Ventricular Assist Device Insertion Research Articles

(807) - Gender Trends of Left Ventricular Assist Device Insertion in Australia

(807) - Gender Trends of Left Ventricular Assist Device Insertion in Australia

A single-institutional experience with 36 children less than 5 kilograms supported with the Berlin Heart: Comparison of congenital versus acquired heart disease.

We reviewed outcomes in all 36 consecutive children <5 kg supported with the Berlin Heart pulsatile ventricular assist device at the University of Florida, comparing those with acquired heart disease (n = 8) to those with congenital heart disease (CHD) (n = 28). The primary outcome was mortality. The Kaplan-Meier method and log-rank tests were used to assess group differences in long-term survival after ventricular assist device insertion. T-tests using estimated survival proportions were used to compare groups at specific time points. Of 82 patients supported with the Berlin Heart at our institution, 49 (49/82 = 59.76%) weighed <10 kg and 36 (36/82 = 43.90%) weighed <5 kg. Of 36 patients <5 kg, 26 (26/36 = 72.22%) were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 36 patients <5 kg was [days]: median = 109, range = 4-305.) Eight out of 36 patients <5 kg had acquired heart disease, and all eight [8/8 = 100%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 8 patients <5 kg with acquired heart disease was [days]: median = 50, range = 9-130.) Twenty-eight of 36 patients <5 kg had congenital heart disease. Eighteen of these 28 [64.3%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 28 patients <5 kg with congenital heart disease was [days]: median = 136, range = 4-305.) For all 36 patients who weighed <5 kg: 1-year survival estimate after ventricular assist device insertion = 62.7% (95% confidence interval = 48.5-81.2%) and 5-year survival estimate after ventricular assist device insertion = 58.5% (95% confidence interval = 43.8-78.3%). One-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 55.6% (95% confidence interval = 39.5-78.2%) in CHD, P = 0.036. Five-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 48.6% (95% confidence interval = 31.6-74.8%) in CHD, P = 0.014. Pulsatile ventricular assist device facilitates bridge to transplantation in neonates and infants weighing <5 kg; however, survival after ventricular assist device insertion in these small patients is less in those with CHD in comparison to those with acquired heart disease.

Abstract 14742: Clinical Predictors of Bleeding Complications Following Percutaneous Ventricular Assist Device Insertion: Insights From the J-PVAD (Japanese Registry for Percutaneous Ventricular Assist Device) Registry

Introduction: Bleeding complications are significant concerns in clinical use of percutaneous ventricular assist devices (PVAD). This study aimed to identify predictors of bleedings in PVAD use. Methods: We analyzed 3059 cases from the J-PVAD registry, a comprehensive national registry of PVAD use in Japan, excluding 53 cases without follow-up data. Patients were stratified based on whether they had acute coronary syndrome (ACS) on the onset or not, and incidence of bleeding was evaluated within each stratum, considering the clinically selected variables, including other mechanical circulatory support (MCS) use. Risk factors were explored through multivariate analyses. The primary outcome measure was any bleeding, while major bleeding was defined as a composite of cerebral bleeding, severe bleeding (defined as life-threatening, hospitalization-requiring, disability-causing, or congenital anomaly-inducing bleeding events), and blood transfusions. Results: The median follow-up period was 32 days. The cohort included 1459 patients with ACS and 1575 without ACS. The incidence of any bleeding did not differ significantly between the ACS and Non-ACS stratum (30-day incidence: 25.4% and 27.6%, P = 0.57, respectively). We observed the same trends for major bleeding. Most any bleeding or major bleeding occurred on the day of insertion of PVAD or within a few days. The groups with MCS had significantly more bleeding complications than those without MCS in each stratum (Figure). In a multivariate analysis using the Cox proportional hazards model, adding MCS on PVAD was the most potent predictor of any bleeding in both strata, with the effects of other variables being modest by comparison. Conclusions: Bleeding complications post-PVAD insertion are often severe and occur shortly after the procedure. Although the incidence of bleeding complications did not differ significantly according to the onset type, the MCS use strongly predicted bleeding complications.

