A Stepwise Approach to Left Ventricular Assist Device Pump Thrombosis.

AIM: Pump thrombosis (PT) is a detrimental complication of left ventricular assist device (LVAD) therapy. There is no consensus on optimal PT treatment. The aim of this study was to present a treatment strategy for patients with PT. METHOD: The hospital records of patients who underwent isolated LVAD implantation between May 2013 and October 2018 were retrospectively evaluated. Pump thrombosis was suspected in the setting of impaired flow/power parameters and haemolysis. Protocols for the management of suspected PT varied by patient presentation. Parameters that increased the PT risk were investigated by dividing the patients into two groups according to the presence of PT. Preoperative and operative data were analysed. RESULTS: Pump thrombosis was observed in 20 of 81 patients. All patients with PT presented elevated lactate dehydrogenase levels and higher power and/or low-/high-flow alarm at admission. All patients were treated initially with intravenous unfractionated heparin infusion; three patients did not require further treatment, one patient died due to sudden cardiac arrest, and three patients underwent urgent surgery for LVAD exchange. Thirteen (13) patients received tissue plasminogen activator infusion; eight were discharged without any signs of thrombosis, and three were bridged to transplant. One (1) major bleeding event leading to death was observed. Freedom from second PT was found in 91% cases at 6 months and in 68.2% at 1 year. We found that a larger left ventricle and the type of pump determined the risk of PT. CONCLUSIONS: Low-dose thrombolytic therapy should be considered as a feasible treatment option for patients with PT.

More continuous flow, better learning? The effect of aortic valve opening in patients with left ventricular assist device.

PURPOSE: The aim of this study was to analyze neurocognitive function in patients who underwent continuous flow left ventricular assist device (LVAD) implantation. MATERIAL AND METHOD: This cross-sectional study included three groups: LVAD (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). The Rey Auditory-Verbal Learning Test (RAVLT), Judgement of Line Orientation Test (JLOT), Trail Making Test (TMT), Stroop Color-Word Interference Test (SCWIT), Verbal Fluency Test (VFT), Symbol-Digit Modality Test (SDMT) were used to assess the neurocognitive functions. Data were analyzed at a median 12 (3-47) months after LVAD implantation. The LVAD patients were also divided by aortic valve opening (AVO) into three subgroups as "closed" (n = 9), "1-6" (n = 8) and "7-10" (n = 14) opening per ten beats and data were re-analyzed accordingly. RESULTS: There was no significant difference among the groups according to SCWIT, JLOT, SDMT, TMT, and VFT scores. Post-hoc analyzes of RAVLT scores showed significant differences between the LVAD and the other two groups in favor of the LVAD group. Also, the patients with AVO "7-10" the response times were longer and learning scores were found to be lower than those without AVO. CONCLUSION: With continuous-flow LVAD, neurocognitive functions were not impaired. The learning performance was better in cases where there was no AVO and flow was completely device dependent. We may speculate that neurocognitive functions are not worsening with continuous cerebral blood flow and even it may improve learning performance.

International experience using a durable, centrifugal-flow ventricular assist device for biventricular support.

BACKGROUND: Heart transplantation is limited by the scarcity of suitable donors. Patients with advanced biventricular failure may require biventricular support to provide optimal cardiac output and end-organ perfusion. We highlight the outcomes of using the HeartWare HVAD System (HVAD) in a biventricular configuration. METHODS: This retrospective study included patients implanted with HVAD as a biventricular assist device (BiVAD) between 2009 and 2017 at 12 participating centers. When used as a right ventricular assist device (VAD) (RVAD), the HVAD can be attached to the right ventricle (RV) or the right atrium (RA). Kaplan-Meier survival estimates were calculated comparing the 2 RVAD implant locations. Comparisons were also made between the timing of RVAD implantation (primary vs staged) on adverse event (AE) profiles and survival. RESULTS: Among the 93 patients who were implanted with a HVAD BiVAD, Kaplan-Meier survivals at 1-year and 2-year were 56% and 47%, respectively. Survival was independent of the location of the HVAD RVAD implant or whether there was an interval between left VAD and RVAD implantation. The most common AEs were bleeding (35.5%), infection (25.8%), and respiratory failure (20.4%). CONCLUSIONS: This study illustrated similar survival in patients receiving a primary or staged HVAD BiVAD implant at 1 year and 2 years. This study also established that the locations of the RVAD implant (RV or RA) result in similar AE profiles.

