Predicting risk of tracheostomy after cardiac surgery: a decade of insights from nearly 10,000 patients.

Objective: Studies have shown that requiring tracheostomy following cardiac surgery has significant implications on outcomes. This study proposes a risk stratification model to predict the likelihood of requiring a tracheostomy after cardiac surgery. Methods: Patients who underwent cardiac surgery between January 2010 and December 2019 were analyzed. Kaplan-Meier analysis and log-rank test were used to estimate and compare survival between cohorts. A prediction model for the need for postoperative tracheostomy was developed with logistic regression combined with undersampling analysis. Results: A total of 9849 patients underwent cardiac surgery, and 176 (1.8%) required postoperative tracheostomy. Tracheostomy patients were older (mean age 68.4 ± 12.3 vs 65.9 ± 11.2 years; P < 0.01) and more likely female (43.8% vs 28.5%; P < 0.01). Predictors for requiring tracheostomy included hypertension (odds ratio [OR] 1.91; P = 0.05), New York Heart Association III/IV (OR 2.68; P < 0.001), chronic lung disease (OR 3.27; P < 0.001), and history of prior myocardial infarction (OR 3.32; P < 0.001). Three-year Kaplan-Meier survival was worse in patients who received tracheostomy (log-rank P < 0.001). Conclusions: A risk prediction model for requiring tracheostomy after cardiac surgery is proposed in this study. A history of New York Heart Association III/IV, chronic lung disease, and myocardial infarction as well as undergoing valve surgeries were associated with increased risk of requiring a tracheostomy.

Case report: management of refractory cardiogenic shock with Impella 5.5 in patients with transcatheter aortic valves.

Background: Impella is a transaortic valvular pump commonly utilized in patients with cardiogenic shock. However, its use with transcatheter aortic valves (TAVI) remains rare. We present two cases where surgical Impella 5.5 was placed across both Sapien 3 Ultra and Evolute Pro+ valves. Case summary: Patient 1: A 74-year-old male with history of ischaemic cardiomyopathy with ejection fraction 20-25% status post-cardiac resynchronization therapy with a defibrillator, severe aortic stenosis (AS) status post-recent Sapien 3 Ultra TAVI presented with cardiogenic shock. Due to persistent unstable haemodynamic status, Impella 5.5 was placed and was utilized as a bridge to left ventricular assist device. Patient 2: A 74-year-old male with a history of alcoholic cirrhosis and AS underwent Evolute Pro+ TAVI at outside facility. The implantation was complicated by left main coronary artery occlusion, leading to cardiogenic shock. Patient required femoral veno-arterial extracorporeal membrane oxygenation (ECMO) support and emergent single vessel coronary bypass of a saphenous venous graft to the left anterior descending artery. Extracorporeal membrane oxygenation was decannulated on Day 20 and Impella 5.5 was placed as a bridge to recovery. In both cases, there were no procedural complications or residual aortic or perivalvular regurgitation. Discussion: Impella 5.5 implanted via the axillary surgical cutdown is safe and feasible approach to manage refractory cardiogenic shock in patients with TAVI including different types of valves, Sapien 3 Ultra, and Evolute Pro+. As it can provide full haemodynamic support, Impella 5.5 can be used as bridge to recovery or durable mechanical support.

Outcomes of surgical Impella placement in acute cardiogenic shock.

