Time Of Left Ventricular Assist Device Implantation Research Articles

Driveline Infection in Patients With Left Ventricular Assist Devices Implanted as Destination Therapy

Donor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs). This study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022. There were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus. Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.

The safety of sodium glucose transporter 2 inhibitors and trends in clinical and hemodynamic parameters in patients with left ventricular assist devices.

The safety and impact of sodium glucose transporter 2 inhibitors (SGLT2-I) in patients with left ventricular assist devices (LVAD) are unknown. A retrospective analysis of all consecutive patients who underwent LVAD Heart Mate 3 (HM3) implantation at a single medical center and received SGLT2-I therapy following surgery was conducted. LVAD parameters, medical therapy, laboratory tests, echocardiography, and right heart catheterization (RHC) study results were recorded and compared before and after initiation of SGLT2-I. SGLT2-I medications were initiated in 29 (21%) of 138 patients following HM3 implantation (23 (79%) received Empagliflozin and 6 (21%) Dapagliflozin). The mean age at the time of LVAD implantation was 62 ± 6.7 years, 25 (86%) were male, and 23 (79%) had diabetes mellitus. The median time from HM3 implantation to SGLT2-I initiation was 108 days, IQR (26-477). Following SGLT2-I therapy, the daily dose of furosemide decreased from 47 to 23.5 mg/day (mean difference = 23.5 mg/d, 95% CI 8.2-38.7, p = 0.004) and significant weight reduction was observed (mean difference 2.5 kg, 95% CI 0.7-4.3, p = 0.008). Moreover, a significant 5.6 mm Hg reduction in systolic pulmonary artery pressure (sPAP) was measured during RHC (95% CI 0.23-11, p = 0.042) in a subgroup of 11 (38%) patients. LVAD parameters were similar before and after SGLT2-I initiation (p > 0.2 for all). No adverse events were recorded during median follow-up of 354 days, IQR (206-786). SGLT2-I treatment is safe in LVAD patients and might contribute to reduction in patients sPAP.

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

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

Body mass index-dependent immunological profile changes after left ventricular assist device implantation.

Infection is a common complication following left ventricular assist device (LVAD) implantation. Patients with obesity are particularly at risk due to their high percentage of adipose tissue and the resulting chronic inflammatory state and resulting immunological changes. This study investigated changes of immunological parameters in relation to body mass index (BMI) during the first year after LVAD implantation. Blood samples were obtained prior to LVAD implantation and at 3 (1st FU), 6 (2nd FU) and 12 mo (3rd FU) after LVAD implantation. Patients were divided into three groups (normal weight: BMI of 18.5-24.9 kg/m2; n=12; pre-obesity: 25.0-29.9 kg/m2; n=15; obesity: ≥ 30.0 kg/m2; n=17) based on their BMI at the time of LVAD implantation. Flow cytometric analyses for CD4+ and CD8+ T cells, regulatory T cells (Tregs), B cells as well as dendritic cells (DCs) were performed. After LVAD implantation, obese patients (0.51 ± 0.20%) showed a higher proportion of overall DCs than normal-weight (0.28 ± 0.10%) and pre-obese patients (0.32 ± 0.11%, p<0.01) at 3rd FU. The proportion of BDCA3+ myeloid DCs was lower in obese patients (64.3 ± 26.5%) compared to normal-weight patients (82.7 ± 10.0%, pnormal-weight vs. obesity=0.05) at 2nd FU after LVAD implantation. The analysis of BDCA4+ plasmacytoid DCs revealed a reduced proportion in pre-obese (21.1 ± 9.8%, pnormal-weight vs. pre-obesity=0.01) and obese patients (23.7 ± 10.6%, pnormal-weight vs. obesity=0.05) compared to normal-weight patients (33.1 ± 8.2%) in the 1st FU. T cell analysis showed that CD4+ T cells of obese patients (62.4 ± 9.0%) significantly increased in comparison to pre-obese patients (52.7 ± 10.0%, ppre-obesity vs. obesity=0.05) and CD8+ T cells were lower in obese patients (31.8 ± 8.5%) than in normal-weight patients (42.4 ± 14.2%; pnormal-weight vs. obesity=0.04) at the 3rd FU. Furthermore, we observed significantly reduced proportions of Tregs in pre-obese patients compared to normal-weight and obese patients at 2nd FU (p=0.02) and 3rd FU (p=0.01) after LVAD implantation. This study reported changes of the innate and adaptive immune system of pre-obese and obese compared to normal-weight patients one year after LVAD implantation. DCs and their subsets, CD8+ T cells and Tregs were affected immune cell populations that indicate immunological changes which might increase the incidence of postoperative infection.

