Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support

Die Anwendung eines extrakorporal implantierbaren Lebensunterstützungssystems (Extracorporeal Life Support, ECLS) kann als eine Überbrückungstechnik für die weitere Diagnostik oder als Indikationsstellung für die Therapie mit einem dauerhaft implantierbaren linksventrikulären Unterstützungssystem (Left Ventricular Assist Device, LVAD) dienen. Von 1/2012 bis 1/2018 wurden insgesamt 714 Patienten mit ECLS am Deutschen Herzzentrum Berlin (DHZB) unterstützt. In diesem Zeitraum wurde bei 618 Patienten die Implantation eines dauerhaften LVAD durchgeführt. Davon erhielten 100 Patienten eine ECLS-Unterstützung unmittelbar vor LVAD-Implantation. Wir analysierten retrospektiv die Daten dieser 100 Patienten mit dem Ziel, einen Algorithmus für die Überlebensvorhersage und somit für den rationalisierten Einsatz einer langfristigen LVAD-Therapie zu erstellen. Das mittlere Alter der Gruppe von 100 Patienten betrug 54.1 ±11.6 Jahre, 72 davon waren Männer. 29 Patienten hatten einen Body Mass Index (BMI) > 30 kg/m². 33 Patienten erhielten ein temporäres rechtsventrikuläres Unterstützungssystem (Temporary Right Ventricular Assist Device, tRVAD) postoperativ. Das 30-Tage-, 1-Jahres- und 2-Jahres-Überleben nach VAD-Implantation waren entsprechend 62.0 % (95 % Konfidenzinterval (CI): 53.2–72.3), 43.0 % (95 % CI: 34.3–53.9) und 37.1 % (95 % CI: 28.2–48.7). Die pönalisierte multivariable logistische regressive Analyse hat folgende Prädiktoren für die 1-Jahres-Mortalität gezeigt: Bilirubin-Anstieg per mg/dl (OR 1.41 (95 % CI 1.12-1.77), Anstieg C-reaktives Protein (CRP) per mg/dl (OR 1.11 95 % CI 1.05–1.19) ), ECLS-Dauer > 7 Tage (OR 4.90, 95 % CI 4.89, 95 % CI 1.66–14.41), BMI > 30 kg/m² (OR 1.41 (95 % CI 1.05–8.52) und weibliches Geschlecht (OR 3.06 (95 % CI 1.02–9.23). Anhand dieser Daten wurde ein Nomogramm zur Einschätzung einer 1-Jahres-Mortalität nach LVAD-Implantation erstellt. Bei Patienten mit kardiogenem Schock ist nach Stabilisierung mittels ECLS die Durchführung einer LVAD-Implantation zwar mit einer erhöhten Mortalität verbunden, dabei aber die einzige mögliche Option, den Tod zu vermeiden. Eine Dysfunktion der Leber, inflammatorische Reaktionen sowie Adipositas erhöhen das Risiko einer mittelfristigen Mortalität.Extracorporeal life support (ECLS) can be applied as a bridge to diagnosis and decision-making for further treatment with long-term left ventricular assist devices (LVAD). In 01/2012-01/2018, 714 patients were supported with ECLS at the German Heart Center (DHZB). During the same period 618 patients received an LVAD for long-term support. Out of these, 100 were supported with ECLS directly before LVAD implantation. We retrospectively analyzed the datasets of these 100 consecutive patients with the goal to develop an algorithm to predict outcomes for a rational use of long term VAD therapy in this setting. Mean age of the 100 patients was 54.1 ±11.6 years; 72 were male. Twenty-nine patients had BMI >30 kg/m². In 33 patients a temporary right ventricular assist device (tRVAD) was necessary postoperatively. The 30-day, 1-year and 2-year survival after VAD implantation was 62.0% (95% Confidence Interval (CI): 53.2-72.3), 43.0% (95% CI: 34.3-53.9) and 37.1% (95% CI: 28.2%-48.7), respectively. Penalized multivariable logistic regression analysis showed following predictors for 1-year mortality: bilirubin increase per mg/dl (OR 1.41 (95% CI 1.12-1.77), C-reactive Proteine (CRP) increase per mg/dl (OR 1.11 95% CI 1.05-1.19)), ECLS duration > 7 days (OR 4.90, 95% CI 4.89, 95% CI 1.66-14.41), BMI > 30 kg/m² (OR 1.41 (95% CI 1.05-8.52) , and female gender (OR 3.06 (95% CI 1.02-9.23). On the basis of these data, a nomogram to estimate 1-year mortality after LVAD implantation was created. After stabilization of patients suffering from cardiogenic shock with ECLS, LVAD implantation can be performed with an increased mortality in an otherwise dead-end situation. Liver dysfunction, inflammatory status and obesity increase the risk for mid-term mortality.

