Automated titanium fastener for surgical aortic valve replacement-preventive role for infective endocarditis?

OBJECTIVES: Evidence on long-term clinical outcomes considering suture-securing techniques used for surgical aortic valve replacement is still uncertain. METHODS: A total of 1405 patients who underwent surgical aortic valve replacement between January 2016 and December 2022 were included and grouped according to the suture-securing technique used (automated titanium fastener versus hand-tied knots). The occurrence of infective endocarditis during follow-up was set as the primary study end-point. As secondary study end-points, stroke, all-cause mortality and a composite outcome of either infective endocarditis, stroke, or all-cause mortality were assessed. RESULTS: The automated titanium fastener was used in 829 (59%) patients, whereas the hand-knot tying technique was used in 576 (41%) patients. The multivariable proportional competing risk regression analysis showed a significantly lower risk of infective endocarditis during follow-up in the automated titanium fastener group (adjusted sub-hazard ratio 0.44, 95% confidence interval 0.20-0.94, P = 0.035). The automated titanium fastener group was not associated with an increased risk of mortality or attaining the composite outcome, respectively (adjusted hazard ratio 0.81, 95% confidence interval 0.60-1.09, P = 0.169; adjusted hazard ratio 0.82, 95% confidence interval 0.63-1.07, P = 0.152). This group was not associated with an increased risk of stroke (adjusted sub-hazard ratio 0.82, 95% confidence interval 0.47-1.45, P = 0.504). Also, a significantly lower rate of early-onset infective endocarditis was observed in the automated titanium fastener group, (0.4% vs 1.4%, P = 0.032). CONCLUSIONS: Suture-securing with an automated titanium fastener device appears to be superior compared to the hand-knot tying technique in terms of lower risk of infective endocarditis.

Automated titanium fastener vs. hand-tied knots for prosthesis fixation in infective endocarditis.

Objectives: To date, there is no evidence regarding the safety of automated titanium fastener compared with hand-tied knots for prosthesis fixation in infective endocarditis. Methods: Between January 2016 and December 2022, a total of 220 patients requiring surgery for infective endocarditis were included in this retrospective analysis. The primary study endpoint was re-endocarditis during follow-up. The secondary study endpoints included stroke onset, all-cause mortality, and a composite outcome of either re-endocarditis, stroke, or all-cause mortality during follow-up. Results: Suture-securing with an automated titanium fastener was performed in 114 (51.8%) patients, whereas the conventional technique of hand knot-tying was used in 106 (48.2%) patients. The risk of re-endocarditis was significantly lower in the automated titanium fastener group, as shown in a multivariable proportional competing risk regression model (adjusted sub-hazard ratio 0.33, 95% confidence interval 0.11-0.99, p = 0.048). The multivariable Cox proportional hazards regression analysis showed that the automated titanium fastener group was not associated with an increased risk of stroke-onset or attaining the composite outcome, respectively, (adjusted hazard ratio 0.54, 95% confidence interval 0.27-1.08, p = 0.082), (adjusted hazard ratio 0.65, 95% confidence interval 0.42-1.02, p = 0.061). Also, this group was not associated with an increased risk of all-cause mortality, as demonstrated in the multivariable Poisson regression analysis (adjusted incidence-rate ratio 1.42, 95% confidence interval 0.83-2.42, p = 0.202). Conclusions: The use of automated titanium fastener device seems to be safe for infective endocarditis. Analyses of larger cohorts are required.

Disparities in donor heart acceptance between the USA and Europe: clinical implications.

BACKGROUND AND AIMS: Given limited evidence and lack of consensus on donor acceptance for heart transplant (HT), selection practices vary widely across HT centres in the USA. Similar variation likely exists on a broader scale-across countries and HT systems-but remains largely unexplored. This study characterized differences in heart donor populations and selection practices between the USA and Eurotransplant-a consortium of eight European countries-and their implications for system-wide outcomes. METHODS: Characteristics of adult reported heart donors and their utilization (the percentage of reported donors accepted for HT) were compared between Eurotransplant (n = 8714) and the USA (n = 60 882) from 2010 to 2020. Predictors of donor acceptance were identified using multivariable logistic regression. Additional analyses estimated the impact of achieving Eurotransplant-level utilization in the USA amongst donors of matched quality, using probability of acceptance as a marker of quality. RESULTS: Eurotransplant reported donors were older with more cardiovascular risk factors but with higher utilization than in the USA (70% vs. 44%). Donor age, smoking history, and diabetes mellitus predicted non-acceptance in the USA and, by a lesser magnitude, in Eurotransplant; donor obesity and hypertension predicted non-acceptance in the USA only. Achieving Eurotransplant-level utilization amongst the top 30%-50% of donors (by quality) would produce an additional 506-930 US HTs annually. CONCLUSIONS: Eurotransplant countries exhibit more liberal donor heart acceptance practices than the USA. Adopting similar acceptance practices could help alleviate the scarcity of donor hearts and reduce waitlist morbidity in the USA.

