Biventricular Ventricular Assist Devices Research Articles

Perioperative Morbidity and Outcomes in Pediatric Patients Transitioned From Extracorporeal Membrane Oxygenation to Ventricular Assist Device Support: A Study of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

As a bridge to transplant strategy, children transitioned from extracorporeal membrane oxygenation (ECMO) to ventricular assist device (VAD) have higher waitlist mortality compared with those who receive de novo VAD. However, the contribution of the immediate perioperative period and differences in the two groups are not well studied. We performed a nested case-control study between children receiving de novo VAD (group 1) and those transitioned from ECMO to VAD (group 2) between 2014 and 2019 using The Society of Thoracic Surgeons (STS) database. A total of 735 children underwent VAD placement with 498 in group 1 and 237 in group 2. Patients in group 2 were significantly younger, smaller, and significantly sicker, were twice as likely to transition to biventricular VAD and need unplanned reoperations. Overall mortality was 16% for group 1 and 34% for group 2 ( p < 0.01). Regression analysis showed that ECMO use (odds ratio [OR], 2.17 [1.3-3.4]), ventilator need (OR, 2.2 [1.3-3.9]), and cardiogenic shock (OR, 1.8 [1.2-2.8]) were all independent preoperative predictors of VAD mortality while dialysis need (OR, 25.5 [8.6-75.3]), stroke (OR, 6.2 [3.1-12.6]), and bleeding (OR, 1.9 [1.1-3.4]) were independent postoperative predictors of VAD mortality within 30 days (all p < 0.05). The study demonstrated significant baseline differences between the two cohorts, warranting avoidance of comparison. Early elective VAD placement in this cohort of patients should be sought to avoid interim ECMO and high post-VAD mortality.

Adverse Events Associated with Cardiac Catheterization in Children Supported with Ventricular Assist Devices.

Children on ventricular assist device (VAD) support can present several unique challenges, including small patient size, univentricular or biventricular congenital heart disease (1V- or 2V-CHD) and need for biventricular VAD (BiVAD) support. While cardiac catheterization can provide valuable information, it is an invasive procedure with inherent risks. We sought to evaluate the safety of catheterization in pediatric patients on VAD support. We performed a retrospective review of patients on VAD support who underwent catheterization at Lucile Packard Children's Hospital between January 1, 2014 and September 1, 2019. Using definitions adapted from Pedimacs, adverse events (AEs) after catheterization were identified, including arrhythmia; major bleeding or acute kidney injury within 24 hours; respiratory failure persisting at 24 hours; and stroke, pericardial effusion, device malfunction, bacteremia or death within 7 days. AEs were categorized as related or unrelated to catheterization. Sixty procedures were performed on 39 patients. Underlying diagnoses were dilated cardiomyopathy (48%), 1V-CHD (35%), 2V-CHD (8%), and other (8%). Devices were implantable continuous flow (72%), paracorporeal pulsatile (18%) and paracorporeal continuous flow (10%). Catheterizations were performed on patients in the ICU (60%), on inotropic support (42%), with deteriorating clinical status (37%) and on BiVAD support (12%). There were 9 AEs possibly related to catheterization including 6 episodes of respiratory failure, 2 major bleeding events, and 1 procedural arrhythmia. AE occurrence was associated with ICU status ( P = 0.01), BiVAD support ( P = 0.04) and procedural indication to evaluate worsening clinical status ( P = 0.04). Despite high medical acuity, catheterization can be performed with an acceptable AE profile in children on VAD support.

Cardiac Rehabilitation in Patients With Ventricular Assist Device.

The aim of this study was to investigate changes in exercise capacity (EC) and quality of life (QoL) of patients with ventricular assist devices (VADs) during cardiac rehabilitation (CR). Data from patients with VAD implantation and subsequent CR between 2007 and 2017 were analyzed retrospectively. Measures of the 6-min walk test [6MWT] distance, Functional Independence Measure [FIM], ergometry, MacNew Heart Disease Questionnaire [MNH], and Hospital Anxiety and Depression Scale [HADS] at entry and discharge were examined. Data from 110 patients (age 53 ± 12 yr; male 82%) were analyzed. Patients improved during CR significantly in the 6MWT (114 ± 85 m, P < .001), ergometry (20 ± 17 W, P = .002), FIM (8 ± 7 points, P < .001), and MNH (0.8 ± 0.7 points, P < .001). Initial HADS levels were high with a mean value of 9 and did not improve during CR (-0.4 ± 5 points, P = .637). Significant differences of improvements in the 6MWT were observed between left and biventricular VAD (129 ± 90 m vs 85 ± 67 m, P = .043) as well as destination therapy and bridge-to-transplant (184 ± 88 m vs 102 ± 82 m, P = .005). Patients with VAD implantation had statistically and clinically significant improvements in EC and QoL as assessed with the MNH during CR. Patients on destination therapy showed a larger benefit from CR than bridge-to-transplant patients and patients with left VAD improved more than biventricular VAD patients.

