TRICUSPID VALVE DISEASE AND RIGHT VENTRICULAR DYSFUNCTION AFTER RIGHT VENTRICULAR TRANSVENOUS LEAD PLACEMENT IN PATIENTS WITH TRICUSPID VALVE PROSTHESIS

Background: First time transvenous right ventricular (RV) lead implant after tricuspid valve (TV) repair or bioprosthetic replacement is common. We evaluated outcomes in TV regurgitation (TR) and RV function in this population. Methods: We conducted single-center retrospective study on patients with TV repair or replacement from 2000 to 2020 followed by first-time transvenous RV lead implant. Primary outcomes were change in TR severity (defined as defined as none/trivial, mild, moderate, moderate-severe, or severe) and RV function (normal, mild, moderate, or severe). Baseline and follow-up echocardiogram (ECHO) data was reviewed, as well as time to death. Results: 52 patients were identified (29 female, 47 had hypertension, 41 had atrial fibrillation, 49 had TV repair, 3 had replacement). Median time from surgery to implant was 1.7 months and to last ECHO was 39.7 months. In TV repair, baseline TR was none/trivial in 15 (30.6%) and mild in 21 (42.8%) patients. RV function was normal in 33 (67.3%) patients. 58% had worsened TR (mean 0.9 levels) (Figure). No TR change was seen in TV replacement. Mean worsening RV function was by 0.9 levels. There was statistically significant correlation with RV pacing and RV dysfunction (Spearman correlation coefficient 0.37, p = 0.017), but not with change in TR (p = 0.36). 22 patients died at median follow-up (48.9 months). Conclusion: Presence of an RV lead after TV repair correlated with worsening TR. Higher RV pacing level correlated with RV dysfunction but not TR severity

COMPARING NERVE BLOCK PAIN PUMPS TO STANDARD OF CARE IN PATIENTS FOLLOWING CARDIOTHORACIC SURGERY

INTRODUCTION: Post-operative pain management following cardiothoracic surgery (CTS) can be challenging. Although opioids are commonly prescribed, multimodal strategies are used to decrease opioid consumption. One strategy includes the use of local anesthetics via peripheral nerve block pain pumps (PNBPP). However, literature in CTS patients is limited and conflicting. This study evaluated the efficacy and safety of PNBPP in patients following CTS. METHODS: This was a quasi-experimental study that included adult patients admitted to the cardiac intensive care unit following CTS. The intervention group included those who received PNBPP and they were compared to a group that received standard of care (SOC). The primary endpoint was the total oral morphine milligram equivalents (MMEs) used in the four days following surgery. Secondary endpoints included adverse events, incidence of post-operative ileus, time to first bowel movement, pain scores, length of stay and cost of intervention. Statistical analysis was performed with Chi-square, Fisher\u27s exact, Mann-Whitney U and t-tests where appropriate (IBM SPSS Statistics Software version 28.0.1.1). A sample size of 126 was calculated to detect a 50% reduction in opioid consumption with an alpha of 0.05 and power of 80%. RESULTS: Baseline characteristics were similar between groups with a median age of 60 and 63 in the PNBPP and SOC groups, respectively. The majority of patients were male and had a coronary artery bypass graft performed. Median oral MMEs was 375 (IQR: 268.5, 457.5) in the SOC group compared to 304.5 (IQR: 240, 416) in the PNBPP group (p-value 0.189). When comparing the SOC and PNBPP groups, incidence of post-operative ileus was 2 (3.2%) and 12 (19%) (p-value 0.005) with median time in hours to first bowel movement of 68.38 (IQR: 50.31, 85.50) and 66.11 (IQR: 50.28, 76.13) (p-value 0.336). There was no significant difference between groups in pain scores or length of stay. Median cost (USD) of PNBPP therapy was $125 in those that received an electronic pump and$3,138 in those that received an elastomeric pump. CONCLUSIONS: Addition of PNBPP post-CTS did not significantly reduce opioid consumption compared to SOC. Larger studies are needed to better define the role of PNBPP in post-operative pain management following CTS

