Concomitant Valve Procedures Research Articles

Medium-Term Outcomes of Concomitant Aortic Valve Repair in Patients with Continuous-Flow Left Ventricular Assist Device

Our objective was to analyze the development of aortic insufficiency in patients who received central aortic valve repair when undergoing continuous-flow left ventricular assist device implantation. We conducted a retrospective review of patients who underwent HeartMate II or 3 (Abbott Lab) implantation between 2004 and 2022. Ninety-four patients were excluded from analysis for history of aortic valve procedures, a bicuspid aortic valve, baseline trace aortic insufficiency, or other concomitant aortic valve procedure. Patients who had ≥ mild aortic insufficiency had concomitant aortic valve repair. Clinical characteristics, serial echocardiograms, and outcomes were determined. Of the 656 patients who underwent HeartMate II or 3 implantation, 105 patients (59 HeartMate II and 46 HeartMate 3) met study criteria. Median age was 68 years [60-74 years], 91.4% [n=96] were male, 54.4% [n=56] were white, and 68.6% [n=72] received support as destination therapy. Preoperative aortic insufficiency degree was 54.3% (n=57) mild, 23.8% (n=25) mild-to-moderate, 20.0% (n=21) moderate, 1.0% (n=1) moderate-to-severe, 1.0% (n=1) severe. In hospital mortality was 5.7% [n=6]. Freedom from ≥ moderate aortic insufficiency was 96.4% (95%CI: 92.5%-100%), 93.3% (95%CI: 87.6%-99.2%), and 91.0% (95%CI: 84.1%-98.5%) at 1-year, 2-year, and 3-year post-implantation, respectively. One HeartMate II patient experienced severe aortic insufficiency and was treated with a heart transplant. Three-year survival was 63.4% [95%CI: 52.9%-75.9%]. Central aortic valve repair may be an effective technique to mitigate aortic insufficiency in HeartMate II and 3. A larger cohort study with longer duration of follow up is warranted to further investigate the clinical impact.

(590) - Outcome of Left Ventricular Assist Device Implantation with Concomitant Aortic Valve Procedure

(590) - Outcome of Left Ventricular Assist Device Implantation with Concomitant Aortic Valve Procedure

Coronary artery bypass grafting in octogenarians: an Australian experience.

The aims of this study were to describe early and mid-term morbidity and mortality in octogenarian patients undergoing CABG, to determine if outcomes are comparable to younger patients undergoing the same procedure. We conducted a retrospective analysis of the first 901 patients who underwent cardiac surgery at a large newly established tertiary hospital in Western Australia from February 2015 to September 2019. Inclusion criteria involved all patients undergoing coronary artery bypass grafting. Exclusion criteria included patients who underwent concomitant valve or aortic procedure. From a cohort of 901 patients, 37 octogenarian patients underwent CABG. Octogenarian patients had a higher rate of post-operative transfusion 35.1% versus 21.4% (P = 0.048), a higher rate of post-op acute kidney injury 40.5% versus 17.2% (P < 0.0001), a higher rate of post-operative atrial arrythmia requiring treatment 40.5% versus 22.5% (P = 0.011) and higher rate of return to theatre (13.5% versus 4.7%, P = 0.018), with bleeding/tamponade being the most likely reason (10.8% versus 2.7%). Octogenarian patients had a longer post-operative length of stay (LOS) with a median LOS of 10 versus 7 days (P < 0.0001). There was no increase in hospital readmission rate, in-hospital mortality or 1 year mortality in octogenarian patients. 24-month and 36-month survivals were 95.2% and 89.6% in octogenarians and 95.3% and 91.5% in the younger group. Despite an increase in post-operative morbidity and LOS, there was no difference in hospital readmission, in-hospital mortality or 1 year mortality in octogenarian patients who underwent CABG. CABG is safe and remains an important management option for these patients.

