Left Ventricular Assist Device Complications Research Articles

Severe obesity among patients with left ventricular assist devices

Patients with obesity and advanced heart failure requiring left ventricular assist device (LVAD) support are more likely to experience LVAD complications and may be disproportionately Black and/or female when compared to patients without obesity. Among these patients, obesity may represent a barrier to transplant eligibility and a marker of inequity in heart transplantation and health outcomes in advanced heart failure. To better understand this issue at our institution, we examined our active LVAD cohort and found that almost one-third of all patients had severe obesity with BMI ≥ 35 kg/m2. Patients with LVADs and severe obesity were significantly younger and more likely to self-identify as Black, and numerically more likely to be female. Weight management in this group represents a vital area for improved equity in health outcomes and barriers to heart transplantation. NA.

Cellular and Molecular Mechanisms Activated by a Left Ventricular Assist Device.

Left ventricular assist devices (LVADs) represent the final treatment for patients with end-stage heart failure (HF) not eligible for transplantation. Although LVAD design has been further improved in the last decade, their use is associated with different complications. Specifically, inflammation, fibrosis, bleeding events, right ventricular failure, and aortic valve regurgitation may occur. In addition, reverse remodeling is associated with substantial cellular and molecular changes of the failing myocardium during LVAD support with positive effects on patients' health. All these processes also lead to the identification of biomarkers identifying LVAD patients as having an augmented risk of developing associated adverse events, thus highlighting the possibility of identifying new therapeutic targets. Additionally, it has been reported that LVAD complications could cause or exacerbate a state of malnutrition, suggesting that, with an adjustment in nutrition, the general health of these patients could be improved.

Abstract 18112: LVAD Recipient and Caregiver Perspective on Prognosis and End of Life Care: A Qualitative Study

Background: For left ventricular assist device (LVAD) recipients and caregivers, accurate understanding of prognosis is central to shared decision making. Our study evaluates (i) patient and caregiver estimated survival after a LVAD and (ii) describes how patients and caregivers rationalize estimated survival. Methods: We conducted a qualitative study with 18 LVAD recipients and 9 caregivers using semi-structured interviews. Interviews were transcribed and coded, with themes identified using rapid qualitative analysis. Results: Included patients had a median (range) age of 60.5 (28-83) years, 12 (67%) were men and 10 (56%) received their LVAD as destination therapy (DT). Participating caregivers included 8 (89%) women supporting 5 (56%) DT LVAD recipients. Depression was reported by 7 (39%) patients and 2 (22%) caregivers. Reported quality of life was low for most participants [median EQ-VAS score 60 (range 25-70) for patients and 50 (range 20-80) for caregivers]. Only 6 patients reported willingness to trade survival in favor of better quality of life. In the event of cardiac arrest, 15 (83%) patients and 7 (78%) caregivers reported wanting CPR for themselves or loved one. Although most participants reported health concerns primarily relating to their cardiac health and LVAD complications, both patients and caregivers provided high estimates of life expectancy [median 16 (range 3-45) and 14 (range 3-32) years respectively]. We identified three themes explaining how LVAD recipients and caregivers rationalize their estimated survival (i) survivor’s bias (ii) optimism (iii) minimization. Exemplary quotes are provided in the Table below. Conclusions: Several patients and caregivers reported low quality of life with concerns around poor cardiovascular health and LVAD complications. However, their estimated survival frequently exceeded clinically observed survival. This suggests an opportunity for improving patient-physician prognosis communication.