Introduction: Although a role for percutaneous Impella devices has been established, there is a paucity of data regarding the utility and outcomes of larger surgically implanted Impella devices. Methods: We conducted a retrospective review of all surgical Impella implants at our institution. All Impella 5.0 and Impella 5.5 devices were included. The primary outcome was survival. Secondary outcomes included hemodynamic and end-organ perfusion as well as commonly encountered surgical complications. Results: From 2012 to 2022, 90 surgical Impella devices were implanted. The median age was 63 [53-70] years, the mean creatinine was 2.07 ± 1.22 mg/dL, and the average lactate level was 3.32 ± 2.90 mmol/L. Prior to implantation, 47 patients (52%) were supported with vasoactive agents, while 43 (48%) were also supported with another device. The most common etiology of shock was acute on chronic heart failure (50, 56%), followed by acute myocardial infarction (22, 24%), and postcardiotomy (17, 19%). Overall, 69 patients (77%) survived to device removal, and 57 (65%) survived to hospital discharge. One-year survival was 54%. Neither etiology of heart failure nor device strategy was associated with 30-day or 1-year survival. On multivariable modeling, the number of vasoactive medications prior to device implantation was strongly associated with 30-day mortality (hazard ratio 1.94 [1.27-2.96], P < 0.01). Surgical Impella placement was associated with a significant decreased need for vasoactive infusions (P < 0.01) and decreased acidosis (P = 0.01). Conclusions: Surgical Impella support for patients in acute cardiogenic shock is associated with lower vasoactive medication use, improved hemodynamics, increased end-organ perfusion, and acceptable morbidity and mortality.

Managing Right Ventricular Failure After Left Ventricular Assist Device Implant at a Destination Therapy Center.

Although left ventricular assist device (LVAD) implant is associated with an increased survival in patients with end-stage heart failure, severe right ventricular failure requiring a right ventricular assist device (RVAD) placement is associated with increased short-term morbidity and mortality. Patients not eligible for transplant have limited options, which may impact decision-making and outcomes at nontransplant centers. We conducted a retrospective review of all LVAD implants at our nontransplant center. Primary stratification was by the need for a postoperative RVAD implant. The primary outcome was survival. The Cox proportional hazards regression modeling was used to further evaluate mortality. From 2017 to 2022, 128 patients underwent a primary LVAD implant and 24 (18.75%) required a perioperative RVAD placement. RVAD implant was associated with increased operative mortality (1.92% vs 33.33%, p <0.01) and decreased 1-year (91.29% vs 60.60%, p <0.01) and 2-year survival (84.05% vs 36.36%, p <0.01). However, in patients who survived their index hospitalization, 1-year (93.00% vs 91.67%, p = 0.78) and 2-year (86.16% vs 55.00%, p = 0.10) mortality were similar. On multivariable analysis, the need for a RVAD was associated with an increased hazard of 1-year (5.60 [1.96 to 16.01], p <0.01) and 2-year (5.17 [2.01 to 13.28], p <0.01) mortality. In conclusion, our series from a nontransplant center suggests that patients who survive the implant have acceptable short-term survival, even if they do not have a transplant option; thus, carefully selected patients with biventricular failure may benefit from an LVAD implant, even if an RVAD is needed.

Extracorporeal membrane oxygenation for large pulmonary emboli.

Massive and submassive pulmonary emboli (PE) are increasingly being treated with percutaneous lytic and embolectomy procedures. While these procedures are overwhelmingly safe, patients with significant right ventricular strain are at risk for hemodynamic compromise requiring extracorporeal membrane oxygenation (ECMO). We conducted a retrospective study of all patients requiring ECMO support for PE from 2014 through 2022. The primary outcome was survival. Secondary outcomes included commonly encountered ECMO complications. From 2014 to 2022, 10 patients with submassive or massive PE required ECMO support. All 10 patients (100%) had right ventricular strain on echocardiography, 7 (70%) had a saddle PE, and 3 (30%) had extensive bilateral PE. Six (60%) patients required cardiopulmonary resuscitation prior to ECMO cannulation, and 4 (40%) were undergoing cardiopulmonary resuscitation while being cannulated. Nine (90%) patients were placed on venoarterial ECMO through the femoral vessels, while 1 (10%) was cannulated with right atrial to pulmonary artery ECMO. The median duration of support was 4 [3-8] days. During their course, 5 patients underwent percutaneous embolectomy, 1 underwent surgical embolectomy, and 4 underwent percutaneous lytic therapy. All patients (100%) survived to ECMO decannulation, and 6 (60%) survived to discharge. With a mean follow-up of 496 days, there were no postdischarge mortalities. In conclusion, although therapy for large PE is well tolerated, a small number of patients will experience periprocedural hemodynamic collapse requiring ECMO support. ECMO for PE patients is associated with acceptable morbidity and mortality. Further investigation is warranted to better characterize which patients are likely to require ECMO support.

