Short and long term outcomes of 200 patients supported by continuous-flow left ventricular assist devices

AIM: To study the institutional experience over 8 years with 200 continuous-flow (CF) - left ventricular assist devices (LVAD). METHODS: We evaluated our institution\u27s LVAD database and analyzed all patients who received a CF LVAD as a bridge to transplant (BTT) or destination therapy from March 2006 until June 2014. We identified 200 patients, of which 179 were implanted with a HeartMate II device (Thoratec Corp., Pleasanton, CA) and 21 received a Heartware HVAD (HeartWare Inc., Framingham, MA). RESULTS: The mean age of our LVAD recipients was 59.3 years (range 17-81), 76% (152/200) were males, and 49% were implanted for the indication of BTT. The survival rate for our LVAD patients at 30 d, 6 mo, 12 mo, 2 years, 3 years, and 4 years was 94%, 86%, 78%, 71%, 62% and 45% respectively. The mean duration of LVAD support was 581 d (range 2-2595 d). Gastrointestinal bleeding (was the most common adverse event (43/200, 21%), followed by right ventricular failure (38/200, 19%), stroke (31/200, 15%), re exploration for bleeding (31/200, 15%), ventilator dependent respiratory failure (19/200, 9%) and pneumonia (15/200, 7%). Our driveline infection rate was 7%. Pump thrombosis occurred in 6% of patients. Device exchanged was needed in 6% of patients. On multivariate analysis, preoperative liver dysfunction, ventilator dependent respiratory failure, tracheostomy and right ventricular failure requiring right ventricular assist device support were significant predictors of post LVAD survival. CONCLUSION: Short and long term survival for patients on LVAD support are excellent, although outcomes still remain inferior compared to heart transplantation. The incidence of driveline infections, pump thrombosis and pump exchange have declined significantly in recent years

Resolution of Mitral Regurgitation With Left Ventricular Assist Device Support

BACKGROUND: Cardiac valve disease is common in patients with end-stage heart failure undergoing left ventricular assist device implantation (LVAD). The aim of this study was to determine if preoperative mitral regurgitation (MR) affects outcomes and hemodynamics in patients after LVAD implantation. METHODS: From March 2006 through May 2015, 238 consecutive patients underwent LVAD implantation. Patient cohorts included less than moderate to severe MR (\u3c moderate-severe, n = 195) and greater than or equal to moderate to severe MR (≥ moderate-severe, n = 43). Demographics, operative characteristics, postoperative outcomes, hemodynamic and echocardiographic data, and resolution of MR were compared at 30 and 180 days post-LVAD. RESULTS: Significant hemodynamic improvements were seen in central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, cardiac index, left ventricular ejection fraction, and left ventricular end-diastolic diameter, irrespective of preoperative MR severity. Significant resolution of MR occurred across both cohorts, with only 4 of 168 (2.4%) patients with ≥ moderate-severe MR at 180 days post-LVAD. There were no differences in complications or survival between MR severity cohorts postoperatively. CONCLUSIONS: LVAD implantation unloads the left ventricle to promote left ventricle reverse remodeling and correct functional MR across all severity levels. The resolution of MR is sustained at 180 days post-LVAD. These results coupled with no survival difference with uncorrected MR between \u3c moderate-severe MR and ≥ moderate-severe MR makes concomitant mitral valve repair or replacement at the time of LVAD implantation unnecessary

Effect of Body Mass Index on Outcomes in Left Ventricular Assist Device Recipients

BACKGROUND AND AIM: Obesity is associated with higher mortality following heart transplantation, but there remains no consensus regarding outcomes in left ventricular assist device (LVAD) recipients. We sought to determine the impact of body mass index (BMI) on outcomes in patients undergoing LVAD implantation. METHODS: This was a single-institution retrospective review, including all patients who received a HeartMate II LVAD or HeartWare HVAD between March 2006 and June 2014. Patients were stratified into three groups based on normal (/m(2) ), overweight (25-30 kg/m(2) ), and obese (\u3e30 kg/m(2) ) BMI. RESULTS: Two hundred patients were included in the analysis. Mean BMI was 28.3 kg/m(2) , (27% normal, 36% overweight, and 36.5% obese). Obese patients were younger (51.9 years, p = 0.03) and had higher incidence of diabetes (58.9% vs. 24.1%; p \u3c 0.001) and peripheral vascular disease (16.4% vs. 1.9%; p = 0.03). Normal BMI patients were more likely to undergo LVAD implantation as destination therapy compared to the overweight and obese groups (67% vs. 39% vs. 51%; p = 0.01) and had higher incidence of postoperative stroke/transient ischemic attack (22.2% vs. 6.9% vs. 12.3%; p = 0.04) and postoperative bleeding requiring reoperation (27.8% vs. 12.5% vs. 9.6%; p = 0.01). Survival at one, three, and five years was similar across all BMI groups. BMI was not an independent predictor of overall survival. CONCLUSIONS: Appropriately-selected patients at the extremes of BMI can safely undergo LVAD implantation with no difference in survival. BMI should not in itself be considered a contraindication to LVAD placement