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

Characterizing Outflow Graft Narrowing over Time

Purpose: Cases of pump dysfunction due to outflow graft (OG) anastomosis obstruction related to serous fluid accumulation have been reported but the rate of occlusion and actual frequency of asymptomatic OG diminution is not known. Methods: This was a multicenter retrospective analysis of patients on HeartMate II (HMII) or HeartMate 3 (HM3) support surviving at least 180 days with at least one chest computed tomography (CT) scan at 6 months, 1, 2, and/or 3 years postoperative. Patients with OG obstruction due to torsion were excluded. The outflow graft (OG) diameter was measured at its narrowest region; region was categorized as external outflow graft (EOG), mid-graft, or within 2 cm of the aortic anastomosis. Mixed models with repeated measure linear regression was used to assess OG diameter change over time, with 14 mm as reference. Using the narrowest measure, OG diameter was modelled for freedom from death, admission for HF and low flow alarms with hazard ratio [95% CI presented]. Results: Of 71 patients included herein, 25% and 75% were on HMII and HM3 support for a median [25th, 75th] 1230 [703,1592] days. The median CT count was 2 [1,2] per patient. At follow-up, small (1-3 mm, table), but statistically significant reductions in OG diameter were noted (Figure). The median OG narrowing was 7% [0%, 20%]. Time from device implant was the most significant contributing factor (p\u3c0.001) while wrapping of the outflow was nonsignificantly correlated with OG narrowing (p=0.071). Device model was not correlative (p=0.16). OG diameter was not correlated with survival (HR 1.04 [0.81-1.3]), stroke (HR 0.94 [0.78-1.1]) or admissions for heart failure (HR 1.06 [0.88-1.3]), or VAD alarms (HR 0.93 [0.79-1.1]). Conclusion: Minor narrowing of the OG was noted over time, irrespective of LVAD model. The observed degrees of non-twist related-OG narrowing herein did not lead to increase mortality or events. OG wrapping may be associated with OG narrowing over time. Larger sample analyses aim to define degrees of narrowing that elicit device dysfunction

Minimally Invasive Mitral Valve Repair Complicated By Intraoperative Right Coronary Artery Occlusion

Introduction: Iatrogenic injury of coronary arteries can complicate mitral valve replacement or repair. Direct injury to the circumflex coronary artery can occur due to the proximity of these vessels to the mitral valve. Acute injury of the right coronary artery on the other hand is seen during tricuspid valve repairs and is almost never seen with mitral valve surgery given its distance from the mitral valve. Case: We describe an interesting case of minimally invasive mitral valve repair which was complicated by intraoperative right coronary artery occlusion. It was managed by angiography and percutaneous intervention. Conclusion: While myocardial infarctions are rare in patients undergoing valvular surgery with normal preoperative coronary angiography, it must be suspected in patients with difficulty weaning from cardiopulmonary bypass and sudden reductions in cardiac function. In minimally invasive procedures with thoracotomy incisions, intraoperative angiography can be an indispensable tool. Swift intervention for revascularization and the use of postoperative cardiac assist devices can lead to favorable outcomes.https://scholarlycommons.henryford.com/sarcd2021/1002/thumbnail.jp

Characterizing Outflow Graft Narrowing over Time

Purpose: Cases of pump dysfunction due to outflow graft (OG) anastomosis obstruction related to serous fluid accumulation have been reported but the rate of occlusion and actual frequency of asymptomatic OG diminution is not known. Methods: This was a multicenter retrospective analysis of patients on HeartMate II (HMII) or HeartMate 3 (HM3) support surviving at least 180 days with at least one chest computed tomography (CT) scan at 6 months, 1, 2, and/or 3 years postoperative. Patients with OG obstruction due to torsion were excluded. The outflow graft (OG) diameter was measured at its narrowest region; region was categorized as external outflow graft (EOG), mid-graft, or within 2 cm of the aortic anastomosis. Mixed models with repeated measure linear regression was used to assess OG diameter change over time, with 14 mm as reference. Using the narrowest measure, OG diameter was modelled for freedom from death, admission for HF and low flow alarms with hazard ratio [95% CI presented]. Results: Of 71 patients included herein, 25% and 75% were on HMII and HM3 support for a median [25th, 75th] 1230 [703,1592] days. The median CT count was 2 [1,2] per patient. At follow-up, small (1-3 mm, table), but statistically significant reductions in OG diameter were noted (Figure). The median OG narrowing was 7% [0%, 20%]. Time from device implant was the most significant contributing factor (p\u3c0.001) while wrapping of the outflow was nonsignificantly correlated with OG narrowing (p=0.071). Device model was not correlative (p=0.16). OG diameter was not correlated with survival (HR 1.04 [0.81-1.3]), stroke (HR 0.94 [0.78-1.1]) or admissions for heart failure (HR 1.06 [0.88-1.3]), or VAD alarms (HR 0.93 [0.79-1.1]). Conclusion: Minor narrowing of the OG was noted over time, irrespective of LVAD model. The observed degrees of non-twist related-OG narrowing herein did not lead to increase mortality or events. OG wrapping may be associated with OG narrowing over time. Larger sample analyses aim to define degrees of narrowing that elicit device dysfunction

