Patients Undergoing Left Ventricular Assist Device Implantation Research Articles

Subcutaneous implantable cardioverter-defibrillator troubleshooting in patients with a left ventricular assist device: A case series and systematic review

There are limited data on the performance of the subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients with a left ventricular assist device (LVAD). The purpose of this study was to describe the clinical course and outcomes of patients with both an S-ICD and an LVAD at our institution and via a systematic review of published studies. We performed a retrospective cohort study of all patients who underwent LVAD implantation from 2009 to 2019 at Duke University Hospital. We also performed a systematic review of studies involving patients with an S-ICD and LVAD using the PubMed/Embase databases. Of 588 patients undergoing LVAD implantation with a preexisting implantable cardioverter-defibrillator, 4 had an S-ICD in situ after LVAD implantation. All 4 patients developed electromagnetic interference (EMI) in the primary/secondary vectors after LVAD implantation, resulting in inappropriate implantable cardioverter-defibrillator shocks in 2 patients. Sensing in the alternate vector was adequate immediately postoperatively in 1 patient. Postoperative undersensing was present in the alternate vector in 3 patients but improved at first outpatient follow-up in 2 patients, allowing tachy therapies to be reenabled. Eight studies involving 27 patients were identified in the systematic review. EMI was common and frequently absent in the alternate vector (6 of 7 patients). Undersensing and EMI are common after LVAD implantation in patients with an S-ICD in situ, particularly in the primary and secondary sensing vectors. Undersensing in the alternate vector may improve during follow-up, obviating the need for device revision or extraction.

Carbon Monoxide Diffusing Capacity Predicts Cardiac Readmission in Patients Undergoing Left Ventricular Assist Device Implantation

The use of a left ventricular assist device (LVAD) is an effective therapeutic option for advanced heart failure. Patients with heart failure have impaired carbon monoxide diffusing capacity (DLco), which has not been well investigated in the LVAD population. Thus, we explored the predictive value of preoperative DLco in the survival and cardiac readmission rates in patients undergoing LVAD implantations in Japan. Patients who (i) received continuous-flow LVAD as bridge-to-transplant therapy from November 2007 to September 2018 at our institution, (ii) were more than 16 years old, (iii) were not converted from extracorporeal LVAD (iv) survived until discharge, and (v) underwent pulmonary function tests before LVAD implantation were included. The eligible patients were divided into 2 groups according to preoperative percent of predicted DLco (%DLco).The primary endpoints were all-cause death and hospital readmission for heart failure or arrhythmia (cardiac readmission). We retrospectively examined the records of 76 patients, resulting in 45 patients in the low DLco group (%DLco <80%) and 31 patients in the high DLco group (%DLco ≥80%). The 2-year cardiac readmission rate was 33.5% of the patients in the low DLco group and 8.7% in the high DLco group (p = 0.028). However, the mortality rate was not different between the two groups. %DLco was found to be associated with cardiac readmission in the univariate and multivariate analyses (hazard ratio 4.32, 95% confidence interval 1.50-15.9, p = 0.005). Low %DLco is a risk factor of cardiac readmission in patients undergoing LVAD implantation.

The Clinical Importance of Functional Mitral Regurgitation and Atrial Fibrillation in Patients with Left Ventricular Assist Device

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. The aim of this study is to investigate the prognostic significance of FMR and AF in patients with LVAD. We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We excluded patients who had previous or concomitant mitral valve procedure and patients who had insufficient quality of echocardiographic images. We defined significant FMR as MR color jet area / left atrial area > 0.2 and AF as persistent AF at LVAD implantation. 427 patient's charts were reviews (125 patients had previous or concomitant mitral valve procedure and 31 patients had insufficient quality of echocardiographic images). 271 were included in this analysis. Mean age of cohort was 57.1 +/-13.0 years, and 84% were male. Of all, 110 (41%) patients had significant FMR and 51 (19%) patients had persistent AF. Patients were divided into 4 groups: no AF and no significant FMR (Group1, n=136), no AF and significant FMR (Group 2, n=84), AF and no significant FMR(Group 3, n=25), and AF and significant FMR (Group 4, n=26). Forty-four (16%) patients died within 2years. Kaplan-Meier curve analysis demonstrated 2-year survival of 77% in Group 1, 87% in Group 2, 92% in Group 3, and 47% in Group 4 (P=0.0006). On the multivariate Cox proportional hazard model Group 4 was significant predictor of mortality [hazard ratio (HR), 2.62; 95% confidence interval (CI),1.27-5.41; P =0.009], independently of other parameters. Coexistence of significant FMR and AF is a poor prognostic marker in patients undergoing LVAD implantation.