Health status analysis is comparable in HM3 patients with different preoperative grades of mitral regurgitation

BackgroundThe guidelines for mechanical circulatory support of the International Society for Heart and Lung Transplantation do not recommend the routine replacement or repair of the mitral valve at the time point of left ventricular assist device (LVAD) implantation. We investigated different parameters of health status including exercise capacity, anxiety and depression after LVAD implantation in patients with different preoperative grades of mitral regurgitation (MR).MethodsA single-center analysis of health status was performed including 45 patients with HeartMate 3 (HM 3) implantation using the 12-items Short Form Health Survey (SF-12) and the Hospital Anxiety and Depression Score (HADS) questionnaires. The study groups were classified according to echocardiographically defined preoperative grade of MR. The group without severe MR comprised 33 patients; the group with severe MR comprised 12 patients.ResultsDemographic and preclinical characteristics as well as LVAD complications such as thrombosis and bleeding events were comparable between LVAD patients with severe and not severe MR (p > 0.05). Severe MR resolved in all patients after LVAD implantation and improved to moderate, mild or no MR in both groups in a period ranging from 6 months until 2 years. The analyses of SF-12 questionnaire revealed that the physical (p = 0.44) and mental health (p = 0.64) was comparable. The grade of anxiety (p = 0.34) and depression (p = 0.44) was comparable between the groups. Exercise capacity measured by the 6 min walk test correlated positively with the SF-12-determined physical health (p < 0.01, r = 0.518) and negatively with the HADS anxiety (p = 0.01, r = −0.399) and depression (p < 0.01, r = −0.570) scores.ConclusionsOur data showed that the health status is comparable in HM 3 patients with different preoperative MR severities in the post-LVAD period. Preoperative severe MR resolves in the majority of patients early after LVAD implantation and is not associated with concomitant mitral valve repair or replacement at the time of LVAD implantation.

Association of Nutritional Risk Index With Continuous Flow Left Ventricular Assist Device Complications

Studies revealing the relationship between major surgery outcomes and nutritional parameters are increasing daily. Publications demonstrating the relationship between early postoperative success and surgical complications in patients with chronic heart failure and continuous flow left ventricular assist device (cf-LVAD) are limited. The vast majority of patients with advanced chronic heart failure are cachexic, and the reason for this is multifactorial. The aim of this study is to investigate the link between the modified nutritional risk index (NRI) and 6-month survival and complication rates in patients with a cf-LVAD. This study included statistical analysis of NRI and postoperative parameters of 456 patients with advanced heart failure who had cf-LVAD implantation between 2010 and 2020. The results of this study showed a statistically significant difference between mean NRI values and postoperative parameters such as 6-month survival (P=.001), right ventricular failure (P=.003), infection (P=.001), driveline infection (P=.000), and sepsis (P=.000). This study revealed that 6-month postoperative complications and mortality rates of patients with advanced heart failure in patients with cf-LVAD are closely related to malnutrition status. In these patients, nutrition specialist use would be beneficial both preoperatively and postoperatively to increase surveillance and reduce postoperative complications.

Automatic non-invasive blood pressure measurement in left ventricular assist device patients with a photoplethysmography assisted device

Non-invasive measurement of blood pressure in patients with a left ventricular assist device (LVAD) is challenging due to the mechanical properties of these circulatory support devices. Keeping blood pressure in a target range is crucial to reduce the risk of LVAD complications. As current assessment methods require trained personnel resulting in infrequent monitoring, devices for home-based measurements are sorely needed. In this paper, we report a measurement method and a custom-made monitoring device based on photoplethysmography (PPG) enabling automated measurement of the mean arterial pressure (MAP) of patients with LVAD. The method and the device were tested on 21 adult patients with LVAD, and the estimated MAP values were compared to MAP values measured simultaneously by a human expert applying the commonly used Doppler-based method. Results of the proposed method showed highly significant correlation with Doppler-based MAP values (R = 0.85 for inflation, p < 0.001; R = 0.96 for deflation, p<0.001). The mean difference of the proposed method to the Doppler-based MAP values was 1.48 ± 5.43 mmHg for inflation and -0.19 ± 2.71 mmHg for deflation. The results demonstrate that the proposed method is a promising direction to achieve accurate, automated, non-invasive BP measurement, applicable in home health monitoring for patients with LVAD.