Mechanical Circulatory Support Prior to Heart Transplantation Predicts Early Post-Operative Stroke

BackgroundMechanical circulatory support (MCS) devices are often deployed to treat patients with refractory cardiogenic shock, rapid deterioration of heart failure, and inotrope-dependent patients. Stroke is a common complication of MCS therapy. This study assesses the risk of stroke during the early post-heart transplantation (HT) period (days from successful HT to discharge or death) in patients who received MCS therapy leading to HT. MethodsData were derived from the United Organ Sharing (UNOS) database. MCS modalities studied include left ventricular assist devices (LVAD), right ventricular assist devices (RVAD), biventricular ventricular assist devices (BiVAD), and extra-corporeal membrane oxygenation (ECMO). A multiple logistic regression model was used to determine the risk of stroke during the early post-HT period associated in patients treated with MCS leading to HT. ResultsBetween 1988 and 2014, 10,258 patients received MCS therapy leading to HT. Of these, 160 patients (1.96%) developed stroke during the early post-HT period. Multiple regression analysis showed that MCS modalities and associated odds ratios for early post-HT stroke and associated 95% confidence intervals were as follows: LVAD (1.44, 0.70-2.94), RVAD (2.89, 1.03-8.05, BiVAD (3.24, 1.15-9.10), ECMO (2.27 (1.17-4.40), and any MCS (1.60 (1.20-2.12). ConclusionsWith the exception of left ventricular assist devices, use of MCS modalities leading to HT is significantly and independently associated with stroke during the early post-HT period.

Biventricular Assist Device Support of a Child with Intractable Arrhythmias Secondary to Histiocytoid Cardiomyopathy

Introduction Histiocytoid cardiomyopathy (HICMP) is a rare mitochondrial cardiomyopathy associated with intractable, life-threatening ventricular arrhythmias. Dilated, hypertrophic, and noncompaction phenotypes can also be seen with HICMP and have the potential to progress to heart failure. Heart transplantation (HT) and left ventricular assist device (VAD) support for heart failure in HICMP have been described in case reports, but there has been no published experience on Biventricular VAD (BiVAD) support for intractable arrhythmias in HICMP. Case Report A 13-month-old presented with lethargy, poor perfusion, and ventricular tachycardia (VT) with wide- and narrow-complex morphology. Ejection fraction was 54% with left ventricular (LV) noncompaction. Electrical and chemical rhythm control were unsuccessful, and rate control was complicated by symptomatic bradycardia. Rhythm control was transiently achieved with percutaneous stellate ganglion block, but the frequency of breakthrough ventricular fibrillation (VF) subsequently increased. PediMag® BiVAD with LV apical cannulation was implanted as a bridge to transplantation (BTT), with eventual conversion to Berlin Heart EXCOR® BiVAD. HICMP was confirmed by pathology at time of implant. Post-operative course was complicated by suction events, likely secondary to cannula position and underlying rhythm, as suction only occurred during systole in sinus rhythm. Suction events resolved with revision to left atrial cannulation. She continued to alternate between sinus rhythm, VF, VT, and asystole and intermittent “pauses” (no fill/no eject) were observed during sinus rhythm, likely due to competition from intrinsic ejection. She is now 4 months into BiVAD support with alternating sinus, VT, and VF rhythms, no device related complications, and excellent rehabilitation as she awaits HT. Summary We report our experience with BiVAD support of a 13-month-old with HICMP and intractable arrhythmias as BTT. In small children, it is important to understand the potential impact of cannula position and heart rhythm on device performance. Even in the absence of ventricular dysfunction, BiVAD support with atrial cannulation can provide excellent hemodynamic support for patients with HICMP and life-threatening arrhythmias.