Impella 5.5 and venovenous extracorporeal membrane oxygenation as a bridge to ventricular assist device in cardiopulmonary failure.

Venoarterial extracorporeal membrane oxygenation (ECMO) in the setting of combined cardiopulmonary failure provides full support of both cardiac and respiratory systems. However, it is difficult to isolate and evaluate pulmonary recovery independent of cardiac function on venoarterial ECMO. In this case report, we demonstrate the advantage of supporting a patient in cardiopulmonary failure with venovenous ECMO and the Impella 5.5 as a method to isolate organ dysfunction, wean off ECMO as respiratory function improves, and bridge to a left ventricular assist device with Impella 5.5 monotherapy.

The Impact of MOMENTUM 3 Trial Eligibility on Left Ventricular Assist Device Outcomes: A Real-World Experience.

INTRODUCTION: Although the landmark MOMENTUM 3 trial was associated with excellent short-term left ventricular assist device (LVAD) outcomes, many end-stage heart failure patients would not have met the trial eligibility criteria. Moreover, the outcomes of trial ineligible patients are poorly characterized. Therefore, we undertook this study to compare MOMENTUM 3 eligible and ineligible patients. METHODS: We conducted a retrospective review of all primary LVAD implants from 2017 to 2022. Primary stratification was according to MOMENTUM 3 inclusion and exclusion criteria. Primary outcome was survival. Secondary outcomes included complications and length of stay. Multivariable Cox proportional hazards regression models were constructed to further characterize outcomes. RESULTS: From 2017 to 2022, 96 patients underwent primary LVAD implantation. Thirty-seven (38.54%) patients were trial eligible while 59 (61.46%) were ineligible. When stratified by trial eligibility, patients who were trial eligible had higher 1-year (80.15% versus 94.52%, P = 0.04) and 2-year survival (70.17% versus 94.52%, P = 0.02). Multivariable analysis showed that trial eligibility was protective of mortality at both 1 y (HR: 0.19 [0.04-0.99], P = 0.049) and 2 y (HR: 0.17 [0.03-0.81], P = 0.03). Although the groups had similar rates of bleeding, stroke, and right ventricular failure, trial ineligibility was associated with a longer periprocedural length of stay. CONCLUSIONS: In conclusion, the majority of contemporary LVAD patients would not have been eligible for the MOMENTUM 3 trial. Ineligible patients have decreased but acceptable short-term survival. Our findings suggest that a simply reductionist approach to short-term mortality may improve outcomes but fail to capture the majority of patients who could benefit from therapy.

Elderly Patients With Higher Acuity Have Similar Left Ventricular Assist Device Outcomes as Younger Patients at a Nontransplant Center.

Although left ventricular assist device (LVAD) implantation is associated with acceptable survival, previous reports have demonstrated that advanced age is associated with increased short-term mortality. Because age is a relative contraindication to transplantation, nontransplant centers tend to implant a disproportionate number of elderly patients. We undertook this study to evaluate the impact of advanced age on LVAD outcomes at a nontransplant center. We conducted a retrospective review of all LVAD implants at our center from 2017 to 2022. Primary stratification was by age >70 years. The primary outcome was survival as assessed by the Kaplan-Meier method. The risk of 1-year mortality was further evaluated using multivariable Cox proportional hazards regression modeling. From 2017 to 2022, 93 patients underwent LVAD implantation. The mean age was 65.03 ± 11.28 years, with a median age of 68 (60 to 73) years. Most patients were INTERMACS 1 or 2 (71 patients; 76.34%). When stratified by age, 41 patients (44.09%) were aged ≥70 years. Patients aged ≥70 years had similar 30-day (96.15% vs 100.00%, p = 0.213), 1-year (90.05% vs 84.00%, p = 0.444), and 2-year survival (82.03% vs 84.00%, p = 0.870). When only the INTERMACS 1 and 2 patients with higher acuity were included, there was still no difference in 30-day, 1-year, or 2-year survival. On multivariable analysis, age >70 years was not associated with an increased hazard of 1-year mortality (0.90 [0.22 to 3.67], p = 0.878). In conclusion, in carefully selected patients, age >70 years is not associated with increased short-term mortality. Age alone should not be a contraindication to LVAD therapy.