Anesthetic Management of Left Ventricular Assist Device Exchange in a Patient with Intracranial Hemorrhage.

The gold standard treatment for end-stage heart failure is heart transplantation; however, the rate of transplantation remains inadequate because of the paucity of organ donation. The left ventricular assist device (LVAD) has been used as a bridge therapy before transplantation. The LVAD is being used increasingly because it reduces mortality despite the accompanying morbidities. Therefore, the anesthetic management of LVAD-related morbidities is important and requires experience and knowledge. Herein, we describe a 60-year-old male patient with an LVAD with complaints of right hemiparesis, dysphasia, and facial paralysis. We aim to present the anesthetic management of a patient with intracranial hemorrhage who underwent LVAD exchange due to thrombosis.

Early and long-term results of heart transplantation with reoperative sternotomy.

BACKGROUND: This study aims to investigate the effects of reoperative sternotomy on early and long-term outcomes after heart transplantation. METHODS: We retrospectively reviewed data of a total of 92 patients (72 males, 20 females; mean age 36 years; range, 3 to 61 years) who underwent orthotopic heart transplantation between May 1998 and July 2014. The patients were divided into three groups. Group A (n=23) included patients who underwent previous cardiac surgery with sternotomy other than ventricular assist device implantation; Group B (n=12) included patients who were bridged-to-transplant with a ventricular assist device; and Group C (n=57) included patients who for the first time underwent heart transplantation without previous sternotomy. Preoperative and operative data of the three groups were compared. The short- and long-term outcomes of all groups were analyzed. RESULTS: There was no significant difference among the groups, except for the age and preoperative international normalized ratio. Total ischemia time in the ventricular assist device group was longer than Group C. The length of intensive care unit stay was also longer in the ventricular assist device group than the other groups. The amount of postoperative chest tube drainage and blood transfusion was higher in Group A. Early mortality rate was significantly higher in Group A. There was no significant difference in survival among the three groups in the long-term. According to the logistic regression analysis, no variable was found to be a significant risk factor for mortality. CONCLUSION: Reoperative sternotomy other than ventricular assist device implantation was found to be a risk factor for early mortality; however, mid and long-term survival rates were similar to patients in whom transplantation was the primary procedure. In patients with reoperative sternotomy, heart transplantation can be performed with similar risks to patients without resternotomy with careful selection and accurate pre- and intraoperative surgical approach.

Inhaled Iloprost and Oral Sildenafil Combination Therapy: Is it a Chance for Heart Transplant Candidacy?

BACKGROUND: Severe pulmonary hypertension is a risk factor for mortality, due to increased postoperative right ventricular failure, in a heart transplant patient. Elevated pulmonary vascular resistance (PVR) in heart transplant candidates can be reduced using a left ventricular assist device or medical therapy. This study analysed the effect of inhaled iloprost and oral sildenafil combination therapy (ilo-sil) on pulmonary haemodynamic parameters in patients with secondary pulmonary hypertension. METHODS: Between May 2011 and April 2014, 25 patients who were unresponsive to reversibility test and PVR >3.5 Wood units (WU) during right heart catheterisation were included in this study. After 6 months of oral sildenafil (3 × 20 mg/day) and inhaled iloprost (6 × 5 µg/day) combination therapy, second right heart catheterisations were performed and eligibility for heart transplant was evaluated. RESULTS: Repeat right heart catheterisation revealed that there was a significant decrease in the PVR from 5.4 ± 1.6 WU to 3.54 ± 2.5 WU (p<0.001), with trans-pulmonary gradient from 13.7 ± 5.6 to 11.46 ± 6.64 (p=0.042), and mean cardiac index (CI) increasing non-significantly from 1.45 ± 0.51 L/min/m2 to 1.82 ± 0.60 (p=0.157). The mean sPAP was initially 57.54 ± 14.79 mmHg and fell to 52.93 ± 16.83 mm Hg (p=0.03). Twenty (20) (80%) patients were enrolled in the waiting list since their PVR values decreased to <3.5 WU. Of these 20 patients, one had undergone heart transplant and four were bridged to transplant with mechanical circulatory support devices. CONCLUSIONS: After a decrease in PVR with ilo-sil combination therapy for patients with severe pulmonary hypertension, these patients may become candidates for heart transplant without bearing additional risk. Ilo-sil combination therapy could be a viable option with which to evaluate the reversibility of PVR.