Safety and Efficacy of Single Dose Del Nido Cardioplegia Solution in Left Ventricular Assist Device Implantation- A Propensity Matched Study

Del Nido cardioplegia (DN) has recently become more in common use as a "single" dose cardioplegia in adult cardiac surgery. However, it is not well described in left ventricular assist device (LVAD) surgery. The purpose of this study was to summarize our clinical experience with single dose DN solution in LVAD implantation and to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB). A total of 524 consecutive patients underwent LVAD implantation between July 2008 and August 2019. Among them, 137 patients who required aortic cross-clamp for concomitant cardiac procedures were included in this study. The DN protocol was to administer the initial dose as a single dose. CWB was given every 20 minutes. Propensity matching identified 40 matched pairs for analysis. Cross-clamp time was significantly shorter in the DN group compared with the CWB group (58± 20 min vs. 70± 33 min, p=0.0497). The retrograde cardioplegia technique was used in 6 (15.0%) patients in the DN group and 36 (90.0%) patients in the CWB group (p<0.0001). There were no significant differences in the rates of postoperative prolonged use of inotropes (>14 days) (DN: 3/40, 7.5% vs. CWB: 3/40, 7.5%, p=1), requiring postoperative right VAD (DN: 2/40, 5.0% vs. CWB: 2/40, 5.0%, p=1), and requiring blood transfusion (Table). Freedom from re-admission at 1 year was similar between two groups (DN: 69.6±7.7% vs. CWB: 74.3±7.5%, Log-Rank p=0.5522). Mid-term clinical outcomes in the patients undergoing LVAD implantation with the DN protocol was acceptable. This study showed the DN protocol was associated with shortened cross-clamp time and less frequent usage of the retrograde cannula technique.

A Novel Method for Evaluation of Right Ventricular Performance during Left Ventricular Assist Device Implantation

Left ventricular assist devices (LVAD) are utilized in patients diagnosed with advanced heart failure. Right ventricular (RV) failure can affect up to 20% of patients undergoing LVAD implantation. In this case study, we evaluated perioperative RV performance with simultaneous use of Swan-Ganz catheterization and high-fidelity conductance catheters to generate real time RV pressure- volume (PV) loops. A 75- year old male patient undergoing LVAD implantation was chosen for evaluation. A high-fidelity conductance catheter was advanced into the RV. The catheter was removed on postoperative day one. Data obtained from the catheter were used to evaluate RV work, contractility, diastolic function, and compliance. These results were compared to standard measurements of the patient's clinical status and biventricular performance. Consent and IRB approval was obtained as part of an ongoing study. The patient developed RV dysfunction in the immediate perioperative period, as demonstrated by increasing central venous pressure to pulmonary artery pressure ratio, decreased cardiac index, and evidence of elevated filling pressures by echocardiogram. Using a high-fidelity catheter, we demonstrated a uniform reduction in preload recruitable stroke work and Starling contractile index on postoperative day one. Pressure-volume loops initially demonstrated appropriate ventricular unloading, however RV dysfunction was exposed with changes in loading conditions over time (figure 1). Pressure-volume loop analysis represents a novel method for evaluation of RV performance during LVAD implantation. Compared to standard monitoring, PV loops provide increased granularity in understanding RV function.

Psoas Muscle Area Serves as Prognostic Marker in Patients Receiving Left Ventricular Assist Device Implantation

