Right Ventricular Assist Device Research Articles

In vitro Hemocompatibility Evaluation of the HeartWare Ventricular Assist Device Under Systemic, Pediatric and Pulmonary Support Conditions

The development of adult use right ventricular assist devices (RVADs) and pediatric left ventricular assist devices (pediatric LVADs) have significantly lagged behind compared to adult use left ventricular assist devices (LVADs). The HeartWare ventricular assist device (HVAD) intended to be used for adult's systemic support, is increasingly used off-label for adult pulmonary and pediatric systemic support. Due to different hemodynamics and physiology, however, the HVAD's hemocompatibility profiles can be drastically different when used in adult pulmonary circulation or in children, compared to its intended usage state, which could have a direct clinical and developmental relevance. Taking these considerations in mind, we sought to conduct in vitro hemocompatibility testing of HVAD in adult systemic, pediatric systemic and adult pulmonary support conditions. Two HVADs coupled to custom-built blood circulation loops were tested for 6 hours using bovine blood at 37°C under adult systemic, pediatric systemic, and adult pulmonary flow conditions (flow rate = 5.0, 2.5, and 4.5 L/min; differential pressure = 100, 69, and 20 mm Hg, respectively). Normalized index of hemolysis for adult systemic, pediatric systemic, and adult pulmonary conditions were 0.0083, 0.0039, and 0.0017 g/100 L, respectively. No significant difference was seen in platelet activation for these given conditions. High molecular weight von Willebrand factor multimer degradation was evident in all conditions (p < 0.05). In conclusion, alterations in the usage mode produce substantial differences in hemocompatibility of the HVAD. These findings would not only have clinical relevance but will also facilitate future adult use RVAD and pediatric LVAD development.

Statistics of heart failure and mechanical circulatory support in 2020.

Heart failure is increasing in prevalence, with approximately 26 million patients affected worldwide. This represents a significant cause of morbidity and mortality. Statistics regarding heart failure patient age, hospitalization likelihood, and mortality differ significantly by country. Heart failure patients are typically classified by ejection fraction, with distinct phenotypes associated with reduced ejection fraction (rEF) or preserved ejection fraction (pEF). Heart failure has a significant financial impact related to hospitalization, medication, and procedural expenses. The costs of heart failure also extend to the reduced quality of life conferred by heart failure symptoms. Management of heart failure includes a variety of interventions, including mechanical circulatory support (MCS). MCS, including left ventricular assist devices (LVADs), right ventricular assist devices (RVADs) and extracorporeal membrane oxygenation (ECMO), has been a means of managing end stage heart failure. Given the relative scarcity of transplant organs, the utilization of MCS, particularly as a bridge to transplantation (BTT) has grown significantly. In this review, we discuss statistics related to heart failure and MCS. We evaluate how patients are classified and examine global trends and regional differences. We then address MCS therapies, the costs associated with heart failure, the impact of heart failure on patient quality of life, and data regarding morbidity and mortality.

Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices.

Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies are needed.

Outcomes of percutaneous temporary biventricular mechanical support: a systematic review.

Percutaneous biventricular assist devices (BiVAD) are a recently developed treatment option for severe cardiogenic shock. This systematic review sought to identify indications and outcomes of patients placed on percutaneous BiVAD support. An electronic search was performed to identify all appropriate studies utilizing a percutaneous BiVAD configuration. Fifteen studies comprising of 20 patients were identified. Individual patient survival and outcomes data were combined for statistical analysis. All 20 patients were supported with a microaxial LVAD, 12/20 (60%) of those patients were supported with a microaxial (RMA) right ventricular assist device (RVAD), and the remaining 8/20 (40%) patients were supported with a centrifugal extracorporeal RVAD (RCF). All patients presented with cardiogenic shock, and of these, 12/20 (60%) presented with a non-ischemic etiology vs 8/20 (40%) with ischemic disease. For the RMA group, RVAD support was significantly longer [RMA 5 (IQR 4-7) days vs RCF 1 (IQR 1-2) days, p = 0.03]. Intravascular hemolysis post-BiVAD occurred in three patients (27.3%) [RMA 3 (33.3%) vs RCF 0 (0%), p = 0.94]. Five patients received a durable left ventricular assist device, one patient received a total artificial heart, and one patient underwent a heart transplantation. Estimated 30-day mortality was 15.0%, and 78.6% were discharged alive. Both strategies for percutaneous BiVAD support appear to be viable options for severe cardiogenic shock.