Optimization with levosimendan improves outcomes after left ventricular assist device implantation.

OBJECTIVES: The aim of this study was to examine the haemodynamic effects of preoperative levosimendan infusion in patients who underwent left ventricular assist device implantation and evaluate the prognoses. METHODS: Between May 2013 and October 2018, 85 adult patients who underwent left ventricular assist device implantation were included; 44 and 41 patients suffered from dilated cardiomyopathy and ischaemic cardiomyopathy, respectively. Patients were divided into 2 groups: group A (58 patients) included those who received levosimendan infusion in addition to other inotropes and group B (27 patients) included those who received inotropic agents other than levosimendan. Levosimendan infusion was started at a dose of 0.1 µg⋅kg-1⋅min-1 for a maximum of 48 h without a bolus. The primary outcome was early right ventricular failure (RVF). The secondary outcomes were in-hospital mortality, need for right ventricular assist device, late RVF and recovery of end-organ functions. The safety end points of levosimendan included hypotension, atrial fibrillation, ventricular tachycardia or fibrillation and resuscitated cardiac arrest. RESULTS: Patient characteristics were similar in both groups. No significant differences between groups were observed in the rates of early mortality, RVF, need for right ventricular assist device, cardiopulmonary bypass time and intensive care unit stay. Survival rates at 30 days, 1 year and 3 years and freedom from late RVF were similar between the groups. Administration of levosimendan was safe, generally well-tolerated and not interrupted because of side effects. CONCLUSIONS: Levosimendan therapy was well-tolerated in patients who received permanent left ventricular assist devices. Combined preoperative therapy with inotropes and levosimendan significantly improves end-organ functions.

Effects of continuous-flow left ventricular assist devices on cerebral hemodynamics.

Continuous-flow left ventricular assist devices (LVADs) reduce peak systolic flow, increase diastolic flow, and eliminate pulsatility of circulation. Altered blood flow may lead to a change in end-organ perfusion. Analysis of the flow dynamics of the arteries of end organs, such as the brain, may indicate whether an organ is perfused sufficiently. The aim of this study is to evaluate and identify the flow pattern changes of carotid (CA) and middle cerebral arteries (MCA) in LVAD patients and to compare with heart failure patients and healthy volunteers. Eighty-nine individuals were included in this cross-sectional study. Participants were divided into three groups: LVAD patients (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). Carotid and transcranial Doppler ultrasonography were performed for all study groups for peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility (PI), and resistive (RI) indices of CA and MCA. Flow dynamics were compared between the groups. Doppler ultrasonographic data were analyzed at a median 12 (3-47) months after LVAD implantation. CA-PSV was lower in LVAD group compared with the other two groups (P < .001), MCA-PSV of LVAD and heart failure groups were similar and lower than healthy volunteers (P < .05). The highest values for CA-EDV were found in the LVAD group (P < .05). MCA-EDV values were found to be lowest in heart failure group (P < .05). For PI and RI, in all CA and MCA, the LVAD group had lower indices compared with the other two groups (P < .001). In addition, MCA flow analysis in patients with LVADs was identified for the first time with this study.

HeartMate 3 implantation via left thoracotomy with descending aortic anastomosis.

Left ventricular assist device implantation through left thoracotomy with outflow anastomosis to the descending aorta is an uncommon approach, particularly in patients with previous sternotomies. However, this approach has certain advantages, such as better surgical outcomes and lower complication rates. Here, we report the technique adapted for HeartMate 3 implantation through left thoracotomy with descending aortic anastomosis.

Tp-e interval and Tp-e/QT ratio in clinically stable pediatric heart transplant recipients.