Impact of preoperative atrial fibrillation on thromboembolic events and pump thrombosis in long-term left ventricular assist device therapy

ISSN:1010-7940ISSN:1873-734

Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support

Objectives: Extracorporeal life support (ECLS) can be applied as a bridge to diagnosis and decision-making for further treatment with long-term left ventricular assist devices (LVADs). Methods: From January 2012 to January 2018, 714 adult patients were treated with ECLS in our institution. During the same period, 618 patients received an LVAD for long-term support. Of them, 100 patients were further supported with a long-term LVAD. We retrospectively analysed the datasets of these 100 consecutive patients with the goal of developing an algorithm to predict outcomes for a rational use of long-term ventricular assist device therapy in this setting. Results: The mean age of the 100 patients was 54.1 ± 11.6 years, and 72 were men. Twenty-nine patients had a BMI of >30 kg/m². In 33 patients, a temporary right ventricular assist device was necessary postoperatively. The 30-day, 1-year and 2-year survival after ventricular assist device implantation was 62.0% [95% confidence interval (CI) 53.2–72.3], 43.0% (95% CI 34.3–53.9) and 37.1% (95% CI 28.2–48.7%), respectively. Penalized multivariable logistic regression analysis showed following predictors for 1-year mortality: bilirubin increase per mg/dl [odds ratio (OR) 1.41, 95% CI 1.12–1.77], C-reactive protein increase per mg/dl (OR 1.11, 95% CI 1.05–1.19), ECLS duration >7 days (OR 4.90, 95% CI 1.66–14.41), BMI >30 kg/m² (OR 1.41, 95% CI 1.05–8.52) and female gender (OR 3.06, 95% CI 1.02–9.23). On the basis of these data, a nomogram to estimate 1-year mortality after LVAD implantation was created. Conclusion: After stabilization of patients experiencing cardiogenic shock using ECLS, LVAD implantation can be performed with elevated mortality in an otherwise futile situation. Liver dysfunction, inflammatory status and obesity increase the risk for mid-term mortality.ISSN:1010-7940ISSN:1873-734

Corrigendum to 'Retrospective 1-year outcome follow-up in 200 patients supported with HeartMate 3 and HeartWare left ventricular assist devices in a single centre' [Eur J Cardiothorac Surg 2020;57:1160-5

ISSN:1010-7940ISSN:1873-734

Retrospective 1-year outcome follow-up in 200 patients supported with HeartMate 3 and HeartWare left ventricular assist devices in a single centre

ISSN:1010-7940ISSN:1873-734

Results from a multicentre evaluation of plug use for left ventricular assist device explantation

OBJECTIVES Myocardial recovery allows for left ventricular assist device (LVAD) explantations after long-term support. Several surgical approaches, including interventional decommissioning, off-pump explantation using a custom-made plug and complete LVAD removal through redo sternotomy, have been described. We present the results from an evaluation of the long-term follow-up of patients who received a titanium sintered plug after LVAD explantation. METHODS We performed a retrospective, European, multicentre analysis of patients who received a titanium sintered plug to seal the apical fixation ring after LVAD explantation. Data were collected from a questionnaire that included demographics, procedural details and follow-up information. RESULTS Out of 54 contacted centres in 12 countries (n = 179 patients), a total of 68 patients were successfully included in the study. The median follow-up was 34 months (interquartile range: 17–58.5 months); 57 (84%) patients had >1-year follow-up. At the time of the last follow-up, 55 (81%) patients were alive, with a Kaplan–Meier 1-year survival of 90.1% (95% confidence interval: 84.0–98.1%) and a 5-year survival of 80.0% (95% confidence interval: 68.4–92.9%). One patient (1.5%) developed a plug infection originating from an infected part of the incorporated driveline and, after complete removal, is currently in good condition. No postoperative stroke has been reported after plug implantation. CONCLUSIONS In this European multicentre study, the use of a custom-made titanium plug to close the apical fixation ring after LVAD explantation resulted in a low incidence of plug-related complications. With the volume of patients undergoing LVAD explantations after myocardial recovery increasing, the plug has evolved as a simple alternative to more invasive device explantation procedures or decommissioning with a high risk for infection of the remaining system or stroke.ISSN:1569-9293ISSN:1569-928