Bloody Transplants! Impact of Prior Sternotomy on Transfusion Rate in Heart Transplantation

<h3>Purpose</h3> Ventricular Assist device (VAD) patients are at higher risk of bleeding at the time of heart transplant. Moreover, the quantity of packed red cells (RBC) received during the first 24 hours postoperatively correlates with increased mortality. Whether this is related to surgical issues or due to the anticoagulation associated with VADs is unknown. <h3>Methods</h3> Operative transfusion requirements and demographics data was obtained from our hospital cardiothoracic database for all patients who underwent heart transplantation between 2006 and 2020. Patients were divided into three groups - No previous sternotomy (NPS), VAD explant (VE) and Previous (non-VAD) Sternotomy (PS). Biventricular VAD, total artificial heart explants and multi-organ transplants were excluded. <h3>Results</h3> 428 patients were included in the analysis. Median age was 54 years (IQR 43-61), 131 patients were female (31%), median eGFR was 78ml/min/1.73m2 (IQR 54-95). 236 patients (54.2%) were in the NPS group, 133 (31.1%) in the VE group and 62 patients (14.6%) in the PS group. There was a strong association between blood transfusion and re-do sternotomy (both VE and PS groups) (p<0.001), but no difference between the VE and PS groups. A lower mean eGFR (<78ml/min/1.73m2) was associated with higher transfusion requirement (P<0.001). <h3>Conclusion</h3> Sternotomy patients (with or without VAD explant) demonstrated a higher RBC transfusion requirement compared to clean skin and these patients tended to have a lower renal function post-operatively. The lack of difference in RBC requirement between VE and PS patients suggest that anticoagulated VAD patients who have received Vitamin K do not necessarily have higher bleeding risk than other re-do sternotomy patients.

Comparison of Outcomes between Permanent and Temporary Right Ventricular Assist Devices Following Left Ventricular Assist Device Implantation

Purpose Right heart failure (RHF) affects 20-30% of left ventricular assist device (VAD) recipients, and is a major cause of morbidity and mortality. We hypothesized that the benefits of temporary right VADs (tRVADs) may be overestimated, and insertion of a planned permanent right VAD (pRVAD) may have better survival, reduced morbidity, and reduced re-admission rates. Methods Retrospective analysis was performed on 116 consecutive patients undergoing LVAD insertion at The Alfred Hospital, Australia between 2011 to 2018, utilizing retrospective and prospectively collected data. Results Of the 116 LVAD patients, 32 received either a tRVAD (n=22) or pRVAD (n=10) at the time of LVAD implant. Of the 22 tRVAD patients, 9 were not able to be weaned. Four died, and 5 (22.7%) were converted to a permanent device. There was no significant difference in survival to discharge whether a permanent or temporary RVAD was primarily implanted (pRVAD 90%, tRVAD 81.8%; p = 0.56). Patients who were discharged following a successful tRVAD wean - that is no right-side device on discharge - had more readmission days for heart failure, compared with those discharged with a pRVAD (0.5 days [95%CI 0 - 10] vs 0 days [95%CI 0 - 0], respectively; p = 0.014). Conclusion Temporary RVAD support, although attractive as a low cost option, is associated with more heart failure readmissions in LVAD patients compared to those discharged on biventricular VAD support.

Pediatric Ventricular Assist Device Implantation: An Anesthesia Perspective.

Ventricular assist devices (VADs) are increasingly being implanted in children, yet there is little literature to guide anesthetic management for these procedures. To describe the pediatric population presenting for VAD implantation and the anesthetic management these patients receive. To compare (a) children under and over 12 months of age and (b) children with and without congenital heart disease. Retrospective review of patients aged 0 to 17 years who underwent VAD implantation at a single center between 2014 and 2019. Seventy-seven VADs were implanted in 68 patients (46 left VADs, 24 biventricular VADs, 6 right VADs, and 1 univentricular VAD). One procedure was abandoned. Preoperatively, 20 (26%) patients were supported with extracorporeal membrane oxygenation and 57 (73%) patients were ventilated. Intraoperative donor blood products were required in 74 (95%) cases. Postimplantation inotropic support was required in 66 (85%) cases overall and 46 (100%) patients receiving a left VAD. Infants under 12 months were more likely to require preoperative extracorporeal membrane oxygenation (42% vs 19%), have femoral venous access (54% vs 28%), receive an intraoperative vasoconstrictor (42% vs 24%), and have delayed sternal closure (63 vs 22%). Mortality was higher in patients under 12 months (25% vs 19%) and in patients with congenital heart disease (25% vs 20%). Children undergoing VAD implantation require high levels of preoperative organ support, high-dose intraoperative inotropic support, and high-volume blood transfusion. Children under 12 months and those with congenital heart disease are particularly challenging for anesthesiologists and have worse overall outcomes.