Discussion to: Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery

Discussion to: Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery

Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery

ObjectivesThe aim of this study was to explore the associations between percutaneous ventricular assist device (pVAD) insertion timing relative to cardiac surgery and patient outcomes. MethodsThe Nationwide Inpatient Sample was queried for patients undergoing cardiac surgery and pVAD insertion in the same admission from 2016 to 2019. Patients were stratified by timing of pVAD insertion. Preoperative characteristics, postoperative complications, and mortality were compared among groups. ResultsOverall, 3695 patients underwent cardiac surgery and pVAD insertion during the same hospitalization (pre: 1130, intra: 1690, and post: 875). The distribution of cardiac surgery procedures was similar across groups. Median Elixhauser Comorbidity Index was 13 for pre-, 15 for intra-, and 17 for postoperative pVAD patients (P = .021). Patients who received a postoperative pVAD were associated with increased mortality (pre: 18%, intra: 39%, and post: 54%; P < .01). Increased complication rates were also associated with postoperative pVAD insertion (pre: 61%, intra: 55%, and post: 75%; P < .01). Preoperative pVAD insertion was associated with increase rates of sepsis (pre: 18%, intra: 9.8%, and post: 17%; P = .01) and pneumonia (pre: 38%, intra: 23%, and post: 31%; P < .01). Postoperative pVAD insertion was associated with increased rates of gastrointestinal bleeding (pre: 2.2%, intra: 3.0%, and post: 7.4%; P = .01), renal failure (pre: 10%, intra: 9.2%, and post: 17%; P = .01), and prolonged ventilation (pre: 44%, intra: 41%, and post: 54%; P = .02). ConclusionsPostoperative pVAD insertion following cardiac surgery was associated with increased complications and mortality compared with preoperative or intraoperative insertion. Further studies should explore optimal utilization and timing of pVAD insertion in patients undergoing cardiac surgery.

Outcomes of Children Supported With Pulsatile Paracorporeal Ventricular Assist Device: Congenital Versus Acquired Heart Disease.

We reviewed the outcomes of 82 consecutive pediatric patients (less than 18 years of age) supported with the Berlin Heart ventricular assist device (VAD), comparing those with congenital heart disease (CHD; n = 44) with those with acquired heart disease (AHD; n = 37). The primary outcome was mortality after VAD insertion. Kaplan-Meier methods and log-rank tests were used to assess group differences in long-term survival. Forty-four CHD patients were supported (age: median = 65 days, range = 4 days-13.3 years; weight [kg]: median = 4, range = 2.4-42.3). Ten biventricular CHD patients were supported with eight biventricular assist devices (BiVADs), one left ventricular assist device (LVAD) only, and one LVAD converted to BiVAD, while 34 univentricular CHD patients were supported with single ventricle-ventricular assist devices (sVADs). In CHD patients, duration of VAD support was [days]: median = 134, range = 4-554. Of 44 CHD patients, 28 underwent heart transplantation, 15 died on VAD, and one was still on VAD. Thirty-seven AHD patients were supported (age: median = 1.9 years, range = 27 days-17.7 years; weight [kg]: median = 11, range = 3.1-112), including 34 BiVAD and 3 LVAD. In AHD patients, duration of VAD support was [days]: median = 97, range = 4-315. Of 37 AHD patients, 28 underwent transplantation, three died on VAD, five weaned off VAD (one of whom underwent heart transplantation 334 days after weaning), and one was still on VAD. One-year survival after VAD insertion was 59.9% (95% CI = 46.7%-76.7%) in CHD and 88.6% (95% CI = 78.8%-99.8%) in AHD, P = .0004. Five-year survival after VAD insertion was 55.4% (95% CI = 40.8%-75.2%) in CHD and 85.3% (95% CI = 74.0%-98.2%) in AHD, P = .002. Pulsatile VAD facilitates bridge-to-transplantation in neonates, infants, and children with CHD; however, survival after VAD insertion is worse in patients with CHD than in patients with AHD.