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived \u3e24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P \u3c .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended

Normothermic Ex Vivo Lung Perfusion (Novel) as an Assessment of Extended Criteria Donor Lungs: A Prospective Multi-Center Clinical Trial

Purpose: Ex vivo lung perfusion (EVLP) allows re-evaluation of extended criteria/marginal donor lungs. This can increase the number of lung transplants. However, the long-term outcomes of transplanting EVLP-screened lungs in a multicenter setting are unknown. We proposed to evaluate the short- and long-term outcomes of EVLP performed at multiple centers. Methods: This is a prospective, nonrandomized clinical trial. Seventeen lung transplant centers in the United States. Adult patients with end-stage pulmonary disease requiring lung transplant from May 2011 to December 2017 were eligible. Lung allografts initially deemed extended criteria/marginal (n=216) were placed on EVLP and re-evaluated prior to transplant. Patients received either standard donors (n=116) or lungs screened with EVLP (n=110). Results: Half of the lung grafts (110/216, 50.9%) placed on EVLP were transplanted. The incidence of primary graft dysfunction 24 hours post-transplant was higher in the EVLP group (25.5% vs 10.3%, p=0.003), but was not significantly different 48 hours (EVLP: 15.5%, control: 9.5%, p=0.49) and 72 hours (13.6% vs 6.9%, p=0.34) post-transplant. Survival was not significantly different between the 2 groups 1 year (n=226, EVLP: 86%, control: 94%, p=0.06), 3 years (n=226, EVLP: 68%, control: 76%, p=0.16, Figure), or 5 years (n=159, EVLP: 59%, control: 65%, p=0.68) post-transplant. There were also no differences in pulmonary function, the incidence of chronic lung allograft dysfunction or quality of life measures post-transplant. Conclusion: In this multicenter study, recipients of lungs that were re-evaluated on EVLP and deemed suitable for transplant had similar outcomes as a recipients of a standard lung transplants. EVLP offers the opportunity to screen donated lungs initially considered high risk and can safely increase the availability of transplantable lungs without compromising outcomes

Left ventricular assist devices complicated by gastrointestinal bleeding and outcomes on transplant

Left Ventricular Assist Devices (LVAD) are becoming the standard of care in advanced heart failure patients. However, despite ongoing advances in this technology, there remains a signifi cant early postoperative morbidity and mortality. LVAD implantation is associated with signifi cant complications including infection, arrhythmias, post-operative, and non-surgical bleeding. Gastrointestinal bleeding (GIB) is one of the most common long-term complications with an incidence approaching 30%. There is literature pertaining to global outcomes after LVAD implantation, but few have studied outcomes after transplant in the presence of GIB. In this retrospective study, 234 patients who received FDA approved LVAD devices (HeartMate II or HeartWare) in a tertiary care center between 2005 and 2015 were studied. Demographics such as age, race, sex, and socioeconomic status were recorded along with comorbidities such as hypertension, diabetes, coronary artery disease, and etiology of heart failure. Incidence of GIB was investigated along with post-transplant outcomes. 68 patients (29.06%) had GIB whereas 166 (70.94%) did not have any occurence of GIB. Out of the GIB cohort, 28 (41.18%) underwent transplant whereas 40 (58.82%) did not undergo transplant or died. 63 (37.95%) of the non-GIB cohort underwent transplant. There was no signifi cant difference between the groups in the likelihood of receiving a transplant (p=0.755). 1 year post-transplant outcomes did not differ signifi cantly between the cohorts. Specifically, length of stay for the transplant hospitalization was 30.4 days in the GIB transplant group compared to 27.83 in non-GIB transplant patients (p=0.77). There were 2 incidences of rejection (defi ned as grade 2R/3A) in the GIB transplant group compared to 4 in the non-GIB transplant group (p=1.00). Patients with GIB had an average 1.33 readmissions post-transplant compared to 2.03 in the non-GIB group (p=0.148). Only 2 patients died (7.14%) in the GIB group compared to 12 deaths (19.05%) in the non-GIB group (p=0.255). Our results of a single center study reveal that GIB in patients who have LVAD is not predictive of transplant outcomes. Nonetheless, health care providers need to appropriately manage GIB as this will continue to occur when LVADs are implanted as destination therapy or bridge to transplant. Understanding prognostic factors in this high risk population can help appropriately and effectively target patient needs