Impact of left ventricular assist device complications on heart transplant outcomes under the 2018 heart transplant allocation policy

ObjectiveThe study objective was to determine the impact of left ventricular assist device complications on post–heart transplant survival before and after the 2018 US heart transplant allocation policy change. MethodsAdult patients (age >18 years) supported by left ventricular assist devices at the time of listing or transplantation in the United Network for Organ Sharing between October 18, 2015, and December 31, 2021, were included. Left ventricular assist device complications were defined by status at transplant (nonelective 1A in the prior era or new era status 2 or 3). Post-transplant survival (primary analysis) and baseline characteristics were compared among those with and without left ventricular assist device complications and by allocation era using multivariable Cox regression analyses. ResultsThe primary analysis included 4160 patients with left ventricular assist devices who underwent heart transplant (prior era n = 2458, new era n = 1702). Patients who underwent heart transplant with left ventricular assist device complications were on left ventricular assist device support longer under the new era (498 days vs 423 days P < .001). Post-transplant survival was highest in the prior era among those without left ventricular assist device complications. Patients who underwent transplantation in the prior era with a complication and in the new era without complications were not statistically different. Left ventricular assist device complications in the new era were associated with the highest post-transplant mortality (status 2 adjusted hazard ratio, 1.87, 95% confidence interval, 1.31-2.67, P < .001, status 3 adjusted hazard ratio, 1.50, 95% confidence interval, 1.11-2.04, P = .009). ConclusionsLeft ventricular assist device complications in the new era are associated with increased post-transplant mortality. As a heart allocation score is being considered, modeling time on left ventricular assist device support to promote heart transplant before development of left ventricular assist device–related complications may improve outcomes for patients with left ventricular assist devices.

Relation of Sociodemographic Factors With Primary Cause of Hospitalization Among Patients With Left Ventricular Assist Devices (from the National Inpatient Sample 2012 to 2017)

Left ventricular assist devices (LVADs) are an established intervention for end-stage heart failure (HF). Rehospitalization for serious complications remains common during the continuous-flow LVAD era. Whether sociodemographic factors are associated with differences in the frequency of severe complications leading to hospitalization remains unclear. Using data from the National Inpatient Sample, we identified all hospitalizations from 2012 to 2017 of adults aged ≥18 years with previous LVAD placement. We categorized the primary cause of hospitalizations into key adverse diagnoses, including bleeding, HF, arrhythmias, LVAD complications, stroke, and a composite of device-related infection or sepsis. We assessed the association of sociodemographic markers with primary diagnoses using modified Poisson regression. We identified 62,630 hospitalizations during the study period (41% aged ≥65, 77% men, 26% Black, 5% Hispanic). Bleeding (18%), infections (15%), and HF (15%) were the most common primary diagnoses. In the multivariable analyses, gastrointestinal bleeding was more likely among older adults (relative risk [RR] 95% confidence interval [CI] 4.69 [3.57 to 6.16]; age ≥65 vs 18 to 44 years), among Black than White patients (RR 95% CI 1.17 [1.04 to 1.32]), and less likely for the highest income quartile than the lowest (RR 95% CI 0.79 [0.69 to 0.91]). Device-related infection/sepsis was also less likely for patients with higher income (RR 95% CI 0.80 [0.67 to 0.96]). Ventricular arrhythmias were less frequent diagnoses for women than men (RR 95% CI 0.59 [0.46 to 0.75]). LVADs complications were less likely in older adults than younger adults (RR 95% CI 0.70 [0.50 to 0.98]). In conclusion, after LVAD implantation, the frequency in which specific adverse events are the primary cause of rehospitalization varies significantly by sociodemographic factors. Further study is needed to determine if there are opportunities for targeted preventive measures based on sociodemographic markers.

Association of Genetic Polymorphisms with Complications of Implanted LVAD Devices in Patients with Congestive Heart Failure: A Kazakhstani Study.

