Long-term Safety of Minimally Invasive Left Ventricular Assist Device Discontinuation for Myocardial Recovery.

BACKGROUND: Left ventricular assist devices (LVADs) play important roles in advanced heart failure (HF) management. In patients who experience myocardial recovery, the LVAD is often explanted via a resternotomy, which may negatively impact the newly recovered heart. We describe a case-series of LVAD discontinuation using a minimally invasive approach, focusing on thromboembolic phenomenon and infection rates in long-term follow-up. METHODS: Our study is a single-center, retrospective case series of patients with myocardial recovery after mechanical unloading with an LVAD. Patients underwent outflow graft ligation through a minimally invasive approach with driveline excision. Postdiscontinuation, patients obtained serial transthoracic echocardiograms for a minimum of 6 months and followed with our heart failure specialist. RESULTS: All 7 recovery patients had nonischemic cardiomyopathy and included 4 women (57%). Mean age was 44.3 ± 15.6 years. Median LVAD support duration was 454 (interquartile range, 326 to 1096) days. Intensive care unit length of stay and total length of stay were 3.4 ± 1.9 days and 6.3 ± 2.3 days, respectively. Blood transfusion rate was 0.86 ± 1.1 units. At a median follow-up of 874 (interquartile range, 864 to 1007) days, no patients developed thromboembolic phenomena despite use of aspirin only for prophylaxis. One patient experienced driveline infection, who had persistent driveline infection before procedure. CONCLUSIONS: This minimally invasive approach for LVAD discontinuation through outflow graft ligation, driveline removal, and LVAD stoppage in setting of myocardial recovery avoids resternotomy risks. Despite leaving the LVAD in situ, there was no risk of thromboembolism or infection associated with residual hardware.

End-organ recovery is key to success for extracorporeal membrane oxygenation as a bridge to implantable left ventricular assist device.

Preexisting organ dysfunctions are known factors of death after placement of implantable mechanical circulatory support (MCS). Extracorporeal membrane oxygenation (ECMO) may able to stabilize organ function in patients with cardiogenic shock before MCS implantation. Between 2008 and 2012, 17 patients with cardiogenic shock were supported with ECMO before implantable MCS placement. Patient's end-organ functions were assessed by metabolic, cardiac, hepatic, renal, and respiratory parameters. Survival data after MCS implantations were analyzed for overall survival to discharge, complications, and breakpoint in days on ECMO to survival. Before MCS implantation, lactate, hepatic, and renal functions were improved and pulmonary edema was resolved. The interval between ECMO initiation and MCS placement was 12.1 ± 7.9 days. Overall survival rate to discharge after left ventricular assist device/total artificial heart placement was 76%. The survival of patients transitioned from ECMO to MCS within 14 days was 92% and was significantly better than the survival of patients from ECMO to MCS supported longer than 14 days, 25%, p < 0.05. ECMO support can immediately stabilize organ dysfunction in patients with cardiogenic shock. After improvement of organ function, MCS implantation should be done without delay, since the patients supported for longer than 14 days with ECMO had inferior survival compared to national data.

Recurrent orthostatic syncope due to left atrial and left ventricular collapse after a continuous-flow left ventricular assist device implantation.

Left ventricular assist devices (LVADs) have become an established treatment for patients with advanced heart failure as a bridge to transplantation or for permanent support as an alternative to heart transplantation. Continuous-flow LVADs have been shown to improve outcomes, including survival, and reduce device failure compared with pulsatile devices. Although LVADs have been shown to be a good option for patients with end-stage heart failure, unanticipated complications may occur. We describe dynamic left atrial and left ventricular chamber collapse related to postural changes in a patient with a recent continuous-flow LVAD implantation.

Contained rupture of a pseudoaneurysm of the descending thoracic aorta related to remnant outflow graft of left ventricular assist device after heart transplantation.

The Jarvik 2000 left ventricular assist device is inserted via a left thoracotomy with the outflow graft anastomosed to the descending thoracic aorta. Removal of the device during heart transplantation involves division of the outflow graft, resulting in a retained remnant. We describe the first reported case of a mycotic pseudoaneurysm of the descending thoracic aorta related to the remnant of a left ventricular assist device outflow graft in an immunosuppressed heart recipient complicated with systemic Pseudomonas infection. The pseudoaneurysm was temporarily treated with endovascular stent grafting followed by delayed thoracotomy, pseudoaneurysm excision, and placement of an aortic interposition graft using an aortic allograft.