Management of Vasoplegic Shock in Left Ventricular Assist Device Insertion Procedures.

Management of Vasoplegic Shock in Left Ventricular Assist Device Insertion Procedures.

3D Virtual modelling, 3D printing and extended reality for planning of implant procedure of short-term and long-term mechanical circulatory support devices and heart transplantation.

The use of three-dimensional (3D) reconstruction and printing technology, together with extended reality applied to advanced heart failure adult patients with complex anatomy, is rapidly spreading in clinical practice. We report practical experience with application to acute and chronic heart failure: planning and performing mechanical circulatory device insertion or heart transplantation. From November 2019 until February 2022, 53 3D virtual biomodels were produced for intervention planning (using Virtual/Augmented Reality and/or 3D printing), following a specific segmentation and preprocessing workflow for biomodelling, in patients with advanced heart failure due to structural heart disease or cardiomyopathies. Four of those patients were complex cases requiring mechanical circulatory support implant procedures in our center. One short-term and three long-term ventricular assist device system were successfully clinically implanted after application of this technique. In other two cases with extremely high procedural risk, visualized after application of this multimodality imaging, heart transplantation was elected. 3D printing based planning and virtual procedure simulation, are of great importance to select appropriate candidates for mechanical circulatory support in case of complex patient anatomy and may help to diminish periprocedural complications. Extended reality represents a perspective tool in planification of complex surgical procedures or ventricular assist device insertion in this setting.

(289) Does Lateral Approach Preserve Better Right Ventricular Function after Left Ventricular Assist Device Insertion?

(289) Does Lateral Approach Preserve Better Right Ventricular Function after Left Ventricular Assist Device Insertion?

Support with Single Ventricle-Ventricular Assist Device (sVAD) in Patients with Functionally Univentricular Circulation Prior to Fontan Operation.

Some patients with functionally univentricular circulation develop cardiac failure refractory to maximal management and are supported with a ventricular assist device (VAD). The purpose of this manuscript is to summarize our previous publications related to single ventricle-ventricular assist device (sVAD) support in patients with functionally univentricular circulation and to describe our current institutional approach at University of Florida to sVAD support in neonates, infants, and children prior to Fontan. Our programmatic philosophy at University of Florida is to strive to identify the minority of neonates with functionally univentricular circulation who are extremely high-risk prior to initiating staged palliation and to stabilize these neonates with primary preemptive sVAD in preparation for cardiac transplantation; our rationale for this approach is related to the challenges associated with failed staged palliation and subsequent bail-out sVAD support and transplantation. A subset of extremely high-risk neonates and infants with functionally univentricular ductal-dependent circulation undergo primary preemptive sVAD insertion and subsequent cardiac transplantation. Support with VAD clearly facilitates survival on the waiting list during prolonged wait times and optimizes outcomes after Norwood (Stage 1) by providing an alternative pathway for extremely high-risk patients. Therefore, the selective utilization of sVAD in extremely high-risk neonates facilitates improved outcomes for all patients with functionally univentricular ductal-dependent circulation. At University of Florida, our programmatic approach to utilizing sVAD support as a bridge to transplantation in the minority of neonates with functionally univentricular circulation who are extremely high-risk for staged palliation is associated with Operative Mortality after Norwood (Stage 1) Operation of 2.9% (2/68) and a one-year survival of 91.1% (82/90) for all neonates presenting with hypoplastic left heart syndrome (HLHS) or HLHS-related malformation with functionally univentricular ductal-dependent systemic circulation. Meanwhile, at University of Florida, for all 82 consecutive neonates, infants, and children supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 73.3% (95% confidence interval [CI] = 64.1-83.8%), and Kaplan-Meier survival estimated five years after VAD insertion = 68.3% (95% CI = 58.4-79.8%). For all 48 consecutive neonates, infants, and children at University of Florida with biventricular circulation supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 82.7% (95% CI = 72.4-94.4%), and Kaplan-Meier survival estimated five years after VAD insertion = 79.7% (95% CI = 68.6-92.6%). For all 34 consecutive neonates, infants, and children at University of Florida with functionally univentricular circulation supported with pulsatile paracorporeal sVAD: Kaplan-Meier survival estimated one year after VAD insertion = 59.7% (95% CI = 44.9-79.5%), and Kaplan-Meier survival estimated five years after VAD insertion = 50.5% (95% CI = 35.0-73.0%). These Kaplan-Meier survival estimates for patients supported with pulsatile paracorporeal VAD are better in patients with biventricular circulation in comparison to patients with functionally univentricular circulation both one year after VAD insertion (P=0.026) and five years after VAD insertion (P=0.010). Although outcomes after VAD support in functionally univentricular patients are worse than in patients with biventricular circulation, sVAD provides a reasonable chance for survival. Ongoing research is necessary to improve the outcomes of these challenging patients, with the goal of developing strategies where outcomes after sVAD support in functionally univentricular patients are equivalent to the outcomes achieved after VAD support in patients with biventricular circulation.