Abstract 15376: Candidacy and Fate of Right Heart Failure Patients Undergoing Tricuspid Valve Surgery

Objective: There are no current guidelines for risks and benefits of cardiac surgery for patients with right heart failure (RHF). In this study, we analyzed pre-operative RHF variables aiming to assess candidacy for surgery and impact of tricuspid intervention. Methods: We retrospectively identified 522 patients with severe (+3 or more) tricuspid regurgitation (TR) who underwent cardiac surgery between 01/2007 and 01/2014 . The mean follow up was 4.7 years (± 4.3 years). Cluster analysis was performed using preoperative RHF clinical and hemodynamics variables, and outcomes after surgery were assessed. Results: Cluster analysis divided the cohort into three distinct clusters representing different phenotypes of patients with RHF-associated TR (cluster 1: 220 patient, cluster 2: 224 patients, cluster 3: 78 patients). Cluster I had highest concomitant left-sided valve procedure (72% mitral valve surgery, p&lt;.0001) with best RV function (fractional area change % 35 ± 13, p=.0002). Cluster II had highest MELD score (14 ± 4, p&lt;.0001), creatinine (1.4 ± 0.6, p&lt;.0001), and worst RV function (fractional area change % 30 ± 12, p=.0002). Cluster III had the most dilated right heart with right atrial area of 42 ± 14 mm, p&lt;.0001 and RV area in diastole 42 ± 10 mm, p&lt;.0001. Survival was best in Cluster I followed by Cluster III while worst in Cluster II (70%, 59%, and 29% at 8-years, respectively), Figure 1. Recurrent TR was highest in Cluster III, followed by Cluster II while least in Cluster I at 10-years (9%, 8%, and 5%, respectively). Conclusions: Cluster analysis of RHF identified three distinct groups of patients presenting for cardiac surgery. Pre-operative RV dysfunction was associated with worse clinical outcomes and need careful assessment before surgery. Pre-operative right heart dilation was associated with recurrent TR for which more aggressive tricuspid repair or even replacement might be considered.

Outcomes of concomitant aortic valve procedures and left ventricular assist device implantation: A systematic review and meta-analysis.

Left ventricular assist device (LVAD) implantation is frequently employed in patients with end-stage heart failure. The outcomes of addressing the repair of all substantial aortic valvular disease at the time of LVAD implantation remain unclear. We sought to assess the clinical outcomes in patients undergoing LVAD implantation concomitant with aortic valve procedures (AVPs) compared with isolated LVAD implantation. A literature search was performed using PubMed, Embase, and Cochrane library from inception till June 2022. Primary outcomes included short-term mortality and long-term survival. Random effects models were used to compute mean differences and odds ratios with 95% confidence intervals (CIs). A total of 14 observational studies (N=52 693) met our inclusion criteria. Concomitant LVAD implantation and AVPs were associated with higher short-term mortality (OR=1.61 [95% CI, 1.06-2.42]; p=0.02) and mean CPBt (MD=43.25 [95% CI, 22.95-63.56]; p < 0.0001), and reduced long-term survival (OR=0.70 [95% CI, 0.55-0.88]; p=0.003) compared with isolated LVAD implantation. No difference in the odds of cerebrovascular accident (OR=1.05 [95% CI, 0.79-1.39]; p=0.74) and mean length of hospital stay (MD=2.89 [95% CI, -4.04 to 9.82]; p=0.41) was observed between the two groups. On adjusted analysis, short-term mortality was significantly higher in the LVAD group with concurrent AVPs when compared with the isolated LVAD group (aHR=1.50 [95% CI, 1.20-1.87]; p=0.0004). Concurrent AVPs were associated with higher short-term mortality and reduced long-term survival in patients undergoing LVAD implantation compared with isolated LVAD implantation.

Abstract 14886: Utilization Patterns and Outcomes of Home Health Care After Coronary Artery Bypass Grafting

