The impact of extreme obesity on outcomes after left ventricular assist device implantation.

BACKGROUND: The association between extreme body mass index (BMI) and outcomes in left ventricular assist device (LVAD) patients has not been well established. With the commercial use of LVADs a larger number of patients with a BMI >40 have undergone device implantation. The purpose of this study was to evaluate the short and long-term outcomes of LVAD patients with extreme obesity. METHODS: A retrospective review of all patients (n=383) at our center who received a LVAD as primary implant between 2005-2015 was performed. Demographics, preoperative laboratory values, and postoperative outcomes were analyzed. Patients were divided into three groups based on BMI (kg/m2) classification (group 1: ≤25; group 2: 25 to 35; group 3: ≥35) and compared using one-way analysis of variance (ANOVA), Kruskal-Wallis and Chi-squared analysis as appropriate. RESULTS: Comparison of postoperative outcomes demonstrated an increased risk of respiratory failure and right ventricular (RV) failure in patients with a BMI ≥35 (range, 35-59). Length of stay, sternal infection, driveline/pocket infection, systemic infection, GI-bleeding, and neurological events within the first year of device therapy were not related to BMI. Survival at 30-day, 1- and 2-year was not significantly different among the three groups. The group with the smallest BMI demonstrated an increased risk for re-operative bleeding. CONCLUSIONS: Despite an increased risk of early morbidity in patients with extreme obesity, long term survival was not significantly different between the BMI groups. Careful consideration is recommended when evaluating patients with an excessive BMI for LVAD therapy although it should not be a contraindication for device placement.

Peritoneal dialysis after left ventricular assist device placement.

Patients with refractory congestive heart failure may be considered for implantation of a left ventricular assist device (LVAD). Renal failure after LVAD placement can occur to varying degrees from cardiorenal syndrome (CRS) or due to intrinsic renal disease. Patients with severely impaired renal function after LVAD may require renal replacement therapy (RRT) as a temporary or permanent means of support. We present a unique case of a patient who initiated peritoneal dialysis (PD) 1 year after placement of an LVAD for destination therapy (DT). One year later, PD continues to be successfully utilized by this patient for RRT. There are several proven and theoretical benefits to PD in LVAD patients. Peritoneal dialysis can provide sustained daily ultrafiltration offering greater hemodynamic stability, preservation of residual renal function, and a lower risk of systemic infection. Conversely, limitations to PD include nutritional risks due to peritoneal albumin losses, hyperglycemia, and potential limitations to successful catheter placement. Considering our patient's successful outcome and the potential benefits associated with PD, despite the limitations, we conclude that PD should strongly be considered in patients with LVADs that require RRT.

Evaluation and management of emergencies in patients with mechanical circulatory support devices.

Mechanical circulatory support devices such as ventricular assist devices have become the approved and accepted treatment option to improve survival and quality of life in patients with advanced heart failure refractory to medical therapy. Patients as a result are living longer and presenting to emergency medical services, primary care facilities, emergency departments, and critical care units more frequently. Currently, health care providers have limited experience in managing this complex patient population. Thus, we created a standardized method of initial evaluation and algorithmic approach of management to help in the management of emergencies in this unique patient population. We present a comprehensive overview of the types of mechanical assist devices, their complications, and an algorithmic approach to the emergency management in the patients with mechanical circulatory support. A systematic method is crucial in prompt and early recognition of emergencies to ensure appropriate management of these patients.