Increased Drop in Activity of Alkaline Phosphatase in Plasma from Patients with Endocarditis.

(1) Infective endocarditis is a severe inflammatory disease associated with substantial mortality and morbidity. Alkaline phosphatase (AP) levels have been shown to change significantly during sepsis. Additionally, we previously found that a higher initial AP drop after cardiac surgery is associated with unfavorable outcomes. Therefore, the course of AP after surgery for endocarditis is of special interest. (2) A total of 314 patients with active isolated left-sided infective endocarditis at the Department of Cardiac Surgery (Medical University of Vienna, Vienna, Austria) between 2009 and 2018 were enrolled in this retrospective analysis. Blood samples were analyzed at different time points (baseline, postoperative days 1-7, postoperative days 14 and 30). Patients were categorized according to relative alkaline phosphatase drop (≥30% vs. <30%). (3) A higher rate of postoperative renal replacement therapy with or without prior renal replacement therapy (7.4 vs. 21.8%; p = 0.001 and 6.7 vs. 15.6%; p = 0.015, respectively) and extracorporeal membrane oxygenation (2.2 vs. 19.0%; p = 0.000) was observed after a higher initial alkaline phosphatase drop. Short-term (30-day mortality 3.0 vs. 10.6%; p = 0.010) and long-term mortality (p = 0.008) were significantly impaired after a higher initial alkaline phosphatase drop. (4) The higher initial alkaline phosphatase drop was accompanied by impaired short- and long-term outcomes after cardiac surgery for endocarditis. Future risk assessment scores for cardiac surgery should consider alkaline phosphatase.

Dynamic electrophysiological mechanism in patients with long-standing persistent atrial fibrillation.

Background: Improved understanding of the mechanisms that sustain persistent and long-standing persistent atrial fibrillation (LSpAF) is essential for providing better ablation solutions. The findings of traditional catheter-based electrophysiological studies can be impacted by the sedation required for these procedures. This is not required in non-invasive body-surface mapping (ECGI). ECGI allows for multiple mappings in the same patient at different times. This would expose potential electrophysiological changes over time, such as the location and stability of extra-pulmonary vein drivers and activation patterns in sustained AF. Materials and methods: In this electrophysiological study, 10 open-heart surgery candidates with LSpAF, without previous ablation procedures (6 male, median age 73 years), were mapped on two occasions with a median interval of 11 days (IQR: 8-19) between mappings. Bi-atrial epicardial activation sequences were acquired using ECGI (CardioInsight™, Minneapolis, MN, United States). Results: Bi-atrial electrophysiological abnormalities were documented in all 20 mappings. Interestingly, the anatomic location of focal and rotor activities changed between the mappings in all patients [100% showed changes, 95%CI (69.2-100%), p < 0.001]. Neither AF driver type nor their number varied significantly between the mappings in any patient (median total number of focal activities 8 (IQR: 1-16) versus 6 (IQR: 2-12), p = 0.68; median total number of rotor activities 48 (IQR: 44-67) versus 55 (IQR: 44-61), p = 0.30). However, individual zones showed a high number of quantitative changes (increase/decrease) of driver activity. Most changes of focal activity were found in the left atrial appendage, the region of the left lower pulmonary vein and the right atrial appendage. Most changes in rotor activity were found also at the left lower pulmonary vein region, the upper half of the right atrium and the right atrial appendage. Conclusion: This clinical study documented that driver location and activation patterns in patients with LSpAF changes constantly. Furthermore, bi-atrial pathophysiology was demonstrated, which underscores the importance of treating both atria in LSpAF and the significant role that arrhythmogenic drivers outside the pulmonary veins seem to have in maintaining this complex arrhythmia.

Obesity and outcomes after left ventricular assist device implantation: insights from the EUROMACS Registry.