The results of a single-center experience with HeartMate 3 in a biventricular configuration

Right ventricular (RV) failure after left ventricular assist device (VAD) implantation is a difficult problem. One solution is the implantation of continuous-flow VADs in a biventricular configuration. Disappointing survival and a concerning incidence of right-sided pump thrombosis have been previously reported. From May 2017 to April 2020, a total of 12 patients underwent implantation of HeartMate 3 (HM3) biventricular VADs (BiVADs) as a bridge to cardiac transplantation. The right-sided pump was implanted in the right atrium in all cases. Adverse events and patient outcomes were determined. Patients were male, and the mean age was 44 years. The etiology was dilated cardiomyopathy (6 patients), sarcoid heart disease (2 patients), ischemic cardiomyopathy (1 patient), anthracycline cardiomyopathy (1 patient), non-compaction cardiomyopathy (1 patient), and arrhythmogenic RV cardiomyopathy with biventricular involvement (1 patient). There was 1 death from multisystem failure. There were 3 episodes of right VAD thrombus (thrombosis or clot ingestion); 1 managed medically, 1 recognized intraoperatively treated with clot retrieval, and 1 requiring pump exchange. There were 3 driveline infections. At 18 months after the procedure, 5 patients (41.7%) had undergone cardiac transplantation, 5 patients (41.7%) were alive and on biventricular support, 1 patient had died (8.3%), and 1 patient had VAD explantation for myocardial recovery (8.3%). Actuarial survival at 18 months was 91.7%. In this small study, HM3 BiVAD in these critically ill patients was used with low mortality. This suggests that the timely deployment of biventricular support with HM3 can be associated with favorable outcomes.

Outcomes with Ventricular Assist Device Therapy for Advanced Heart Failure in North Macedonia: First Annual Report

Mechanical circulatory support by a continuous-flow ventricular assist device (VAD) improves survival and quality of life in selected patients with advanced heart failure. Developing countries have been struggling to construct a contemporary and effective health care system to manage advanced heart failure. This observation represents the first annual report on clinical outcomes with VAD for patients with advanced heart failure in the Republic of North Macedonia. Data from all patients with VAD implantations between November 2018 and December 2019 were collected. The etiology of the heart failure was dilated cardiomyopathy in 4 patients (57%), ischemic cardiomyopathy in 2 (28%), and hypertrophic cardiomyopathy in 1 (14%). The primary outcome was survival; secondary outcomes included adverse events defined according to the Interagency Registry for Mechanically Assisted Circulatory Support. A total of 7 patients (85% males, median age 56 years) received a VAD; 5 of them received left VAD, and the remaining 2 received biventricular VAD. There were no deaths. Observed morbidity during a mean follow-up of 216 days included 3 bleeding events in 1 patient, 2 patients with superficial driveline infection, and 1 minor stroke and a pump thrombosis, which were treated with VAD exchange. Significant improvement in quality of life, as assessed by the Kansas City Cardiomyopathy Questionnaire and the Functional Independence Measure™ instrument, was seen with all patients. Our results demonstrate a successful initiation of the VAD program in the Republic of North Macedonia. Proper training of a dedicated HF team supports the reproducibility of this treatment in developing countries.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Adverse Event Profile Associated with Prolonged Use of CentriMag Ventricular Assist Device for Refractory Cardiogenic Shock.

