Magovern J A, Sussman M J, Goldstein A H, Szydlowski G W, Savage E B, Westaby S. Clinical results with the AB-180 left ventricular assist device.  Ann Thorac Surg. 2001;  71 S121-S124
• 12 Nafz B, Stegemann J, Bestle M H et al. Antihypertensive effect of 0.1-Hz blood pressure oscillations to the kidney.  Circulation. 2000;  101 553-557
• 13 Griffith B P, Kormos R L, Borovetz H S et al. HeartMate II left ventricular assist system: from concept to first clinical use.  Ann Thorac Surg. 2001;  71 S116-S120
• 14 Loforte A, Montalto A, Ranocchi F et al. Heartmate II axial-flow left ventricular assist system: management, clinical review and personal experience.  J Cardiovasc Med (Hagerstown). 2009;  10 765-771
• 15 John R. Current axial-flow devices – the HeartMate II and Jarvik 2000 left ventricular assist devices.  Semin Thorac Cardiovasc Surg. 2008;  20 264-272
• 16 McCarthy P M. HeartMate implantable left ventricular assist device: bridge to transplantation and future applications.  Ann Thorac Surg. 1995;  59 S46-S51
• 17 Wieselthaler G M, Riedl M, Schima H et al. Endocrine function is not impaired in patients with continuous MicroMed-DeBakey axial flow pump.  J Thorac Cardiovasc Surg. 2007;  133 2-6