Introduction: Home health care (HHC) use after discharge may improve short-term outcomes and reduce expenditures for patients undergoing coronary artery bypass grafting (CABG), but there is limited data describing utilization patterns of HHC and its association with longer-term outcomes. Thus, we investigated the utilization patterns of HHC and its impact on 1-year outcomes among Medicare beneficiaries who underwent CABG. Methods: Medicare beneficiaries undergoing CABG between July 2016 and December 2018 were identified using 100% Medicare files. Beneficiaries were excluded if they were &lt;65 years old, died during the inpatient stay, or used inpatient post-acute care before or after the index procedure. Use of HHC (yes versus no) was defined as the presence of a home health claim within 0-1 days of discharge. Clinical outcomes included 1-year mortality and all-cause readmission. We created a matched sample using a multivariable probit regression model (1:1) and balanced HHC users to non-users by demographic, clinical, and hospital factors to compare clinical outcomes. Results: Among the 91,166 beneficiaries in our sample, 54,169 (59.4%) used HHC after discharge, and were more likely to be older, female, White, have dual-eligibility status, comorbid, have had a non-elective, a concomitant valve procedure, and longer hospital length of stay. With respect to hospital characteristics, HHC users were more likely to be admitted to hospitals that were major teaching, larger bed size, not-for-profit, and not system-affiliated. Use of HHC varied from 0% to 100% across 976 hospitals, with a median of 66.2% (IQR=44.2%). After matching and adjustment for covariates, there was no significant difference in 1-year mortality among HHC users and non-users (2.2% vs. 2.5%, -0.3%, p=0.029), although 1-year readmission rates were 7.9 percentage points higher (29.4% vs. 21.5%, p&lt;0.001) for HHC users vs. non-users. Conclusions: Over half of Medicare beneficiaries undergoing CABG used HHC after discharge, with significant differences across patients and hospitals and mixed impact on clinical outcomes. While unmeasured severity may account for some of our findings, more research is needed to understand utilization patterns and impact of HHC after CABG.

Successful aortic root enlargement procedure in low resource setting: Two rare cases.

BackgroundSmall aortic root is an unexpected incident during surgical aortic valve replacement in which the prosthesis valve size does not match the case being treated.Case presentationTwo patient-prosthesis mismatches with aortic valve problems underwent surgical aortic valve replacement. Based on calculating the body surface area (BSA) and effective orifice area (iEOA), the selection of prosthesis valve size was determined. When minor aortic root surgery was performed, it was discovered that the procedure of aortic root enlargement had to be conducted. The surgery went smoothly, but both patients had different outputs. The first patient was dead, while the second patient had a better quality of life.DiscussionEvery surgical aortic valve replacement preparation of aortic root enlargement procedure needs to be prepared for the worst-case scenario.ConclusionAortic root enlargement procedure must be anticipated in aortic valve replacement, especially for the patients with small aortic roots, both isolated and with concomitant valve procedure.

Surgical outcomes of pulmonary valve infective endocarditis: A US population-based analysis

BackgroundPulmonary valve infective endocarditis (PVIE) represents a rare subset of right-sided IE. This study aimed to evaluate the population-level surgical outcomes of PVIE in the United States. MethodsWe performed a retrospective observational study using the 2002–2017 National Inpatient Sample database. We included hospitalizations with both IE and PV interventions. We excluded Tetralogy of Fallot, congenital PV malformation, and those who underwent the Ross procedure. The primary outcome was in-hospital mortality. The secondary outcomes included major complications and length of hospital stay. ResultsWe identified 677 PVIE hospitalizations that underwent surgical treatment, accounting for 0.06% of all IE hospitalizations. The mean age was 35.2 ± 1.7 years; 60.0% were White, 30.3% were women, and 11.4% were intravenous drug users. Most were treated in large-sized (70.1%) urban teaching (88.8%) hospitals. Close to 30% of patients received at least one concomitant valve procedure. The in-hospital mortality was 5.5% for the entire cohort, and the median length of stay was 16 days. Major complications included complete heart block (8.7%), acute kidney injury (8.1%), and stroke (1.3%). The differences in mortality and complications rate comparing PV repair and replacement were not statistically significant. PV repair was associated with a longer length of hospital stay compared to PV replacement (median: 25 vs. 16 days, p = 0.03). ConclusionsThis study defines the population-level in-hospital outcomes after surgical intervention of PVIE. Surgically treated PVIE patients are associated with relatively low mortality and morbidities. The outcomes between PV replacement and repair are similar.

The value of perioperative biomarker release for the assessment of myocardial injury or infarction in cardiac surgery