Several studies have investigated early outcomes with a surgical short-term ventricular assist device (VAD), but little is known about adverse event profile during prolonged support with a surgical short-term VAD. This is a retrospective analysis of 161 patients who received a CentriMag ventricular assist system (Abbott Laboratories, Abbott Park, IL) at our institution between January 2007 and June 2014. Device-related adverse events include major bleeding, infection, and stroke incidents occurring during CentriMag support. Cumulative frequency of adverse events was estimated by Nelson's nonparametric method. One hundred and forty-three (88.8%) patients had biventricular VAD and 18 (11.2%) had isolated left VAD. Median duration of support was 16 days (interquartile range [IQR]: 10-29). Mortality was 24.8% and 1 year overall survival is 51.8% (95% CI: 43.3-59.5%). The most common adverse event during support was major bleeding (n = 121, 75.1%). Ninety-five (59.0%) developed major infections such as pneumonia and urinary tract infection. Sixteen patients (10%) experienced stroke. Cumulative data analysis showed that stroke and reoperation caused by bleeding were rare beyond 30 days, whereas infection and nonsurgical bleeding events were directly related to support time. In conclusion, temporary VAD with CentriMag support is an effective treatment for patients in refractory cardiogenic shock. Despite its side effect, profile including a high rate of blood transfusion early in the immediate postoperative period of CentriMag support, aggressive use of the CentriMag support device has acceptable survival to discharge and 1 year survival.

Pediatric ventricular assist device therapy for advanced heart failure-Hong Kong experience.

Ventricular assist devices (VADs) are life-saving options for children with heart failure unresponsive to medical therapy as a bridge to transplantation or cardiac recovery. We present a retrospective review of 13 consecutive children who underwent implantation of VAD between 2001 and 2018 in our center. The median age was 12years (1-17years), weight was 45kg (10-82kg). Etiologies of heart failure were dilated cardiomyopathy (CMP) (n = 8), myocarditis (n = 2), ischemic CMP (n = 1), restrictive CMP (n = 1) and congenital heart disease (n = 1). Pre-implantation ECMO was used in 5, mechanical ventilation in 4, renal replacement therapy in 2 and IABP in 1. Devices used were: Berlin Heart EXCOR left VAD (LVAD), biventricular VAD (BIVAD) (n = 5, 2), CentriMag LVAD, BIVAD (n = 1, 2), HeartWare (n = 2), HeartMate II (n = 1). Median duration of support was 45days (3-823days). Overall survival was 85%. Four patients were successfully bridged to transplantation, 2 died while on a device, 4 remain on support and 3 were weaned from VAD. Late death occurred in 2 transplanted patients. Complications included bleeding requiring reoperation in 1, neurologic events in 3, driveline infections and pericardial effusion in 2 each. In one patient, CentriMag BIVAD provided support for 235days, which is longest reported duration on such a VAD in the Asia Pacific region. Survival for pediatric patients of all ages is excellent using VADs. Given the severity of illness in these children morbidity and mortality is acceptable. VADs could potentially be used as a long-term bridge to transplantation in view of the donor shortage in the pediatric population.

A Challenging Case: Durable Biventricular Assist Device, Bleeding, Thrombosis, and a Hole

Introduction Cardiogenic shock requiring mechanical circulatory support as a bridge to recovery continues to pose challenges. For patients who are unable to be weaned off of temporary device support, durable assist devices are an option. Unfortunately, patients receiving durable biventricular ventricular assist devices (BiVADs) represent a critically ill population with high operative mortality and RVAD thrombosis rates. Case A 58 year-old male with hypertension underwent an elective laparoscopic hemicolectomy. Post-surgery, he developed chest pain. ECG showed an anterior STEMI and transthoracic echocardiogram revealed a new ejection fraction of 30% with anterolateral and lateral wall hypokinesis. Cardiac catheterization revealed a 100% occluded left anterior descending artery, which prompted percutaneous coronary intervention and intra-aortic balloon placement. Due to worsening hemodynamics, he required emergent central veno-arterial extracorporeal membrane oxygenation (VA ECMO) placement. Due to sustained ventricular fibrillation and biventricular dysfunction on VA ECMO, he underwent ECMO revision, with placement of temporary CentriMag BiVADs. After 60 days of inability to wean temporary biventricular support, durable Medtronic Heartware BiVADs were placed as bridge to transplant. One week after durable BiVAD placement, patient developed low flows on the RVAD and profound hypoxia. He was taken to operating room emergently, and was found to have RVAD thrombosis and an apical ventricular septal defect (VSD). The RVAD was replaced and the VSD was repaired. After 18-months on BiVAD support he had a successful orthotropic heart transplant and continues to do well post-transplant. Conclusion Our case demonstrates challenges associated with selecting appropriate mechanical circulatory support devices for adequate cardiovascular support and navigating potential device related complications. Frequent reassessment is necessary to impact positive outcomes in this critically ill patient population.