Direct right ventricular Impella LD implantation enables postoperative ambulation and may avoid sternal re‐entry

Right ventricular assist devices (RVADs) typically require groin cannulation or sternal re-entry which can be avoided by direct pulmonary artery implantation with an Impella. We report the first use of the Impella LD as a directly implanted RVAD.

Temporal trends and outcomes of patients waiting on left ventricular assist devices and inotropes for heart transplantation.

We sought to evaluate the trends and outcomes of patients with left ventricular assist devices (LVADs) and inotropes at the time of listing for heart transplantation. Adults with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between 2010 and 2017. Patients were grouped according to the presence or absence of inotropes at the time of listing and transplantation. A total of 2714 patients were included in the study including 664 patients on inotropes at the time of listing, 235 at the time of transplantation, and 118 on inotropes both at listing and at the time of transplantation. Patients on LVAD and inotropes at the time of listing were more frequently supported with a right ventricular assist device (RVAD) (P<.001), had higher risk of death in the waiting list (sub-hazard ratio [SHR]=1.48, 95% CI 1.14-1.90, P=.002), and were less likely to be transplanted (SHR=0.70, 95% CI 0.63-0.78, P<.001) compared with those not on inotropes, after adjusting for described confounders. Approximately 1 in 10 LVAD recipients listed as status 1A are on inotropic therapy at the time of heart transplantation. Patients on LVAD and inotropes have worse outcomes in terms of survival and lower rates of transplantation.

Right Ventricular Device HeartWare Implant to the Right Atrium with Fixation to the Chest Wall in Patient with Biventricular Support.

Right Ventricular Device HeartWare Implant to the Right Atrium with Fixation to the Chest Wall in Patient with Biventricular Support.

Concurrent RVAD Improves Survival for Patients with RV Failure at the Time of LVAD Implantation

Right ventricular (RV) failure is associated with poor outcomes after left ventricular assist device (LVAD) placement. This can be treated with a temporary right ventricular assist device (RVAD), which ideally should be placed before the development of multisystem organ failure. The purpose of this study was to determine if there is any outcome difference in patients who underwent early or concurrent RVAD as compared to delayed RVAD implantation. Via retrospective chart review, 32 patients who received temporary RVAD (30 CentriMag and 2 Protek Duo) were identified between 1/2013 and 7/2018. Subjects were divided into two groups as concurrent RVAD placement (defined as RVAD at the time of LVAD implantation) versus delayed RVAD placement (defined as an RVAD placed at any time after leaving the operating room for the LVAD implant). Survival, ICU and total length of stay (LOS), and total number of days on RVAD were compared utilizing Chi-square and two tailed t-test. Patients in the concurrent RVAD group had higher preoperative central venous pressure (p = 0.037). Survival rate at three months (χ² = 6.647, p 0.010) and one year (χ² = 3.983, p 0.046) was statistically significantly better among patients who received concurrent LVAD. ICU LOS, total hospital LOS, and number of days on RVAD were not statistically significant between the two groups. Concurrent placement of a temporary RVAD for patients with RV failure at the time of LVAD implantation improves short- and long-term survival post LVAD implantation as compared to a delayed RVAD approach.