Novel Estimates of Renal Function are Associated with Short-Term Left Ventricular Assist Device Outcomes.

INTRODUCTION: Although preoperative kidney function has been associated with left ventricular assist device (LVAD) outcomes, most previous estimates of glomerular filtration rates (eGFRs) have utilized race in the calculation. Recently, novel eGFR equations independent of race have been suggested and validated. Therefore, we undertook this study to evaluate the predictive value of a novel, non-race-based eGFR calculation on short-term LVAD outcomes. METHODS: We conducted a retrospective review of all primary LVAD implants from 2017 to 2022 at our institution. eGFR was calculated using the novel Chronic Kidney Disease Epidemiology Collaboration 2021 formula (CKD-EPI 2021). eGFR was also calculated according to the Modification of Diet in Renal Disease equation for historical reference. Primary stratification was by eGFR: ≥60, 30-60, and <30. The primary outcome was 1-y survival. Multivariable Cox proportional hazards regression modeling was used to further evaluate the impact of kidney function on 1-y mortality. RESULTS: From 2017 to 2022, 91 patients underwent LVAD implantation with a HeartMate 3 device. The average age was 65.20 ± 11.08, 77 (84.62%) were male, and 14 (15.38%) were Black. The mean CKD-EPI 2021 eGFR was 56.07 ± 23.55 compared with 54.72 ± 26.37 as calculated by Modification of Diet in Renal Disease (P = 0.719). Overall, 30-d and 1-y survival was 96.7% and 85.0%, respectively. When stratified by eGFR, there was a significant difference in 1-y survival (≥60, 93.46%; 30-60, 87.36%; <30, 62.75%; P = 0.016). On multivariable analysis, a preoperative eGFR <30 was associated with an increased hazard of 1-y mortality (5.58 [1.06-29.17], P = 0.043). CONCLUSIONS: In conclusion, non-race-based estimates of renal function are predictive of short-term LVAD outcomes. Further investigation of this phenomenon is warranted.

Temporary Right Ventricular Assist Device Support for Acute Right Heart Failure: A Single-Center Experience.

INTRODUCTION: Severe right ventricular (RV) failure is associated with significant morbidity and mortality. Although right ventricular assist devices (RVADs) are increasingly used for refractory RV failure, there is limited data on their short- and long-term outcomes. Therefore, we undertook this study to better understand our experience with temporary RVADs. METHODS: We conducted a retrospective review of all RVADS performed from 2017 to 2021. Patients supported with surgical RVADs, the Protek Duo device, and the Impella RP device were included. Patients were stratified by the type of RVAD and by etiology of RV failure. Survival was assessed by the Kaplan-Meier method and multivariable Cox proportional hazards regression models. RESULTS: From 2017 to 2021, 42 patients underwent RVAD implantation: 32 with a Protek Duo, 6 with an Impella RP, and 4 with a surgical RVAD. Majority of patients were already supported with an alternate form of mechanical support. Most patients had impaired renal function, decreased hepatic function, and lactic acidosis at the time of cannulation. The median duration of RVAD support was 8.5 [5-19] d. Survival to decannulation was 68.4%, to discharge was 47.4%, and to 1-y was 40.2%. Multivariable analysis identified elevated total bilirubin levels to be associated with 30-d mortality while increased hemoglobin levels were protective. After RVAD cannulation, the median number of pressors and inotropes was lower (P < 0.01) and the lactic acidosis was less (P < 0.01). CONCLUSIONS: In conclusion, RVAD support is associated with lower lactate levels, and decreased number of vasoactive medications, but is associated with significant morbidity and mortality.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery.