Tricuspid valve surgery at the time of left ventricular assist device insertion-digging deeper.

Tricuspid valve surgery at the time of left ventricular assist device insertion-digging deeper.

Outcomes of treatment for deep left ventricular assist device infection

ObjectiveAmong left ventricular assist device patients, the most commonly infected component is the drive line, which can be managed with antibiotics and local debridement. Infection of intrathoracic device components is less common but more difficult to manage. Herein we describe the incidence of deep device infection (DDI) at our center as well as management and outcomes. MethodsWe retrospectively reviewed 658 patients who underwent implantable left ventricular assist device insertion with HeartMate 2 (Abbott) or HeartMate 3 (Abbott) devices between January 2004 and June 2021. DDI was defined according to radiographic and clinical criteria. Cumulative incidence was calculated using a Fine-Gray subdistribution model; survival analysis was performed using the method of Kaplan and Meier. ResultsThere were 32 (4.8%) DDIs during this study period. Drive line infection and re-exploration for bleeding were associated with development of DDI. Cumulative incidence of DDI increased over time, affecting 11% (7%-18%) at 5 years. The dominant microbes involved in DDI were Pseudomonas aeruginosa (19%) and methicillin-resistant Staphylococcus aureus (13%). Nineteen patients (59%) with device infection underwent device exchange, 6 (19%) underwent initial transplant, and 7 (22%) were treated solely with debridement and antibiotics. Of those who underwent device exchange, 12 (63%) developed reinfection of their new device and 6 underwent subsequent heart transplant. Patients who underwent transplantation for management of device infection had improved 5-year survival (80% vs 11%; P = .01) but 3 patients (25%) developed deep sternal wound infection after transplant. ConclusionsDDI is a rare but challenging complication in this destination era. Heart transplantation is the preferred management strategy for eligible patients but infectious complication is common.

Perioperative Ischemic Optic Neuropathy after Cardiac Surgery: Development and Validation of a Preoperative Risk Prediction Model