Superior Vena Cava Syndrome from Percutaneous Right Ventricular Assist Device Use in Right Ventricular Failure

Percutaneous right ventricular assist device (RVAD) support with right internal jugular (IJ) vein access has emerged as a viable solution for treating refractory RV failure. Recent reports have shown that RVAD support with this approach can be beneficial in a variety of clinical scenarios including post cardiotomy RV failure, cardiogenic shock, and severe acute hypoxemic respiratory failure with associated RV dysfunction, as well as decreased mortality compared to surgically implanted RVADs. However, the safety profile of such devices has not been characterized. A comprehensive retrospective review was completed for all patients receiving percutaneous RVAD support via a right internal jugular route with either 28 or 31F cannula at our institution between April 2017 and December 2018. Preoperative patient demographics, intraoperative, and postoperative outcomes, with specific focus on device related complications. Fourty patients (27 men, 67.5%) with mean age of 52 years ± 15.6 and refractory RV failure were managed with a percutaneous RVAD inserted through the right IJ. Of these 40 patients, 3 (7.5%) patients demonstrated device related superior vena cava (SVC) syndrome resulting from obstruction of the SVC with the RVAD cannula. One patient managed by head of bed elevation and early removal of the device (I believe). Two were treated by connecting a "venting" tubing to the side port on the introducer sheath and placing into the ECMO circuit to for decompression. Symptoms resolved in all 3 patients and no deaths resulted from SVC syndrome. SVC syndrome related to percutaneous RVAD placement is an important, but previously undescribed postoperative complication of RVAD use. Early identification allows safe management of this complication, which does not detract from the safety of percutaneous RVAD support.

Pulmonary Artery Pulsatility Index (PAPi) is a Predictor of Right Ventricular Assist Device (RVAD) Use Following HeartMate 3 LVAD Implantation

Pulmonary artery pulsatility index (PAPi) recently emerged as a predictor of right ventricular failure after Heartmate II LVAD Implantation. Clinical utility of this marker in Heartmate 3 patients is unknown. We hypothesized that PAPi is a stronger predictor of RV failure compared to central venous pressure to pulmonary artery capillary wedge pressure ratio (CVP/PCWP) or RV stroke work index (RVSWI) in Heartmate 3 population. 175 patients who received a Heartmate 3 LVAD at a single academic center between 2014 - 2019 were included in the study. Primary outcome was right ventricular assist device (RVAD) use following HM3 implant. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis determined predictors of RVAD use in HM3 patients. 55 patients (31.4%) required RVAD following HM3 implantation including 19 percutaneous, 24 paracorporeal, and 2 durable RVADs. Age, gender, and implant strategy were comparable between RVAD and no RVAD groups. Patients requiring RVAD were more likely to be INTERMACS Class I or II (78.2% vs. 56.6%), have a higher WBC count (9.2±3.4 vs. 8.1±2.8) and C-reactive protein (57.7±59.2 vs. 38.4±34.7) prior to device implant (all p <0.05). RVAD group had significantly lower PAPi (3.4±2.0 vs. 6.0±6.8, p=0.001), higher CVP/PCWP ratio (0.50±0.27 vs. 0.42±0.25, p=0.036) and comparable RVSWI (0.534±0.285 vs. 0.572±0.240, p=0.368) before device implant. ROC curve analysis provided higher AUC for PAPi compared to CVP/PCWP ratio or RVSWI (Figure). After adjusting for age, etiology of HF, creatinine, bilirubin, WBC count, INTERMACS Class, RVSWI, and CVP/PCWP ratio, PAPi was the only significant predictor of RVAD use in multivariable model (OR 0.913 [95%CI: 0.835 - 0.999], p=0.049). PAPi is an independent predictor of RV failure in Heartmate 3 patients. Incorporating PAPi in clinical decision-making may improve patient selection and perioperative outcomes in this population.