The left ventricular assist device (LVAD) is one of the alternative treatments for heart failure (HF) patients. However, LVAD support is followed by thrombosis, and bleeding complications which are caused by high non-physiologic shear stress and antithrombotic/anticoagulant therapy. A high risk of complications occurs in the presence of the genotype polymorphisms which are involved in the coagulation system, hemostasis function and in the metabolism of the therapy. The aim of the study was to investigate the influence of single-nucleotide polymorphisms (SNP) in HF patients with LVAD complications. We analyzed 21 SNPs in HF patients (n = 98) with/without complications, and healthy controls (n = 95). SNPs rs9934438; rs9923231 in VKORC1, rs5918 in ITGB3 and rs2070959 in UGT1A6 demonstrated significant association with HF patients’ complications (OR (95% CI): 3.96 (1.42–11.02), p = 0.0057), (OR (95% CI): 3.55 (1.28–9.86), p = 0.011), (OR (95% CI): 5.37 (1.79–16.16), p = 0.0056) and OR (95% CI): 4.40 (1.06–18.20), p = 0.044]. Genotype polymorphisms could help to predict complications at pre- and post-LVAD implantation period, which will reduce mortality rate. Our research showed that patients can receive treatment with warfarin and aspirin with a personalized dosage and LVAD complications can be predicted by reference to their genotype polymorphisms in VKORC1, ITGB3 and UGT1A6 genes.

Translocation of LVAD Pump and Driveline Causing Bowel Perforation

Introduction Left ventricular assist devices (LVADs) have known risks of device infection and gastrointestinal (GI) bleeding. We present the first known case of LVAD pump migration causing colonic perforation. Case Report A 67-year old man with ischemic cardiomyopathy status post HeartMate II LVAD implantation presented to the emergency department with melena. He was found to be in hemorrhagic shock requiring pressor support, with a hemoglobin of 5.2 g/dl. He had a history of chronic driveline infection with Stenotrophomonas maltophilia treated with long-term suppressive doxycycline and an outflow graft kink requiring stenting 7 months prior. His GI history was notable for recurrent GI bleeding secondary to colonic AVMs and polyps requiring multiple cauterizations and clips. His anticoagulation was periodically interrupted and restarted, as the patient had several readmissions for recurrent GI bleeding, until it was ultimately stopped 3 months prior. This admission, an abdominal CT showed erosion of the LVAD driveline into the transverse colon (Panel A). Subsequent colonoscopy identified the driveline within transverse colon lumen (Panel B). In conjunction with both cardiothoracic and abdominal surgery teams, the patient underwent robotic-assisted colonic exploration which revealed both driveline and LVAD pump had migrated into the colon. Patient underwent removal of the LVAD and primary colo-colonic anastomosis with abdominal washout. Laparoscopic omentopexy was performed to cover the intraabdominal LVAD components. His postoperative course was uncomplicated. Summary This case illustrates a rare but serious complication of LVAD and chronic device infection: migration of LVAD pump and driveline causing colonic perforation. Left ventricular assist devices (LVADs) have known risks of device infection and gastrointestinal (GI) bleeding. We present the first known case of LVAD pump migration causing colonic perforation. A 67-year old man with ischemic cardiomyopathy status post HeartMate II LVAD implantation presented to the emergency department with melena. He was found to be in hemorrhagic shock requiring pressor support, with a hemoglobin of 5.2 g/dl. He had a history of chronic driveline infection with Stenotrophomonas maltophilia treated with long-term suppressive doxycycline and an outflow graft kink requiring stenting 7 months prior. His GI history was notable for recurrent GI bleeding secondary to colonic AVMs and polyps requiring multiple cauterizations and clips. His anticoagulation was periodically interrupted and restarted, as the patient had several readmissions for recurrent GI bleeding, until it was ultimately stopped 3 months prior. This admission, an abdominal CT showed erosion of the LVAD driveline into the transverse colon (Panel A). Subsequent colonoscopy identified the driveline within transverse colon lumen (Panel B). In conjunction with both cardiothoracic and abdominal surgery teams, the patient underwent robotic-assisted colonic exploration which revealed both driveline and LVAD pump had migrated into the colon. Patient underwent removal of the LVAD and primary colo-colonic anastomosis with abdominal washout. Laparoscopic omentopexy was performed to cover the intraabdominal LVAD components. His postoperative course was uncomplicated. This case illustrates a rare but serious complication of LVAD and chronic device infection: migration of LVAD pump and driveline causing colonic perforation.

Computational sentiment analysis of an online left ventricular assist device support forum: positivity predominates.