Should Patients with Hepatic Fibrosis Undergo LVAD Implantation: A Comparative Analysis

The purpose of our study was to evaluate outcomes in patients with hepatic fibrosis at the time of LVAD implantation. There were five (2.1%) patients with preoperative hepatic fibrosis with a mean age of 51.2 ± 16.8 years. Survival at 180 days was significantly reduced in patients with hepatic fibrosis, 40.0% vs. 88.0%; p = 0.001. Hepatic fibrosis was a significant independent predictor of mortality in multivariate analysis (hazard ratio [HR] 2.27, p = 0.036)

Operative strokes after repair of acute type a dissections: predisposing factors and implications

BACKGROUND: Type A aortic dissection is a surgical emergency with a high morbidity and mortality. Strokes occur in up to 25% and are among the most feared complications. This study aims to evaluate factors linked to stroke development and the implications of strokes on outcomes. METHODS: Patients from 2000-2014 were stratified based on the development of stroke. Factors were compared between the groups using chi-square or Fisher\u27s exact tests for categorical variables, and independent two-group t-tests for continuous variables. Impact on survival at 30 days, 1 and 5 years were evaluated using the life-test method. RESULTS: 200 patients were analyzed. 40 (20%) developed a stroke. Preoperative factors associated with stroke were female gender (34% vs 14% p=0.01), presentation with shock (32% vs 17%; p=0.035), and history of stroke (64% vs 17%; p \u3c 0.001). Femoral cannulation was the only technical variable associated with stroke (49% vs 32%; p=0.035). Stroke patients had a higher rate of pneumonia (41% vs 11%; p\u3c0.001), respiratory failure (36% vs 7%; p\u3c0.001), hemodialysis requirement (38% vs 16%; p=0.015), and longer hospital stay (23.9 +/- 17.8 days vs 16.1 +/- 13.5 days; p=0.012). Stroke was associated with a lower survival probability at 30-days (0.73 vs 0.89), 1-year (0.56 vs 0.78) and 5-years (0.29 vs 0.70) (p\u3c0.001). CONCLUSIONS: Patients who developed stroke after type A dissection repair had higher complication rates and a higher mortality rate at 30 days, 1 year, and 5 years. Femoral cannulation was the only technical factor associated with a higher rate of strokes

Operative strokes after repair of acute type a dissections: predisposing factors and implications

BACKGROUND: Type A aortic dissection is a surgical emergency with a high morbidity and mortality. Strokes occur in up to 25% and are among the most feared complications. This study aims to evaluate factors linked to stroke development and the implications of strokes on outcomes. METHODS: Patients from 2000-2014 were stratified based on the development of stroke. Factors were compared between the groups using chi-square or Fisher\u27s exact tests for categorical variables, and independent two-group t-tests for continuous variables. Impact on survival at 30 days, 1 and 5 years were evaluated using the life-test method. RESULTS: 200 patients were analyzed. 40 (20%) developed a stroke. Preoperative factors associated with stroke were female gender (34% vs 14% p=0.01), presentation with shock (32% vs 17%; p=0.035), and history of stroke (64% vs 17%; p \u3c 0.001). Femoral cannulation was the only technical variable associated with stroke (49% vs 32%; p=0.035). Stroke patients had a higher rate of pneumonia (41% vs 11%; p CONCLUSIONS: Patients who developed stroke after type A dissection repair had higher complication rates and a higher mortality rate at 30 days, 1 year, and 5 years. Femoral cannulation was the only technical factor associated with a higher rate of strokes

Effect of Preoperative Albumin Levels on Outcomes in Patients Undergoing Left Ventricular Device Implantation

Hypoalbuminemia is a well-known predictor of morbidity and mortality in cardiac surgery. Our aim was to establish the impact of serum albumin on outcomes after left ventricular assist device (LVAD) implantation. This was a single-institution retrospective review, including all patients who underwent LVAD implantation between March 2006 and June 2014. Two hundred patients were included in the analysis. Mean serum albumin was 3.27 ± 0.47 g/dl, with 7% in the low albumin group (3.5 mg/dl). Lower albumin was associated with a significant increase in postoperative renal failure (42.9 vs. 16.5 vs. 17.3%; p = 0.05) and prolonged hospitalization (median 28.5 vs. 16 vs. 15.5 days; p = 0.008). Six month, 1 year, and 5 year survival was 79%, 79%, and 49% with low, 84%, 78%, and 51% with mid-range, and 94%, 88%, and 60% with normal albumin, respectively (p = 0.22). Preoperative hypoalbuminemia is associated with postoperative acute renal failure (ARF) and prolonged hospitalization after LVAD implantation, with no effect on overall survival. Hypoalbuminemia is most likely a marker of advanced disease and should not, in itself, be considered a contraindication to LVAD candidacy