Several risk scores and classifications are available to predict peri- and post-operative mortality of patients with end stage heart failure receiving Left Ventricular Assist Device (LVAD) implantation. The INTERMACS classification is most commonly used but recently assessment of sarcopenia has been suggested as additional predictor for post-operative outcome. Therefore, we evaluated whether or not psoas muscle area can serve as additional prognostic marker. A retrospective analysis on our patient cohort in the time span from January 2014 to April 2019 was performed. During that time period a total of 178 adult LVAD implantations were performed (Heart Ware n=42, HeartMate II n=4, HeartMate III n=61). Of those, 107 patients received an abdominal CT scan prior to surgery. Psoas mean area at level of the superior endplate of the third lumbar vertebra was measured axially corrected and correlated with patients body surface area, giving the indexed psoas mean area (PMAi). Patients then were divided in high or moderate muscle mass and low muscle mass in accordance to patient sex. Estimated survival calculated using the Kaplan-Meier-curve found a significant higher 30-day mortality in patients with low PMAi (log rank: 0.009). Whereas no differences were observed concerning in-hospital, 90-day and 1-year mortality. Lower muscle mass also had no impact on the length of ICU stay or necessity of temporary RVAD. Comparison of the distribution on the INTERMACS classification, revealed that patients with lower muscle mass had a higher probability to classify as INTERMACS level 1 or 2 (Level 1: 21% vs. 38.1%; Level 2: 14.8% vs. 23.8%). Patients with low PMAi in our cohort represented the sicker patients and had statistically significant higher short-term mortality. These findings suggest that PMAi can be used as an additional tool for risk stratification in patients undergoing LVAD implantation.

Racial Disparities among Patients Undergoing Left Ventricular Assist Device: A Single Center Experience

The impact of race on outcomes of left ventricular assist device (LVAD) recipients remains a topic of debate as prior studies have demonstrated inconsistent results. We thought to investigate clinical outcomes of Hispanics LVAD recipients compared to Caucasians and African Americans at our institution. We retrospectively identified LVAD recipients between 2009 and 2018. Patients were stratified according to race. Demographics and clinical acuity data were collected. The primary endpoint was survival. Secondary outcomes included the incidence of thrombosis, neurological events (NE), infection (INX), and right heart failure (RHF). The Kaplan-Meier method was used to compare survival between the two groups. The Cox proportional hazards regression model was used to conduct multivariable analysis. A total of 147 patients were included in the analysis (62 Hispanics, 39 Caucasians, 46 African Americans). The prevalence of hypertension was highest among Hispanics (69%) compared to Caucasians (41%) and African Americans (54%), p = 0.018. Similarly, more Hispanics suffered from diabetes (55%, 31%, 30%, p = 0.015). Unadjusted 1-year survival was not significantly different among the groups (p = 0.222 by log-rank test). Among the clinical acuity factors analyzed, total bilirubin was a predictor of mortality (HR 1.24 95% CI 1.05-1.47, p = 0.010). The incidence of thrombosis, NE, INX, and RHF were not significantly different among the three groups. Race does not appear to impact clinical outcomes of advanced heart failure patients undergoing LVAD implantation. Total bilirubin at the time of LVAD implantation is a strong predictor of mortality.

Symptom Frequency and Severity over Time for Patients Undergoing LVAD Implantation

Patients (pts) with advanced heart failure (HF) describe debilitating HF-related symptoms. Those who undergo left ventricular assist device (LVAD) implantation report new surgical and device-related symptoms. We sought to quantify change in both HF and LVAD-related symptoms over time. Using a longitudinal design, we evaluated data at baseline, 3, and 6 months (mos) post implant at 9 U.S. sites from 10/26/16 - 9/9/19. Measures assessed HF symptoms: fatigue (PROMIS, v1.0), dyspnea (10-item short form), swelling in extremities, abdominal bloating, poor appetite (single items), and LVAD-related symptoms: severity of pain at driveline exit site and chest incision, severity of discomfort wearing LVAD peripherals, and frequency of dizziness and fluid leaking around driveline exit site (single items). Linear mixed effects models were estimated using all available longitudinal data, assuming a missing at random mechanism. Pts (n=126) were primarily male (72%) and non-Hispanic White (62%), with mean age= 55±11.7 years. HF symptoms (i.e., fatigue, dyspnea, extremity swelling, abdominal bloating, and poor appetite) decreased from before to after implant (table). From 3-6 months after LVAD implant, severity of driveline exit site pain was none-mild and did not change; severity of chest incision pain was mild and decreased from 3 to 6 months; discomfort wearing peripherals was mild-moderate with no change, dizziness occurred rarely to occasionally and did not change, and fluid leaking at the driveline exit site occurred never to rarely and did not change (table). Using novel measures, pts with advanced HF experienced considerable improvement of HF symptoms after LVAD implant. However, pts also reported mild/moderate discomfort wearing LVAD-related peripherals, which did not change over time. Other LVAD-related symptoms were less frequent or no more than mild in severity. These findings provide important information for pt decision making and should guide device design.

