Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes.

PURPOSE: We report on the clinical course and management of patients supported with durable implantable LVADs who developed outflow graft obstructions at a large academic center. METHODS: We performed a retrospective review of patients receiving LVAD support from 2012 through 2020. Patients who developed an outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. RESULTS: Of the 324 patients supported by LVAD at our institution, 11 patients (3.4%) were diagnosed with outflow graft obstructions. The most common presentation was low flow alarms, which was present in 10/11 patients, and the remaining patient presented with lightheadedness. Patients had minimal LDH elevation with 8/11 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/11 of the patients. Three patients with extrinsic compression of the outflow graft successfully underwent endovascular stent placement, and three patients with outflow cannula kinks received supportive care. Of the five patients diagnosed with intraluminal thromboses, one received a heart transplant, one underwent an outflow graft revision, and three received supportive care due to comorbidities. CONCLUSION: Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation. CTA is a pivotal non-invasive diagnostic step. Patients with external compression were successfully treated with endovascular stenting.

Safety and Effectiveness of Intravenous Iron Therapy in Patients Supported by Durable Left Ventricular Assist Devices.

AIMS: While it is common practice to use intravenous (IV) iron in patients with left ventricular assist devices (LVADs) and iron deficiency, there is insufficient evidence regarding outcomes in this patient population. We evaluated the safety and effectiveness of IV iron therapy in patients supported by LVADs with iron deficiency. METHODS: We performed a retrospective analysis of iron deficient patients on continuous LVAD support at a large academic center between 2008 and 2019. Patients were divided into two cohorts based on IV iron sucrose treatment. The primary endpoint was hemoglobin at 12 weeks. Secondary endpoints were mean corpuscular volume (MCV) and New York Heart Association (NYHA) class at 12 weeks. Safety endpoints included hospitalization, infection, pump thrombosis, arrhythmia, and gastrointestinal bleed. Models were weighted by the inverse probability of receiving IV iron using a propensity score, and endpoints were adjusted for their corresponding baseline values. RESULTS: Among 213 patients, 70 patients received IV iron and 143 patients did not. Hemoglobin at 12 weeks was significantly greater among those treated (intergroup difference: 0.6 g/dL; 95% CI, 0.1 to 1.1; p = 0.01), while MCV was similar in both groups (intergroup difference: 0.7 µm3; 95% CI, -1.3 to 2.7; p = 0.50). NYHA class distribution at 12 weeks was significantly different (odds ratio for improvement: 2.84; 95% CI, 1.42 to 4.68; p = 0.003). The hazards of adverse events in each group were similar. CONCLUSIONS: In patients with LVADs and iron deficiency, treatment with IV iron sucrose was safe and associated with improvements in functional status and hemoglobin.

Characteristics and Outcomes of Candidemia in Patients with Durable Left Ventricular Assist Device Support.

There are limited data on the characteristics and clinical course of fungal infections in patients on durable left ventricular assist device (LVAD) support. We sought to further characterize the epidemiology and outcomes of LVAD patients with fungemia. We performed a retrospective review of patients receiving LVAD support from January 2012 through June 2020 at a large academic institution. Among 336 patients on LVAD support, five (1.4%) were diagnosed with fungemia during the study period. Three patients had diabetes with mean hemoglobin A1c 7.1% (R 6.6, 7.4). Fever and leukocytosis (mean white blood count 17.0 thousand/µL [R 12.5, 29.9]) were the most common symptoms. Fungemia was diagnosed early after LVAD implantation (mean 14.4 support days [R 2, 19]). All patients were infected with Candida species, and four isolates were susceptible to fluconazole. Central nervous system outcomes included an ischemic stroke, subarachnoid hemorrhage, and malignant hemorrhagic stroke. Two patients were successfully transplanted, and two patients on destination therapy remain on suppressive fluconazole. In conclusion, fungemia is a rare and severe complication in LVAD patients occurring early postimplant.