Role of paediatric assist device in bridge to transplant.

While heart transplantation has gained recognition as the gold standard therapy for advanced heart failure, the scarcity of donor organs has become an important concern. The evolution of surgical alternatives such as ventricular assist devices (VADs), allow for recovery of the myocardium and ensure patient survival until heart transplantation becomes possible. This report elaborates the role of VADs as a bridge to heart transplantation in infants and children (≤18 years old) with end-stage heart failure. A retrospective review of the medical records of 201 heart transplant recipients between May 1986 and September 2014 identified 78 children [38.8%; mean age 7.2 (7.8±6.0) years old; IQR: 2.6-11.8 years] with advanced heart failure who were supported with a VAD [left VAD (LVAD) =21; biventricular VAD (BVAD) =57] as a bridge to heart transplantation. Fourteen (17.9%) patients were less than 1 year old; 15 (19.2%) children had a cardiac arrest and underwent cardiopulmonary resuscitation, with 7 of these patients also requiring extracorporeal membrane oxygenation (ECMO) support prior to implantation of a VAD. The aetiology of heart failure was primarily cardiomyopathy (dilative, restrictive from endocardial fibrosis, idiopathic or toxic-induced), reported in 56 (71.8%) patients. The VADs employed were primarily Berlin Heart EXCOR® (n=63), HeartWare (n=13), Berlin Heart INCOR® (n=1), and Toyobo (n=1). Mean duration of VAD support was 59 (133.37±191.57) days (range, 1-945 days; IQR: 23-133 days) before a donor heart became available. The primary complication encountered while patients were being bridged to transplant was mediastinal bleeding (7.8%). The main indication for pump exchanges was thrombus formation in the valves. There was no incidence of technical failure of the blood pump or driving system components. Skin infections around the cannulae occurred in 2.5%. Adverse neurological symptoms (thromboembolism 11.1%, cerebral haemorrhage 3.6%) that occurred did not have any permanent neurological sequelae that could be detected on clinical examination in this study. Mean duration of follow-up was 9.4 (10.3±7.6) years (IQR: 3.74-15.14 years). Cumulative survival rates of patients bridged to transplantation with VAD were 93.6%±2.8%, 84.6%±4.1%, 79.1%±4.7%, 63.8%±6.2%, 61.6%±7.1%, and 52.1%±9.3% at 30 days, 1, 5, 10, 15 and 20 years, respectively. There was no statistically significant difference (P=0.79) in survival rates of patients bridged to heart transplantation with VAD compared to those who underwent primary heart transplantation. Post-transplant survival rates stratified according to the type of VAD implanted and number of ventricles supported were not statistically different (P=0.93 and 0.73, respectively). In addition, post-transplant survival rates were not significantly different when age, gender and diagnosis were adjusted for. Furthermore, no statistically significant difference was found when post-transplant survival rates of children who had episodes of rejection were compared to those who did not have episodes of rejection. The results in this series demonstrate that VADs satisfactorily support paediatric patients with advanced heart failure from a variety of aetiologies until heart transplantation. The data further suggests that patients bridged with VADs have comparable long-term post-transplant survival as those undergoing primary heart transplantation.

Temporary biventricular support with extracorporeal membrane oxygenation: a feasible therapeutic approach for cardiogenic shock with multiple organ failure.

Various strategies using a ventricular assist device (VAD) are applied to rescue Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (Profile-1) patients. However, the optimal use of VAD in Profile-1 patients has not been completely elucidated. We retrospectively reviewed 23 Profile-1 patients [mean age 36.9±16.6years, 14 males; 11 with non-ischemic cardiomyopathy (NICM), 9 with fulminant myocarditis (FM), 2 with ischemic cardiomyopathy (ICM), and 1 with peripartum cardiomyopathy (PPCM); 18 with pre-operative percutaneous extracorporeal membrane oxygenation (p-ECMO) support] who underwent VAD implantation from 2011 to 2015 at our institution. Nine initially received left VAD (LVAD) alone (NICM in 9, ICM in 2 with ICM, and FM in 1), one with NICM received biventricular VAD (BiVAD; n=1), and 10 received LVAD combined with right ventricular support using an ECMO circuit (BiVAD-ECMO) (FM in 8, NICM in 1, and PPCM in 1). Paracorporeal VAD was used in all patients. ECMO was used for the patients with severe pulmonary edema, inflammation, anemia, and thrombopenia. The BiVAD patient died 1.4months after VAD implantation. The overall survival was comparable between patients with BiVAD-ECMO and LVAD (2-year survival, 80.0 and 75.0%, respectively). Three VAD strategies were initially applied in Profile-1 patients. Among them, the BiVAD-ECMO strategy is a promising therapeutic option to rescue Profile-1 patients with multiple organ failure.