OBJECTIVES: The objective was to analyse associations between obesity and outcomes after left ventricular assist device (LVAD) implantation. METHODS: A retrospective analysis of the EUROMACS Registry was performed. Adult patients undergoing primary implantation of a continuous-flow LVAD between 2006 and 2019 were included (Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). Patients were classified into 4 different groups according to body mass index at the time of surgery (body mass index <20 kg/m2: n = 254; 20-24.9 kg/m2: n = 1281; 25-29.9 kg/m2: n = 1238; ≥ 30 kg/m2: n = 691). RESULTS: The study cohort was comprised of 3464 patients. Multivariable Cox proportional cause-specific hazards regression analysis demonstrated that obesity (body mass index ≥30 kg/m2) was independently associated with significantly increased risk of mortality (body mass index ≥30 vs 20-24.9 kg/m2: hazard ratio 1.36, 95% confidence interval 1.18-1.57, overall P < 0.001). Moreover, obesity was associated with significantly increased risk of infection and driveline infection. The probability to undergo heart transplantation was significantly decreased in obese patients (body mass index ≥30 vs 20-24.9 kg/m2: hazard ratio 0.59, 95% confidence interval 0.48-0.74, overall P < 0.001). CONCLUSIONS: Obesity at the time of LVAD implantation is associated with significantly higher mortality and increased risk of infection as well as driveline infection. The probability to undergo heart transplantation is significantly decreased. These aspects should be considered when devising a treatment strategy before surgery.

Extracorporeal Photopheresis With Low-Dose Immunosuppression in High-Risk Heart Transplant Patients-A Pilot Study.

In severely ill patients undergoing urgent heart transplant (HTX), immunosuppression carries high risks of infection, malignancy, and death. Low-dose immunosuppressive protocols have higher rejection rates. We combined extracorporeal photopheresis (ECP), an established therapy for acute rejection, with reduced-intensity immunosuppression. Twenty-eight high-risk patients (13 with high risk of infection due to infection at the time of transplant, 7 bridging to transplant via extracorporeal membrane oxygenation, 8 with high risk of malignancy) were treated, without induction therapy. Prophylactic ECP for 6 months (24 procedures) was initiated immediately postoperatively. Immunosuppression consisted of low-dose tacrolimus (8-10 ng/ml, months 1-6; 5-8 ng/ml, >6 months) with delayed start; mycophenolate mofetil (MMF); and low maintenance steroid with delayed start (POD 7) and tapering in the first year. One-year survival was 88.5%. Three patients died from infection (POD 12, 51, 351), and one from recurrence of cancer (POD 400). Incidence of severe infection was 17.9% (n = 5, respiratory tract). Within the first year, antibody-mediated rejection was detected in one patient (3.6%) and acute cellular rejection in four (14.3%). ECP with reduced-intensity immunosuppression is safe and effective in avoiding allograft rejection in HTX recipients with risk of severe infection or cancer recurrence.

Effects of the harvesting technique and external stenting on progression of vein graft disease 2 years after coronary artery bypass.

OBJECTIVES: In a post hoc analysis of the VEST III trial, we investigated the effect of the harvesting technique on saphenous vein graft (SVG) patency and disease progression after coronary artery bypass grafting. METHODS: Angiographic outcomes were assessed in 183 patients undergoing open (126 patients, 252 SVG) or endoscopic harvesting (57 patients, 114 SVG). Overall SVG patency was assessed by computed tomography angiography at 6 months and by coronary angiography at 2 years. Fitzgibbon patency (FP I, II and III) and intimal hyperplasia (IH) in a patient subset were assessed by coronary angiography and intravascular ultrasound, respectively, at 2 years. RESULTS: Baseline characteristics were similar between patients who underwent open and those who underwent endoscopic harvesting. Open compared with endoscopic harvesting was associated with higher overall SVG patency rates at 6 months (92.9% vs 80.4%, P = 0.04) and 2 years (90.8% vs 73.9%, P = 0.01), improved FP I, II and III rates (65.2% vs 49.2%; 25.3% vs 45.9%, and 9.5% vs 4.9%, respectively; odds ratio 2.81, P = 0.09) and reduced IH area (-31.8%; P = 0.04) and thickness (-28.9%; P = 0.04). External stenting was associated with improved FP I, II and III rates (odds ratio 2.84, P = 0.01), reduced IH area (-19.5%; P < 0.001) and thickness (-25.0%; P < 0.001) in the open-harvest group and reduced IH area (-12.7%; P = 0.01) and thickness (-9.5%; P = 0.21) in the endoscopic-harvest group. CONCLUSIONS: A post-hoc analysis of the VEST III trial showed that open harvesting is associated with improved overall SVG patency and reduced IH. External stenting reduces SVG disease progression, particularly with open harvesting.

