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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 4, July/August 2016



its long-term outcomes. The aim of our study was to describe

this small, new-generation pump and the first implantation

experience from Istanbul, Turkey.


From December 2011 to December 2013, Heart Assist 5 LVADs

were implanted in nine patients at our hospital. Eight patients

had ischaemic cardiomyopathy and one had adriamycin-induced

cardiomyopathy. The mean age of the patients was 53



(34–64) years (Table 1).

All patients’ pre-operative data (catheterisation,

echocardiography, laboratory and infection parameters) and

haemodynamic status had been assessed at the hospital’s medical

review board meeting to evaluate their selection for LVAD

implantation. All patients had signed informed consent and the

study protocol was approved by the institutional review board.

In December 2011, 55 serial two-dimensional transthoracic

echocardiographic (TTE) examinations had been performed

on these patients with the Vivid 3 (General Electric, Fairfield,

Connecticut), and 16 serial three-dimensional TTE examinations

had been done with the Philips IE33 xMATRIX (Royal Philips

Electronics, Amsterdam, Netherlands). Nine transoesophageal

echocardiograms (TEE) were done in the operating room

under general anaesthesia during the LVAD implantation to

evaluate inflow cannula and septum position, and to monitor

the de-airing process while weaning from cardiopulmonary

bypass. The specific protocol used for these echocardiographic

studies included standard TTE parasternal, apical, subcostal and

suprasternal notch views.


All TTEs and TEEs were performed by certified cardiologists

in different clinical settings. In hospital during the pre-implant

period, they evaluated the intracardiac structure [patent foramen

ovale (PFO), atrial septal defect (ASD)], chamber dimensions,

left ventricular (LV) and right ventricular (RV) function, valvular

structure and function, pericardial disease, volume status and

abnormalities of the aorta. In hospital during the post-implant

LVAD period, the aim was to visualise the septum and inflow

cannula position, the intracardiac volume, outflow conduit,

decompression of the left ventricle with rpm speed change and

its effects on the aortic valve opening time. Doppler interrogation

of the inlet cannula and outflow conduit flows were performed

as described in the literature.


Follow-up TTEs were done for

clinical indications, including LV and RV ejection fraction (EF),

RV fractional area contraction (RVFAC), unexplained change in

haemodynamic status including minor dehydration, ventricular

tachycardia attacks, suspicion of device malfunction, excess

current alarms, and optimisation of LVAD speed.

Echo-specific parameters and differences in image quality or

artifact generation were not evaluated in our study. During all

echocardiographic studies, the transplant surgeons were at the

bedside or in the out-patient clinic, in communication with the heart

failure cardiologist setting up the pump parameters, optimising the

LVAD speed, and observing the aortic valve opening times and

septum inflow cannula position to prevent the suction cascade.

Images from 55 TTEs were retrospectively analysed by the

heart failure cardiologist who had mainly performed all these

echo studies. The inlet cannula/outflow conduit velocities were

measured in m/s by spectral Doppler. The pulsality index of the

pump, LV end-diastolic dimension (LVEDD), LV end-systolic

dimension (LVESD), interventricular septum (IVS), posterior

wall thickness, RVFAC, and tricuspid annular plane systolic

excursion (TAPSE) were measured, and the functioning of the

valves was routinely evaluated pre-implant and at the second

week, and first, third, sixth, ninth and 12th months post-implant.

Statistical analysis

All echocardiographic data were collected in parallel with the

patients’ laboratory parameters (biochemical, blood count,

coagulation profile) in an electronic database, and descriptive

statistics were calculated using Microsoft Excel (Microsoft Corp,

Redmond, Washington). Continuous variables were expressed as

the mean value


standard deviation.


As our Heart Assist 5 LVAD patient data were limited, we did

not compare the patients’ outcome parameters pre- versus post-

implant, knowing that with this small group, all analyses would

be statistically non-significant. We therefore analysed these

patients’ data as descriptive statistics.

The titanium impeller of Heart Assist 5 LVAD is small, light-

weight and located pericardially. The titanium housing enables

direct visualisation of the impeller. The outflow and inflow

cannulas were visualised in all studies. The inflow cannula and

septum (left, right, neutral) position, outflow graft anastomosis

to the aorta, aortic valve cusp status, and aortic valve opening

times with speed changes were evaluated and visualised in all 55

echocardiographic studies (Figs 4–6).

Pre-implant echocardiographic data of the six patients: mean

EF was 23


5 (18–28)%, mean LVEDD was 6.9


0.6 (6.3–7.7)

cm, mean LVESD was 5.8


0.5 (5.1–6.4) cm, mean IVS was 0.9


0.1 (0.9–1.1) cm, mean RVFAC was 43


9 (35–55)%, and mean

TAPSE was 17


4 (13–23) mm.

The 12-month post-implant echocardiographic data of the

six patients were: mean EF was 19


6 (10–25)%, mean LVEDD

was 6.4


0.4 (6.1–7.0) cm, mean LVESD was 5.6


0.3 (5.2–6.0)

cm, mean RVFAC was 35


11(21–43), mean TAPSE was 13



(11–16) mm, mean rpmwas 9 800


600 (9 500–10 400) rpm, mean

pulsality index (PI) was 2.79


1.7 (1.9–4.9) m/s, outflow cannula

Fig. 4.

Outflow cannula velocity measurement with Doppler.