Chronic Mechanical Circulatory Support for Inotrope-Dependent Heart Failure Patients Who Are Not Transplant Candidates Results of the INTrEPID Trial

ObjectivesThis study evaluated the impact of left ventricular assist device (LVAD) support on survival and quality of life in inotrope-dependent heart failure patients ineligible for cardiac transplantation.BackgroundThe role for LVADs as a bridge to cardiac transplantation has been established, but data supporting their role as permanent therapy in nontransplant candidates are limited.MethodsThe INTrEPID (Investigation of Nontransplant-Eligible Patients Who Are Inotrope Dependent) trial was a prospective, nonrandomized clinical trial comparing LVAD with optimal medical therapy (OMT). Fifty-five patients with New York Heart Association functional class IV symptoms who failed weaning from inotropic support were offered a Novacor LVAD. Eighteen of these patients did not receive an LVAD owing to patient preference (n = 14) or unavailability of the device (n = 4) but consented to follow-up and constitute a contemporaneous control group.ResultsThe LVAD and OMT patients were well matched for demographic and disease severity measures, except OMT patients had a lower mean serum sodium (128 mg/dl vs. 134 mg/dl; p = 0.001) and a higher mean blood urea nitrogen concentration (59 vs. 40; p = 0.02). The LVAD-treated patients had superior survival rates at 6 months (46% vs. 22%; p = 0.03) and 12 months (27% vs. 11%; p = 0.02). Adverse event rates were higher in the OMT group. Eighty-five percent of the LVAD-treated patients had minimal or no heart failure symptoms. Five LVAD patients and 1 OMT patient improved sufficiently while on therapy to qualify for cardiac transplantation.ConclusionsInotrope-dependent heart failure patients who are ineligible for transplantation have a high short-term mortality rate and derive a significant survival advantage from “destination” mechanical circulatory support

Direct Pull-Through Technique to Insert the Impella RP Device Without Using Fluoroscopy

We describe a technique for insertion of the Impella RP device that does not require fluoroscopy. Venous cannulation was performed via the superior vena cava and femoral vein percutaneously. After right atriotomy, the Impella RP is percutaneously inserted and advanced to the right atrium under transesophageal echocardiography guidance. Next, via a longitudinal 2 cm incision in the main pulmonary artery (PA), a large C-shaped clamp is advanced retrograde through the pulmonic and tricuspid valves into the right atrium. The pigtail portion is grasped, pulled through to the main PA, and the device is positioned in the PA under direct vision

Less Invasive Reoperative Ventricular Assist Device Insertion for Patients With Patent Bypass Grafts

We report our technique for left ventricular assist device insertion that is useful in patients with patent coronary artery bypass grafts or mediastinal adhesions from other previous surgeries. An inverted-T upper hemisternotomy is made at the level of the second or third intercostal space, and with the left sternal section retracted, dissection is carried along the chest wall into the left pleural space. The device is implanted in the left ventricular apex via a left thoracotomy in the fifth or sixth intercostal space. The outflow graft is routed through the left pleural space and anastomosed to the ascending aorta

Extended Arch Procedures for Acute Type A Aortic Dissection: A Downstream Problem?

Current discussion regarding the management of acute type A aortic dissection is focused on whether to perform a standard hemiarch resection or perform an extended repair, in hopes of improving long-term outcomes by avoiding late, distal aortic sequelae. Critical to this discussion is an estimation of the short-term risks of an extended procedure and the magnitude of the late downstream problem. Extension of the hemiarch to a total arch plus frozen elephant trunk does not improve survival; carries some increased perioperative risk, not the least of which is paraplegia; but decreases late aortic events, the most common of which is reoperation on the distal aorta. However, these reoperations are low frequency, primarily elective, low-risk events and it should be noted that extended index repairs do not eliminate or necessarily decrease the incidence of late reoperations. Routine extension of the index procedure puts 100% of patients at risk in order to protect a minority that may benefit. Therefore, it is important to select patients at high risk for reoperation if an extended repair is to be performed. Predictors that may identify this high-risk group include the size and location of the entry tear, aortic and luminal dimensions, degree of luminal flow and thrombosis, and the presence of a connective tissue disorder. Timing may also be important and, in patients at high risk for late events, early complications may be minimized by strategies that delay an extension of the proximal repair until the subacute period