Outcomes of gastrointestinal bleeding in patients with left ventricular assist devices: a tertiary care experience.

Background and study aims Left ventricular assist device (LVAD) placement is a therapeutic modality for patients with end-stage heart failure. Gastrointestinal bleeding is a common complication following LVAD implantation. The aim of this study was to report our experience in management and outcomes of gastrointestinal bleeding in a large cohort of patients with LVADs. Patients and methods We performed a retrospective review of all patients who underwent LVAD implantation at the University of Rochester Medical Center from January 2008 to June 2017. Data were collected on patient characteristics, clinical aspects of gastrointestinal bleeding events, and procedural interventions. A Cox proportional hazard model was utilized to identify potential risk factors for a gastrointestinal bleeding event. Results During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2 %) experienced 297 gastrointestinal bleeding events resulting in 533 endoscopic procedures. The diagnostic yield of endoscopy in determining a bleeding source was 49.5 %. If required, therapeutic interventions were successful in achieving homeostasis in 96.2 % of procedures. Our 30-day overall post-procedure adverse event (AE) rate was 6.6 %. Procedure-related (bleeding, infection, and perforation) AEs were very minimal (2.8 %). A Cox proportional hazard model indicated that older age at implant, female sex, African-American race, diabetes mellitus, and pulmonary hypertension were statistically significant predictors of a gastrointestinal bleeding event following LVAD implantation. Conclusions LVAD patients have a high risk of gastrointestinal bleeding. Endoscopy was able to safely locate a bleeding lesion in approximately half of our patients and was successful in treating bleeding lesions in a majority of the cases.

Impact of Atrial Fibrillation on In-Hospital Mortality and Thromboembolic Complications after Left Ventricular Assist Device Implantation.

The association between atrial fibrillation (AF) and thromboembolic (TE) complications in left ventricular assist device (LVAD) recipients is controversial, and there is paucity of large-scale data evaluating the impact of AF on early outcomes after device implantation. Using the National Inpatient Sample, we identified hospitalizations where patients underwent LVAD implantation from 2010 to 2015. Multivariate logistic regression was used to evaluate the association of AF on in-hospital outcomes. A total of 18,378 patients (41.7% with AF) underwent LVAD implantation. Patients with AF were older (59.9 vs. 54.0years, p< 0.001), more commonly male (79.9 vs. 74.1%, p< 0.001), and had a greater burden of comorbidities as measured by the Elixhauser comorbidity index (7.2 vs. 6.3, p< 0.001). Patients with AF had less incidence of ischemic stroke (3.1 vs. 4.7%, p= 0.04, OR 0.68), hemorrhagic stroke (1.0 vs. 2.4%, p= 0.006, OR 0.43), and other systemic embolism (1.8 vs. 3.7%, p= 0.01, OR 0.55). There was no significant difference in the incidence of bleeding requiring transfusion between AF and no AF cohorts (29.3 vs. 24.2%, p= 0.09, OR 1.15). LOS was shorter in patients with AF (32.9 vs. 36.7 mean days, p< 0.001). Patients with AF had lower in-hospital mortality (8.9 vs. 14.9%, p< 0.001, OR 0.48). In a large real-world US cohort of patients undergoing LVAD implantation, a diagnosis of AF was common among device recipients. After adjustment for demographics and comorbidities, AF was associated with reduced TE events and in-hospital mortality.

Controlling Nutritional Status Score As a Predictive Marker for Patients With Implantable Left Ventricular Assist Device.

Although a correlation between the nutritional status and the prognosis of patients with heart failure has been suggested, a correlation between the nutritional status and outcomes after the left ventricular assist device (LVAD) implantation remains unclear. We aimed to investigate the efficacy of the Controlling Nutritional Status (CONUT) score (range 0-12, including serum albumin, total cholesterol, and lymphocytes) as a nutritional index in speculating the prognosis of patients undergoing LVAD implantation. We examined 63 consecutive patients who underwent the continuous-flow LVAD implantation. Using the preoperative CONUT score, patients were categorized into two groups: lower CONUT score (0-4: normal to mild malnutrition) and higher CONUT score (5-12: moderate to severe malnutrition). We compared for the backgrounds and the clinical events after LVAD implantation. The higher CONUT group exhibited a significantly higher mean right atrial pressure (10.9 ± 4.7 vs. 7.3 ± 4.1 mmHg; p = 0.0019). In that group, the mortality rate was significantly higher (25% vs. 2.6%; p = 0.0059) and the Kaplan-Meier analysis showed lower survival rate. Furthermore, more bleeding events significantly occurred in the higher CONUT group. The preoperative CONUT score may reflect systemic venous congestion and offer a useful prognostic index of clinical courses after LVAD implantation.