Mechanical versus biological valve prostheses for left-sided infective endocarditis.

OBJECTIVES: Our aim was to analyse outcomes after implantation of mechanical versus biological valve prostheses in patients presenting with left-sided infective endocarditis. METHODS: We conducted a retrospective single-centre cohort study, analysing adults requiring valve surgery for left-sided infective endocarditis between January 2009 and December 2018 at the Department of Cardiac Surgery, Medical University of Vienna. The primary outcome variable was all-cause mortality. Secondary outcome variables included the occurrence of a combined event (death, stroke, intracerebral bleeding or reoperation) and the risk of re-endocarditis. RESULTS: Among 220 patients, 76 (34.5%) underwent mechanical valve replacement, while 144 (65.5%) underwent biological valve replacement. Recipients of mechanical valve prostheses were younger at the time of surgery and presented with lower European System for Cardiac Operative Risk Evaluation II values. In patients <55 years of age, implantation of a mechanical valve prosthesis was independently associated with significantly lower risk of all-cause mortality (adjusted hazard ratio 0.35, 95% confidence interval 0.15-0.80, P = 0.013). Moreover, this group was at significantly lower risk of a combined event (adjusted hazard ratio 0.38, 95% confidence interval 0.19-0.76, P = 0.006). Implantation of a mechanical valve prosthesis was not associated with increased risk of re-endocarditis. The presence of an annular abscess significantly increased the risk of re-endocarditis (adjusted hazard ratio 3.06, 95% confidence interval 1.40-6.71, P = 0.005). CONCLUSIONS: In patients presenting with left-sided infective endocarditis <55 years of age, implantation of a mechanical valve prosthesis is associated with superior outcomes. A prospective randomized controlled trial is warranted to confirm these results.

External stenting of saphenous vein grafts for coronary artery bypass: a single-center analysis of clinical outcomes.

BACKGROUND: Angiographic studies have shown that external stenting reduces disease progression in saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG). However, reports of clinical outcomes of external SVG stenting are limited. METHODS: We conducted a retrospective analysis using a prospectively maintained national registry to evaluate clinical outcomes in patients undergoing either isolated CABG or combined (CABG + valve) procedures with use of an external SVG stent between December 2015 and December 2019. Median follow-up was 36.2 months (IQR: 24.4-41.6 months). The primary endpoint was ischemia-driven target vessel revascularization at 1 year. Secondary endpoints included all-cause death, non-fatal myocardial infarction (MI), stroke, and the composite of death, non-fatal MI or stroke at 1 year. Kaplan-Meier rates of survival, freedom from the composite of death, non-fatal MI or stroke and freedom from repeat revascularization were calculated at 3 years. RESULTS: The study population included 74 patients (isolated CABG, N.=61; combined procedure, N.=13). Mean age was 65.5±9.2 years, and 81% were male. External stenting of one SVG was performed in 63 patients (85%) and external stenting of 2 SVG in 11 patients (15%). External stenting was most frequently performed on an SVG to the right coronary artery (N.=45 patients; 53%). Ischemia-driven target-vessel revascularization occurred in 0% at 1 year. All-cause death, MI, stroke, and the composite of death, MI, or stroke at 1 year occurred in 2.7% (2/74), 0% (0/74), 1.4% (1/74), and 4.1% (3/74), respectively. At 3 years, the rates of survival, freedom from the composite of death, non-fatal MI or stroke, and freedom from repeat revascularization were 89.7% (95% CI: 78.0-95.3), 88.3% (95% CI: 76.5-94.4), and 94.8% (95% CI: 84.6-98.3), respectively. CONCLUSIONS: Clinical outcomes with external SVG stenting are excellent without ischemia-driven target-vessel revascularization at 1 year, and low rates of repeat revascularization at 3 years. Further follow-up will show whether external stenting reduces SVG failure with a benefit on long-term clinical outcomes.

Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes.

