Anatomic classification of mitral annular calcification for surgical and transcatheter mitral valve replacement.

BACKGROUND AND AIM OF THE STUDY: A systematic approach to quantify mitral annular calcification (MAC) in all-comers by multidetector computed tomography (MDCT) is essential to guide treatment, but lacking. METHODS: From September 2015 to July 2019, 82 patients with MAC underwent MDCT at two institutions to evaluate for surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management. Type 1 MAC was defined as <270° annular calcium and Type 2 as ≥270°. Absence/presence of predicted left ventricular outflow tract (LVOT) obstruction with virtual valve placement was used to further define Type 2 MAC into 2A/B for our treatment algorithm. RESULTS: Type 1 MAC was present in 51.2%, Type 2A in 18.3%, and Type 2B in 30.5%. Operable Type 1 patients (50.0%) underwent hybrid transatrial TMVR or SMVR. Type 2A underwent a variety of treatments, and Type 2B surgical candidates (40.0%) underwent hybrid transatrial TMVR secondary to difficult suture anchoring with significant MAC and predicted LVOT obstruction. At a follow-up of 29.6 ± 12.0 months, mortality was 42.7% with 46.3% in the intervention group and 39.0% in the medical group (p = 0.47). All percutaneous TMVR patients expired. This translated to a disproportionate number of Type 2A deaths (80.0% with intervention), but all were high/extreme surgical risk. The hybrid TMVR group consisted of 95.0% Type 1/2B patients and had a lower Society of Thoracic Surgeons predicted risk of operative mortality (7.4% vs. 9.2%, p = 0.43)/mortality. CONCLUSIONS: The highest mortality was seen in percutaneous TMVR Type 2A MAC patients, but they were at the greatest risk. Here we provide an objective MAC treatment algorithm for all-comers based on operability/anatomy.

Ten-year outcomes of extracorporeal life support for in-hospital cardiac arrest at a tertiary center.

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45-72) with a median ECLS duration of 2.2 days (IQR 0.6-5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30-50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22-8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14-0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. METHODS: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. RESULTS: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. CONCLUSIONS: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.

Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients.

OBJECTIVE: Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development. METHODS: We conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome. RESULTS: Median age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention. CONCLUSIONS: Lymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.

Impact of small prosthesis size on transcatheter or surgical aortic valve replacement outcomes.

OBJECTIVES: Determine the comparative impact of small prosthesis size on transcatheter and surgical aortic valve replacement (SAVR) outcomes. BACKGROUND: Patients with small aortic annuli tend to have worse postoperative outcomes and hemodynamics. We sought to describe surgical outcomes in patients with very small aortic annuli and then compare early hemodynamic and clinical outcomes in patients undergoing surgical or transcatheter aortic valve replacement (TAVR) with the smallest available valves to assist in optimal prosthesis selection for this challenging patient population. METHODS: A retrospective single-center study comparing patient data from 2143 patients undergoing SAVR with valves having a true internal diameter (ID) of ≥19 mm with 130 patients receiving surgical valves with true ID's <19 mm (SmSAVR). Outcomes of SmSAVR patients were then compared with 40 patients undergoing TAVR receiving small valves (SmTAVR). A representative SmSAVR cohort was then compared with the SmTAVR patients for post-operative hemodynamics. RESULTS: Receiving a small surgical valve may significantly increase 1-year mortality compared with standard-sized surgical valves (HR 1.93; 95% confidence interval 1.03-3.61). SmTAVR patients had significantly shorter lengths of stay than SmSAVR (median 5 vs. 9 days), and significantly better postoperative hemodynamic profiles (mean gradient 13.4 ± 7.8 vs. 18.1 ± 8.4 mm Hg, P = 0.006, peak velocity of 2.5 ± 0.6 vs. 2.9 ± 0.6 m/s, P = 0.003). CONCLUSIONS: TAVR is a safe and reasonable option for patients with small aortic annuli and is associated with shorter hospital stays and more favorable postoperative hemodynamic outcomes compared with SAVR. © 2017 Wiley Periodicals, Inc.

