Less-invasive ventricular assist device implantation: A multicenter study.

BACKGROUND: Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach. METHODS: Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation. RESULTS: The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77). CONCLUSIONS: The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.

Treatment of Postoperative New Onset Atrial Fibrillation with Repolarization Delaying Agents after Heart Surgery.

PURPOSE: The aim of this study was to evaluate the efficacy of the multichannel-blocker dronedarone for postoperative new onset atrial fibrillation (POAF) as compared to amiodarone. METHODS: Out of 990 patients who underwent cardiothoracic surgery between March 2011 and March 2012, 166 patients who developed POAF and treated with amiodarone or dronedarone were enrolled in this study. RESULTS: Eighty-nine patients were treated with amiodarone and 77 patients were treated with dronedarone at discharge. Seventy-five percent of patients with dronedarone were treated initially with intravenous amiodarone but quickly converted to oral dronedarone as soon as the mechanical ventilation was weaned off. The rate of conversion in sinus rhythm was not influenced by the resulting amiodarone-to-dronedarone crossover as compared to oral dronedarone only (p <0.247 at the ICU and p <0.640 at the normal care unit). At hospital discharge sinus rhythm was documented in 44% of the amiodarone patients and 99% of the dronedarone patients (p <0.001). The maintenance of sinus rhythm was demonstrated in 82% of the amiodarone patients versus 81% of the dronedarone patients at 6-month follow-up (p <0.804). CONCLUSIONS: Our data demonstrated the higher conversion rate to sinus rhythm in the early phase in the dronedarone group despite a comparable conversion rate in the mid-term phase compared to amiodarone.

Less invasive surgical implant strategy and right heart failure after LVAD implantation.

BACKGROUND: Conventional median sternotomy (CMS) is still the standard technique utilized to implant left ventricular assist devices (LVADs). Recent studies suggest that less invasive surgery (LIS) may be beneficial; however, robust data on differences in right heart failure (RHF) are lacking. This study aimed to determine the impact of LIS compared with that of CMS on RHF outcomes after LVAD implantation. METHODS: An international multicenter retrospective cohort study was conducted across 5 centers. Patients were grouped according to their implantation technique (LIS vs CMS). Only centrifugal devices were included. RHF was defined as severe or severe acute RHF according to the 2013 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definition. Logistic multivariate regression and propensity score‒matched analyses were performed to account for confounding. RESULTS: Overall, 427 implantations occurred during the study period, with 305 patients implanted using CMS and 122 using LIS. Pre-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) use was more common in the CMS group; off-pump implantation was more common in the LIS group. Other pre-implant variables, including age, creatinine, hemodynamics, and tricuspid regurgitation, did not differ between the 2 groups. Post-operative RHF was less common in the patients who underwent LIS than in those who underwent CMS as was post-operative right ventricular assist device (RVAD) use. LIS remained associated with less RHF in the multivariate analysis. After propensity score matching conditional for age, sex, INTERMACS profile, ECMO, and IABP use in a ratio of 2:1 (CMS to LIS), RHF (29.9% vs 18.6%, p = 0.001) and the need for post-operative RVAD (18.6% vs 8.2%; p = 0.009) remained more common in the CMS group than in the LIS group. There were no significant differences in survival up to 1 year between the groups. CONCLUSIONS: LIS may be associated with less RHF after LVAD implantation compared with CMS. Despite the possible reduction in RHF, there was no difference in 1-year survival. LIS is an alternative to traditional CMS.