Durable Left Ventricular Assist Device Implantation Research Articles

Impact of concomitant aortic valve replacement in patients with mild-to-moderate aortic valve regurgitation undergoing left ventricular assist device implantation: EUROMACS analysis.

Left ventricular assist device (LVAD) therapy may lead to an aortic regurgitation, limiting left ventricular unloading and causing adverse events. Whether concomitant aortic valve replacement may improve outcomes in patients with preoperative mild-to-moderate aortic regurgitation remains unclear. A retrospective propensity score-matched analysis of adult patients with preoperative mild-to-moderate aortic regurgitation undergoing durable LVAD implantation between 01/01/2011 and 30/11/2021 was performed. Patients undergoing concomitant valve surgery other than biological aortic valve replacement were excluded, resulting in 77 with concomitant biological aortic valve replacement and 385 without. Following 1:1 propensity score matching, two groups of 55 patients with and without biological aortic valve replacement were obtained, (mean age 59 ± 11 years, 92% male, 59.1% HeartWare). Aortic regurgitation was mild in 72.7% and 76.4% and moderate in 27.3% and 23.6% in non-replacement and replacement cohorts respectively. The 30-day survival was 89.1% vs. 85.5% (p = 0.59), 1-year survival 69.1% vs. 56.4% (p = 0.19), and 2-year survival 61.8% vs. 47.3% (p = 0.10) in the non-replacement and replacement groups, respectively. After a mean follow-up of 1.2 years, non-replacement patients had a higher incidence of pump thrombosis (11 [20%] vs. 3 [5.5%], p = 0.022) and fewer major bleedings (2 [3.6%] vs. 11 [20%], p = 0.008). Compared with those treated conservatively, patients with mild-to-moderate aortic regurgitation undergoing concomitant aortic valve replacement during LVAD implantation have a similar survival up to 2 years on support. Patients with concomitant valve replacement had a higher risk of bleeding complications but fewer pump thromboses.

Abstract 4127071: Pulmonary Artery Catheter Utilization in Cardiogenic Shock: Clinical Characteristics and Outcomes

Background: The pulmonary artery catheter (PAC) is used for hemodynamic monitoring, but its impact on patient outcomes, especially in cardiogenic shock (CS), is controversial. Several studies have shown no significant benefits and noted complications, leading to a decline in PAC use. However, PAC use appears to have increased recently in guiding management decisions in CS. Our study aims to assess the clinical characteristics and outcomes of CS patients receiving PACs versus not. Methods: We included patients with CS admitted to a tertiary academic medical center between May 2015 and December 2023. Variables were compared using Kruskal-Wallis, chi-squared, and Fisher's exact tests. Hemodynamic parameters were collected from either right heart catheterization or from a PAC. Endpoints included native heart survival to discharge, durable left ventricular assist device (LVAD) implantation, heart transplant (HTx), and 30-day and 1-year survival from discharge. Results: The study group consisted of 742 patients with CS. Of these, 385 (52%) received a PAC and 357 (48%) did not. The baseline characteristics of the two groups are shown in Table 1A . PAC patients had more severe shock, worse hemodynamics, and higher rates of temporary mechanical circulatory support (MCS) use. Hemodynamic measurements at shock onset differed, with PAC patients having higher right atrial pressures and lower cardiac index by Fick. Clinical outcomes and MCS related complications are shown in Table 1B. There was no significant difference in native heart survival at discharge, but HTx and durable LVAD implantation was higher in the PAC group. PAC placement was associated with longer hospital stays and more MCS related complications, including bleeding and hemolysis. The 30-day survival rate was similar between groups, and 1-year survival was marginally higher in the PAC group. Conclusion: PAC patients exhibited more severe clinical characteristics, longer hospital stays, higher rates of temporary MCS use and complications, durable LVAD implantation, and HTx. Short-term survival rates were similar, but 1-year survival was slightly better for PAC patients. Further studies are needed to provide clearer insights into PAC use in CS.

Impella as Bridge to Durable Left Ventricular Assist Device in Acute Myocardial Infarction Cardiogenic Shock Patients.