INTRODUCTION: Isolated tricuspid valve (TV) surgery is uncommonly performed and has historically been associated with excessive operative mortality. We previously reported improved short-term outcomes at our center. Understanding contemporary outcomes of isolated TV surgery beyond the perioperative period is essential to properly benchmark outcomes of newer transcatheter interventions. METHODS: Patients who underwent isolated TV surgery from 2007 to 2021 at a single institution were retrospectively reviewed. Survival was estimated using the Kaplan-Meier method and multivariable Cox proportional hazards regression modeling identified independent risk factors for all-cause mortality. RESULTS: Among 173 patients undergoing isolated TV surgery, 103 (60%) underwent TV repair and 70 (40%) underwent TV replacement. Mean age was 60.3 ± 18.9 y and 55 (32%) were male. The most common etiology of TV disease was functional (46%). In-hospital mortality was 4.1% (7/173), with no difference between TV repair and replacement (P = 0.06). Overall survival at 1 y and 5 y was 78.3% (111/142) and 64.5% (53/82), respectively. After median (interquartile range) follow-up of 2.0 (0.6-4.4) y, patients undergoing TV repair experienced a higher unadjusted survival as compared to those undergoing TV replacement (log-rank P = 0.02). However, after adjusting for covariates, TV replacement was not an independent predictor of all-cause mortality (hazard ratio 1.40; 95% confidence interval, 0.71-2.76; P = 0.33). CONCLUSIONS: Isolated TV surgery can be performed with lower operative mortality than historically reported. Establishing survival benchmarks from TV surgery is important in the era of developing transcatheter interventions.

Surgical implantation of balloon-expandable heart valves for the treatment of mitral annular calcification.

OBJECTIVES: The treatment of mitral valve disease in the presence of mitral annular calcification (MAC) is associated with an increased risk of cardiovascular and all-cause mortality. Various surgical and transcatheter techniques for the treatment of mitral disease with severe MAC have been described. However, these procedures are associated with high risk of operative morbidity and mortality. We describe our experience with open surgical implantation of a balloon-expandable valve (BEV) in patients with severe MAC as an alternative approach. METHODS: BEV implantation was performed with direct vision through the left atrium via a median sternotomy or minimally invasive approach. The midportion of the anterior leaflet is excised, and a ventricular septal myectomy performed if there is high risk for left ventricular outflow tract obstruction. The primary outcome was technical success according to the Mitral Valve Academic Research Consortium criteria; secondary outcomes were 30-day and 1-year mortality. RESULTS: From October 2015 through October 2020, 51 patients at 2 institutions underwent BEV-in-MAC (mean age, 73.9 ± 8.8 years; 60.8% [31/51] were female; mean Society of Thoracic Surgeons predicted risk of mortality: 6.8% ± 4.8%). Technical success was 94.1% (48/51). Thirty-day and 1-year mortality were 13.7% (7/51) and 33.3% (15/45), and for stroke 3.9% (2/51) and 4.4% (2/45), respectively. CONCLUSIONS: Surgical implantation of a BEV in the mitral position offers a treatment option for patients with mitral valve disease complicated by severe MAC who are at increased risk for conventional surgical approaches and at risk for left ventricular outflow tract obstruction with transcatheter approaches.