The impact of left ventricular assist device (LVAD) complications on the individual patient, overall sentiment, and its effect on referral patterns, is not fully understood. We sought to better understand patient attitudes towards LVAD therapy using a computational sentiment analysis approach. Posts, comments, and titles were parsed from MyLVAD.com's HTML as a text file using custom Python scripts (version 3.6). Individual word frequency was computed with word classification as 'positive', 'negative', or 'neutral'. Data transformation and cleaning, sentiment determination, and analysis was performed with a binary dictionary package using R software (version 3.6). Sixty-six thousand eight hundred and twenty-one unique words were noted, including 4,623 (6.9%) with positive sentiment and 3,248 (4.8%) with negative sentiment. Net sentiment ratio [(number of positive words - number of negative words)/(number of total words)] was 2.1%. Positive sentiment dominated the 20 most commonly used words. Odds ratio of non-neutral words [(number of positive words/number of negative words)] was 1.42, indicating a less obvious disparity in sentiment when expanding analysis beyond the top 20 words. Word cloud analysis of positive and negative sentiments was performed, indicating common use of "infection" (208 mentions) compared to other complications such as "stroke" (29 mentions), "bleeding" (30 mentions), and "thrombosis" or "clot" (32 mentions). Positive sentiment dominates the most frequently used words, yet this disparity decreases when considering the totality of words. "Infection" is mentioned a disproportionate number of times compared to other LVAD complications. Further research is required to address analysis limitations, including selection bias.

Effect of Radiation in Patients with HeartMate 3 LVAD Therapy

Introduction Radiation therapy in patients with axial flow left ventricular assist devices (LVAD) has not been associated with significant device malfunction. However, the effects of radiation on the fully magnetically levitated HeartMate 3 (Abbott, Abbott Park, IL) LVAD are not well known. We report two cases of stereotactic bone radiation therapy (SBRT) in patients with a HeartMate 3 LVAD implantation. Case Report Patient 1 71-year-old woman with history of chronic systolic heart failure status post HeartMate 3 LVAD and history of left upper lobe non-small cell lung cancer status post lobectomy was found to have an incidental left lateral thorax wall mass on CT imaging with subsequent biopsy consistent for recurrent oligometastatic lung adenocarcinoma. She consequently underwent 5 fractions of 600 cGy SBRT to her left lateral chest wall over a period of 10 days. Mild fatigue was reported following radiation, however LVAD log files sent subsequent to each fraction were unremarkable. On follow up, no cardiac symptoms were reported and LVAD parameters were normal with flow 4.6 L/min, speed 5600 rpm, pulse index 2.8 and power 4.4 watts. Device malfunction has not been witnessed during 1 year follow up. Patient 2 70-year-old man with history of advanced systolic heart failure status post HeartMate 3 LVAD implantation was found to have a right upper lobe nodule and mediastinal lymphadenopathy on CT imaging. Ensuing biopsy diagnosed squamous cell lung cancer without metastatic disease. SBRT was initiated and 5 treatments of 1000 cGy were delivered to the right upper lobe lesion within 10 days. No LVAD complications or symptoms of heart failure were witnessed during treatment. On follow up, patient denied any symptoms and LVAD function remained normal with observed with flow 4.3 L/min, speed 5200 rpm, pulse index 4.8 and power 3.8 watts. Device malfunction has not been witnessed during 1 year follow up. Summary Our 2 cases suggests that SBRT in patients with HeartMate 3 LVAD implantation may be safe and likely not associated with device malfunction. Larger studies are required to better evaluate this relationship and to determine long term safety profile.

Antiplatelet and anticoagulation strategies for left ventricular assist devices.

Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.

Left Ventricular Assist Device Flow Pattern Analysis Using a Novel Model Incorporating Left Ventricular Pulsatility.