Abstract OBJECTIVES Cardiac biomarkers are indicators of irreversible cell damage. Current myocardial infarction (MI) definitions require concomitant clinical characteristics. For perioperative MI, a correlation of biomarker elevations and mortality has been suggested. Definitions emerged relying on cardiac biomarker release only. This approach is questionable as several clinical and experimental scenarios exist where relevant biomarker release can occur apart from MI. METHODS We reviewed the clinical and basic science literature and revealed important aspects regarding the use and interpretation of cardiac biomarker release with special focus on their interpretation in the perioperative setting. RESULTS Ischaemic biomarkers may be released without cell death in multiple conditions, such as after endurance runs in athletes, temporary inotropic stimulation in animal models and flow variations in in vitro cell models. In addition, access through atrial tissue during cannulation or concomitant valve procedures adds sources of enzyme release that may not be related to ventricular ischaemia (i.e. MI). Such non-cell death-related mechanisms may explain the lack of poor correlations of enzyme release and long-term outcomes in recent trials. In addition, the 3 main biomarkers, troponin T, I and creatine kinase myocardial band, differ in their release kinetics, which may differentially trigger MI events in trial patients. CONCLUSIONS The identification of irreversible myocardial injury in cardiac surgery based only on biomarker release is unreliable. Cell death- and non-cell death-related mechanisms create a mix in the perioperative setting that requires additional markers for proper identification of MI. In addition, the 3 most common ischaemic biomarkers display different release kinetics adding to the confusion. We review the topic.

Long-term outcomes of atrioventricular septal defect and single ventricle: A multicenter study

ObjectiveThe study objective was to analyze survival and incidence of Fontan completion of patients with single-ventricle and concomitant unbalanced atrioventricular septal defect. MethodsData from 4 Dutch and 3 Belgian institutional databases were retrospectively collected. A total of 151 patients with single-ventricle atrioventricular septal defect were selected; 36 patients underwent an atrioventricular valve procedure (valve surgery group). End points were survival, incidence of Fontan completion, and freedom from atrioventricular valve reoperation. ResultsMedian follow-up was 13.4 years. Cumulative survival was 71.2%, 70%, and 68.5% at 10, 15, and 20 years, respectively. An atrioventricular valve procedure was not a risk factor for mortality. Patients with moderate-severe or severe atrioventricular valve regurgitation at echocardiographic follow-up had a significantly worse 15-year survival (58.3%) compared with patients with no or mild regurgitation (89.2%) and patients with moderate regurgitation (88.6%) (P = .033). Cumulative incidence of Fontan completion was 56.5%, 71%, and 77.6% at 5, 10, and 15 years, respectively. An atrioventricular valve procedure was not associated with the incidence of Fontan completion. In the valve surgery group, freedom from atrioventricular valve reoperation was 85.7% at 1 year and 52.6% at 5 years. ConclusionsThe long-term survival and incidence of Fontan completion in our study were better than previously described for patients with single-ventricle atrioventricular septal defect. A concomitant atrioventricular valve procedure did not increase the mortality rate or decrease the incidence of Fontan completion, whereas patients with moderate-severe or severe valve regurgitation at follow-up had a worse survival. Therefore, in patients with single-ventricle atrioventricular septal defect when atrioventricular valve regurgitation exceeds a moderate degree, the atrioventricular valve should be repaired.

Clinical outcomes of radial artery as the second arterial conduit in coronary artery bypass

Objective: To examine the clinical experience and outcomes of coronary artery bypass grafting (CABG) using radial artery as the second arterial graft. Methods: Totally 585 patients in whom both left internal thoracic artery and radial artery as arterial conduits were used in CABG in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University from April 2008 to August 2019 were consecutively enrolled. There were 436 males and 149 females, aging (63±10) years (range: 36 to 86 years). There were 40.7% (238/585) of patients had diabetes and 75.6% (442/585) of them had multivessel disease (two-vessel or three-vessel diseases). From January 2017, transit time flow measurement was performed on every patient. Demographic and perioperative data were retrospectively collected, as well as follow-up data for patients who underwent CABG from January 2014 to August 2019. Analysis were made on their early and late outcomes. Results: 81.9%(479/585) Most patients in this cohort (81.9%) received on-pump CABG and 11 patients had intraoperative intro-aortic balloon counterpulsation (prior to CABG) support. Forty-three patients had concomitant valve procedures. The number of distal anastomosis was 3.6±0.9 (range: 2 to 6) and number of arterial distal anastomosis was 2.1±0.3. Radial artery was anastomosed to left obtuse marginal artery in 95.8% (560/585) patients. All target vessels for radial artery conduit had significant proximal stenosis (>70%) and 72.5% (424/585) of target vessels had proximal stenosis which was >90%. Intraoperative transit-time flow measurement of 151 cases showed that radial artery conduits had a flow of (29.8±10.2) ml/minutes (range: 10 to 150 ml/min), and pulsatility index of 2.5±1.4 (range: 0.7 to 5.0). There was no operative death. Two in-hospital death occurred more than 30 days after index surgery. There was no perioperative myocardial infarction. There were 188 patients who received CABG from January 2014 to August 2019 followed-up for a median duration of 3.2 years. There were two noncardiac death. No patient had myocardial infarction or to receive myocardial revascularization. Conclusions: Radial artery as the second arterial conduit is a safe and effective strategy for CABG. Good selection of target vessel and intraoperative transit-time flow measurement may help achieve good patency, as well as the short and mid-term outcome.