Implantation of durable left ventricular assist device (LVAD) in cardiogenic shock (CS) patients after acute myocardial infarction (AMI) poses specific challenges (small left ventricular size, acute infarct area, need for antithrombotic therapy, status Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 with impaired organ function and derangements in coagulation and inflammatory parameters) which may affect outcomes. We reviewed data of all AMI-CS patients who were implanted LVAD after Impella support at a referral center with the aim to analyze feasibility, timing, and outcomes of durable LVAD implantation after tMCS with Impella due to AMI-CS. Twenty-one patients were treated between 2013 and 2023: all were in Society for Cardiovascular Angiography & Interventions (SCAI) class D-E and INTERMACS 1-2 at presentation, median LV ejection fraction (EF) and LV end-diastolic diameter (EDD) were 15 (10-20)% and 57 (54-60) mm, respectively. Eleven patients (52%) were supported with Impella CP, seven with Impella 5.0 (33%), and three (14%) with Impella 2.5. Axillary cannulation was performed in nine patients (43%). Five patients (24%) had concomitant venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Median duration of Impella support was 12 (8-14) days. Overall, the use of Impella was characterized by low rate of complications and allowed successful bridge to durable LVAD in all patients, with 100% 30 day survival rate.

Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival.

Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 ( p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.

Early Ventricular Arrhythmias After Left Ventricular Assist Device Implantation

BackgroundAlthough sustained ventricular arrhythmias (VAs) are a common complication after durable left ventricular assist device (LVAD) implantation, the incidence, risk factors, and prognostic implications of postoperative early VAs (EVAs) in contemporary patients with LVAD are poorly understood. Methods and ResultsA single-center retrospective analysis was performed of patients who underwent LVAD implantation from October 1, 2006, to October 1, 2022. EVA was defined as an episode of sustained VA identified ≤30 days after LVAD implantation. A total of 789 patients underwent LVAD implantation (mean age 62.9 ± 0. years 5, HeartMate 3 41.4%, destination therapy 43.3%). EVAs occurred in 100 patients (12.7%). A history of end-stage renal disease (odds ratio [OR] 5.6, 95% confidence interval [CI] 1.45–21.70), preoperative electrical storm (OR 2.82, 95% CI 1.11–7.16), and appropriate implantable cardiac defibrillator therapy before implantation (OR 2.8, 95% CI 1.26–6.19) are independently associated with EVAs. EVA was associated with decreased 30-day survival (hazard ratio 3.02, 95% CI 1.1–8.3, P = .032). There was no difference in transplant-free survival time between patients with and without EVAs (hazard ratio 0.82, 95% CI 0.5–1.4, P = .454). ConclusionsEVAs are common after durable LVAD implantation and are associated with an increased risk of 30-day mortality.

Abstract 13334: Safety of Chest Compressions in Patients With a Durable Left Ventricular Assist Device

Introduction: The safety of chest compressions (CC) during cardiopulmonary resuscitation (CPR) among pts with a durable left ventricular assist device (LVAD) is an area of controversy. Concerns regarding device malfunction or dislodgment with CC may result in significant delays or the withholding of life-sustaining intervention entirely. Current societal guidelines, based on small case reports, suggest that manual CC are probably not harmful, but offer no additional guidance. Furthermore, they acknowledge that there are no data regarding the use of machine-assisted CC. Methods: We retrospectively reviewed medical records of consecutive pts who underwent durable LVAD implantation at Duke University from 2013-2022. Charts were searched for “code”, “arrest”, “compressions”, and “rapid response team” to identify all instances of cardiac arrest (CA). Baseline pt characteristics, details of the arrest (including CC details), in-hospital care processes, and pt outcomes were abstracted. Results: Of 750 pts reviewed, 58 (mean age 64 years, 76% male, median LVAD support duration 19 months) had documented CA. Fifteen (26%) pts presented with an out-of-hospital CA. Twenty-four (41%) pts did not receive CC. The most commonly reported reason for avoiding CC was “LVAD in place - contraindicated.” The CPR duration was longer among those who received CC (median 30mins, range: 1-120 mins) than those who did not (median 20 mins, range: 2-79 mins). Two pts had support from a Lund University Cardiac Assist System (LUCAS) device. Among those who survived either manual and machine-assisted CC, 27% had a post-arrest TTE and none showed evidence of LVAD malfunction/dislodgment. Conclusions: Among pts with a durable LVAD who underwent CPR for CA we found no evidence of device dislodgment or safety concerns associated with either manual or LUCAS-assisted CPR. Future multicenter and prospective evaluation is necessary to both confirm these findings and to inform the guidelines.

Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation

This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. Single-center retrospective observational cohort study. The University of Kansas Medical Center, a tertiary-care academic medical center. Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n=20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p=0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.