Clinical Implications of Respiratory Failure in Patients Receiving Durable Left Ventricular Assist Devices for End-Stage Heart Failure.

The impact of respiratory failure on patients undergoing left ventricular assist device (LVAD) implantation is not well understood, especially since these patients were excluded from landmark clinical trials. We sought to evaluate the associations between immediate preimplant and postimplant respiratory failure on outcomes in advanced heart failure patients undergoing LVAD implantation. We included all patients in the Interagency Registry for Mechanically Assisted Circulatory Support who were implanted with continuous-flow LVADs from 2008 to 2016. Of the 16 362 patients who underwent continuous-flow LVAD placement, 906 (5.5%) required preimplant intubation within 48 hours before implantation, and 1001 (6.1%) patients developed respiratory failure within 1 week after implantation. A higher proportion of patients requiring preimplant intubation were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, required mechanical circulatory support, and presented with cardiac arrest or myocardial infarction (P<0.001, all). At 1 year, 54.3% of patients intubated preimplant were alive without transplant, 20.1% had been transplanted, and 24.2% died before transplant. Patients requiring preimplant intubation had higher rates of postimplant complications, including bleeding, stroke, and right ventricular assist device implantation (P<0.01 for all). Among Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients, preimplant intubation incurred additional risk of death at 1 year compared with Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients not intubated (hazard ratio, 1.37 [95% CI, 1.13-1.65]; P=0.001). After multivariable analysis, both preimplant intubation (hazard ratio, 1.20 [95% CI, 1.03-1.41]; P=0.021) and respiratory failure within 1 week (hazard ratio, 2.54 [95% CI, 2.26-2.85]; P<0.001) were associated with higher all-cause 1-year mortality. Respiratory failure both before and after LVAD implantation identifies an advanced heart failure population with significantly worse 1-year mortality. This data might be helpful in counseling patients and their families about expectations about life with an LVAD.

Right Ventricular Failure Post-Implantation of Left Ventricular Assist Device: Prevalence, Pathophysiology, and Predictors.

Despite advances in left ventricular assist device (LVAD) technology, right ventricular failure (RVF) continues to be a complication after implantation. Most patients undergoing LVAD implantation have underlying right ventricular (RV) dysfunction (either as a result of prolonged LV failure or systemic disorders) that becomes decompensated post-implantation. Additional insults include intra-operative factors or a sudden increase in preload in the setting of increased cardiac output. The current literature estimates post-LVAD RVF from 3.9% to 53% using a diverse set of definitions. A few of the risk factors that have been identified include markers of cardiogenic shock (e.g., dependence on inotropes and Interagency Registry for Mechanically Assisted Circulatory Support profiles) as well as evidence of cardiorenal or cardiohepatic syndromes. Several studies have devised multivariable risk scores; however, their performance has been limited. A new functional assessment of RVF and a novel hepatic marker that describe cholestatic properties of congestive hepatopathy may provide additional predictive value. Furthermore, future studies can help better understand the relationship between pulmonary hypertension and post-LVAD RVF. To achieve our ultimate goal-to prevent and effectively manage RVF post-LVAD-we must start with a better understanding of the risk factors and pathophysiology. Future research on the different etiologies of RVF-ranging from acute post-surgical complication to late-onset RV cardiomyopathy-will help standardize definitions and tailor therapies appropriately.

Prediction of acute kidney injury after left ventricular assist device implantation: Evaluation of clinical risk scores.

