Implantation of a fully magnetically levitated left ventricular assist device to a 3-year-old patient with body surface area of 0.57 m2.

Postoperative 3D thorax computed tomographic scan image of the patient.

Should we touch tricuspid valve at the time of LVAD implantation? A young patient series.

BACKGROUND: The aim of the study is to compare the results of patients who had moderate or severe tricuspid insufficiency (TI) at the time of left ventricular assist device (LVAD) implantation that did not undergo intervention. METHODS: Between October 2013 and December 2019, 144 patients who did not undergo tricuspid valve repair (TVR) during LVAD implantation in our department were included in the study. The patients were divided into two groups according to the TI grade; Group 1: 106 patients (73.6%) with moderate TI and Group 2: 38 patients (26.4%) with severe TI. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, duration of mechanical ventilation, and early and late right ventricular failure (RVF). Minimally invasive technique was favored in patients with worse right ventricular (RV) function to prevent the need for postoperative RV support and bleeding. RESULTS: The mean ages of the patients in the Group 1 and Group 2 were 46 ± 15 years (82% male), and 45 ± 11.2 years (81.5% males), respectively. Post-operative duration of mechanical ventilation, ICU stay, blood loss, and reoperations were similar (p > 0.05). There was no significant difference in early RVF, pump thrombosis, stroke, bleeding, and 30-day mortality between groups (p > 0.05). Incidence of late RVF was higher in Group 2 (p < 0.05). CONCLUSION: Although the risk of late RVF may increase in patients with preoperative severe TI, not intervening in TI during LVAD implantation does not cause adverse clinical outcomes in the early period.

Adaptation of adult right ventricular scoring systems to pediatric patients undergoing continuous LVAD implantation: Feasible or not?

PURPOSE: The aim of this study is to investigate the efficacy of adaptation of right ventricular (RV) risk scores used in adult patients to pediatric age group undergoing LVAD implantation. METHODS: Twenty-two pediatric patients who underwent LVAD implantation were retrospectively reviewed from January 2014 to September 2018. Preoperative patient characteristics, hemodynamic parameters, and echocardiographic data were collected. Adult RV risk scores were calculated for all patients. Effects of all the parameters on RV function were also investigated. Study endpoints were RVF and in-hospital mortality. RESULTS: Eleven (50%) of 22 patients were male. The mean age of the patients was 13.4 ± 3.8 years. The mean body surface area of the patients was 1.4 ± 0.4 m2. In five patients BiVAD implantation was performed. Of these five BiVAD patients two underwent successful heart transplant; two weaned from temporary RVAD and last patient died due to multi-organ failure. Four patients showed signs of early RVF; one patient was transplanted successfully while on medical support. Three patients developing RVF did not respond medical therapy necessitating ECMO and died in the early postoperative period. All risk scores and potential predictive factors were evaluated individually and in combination of several parameters. No significant predictor for RVF in pediatric patients that underwent LVAD implantation was found (p > 0.05). CONCLUSION: Neither an adult risk score nor a predictive factor was successful in predicting RVF, alone or in combination due to limited number of patients and events. Large further investigations are needed to identify the predictors or scoring system in pediatric population.

Off-pump implantation of left ventricular assist device via minimally invasive left thoracotomy: Our single-center experience.

Background: The aim of this study was to compare our experience of left ventricular assist device implantation via minimally invasive left thoracotomy with off-pump versus on-pump technique. Methods: Between June 2013 and April 2020, nine patients (8 males, 1 female; mean age: 47±11.9 years; range, 30 to 61 years) who underwent off-pump left ventricular assist device implantation and nine patients (8 males, 1 female; mean age: 47±11.4 years; range, 29 to 60 years) who underwent on-pump minimally invasive left thoracotomy were retrospectively analyzed. Postoperative outcomes and mid-term results of both groups were evaluated. Results: Outflow graft was anastomosed to the ascending aorta with J-sternotomy in all patients. The median duration of intubation and intensive care unit stay were one (IQR: 1.5) day and eight (IQR: 6.5) days in the off-pump group, respectively and one (IQR: 0) day and seven (IQR: 7) days in the on-pump group, respectively. Intra-aortic balloon pump was needed during the weaning of cardiopulmonary bypass in one (11%) of the patients in both groups. Postoperative right ventricular failure was observed in two (22%) patients in the offpump group who were treated medically and recovered. There was no need for revision due to bleeding or postoperative extracorporeal membrane oxygenator implantation in either group. In the off-pump group, three patients underwent heart transplantation after median 854 (IQR: 960) days. Three patients died one month, two and four years after implantation. Three patients were still alive with left ventricular assist device and were being uneventfully followed for 365, 400, and 700 days after implantation. Conclusion: Off-pump technique is safe and feasible option for implantation of left ventricular assist device via minimally invasive left thoracotomy.