Our current understanding of flow through the circuit of left ventricular assist device (LVAD), left ventricle and ascending aorta remains incompletely understood. Computational fluid dynamics, which allow for analysis of flow in the cardiovascular system, have been used for this purpose, although current simulation models have failed to fully incorporate the interplay between the pulsatile left ventricle and continuous-flow generated by the LVAD. Flow-through the LVAD is dependent on the interaction between device and patient-specific factors with suboptimal flow patterns evoking increased risk of LVAD-related complications. Computational fluid dynamics can be used to analyze how different pump and patient factors affect flow patterns in the left ventricle and the aorta. Computational fluid dynamics simulations were carried out on a patient with a HeartMate II. Simulations were also conducted for theoretical scenarios substituting HeartWare HVAD, HeartMate 3 (HM3) in continuous mode and HM3 with Artificial Pulse. An anatomical model of the patient was reconstructed from computed tomography (CT) images, and the LVAD outflow was used as the inflow boundary condition. The LVAD outflow was calculated separately using a lumped-parameter-model of the systemic circulation, which was calibrated to the patient based on the patient-specific ventricular volume change reconstructed from 4 dimensional computed tomography and pulmonary capillary wedge pressure tracings. The LVADs were implemented in the lumped-parameter-model via published pressure head versus flow (H-Q) curves. To quantify the flushing effect, virtual contrast agent was released in the ascending aorta and its flushing over the cycles was quantified. Shear stress acting on the aortic endothelium and shear rate in the bloodstream were also quantified as indicators of normal/abnormal blood flow, especially the latter being a biomarker of platelet activation and hemolysis. LVAD speeds for the HVAD and HM3 were selected to match flow rates for the patient's HMII (9,000 RPM for HMII, 5,500 RPM for HM3, and 2,200 RPM for HVAD), the cardiac outputs were 5.81 L/min, 5.83 L/min, and 5.92 L/min, respectively. The velocity of blood flow in the outflow cannula was higher in the HVAD than in the two HeartMate pumps with a cycle average (range) of 0.92 m/s (0.78-1.19 m/s), 0.91 m/s (0.86-1.00 m/s), and 1.74 m/s (1.40-2.24 m/s) for HMII, HM3, and HVAD, respectively. Artificial pulse increased the peak flow rate to 9.84 L/min for the HM3 but the overall cardiac output was 5.96 L/min, which was similar to the continuous mode. Artificial pulse markedly decreased blood stagnation in the ascending aorta; after six cardiac cycles, 48% of the blood was flushed out from the ascending aorta under the continuous operation mode while 60% was flushed under artificial pulse. Shear stress and shear rate in the aortic arch were higher with the HVAD compared to the HMII and HM3, respectively (shear stress: 1.76 vs. 1.33 vs. 1.33 Pa, shear rate: 136 vs. 91.5 vs. 89.4 s-1). Pump-specific factors such as LVAD type and programmed flow algorithms lead to unique flow patterns which influence blood stagnation, shear stress, and platelet activation. The pump-patient interaction can be studied using a novel computational fluid dynamics model to better understand and potentially mitigate the risk of downstream LVAD complications.

Complications of left ventricular assist devices causing high urgency status on waiting list: impact on outcome after heart transplantation

AimsHeart transplantation (HTx) represents optimal care for advanced heart failure. Left ventricular assist devices (LVADs) are often needed as a bridge‐to‐transplant (BTT) therapy to support patients during the wait for a donor organ. Prolonged support increases the risk for LVAD complications that may affect the outcome after HTx.Methods and resultsA total of 342 patients undergoing HTx after LVAD as BTT in a 10‐year period in two German high‐volume HTx centres were retrospectively analysed. While 73 patients were transplanted without LVAD complications and with regular waiting list status (T, n = 73), the remaining 269 patients were transplanted with high urgency status (HU) and further divided with regard to the observed leading LVAD complications (infection: HU1, n = 91; thrombosis: HU2, n = 32; stroke: HU3, n = 38; right heart failure: HU4, n = 41; arrhythmia: HU5, n = 23; bleeding: HU6, n = 18; device malfunction: HU7, n = 26). Postoperative hospitalization was prolonged in patients with LVAD complications. Analyses of perioperative morbidity revealed no differences regarding primary graft dysfunction, renal failure, and neurological events except postoperative infections. Short‐term survival, as well as Kaplan–Meier survival analysis, indicated comparable results between the different study groups without disadvantages for patients with LVAD complications.ConclusionsLeft ventricular assist device therapy can impair the outcome after HTx. However, the occurrence of LVAD complications may not impact on outcome after HTx. Thus, we cannot support the prioritization or discrimination of HTx candidates according to distinct mechanical circulatory support‐associated complications. Future allocation strategies have to respect that device‐related complications may define urgency but do not impact on the outcome after HTx.