Left ventricular assist device implantation without sternotomy (LIS) may simplify heart transplantation (HTX) by avoiding adhesions and eliminating the need for a re-sternotomy. This study investigates the impact of LIS LVAD implantation on HTX outcomes. A retrospective comparison of 46 patients undergoing HTX between 07/13 and 06/19 after conventional LVAD implantation with a full sternotomy (FS) and LIS LVAD implantation (LIS: n = 27 patients, 59%; FS: n = 19 patients, 41%) was performed. Endpoints were perioperative data including blood product use, de-novo formation of donor specific antibodies (DSAs) and survival. Patient demographics (mean age FS: 60.3 ± 9.3 years vs LIS 58.0 ± 7.7 years, P = 0.313; male gender FS: 84% vs LIS: 82%, P = 1.000; urgent HTX FS: 16% vs LIS 18%, P = 1.000) were comparable between LIS and FS patients. The primary finding was a significantly higher risk to develop de novo donor specific antibodies (DSAs) after HTX in patients of the FS group (FS: 36% vs LIS: 4%; P = 0.006). LIS patients had a significant reduction of intraoperative packed red blood cells (PRBCs) use (LIS: 4 (IQR 2-7) Units vs FS: 7 (IQR 4-8) Units; P = 0.045). Other adverse events rates and in-hospital mortality (LIS: 7% vs FS 5%, P = 1.000) were comparable between both groups. LIS LVAD reduces formation of donor specific antibodies after HTX.

Type A Acute Aortic Dissection Presenting With Cerebrovascular Accident at Advanced Age.

Our aim was to analyze outcomes of patients aged 70 years or above presenting with type A acute aortic dissection (TAAAD) and cerebrovascular accident (CVA). A retrospective analysis of the International Registry of Acute Aortic Dissection (IRAD) was conducted. Patients aged 70 years or above (n = 1449) were stratified according to presence or absence of CVA before surgery (CVA: n = 110, 7.6%). In-hospital outcomes and mortality up to 5 years were analyzed. Additionally, in-hospital outcomes of patients who received medical management were described. No patient presenting with CVA over the age of 87 years underwent surgery. The rates of in-hospital mortality and post-operative CVA were significantly higher in patients presenting with CVA (in-hospital mortality: 32.7% vs 21.7%, P = 0.008; post-operative CVA: 23.4% vs 8.3%, P < 0.001). Presence of CVA was independently associated with significantly increased in-hospital mortality (odds ratio 2.99, 95% confidence interval 1.35 - 6.60, P = 0.007). In survivors of the hospital stay, presenting CVA had no independent influence on mortality up to 5 years (hazard ratio 1.52, 95% confidence interval 0.99 - 2.31, P = 0.54). In medically managed patients, exceedingly high rates of in-hospital mortality (71.4%) and CVA (90.9%) were noted. Patients presenting with TAAAD and CVA at ≥ 70 years of age are at significantly increased risk of in-hospital mortality, although long-term mortality is not affected in hospital survivors. Medical management is associated with poor outcomes. We believe that surgical management should be offered after critical assessment of comorbidities.

Incidence, clinical relevance and therapeutic options for outflow graft stenosis in patients with left ventricular assist devices.

OBJECTIVES: We reviewed our institutional experience with outflow graft stenosis (OGS) in 3 contemporary left ventricular assist devices (LVAD). METHODS: Data from 347 consecutive adult recipients of LVAD [Medtronic HVAD (n = 184, 53.0%), Abbott HeartMate II (n = 62, 17.9%) and Abbott HeartMate 3 (n = 101, 29.1%)] implanted between March 2006 and October 2019 were analysed retrospectively. Primary study end points were the incidence of OGS necessitating treatment and survival on LVAD support. RESULTS: During the study period, 17 patients (4.9%) developed OGS requiring treatment with a probability of 0.6% at 1 year, 1.9% at 2 years, 3.8% at 3 years, 4.7% at 4 years and 5.9% at 5 years of LVAD support. Notably, in 13.8% of patients, a compression-related narrowing of the outflow graft with a probability of 1.5% at 6 months, 1.8% 1 year, 6.0% at 2 years, 12.3% at 3 years, 15.4% at 4 years and 16.6% at 5 years of LVAD support with no difference between devices (P = 0.26) was observed. There was a trend towards increased risk of mortality with OGS (hazard ratio 2.21, 95% confidence interval 0.87-5.51; P = 0.09). OGS preferentially occurred in segments of the outflow graft covered by a protective coating. CONCLUSIONS: OGS is a rare but potentially lethal complication during LVAD support. Modifications of pump design and implant techniques may be needed because OGS preferentially occurs within covered portions of the outflow graft. Systematic screening may be warranted.

Femoral cannulation for cardiopulmonary bypass with a novel bidirectional perfusion cannula.

The use of the novel bidirectional femoral cannula is described in this video tutorial. We demonstrate the percutaneous cannulation and decannulation of the femoral artery for cardiopulmonary bypass in a patient undergoing minimally invasive mitral valve surgery. The procedure itself is presented step by step for each important phase. Finally, we report the postoperative course following the successful use of a peripheral bidirectional cannula.