Survival following a concomitant aortic valve procedure during left ventricular assist device surgery: an ISHLT Mechanically Assisted Circulatory Support (IMACS) Registry analysis.

AimsThe aim of this study was to compare early‐ and late‐term survival and causes of death between patients with and without a concomitant aortic valve (AoV) procedure during continuous‐flow left ventricular assist device (LVAD) surgery.Methods and resultsAll adult primary continuous‐flow LVAD patients on the International Society of Heart and Lung Transplantation (ISHLT) Mechanically Assisted Circulatory Support (IMACS) Registry (n = 15 267) were included in this analysis and stratified into patients submitted to a concomitant AoV procedure (AoV replacement or AoV repair) and patients without an AoV procedure. The primary outcome was early (≤90 days) survival post‐LVAD surgery. Secondary outcomes were late survival (survival during the entire follow‐up period) and conditional survival (in patients who survived the first 90 days post‐LVAD surgery), and determinants. Patients who underwent concomitant AoV replacement (n = 457) had significantly reduced late survival compared with patients with AoV repair (n = 328) or without an AoV procedure (n = 14 482) (56% vs. 61% and 62%, respectively; P = 0.001). After adjustment for other significant predictors, concomitant AoV replacement remained an independent predictor for early [hazard ratio (HR) 1.226, 95% confidence interval (CI) 1.037–1.449] and late (HR 1.477, 95% CI 1.154–1.890) mortality. However, patients undergoing AoV replacement or repair, in whom the presence of moderate‐to‐severe AoV regurgitation was diagnosed prior to LVAD implantation, had survival similar to patients not undergoing AoV interventions.ConclusionsConcomitant AoV surgery in patients undergoing LVAD implantation is an independent predictor of mortality. Additional research is needed to determine the best AoV surgical strategy at the time of LVAD surgery.

The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation

ObjectiveThe study objective was to investigate the progression of uncorrected mild aortic insufficiency and its impact on survival and functional status after left ventricular assist device implantation. MethodsWe retrospectively reviewed 694 consecutive patients who underwent implantation of a continuous-flow left ventricular assist device between January 2006 and March 2018. Pre–left ventricular assist device transthoracic echocardiography identified 111 patients with mild aortic insufficiency and 493 patients with trace or no aortic insufficiency. To adjust for differences in preoperative factors, propensity score matching was used, resulting in 101 matched patients in each of the mild aortic insufficiency and no aortic insufficiency groups. ResultsAlthough both groups showed similar survival (P = .58), the mild aortic insufficiency group experienced higher incidence of readmission caused by heart failure (hazard ratio, 2.62; 95% confidence interval, 1.42-4.69; P < .01). By using the mixed effect model, pre–left ventricular assist device mild aortic insufficiency was a significant risk factor for both moderate or greater aortic insufficiency and worsening New York Heart Association functional status (P < .01). ConclusionsPatients with uncorrected mild aortic insufficiency had a higher risk of progression to moderate or greater aortic insufficiency after left ventricular assist device implantation with worse functional status and higher incidence of readmission caused by heart failure compared with patients without aortic insufficiency. Further investigations into the safety and efficacy of concomitant aortic valve procedures for mild aortic insufficiency at the time of left ventricular assist device implant are warranted to improve patients' quality of life, considering the longer left ventricular assist device use as destination therapy and bridge to transplant with the new US heart allocation system.

Thoracic Aortic Aneurysm Surgery in Marfan Patients: a Perspective from the UK.

ObjectiveCardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes.MethodsA total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival.ResultsRoot and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%.ConclusionThe outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.

Short Term Outcomes of Coronary Artery Bypass Grafting and Concomitant Valve Procedure: A Retrospective Review

Short Term Outcomes of Coronary Artery Bypass Grafting and Concomitant Valve Procedure: A Retrospective Review

Pulmonary artery aneurysms: Preoperative, intraoperative, and postoperative findings.

Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution. We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017. The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22-26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross-clamp times were 108.5 and 65 minutes. Operative and 30-day mortality was 0%. Average length of stay was 10.5 days. Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Impact of Concomitant Valve Surgery at the Time of HeartMate II Implantation; Japanese Multicenter Study

Purpose Although preexisting valve pathology is prevalent in patients with end-stage heart failure, the impact of concomitant valve surgery with the left ventricular assist device (LVAD) implantation has not been fully described. We aimed to review the clinical outcomes of concurrent valve surgery with HeartMate II (HM II) implantation using Japanese national database. Methods The total of 410 patients (mean age, 44 years, 76% male) underwent HM II implantation as a bridge to transplantation between April 2013 and November 2017 at 30 Japanese centers. Of these, 121 patients (30%) underwent concomitant valve surgery (only Aortic 7, only Mitral 17, only Tricuspid 82, A+T 2, M+T 13) with HM II implantation and 137 patients (33%) received HM II implantation alone. Patients who had undergone prior cardiac surgery (LVAD implantation (n=110), valve surgery (n=34), others (n=6)) and 2 patients who underwent aortic surgery with LVAD implantation were excluded. Results The mean follow-up period was 620 days. Patients undergoing concomitant valve surgery had significantly higher right atrial pressure, pulmonary capillary wedge pressure, mean pulmonary artery pressure, and lower albumin levels. Concomitant valve procedures resulted in significantly longer cardiopulmonary bypass time (155 min vs 106 min) and operation time (488 min vs 382 min) compared to HM II implantation alone. Although patients requiring concomitant valve surgery seemed to be sicker, there was no significant difference in long-term survival and freedom from right heart failure (RHF), stroke, and gastrointestinal bleeding between the 2 groups. Additionally, there were no significant difference in survival and freedom from RHF between HM II alone and each kind of valve operation cohorts. Multivariate analysis revealed that right ventricular stroke work index and longer operation time were the predictors of postoperative RHF. Conclusion Concomitant valve surgery with HM II implantation was performed with considerable frequency in Japan. Clinical outcomes of concurrent valve surgery with HM II implantation were comparable to HM II alone despite sicker patient background. Further studies are needed to determine optimized concomitant valve surgery with HM II implantation.

Concurrent Mitral Valve Repair during Placement of Continuous-Flow Left Ventricular Assist Device

Purpose Pre-existing mitral valve pathology is common in patients undergoing continuous-flow left ventricular assist device (LVAD) implantation. Best management of pre-existingmitral valve disease remains controversial. Methods Between March 2004 and December 2017, a total of 594 patients received a continuous-flow left ventricular assist device. Of these, a total of 93 patients (16%) underwent a concurrent mitral valve repair, either with an Alfieri stitch via the left ventricular (LV) apex coring site (n =30, 32%) or with an annuloplasty ring via a left atriotomy (n = 63, 68%). Outcomes were compared between patients who received an Alfieri stitch and those who received an annuloplasty ring repair. Results All patients had moderate or greater mitral regurgitation at the time of LVAD implantation. Median age was 54 years (interquartile range [IQR], 43-74) in the annuloplasty cohort, and 56 years (interquartile range [IQR], 44-79) in the Alfieri stitch group. A proportionately greater number of women underwent Alfieri stitch repair (n = 6, 20%) compared to ring annuloplasty (n = 5, 8%; p = 0.01). Additionally, a greater number of patients in the Alfieri group underwent a concomitant valve intervention such as a Park stitch or tricuspid repair (n = 15, or 50%) compared to those patients undergoing a ring annuloplasty (n = 28, 44%; p = 0.04). Cardiopulmonary bypass times were shorter on average in the Alfieri patients, independent of concomitant valve procedure (111 minutes versus 134 minutes, p = .02). Thirty-day survival in the Alfieri group (n = 27, 90%) was similar to that of the ring annuloplasty group (n = 57, 91%); p > 0.05. However, in the 84 patients for whom data was available, 1-year survival was higher in the Alfieri group compared to the ring annuloplasty group (26.3% versus 18.6%, p = 0.032). Conclusion Concomitant mitral valve intervention is fairly common in patients undergoing continuous-flow LVAD placement. Our findings suggest that short-term outcomes are not impacted by type of mitral valve repair technique, but mitral valve repair via the LV apex coring site may be a favorable approach.