Planned Concomitant Left and Right Ventricular Assist Device Insertion to Avoid Long-term Biventricular Mechanical Support: Bridge to Right Ventricular Recovery.

INTRODUCTION: The planned use of a temporary right ventricular assist device (RVAD) at the time of left ventricular assist device (LVAD) implantation may prevent the need for a permanent biventricular assist device (BiVAD). Herein we describe our RVAD weaning protocol that was effectively employed in 4 patients to prevent the need for permanent BiVAD. METHODS: Four patients in refractory cardiogenic shock underwent planned RVAD insertion during LVAD implantation due to severely depressed right ventricular function with dilation preoperatively. A standardized RVAD weaning protocol was employed in these 4 patients in preparation for decannulation. RESULTS: Temporary RVADs were successfully placed in all 4 patients at the time of LVAD implantation. All patients survived to RVAD decannulation and discharge and were alive at the time of most recent follow-up (range, 528-742 days post-RVAD decannulation). CONCLUSION: Planned implantation of a temporary RVAD in high risk patients may avoid the need for biventricular mechanical support in the future.

Extracorporeal lung support.

PURPOSE OF REVIEW: The applications for extracorporeal membrane oxygenation for lung support are constantly evolving. This review highlights fundamental concepts in extracorporeal lung support and describes directions for future research. RECENT FINDINGS: Since the 1950s, extracorporeal lung support has experienced continuous advancements in circuit design and safety in acute respiratory distress syndrome, chronic obstructive pulmonary disease exacerbations, as a bridge to transplantation, intraoperative cardiopulmonary support, and for transportation to referral centers. Patients on extracorporeal membrane oxygenation are now capable of being awake, extubated, and ambulatory for accelerated recovery or optimization for transplantation. SUMMARY: Extracorporeal lung support is a safe and an easily implemented intervention for refractory respiratory failure. Recent advances have extended its use beyond acute illnesses and the developments for chronic support will facilitate the development of durable devices and possible artificial lung development.

COR-KNOT-Induced Leaflet Perforation: How It Happens and How to Prevent It: A Case Report.

The COR-KNOT suture fastening device has dramatically improved the efficiency of valve suture fixation. Despite its relative ease of use, there are important considerations in deployment to limit the risk of prosthetic valve injury. Herein, we report a case of iatrogenic aortic bioprosthetic insufficiency caused by poorly positioned COR-KNOTs and outline technical strategies to ensure success.

Financial Well-Being for Thoracic Surgeons.

The authors provide a brief overview for thoracic surgeons in topics essential to achieving financial well-being as a student, trainee, practicing surgeon, and beyond. While broad in nature, the authors' article is comprehensive, and they cover topics including student loans, asset and wealth management, investment opportunities, financial and estate planning, and insurances. It is hoped that the information provided will allow thoracic surgeons to become more familiar with the financial topics that pertain to thoracic surgeons and provide an introduction to explore financial wellness and literacy more thoroughly.

Aortic insufficiency following balloon aortic valvuloplasty does not impact long-term autograft durability after the Ross procedure.

OBJECTIVE: Preoperative aortic insufficiency (AI) is associated with inferior autograft durability after the Ross procedure. However, many patients with aortic stenosis (AS) undergo balloon aortic valvuloplasty (BAV) early and present with longstanding AI before Ross. We studied how BAV and subsequent valvular pathology impacts autograft durability. METHODS: Patients undergoing the Ross operation from 1993 to 2020 were identified. Those who underwent BAV before Ross were compared with patients who did not undergo BAV and underwent Ross for predominant AI (AI group) or AS (AS group). Those who underwent previous open surgical aortic valve intervention were excluded. Primary outcome of interest was autograft failure, defined as a composite of autograft reintervention or severe insufficiency. RESULTS: A total of 198 patients were included. Seventy-nine (39.9%) underwent BAV and subsequently underwent the Ross for predominant AI (45.6%) or AS (54.4%). Of patients who did not undergo BAV, 66 (33.3%) presented with predominant AI and 53 (26.8%) with AS. Freedom from autograft failure at 15 years was 90%, 92%, and 62% in BAV, AS, and AI groups, respectively. The AI group was at significantly increased risk of long-term autograft failure (hazard ratio, 5.6; P = .01), whereas the AS and BAV groups had similar, low risk (hazard ratio, 1.1; P = .91). Autograft durability was similar among patients who received BAV and presented with AS or AI before the Ross (P = .84). CONCLUSIONS: BAV before the Ross procedure is common in patients with AS. These patients have excellent long-term autograft durability regardless of preoperative valvular pathology and should strongly be considered for the Ross operation.