Pseudothrombocytopenia Inducing Nonindicated Platelet Transfusion after Cardiac Surgery.

Pseudothrombocytopenia (PTCP) is an in vitro phenomenon of low platelet count caused by the agglutination of platelets, leading to false low platelet counts in automated cell counting. Typically, ethylenediaminetetraacetic acid (EDTA) mediates this platelet clumping. PTCP has little clinical significance, but misdiagnosis may lead to unnecessary diagnostic tests and treatment. In this case report, we present a 65-year-old Caucasian female suffering from multiple complications during and after cardiac surgery. During her postoperative stay at the ICU, she was diagnosed with thrombocytopenia and an inadequate response to platelet supplementation.

Less Invasive Left Ventricular Assist Device Implantation Is Safe and Reduces Intraoperative Blood Product Use: A Propensity Score Analysis VAD Implantation Techniques and Blood Product Use.

Despite increasing popularity and multiple postulated benefits, less invasive (LIS) left ventricular assist device (LVAD) implantation has not been sufficiently compared with standard full sternotomy (FS). We report the outcomes of a propensity score analysis designed to compare LIS and FS LVAD implantation, with perioperative blood product use, adverse event rates, and mortality as primary objective. From September 2010 to August 2016, 159 consecutive patients received a Medtronic HVAD or Abbott HeartMate 3 LVAD via a FS or LIS approach. Outcomes were analyzed using proportional hazard Cox regression, with risk adjustment based on a LIS approach propensity score model computed from demographics, risk factors, and operative covariates. Seventy-five patients were matched and compared (HVAD 83% [n = 62]; LIS approach 43% [n = 32]; mean age 60 ± 12 years; 89% [n = 67] male; 48% [n = 36] ischemic cardiomyopathy [ICMP]; 37% [n = 28]). Patient groups were comparable with regard to preoperative patient characteristics. Less invasive LVAD implantation was successful in all patients with no intraoperative conversions. In-hospital mortality was 16% in both groups, despite 37% Interagency Registry for Mechanically Assisted Circulatory Support Level I patients. Overall, 28% of the LIS patients did not receive any blood products intraoperatively, whereas, in the FS group, only two patients (5%) did not require the administration of blood products (p = 0.000). This was also a significant finding in the overall perioperative phase in which seven LIS patients (22%) who not receive any blood products versus two FS patients (5%; p = 0.033). Otherwise, outcomes were comparable. Less invasive LVAD implantation is a feasible, safe, and reduces blood product use.

Severe gastroparesis after orthotopic heart transplantation.

We present a case of severe gastroparesis in a recipient of orthotopic heart transplantation. Although a rare condition after heart transplantation, it is a potential cause of significant morbidity, including vomiting, aspiration and pneumonia. Moreover, impaired gastric emptying alters the pharmacokinetics of immunosuppressive medication with increased risk of severe side effects. Herein, we describe a diagnostic and therapeutic strategy that was successfully applied in a patient with gastroparesis.

Thrombolysis as first-line therapy for Medtronic/HeartWare HVAD left ventricular assist device thrombosis.

OBJECTIVES: We reviewed our institutional experience with intravenous thrombolysis (TL) as first-line therapy in patients with Medtronic/HeartWare HVAD left ventricular assist device pump thrombosis (PT). METHODS: From March 2006 to November 2018, 30 Medtronic/HeartWare HVAD left ventricular assist device patients had 48 PT events. We analysed outcomes with intravenous Alteplase as a first-line therapy for PT. Pump exchange or urgent heart transplantation was only considered after the failure of TL or existing contraindications to TL. RESULTS: TL was used as the first-line therapy in 44 PT events in 28 patients without a contraindication to TL. TL was successful in 61.4% of PT events. More than 1 cycle of TL was necessary in 55.6% of events. The combined success of TL and heart transplantation or device exchange was 81.8%. In 15.9% of events, PT was fatal. Causes of death were severe complications (9.1%) related to TL or discontinuation of therapy for multi-organ failure (6.8%). Intracranial bleeding and arterial thromboembolism were observed in 4.5% and 11.5% of the PT events after TL. CONCLUSIONS: Intravenous TL as a first-line therapy for PT in Medtronic/HeartWare HVAD patients can be a reasonable treatment option and does not preclude subsequent heart transplantation or device exchange. However, thromboembolic and bleeding complications are common. The decision to perform TL or device exchange should, therefore, be made on an individual basis after balancing the risks and benefits of different treatment approaches.