CoronaVac, BNT162b2 and heterologous COVID-19 vaccine outcomes in patients with ventricular assist device.

BACKGROUND: A consensus has not yet been reached regarding which COVID-19 vaccine program should be applied in patients with ventricular assist device (VAD). Our aim was to assess the clinical outcome of inactivated, mRNA and heterologous vaccine program in patient with VAD. METHODS: In this retrospective and cross-sectional study; adult patients who underwent VAD implantation between January 2012 and September 2021 and received any vaccine that were used in Republic of Türkiye for COVID-19, were included. The patients were divided into three groups according to the type of vaccine; "inactivated," "mRNA" and "heterologous." Clinical outcomes were analyzed. RESULTS: Eighteen patients were in each group in the "inactivated," "mRNA" and "heterologous" groups. Mean age was 51.6 ± 12 years in "inactivated" group, 42.5 ± 15.5 years in "mRNA" group and 41.1 ± 15.4 years in "heterologous" group. There was no significant difference between the groups in age, gender, body surface area, body mass index and etiology (p > 0.05). After last dose of vaccines, the number of patients had COVID-19 positive test were three (16.7%), one (5.6%), and two (11.1%) in "inactivated," "mRNA" and "heterologous" groups, respectively. Pump thrombosis was seen in two patients in "mRNA" group and one patient in "heterologous" group. No pump thrombosis was seen in "inactivated" group. COVID-19-related death or intubation was not observed. CONCLUSION: All vaccine that used for COVID-19 are safe and effective in patients with VAD. In countries that give priority to inactivated vaccines, mRNA vaccines may then be made as boosters.

A rare case of intracardiac leiomyomatosis in a patient who underwent complete tumor resection only using the laparotomic approach.

Intracardiac leiomyomatosis (ICLM) is a rare tumor that usually originates from the mesenchymal cells of the uterus. If left untreated, it may lead to cardiac symptoms and sudden death. The present case was a 45-year-old female patient who presented with occasional palpitations. The imaging methods revealed a heterogeneous mass likely to be leiomyoma with intense enhancement in the arterial phase in the uterus, extending from the ovarian and uterine veins to the heart through the inferior vena cava. The tumor council attributed these findings to intravenous leiomyomatosis with intracardiac extension. Accordingly, a multidisciplinary surgical team performed complete excision of the intracardiac leiomyomatosis in the patient presented herein using only the laparotomic approach. The gold standard in the treatment of ICLM is complete tumor excision. Excision of intracardiac tumors can be performed through controlled traction from the abdominal region.

Relationship Between Preoperative NT-proBNP and Postoperative Adverse Events in Patients with Left Ventricular Assist Device.