Carbon monoxide releasing molecules inhibit cell death resulting from renal transplantation related stress.

PURPOSE: Organ cold storage and subsequent transplantation are associated with significant ischemia-reperfusion injury, leading to cell death, graft inflammation and decreased graft function. MATERIALS AND METHODS: CORM-3s reduce oxidative stress and prevent inflammation in kidneys stored at 4C and subsequently transplanted. Graft survival and function are markedly improved compared to kidneys preserved and stored in University of Wisconsin solution alone. We determined whether CORM-3 has direct antiapoptotic effects on in vitro preparations of human HUVECs exposed to anoxic conditions. We also determined whether direct administration of CORM-3 to renal grafts before and/or after cold storage would prevent renal damage during the transplantation process. RESULTS: CORM-3 supplementation led to a significantly increased frequency of live cells (mean ± SD 72.3% ± 1.9%, p <0.01), reduced apoptosis (14.9% ± 6.1%, p <0.01) and decreased mitochondrial transmembrane potential (40.2% ± 7.2%, p <0.05) in HUVECs exposed to 20 hours of cold storage compared to controls (11.6% ± 3.5%, 82.2% ± 2.3% and 78.2% ± 3.2%, respectively). In keeping with this antiapoptotic effect CORM-3 supplementation led to a mean 7.4 ± 2.1-fold up-regulation in Bcl-2 gene expression. CORM-3 supplementation in standard preservation solution was most beneficial at initial ischemic injury and before cold storage exposure. However, additional reflushing before vascular reperfusion showed an additive benefit to graft survival and function after transplantation. This was confirmed by decreased glomerular and tubular necrosis, and apoptosis in double flushed grafts. CONCLUSIONS: CORM-3 supplementation in standard University of Wisconsin solution has a significant impact on decreasing cellular and graft injury, and improving survival through its antiapoptotic effects, which are likely mediated through mitochondrial membrane stabilization.

Surgeon Strength: Ergonomics and Strength Training in Cardiothoracic Surgery.

With the high prevalence of musculoskeletal pain in surgeons and interventionalists, it is critical to analyze the impact of ergonomics on cardiothoracic surgeon health. Here, we review the existing literature and propose recommendations to improve physical preparedness for surgery both in and outside the operating room. For decades, cardiothoracic surgeons have suffered from musculoskeletal pain, most commonly in the neck, and back due to a lack of proper ergonomics during surgery. A lack of dedicated ergonomics curriculum during training may leave surgeons at a high predisposition for work-related musculoskeletal disorders. We searched PubMed, Google Scholar, and other sources for studies relevant to surgical ergonomics and prevalence of musculoskeletal disease among surgeons and interventionalists. Whenever possible, data from quantitative studies, and meta-analyses are presented. We also contacted experts and propose an exercise routine to improve physical preparedness for demands of surgery. To date, many studies have reported astonishingly high rates of work-related pain in surgeons with rates as high as 87% in minimally-invasive surgeons. Several optimizations regarding correct table height, monitor positioning, and loupe angles have been discussed. Lastly, implementation of ergonomics training at some programs have been effective at reducing the rates of musculoskeletal pain among surgeons. Surgical work-related stress injuries are more common than we think. Many factors including smaller incisions and technological advancements have led to this plight. Ultimately, work-related injuries are underreported and understudied and the field of surgical ergonomics remains open for investigative study.