OBJECTIVE: A study of the T wave peak-to-end (Tp-e) interval, the Tp-e/QT ratio, and the Tp-e/QTc ratio in pediatric heart transplant recipients (HTRs), a group which has a higher risk of sudden cardiac death than the normal population, has not previously been reported. The aim of this study was to assess alterations in ventricular repolarization using the Tp-e interval, Tp-e/ QT ratio, and Tp-e/QTc ratio in clinically stable pediatric HTRs. METHODS: A total of 13 clinically stable HTRs, 13 patients who had undergone cardiac surgery (CS) under cardiopulmonary bypass, and 16 healthy controls under 18 years of age were retrospectively evaluated. RESULTS: No significant differences were observed between the HTR, CS, and control groups in terms of QTc, JTc interval, and T wave amplitude (p>0.05). The Tp-e interval (p=0.001), Tp-e/QT ratio (p<0.001), and Tp-e/QTc ratio (p=0.001) were significantly higher in the HTR group compared with the CS and normal control participants. CONCLUSION: The Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were elevated in stable HTRs compared with the normal and CS groups.

HeartWare Left Ventricular Assist Device Implantation Combined with Surgical Ventricular Reconstruction.

Left ventricular assist devices (LVADs) extend survival of patients with end-stage heart failure as a bridge to transplant or for destination therapy. However, implant of these devices may be challenging, especially in cases of a left ventricular aneurysm involving the left ventricular apical wall. In this report, we describe a symptomatic patient with ischemic cardiomyopathy and a large left ventricular anterior aneurysm treated by reconstruction of the left ventricle and simultaneous implant of the HeartWare LVAD system (HVAD; HeartWare International, Inc., Framingham, MA, USA).

Quality of life among patients with left ventricular assist device: Comparison of two populations.

BACKGROUND: This study aims to evaluate quality of life among patients with an implanted left ventricular assist device in two different populations. METHODS: This cross-sectional study included a total of 20 patients (15 males, 5 females; mean age 41.8±13.4 years; range, 20 to 65 years) from Turkey and 40 patients (33 males, 7 females; mean age 55.1±11.6 years; range, 21 to 76 years) from Germany who underwent left ventricular assist device implantation and reached their third month of treatment between January 2016 and August 2016. The Euro Quality of Life-5 Dimension Questionnaire and Kansas City Cardiomyopathy Questionnaire-12 were used to assess quality of life of both groups. RESULTS: Sixty-five percent of the German patients returned to work, while none of the Turkish patients returned after implantation (p=0.000). The Turkish (70%) and German (40%) patients reported that they had difficulty in living with a left ventricular assist device (p=0.028). The mean Euro Quality of Life-5 Dimension Questionnaire visual analog scale scores of the Turkish and German patients were 70.50% and 62.38%, respectively. The mean Kansas City Cardiomyopathy Questionnaire-12 scores of the Turkish patients were significantly higher than those of the German patients (p=0.01). CONCLUSION: Left ventricular assist device implantation improved the quality of life of both Turkish and German patients. Turkish patients with left ventricular assist device should be encouraged to adopt a more independent life, not to limit their lives to home and to return to work according to their functional capacity.

Is it Possible to Implant HeartMate 3 Less Invasively? New Pump, New Approach.

HeartMate 3 (HM3) left ventricular assist device (LVAD) is a compact, intrapericardial, centrifugal flow pump with a fully magnetically levitated rotor and a wide range of operation (2-10 L/min) to accommodate a broad range of clinical needs. We analyzed our experience with Heartware VAD (HVAD) and HM3 implantation through minimally invasive left thoracotomy (MILT) and upper minimal J sternotomy. Between March 2015 and October 2016, 31 patients who underwent LVAD implantation through MILT were included in this study. Twenty-three patients had HVAD (Group A) implantation, whereas 8 patients had HM3 (Group B). To compare outcomes of these pumps, measures were; mortality, cardiopulmonary bypass (CPB) time, duration of mechanical ventilatory support, blood loss and transfusion, intensive care unit (ICU) stay, right ventricular failure (RVF) and requirement of support with temporary devices, stroke, pump thrombosis, gastrointestinal bleeding and driveline infection rates. Interagency Registry for Mechanically Assisted Circulatory Support profiles, Pennsylvania and Michigan Risk Scores, right ventricular stroke work index and central venous pressure/pulmonary capillary wedge pressure ratio did not differ between these two groups. There was no difference in the length of ICU stay (P = 0.056), post-operative blood product administration (P = 0.701), total time on mechanical ventilation (P = 0.386), RVF (P = 1) or duration of CPB (P = 0.836). In-hospital cerebrovascular event rate was 13% in Group A and 0% in Group B, respectively. The HM3 assist system can be successfully implanted with minimally invasive techniques. This technique has proved to be safe and reproducible, with good clinical outcomes. Further, large collaborative studies are needed to identify the advantages of this approach.