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVADpatients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the ClevelandClinicScore (CCS), the SocietyofThoracicSurgeonsScore (STS), and the Simplified Renal Index Score(SRI) were evaluated. 76 patients underwent LVADimplantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stayon the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P<.01). Whereas the Thakar Score (7.43±1.75 vs 6.44±1.44, P=.02) and the Mehta Score (28.12±15.08 vs 21.53±5.43, P=.02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96±1.15 vs 3.44±1.05, P=.08). Using ROCanalyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P=.040), 0.637±0.079 (P=.792), and 0.618±0.075 (P=.764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De RitisRatio (OR 2.67, P=.034) and MELD (OR 1.11, P=.028) were identified as predictors of postoperative RRT. Risk scores which arepredictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population.

P3440Can pre-operative echocardiography predict RV failure post-LVAD implantation in children?

Abstract Background One of the most frequent complications of left ventricular assist device (LVAD) implantation is the development of right ventricular (RV) failure, which occurs in 10%-40% of patients. It is, therefore, essential to identify which LVAD candidates are at risk for RV failure and will require additional RV mechanical support with a biventricular assist device (BiVAD). However, the echocardiographic assessment of the RV is challenging due to its complex geometry and marked load dependence of its function indices. To our knowledge, there is no published evidence regarding which specific RV echocardiographic parameters should inform this decision in the paediatric population. Aims We sought to determine which pre-operative RV echocardiographic parameters best correlate with the need for a BiVAD, as opposed to LVAD alone, in a paediatric population undergoing VAD insertion at a tertiary care institution. Methods Retrospective review of the pre-operative echocardiograms of children (&lt;18 years) with dilated cardiomyopathy undergoing elective VAD implantation at our institution, from November 2007 to December 2018. Preoperative quantitative and qualitative RV echocardiographic parameters described in the literature to be associated with RV failure after LVAD implantation in adults were collected. Moreover, qualitative RV function was independently assessed by three echocardiographers, blinded to the outcome of the patients. Results 89 patients were included, 39 (43.8%) males, median age = 1.7 years (IQR = 6.9), median weight = 11.6 kg (IQR = 13.8). 49 (55.1%) patients had an LVAD implanted, whereas 40 (44.9%) were deemed to need biventricular support. 45 (50.6%) patients received an EXCOR Berlin Heart, 16 (18%) a HeartWare HVAD and 28 (31.4%) a Levitronix Centrimag device. Requirement of BiVAD support was significantly more common in patients with moderate to severe RV impairment, as per expert assessment (OR = 2.864; 95% CI: 1.188–6.903, p=0.018), and tricuspid regurgitation &gt; grade III (OR = 3.154; 95% CI: 1.124–8.850, p=0.025). All the other parameters collected – tricuspid annular plane systolic excursion (TAPSE), tricuspid regurgitant jet velocity, tricuspid regurgitation duration corrected for heart rate, RV tissue Doppler indices, RV fractional area change, and RV/LV diameter ratio– were not significantly different among groups. Conclusions In our paediatric population, expert assessment of RV function and degree of tricuspid regurgitation were strong predictors of RV failure among patients undergoing LVAD implantation, allowing for pre-emptive RVAD implantation and improving patient outcomes.

Incidence, Trends and Predictors of Palliative Care Consultation among Patients Admitted for LVAD Implantation in the United States

Aim Left ventricular assist devices (LVAD) have become an important part of advanced heart failure management either as a bridge to transplantation or destination therapy. Patients with advanced heart failure have a poor prognosis and may benefit from palliative care (PC) services. However, there is scarce data regarding the incidence, trends, and predictors of palliative care consultation among patients undergoing LVAD implantation. The main objective of this study is to assess the incidence, trends, and predictors of PC referral in LVAD recipients using the Nationwide Inpatient Sample (NIS) database from 2010 till 2014. Methods We conducted a weighted analysis on patients who underwent LVAD implantation during their index hospitalization in the 2010 - 2014 NIS data. We compared those who had palliative care referral with those who did not. We further examined the trend in palliative care utilization. Adjusted odds ratio (aOR) was calculated to identify patients’ demographic, social and hospital characteristics associated with PC consult using multivariable logistic regression analysis. Results A total of 13,825 admissions (mean age: 57.02+13.4 years, 23.3% female) who had LVAD implantation were identified. Also, 559 (4.2%) had PC during the hospital stay. PC referral increased in the time frame from 14 per 1000 LVAD implantations in 2010 to 55 per 1000 in 2014 (P=0.001). Age≥75years (aOR 1.61), higher median household income (aOR 1.746), female (aOR 1.43), cardiac arrest (aOR 1.46) were associated with higher PC referral. PC referral was also higher in private owned hospitals when compared to government-owned hospitals (aOR 2.4). Midwest had higher PC referrals compared with Northeast region (aOR 1.768). Mortality was significantly higher among those who had PC referral (aOR 10.76) Conclusion There was an increase in trends for in-hospital PC referral in LVAD admissions over the 5-year study period. However, the overall rate of PC referrals during the index hospitalization remains low. Significant mortality among patients with PC referral may reflect the erroneous belief that palliative care consultation is only indicated among those with a higher likelihood of dying after the procedure.