The Impact of Intrapericardial versus Intrapleural HeartMate 3 Pump Placement on Clinical Outcomes.

Background: The integrated design of the HeartMate 3 (Abbott Laboratories, Chicago, IL, USA) affords flexibility to place the pump within the pericardium or thoracic cavity. We sought to determine whether the presence of a left ventricular assist device (LVAD) in either location has a meaningful impact on overall patient outcomes. Methods: A retrospective cohort study was conducted of all 165 patients who received a HeartMate 3 LVAD via a median sternotomy from November 2014 to August 2019 at our center. Based on operative reports and imaging, patients were divided into intrapleural (n=81) and intrapericardial (n=84) cohorts. The primary outcome of interest was in-hospital mortality, while secondary outcomes included postoperative complications, cumulative readmission incidence, and 3-year survival. Results: There were no significant between-group differences in baseline demographics, risk factors, or preoperative hemodynamics. The overall in-hospital mortality rate was 6%, with no significant difference between the cohorts (9% vs. 4%, p=0.20). There were no significant differences in the postoperative rates of right ventricular failure, kidney failure requiring hemodialysis, stroke, tracheostomy, or arrhythmias. Over 3 years, despite similar mortality rates, intrapleural patients had significantly more readmissions (n=180 vs. n=117, p<0.01) with the most common reason being infection (n=68/165), predominantly unrelated to the device. Intrapleural patients had significantly more infection-related readmissions, predominantly driven by non-ventricular assist device-related infections (p=0.02), with 41% of these due to respiratory infections compared with 28% of intrapericardial patients. Conclusion: Compared with intrapericardial placement, insertion of an intrapleural HM3 may be associated with a higher incidence of readmission, especially due to respiratory infection.

Spinal Cord Infarction During Femoral Venoarterial Extracorporeal Membrane Oxygenation.

We describe 4 cases of spinal cord ischemia resulting in paraplegia after peripheral venoarterial extracorporeal membrane oxygenation for cardiogenic shock. This is an uncommon, but possibly underreported, complication with significant irreversible long-term morbidity. While causes are likely multifactorial, it is possible that thrombosis may occur at the level of the mixing cloud due to turbulent flow. Additional studies will be needed to elucidate the true incidence of this complication and investigate whether flow dynamics may potentiate clot formation.

Obesity is not a contraindication to veno-arterial extracorporeal life support.

OBJECTIVES: Obesity may complicate the peripheral cannulation and delivery of veno-arterial extracorporeal life support (ECLS). With rising global body mass indices (BMI), obesity is becoming increasingly prevalent in severe cardiogenic shock yet its impact on outcomes is not well described. This study sought to examine the relationship between BMI and veno-arterial ECLS outcomes to better inform clinical decision-making. METHODS: All cardiogenic shock patients undergoing peripheral veno-arterial ECLS at our institution from March 2008 to January 2019 were retrospectively analysed (n = 431). Patients were divided into 4 groups, BMI 17.5-24.9, 25-29.9, 30-34.9 and ≥35 kg/m2, and compared on clinical outcomes. Multivariable logistic regression was performed to identify variables associated with survival to discharge, the primary outcome of interest. RESULTS: The median BMI was 28.3 kg/m2 (interquartile range 24.8-32.6) with a range of 17.0-69.1 kg/m2. Obese patients achieved significantly lower percentages of predicted flow rates compared with BMI < 25 kg/m2 patients though did not differ in their lactate clearances. Patients with BMI ≥35 kg/m2 had similar complication rates to the other cohorts but were more likely to require continuous veno-venous haemodialysis (51% vs 25-40% in other cohorts, P = 0.002). Overall survival to discharge was 48% (n = 207/431) with no differences between the cohorts (P = 0.92). Patients with BMI ≥35 kg/m2 had considerably lower survival (10%) in extracorporeal membrane oxygenation cardiopulmonary resuscitation compared with the other groups (P = 0.17). On multivariable logistic regression, BMI was not significantly associated with failure to survive to discharge. CONCLUSIONS: In conclusion, with the rising global prevalence of obesity, the results of our study suggest that clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring ECLS.