Thoratec HeartMate II(®) left ventricular assist device implantation in patient with patent ventriculoperitoneal shunt.

We report a case of HeartMate II(®) left ventricular assist device (LVAD) implantation as a destination therapy in a patient with a patent ventriculoperitoneal (VP) shunt after being suffered from subarachnoid hemorrhage. Because the patient's VP shunt was running through her right anterior chest and abdominal wall, a driveline exit site was selected in her left upper quadrant to avoid unnecessary perioperative complication in relation to the patent VP shunt tube. Tailored driveline placement was a key element of this LVAD implantation in this already sick patient with multiple comorbidities.

Surgical treatment of infective endocarditis in patients undergoing chronic hemodialysis.

BACKGROUND AND AIM OF THE STUDY: Infective endocarditis (IE) is a devastating complication in patients undergoing chronic hemodialysis (HD). The study aim was to reveal the characteristics and outcomes of surgically managed IE in chronic HD patients. METHODS: Between April 1998 and August 2011, a total of 119 patients underwent surgery to treat IE. Of these patients, 16 were receiving chronic HD preoperatively. A comparison between non-HD patients (n = 103) and HD patients (n = 16) was conducted with regards to perioperative variables and postoperative morbidity and mortality. A survival analysis was performed using the Kaplan-Meier method. RESULTS: Preoperatively, a greater proportion of HD patients had diabetes mellitus than did non-HD patients (44% versus 16%, p = 0.015). Staphylococcus spp. (56%) and Enterococcus spp. (25%) were the predominant microorganisms in HD patients, while Staphylococcus spp. (37%) and Streptococcus spp. (21%) were predominant in non-HD patients. The most affected valve position was the aortic valve, followed by the mitral and the tricuspid in both groups. An annular reconstruction was performed in 56% of HD patients and in 30% of non-HD patients (p = 0.039). The HD patients had a higher incidence of perioperative use of intra-aortic balloon pump placement (25% versus 6.9%, p = 0.042), postoperative open-chest management (38% versus 9.8%, p = 0.009), and prolonged ventilation (63% versus 33%, p = 0.025). The operative mortality was 9.7% in non-HD patients and 38% in HD patients (p = 0.008). Survival at one year was 82% in the non-HD group and 34% in the HD group (p < 0.001). Multivariable analysis revealed that chronic HD is an independent predictor of operative and long-term mortality. CONCLUSION: The operative outcome after endocarditis in HD patients remains poor, and the importance of preventing endocarditis in chronic HD patients is further emphasized.

Conventional aortic valve replacement for elderly patients in the current era.

BACKGROUND: Because of the rising expectation of prolonged life in the general population and the recent recognition of undertreated aortic valve disease in the elderly, updating the available results of aortic valve surgery is imperative, especially considering the rapid evolution of the transcatheter valve implantation procedure. METHODS AND RESULTS: Between 1997 and 2010, 308 patients aged 70 years or older underwent aortic valve replacement (AVR) for aortic stenosis (AS). Short- and long-term results were analyzed and risk factors for long-term mortality were determined. Mean age was 78.5 years and 124 patients were aged 80 or older. Concomitant coronary artery bypass grafting (CABG) was performed in 46% of the cases. Mean left ventricular ejection fraction (LVEF) was 52%. Overall observed and expected operative mortality using the Society of Thoracic Surgeons-Predicted Risk of Mortality score was 3.9% and 4.8%, respectively. Overall survival rates at 1, 5, and 10 years were 88.6%, 71.6%, and 31.8%, respectively. Predictors of long-term mortality included diabetes; preoperative shock; LVEF ≤ 40%; New York Heart Association functional class III or IV; and age. CONCLUSIONS: Short- and long-term results of conventional AVR in the elderly prove it to be durable and, especially in relatively low-risk patients and patients who require concomitant CABG, operative mortality is reasonably low. Conventional AVR ± CABG remains the gold standard for elderly patients with AS.