Early mobilization in coronavirus-19 patients treated with extracorporeal membrane oxygenation.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pneumonia can be associated with refractory respiratory failure requiring extracorporeal membrane oxygenation(ECMO). Although ECMO has helped many COVID patients, optimal management strategies for these patients remain unknown. METHODS: We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. Six months into the pandemic, we changed our management strategy to focus on early mobilization. The early mobilization effort included tracheostomy within 48 h of cannulation, decreasing sedation, and an aggressive physical and occupational therapy program progressing toward early ambulation while on ECMO. The primary outcome measured was survival to discharge. The primary stratification was based on the mobilization strategy. RESULTS: From 2020 to 2021, 47 COVID patients have been supported with ECMO at our institution. Five are still in the hospital on ECMO. 39 (83%) were supported with venovenous ECMO while 8 (17%) were supported with venoarterial or a right ventricular assist device type configuration. All 47 (100%) were cannulated at bedside with transesophageal echocardiographic guidance. The average age was 47 ± 9 years; 36(77%) were male; and 20 (43%) were Hispanic. The median duration of support was 22 (11-44) days. Excluding those who remain in the hospital and on support, overall survival to discharge was 24/42 (57%). When stratified by mobilization strategy, early tracheostomy and mobilization were associated with significantly improved survival (74% [17/23] vs. 37% [7/19], p = .02). There were no changes in patient acuity or duration of support throughout the study period. CONCLUSION: In conclusion, early tracheostomy, decreased sedation, and aggressive mobilization of COVID-19 ECMO patients is associated with improved survival.

An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation.

OBJECTIVE: To assess survival outcomes with the intervention of an interprofessional mobilization program for patients with COVID-19 who were receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN: Preintervention and postintervention retrospective cohort study. METHODS: Survival outcomes of nonmobilized, adult patients (n = 16) with COVID-19 who were receiving VV-ECMO (May 2020 through December 2020) were compared with those of 26 patients who received a mobility care plan (January 2021 through November 2021). In the preintervention group, full sedation and paralysis were used. In the postintervention group, an early mobilization strategy involving interprofessional collaboration was introduced. RESULTS: The postintervention group had improved survival (73.1% vs 43.8%; P < .04); fewer days of receiving paralytics, fentanyl, and midazolam (P < .01 for all); but more days of dexmedetomidine, morphine, and ketamine administration (P < .01 for all). Concomitantly, more patients in the postintervention cohort received oral or transdermal analgesics, oral anxiolytics, and oral antipsychotics (P < .01 for all), and also required more VV-ECMO cannula adjustments (P = .03). CONCLUSION: Early mobilization of patients with COVID-19 who were receiving VV-ECMO improved survival rates but led to more cannula adjustments.

Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO.

BACKGROUND: Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS: This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS: Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS: There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.

Impact of preoperative Impella support on destination left ventricular assist device outcomes.

BACKGROUND: Although left ventricular assist device (LVAD) implantation is associated with improved heart failure survival, the impact of pre-implantation Impella support on outcomes is unknown. We undertook this study to evaluate the impact of preoperative Impella support on LVAD outcomes. METHODS: We conducted a retrospective review of all Heartmate 3 LVAD implants. Primary stratification was by the need for preoperative Impella support with the 5.0/5.5 device. Longitudinal survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models were developed to evaluate mortality. Secondary outcomes included changes in laboratory values during Impella support. RESULTS: From 2017 to 2021, 87 patients underwent LVAD implantation. Sixteen were supported with a single inotrope, 36 with dual inotropes, 27 with Impella, and 3 with extracorporeal membrane oxygenation (ECMO). When stratified by the need for Impella, there was no difference in survival at 30-days (98.3 [88.2-99.8]% vs. 96.3 [76.5-99.5]%, p = .59), 1-year (91.0 [79.8-96.2] vs. 74.9 [51.7-88.2], p = .10), or at 2 years (87.9 [74.3-94.5] vs. 74.9 [51.7-88.2], p = .15). On multivariable modeling, the need for preoperative Impella was not associated with an increased hazard of 1-year (1.24 [0.23-6.73], p = .81) or 2-year mortality (1.05 [0.21-5.19], p = .95). After 7 (5-10) days of Impella support, recipient creatinine (p < .01), creatinine clearance (p = .02), and total bilirubin (p = .053) improved and lactic acidosis resolved (p < .01). CONCLUSIONS: Preoperative Impella support is not associated with increased short or long-term mortality but is associated with improved renal and hepatic function as well as total body perfusion before LVAD implantation.