ObjectivePrevious studies identified risk factors for ischemic optic neuropathy (ION) after cardiac surgery; however, there is no easy-to-use risk calculator for the physician to identify high-risk patients for ION before cardiac surgery. The authors sought to develop and validate a simple-to-use predictive model and calculator to assist with preoperative identification of risk and informed consent for this rare but serious complication. DesignRetrospective case-control study. SettingHospital discharge records. PatientsA total of 5,561,177 discharges in the National Inpatient Sample >18 years of age, with procedure codes for coronary artery bypass grafting, heart valve repair/replacement, or left ventricular assist device insertion. InterventionsAll patients had undergone cardiac surgery. Measurements and Main ResultsKnown preoperative risk factors for ION after cardiac surgery were assessed to develop a risk score and prediction model. This model was validated internally using the split-sample method. There were 771 cases of ION among 5,561,177 patients in the National Inpatient Sample. The risk factors for ION used in the model were carotid artery stenosis, cataract, diabetic retinopathy, macular degeneration, glaucoma, male sex, and prior stroke; whereas uncomplicated diabetes decreased risk. With the internal validation, the predictive model had an area under the receiver operating characteristic curve of 0.66. A risk score cutoff ≥3 had 98.4% specificity. ConclusionsThis predictive model, based on previously identified preoperative factors, predicted risk of perioperative ION with a fair area under the receiver operating characteristic curve. This predictive model could enable screening to provide a more accurate risk assessment for ION, and consent process for cardiac surgery.

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) withnormal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP),remains a significant cause of morbidity and mortality worldwide if left untreated.Therapies for the treatment of RV shock rangefrom medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.

Analysis of 82 Children Supported With Pulsatile Paracorporeal Ventricular Assist Device: Comparison of Patients With Biventricular Versus Univentricular Circulation

We reviewed outcomes in 82 consecutive children supported with the Berlin Heart pulsatile ventricular assist device (VAD), comparing those with functionally univentricular circulation (n = 34) to those with biventricular circulation (n = 48). The primary outcome was mortality. Kaplan-Meier (KM) methods and log-rank tests were used to assess group differences in long-term survival. T-tests using KM-estimated survival proportions and standard errors were used to compare groups at specific time points. 48 biventricular patients were supported (Age: median = 1.4 years, range = 17 days-17.7 years; Weight [kilograms]: median = 9.4, range = 3.1-112), including 43 BiVAD, 4 LVAD only, and 1 LVAD converted to BiVAD. In biventricular patients, duration of VAD support [days]: median = 97, range = 4-315. Of 48 biventricular patients, 35 underwent heart transplantation, 7 died on VAD, 5 weaned off VAD (1 of whom underwent heart transplantation 334 days after weaning), and 1 is still on VAD. 34 univentricular patients were supported with single VAD (sVAD) (Age: median = 38.5 days, range = 4 days-13.3 years; Weight [kilograms]: median = 3.98, range = 2.4-32.6). In univentricular patients, duration of VAD support [days]: median = 138, range = 4-554. Of 34 univentricular patients, 22 underwent transplantation, 11 died on VAD, and 1 is still on VAD. One-year survival after VAD insertion was 82.7% (95% CI = 72.4-94.4%) in biventricular patients and 59.7% (95% CI = 44.9-79.5%) in univentricular patients, p = 0.026. Five-year survival after VAD insertion was 79.7% (95% CI = 68.6-92.6%) in biventricular patients and 50.5% (95% CI = 35.0-73.0%) in univentricular patients, p = 0.010. Pulsatile VAD facilitates bridge to transplantation in neonates, infants, and children with functionally univentricular circulation; however, survival is worse than in patients with biventricular circulation.

HLA Sensitization within One-Year of VAD Implantation: Prospective Study in Adults and Pediatrics

