Left ventricular assist device implantation after acute anterior wall myocardial infarction and cardiogenic shock: A two-center study

ObjectiveLeft ventricular assist device (LVAD) insertion after anterior wall myocardial infarction complicated by cardiogenic shock is an accepted modality of support in select patients. Results of primary revascularization for these patients are poor. We seek to determine the outcomes of patients with myocardial infarction and shock who undergo LVAD insertion alone versus surgical revascularization before LVAD insertion.MethodsSeventy-four patients at 2 institutions underwent LVAD implantation for myocardial infarction and shock over a 12-year period. Twenty-eight underwent direct LVAD placement, and 46 underwent revascularization through coronary artery bypass grafting before LVAD placement. Variables examined included patient demographics, myocardial infarction–LVAD interval, bridge to transplantation, early mortality (≤30 days), survival after LVAD placement, and posttransplantation survivals.ResultsThere were no differences in demographics between the 2 groups. The group undergoing revascularization before LVAD placement had a lower bridge to transplantation, higher early mortality, and lower overall 6- and 12-month survivals after LVAD placement compared with the group undergoing direct LVAD placement (45.50% vs 70.40%, P = .041; 39.10% vs 14.30%, P = .020; 89.3% and 82.1% vs 54.4% and 52.2%, respectively, P = .006). Posttransplantation survival and LVAD explantation rates were equivalent in both groups.ConclusionsCoronary artery bypass grafting before LVAD insertion for cardiogenic shock complicating myocardial infarction adversely affects survival. Confirmation of these findings would require conducting a large, multicenter, randomized clinical trial comparing revascularization versus LVAD support as primary therapy in this setting

Design and characteristics of the prophylactic intra-operative ventricular arrhythmia ablation in high-risk LVAD candidates (PIVATAL) trial

BACKGROUND: The use of a Left Ventricular Assist Device (LVAD) in patients with advanced heart failure refractory to optimal medical management has progressed steadily over the past two decades. Data have demonstrated reduced LVAD efficacy, worse clinical outcome, and higher mortality for patients who experience significant ventricular tachyarrhythmia (VTA). We hypothesize that a novel prophylactic intra-operative VTA ablation protocol at the time of LVAD implantation may reduce the recurrent VTA and adverse events postimplant. METHODS: We designed a prospective, multicenter, open-label, randomized-controlled clinical trial enrolling 100 patients who are LVAD candidates with a history of VTA in the previous 5 years. Enrolled patients will be randomized in a 1:1 fashion to intra-operative VTA ablation (n = 50) versus conventional medical management (n = 50) with LVAD implant. Arrhythmia outcomes data will be captured by an implantable cardioverter defibrillator (ICD) to monitor VTA events, with a uniform ICD programming protocol. Patients will be followed prospectively over a mean of 18 months (with a minimum of 9 months) after LVAD implantation to evaluate recurrent VTA, adverse events, and procedural outcomes. Secondary endpoints include right heart function/hemodynamics, healthcare utilization, and quality of life. CONCLUSION: The primary aim of this first-ever randomized trial is to assess the efficacy of intra-operative ablation during LVAD surgery in reducing VTA recurrence and improving clinical outcomes for patients with a history of VTA

A modified 'single patch' technique for complete atrioventricular septal defect correction

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