BACKGROUND: The aim of this study is to investigate the relationship of preoperative NT-proBNP values with postoperative adverse events in patient left ventricular assist device (LVAD) implantation. METHOD: Forty-six patients (35 males; mean age 49.4 ± 12.9 years) who underwent LVAD implantation between 2016 and 2018 were evaluated in this study. The analysis was made on the relationship between preoperative NT-proBNP and mortality, postoperative right ventricular failure (RVF), postoperative drainage, duration of intubation, and intensive care unit stay, was examined. The optimal NT-proBNP cut-off values for predicting mortality were determined using Receiver Operator Characteristic (ROC) curve analysis and the patients were divided into two groups according to the specified cut-off point. RESULT: Median NT-proBNP was higher in patients who died, had postoperative extracorporeal membrane oxygenation, and early RVF. The median NT-proBNP was 11,103 pg/ml in patients with IABP, and 2943 pg/ml in patients without IABP, and the difference was statistically significant (p = 0.002). The cut-off point for NT-proBNP was found to be 1725.5 pg/ml (Sensitivity:0.929, Specificity:0.688). Accordingly, when the patients were divided into two groups and analyzed, no statistically significant difference was found between preoperative NT-proBNP below or above 1725.5 and postoperative adverse events. There was no statistically significant correlation between preoperative NT-proBNP and postoperative drainage, duration of intubation time, and duration of ICU stay (p > 0.05). CONCLUSION: Routine monitoring of preoperative NT-proBNP and comparison with postoperative values are important in terms of patient selection, the timing of surgery, follow-up of postoperative adverse events, and improving outcomes in VAD patients.

Prolonged Extracorporeal Membrane Oxygenation Support as a Bridge to Heart Transplant.

Heart transplant is in high demand, but the wait list exceeds 6 months in Turkey. Until a donor heart can be procured, venoarterial extracorporeal membrane oxygenation is an important support option to bridge patients on the wait list or as a rescue therapy for patients with right ventricular failure after implant of left ventricular assist device; it is less expensive than other options, provides benefits such as simple percutaneous insertion, and requires neither sternotomy nor biventricular and respiratory support. We present a case of a patient bridged to transplant with 5 months of extracorporeal membrane oxygenation support.

Does minimally invasive approach reduce risk of infection after ventricular assist device implantation?

BACKGROUND: We analyzed patients with left ventricular assist device (LVAD) related and specific infection, and aimed to determine whether surgical technique implantation affect the frequency of infection. METHODS: We retrospectively analyzed the data of 99 patients who received LVAD at our department between June 2013 and June 2019. Patients were divided into two groups according to the surgical technique. Group A (n = 58) was conventional sternotomy (CS) and group B (n = 41) was on-pump minimally invasive left thoracotomy (MILT). Demographics, preoperative risk factors, LVAD infections, surgical incision site, driveline site, and outcomes were compared between these two groups. RESULTS: Mean follow up time was 589 ± 480 (31-2171) days. Infection was detected in 34% (41/99) of LVAD patients. Admission to emergency department and intensive care unit (ICU) in last 6 months were significantly higher in MILT group. There was no difference between the two groups in terms of driveline exit site infection (CS: 28%, MILT: 27%) (p > 0.05). Seven (17%) patients had infection in the thoracotomy incision site area in the MILT group. The rate of ICU hospitalization in the last 6 months was seen as the only independent risk factor increasing the frequency of infection (R = 0.30; p = 0.016). Survival analysis at 60 days, 1 year and 2 years showed no difference between the two groups (p = 0.09). CONCLUSIONS: Despite advances in pump technology and surgical technique, infection is still an important cause of mortality and morbidity.

A Stepwise Approach to Left Ventricular Assist Device Pump Thrombosis.

AIM: Pump thrombosis (PT) is a detrimental complication of left ventricular assist device (LVAD) therapy. There is no consensus on optimal PT treatment. The aim of this study was to present a treatment strategy for patients with PT. METHOD: The hospital records of patients who underwent isolated LVAD implantation between May 2013 and October 2018 were retrospectively evaluated. Pump thrombosis was suspected in the setting of impaired flow/power parameters and haemolysis. Protocols for the management of suspected PT varied by patient presentation. Parameters that increased the PT risk were investigated by dividing the patients into two groups according to the presence of PT. Preoperative and operative data were analysed. RESULTS: Pump thrombosis was observed in 20 of 81 patients. All patients with PT presented elevated lactate dehydrogenase levels and higher power and/or low-/high-flow alarm at admission. All patients were treated initially with intravenous unfractionated heparin infusion; three patients did not require further treatment, one patient died due to sudden cardiac arrest, and three patients underwent urgent surgery for LVAD exchange. Thirteen (13) patients received tissue plasminogen activator infusion; eight were discharged without any signs of thrombosis, and three were bridged to transplant. One (1) major bleeding event leading to death was observed. Freedom from second PT was found in 91% cases at 6 months and in 68.2% at 1 year. We found that a larger left ventricle and the type of pump determined the risk of PT. CONCLUSIONS: Low-dose thrombolytic therapy should be considered as a feasible treatment option for patients with PT.