Surgical Explantation of Impella 5.5 With Inflow Thrombus in Patients Undergoing Durable Left Ventricular Assist Device Implantation.

The Impella 5.5® (Abiomed, Danvers, MA, USA) is a microaxial flow pump that promotes left ventricular unloading and improves end-organ perfusion before durable left ventricular assist device (LVAD) implantation. Thrombus formation after Impella 5.5 insertion can occur and represents a significant challenge to device explantation. Durable LVAD implantation is typically performed without aortic cross-clamping, so a dislodged thrombus can potentially embolize and lead to catastrophic events. We describe our technique to safely explant an Impella 5.5 in patients who develop a thrombus on the inflow portion of the device before surgical LVAD implantation.

Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study.

Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.

Novel Scoring System to Risk Stratify Patients Receiving Durable Left Ventricular Assist Device From J-MACS Registry Data.

Recently, destination therapy (DT) was approved in Japan, and patients ineligible for heart transplantation may now receive durable left ventricular assist devices (LVADs). Several conventional risk scores are available, but a risk score that is best to select optimal candidates for DT in the Japanese population remains unestablished.Methods and Results: A total of 1,287 patients who underwent durable LVAD implantation and were listed for the Japanese registry for Mechanically Assisted Circulatory Support (J-MACS) were eligible for inclusion. Finally, 494 patients were assigned to the derivation cohort and 487 patients were assigned to the validation cohort. According to the time-to-event analyses, J-MACS risk scores were newly constructed to predict 3-year mortality rate, consisting of age, history of cardiac surgery, serum creatinine level, and central venous pressure to pulmonary artery wedge pressure ratio >0.71. The J-MACS risk score had the highest predictability of 3-year death compared with other conventional scores in the validation cohort, including HeartMate II risk score and HeartMate 3 risk score. We constructed the J-MACS risk score to estimate 3-year mortality rate after durable LVAD implantation using large-scale multicenter Japanese data. The clinical utility of this scoring to guide the indication of DT should be validated in the next study.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Association of Days Alive and Out of the Hospital After Ventricular Assist Device Implantation With Adverse Events and Quality of Life

There is a need to better assess the cumulative effect on morbidity and mortality in patients undergoing durable left ventricular assist device (LVAD) implantation. This study evaluates a patient-centered performance metric (days alive and out of hospital [DAOH]) for durable LVAD therapy. To determine the incidence of percent of DAOH before and after LVAD implantation and (2) explore its association with established quality metrics (death, adverse events [AEs], quality of life). This was a retrospective national cohort study of Medicare beneficiaries implanted with a durable continuous-flow LVAD between April 2012 and December 2016. The data were analyzed from December 2021 to May 2022. Follow-up was 100% complete at 1 year. Data from The Society of Thoracic Surgeons Intermacs registry were linked to Medicare claims. The number of DAOH 180 days before and 365 days after LVAD implantation and daily patient location (home, index hospital, nonindex hospital, skilled nursing facility, rehabilitation center, hospice) were calculated. Percent of DAOH was indexed to each beneficiary's pre- (percent DAOH-BF) and postimplantation (percentage of DAOH-AF) follow-up time. The cohort was stratified by terciles of percentage of DAOH-AF. Among the 3387 patients included (median [IQR] age: 66.3 [57.9-70.9] years), 80.9% were male, 33.6% and 37.1% were Interfaces Patient Profile 2 and 3, respectively, and 61.1% received implants as destination therapy. Median (IQR) percent of DAOH-BF was 88.8% (82.7%-93.8%) and 84.6% (62.1-91.5%) for percent of DAOH-AF. While DAOH-BF was not associated with post-LVAD outcomes, patients in the low tercile of percentage of DAOH-AF had a longer index hospitalization stay (mean, 44 days; 95% CI, 16-77), were less likely to be discharged home (mean. -46.4 days; 95% CI, 44.2-49.1), and spent more time in a skilled nursing facility (mean, 27 days; 95% CI, 24-29), rehabilitation center (mean, 10 days; 95% CI, 8-12), or hospice (mean, 6 days; 95% CI, 4-8). Increasing percentage of DAOH-AF was associated with patient risk, AEs, and indices of HRQoL. Patients experiencing non-LVAD-related AEs had the lowest percentage of DAOH-AF. Significant variability existed in the percentage of DAOH within a 1-year time horizon and was associated with the cumulative AEs burden. This patient-centered measure may assist clinicians in informing patients about expectations after durable LVAD implantation. Validation of percentage DAOH as a quality metric for LVAD therapy across centers should be explored.