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.

Should we touch tricuspid valve at the time of LVAD implantation? A young patient series.

The aim of the study is to compare the results of patients who had moderate or severe tricuspid insufficiency (TI) at the time of left ventricular assist device (LVAD) implantation that did not undergo intervention. Between October 2013 and December 2019, 144 patients who did not undergo tricuspid valve repair (TVR) during LVAD implantation in our department were included in the study. The patients were divided into two groups according to the TI grade; Group 1: 106 patients (73.6%) with moderate TI and Group 2: 38 patients (26.4%) with severe TI. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, duration of mechanical ventilation, and early and late right ventricular failure (RVF). Minimally invasive technique was favored in patients with worse right ventricular (RV) function to prevent the need for postoperative RV support and bleeding. The mean ages of the patients in the Group 1 and Group 2 were 46 ± 15 years (82% male), and 45 ± 11.2 years (81.5% males), respectively. Post-operative duration of mechanical ventilation, ICU stay, blood loss, and reoperations were similar (p > 0.05). There was no significant difference in early RVF, pump thrombosis, stroke, bleeding, and 30-day mortality between groups (p > 0.05). Incidence of late RVF was higher in Group 2 (p < 0.05). Although the risk of late RVF may increase in patients with preoperative severe TI, not intervening in TI during LVAD implantation does not cause adverse clinical outcomes in the early period.

314 Radiographic Risk Factors for Intracranial Hemorrhage in Patients with Left Ventricular Assist Devices

INTRODUCTION: Intracranial hemorrhage (ICH) in patients with left ventricular assist devices (LVAD) is a complication with significant morbidity and mortality. Many studies have identified demographic risk factors for ICH in LVAD patients; however, anatomic pre-disposition to ICH in these patients has not yet been investigated. METHODS: We reviewed 440 patients who received an LVAD at our institution. We then selected patients who received CT scans of the head for any reason near the time of LVAD placement. 288 patients (21 ICH, 278 Control) with CT scans were included in the analysis. A detailed chart review was then performed to collect data on patient demographics, radiographic findings, and complications. RESULTS: The incidence of ICH in our complete cohort was 8.6% (38/440). The presence of pump thrombosis (p = 0.001), driveline infection (p = 0.034), other hemorrhage (p = 0.001), or previous placement of a cardio-defibrillator (p = .003) during the period of LVAD implantation was associated with increased risk for ICH. An analysis of patient imaging revealed that the presence of a mass (p = 0.006), vascular malformation (p = 0.001), and microangiopathy (p = 0.04) was significantly associated with ICH in LVAD patients. We further validated the significance of these radiographic features using a multivariate logistic regression which showed that the presence of a mass (aOR 332.1, 95% CI: 14.7-7485.1, p &lt; 0.001), vascular malformation (aOR 69.7, 95% CI: 1.8-2658.8, p = 0.022), and microangiopathy (aOR 6.5, 95% CI: 1.1-37.6, p = 0.035) were independently associated with ICH. CONCLUSIONS: Radiographic evidence of microangiopathy, intracranial mass, and vascular malformation are independent risk factors for ICH which may be identified at or before the time of LVAD implantation. We advocate that CT imaging may be used to further stratify patients at highest risk of ICH during treatment with an LVAD.

Reciprocal interferences of the left ventricular assist device and the aortic valve competence.

Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach via percutaneous occluding device or transcatheter aortic valve implantation. In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.