More continuous flow, better learning? The effect of aortic valve opening in patients with left ventricular assist device.

PURPOSE: The aim of this study was to analyze neurocognitive function in patients who underwent continuous flow left ventricular assist device (LVAD) implantation. MATERIAL AND METHOD: This cross-sectional study included three groups: LVAD (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). The Rey Auditory-Verbal Learning Test (RAVLT), Judgement of Line Orientation Test (JLOT), Trail Making Test (TMT), Stroop Color-Word Interference Test (SCWIT), Verbal Fluency Test (VFT), Symbol-Digit Modality Test (SDMT) were used to assess the neurocognitive functions. Data were analyzed at a median 12 (3-47) months after LVAD implantation. The LVAD patients were also divided by aortic valve opening (AVO) into three subgroups as "closed" (n = 9), "1-6" (n = 8) and "7-10" (n = 14) opening per ten beats and data were re-analyzed accordingly. RESULTS: There was no significant difference among the groups according to SCWIT, JLOT, SDMT, TMT, and VFT scores. Post-hoc analyzes of RAVLT scores showed significant differences between the LVAD and the other two groups in favor of the LVAD group. Also, the patients with AVO "7-10" the response times were longer and learning scores were found to be lower than those without AVO. CONCLUSION: With continuous-flow LVAD, neurocognitive functions were not impaired. The learning performance was better in cases where there was no AVO and flow was completely device dependent. We may speculate that neurocognitive functions are not worsening with continuous cerebral blood flow and even it may improve learning performance.

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions.

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.

Prediction of right ventricular failure after continuous flow left ventricular assist device implantation.

BACKGROUND: Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Prediction of this clinical situation in LVAD patients with different clinical scores is still an enigma. The aim of this study is to analyze the predictive power of clinical parameters and risk scores and their combinations to discriminate RVF after LVAD implantation. METHODS: A retrospective, single center review of 71 patients who underwent continuous flow-LVAD implantation between September 2013 and September 2016, was performed. RVF was defined as need for RVAD and/or administration of inotropic agents more than 14 days after LVAD implantation. Patients with and without RVF were divided into two groups and predictive power of the nine parameters (tricuspid annular plane systolic excursion (TAPSE), Michigan score, Pennsylvania score, central venous pressure/pulmonary artery wedge pressure ratio (CVP/PCWP), and right ventricular stroke work index, pulmonary artery pulsatility index, CRITT score, ALMA score, European registry for patients with mechanical circulatory support (EUROMACS) right heart failure model and their combinations were analyzed to predict postoperative RVF. RESULTS: Of 71 patients, 21 had RVF after implantation. For the variables that can be used to discriminate between RVF and non-RVF groups, the diagnostic performance of the best cut-off points and tests was obtained using receiver operating characteristic (ROC) curve analysis. Discrimination analysis was performed to determine the combinations of tests. For all single risk scores and parameters; the area under the ROC curve (AUC) was below 0.7 which is considered to be a poor level of discrimination except EUROMACS score (AUC: 0.789, P < .001) and CRITT score (AUC: 0.739, P = .004). AUC for the combination of TAPSE and Pennsylvania score was 0.722, combination of Michigan and Pennsylvania scores represented AUC of 0.732 in the analysis. The combination of TAPSE + Pennsylvania score was found to have the highest sensitivity (85%), whereas TAPSE + Michigan score + CVP/PCWP appeared as the most specific (97%) combination. CONCLUSION: EUROMACS and CRITT scores predict RVF with high discrimination after LVAD implantation. Although, no other single test predicts RVF ideally, combination of risk scores and parameters discriminate RVF acceptably.