Association of Atrial Fibrillation and Postoperative Right Ventricular Failure after Left Ventricular Assist Device Implantation: Systematic Review and Meta-Analysis

Background Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Atrial fibrillation (AF) is a common arrhythmia in advanced heart failure patients undergoing LVAD implantation. Studies have shown that AF is a predictor for RVF in decompensated heart failure patients. Little is known about the association between AF and risk of developing RVF early after LVAD implantation. Method We performed a comprehensive literature search through March 2019 using MEDLINE, EMBASE, Scopus and the Cochrane Library. Included studies were prospective or retrospective cohort studies that compared the risk of developing postoperative RVF or use of emergent/unplanned right ventricular assist device (RVAD) after LVAD implantation in patients with and without AF. We calculated the pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic using the random-effect model. Results Nine studies were included in the analysis. The pooled prevalence of AF was 31%. Postoperative RVF after LVAD implantation was reported in 6 studies involving 1,575 patients (581 AF, 994 non-AF) and unplanned RVAD implantation was reported in 6 studies involving 2,089 patients (640 AF, 1449 non-AF). The incidence of postoperative RVF was 37% and 32% in patients with and without AF, respectively. The incidence of unplanned RVAD implantation was 15% and 12% in patients with and without AF, respectively. There is a significant association between AF and postoperative RVF (OR=1.29, 95%CI=1.03-1.61: p=0.03) but not between AF and unplanned RVAD implantation (OR=1.29, 95%CI=0.96-1.75: p=0.09) (See Figure 1). Conclusions Our meta-analysis suggests that concomitant AF was common in patients undergoing LVAD implantation. The presence of AF is associated with an increased risk of postoperative RVF but not unplanned RVAD support following LVAD implantation.

Longer Duration of Milrinone Associated with Higher Risk for Right Ventricular Failure Following Left Ventricular Assist Device Implantation in Stage D Heart Failure Patients

Background Milrinone is a phosphodiesterase inhibitor that is used for the management of end stage heart failure (HF) patients, either as a palliative treatment or as a bridge to advanced HF therapies. Left ventricular assist device (LVAD) implantation has become a mainstay of advanced HF therapies, due to the limited number of available hearts for transplant. Unfortunately, up to 20% to 40% of device implantations are complicated by right ventricular failure (RVF), which results in significant morbidity and mortality. We aimed to investigate whether the duration on milrinone infusion is an independent risk factor for RVF following LVAD implantation. Methods This was a retrospectively review of medical records. We included all adult with ACC/AHA stage D HF patients who underwent LVAD implantation at our institution between January, 2010 and December, 2018. Patients were divided into two groups, those on short term ( 30 days) milrinone infusion. The primary endpoint for this study was the incidence of severe RVF (need for RV assist device or inotropic support for more than 14 days after LVAD) within 30 days post LVAD implantation. Results Total of 104 patients underwent LVAD implantation. Short term (STM) group had 55 pts and long term (LTM) had 49 patients. There were no significant differences between STM and LTM patients at baseline demographic, echocardiographic and right heart catheterization data. Following LVAD implantation, 5 (9.1%) patients in the STM group versus 9 (18.4%) in the LTM group needed RVAD support, and, 9 (16.4%) patients versus 22 (44.9%) needed inotropic support for more than 14 days (Figure 1). Overall, 45 (43.3%) patients developed RVF. LTM patients had a higher incidence of RVF; OR= 5.04 (95% CI 2.18 - 11.68), P=0.0002. After adjusting for age, gender, baseline RV function, atrial fibrillation, coronary artery disease, cerebrovascular disease, chronic kidney disease, and diabetes mellitus, the OR was 6.33 (95% CI 2.51 - 15.93), P Conclusion Longer duration on inotropes was associated with significantly higher incidence of early right ventricular failure following LVAD implantation.