1801. LVAD antimicrobial prophylaxis and infections, a 12-year experience

Abstract Background The incidence of end-stage heart failure necessitating advanced cardiac therapy continues to increase in the United states. Implantable left ventricular assist devices (LVADs) represent an important modality that is utilized both as a bridge to heart transplant or as destination therapy. LVAD-associated infections, ranging from driveline exit site or pocket infections to endovascular infections, are a major complication with high mortality. Antibiotic prophylaxis at time of LVAD implantation is therefore an important strategy to mitigate infections. However, a clear surgical infection prophylaxis regimen and associated outcomes have not been reported. Methods We performed a single center, retrospective cohort study evaluating the impact of antimicrobial prophylaxis on risk of infection in patients who underwent LVAD implantation between February 2007 and June 2019 at Mayo Clinic. LVAD-specific and related infections were defined according to the International Society of Heart Lung Transplantation criteria. Single drug prophylaxis (SDP) included cefazolin only, vancomycin only, or cefazolin and vancomycin; multidrug (MDP) regimen includes either of the SDP regimens plus another antibiotic. We compared incidence of infection within 90-day and within one-year of implantation, as well as risk of C. difficile infections between the SDP and MDP cohorts. Results We reviewed 403 patients who received LVAD implantation (Table 1), 402 of had information on surgical prophylaxis. 307 (76%) patients received SDP and 95 patients (24%) received MDP. 14 patients developed an infection within 1 year of implantation (Table 2). There was no difference in the incidence of infections between SDP and MDP arms both at 90 days and 1-year post-implantation (p=0.11). The median time of infection since LVAD implantation was similar between SDP and MDP (p=0.37) arms. Incidence of C. difficile infection was not different between groups (p=0.10) (Table 3). Conclusion There was no significant difference in incidence or time to first infection, within 90-day and 1-year of implantation, between single- and multidrug antibiotic surgical prophylaxis regimens administered at the time of LVAD implantation. Future prospective trials are needed to develop a clear LVAD antibiotic prophylaxis protocol. Disclosures John C. O'Horo, Sr., MD, MPH, Bates college: Advisor/Consultant|MITRE corporation: Grant/Research Support|nferenec, Inc: Grant/Research Support.

Obesity and outcomes after left ventricular assist device implantation: insights from the EUROMACS Registry.

The objective was to analyse associations between obesity and outcomes after left ventricular assist device (LVAD) implantation. A retrospective analysis of the EUROMACS Registry was performed. Adult patients undergoing primary implantation of a continuous-flow LVAD between 2006 and 2019 were included (Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). Patients were classified into 4 different groups according to body mass index at the time of surgery (body mass index <20 kg/m2: n = 254; 20-24.9 kg/m2: n = 1281; 25-29.9 kg/m2: n = 1238; ≥ 30 kg/m2: n = 691). The study cohort was comprised of 3464 patients. Multivariable Cox proportional cause-specific hazards regression analysis demonstrated that obesity (body mass index ≥30 kg/m2) was independently associated with significantly increased risk of mortality (body mass index ≥30 vs 20-24.9 kg/m2: hazard ratio 1.36, 95% confidence interval 1.18-1.57, overall P < 0.001). Moreover, obesity was associated with significantly increased risk of infection and driveline infection. The probability to undergo heart transplantation was significantly decreased in obese patients (body mass index ≥30 vs 20-24.9 kg/m2: hazard ratio 0.59, 95% confidence interval 0.48-0.74, overall P < 0.001). Obesity at the time of LVAD implantation is associated with significantly higher mortality and increased risk of infection as well as driveline infection. The probability to undergo heart transplantation is significantly decreased. These aspects should be considered when devising a treatment strategy before surgery.