Cerebrovascular events in children on intracorporeal continuous-flow left ventricular assist devices.

Continuous-flow intracorporeal left ventricular assist devices (CF-LVAD) are used more frequently in the pediatric population. One of the major complications of CF-LVAD is cerebrovascular events (CVEs). Limited information is available on this complication in pediatric patients. We hereby present our experience on CVEs in children under CF-LVAD support in our institution. A retrospective, single center review of 21 patients younger than 19 years of age who underwent CF-LVAD implantation between June 2014 and September 2018 was performed. Patients on biventricular support and extracorporeal devices were excluded. Cerebrovascular accidents (CVAs)-ischemic or hemorrhagic-were investigated. CVE was confirmed by brain computed tomographic scan. Of 21 pediatric patients, 11 were male. Mean BSA was 1.05 ± 0.41 m2 and mean age was 11.05 ± 4.07 years. Dilated cardiomyopathy was the leading cause of heart failure. The patients were implanted with HeartWare hVAD (n = 19), HeartMate II (n = 1), and HeartMate 3 (n = 1). Mean support time was 421 ± 448 (18-1460) days. Target international normalized ratio was between 2.5 and 3.0. Nine (43%) patients underwent transplantation, one patient recovered with subsequent device explantation. Four (17%) patients were still on support. One patient (5%) died in the early postoperative period and six (28%) patients died on VAD support after a mean duration of 194 days. There were overall five cerebral hemorrhagic strokes in four patients (0.2 events per patient-year). CVA occurred between 250 and 1320 days (mean 600 days). No ischemic stroke was documented. Only one (20%) patient died after hemorrhagic stroke; the other three patients recovered and were discharged from the hospital with minor sequelae. Incidence of CVE in children on CF-LVAD is relatively low compared with adults on VAD and severity of stroke is milder than adult population.

Early and long-term results of heart transplantation with reoperative sternotomy.

BACKGROUND: This study aims to investigate the effects of reoperative sternotomy on early and long-term outcomes after heart transplantation. METHODS: We retrospectively reviewed data of a total of 92 patients (72 males, 20 females; mean age 36 years; range, 3 to 61 years) who underwent orthotopic heart transplantation between May 1998 and July 2014. The patients were divided into three groups. Group A (n=23) included patients who underwent previous cardiac surgery with sternotomy other than ventricular assist device implantation; Group B (n=12) included patients who were bridged-to-transplant with a ventricular assist device; and Group C (n=57) included patients who for the first time underwent heart transplantation without previous sternotomy. Preoperative and operative data of the three groups were compared. The short- and long-term outcomes of all groups were analyzed. RESULTS: There was no significant difference among the groups, except for the age and preoperative international normalized ratio. Total ischemia time in the ventricular assist device group was longer than Group C. The length of intensive care unit stay was also longer in the ventricular assist device group than the other groups. The amount of postoperative chest tube drainage and blood transfusion was higher in Group A. Early mortality rate was significantly higher in Group A. There was no significant difference in survival among the three groups in the long-term. According to the logistic regression analysis, no variable was found to be a significant risk factor for mortality. CONCLUSION: Reoperative sternotomy other than ventricular assist device implantation was found to be a risk factor for early mortality; however, mid and long-term survival rates were similar to patients in whom transplantation was the primary procedure. In patients with reoperative sternotomy, heart transplantation can be performed with similar risks to patients without resternotomy with careful selection and accurate pre- and intraoperative surgical approach.

Optimization with levosimendan improves outcomes after left ventricular assist device implantation.