Key questions about aortic insufficiency in patients with durable left ventricular assist devices.

The development of the latest generation of durable left ventricular assist devices (LVAD) drastically decreased adverse events such as pump thrombosis or disabling strokes. However, time-related complications such as aortic insufficiency (AI) continue to impair outcomes following durable LVAD implantation, especially in the context of long-term therapy. Up to one-quarter of patients with durable LVAD develop moderate or severe AI at 1 year and its incidence increases with the duration of support. The continuous regurgitant flow within the left ventricle can compromise left ventricular unloading, increase filling pressures, decrease forward flow and can thus lead to organ hypoperfusion and heart failure. This review aims to give an overview of the epidemiology, pathophysiology, and clinical consequences of AI in patients with durable LVAD.

Effect of the 2018 heart allocation system on patients with durable left ventricular assist devices

ObjectiveIn this study we report trends and survival of durable left ventricular assist device (LVAD) patients who underwent heart transplantation under the 2018 allocation system. MethodsThe United Network for Organ Sharing database was queried for adult recipients of heart transplants after durable LVAD implantation from January 1, 2016, to December 31, 2020. We excluded patients with additional mechanical support, multiorgan transplants, previous heart transplants, or loss to follow-up. ResultsOne thousand seven hundred eighty-three patients with durable LVADs received heart transplants under the new allocation system (new), and 3445 under the old (old). New recipients were more likely hospitalized at transplant (n = 376 [22.4%] vs n = 446 [13.6%]; P < .001) and inotrope-dependent (n = 134 [7.5%] vs n = 206 [6.0%]; P = .038). Donors of the new cohort were more likely to have history of smoking (n = 234 [13.4%] vs n = 373 [11.0%]; P = .013), cocaine use (n = 506 [29.0%] vs n = 829 [24.4%]; P < .001), Centers for Disease Control and Prevention high risk status (n = 656 [36.8%] vs n = 1046 [30.4%]; P < .001), with ejection fraction <45% (n = 15 [0.8%] vs n = 10 [0.3%]; P = .012), and higher donor sequence numbers (mean 22.3 vs 12.0; P < .001)—trends that are not observed in non-LVAD transplants. Distances were further (mean 240 vs 144 miles; P < .001) and ischemic times longer (3.41 vs 3.04 hours; P < .001). Kaplan–Meier curves show worse survival in new recipients in unadjusted analysis (P = .005), and trends toward worse survival on propensity matching (P = .058). Similarly, increased mortality risk in the new era was shown in univariable Cox regression (hazard ratio, 1.27; 95% CI, 1.07-1.49; P = .005), but not multivariable analysis (P = .090). ConclusionsDurable LVAD patients are more likely to accept marginal donor organs under the new system because of difficulty in receiving offers. Worse survival trends might be attributed to recipient conditions and donor organ differences.

The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure.

Heart failure affects >6 million people in the United States aloneand is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program. A retrospective single-center cohort study was conducted at a single high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1, 2013 and 12, 2017 with a left ventricular ejection fraction < 30% and inotropic dependence or need for mechanical circulatory support were included. Patients with contraindications to durable LVAD were excluded. An adjusted logistic regression model for durable LVAD implantation within 90 days of the index admission was used to determine the effect of race on durable LVAD implantation. Among the 702 study patients (60.9% White, 34.1% Black), durable LVAD implantation was performed within 90 days of the index admission in 183 (26%) of the cohort. After multivariate analysis, Black patients were not found to have a statistically significant difference in durable LVAD implantation rates compared to White patients in our study (OR: 0.68 [95%confidence interval: 0.45-1.04; p: .074]). Black patients in our study did not have a statistically significant difference in the rate of durable LVAD implantation compared with White patients after adjustments were made for age, sex, socioeconomic, and clinical covariates. Larger prospective studies are needed to validate these findings.

Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset.

Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.

Durable mechanical circulatory support as bridge to heart transplantation.