Upfront RVAD Strategy and Early Clinical Outcomes in LVAD Patients

Right ventricular failure (RVF) after LVAD is associated with increased morbidity and mortality. "Delayed right ventricular assist device (RVAD)", as a surgical or percutaneous rescue strategy, carries high complication rates. We recently changed our practice and use "Upfront RVAD" (concurrent with LVAD implant) in selected high-risk pts (INTERMACS 1, severe RVF and renal failure). We sought to investigate the effect of this novel strategy on in-hospital mortality and adverse events. We retrospectively reviewed consecutive pts who received primary LVAD implant between 1/2015 and 8/2019. This cohort was divided into 4 groups (Gs): G1- no evidence of RVF and no RVAD; G2 - RVF treated with inotropes >2 wks; G3 - Delayed RVAD; G4 - Upfront RVAD. Clinical outcomes included in-hospital mortality, renal replacement therapy (RRT), stroke and length of stay (LOS). 225 pts were enrolled in the study: G1 (n=117, 52%); G2 (n=48, 21.3%); G3 (n=26, 11.6%); G4 (n=34, 15.1%). Frequency of INTERMACS 1 profile was significantly different among groups: G1 10.3%; G2 8.3%; G3 11.5%; G4 51.4%; p=0.001. G4 had significantly lower albumin and longer bypass time compared to the other groups. RVAD strategy (Delayed (G3) vs. Upfront (G4)) and type (surgical vs. percutaneous) varied by implant year (Fig 1a). Mean time to Delayed RVAD (G3) was 2.54 (1-15) days. In-hospital mortality of pts in G4 was similar to G2 and numerically lower than G3. RRT and stroke were the highest in G3 and were similar in G4 vs.G2 (Fig 1b-d). Median (IQR) ICU LOS was G1 7(6-10); G2 15(10-21); G3 22(14-28); G4 20(14-41) days (p<0.001). Total post LVAD LOS was G1 21(17-27); G2 32(25-32); G3 36(25-65); G4 38(27-61) days (p<0.001). In-hospital mortality, RRT and stroke events were markedly lower in pts who received Upfront compared to Delayed RVAD. Notably, despite the majority of Upfront RVAD pts being INTERMACS 1, mortality and adverse events were similar to those of pts treated with prolonged inotropes for RVF without RVAD support (<10% INTERMACS).

Increased Right Ventricular Assist Device (RVAD) Utilization in Patients with HeartMate 3 Left Ventricular Assist Device (LVAD) in the Post-Approval Era

MOMENTUM 3 trial excluded patients with planned biventricular support prior to enrollment and 4.2% right ventricular failure requiring RVAD in Heartmate 3 (HM 3) patients. The aim of this study was to assess the use of RVAD in the real-world post-approval era. HM3 implantation at a major academic center were categorized into two era: HM 3 implanted 1) before FDA approval (8/23/2017) [N=67] and 2) after FDA approval [N=107]. Baseline patient characteristics, RVAD utilization patterns, and LVAD complications and mortality were analyzed in the pre- vs. post-approval era. In the post-approval era, HM3 patients were younger (57.5±14.1 vs 61.7±11.2 yrs, p=0.031), more likely to have ischemic etiology of heart failure (55.6% vs 34.3%, p=0.006), to be INTERMACS Class I (21.3% vs. 1.5%, p=0.002), and to have VA-ECMO or paracorporeal VAD support (12.0% vs 0.0%, p=0.012) prior to HM3 implant. 8 (11.9%) patients out of 67 required RVAD in the pre-approval era as opposed to 47 patients out of 108 (43.5%) in the post-approval era (p<0.001). All patients in the pre-approval era received unplanned RVAD (8, 100%) compared to 16 patients (34.0%) in the post-approval era (p<0.001). Despite increased utilization of RVADs, the risk of CVVHD (6.0% vs 10.2%, p=0.413), post-LVAD length of stay (34.3±32.9 vs 41.7±40.0 days), and in-hospital mortality (4.5% vs 6.9%, p=0.741) were comparable in pre- vs. post-approval era. There was no difference in post-implant survival (89.7% vs. 84.7%, log-rank p=0.357), freedom from gastrointestinal bleeding (70.0% vs. 70.4%, log-rank p =0.831) or freedom from stroke (93.2% vs. 92.2% log-rank p = 0.547) at 2-year follow-up in the pre- vs. post- approval period. Level of sickness at the time of device implantation as well as need for RVAD utilization increased substantially in HM3 patients following the FDA approval. However, the change in practice did not adversely affect post-LVAD morbidity or mortality.