OBJECTIVES: The aim of this study was to examine the haemodynamic effects of preoperative levosimendan infusion in patients who underwent left ventricular assist device implantation and evaluate the prognoses. METHODS: Between May 2013 and October 2018, 85 adult patients who underwent left ventricular assist device implantation were included; 44 and 41 patients suffered from dilated cardiomyopathy and ischaemic cardiomyopathy, respectively. Patients were divided into 2 groups: group A (58 patients) included those who received levosimendan infusion in addition to other inotropes and group B (27 patients) included those who received inotropic agents other than levosimendan. Levosimendan infusion was started at a dose of 0.1 µg⋅kg-1⋅min-1 for a maximum of 48 h without a bolus. The primary outcome was early right ventricular failure (RVF). The secondary outcomes were in-hospital mortality, need for right ventricular assist device, late RVF and recovery of end-organ functions. The safety end points of levosimendan included hypotension, atrial fibrillation, ventricular tachycardia or fibrillation and resuscitated cardiac arrest. RESULTS: Patient characteristics were similar in both groups. No significant differences between groups were observed in the rates of early mortality, RVF, need for right ventricular assist device, cardiopulmonary bypass time and intensive care unit stay. Survival rates at 30 days, 1 year and 3 years and freedom from late RVF were similar between the groups. Administration of levosimendan was safe, generally well-tolerated and not interrupted because of side effects. CONCLUSIONS: Levosimendan therapy was well-tolerated in patients who received permanent left ventricular assist devices. Combined preoperative therapy with inotropes and levosimendan significantly improves end-organ functions.

Effects of continuous-flow left ventricular assist devices on cerebral hemodynamics.

Continuous-flow left ventricular assist devices (LVADs) reduce peak systolic flow, increase diastolic flow, and eliminate pulsatility of circulation. Altered blood flow may lead to a change in end-organ perfusion. Analysis of the flow dynamics of the arteries of end organs, such as the brain, may indicate whether an organ is perfused sufficiently. The aim of this study is to evaluate and identify the flow pattern changes of carotid (CA) and middle cerebral arteries (MCA) in LVAD patients and to compare with heart failure patients and healthy volunteers. Eighty-nine individuals were included in this cross-sectional study. Participants were divided into three groups: LVAD patients (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). Carotid and transcranial Doppler ultrasonography were performed for all study groups for peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility (PI), and resistive (RI) indices of CA and MCA. Flow dynamics were compared between the groups. Doppler ultrasonographic data were analyzed at a median 12 (3-47) months after LVAD implantation. CA-PSV was lower in LVAD group compared with the other two groups (P < .001), MCA-PSV of LVAD and heart failure groups were similar and lower than healthy volunteers (P < .05). The highest values for CA-EDV were found in the LVAD group (P < .05). MCA-EDV values were found to be lowest in heart failure group (P < .05). For PI and RI, in all CA and MCA, the LVAD group had lower indices compared with the other two groups (P < .001). In addition, MCA flow analysis in patients with LVADs was identified for the first time with this study.

HeartMate 3 implantation via left thoracotomy with descending aortic anastomosis.

Left ventricular assist device implantation through left thoracotomy with outflow anastomosis to the descending aorta is an uncommon approach, particularly in patients with previous sternotomies. However, this approach has certain advantages, such as better surgical outcomes and lower complication rates. Here, we report the technique adapted for HeartMate 3 implantation through left thoracotomy with descending aortic anastomosis.

Tp-e interval and Tp-e/QT ratio in clinically stable pediatric heart transplant recipients.

OBJECTIVE: A study of the T wave peak-to-end (Tp-e) interval, the Tp-e/QT ratio, and the Tp-e/QTc ratio in pediatric heart transplant recipients (HTRs), a group which has a higher risk of sudden cardiac death than the normal population, has not previously been reported. The aim of this study was to assess alterations in ventricular repolarization using the Tp-e interval, Tp-e/ QT ratio, and Tp-e/QTc ratio in clinically stable pediatric HTRs. METHODS: A total of 13 clinically stable HTRs, 13 patients who had undergone cardiac surgery (CS) under cardiopulmonary bypass, and 16 healthy controls under 18 years of age were retrospectively evaluated. RESULTS: No significant differences were observed between the HTR, CS, and control groups in terms of QTc, JTc interval, and T wave amplitude (p>0.05). The Tp-e interval (p=0.001), Tp-e/QT ratio (p<0.001), and Tp-e/QTc ratio (p=0.001) were significantly higher in the HTR group compared with the CS and normal control participants. CONCLUSION: The Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were elevated in stable HTRs compared with the normal and CS groups.