Outcomes after tricuspid valve surgery concomitant with left ventricular assist device implantation in the EUROMACS registry: a propensity score matched analysis.

Tricuspid regurgitation (TR) is common in patients receiving a left ventricular assist device (LVAD). Controversy exists as to whether concomitant tricuspid valve surgery (TVS) is beneficial in currently treated patients. Therefore, our goal was to investigate the effect of TVS concomitant with a LVAD implant. The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients. Matched patients with and without concomitant TVS were compared using a propensity score matching strategy. In total, 3323 patients underwent LVAD implantation of which 299 (9%) had TVS. After matching, 258 patients without TVS were matched to 258 patients with TVS. In the matched population, hospital deaths, days on inotropic support, temporary right ventricular assist device implants and hospital stay were comparable, whereas stay in the intensive care unit was higher in the TVS cohort (11 vs 15 days; P = 0.026). Late deaths (P = 0.17), cumulative incidence of unexpected hospital readmission (P = 0.15) and right heart failure (P = 0.55) were comparable between patients with and without concomitant TVS. In the matched population, probability of moderate-to-severe TR immediately after surgery was lower in patients with concomitant TVS compared to patients without TVS (33% vs 70%; P = 0.001). Nevertheless, the probability of moderate-to-severe TR decreased more quickly in patients without TVS (P = 0.030), resulting in comparable probabilities of moderate-to-severe TR within 1.5 years of follow-up. In matched patients, TVS concomitant with LVAD implant does not seem to be associated with better clinical outcomes. Concomitant TVS reduced TR significantly early after LVAD implant; however, differences in probability of TR disappeared during the follow-up period.

Managing Intracranial Hemorrhage in Patients with a Durable Continuous Flow Left Ventricular Assist Device

Background&#x0D; While intracranial hemorrhage (ICH) is a known complication of left ventricular assist device (LVAD) support, and is associated with high morbidity and mortality, optimal care pathways have neither been elucidated nor reported. We describe management of LVAD patients following ICH, with a focus on anticoagulation, operative interventions, care team designation, complications, and outcomes.&#x0D; Methods&#x0D; We retrospectively reviewed all durable continuous-flow LVAD implantations at our academic medical center from January 2007 to July 2018. Patients who experienced ICH after LVAD were identified. We defined baseline and ICH characteristics, medical and surgical interventions, care teams, and outcomes including death, device thrombosis, ischemic stroke, and hemorrhage expansion.&#x0D; Results&#x0D; A total of 321 patients underwent LVAD implantation during the study period, and 27 (8%) developed ICH (17 intraparenchymal, 7 subdural, 2 subarachnoid, 1 intraventricular) while on support. Twenty-five were anticoagulated at onset of bleed. Of those, 13 were managed with immediate cessation of anticoagulation and administration of reversal products (Group A). Group A had a median of 6 days off anticoagulation and 60 days of follow up with 1 patient (8%) developing device thrombosis at day 8, 1 (8%) developing subsequent ischemic stroke at day 14, and 4 (31%) with ICH expansion. Seven patients had anticoagulation stopped at onset of bleed without administration of reversal products (Group B). With a median of 2 days off anticoagulation and 2 days of follow up, no patients in Group B developed ischemic stroke or device thrombosis while 1 (14%) had ICH expansion. Five patients had anticoagulation continued at onset of bleed (Group C) with a median follow up of 330 days. One (20%) developed device thrombosis at day 5 while 2 (40%) developed ICH expansion. Four patients with subdural hemorrhage underwent Burr hole drainage with all 4 surviving to discharge. Two patients with intraparenchymal hemorrhage underwent open craniotomy with neither surviving to discharge. An interdisciplinary discussion occurred in all cases. Following ICH, only one-third of patients in the study survived to 6 months.&#x0D; Conclusion&#x0D; LVAD patients who experience an ICH have variable outcomes. Their care is multidisciplinary and can involve operative intervention. The discontinuation and reversal of anticoagulation is generally well-tolerated, with a low risk for early device thrombosis. Like for many hemorrhagic complications of LVADs, ICH often persists or worsens. Additional investigation is needed to elucidate the most optimal management strategies.