Ambulatory RVAD Using Dual Lumen Cannula-Single Center Experience

Right heart failure (RVF) after an LVAD implantation is associated with poor outcomes and increased morbidity and mortality. Right ventricular assist devices (RVAD) support is becoming a standard practice for RVF. Aim of our study is to assess the outcomes in the ambulatory patients who received an RVAD. Single center retrospective review of 16 patients who received an RVAD after an LVAD implantation were analyzed. Primary end point was 30-day survival. Patient's preoperative demographics, medical history, laboratory values, hemodynamics, echo and catheterization data were assessed to find out different variables associated with mortality in this group. Continuous variables are reported as mean ± standard deviation (SD), whereas categorical data are reported as percentages. Mean age was 49.29 ± 11.47 years. 62.5% (n=10) were male and 37.5% (n=6) were female. 62.5% (n=10) were African American patients. All 16 patients were in NYHA class 4 at time of implant. Pre-operative right heart catheterization and 2D Echo data findings were: mean RA pressure 16.83 ± 9.57 mm Hg, PAPI 2.47 ± 2.52, TAPSE 1.39 ± 0.63 and S-Prime 9.76 ± 3.84. Patients received an RVAD support (Protek-Duo, Tandem Life, Pittsburgh, PA) within first 48 hours of LVAD implantation. Survival at 30-days with an RVAD support was 62.5% (n=10) (Table 1). Post-operatively all patients were ambulating while supported with a RVAD and continued participating in physical therapy. 30-day survival in temporary RVAD supported patients with Protek-Duo cannula is comparable to previously published literature with Impella-RP support device (Recover Right study). However, this strategy enabled our patients to be ambulatory and involve themselves with physical therapy providing all the additional benefits of early ambulation.

Placement of a Fully Magnetically Levitated Left Ventricular Assist Device: Intrathoracic versus Intrapericardial

A fully magnetically levitated centrifugal-flow left ventricular assist device can be placed in either the intra-thoracic cavity or the intra-pericardial cavity. This study aimed to investigate the clinical impact of pump location in patients following fully magnetically levitated left ventricular assist device (LVAD) placement. We retrospectively reviewed 161 patients who received fully magnetically levitated centrifugal-flow LVAD at our center between November 2014 and August 2019. Pump location was determined from the operative record and CT scan images if available. We identified 77 patients (48%) with intra-thoracic placement (Group T) and 84 patients (52%) with intra-pericardial placement (Group P). Clinical outcomes were compared between the groups. Patients in Group T were older (61 vs. 57 years, p=0.05), more likely to have prior sternotomy (27% vs. 11%, p=0.008), and more frequently INTERMACS class I (21% vs. 5.9%, p=0.008) compared with patients in Group P. Incidence of perioperative right ventricular assist device (RVAD) was significantly lower in Group T (23% vs. 38%, p=0.045). In-hospital mortality was 8.6% in Group T vs. 3.6% in Group P (p=0.15). Kaplan-meier curve analysis showed 2-year survival of 83% in Group T and 93% in Group P (p=0.15). Multivariate logistic regression analysis demonstrated INTERMACS class I was an independent predictor of RVAD use (OR 16.9, 95% CI 5.09-56.2, p<0.01) but Group P was not a predictor (p=0.2). In our study, intrathoracic vs. intrapericardial fully magnetically levitated centrifugal-flow pump placement did not affect overall clinical outcomes.

Impact of Preoperative Mechanical Support Following Heart Transplant

To determine if the type of non-dischargeable preoperative mechanical support (PMCS) in transplant recipients affects post-transplant outcomes. The SRTR database was used to identify all adult heart transplants requiring PMCS, excluding multi-organ and redo transplants. Intra-aortic balloon pump (IABP), right ventricular assist device (RVAD), total artificial heart (TAH), and extracorporeal membranous oxygenation (ECMO) were identified as PMCS. Groups were compared using an analysis of variance and Chi-square test for continuous and categorical variables respectively. Kaplan-Meier analysis and a Cox model were utilized to examine long-term survival. 4,647 heart transplants requiring PMCS were identified. Recipients with IABP were associated with older age and smoking, and a significantly shorter waitlist time (p<0.01). ECMO patients had a significantly increased 30 & 90 day mortality as well as an increased incidence of dialysis (p<0.01) (Table). Kaplan-Meier analysis revealed worse 1 and 5 year survival for ECMO (IABP: 83.8% and 69.5%; RVAD: 84.7% and 71.4%; TAH: 80.2% and 60.7%; ECMO: 70.5% and 60.9% for 1 and 5 year survival for all groups; p< 0.01) (Figure). The Cox model demonstrated a significant increased risk of mortality with ECMO (hazard ratio 1.51, 95% confidence interval 1.24-1.84, p<0.01). With recent allocation system changes and use of more PMCS, better understanding of the impact of these therapies on transplant candidates is essential. Based on the finding that pretransplant ECMO is associated with significantly worse outcomes, it may be beneficial to avoid ECMO when clinically feasible.