<h3>Purpose</h3> Ventricular assist devices (VADs) have improved survival to heart transplant (HTx). However, VADs have been associated with the development of human leukocyte antigen antibodies (HLA-Ab) which may limit the donor pool and increase risk for worse outcomes post-HTx. Since HLA-Ab development after VAD insertion is poorly understood, the aim of this prospective study was to quantify the incidence of and risk factors for HLA-Ab development post-VAD insertion across the age spectrum. <h3>Methods</h3> Adult and pediatric patients who were undergoing durable VAD placement between 5/2016 and 7/2020 were enrolled. HLA-Ab were assessed pre-VAD and at approximately 1, 3, and 12 months post-implant. HLA-Ab were measured by Luminex screen; all positive/borderline screens were confirmed by Luminex single antigen beads. Factors associated with HLA-Ab development post-VAD implant were explored. <h3>Results</h3> The study cohort included 41 adult and 17 pediatric patients. Following implant, 37% of adults and 41% of pediatric patients developed new HLA-Ab. The majority of patients (19/22) developed HLA-Ab within two months of implant and three patients developed HLA-Ab within four months post-implant. Of those that developed HLA-Ab, class I antibody development was most common (80% adult and 86% pediatric patients). Factors associated with HLA-Ab development within one year are listed in Table 1. <h3>Conclusion</h3> More than one-third of adult and pediatric VAD patients developed new HLA-Ab early after implant with the majority specific to class I. HLA-Ab development in adults was associated with female sex and pre-VAD HLA sensitization; these associations were not identified in pediatric patients. Further studies into the persistence of HLA-Ab over time in VAD patients and the clinical impact of HLA-Ab on long-term outcomes are needed.

VAD Support of High-Risk Infants with HLHS: Comparison of Rescue VAD After Prior Palliation versus Primary VAD Insertion

<h3>Purpose</h3> To evaluate outcomes in high-risk infants with hypoplastic left heart syndrome (HLHS) supported with the Berlin Heart Ventricular Assist Device (VAD), comparing those with rescue VAD after prior palliation vs those with primary VAD insertion. <h3>Methods</h3> We reviewed all 11 high-risk infants with HLHS who were supported with the Berlin Heart VAD at our institution. Patients are divided into two categories: bridged to decision (BTD) and bridged to transplant (BTT). Patients categorized as BTD were either status post prior palliation or had delayed referral for treatment and had cardiac failure and severe end-organ injury. Patients categorized as BTT were deemed too high risk for staged palliation and underwent primary VAD insertion along with placement of bilateral pulmonary artery bands and atrial septectomy if needed. The primary outcome was mortality. <h3>Results</h3> 11 patients were supported by the Berlin Heart EXCOR between 2012-2021. <b>BTT</b>: 64% (n=7) of the patients were categorized as BTT (median age = 20 days; median weight = 3.2 kilograms). Elevated panel reactive antibody was present. Median duration of VAD support was 101 days. 71% (n=5) in the BTT group survived to hospital discharge. All 5 (100%) were alive one year after orthotopic heart transplant. <b>BTD</b>: 36% (n=4) of the patients were categorized as BTD (median age = 121.5 days; median weight = 3.8 kilograms). Elevated panel reactive antibody was present in 50% (n = 2). Median duration of VAD support was 212 days. 50% (n=2) in the BTT group survived to hospital discharge. Zero (0%) were alive one year after orthotopic heart transplant. Additional patient data is summarized in Table 1. <h3>Conclusion</h3> Outcomes for VAD insertion in infants with HLHS and end-organ injury after failed prior palliation or delayed referral are suboptimal and not as good as outcomes after primary VAD insertion. Neonates with HLHS at high risk for staged palliation should be considered for primary VAD insertion to facilitate cardiac transplantation.

Minimally Invasive Left Ventricular Assist Device Insertion with Concomitant Aortic Valve Replacement Despite Prior Sternotomy