Role of Echocardiography in the Management of Patients with a Biventricular Ventricular Assist Device

Role of Echocardiography in the Management of Patients with a Biventricular Ventricular Assist Device

Does Small Size Matter With Continuous Flow Devices?: Analysis of the INTERMACS Database of Adults With BSA ≤1.5 m2

ObjectivesThis study investigated how small patient size affects clinical outcomes in patients implanted with a continuous flow left ventricular assist device (CFLVAD). BackgroundThe development of smaller CFLVADs has allowed ventricular assist device (VAD) use in anatomically smaller patients; however, limited outcome data exist regarding CFLVAD use in patients with a body surface area (BSA) ≤1.5 m2. MethodsAll CFLVAD patients entered in the Interagency Registry for Mechanically Assisted Circulatory Support registry April 2008 to September 2013 and with BSA data were included. Biventricular VAD patients were excluded. Patient characteristics and clinical outcomes were compared between patients with BSA ≤1.5 m2 (small patients) and those >1.5 m2. ResultsOf 10,813 CFLVAD recipients, 231 had a BSA ≤1.5 m2. Small patients were more commonly female patients (68% vs. 20%; p < 0.01), Hispanic (10% vs. 6%; p < 0.03), and on intravenous inotropes (88% vs. 80%; p < 0.01). Small patients had higher bleeding (p < 0.01) and driveline infection (p < 0.01) rates, while exhibiting lower rates of right heart failure (p < 0.01) and renal dysfunction (p < 0.01). Device malfunction rate (p > 0.05), overall survival (p > 0.05), and 1-year competing outcomes (p > 0.05) were similar between BSA groups. ConclusionsPatients with a BSA ≤1.5 m2 supported with a CFLVAD have similar survival to larger patients. These data support the use of CFLVAD in anatomically small patients.

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

Simulation of Ventricular, Cavo-Pulmonary, and Biventricular Ventricular Assist Devices in Failing Fontan.

Considering the lack of donors, ventricular assist devices (VADs) could be an alternative to heart transplantation for failing Fontan patients, in spite of the lack of experience and the complex anatomy and physiopathology of these patients. Considering the high number of variables that play an important role such as type of Fontan failure, type of VAD connection, and setting (right VAD [RVAD], left VAD [LVAD], or biventricular VAD [BIVAD]), a numerical model could be useful to support clinical decisions. The aim of this article is to develop and test a lumped parameter model of the cardiovascular system simulating and comparing the VAD effects on failing Fontan. Hemodynamic and echocardiographic data of 10 Fontan patients were used to simulate the baseline patients' condition using a dedicated lumped parameter model. Starting from the simulated baseline and for each patient, a systolic dysfunction, a diastolic dysfunction, and an increment of the pulmonary vascular resistance were simulated. Then, for each patient and for each pathology, the RVAD, LVAD, and BIVAD implantations were simulated. The model can reproduce patients' baseline well. In the case of systolic dysfunction, the LVAD unloads the single ventricle and increases the cardiac output (CO) (35%) and the arterial systemic pressure (Pas) (25%). With RVAD, a decrement of inferior vena cava pressure (Pvci) (39%) was observed with 34% increment of CO, but an increment of the single ventricle external work (SVEW). With the BIVAD, an increment of Pas (29%) and CO (37%) was observed. In the case of diastolic dysfunction, the LVAD increases CO (42%) and the RVAD decreases the Pvci, while both increase the SVEW. In the case of pulmonary vascular resistance increment, the highest CO (50%) and Pas (28%) increment is obtained with an RVAD with the highest decrement of Pvci (53%) and an increment of the SVEW but with the lowest VAD power consumption. The use of numerical models could be helpful in this innovative field to evaluate the effect of VAD implantation on Fontan patients to support patient and VAD type selection personalizing the assistance.