Minimally Invasive Mechanical Circulatory Support Through the Perioperative Pulmonary Thromboendarterectomy Period: A Case Report

A 64-year-old man being evaluated for pulmonary thromboendarterectomy (PTE) preoperatively experienced pulseless electrical activity secondary to right ventricular failure while undergoing bronchoscopy. After return of spontaneous circulation, a percutaneous right ventricular assist device (RVAD) was placed through the right internal jugular vein. He continued on right ventricular support with demonstration of right ventricular recovery over the following 8 days, and subsequently underwent PTE for treatment of his primary condition. He recovered and was weaned from his RVAD support uneventfully. The need for RVAD support has traditionally been a contraindication for PTE; however, circulatory assist devices have been used as a salvage procedure for right-heart failure after PTE. This case highlights the potential for percutaneous mechanical circulatory support in treating severe perioperative right ventricular dysfunction, and to facilitate successful recovery in patients undergoing PTE.

Novel percutaneous dual-lumen cannula-based right ventricular assist device provides effective support for refractory right ventricular failure after left ventricular assist device implantation.

Right heart failure after left ventricular assist device (LVAD) implantation is associated with significant morbidity and mortality. A new generation of percutaneous right ventricular assist devices (RVADs) may mitigate the need for invasive surgical RVAD implantation. The purpose of this study was to evaluate the safety and efficacy of the Protek Duo (TandemLife, Pittsburgh, PA, USA) RVAD in patients who developed severe acute right heart failure in the intensive care unit after LVAD implantation. This was a retrospective cohort study of 27 patients who received a Protek Duo after LVAD implantation from January 2016 to March 2019 at our centre. The primary outcome of interest was survival to hospital discharge. Secondary outcomes included procedural success, device-related complications and conversion to a surgical RVAD. The median age of patients was 63 years (interquartile range 58-71), 78% were men and 78% were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 or 2. Patients were on a median of 2 inotropes and 2 pressors prior to Protek Duo insertion. The device successfully implanted on the first attempt in all patients a median of 1 day (interquartile range 1-2) after LVAD implantation and the median duration of support was 11 days (interquartile range 7-16). Device weaning occurred in 86% of patients, with 15% in-hospital mortality. Major complications related to the device included new moderate-to-severe tricuspid regurgitation (36%), haemolysis (14%) and cannula migration (7%). Three patients (11%) required conversion to surgical RVAD. Overall survival to 1 year was 81%. The use of the Protek Duo as a percutaneous RVAD is a safe and feasible treatment for patients who develop acute right heart failure after LVAD implantation.

Timing and Trends of Right Atrial Pressure and Risk of Right Heart Failure After Left Ventricular Assist Device Implantation

Elevated right atrial pressure (RAP) is associated with poor outcomes after left ventricular assist device (LVAD) implantation. However, the optimal time for RAP measurement and the importance of resolution of right heart congestion prior to LVAD implantation remain unclear. We performed a retrospective cohort study of 134 consecutive LVAD recipients from our institution. Congestion was defined as RAP ≥ 14 mmHg and was assessed at hospital admission and implant. The primary outcome was death or right ventricular assist device (RVAD) implantation. When stratified by congestion status at admission, congested and non-congested patients had similar event-free survival rates (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 0.6-2.6). However, when stratified at implant, congested patients had a higher rate death or RVAD implantation (HR: 2.5, 95% CI: 1.1-5.6). Patients were then divided into 4 groups based on their trajectory of congestion status: no congestion, resolved congestion, new congestion, or persistent congestion. Patients with no congestion and resolved congestion had similar outcomes, whereas patients with persistent congestion had a markedly increased rate of death or RVAD implantation (HR: 3.1, 95% CI: 1.3-7.6). RAP at LVAD implantation is more strongly associated with postoperative outcomes than admission RAP. Patients not responsive to decongestive therapies, with persistently elevated RAP, represent a high-risk cohort for adverse outcomes following LVAD implantation.