Tricuspid Valve Surgery in Patients Receiving Left Ventricular Assist Devices

Tricuspid regurgitation (TR) is common and related to poor prognosis in patients after left ventricular assist device (LVAD) implantation. The concomitant tricuspid valve surgery (TVS) at the time of LVAD implantation on short and long-term outcomes are controversial in current evidence. This is a single-center, observational, retrospective study. We enrolled patients with moderate-to-severe TR who received LVAD implantations from 2009 to 2020. Postoperative right ventricular failure (RVF), right ventricular assist device (RVAD) use, hospital mortality, new-onset renal replacement therapy (RRT), and acute kidney injury (AKI) were evaluated retrospectively. Sixty-eight patients were included, 36 with and 32 without concomitant TVS. Baseline characteristics did not differ between the two groups. Patients receiving TVS had significantly increased incidences of postoperative RVF (52.8 vs. 25.0%, p = 0.019), RVAD implantation (41.7 vs. 18.8%, p = 0.041), and new-onset RRT (22.2 vs. 0%, p = 0.004). No difference in the incidence of AKI and hospital mortality was detected. Besides, these associations remained consistent in patients who underwent LVAD implantation via median sternotomy. During a median follow-up of 2.76 years, Kaplan-Meier analysis and competing-risk analysis showed that TVS was not associated with better overall survival in patients after LVAD implantation compared with the no-TVS group. Our study suggests that concomitant TVS failed to show benefits in patients receiving LVAD implantation. Even worse, concomitant TVS is associated with significantly increased incidences of RVF, RVAD use, and new-onset of RRT. Considering the small sample size and short follow-up, these findings warrant further study.

Pre-operative sarcopenia is predictive of recurrent gastrointestinal bleeding on left ventricular assist device support: A multicenter analysis.

Whether pre left ventricular assist device (LVAD) sarcopenia is associated with higher incidence of gastrointestinal bleeding (GIB) on LVAD support remains unknown. To study the association between preoperative sarcopenia and post LVAD GIB events, we performed a retrospective, multi-centered study including patients with chest CTs performed ≤ 3 months prior to LVAD implantation at the University of Minnesota (n=143) and Houston Methodist Hospital (n=133). To quantify sarcopenia, unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHUm) were measured on pre-operative chest CT scans. Negative binomial regression analyses were performed to determine the association between pectoralis muscle measures and number of GIB events to 2 years of LVAD support. The study cohort included 276 LVAD recipients with 43 % designated as bridge to transplant at the time of LVAD implantation. High pectoralis muscle mass and tissue attenuation were both protective against GIB events. Each 5 unit increase in PHUm was associated with an adjusted 19 % reduction in the incidence rate of GIB (95 % CI 7-29 %, p=0.002). Each unit increase in PMI was associated with an adjusted 17 % reduction in the incidence of GIB (95 % CI 1- 29 %, p=0.04). The models were adjusted for age, sex, INTERMACS profile, bridge to transplant status, creatinine, albumin and implanting center. Preoperative sarcopenia, as quantified by pectoralis muscle size and attenuation, was associated with the development of recurrent GI bleeding after LVAD implantation. These CT quantitative measures appear to predict not only early mortality but morbidity on LVAD as well.

Cerebral protection during percutaneous intervention for left ventricular assist device outflow graft obstruction.

Left ventricular assist devices (LVAD) outflow graft obstruction is an uncommon complication but carries significant morbidity and mortality. Here we provide a case series of patients with LVAD intrinsic outflow graft obstruction who are deemed to be a high surgical risk for pump exchange and, therefore, underwent percutaneous intervention with the concomitant use of neuroprotective device-Sentinel cerebral protection system(CPS)(Boston Scientific) to prevent embolic stroke. We retrospectively analyzed patients who underwent LVAD placement in our institution and developed LVAD outflow graft obstruction. The diagnosis of LVAD outflow graft obstruction was confirmed by utilizing various cardiac imaging modalities such as echocardiography and/or computed tomography angiography. All patients were treated with percutaneous intervention and a catheter-based CPS. From a total of 501 LVAD implants in our institute, 6 (1.2%) patients with LVAD outflow graft obstruction who underwent percutaneous treatment were included; 4 patients with HeartMate-IIILVAD, 1patient with HeartMate-II LVAD, and 1patient with HeartWare (HVAD). The median age of patients was 56.5 years at the time of LVAD implantation. The median time from the LVAD implantation to the episode of LVAD outflow obstruction was 1343 days. Utilization of Sentinel CPS resulted in the capture and removal of thrombus/debris in all patients. Percutaneous intervention of LVAD outflow graft obstruction is less invasive than surgical pump exchange and an acceptable alternative in properly selected patients. In our experience, utilization of a catheter-based CPScan help in reducing the incidence of periprocedural embolic events.