Physical rehabilitation in the awake patient receiving extracorporeal circulatory or gas exchange support.

Intensive care unit (ICU)-acquired weakness is a common and serious sequela of critical illness. There is a growing body of evidence supporting the use of early mobilization in the ICU to mitigate this adverse effect. Recent data suggest that such a strategy may be feasible in patients with the most severe forms of cardiopulmonary failure-those requiring temporary mechanical circulatory support (TCS) or extracorporeal life support (ECLS). Both the modality of mechanical support and patient-specific characteristics must be taken into consideration when determining the appropriateness of an early mobilization strategy. The purpose of this review is to explore the current understanding of and evidence for mobilization and rehabilitation of patients receiving TCS or ECLS, including the identification of factors that may predict greater success for early mobilization and potential risks and contraindications to active physical therapy. While it is not yet known which of these patients are most likely to benefit from physical rehabilitation, a common theme is the importance of an interprofessional team approach to ensure patient safety and maximize the likelihood of successful mobilization.

Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support.

Patients receiving extracorporeal membrane oxygenation (ECMO) often require prolonged mechanical ventilation. Providers may be reluctant to perform tracheostomies on patients during ECMO due to their tenuous clinical status and systemic anticoagulation. We report our experience with performing open and percutaneous tracheostomies on patients supported on ECMO from August 2009 to December 2017. Of the 127 patients who underwent tracheostomy during ECMO support, the median age was 42 years (interquartile range [IQR], 29-54), 99 (78%) patients had venovenous (VV) cannulation, 22 (17%) patients had venoarterial (VA) cannulation, and six (5%) patients had hybrid configurations. Percutaneous tracheostomy was performed in 110 (87%) patients. Median-activated partial thromboplastin time (aPTT) at the time of tracheostomy was 47.5 seconds (IQR, 41-57.6 seconds). The median time from ECMO initiation to tracheostomy was 7 days (IQR, 4-11 days). A total of 55 patients (43%) received packed red blood cell (pRBC) transfusions within 48 hours after tracheostomy with a median transfusion of 2 units (IQR, 1-3). There was no procedural mortality. Overall, 88 (69%) patients survived to decannulation and 74 (58%) survived to hospital discharge. Our experience with the largest published series of tracheostomies during ECMO demonstrates that excellent outcomes can be achieved without significant morbidity.

Importance of surgical expertise in septal myectomy for obstructive hypertrophic cardiomyopathy.

OBJECTIVE: In 2011, a multidisciplinary hypertrophic cardiomyopathy (HCM) program with a dedicated myectomy surgeon was implemented at our institution. We hypothesized that a dedicated approach allows better identification and management of mitral regurgitation (MR) during septal myectomy (SM) for obstructive HCM with significant mitral regurgitation. METHODS: Between 2006 and 2018, 181 patients had SM at our institution. This study consists of 53 patients with preoperative moderate or greater MR associated with systolic anterior motion who underwent isolated SM with or without mitral intervention. Patients were divided into those who underwent SM by a dedicated myectomy surgeon (group D, n = 31) or by a non-dedicated surgeon (group ND, n = 22). Primary outcome of interest was rate of mitral valve replacement (MVR) at SM. Secondary outcomes include in-hospital mortality, need for permanent pacemaker, mitral valve reoperation, and residual MR and left ventricular outflow tract gradient on postoperative echocardiography. RESULTS: 12 patients (55%) had a concomitant MVR during septal myectomy in group ND compared to 2 patients (6%) in group D (p < 0.01). Among patients who did not undergo MVR, patients in group D less commonly had residual MR than patients in ND after SM (p < 0.01). Group D had 100% survival with NYHA class I in 94% patients at follow-up visit (p = 0.01). Reoperation for MVR was required in four patients in group ND vs. none in group D (p < 0.01). CONCLUSIONS: A dedicated surgeon is able to spare the mitral valve in patients undergoing SM. This study emphasizes the importance of surgical expertise in this cohort.

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

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