Histopathological evaluation of aortic coarctation after conventional balloon angioplasty in neonates.

BACKGROUND: Optimal management strategy for native aortic coarctation in neonates and young infants is still a matter of debate. The surgical procedure, histopathologic research, and clinical outcome in 15 neonates who underwent surgery after successful balloon angioplasty is the basis of this study. METHOD: Between 01 October, 2014 and 01 August, 2017, we enrolled 15 patients with native aortic coarctation for this study. These patients had complications regarding recoarctation, following balloon angioplasty intervention at our institute and other centres. Surgically extracted parts were examined histopathologically and patient's data were collected retrospectively.ResultThe reasons for recurrence of recoarctation after balloon angioplasty are as follows: patients with higher preoperative echocardiographic gradients had recoarctation earlier, neointimal proliferation, aortic intimal fibrosis at the region of ductal insertion, and ductal residual tissue debris after balloon angioplasty. No repeat intervention was required in the 15 patients who underwent surgery followed by balloon angioplasty. Early mortality was seen in one patient after surgery. Postoperative complication in the surgical group occurred in the form of chylothorax in one patient. CONCLUSION: In centres in which the neonatal ICU is inexperienced, balloon angioplasty is particularly recommended. In developing neonatal clinics, balloon angioplasty, when performed on patients at their earliest possible age, delays actual corrective operation to a later date, which in turn provides less risky surgical outcomes in infants who are gaining weight, growing, and do not have any haemodynamic complaints.

Third Generation Ventricular Assist Device: Mid-Term Outcomes of the HeartWare HVAD in Pediatric Patients.

The HeartWare HVAD is a small, third generation continuous flow pump that is intracorporeally placed for support of a failing ventricle in adult patients. This device is small in size when compared to other left ventricular assist devices and can therefore be used in smaller sized pediatric patients. We present our initial experience using the HVAD as a bridge to heart transplantation in the pediatric population. We performed a retrospective, single center, nonrandomized review of 17 pediatric patients who underwent HVAD implantation between June 2013 and March 2016. The primary endpoints evaluated in this study were overall survival to heart transplantation, ongoing device support, or death. In this patient cohort, nine (53%) of 17 patients were male. The median age of the patients was 13.4 ± 3.8 (range 5-17) years. The median body surface area was 1.4 ± 0.4(0.7-2) m2 . Etiologies of heart failure requiring HVAD support were dilated cardiomyopathy (n = 8), myocarditis (n = 5) and noncompaction cardiomyopathy (n = 4). The overall mean length of HVAD support was 254 ± 298 (range 2-804) days. A successful outcome (bridge to transplant and ongoing mechanical support) was achieved in 13 patients (76.5%). Of the 13 patients, nine (69.2%) were bridged to heart transplantation and four continue to receive support (30.7%) and are eligible for transplantation. Post-transplant survival has been 100%, with a mean follow-up of 296 ± 264.5 (range 18-785) days. The most common complication was pump thrombosis (23.5%) in follow-up. Four patients (23.5%) experienced no complications. The HVAD continuous flow ventricular assist device can be safely used to bridge pediatric patients to cardiac transplantation. Favorable outcomes of this device are comparable to the adult population. This analysis demonstrated safe and effective implantation of the HVAD System in a child with a BSA of 0.7 m2 .