Impact of distance from implant center on mechanical circulatory device patient outcomes.

Patients on left ventricular assist device (LVAD) support receive extensive care and education before discharge home. We investigated the impact of patient's residential distance from LVAD implantation center on outcomes and survival. A total of 214 patients received a LVAD between 2006 and 2018 at our institution. Patient's residential distance from the LVAD implantation center, LVAD complications, hospitalization, and death were recorded. Patients were divided into two groups: patients living less than or equal to 100 miles (Group 1), patients living more than 100 (Group 2). A total of 106 patients were assigned to Group 1 and 108 patients were assigned to Group 2. Destination therapy was intended in 20% of patients in Group 1 and 34% in Group 2 (p = .023). Mean length of stay was 13 ± 9 days for Group 1 and 21 ± 12 for Group 2 (p < .001). Major postoperative complications were unplanned readmissions due to infections (9% and 12%), gastrointenstinal bleeding (15% and 14%), cerebrovascular accidents (6% and 7.4%), and acute kidney injury (5% and 2%), respectively for Group 1 and Group 2. There was no difference in major complications (all p > .05) and survival between patients in both groups (p > .05). Distance from implanting center had no impact on adverse outcomes after LVAD implantation. There was a significant increase in hospital stay for patients who live far from the implanting center, suggesting that distance should not be a contraindication when considering patients for LVAD therapy, but plans should be made for prolonged hospital stay or extended local stay near the hospital for close follow-up.

Conversion of the HVAD Left Ventricular Assist Device to the Centrimag Using a Customized Apical Plug

Left ventricular assist device thrombosis is a potentially life-threatening complication often managed acutely with device exchange. In the absence of modifiable risk factors recurrent thrombosis can occur. Recent changes in the heart allocation policy have reduced left ventricular assist device complications from top priority to status 3. In this report we present a patient with recurrent left ventricular assist device thrombosis. Given no modifiable risk factors and recurrence of thrombosis, the HeartWare HVAD ((Medtronic, Minneapolis, MN)) was converted to a temporary Centrimag device device (Abbott, Abbott Park, IL) using a novel plug through the existing sewing ring. With status 2 listing the patient was successfully transplanted on postoperative day3.

LVAD, heart failure journey continues

Introduction Heart failure (HF) is a global pandemic affecting at least 26 million people worldwide and is increasing in prevalence (1). Heart transplantation or implantation of durable mechanical circulatory support (MCS) are the sole therapies available for end-stage heart failure. Such patients have severely impaired systolic ventricular function due to end-stage cardiomyopathies but remain symptomatic despite optimal guideline-recommended treatment (2). Acute MCS can be effectively employed as a bridge to long-term MCS devices and heart transplantation. Heart transplantation has been limited by diminishing donor heart availability leading to a greater role of left ventricular assist device (LVAD) support. Methods Retrospective review of adult patients supported with HeartWare™ HVAD™ Pump as a first long term LVAD between January 2017 and February 2020. Results 73 patients received LVADs at our institution in that period. 59 (80%) males, 14 (20%) females, mean age 50. The most common indications were dilated (40%) and ischaemic (34%) cardiomyopathies. 27% of devices were implanted via sternotomy vs 76% via anterolateral thoracotomy. The most frequent complications were driveline infection 26 (36%), pump thrombosis 18 (25%) and ischaemic stroke 16 (22%). Overall, 30 days survival on LVAD was 85% and 1 year survival 65%. 1-year survival in the thoracotomy group was significantly greater compared to the sternotomy group 72% vs 49%, and less red cell transfusion rate (5.2 vs 9.8 units) in thoracotomy approach group was observed. 4 (5.5%) patients received heart transplant. Discussion Despite the excellent long-term survival data for heart transplantation, patients who are denied a transplant or who will not survive the long high-urgency waiting time, benefit more from a permanent LVAD and achieve outpatient status with acceptable quality of life for a reasonable period of time. The minimally invasive surgical approach implemented at our centre is associated with fewer mediastinal adhesions at time of transplant, which greatly facilitates heart implantation and reduces donor organ ischemic time resulting in improved graft performance (3). With new technology focused on limitations of the most common LVAD complications, implanted via thoracotomy, MCS remains valuable treatment tool and it might potentially play more important role in the future of the HF patients.