Development of a non-transplant left ventricular assist device program.

INTRODUCTION: Although the established long-term benefit of left ventricular assist device (LVAD) therapy has led to its proliferation as destination therapy (DT), few studies have evaluated LVAD outcomes at nontransplant centers. We undertook this study to better evaluate our experience in building a nontransplant, DT LVAD program. METHODS: We conducted a retrospective review of all LVADs implanted from 2010 to 2021. Patient, operative, and outcome data were extracted from the electronic medical record. Secular trends were evaluated by organizing the data into eras of implant. Survival was assessed using the Kaplan-Meier method. Multivariable Cox proportional hazards regression models further evaluated outcomes. RESULTS: From 2010 to 2021, 100 primary LVAD implants were performed. Annual volume grew from 1 to 30 implants per year. The average age of our cohort was 65.7 years, most patients (80%) were male, 51% had an ischemic etiology, and 65 (65%) were INTERMACS profile 1 or 2. Our 1- and 2-year survival were 82% and 79%, respectively. Multivariable analysis of 1-year mortality demonstrated that decreasing renal function and increased cardiopulmonary bypass (CPB) time were associated with increased mortality while preoperative hemoglobin was protective. When stratified by era of implant, our most recent patients were more likely to be INTERMACS profile 1 or 2; had shorter CPB and aortic cross clamp times; required fewer reoperations for bleeding; and suffered less right ventricular failure requiring mechanical support. CONCLUSIONS: A single, nontransplant LVAD center can experience significant growth in volume in a high-acuity cohort while maintaining acceptable outcomes and quality of care.

Extracorporeal membrane oxygenation for respiratory failure in phases of COVID-19 variants.

BACKGROUND: Adaptive mutations of the severe acute respiratory syndrome-related coronavirus (SARS-CoV-2) virus have emerged throughout the coronavirus disease 2019 (COVID-19) pandemic. The characterization of outcomes in patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory distress from COVID-19 during the peak prevalence of different variants is not well known. METHODS: There were 131 patients with laboratory-confirmed SARS-CoV-2 infection supported by ECMO at two referral centers within a large healthcare system. Three predominant variant phase time windows (Pre-Alpha, Alpha, and Delta) were determined by a change-point analyzer based on random population sampling and viral genome sequencing. Patient demographics and outcomes were compared. RESULTS: The average age of patients was 46.9 ± 10.5 years and 70.2% (92/131) were male. Patients cannulated for ECMO during the Delta variant wave were younger compared to earlier Pre-Alpha (39.3 ± 7.8 vs. 48.0 ± 11.1 years) and Alpha phases (39.3 ± 7.8 vs. 47.2 ± 7.7 years) (p < .01). The predominantly affected race in the Pre-Alpha phase was Hispanic (52.2%; 47/90), while in Alpha (61.5%; 16/26) and Delta (40%; 6/15) variant waves, most patients were White (p < .01). Most patients received a tracheostomy (82.4%; 108/131) with a trend toward early intervention in later phases compared to Pre-Alpha (p < .01). There was no significant difference between the duration of ECMO, mechanical support, intensive care unit (ICU) length of stay (LOS), or hospital LOS over the three variant phases. The in-hospital mortality was overall 41.5% (54/131) and was also similar. Six-month survival of patients who survived to discharge was 92.2% (71/77). CONCLUSIONS: There was no significant difference in survival or time on ECMO support in patients during the peak prevalence of the three variants.