Propensity score-based analysis of long-term follow-up in patients supported with durable centrifugal left ventricular assist devices:the EUROMACS analysis

OBJECTIVES: The HeartWare HVAD (HW) and the HeartMate3 (HM3) are presently the most commonly used continuous-flow left ventricular assist devices worldwide. We compared the outcomes of patients supported with either of these 2 devices based on data from the EUROMACS (European Registry for Patients with Mechanical Circulatory Support). METHODS: A retrospective analysis of the survival and complications profile in propensity score-matched adult patients enrolled in the EUROMACS between 01 January 2016 and 01 September 2020 and supported with either an HW or HM3. Matching included demographic parameters, severity of cardiogenic shock and risk-modifying end-organ parameters that impact long-term survival. Survival on device and major postoperative adverse events were analysed. RESULTS: Following 1:1 propensity score matching, each group consisted of 361 patients. Patients were well balanced (<0.1 standardized mean difference). The median follow-up was similar in both groups [396 (interquartile range (IQR) 112-771) days for HW and 376 (IQR 100-816) days for HM3]. The 2-year survival was similar in both groups [HW: 61% 95% confidence interval (CI) (56-67%) vs HM3: 68% 95% CI (63-73%) (stratified hazard ratio for mortality: 1.13 95% CI (0.83-1.54), P = 0.435].The cumulative incidence for combined major adverse events and unexpected readmissions was similar in both groups [subdistribution hazard ratio (SHR) 1.0 (0.84-1.21), P = 0.96]. Patients in the HW group demonstrated a higher risk of device malfunction [SHR 2.44 (1.45-3.71), P < 0.001], neurological dysfunction [SHR 1.29 (1.02-1.61), P = 0.032] and intracranial bleeding [SHR 1.76 (1.13-2.70), P = 0.012]. CONCLUSIONS: Mid-term survival in both groups was similar in a propensity-matched analysis. The risk of device malfunction, neurological dysfunction and intracranial bleeding was significantly higher in HW patients

Outcomes of patients after successful left ventricular assist device explantation: a EUROMACS study

Aims: Sufficient myocardial recovery with the subsequent explantation of a left ventricular assist device (LVAD) occurs in approximately 1–2% of the cases. However, follow-up data about this condition are scarcely available in the literature. This study aimed to report the long-term outcomes and clinical management following LVAD explantation. Methods and results: An analysis of the European Registry for Patients with Mechanical Circulatory Support was performed to identify all adult patients with myocardial recovery and successful explantation. Pre-implant characteristics were retrieved and compared with the non-recovery patients. The follow-up data after explantation were collected via a questionnaire. A Kaplan–Meier analysis for freedom of the composite endpoint of death, heart transplantation, LVAD reimplantion, or heart failure (HF) relapse was conducted. A total of 45 (1.4%) cases with myocardial recovery resulting in successful LVAD explantation were identified. Compared with those who did not experience myocardial recovery, the explanted patients were younger (44 vs. 56 years, P < 0.001), had a shorter duration of cardiac disease (P < 0.001), and were less likely to have ischaemic cardiomyopathy (9% vs. 41.8%, P < 0.001). Follow-up after explantation could be acquired in 28 (62%) cases. The median age at LVAD implantation was 43 years (inter-quartile range: 29–52),

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device

Transaxillary implantation of a temporary microaxial left ventricular assist device in a patient with a rectangular kinked subclavian artery

Transaxillary implantation of a temporary microaxial left ventricular assist device in patients suffering from cardiogenic shock is an established technique. We present a 77-year-old female patient with severe mitral regurgitation. She underwent minimally invasive surgical mitral valve replacement. After an uneventful postoperative course, the patient developed acute heart failure on the 11(th) postoperative day. Transthoracic echocardiography revealed new onset of Takotsubo cardiomyopathy with a severely decreased left ventricular ejection fraction. Implantation of a microaxial flow pump for left ventricular decompression was scheduled. Preoperative computed tomography revealed a rectangular course of the right subclavian artery. To advance the Impella, we employed an introducer fitted over the guidewire behind the Impella device as a 'cue stick' to move the rigid part of the pump forward to overcome the kinking using a 'shuffleboard technique'. The haemodynamic situation stabilized immediately after implantation. The Impella 5.5 was successfully weaned after 6 days of support. In the event of (rectangular) kinking of the subclavian artery, the 'shuffleboard technique' can be used for the successful positioning of the pump.ISSN:2753-670

Mechanical circulatory support of systemic ventricle in adults with transposition of great arteries

We report the successful use of the implantable ventricular assist device HeartWare (HeartWare International Inc., Framingham, MA) to support the systemic circulation in two adult patients with transposition of the great arteries (TGA). One had undergone the Senning procedure as a neonate; the other had congenitally corrected TGA and dextrocardia with palliation in adulthood. It is possible to implant the HeartWare pump into the morphological right ventricle with cannulation of either the diaphragmal surface or the free wall without additional changes in implantation technique and employing off-pump insertion

Revascularization of the occluded right coronary artery during left ventricular assist device implantation

A 62-year-old man with end-stage ischemic cardiomyopathy and left ventricular function of 20% was evaluated for heart transplantation. Cardiac catheterization revealed proximal occlusion of the dominant right coronary artery (RCA) with collateral blood flow and significant stenosis in the distal part, but no significant re-occlusions of the stented left coronary artery and no significant stenosis of the left circumflex artery. When the patient became catecholamine dependent, Novacor left ventricular assist device (LVAD) implantation, as a bridge to transplantation, was considered and the patient operated upon. To avoid ischemic right heart failure after LVAD implantation, a concomitant re-vascularization of the distal RCA was performed. The post-operative course was uneventful. Five weeks later, a control angiogram showed the patent bypass graft. The distal stenosis of the RCA was treated successfully with dilation and stent implantation. The patient is presently in stable condition on LVAD and awaits transplantation as an outpatient