Delayed detection programming significantly reduces inappropriate ICD therapies in patients with left-ventricular assist devices

Abstract Funding Acknowledgements Type of funding sources: None. Background Implantation of a left ventricular assist device (LVAD) is an established therapy for end-stage heart failure, either as bridge to transplantation or as destination therapy. Virtually all LVAD patients carry an implantable cardioverter-defibrillator (ICD) for primary or secondary prevention. The risk of ventricular tachyarrhythmias is significant in LVAD patients, but so is the burden of supraventricular tachycardia and the ensuing risk of inappropriate ICD therapies. The present retrospective study sought to quantify the impact of standard ICD programming vs. a ICD programming with long detection delays on the occurrence of inappropriate ICD therapies. Methods and results We retrospectively identified 337 consecutive patients (292 male, mean age 54.2 ± 12.3 years) who received a continuous-flow LVAD at our institution. Median follow-up duration was 2.3 (IQR 1.3, 3.7) years. Heart failure etiology was ischemic cardiomyopathy in 155 patients (46.0 %) and non-ischemic dilated cardiomyopathy in 150 (44.5 %). Other etiologies accounted for 32 patients (9.4 %). ICDs implanted at the time of LVAD implantation were single chamber devices in 176 patients (52.2 %), dual chamber devices in 45 patients (13.4 %), and CRT-D in 116 patients (34.4 %) A total of 2228 ICD-treated arrhythmia episodes occurred in 153 patients. 2066 (92.6 %) episodes were appropriate interventions for ventricular arrhythmias. 162 (7.3 %) treatments were inappropriate due to supraventricular tachyarrhythmias (n=115; 71.4 %), sinus tachycardia (n=15; 9.3 %) or oversensing (n=21; 12.9%). We retrospectively compared a standard programming (number of intervals for detection [NID] in the slowest therapy zone ≤ 40) and a long delay programming (NID &amp;gt; 40) and investigated the time to the first inappropriate therapy. A total of 285 patients were programmed to NID ≤ 40 at the first ICD interrogation after LVAD implant, 47 were programmed to NID &amp;gt; 40. Therapies were inactive in the remaining 5 patients. Median NID was 30 (IQR 23, 35) in the standard programming group and 60 (IQR 50, 76) in the long delay group, with similar rates for detection (median cycle lengths 340 [IQR 330, 350] ms and 330 [IQR 322, 340] ms for standard and long delay, respectively). Long delay programming was associated with significantly higher freedom from inappropriate therapies during follow-up (Hazard ratio 0.14, p [log rank] 0.027). No significant difference was observed between groups with regard to time to first appropriate therapy. Conclusion A number of intervals for detection greater than 40 in the slowest therapy zone was associated with a significantly increased freedom from inappropriate therapies in this large retrospective single-center cohort of LVAD patients with an ICD and should be considered as the default ICD programming strategy in this population.

Clinical Outcomes Of Ventricular Assist Device Implantation Among Older Individuals: A Comparative Analysis