<h3>Introduction</h3> Minimally-invasive approaches to left ventricular assist device (LVAD) insertion have been described. However, reoperative sternotomy and/or need for concomitant procedures have been regarded as relative contraindications to a minimally-invasive approach. <h3>Case Report</h3> A 61 year-old female with ischemic cardiomyopathy and prior coronary bypass grafting via median sternotomy was deemed an appropriate candidate for LVAD insertion. While preoperative echocardiography demonstrated mild aortic insufficiency, intra-operative imaging revealed moderate aortic insufficiency. Intra-operatively, the aorta was accessed via a partial upper sternotomy to the 4^th intercostal space. The ventricular apex was accessed through a left anterolateral thoracotomy. Cardiopulmonary bypass was established via an aortic cannula inserted via the ascending aorta and a multi-stage venous cannula inserted into the right femoral vein. Cardioplegia was administered first via an antegrade aortic root catheter, and then later via retrograde catheter and direct coronary ostial cannulation during the valve replacement. The aortic valve was replaced with a 21-mm bioprosthetic valve via the partial sternotomy (Fig A). After aortotomy closure, the cross-clamp was removed and the heart re-perfused. An apical ventriculotomy was then created and the LVAD inflow cannula was inserted into the left ventricle and secured to the sewing ring (Fig B). The outflow graft was tunneled to the upper sternotomy and anastomosed to the aorta using a side-biting clamp. The postoperative course was notable for pneumonia leading to temporary re-intubation. She otherwise did well, and was discharged home on post-LVAD day 23. <h3>Summary</h3> Both a history of a prior sternotomy and the need for concomitant procedures present challenges to use of minimally-invasive approaches for LVAD insertion. Here, we demonstrate that concomitant AVR can be safely performed along with LVAD insertion in a reoperative setting.

Pre-Operative Planning to Mitigate Risk in Complex Single Ventricular Assist Devices

<h3>Introduction</h3> Infants with single ventricle (SV) anatomy are a high-risk group for ventricular assist device (VAD) support. Hybrid stage 1 palliation can be utilized to successfully bridge SV patients to transplantation, such as in the setting of atrioventricular valve regurgitation (AVVR) which precludes long-term SV palliation. Our case highlights how comprehensive pre-procedural planning can mitigate future risk of VAD implantation. <h3>Case Report</h3> A neonate with unbalanced right-dominant atrioventricular canal presented with severe AVVR and acute kidney injury (AKI) precluding traditional SV palliation. She underwent hybrid palliation as bridge to transplant. A 6 mm expandable PTFE graft was anastomosed to the pulmonary artery (PA); ductal stenting was performed through the graft which was then left <i>in situ</i>. She stabilized following initial palliation, but after 10 weeks developed progressive ventricular dysfunction and AKI (Figure 1). A PediMag continuous flow VAD was inserted off bypass using the previous graft for arterial outflow and a right atrial inflow cannula (Figure 2). Renal function recovered and the patient is awaiting transplant with stable hemodynamics. <h3>Summary</h3> Anastomosing a graft to the PA during hybrid palliation enabled placement of VAD off bypass in an infant with SV anatomy and AKI. Detailed pre-operative planning at the time of stage 1 palliation in high-risk infants with potential future VAD support needs may be beneficial as part of a strategy to avoid an early VAD when systemic output is adequate while decreasing subsequent operative risk at time of VAD insertion.

Cardiac rehabilitation in a heart failure patient after left ventricular assist device insertion and subsequent heart transplantation: A case report

BACKGROUNDInsertion of a left ventricular assist device (LVAD) and heart transplantation (HT) improve the survival of patients with heart failure. In addition, cardiac rehabilitation (CR) further increases the functional capacity. This case report describes a successful case of CR after LVAD insertion and subsequent HT.CASE SUMMARYIn the present case, during the LVAD insertion period, peak oxygen consumption (VO2) increased by 12.16% after CR. HT was performed 7 mo after the LVAD insertion, and the patient participated in phases I and II CR. The peak VO2 increased from 17.24 to 22.29 mL/kg/min. This improvement was more significant than that reported in previous studies on CR after LVAD insertion or HT. The patient’s quality of life also improved. The total average score of the short form-36 questionnaire increased from 29.5 points at admission to 53.3 points 9 mo after HT.CONCLUSIONA tailored CR program after LVAD insertion or HT may improve the patients’ quality of life and increase survival.