Is it Possible to Implant and Manage Patients with Durable LVADs Who Refuse Blood Products?

Purpose Bloodless left ventricular assist device (LVAD) implantation is rarely performed in patients who refuse blood products under all circumstance including death. The aim of this study is to investigate a single center's experience with these patients regarding LVAD implantation and long term management. Methods This is a retrospective review from a single center academic institution of all patients who refused blood products and received LVADs from 2012 to 2018. Demographics, readmissions, length-of-stay, hemoglobin, INR, distance traveled for therapy, adverse events and overall survival were investigated. Results Total patients N=18. Blood products administered 0. Demographics: 10 (55%) male; age 59+/-11; 76% African American; 82% Intermacs 1-2; miles traveled for therapy 408+/- 366. Operative: devices HVAD 72%, HM2 28%; reoperation sternotomy 33%; concomitant valve procedures 88%; length of stay 22 +/-12 days. Early and late adverse events see table 1. Survival: 30 days 100%, 1 year 88%, 2 year 72%, mean duration of support 2.3 years. Conclusion This study showed that LVADs can be implanted and managed successfully in patients who refuse blood products with severe cardiogenic shock and high surgical complexity. Both short term and long term management is feasible. Refusal of blood products is not a contraindication for LVAD implantation. Bloodless left ventricular assist device (LVAD) implantation is rarely performed in patients who refuse blood products under all circumstance including death. The aim of this study is to investigate a single center's experience with these patients regarding LVAD implantation and long term management. This is a retrospective review from a single center academic institution of all patients who refused blood products and received LVADs from 2012 to 2018. Demographics, readmissions, length-of-stay, hemoglobin, INR, distance traveled for therapy, adverse events and overall survival were investigated. Total patients N=18. Blood products administered 0. Demographics: 10 (55%) male; age 59+/-11; 76% African American; 82% Intermacs 1-2; miles traveled for therapy 408+/- 366. Operative: devices HVAD 72%, HM2 28%; reoperation sternotomy 33%; concomitant valve procedures 88%; length of stay 22 +/-12 days. Early and late adverse events see table 1. Survival: 30 days 100%, 1 year 88%, 2 year 72%, mean duration of support 2.3 years. This study showed that LVADs can be implanted and managed successfully in patients who refuse blood products with severe cardiogenic shock and high surgical complexity. Both short term and long term management is feasible. Refusal of blood products is not a contraindication for LVAD implantation.

Concomitant valve procedures in patients undergoing continuous-flow left ventricular assist device implantation: A single-center experience

ObjectiveLong-term support with continuous-flow left ventricular assist devices (CF-LVADs) has improved the outcomes of patients with end-stage heart failure. However, valve disease management in patients who undergo CF-LVAD implantation remains controversial. The aim of this study was to assess our single-center experience with patients who underwent a concomitant valve procedure during implantation of a CF-LVAD. MethodsFrom November 2003 through March 2016, 526 patients underwent primary CF-LVAD implantation with a HeartMate II (St Jude Inc, St Paul, Minn; n = 403) or HeartWare (Medtronic, Minneapolis, Minn; n = 123) device at our center. Of those, 91 underwent a concomitant valve procedure during implantation (CF-LVAD+valve procedure group), whereas 435 did not (CF-LVAD–only group). We compared preoperative characteristics and short-term and mid-term survival rates between these groups. ResultsThe concomitant valve procedures performed included 13 tricuspid valve repairs, 19 aortic valve repairs or replacements, 30 mitral valve repairs or replacements, and 29 double valve repairs or replacements. Survival rates at 1 month, 6 months, 12 months, and 24 months were 90.3%, 81.4%, 74.9%, and 67.4%, respectively, for the CF-LVAD–only group and 89.0%, 75.8%, 70.3%, and 65.9%, respectively, for the CF-LVAD+valve procedure group (P = .55). The results of Cox regression multivariable modeling showed that performing a concomitant valve procedure was not an independent predictor of mortality (hazard ratio, 1.29; 95% confidence interval, 0.96-1.74; P = .08). ConclusionsIn our experience, performing a concomitant valve procedure during CF-LVAD implantation was not associated with an increased mortality rate. The decision to perform a concomitant valve procedure should be made primarily on the basis of clinical indications for the procedure.