Introduction Left ventricular assist device (LVAD) implantation in older individuals are being increasingly performed over the last decade. Data on outcomes among older patients undergoing LVAD implantation is conflicting. While some studies suggest that patients >70 years of age have similar outcomes to younger patients, other studies suggest older patients have reduced survival. Hypothesis We hypothesize that clinical outcomes of LVAD implantation are less favorable with increasing age. We describe the characteristics and outcomes of patients receiving an LVAD at our center stratified by age. Methods A retrospective, observational, descriptive study was conducted at our center. Patients who were admitted between January 2013 and July 2019 were divided into three groups—younger (aged < 65 years); senior (65-69 years); and older adult (aged ≥ 70 years). Group assignment was based on the age at the time of LVAD implantation. We compared the outcomes of the three groups using analysis of variance and chi-square tests. Results: 330 patients were included in the final analysis. The majority of patients were younger (74.2%, 245/330). Senior patients accounted for 16.4% (54/330) of the population, and 9.4% (31/330) were older adults. All variables (the total length of stay, the length of stay following LVAD implant implantation, the percentage of patients with readmissions at 30 days, and all-cause mortality at 1 year) were similar among the three age-stratified groups. Conclusions Despite the commonly held notion that older patients do not fare well and tend to have a higher incidence of complications resulting in a longer length of stay and higher overall mortality, we found no difference in mortality at 1 year. Well-defined, prospective studies are needed to understand the impact of age and frailty on long-term outcomes. Left ventricular assist device (LVAD) implantation in older individuals are being increasingly performed over the last decade. Data on outcomes among older patients undergoing LVAD implantation is conflicting. While some studies suggest that patients >70 years of age have similar outcomes to younger patients, other studies suggest older patients have reduced survival. We hypothesize that clinical outcomes of LVAD implantation are less favorable with increasing age. We describe the characteristics and outcomes of patients receiving an LVAD at our center stratified by age. A retrospective, observational, descriptive study was conducted at our center. Patients who were admitted between January 2013 and July 2019 were divided into three groups—younger (aged < 65 years); senior (65-69 years); and older adult (aged ≥ 70 years). Group assignment was based on the age at the time of LVAD implantation. We compared the outcomes of the three groups using analysis of variance and chi-square tests. Results: 330 patients were included in the final analysis. The majority of patients were younger (74.2%, 245/330). Senior patients accounted for 16.4% (54/330) of the population, and 9.4% (31/330) were older adults. All variables (the total length of stay, the length of stay following LVAD implant implantation, the percentage of patients with readmissions at 30 days, and all-cause mortality at 1 year) were similar among the three age-stratified groups. Despite the commonly held notion that older patients do not fare well and tend to have a higher incidence of complications resulting in a longer length of stay and higher overall mortality, we found no difference in mortality at 1 year. Well-defined, prospective studies are needed to understand the impact of age and frailty on long-term outcomes.

Should We Touch Tricuspid Valve at the Time of LVAD

<h3>Purpose</h3> The optimal management of tricuspid regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is controversial. The aim of the study is to compare outcomes of the patients who doesn't repair with moderate TR and severe TR on LVAD patient. <h3>Methods</h3> From October 2013 and December 2019, included 144 patients who without tricuspid repair (TVR) at the time of LVAD implantation at our department. Patients were divided into two groups according to the TR; Of 144 patients, 106 have moderate TR (group 1) and 38 with severe TR (group2). All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, time on mechanical ventilation, and postoperative and late right ventricular failure (RVF). Minimally Invasive technique was favored in patients with worse RV function to prevent the need for postoperative RV support and bleeding. <h3>Results</h3> Preoperative baseline characteristics of the two groups were similar. Survival was not significantly different between the groups (P>0.05). Incidence of late RVF was high in severe TR group (P<0.05). Operative and postoperative outcomes were summarized in table 1. <h3>Conclusion</h3> A perfect implant of the LVAD and minimal bleeding is much more important than the TVR. TVR can be neglected during minimally invasive surgery. Incidence of late RVF was high in severe TR group. Further study is necessary to determine what factors lead to recurrence of late TR in LVAD patients both with and without TVR.

Comparison of Early and Late Postoperative Outcomes Between INTERMACS 1/2 vs. 3/4

<h3>Purpose</h3> The INTERMACS profiles are established as important selection and prognostic criteria for Left Ventricular Assist Devices (LVAD) implantation. We sought to investigate the correlation of higher acuity INTERMACS profile and post-LVAD implantation outcomes in carefully selected and optimized patients. <h3>Methods</h3> We conducted a retrospective analysis of all HeartMate 3 LVAD (HM3) implantations in our institution between September 2015 and April 2021. Baseline characteristics and clinical outcomes were compared based on pre-implantation INTERMACS profiles: 1 and 2 (IP1-2) vs. 3 and 4 (IP3-4). Our primary study endpoint was the composite of stroke events and death from time of HM3 implantation through late follow-up. <h3>Results</h3> Of 234 patients implanted with a HM3 during the study period, 116 (49.6%) presented in cardiogenic shock IP1-2, while 118 (50.4%) were less acute IP3-4 (Table 1). Patients in IP1-2 at time of LVAD implantation were younger with de-novo heart failure and worse end-organ function. Postoperatively, patients in the IP1-2 group experienced higher rates of early adverse events including severe right ventricular failure (9% vs. 3%, p=0.025) and prolonged hospital length of stay. There was no statistically significant difference in the Kaplan-Meier estimator (Figure 1.) for the composite end-point of death and stroke between IP groups. <h3>Conclusion</h3> INTERMACS 1/2 patients implanted with HM3 LVAD were younger, had longer intubation times, and longer ICU and hospital lengths of stay. Clinical outcomes were similar between the groups with INTERMACS 3/4 patients showing a trend toward a lower composite event rate of stroke and death.