Durable mechanical circulatory support (MCS) technology has changed over time as devices have evolved from pulsatile to continuous flow support. In this review, we discuss recent data and substantial changes to current practice as it pertains to the subject of current era durable left ventricular assist devices (LVADs) as a bridge to heart transplantation. The results of heart transplantation in patients bridged with durable LVAD support are satisfactory even after prolonged duration of support. Reports of recent experience with LVAD related infection suggest that this complication has limited impact on post-transplant outcomes. Important sex-related disparities continue to exist following durable LVAD implantation. Recent changes in the United Network for Organ Sharing donor heart allocation policy have resulted in a drastic decline in the use of durable LVAD support for Bridge to Transplant in the United States. Durable MCS in the form of LVAD as a BTT strategy continues to evolve over time. Optimization of its role in the treatment of end-stage heart failure, particularly in females will need to be the focus of future research.

Predictive capabilities of the European registry for patients with mechanical circulatory support right-sided heart failure risk score after left ventricular assist device implantation

The prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implantation remains a challenge. Recently, risk scores were derived from analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data, the EUROMACS-RHF, and the modified postoperative EUROMACS-RHF. The authors assessed the performance characteristics of these 2 risk score formulations in a continuous-flow LVAD cohort at their institution. A retrospective, observational study. At a tertiary-care academic medical center. Adult patients who underwent durable LVAD implantation between 2015 and 2018. None MEASUREMENTS AND MAIN RESULTS: Early post-LVAD RHF was defined as follows: (1) need for right ventricular assist device, or (2) inotropic or inhaled pulmonary vasodilator support for ≥14 postoperative days. The authors used logistic regression and examined receiver operating characteristic (ROC) curves to evaluate the ability of the 2 risk scores to distinguish between outcome groups. A total of 207 patients met the inclusion criteria. Of the patients, 16% developed RHF (33/207). The EUROMACS-RHF score was not predictive of RHF in the authors' cohort (odds ratio [OR] 1.25; 95% CI [0.99-1.60]; p=0.06), but the postoperative EUROMACS-RHF CPB score was significantly associated (OR 1.38; 95% CI [1.03-1.89]; p=0.03). The scores had similar ROC curves, with weak discriminatory performance: 0.601 (95% CI [0.509-0.692]) and 0.599 (95% CI [0.505-0.693]) for EUROMACS-RHF and postoperative EUROMACS-RHF, respectively. In the authors' single-center retrospective analysis, the EUROMACS-RHF risk score did not predict early RHF. An optimized risk score for the prediction of RHF after LVAD implantation remains an urgent unmet need.

P53: Postoperative Leukocytosis Trends in Ventricular Assist Device Implantation and Coronary Artery Bypass Graft Surgery

Background and Objective: Leukocytosis is a marker of inflammation due to infectious or non-infectious etiologies and is seen after coronary artery bypass graft surgery (CABG) and left ventricular assist device (LVAD) placement. Differentiating reactive postoperative leukocytosis from post-operative infection can drive antimicrobial stewardship initiatives. In this study, we aimed to describe the expected temporal trend of white blood cell (WBC) counts after LVAD placement compared to CABG. Methods and Analysis: We conducted a retrospective chart review of adult patients who underwent durable LVAD implantation or on-pump CABG between 2017-2019 at a single university-affiliated tertiary care hospital in Washington, DC. We excluded patients who were undergoing LVAD exchange, percutaneous VAD placement, had kidney failure requiring renal replacement therapy or transplant, had thromboembolism <14 days before the procedure, clinical or microbiological evidence of systemic infection <7 days before the procedure, were on steroids ≥5 mg prednisone daily, had a history of hematologic malignancy or acquired immunodeficiency syndrome. We compared the WBC count trend postoperatively after LVAD placement vs. CABG until day 24 or discharge, whichever was earlier. Secondary outcomes included comparing number of patients with bacteremia or clinical evidence of infection requiring antimicrobial therapy among the two groups. Results: We reviewed the charts of 116 LVAD patients and 134 CABG patients with median age 61 years [Interquartile Range (IQR) 53.0, 67.0] and BMI 28.4 kg/m2 [IQR 25.5, 32.8]. In the LVAD group, there was a peak in median WBC count to 14.2 (x103/ μL) [IQR 11.3, 17.6] on Day 2 post-operatively and another peak on Day 10 post-operatively to 14.1 [IQR 10.6, 18.4]. In the CABG group, median WBC peak was observed at Day 2 post-operatively at 11.8 [9.1, 14.2] (Fig. 1). There were 10 (8.6%) LVAD patients with clinical or microbiological evidence of infection compared to 2 (1.5%) CABG patients (p = 0.01). After excluding patients with infections there was no change observed in the trend of the postoperative WBC counts. Conclusion: Post-operative leukocytosis is common in cardiopulmonary bypass and peak WBC are higher in LVAD patients than CABG patients. WBC counts peak in LVAD patients at day 2 and 10 postoperatively. This expected peak should be taken into consideration while evaluating patients for infections and antimicrobial therapy.