A Novel Technique of Subclavian Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: The common femoral artery is the standard site for immediate vascular access when initiating adult venoarterial extracorporeal membrane oxygenation. However, this approach is fraught with problems such as femoral artery occlusion, distal limb ischemia, reperfusion injury resulting in compartment syndrome, retroperitoneal hemorrhage, thrombosis, embolization, and most importantly, pulmonary edema. Here, we show our preference of using the subclavian artery with a side graft as a different cannulation technique for outflow of extracorporeal membrane oxygenation, which can avoid complications associated with different access techniques. MATERIALS AND METHODS: Between September 2013 and December 2014, our group established venoarterial extracorporeal membrane oxygenation via subclavian artery-percutaneous femoral vein cannulation in 11 patients (81.1% men). Mean age was 33 ± 11.1 years (range, 16-55 y). RESULTS: For this technique, the subclavian artery was slung by retrotapes (Retract-o-Tape; Quest Medical Inc. Allen, TX, USA) proximally and distally before arteriotomy. An 8-mm polyethylene terephthalate (Dacron) graft was then sutured in "end-to-side" fashion. The proximal retrotape was removed, and the distal retrotape was passed through a snare. This maneuver allowed us to manage distal flow of subclavian artery by tightening this tape, thus avoiding complications associated with right arm hyperperfusion. After venoarterial extracorporeal membrane oxygenation was established, central venous pressure and lactate levels decreased, and improvements in arterial blood-gas parameters were maintained. CONCLUSIONS: Our protocol for venoarterial extracorporeal membrane oxygenation cannulation uses the subclavian artery for arterial access and provides a safe and perhaps improved means for providing venoarterial extracorporeal membrane oxygenation support.

Low-Dose Valacyclovir for Cytomegalovirus Infection Prophylaxis After a Heart Transplant.

OBJECTIVES: Cytomegalovirus infection is a major cause of morbidity and mortality in solid-organ transplant. Low doses of valacyclovir have been administered as cytomegalovirus prophylaxis in our institution for years. To the best of our knowledge, there is no published study of a low-dose regimen for cytomegalovirus prophylaxis in heart transplant patients. Therefore, our aim was to determine the results of low doses of valacyclovir in heart transplant. MATERIALS AND METHODS: Between September 2006 and December 2014, sixty-eight patients underwent orthotopic heart transplants. All of the patients received triple immunosuppressive therapy after surgery. During the next 6 months, sulfamethoxazole/trimethoprim was administered for Pneumocystis jiroveci pneumonia, and toxoplasmosis. Additionally all patients received valacyclovir hydrochloride (1000 mg/d, oral) for cytomegalovirus prophylaxis and nystatin oral rinse for prophylaxis of fungal infections. RESULTS: There was only 1 cytomegalovirus infection at follow-up. The patient had cytomegalovirus pneumonia at 17-month follow-up. In response to treatment with 1-week intravenous ganciclovir, the patient was discharged with a further 6-month oral valacyclovir therapy (1000 mg/d). CONCLUSIONS: In this study, we hypothesized that daily use of low-dose valacyclovir (1000 mg/d) is not only sufficient for cytomegalovirus prophylaxis but also beneficial in terms of cost.

Glasgow aneurysm scores in patients undergoing open surgical procedure for aortic aneurysm.

BACKGROUND: To assess the applicability of the Glasgow aneurysm score (GAS) in patients with aortic aneurysm undergoing an elective open surgical procedure in our hospital. MATERIALS AND METHODS: A total of 105 patients undergoing elective open surgical procedure between January 2006 and June 2012 were evaluated retrospectively. Glasgow aneurysm score (GAS) was calculated as age+7 points for myocardial disease, +10 points for cerebrovascular disease, and +14 points for renal disease. The best cut-off value for GAS was determined using the ROC curve analysis. RESULTS: The hospital mortality rate was 3.8% (4 patients). GAS was significantly lower in patients who survived the operation (76.05 ± 14.71 vs. 92.0 ± 10.8 respectively, p = 0.031). The ICU stay was also significantly lower in patients who survived the operation (2.37 ± 5.23) compared to the nonsurvivors (25.67 ± 13.80, p = 0.001). No significant difference was observed regarding age, duration of hospital stay, and aortic diameter. The area under the ROC curve was 0.818 and for a 100% sensitivity rate, the cut-off value for GAS was 77.5 with a 58.4% specificity rate (p = 0.031). All patients with a GAS < 77.5 were alive after surgery. CONCLUSION: The GAS appears to be a reliable clinical predictor for in hospital mortality following elective repair of abdominal aortic aneurysm following open surgical procedure.