Experience with a "hotline" service for outpatients on a ventricular assist device.

OBJECTIVES: With the growing number of outpatients on ventricular assist devices (VADs), there is an increasing need for "home discharge programs." One important feature is a 24-hour telephone service. In our center, the perfusionists run a so-called "hotline" for all of our VAD patients. This study analyzes the hotline calls with regard to frequency, the reason for calling, and the type of action undertaken. PATIENTS AND METHODS: Over a period of 5 years, 16 (12 EXCOR and 4 INCOR; Berlin Heart, Berlin, Germany) of 33 VAD patients (48%) were discharged and instructed to use the "hotline" service. All the calls received by the perfusionists were reviewed. We classified the calls into three levels according to the severity of the problem: Level (L) 1 = assistance provided by the perfusionist alone; L2 = calls requiring discussion with the surgeon on duty and/or visit to the outpatient clinic ahead of time; and L3 = immediate action and/or admission to the hospital. RESULTS: Over a period of 2,890 outpatient days (7.9 years), a total of 26 calls were registered. There were 0.9 calls per 100 patient days and 1.6 calls per discharged patient. Out of the 26 calls, 14 calls (54%) were classified as L1, 8 (31%) as L2, and 4 (15%) as L3. The most frequent reasons for L1 or L2 calls were fibrin deposits in the EXCOR pump chamber (39%), followed by battery dysfunction (19%). L3 calls were related to dysfunction of the EXCOR driving units in three cases and to an EXCOR pump chamber disconnection, which the patient did not survive. CONCLUSIONS: The institution of a hotline is an essential component of a VAD outpatient program. It provides a certain level of safety for the patient, although a residual risk remains.

Outpatient endovascular aortic aneurysm repair: experience in 100 consecutive patients.

OBJECTIVES: To present the safety, feasibility, costs, and patient satisfaction of outpatient endovascular aneurysm repair (EVAR). BACKGROUND: Our experience in more than 1000 patients indicated that in technically uncomplicated EVAR procedures, the only need for hospitalization was for access vessel complications (bleeding or occlusion) requiring secondary procedures. These complications could always be identified within the first 3 hours after EVAR. METHODS: Two-center retrospective analysis of prospectively gathered data on 100 consecutive elective outpatient EVAR cases (Outpt EVAR). Inclusion criteria for Outpt EVAR were as follows: asymptomatic clinical state, informed consent, travel time to the hospital if readmission was required of less than 60 minutes, adult observer assistance for the first 24 hours, and a technically uncomplicated EVAR procedure. EVAR was mostly performed under local anesthesia and with percutaneous access. Patients were discharged home after 4 to 6 hours of observation and checked the next morning and on the fifth postoperative day in the outpatient clinic. RESULTS: From 104 patients selected, 4 (3.8%) preferred primary hospitalization and were excluded from further analysis. Four patients (4%) with access vessel complications required additional procedures and had to be hospitalized overnight. The 30-day readmission rate was 4% (4), all due to access vessel stenosis (2) or false aneurysm (2). There was no 30-day mortality. From the 96 outpatients who completed Outpt EVAR, 93 (97%) would undergo Outpt EVAR again and would recommend it to others. Cost comparison showed in 42 matched contemporary patients treated with just a standard stent graft that costs were significantly lower in 21 Outpt EVAR patients than in 21 inpatient EVAR. CONCLUSIONS: Elective Outpt EVAR can be performed safely, provided certain criteria are fulfilled and specific precautions are taken. In this series, Outpt EVAR morbidity was minimal, especially delirium common in elderly patients recovering from inpatient vascular surgery and nosocomial infections did not occur. Finally, patient satisfaction was high and costs were less than with standard inpatient EVAR.

The CentriMag: a new optimized centrifugal blood pump with levitating impeller.

PURPOSE: Blood pumps are routinely used for circulatory and pulmonary support. However, blood trauma and pump failure remain severe drawbacks of currently available pump models. This study evaluated the first clinical application of a new, totally bearingless centrifugal blood pump (CentriMag). MATERIAL AND METHODS: A centrifugal pump consisting of an electromagnetic suspended impeller was used as a blood pump during beating-heart coronary artery bypass grafting in 11 patients (mean weight, 77.4 kg). Heparin in a bolus of 150 IU/kg body weight was administered, and activated clotting time was maintained at approximately 180 to 250 seconds during extracorporeal circulation. Pump-induced blood trauma was evaluated by measurement of plasma free hemoglobin (PFH), lactate dehydrogenase (LDH), hematocrit, total bilirubin, and platelet levels. RESULTS: Mean pump flow was 3.3 +/- 0.62 L/min, and mean pressure gradient through the oxygenator was 69 +/- 4 mm Hg. No pump dysfunction occurred during a mean application time of 105 +/- 26 minutes. Inspection of the pump housings showed no internal thrombus formation despite low-dose heparinization. Only slight hemolysis was observed with a mean PFH level of 1.96 micromol/L; LDH, 460 U/L; hematocrit, 33%; total bilirubin, 25 micromol/L; and platelets, 191 x 10(3)/microL. CONCLUSIONS: The bearingless CentriMag blood pump is a safe and reliable new device that produces only minimal hemolysis. It seems to be suited for long-term evaluation as a blood pump for extracorporeal membrane oxygenation or as ventricular assist device.