A Dual-Lumen Percutaneous Cannula for Managing Refractory Right Ventricular Failure.

A right ventricular assist device (RVAD) using a dual-lumen percutaneous cannula inserted through the right internal jugular vein (IJV) might improve weaning in patients with refractory right ventricular (RV) failure. However, the reported experience with this cannula is limited. We reviewed the records of all patients receiving RVAD support with this new dual-lumen cannula at our institution between April 2017 and February 2019. We recorded data on weaning, mortality, and device-specific complications. We compared outcomes among three subgroups based on the indications for RVAD support (postcardiotomy, cardiogenic shock, and primary respiratory failure) and against similar results in the literature. Mean (standard deviation [SD]) age of the 40 patients (29 men) was 53 (15.5) years. Indications for implantation were postcardiotomy support in 18 patients, cardiogenic shock in 12, and respiratory failure in 10. In all, 17 (94%) patients in the postcardiotomy group were weaned from RVAD support, five (42%) in the cardiogenic shock group, and seven (70%) in the respiratory failure group, overall higher than those reported in the literature (49% to 59%) for surgically placed RVADs. Whereas published in-hospital mortality rates range from 42% to 50% for surgically placed RVADs and from 41% to 50% for RVADs with percutaneous cannulas implanted through the right IJV, mortality was 11%, 58%, and 40% in our subgroups, respectively. There were no major device-related complications. This percutaneous dual-lumen cannula appears to be safe and effective for managing refractory RV failure, with improved weaning and mortality profile, and with limited device-specific adverse events.

1166. Infection Rate in Venous–Venous Extracorporeal Membrane Oxygenation (VV-ECMO)

BackgroundThe Extracorporeal Life Support Organization (ELSO) Infectious Disease Taskforce has identified infection rates as an area requiring further study. We aimed to evaluate our patients on venous–venous extracorporeal membrane oxygenation (VV ECMO) for infection rates, organisms, and specific factors that may alter infection risk.MethodsRetrospective data were collected from September 2012 to 2015 for adult patients on VV ECMO. Demographic information as well as type and location of cannulation, antibiotics prior to and during cannulation, and presence of bacteremia were obtained. Counts and percentages are reported for categorical variables.Results47 patients between 18 and 82 years of age with a median of age of 58 years were included. 76.6% (N = 36) were male. The average number of hospital days until cannulation was 7.8 days. 400 ECMO days were captured with a range of time on ECMO of 1–41 days. 46.8% (N = 22) of patients were alive at the time of discharge. 70.2% (N = 32) of cannulations were in the OR (Figure 1). 55% (N = 26) of patients had a Right Ventricular Assist Device (RVAD) with in-line oxygenator. 66% (N = 31) of all patients were on antibiotics prior to cannulation for other indications while 53% (N = 25) of all patients received perioperative antibiotics (Figure 2). 59% (N = 28) of all patients had blood cultures while on ECMO, with only 8% (N = 4) of all patients returning positive. Of the positive cultures, 2 were true bacteremia resulting in an infection rate of 5 per 1,000 ECMO days (Figure 3). One patient grew Escherichia coli while the other grew Escherichia coli and Streptococcus pneumoniae. Neither patient received antibiotics perioperatively or for other indications (Figure 4). Due to the low number of infected patients, further statistical analysis could not be performed.ConclusionWe report a low rate of bloodstream infection amongst our VV-ECMO patients. Further investigation to ascertain trends in infection rate with cannulation location/type as well as association with antibiotic is currently being pursued. Other avenues of research will include a comparison of infection rates between VV and Venous Arterial (VA) ECMO. Information from these investigations will help aid the development of guidelines to minimize the rate of nosocomial infections in ECMO patients. Disclosures All authors: No reported disclosures.