Left Ventricular Assist Device Outcomes in Non English Speaking Patients

Introduction Non-English speaking (NES) status has been identified as a risk factor for adverse outcomes in patients with cardiovascular disease. Given the complexity of left ventricular assist device (LVAD) care and the need for frequent provider/patient interactions, we aimed to review outcomes of NES LVAD recipients in a single center LVAD cohort. Methods The analysis included all adult patients who underwent first time, continuous flow LVAD implementation at the University of Minnesota Medical Center from June 2005 to July 2019 (n=413). Patients were identified as NES if they identified English as there second language regardless of interpreter use. To assess the impact of NES on post LVAD outcomes, 1-year readmissions and 2-year survival was compared between NES and English speaking LVAD recipients. Results The study cohort included 13 NES (3%) and 400 (97%) English speaking patients. Six of the NES patients (46%) needed an interpreter during clinical interactions. Detailed baseline characteristics and post LVAD complications of the NES cohort are presented (table). Between English Speaking vs. NES LVAD recipients, no statistically significant differences were detected between age (Mean [±SD]) (58 [±14] vs 56 [±15], P=0.65), male sex (80% vs 92%, P=0.28) or bridge to transplant (BTT) status (59% vs 54%, P=0.69). Observed complications among the NES patients over a median (IQR) follow up time of 348 (202, 647) days were the following; driveline infection: 6 (46%), GI bleed: 4 (30%), stroke: 2 (15%), pump thrombosis: 1(8%), and device replacement for driveline malfunction: 1 (8%). No statistically significant differences were detected between 1-year readmissions between English and NES LVAD patients, (2 [IQR 1, 3] vs 1 [IQR 0.5, 4], P=0.86) or 2-year survival (77% vs. 84%, P=0.89). Conclusion Non English Speaking LVAD recipients had a similar survival compared to the larger LVAD cohort in this single center analysis, however this sample size was small. High rates of driveline infections were observed among NES patients. Larger data will be needed to confirm these observations with a higher degree of confidence.

Septuagenarian population has similar survival and outcomes to younger patients after left ventricular assist device implantation

Left ventricular assist device (LVAD) implantation may be an attractive alternative therapeutic option for elderly patients with heart failure who are ineligible for heart transplantation. We aimed to describe the characteristics and outcomes of elderly patients (i.e. aged≥70 years) receiving an LVAD. This observational study was conducted in 19 centres between 2006 and 2016. Patients were divided into two groups-younger (aged<70 years) and elderly (aged≥70 years), based on age at time of LVAD implantation. A total of 652 patients were included in the final analysis, and 74 patients (11.3%) were aged≥70 years at the time of LVAD implantation (maximal age 77.6 years). The proportion of elderly patients receiving an LVAD each year was constant, with a median of 10.6% (interquartile range 8.0-15.4%) per year, and all were implanted as destination therapy. Elderly and younger patients had similar durations of hospitalization in intensive care units and total lengths of hospital stays. Both age groups experienced similar rates of LVAD-related complications (i.e. stroke, bleeding, driveline infection and LVAD exchange), and the occurrence of LVAD complications did not impact survival in the elderly group compared with the younger group. Lastly, when compared with younger patients implanted as destination therapy, the elderly group also exhibited similar mid-term survival. This work strongly suggests that selected elderly adults can be scheduled for LVAD implantation.