Impact of Obstructive Sleep Apnea on Clinical Outcomes Following Left Ventricular Assist Device Implantation

<h3>Purpose</h3> Obstructive sleep apnea (OSA) is frequently implicated in advanced heart failure. However, whether these findings extend to the left ventricular assist device (LVAD) population has yet to be investigated. We, therefore, tested the prognostic impact of concomitant OSA at time of LVAD implantation. <h3>Methods</h3> We conducted a retrospective chart review of 209 patients at a large academic medical center in the United States undergoing LVAD implantation between January 2010 and April 2020. OSA diagnosis was defined in accordance with a pre-implant polysomnography. Univariate Cox proportional hazards regression was used to study overall survival as well as freedom from readmission at 1 and 3 years post LVAD implant between the cohorts. <h3>Results</h3> No significant difference in survival was observed between the two groups at 1 year (HR, 1.07; 95% CI, 0.33-3.46; P=0.915) and 3 years (HR, 1.16; 95% CI, 0.55-2.45; P=0.283). Similarly, no difference in freedom from readmission was seen between the two groups at 1 year (P=0.073) and 3 years (P=0.107). After adjusting for relevant covariates, presence of obstructive sleep apnea remained an insignificant predictor of reduced survival at 1 year (HR, 1.208; 95% CI, 0.298-4.902; P=0.792) and 3 years (HR, 2.007; 95% CI, 0.793-5.082; P=0.142). <h3>Conclusion</h3> Obstructive sleep apnea was not significantly associated with worse clinical outcomes after LVAD implantation. The optimal treatment strategy and significance in managing OSA is still debated. Understanding the impact of common comorbidities such as obstructive sleep apnea on advanced heart failure therapeutic strategies may help tailor patient management towards individual needs.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Right-sided heart reperfusion ("Berlin bridge technique") for right ventricle support during left ventricular assist device (LVAD) implantation.

Outcome of Temporary Circulatory Support As a Bridge-to-Left Ventricular Assist Device Strategy in Cardiogenic Shock Patients.

Temporary circulatory support (TCS) as a bridge-to-left ventricular assist device (BTL) in cardiogenic shock patients has been increasing, but limited data exists on this BTL strategy. We aimed at analyzing the outcome of BTL patients in a population of cardiogenic shock patients compared with those without TCS at the time of the left ventricular assist device (LVAD) surgery and identify predictors of postoperative mortality in this specific population. A multicenter retrospective observational study conducted in 19 centers from 2006 to 2016. Nineteen French centers. A total of 329 cardiogenic shock patients at the time of LVAD implantation were analyzed. Patients were divided in three groups: those under TCS at the time of LVAD implantation (n = 173), those with TCS removal before LVAD surgery (n = 24), and those who did not undergo a bridging strategy (n = 152). Primary endpoint was 30-day mortality. None. Among the BTL group, 68 (39.3%), 18 (10.4%), and 15 (8.7%) patients were under venoarterial extracorporeal membrane oxygenation, Impella, and IABP support alone, and 72 patients (20.6%) were under multiple TCS support. BTL patients presented similar 30 days survival compared with the TCS removal and non-BTL groups. However, BTL group had a significantly longer ICU duration stay, with two-fold duration of mechanical ventilation time, but the three groups experienced similar postoperative complications. Multivariate analysis identified three independent predictors of mortality in the BTL group: combined surgery with LVAD, body mass index (BMI), and heart failure (HF) duration. BTL strategy was not an independent predictor of mortality in cardiogenic shock patients who underwent LVAD. BTL strategy is not associated with a lower survival among cardiogenic shock patients with LVAD implantation. Predictors of mortality are combined surgery with LVAD, higher BMI, and HF duration.