Temporary Mechanical Circulatory Support Bridging Strategies And Post-operative Outcomes In Acute Decompensated Heart Failure-related Cardiogenic Shock Patients Undergoing Heart Transplantation Or Durable Left Ventricular Assist Device Implantation: A Society Of Thoracic Surgeons Database Analysis

Introduction Temporary mechanical circulatory support (TMCS) bridging strategies are increasingly used for acute decompensated heart failure-related cardiogenic shock (ADHF-CS). However, the impact of bridging approach on post-operative outcomes in ADHF-CS patients who receive a durable left ventricular assist device (LVAD) or heart transplant (HT) is unknown. Methods Durable LVAD or HT recipients from July 1, 2014 to December 31, 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by pre-operative TMCS strategy. Associations between TMCS strategies and post-operative outcomes were evaluated using propensity-score matching and adjustment for pre-selected covariates (pre-operative hemoglobin, platelets, albumin, bilirubin, international normalized ratio, creatinine, cardiopulmonary resuscitation, and operative status). Results A total of 8,777 ADHF-CS patients were bridged to LVAD (5,975; 68%) or HT (2,802; 32%). The composite of operative/30-day death following LVAD or HT was highest in patients managed with VA ECMO (22%) and lowest in those managed without TMCS (7%), with a stepwise gradient of incidence by level of hemodynamic support (Figure, top). Other post-operative outcomes including major bleeding, cerebrovascular accident, cardiac arrest, prolonged mechanical ventilation, renal failure, and sepsis/pneumonia followed a similar pattern. However, after propensity score matching and adjustment, there were no differences in the odds of operative/30-day death or major bleeding with IABP versus no TMCS (Figure, bottom). While there was no difference in operative/30-day death, odds of major bleeding were lower with catheter-based MCS compared with IABP (OR 0.70, 95% CI 0.53 - 0.92). Conclusion ADHF-CS patients experience high rates of cardiac and non-cardiac adverse events post- LVAD and HT. A crude relationship between TMCS bridging strategy and post-operative outcomes was observed. However, after adjustment, pre-operative TMCS bridging strategy did not independently confer risk of near-term post-operative mortality among ADHF-CS patients who underwent HT or durable LVAD implantation. Temporary mechanical circulatory support (TMCS) bridging strategies are increasingly used for acute decompensated heart failure-related cardiogenic shock (ADHF-CS). However, the impact of bridging approach on post-operative outcomes in ADHF-CS patients who receive a durable left ventricular assist device (LVAD) or heart transplant (HT) is unknown. Durable LVAD or HT recipients from July 1, 2014 to December 31, 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by pre-operative TMCS strategy. Associations between TMCS strategies and post-operative outcomes were evaluated using propensity-score matching and adjustment for pre-selected covariates (pre-operative hemoglobin, platelets, albumin, bilirubin, international normalized ratio, creatinine, cardiopulmonary resuscitation, and operative status). A total of 8,777 ADHF-CS patients were bridged to LVAD (5,975; 68%) or HT (2,802; 32%). The composite of operative/30-day death following LVAD or HT was highest in patients managed with VA ECMO (22%) and lowest in those managed without TMCS (7%), with a stepwise gradient of incidence by level of hemodynamic support (Figure, top). Other post-operative outcomes including major bleeding, cerebrovascular accident, cardiac arrest, prolonged mechanical ventilation, renal failure, and sepsis/pneumonia followed a similar pattern. However, after propensity score matching and adjustment, there were no differences in the odds of operative/30-day death or major bleeding with IABP versus no TMCS (Figure, bottom). While there was no difference in operative/30-day death, odds of major bleeding were lower with catheter-based MCS compared with IABP (OR 0.70, 95% CI 0.53 - 0.92). ADHF-CS patients experience high rates of cardiac and non-cardiac adverse events post- LVAD and HT. A crude relationship between TMCS bridging strategy and post-operative outcomes was observed. However, after adjustment, pre-operative TMCS bridging strategy did not independently confer risk of near-term post-operative mortality among ADHF-CS patients who underwent HT or durable LVAD implantation.