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The Impact of LVAD Complications on Short-Term Outcomes after Heart Transplantation
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
and CP groups are shown below. No significant differences were observed in LDH or pf-Hb levels across any time point within 3 days of device implant. Conclusion: This is the first study to establish normative LDH and pf-Hb levels among patients receiving the Impella series of axial flow catheters for hemodynamic support. Clinically severe hemolysis was rare.
7( 19) Retained Blood Syndrome Impacts Outcomes after Left Ventricular Assist Device Implantation S. Maltais ,1 E.M. Boyle,2 M.E. Davis,3 J.M. Stulak,1 L.P. Perrault,4 N.A. Haglund.3 1Mayo Clinic, Rochester, MN; 2St-Charles Medical Center, Bend, OR; 3Vanderbilt, Nashville, TN; 4Montreal Heart, Montreal, QC, Canada. Purpose: Chest tubes are utilized to remove retained mediastinal blood in the early postoperative period. Inadequate blood evacuation often requires additional procedures to remove retained blood effusions. We sought to define retained blood syndrome (RBS) in patients undergoing LVAD implantation and its impact on outcomes. Methods: From March 2009 to September 2014, 77 patients (63 males; aged 53 years) underwent primary LVAD implantation. HeartMate II (HMII) was implanted in 49 patients (64%) and HeartWare VAD (HVAD) in 28 (36%). Composite retained blood complex (RBC) outcome consisted of reoperation or delayed closure for bleeding, pericardial or hemothorax drainage, or identification of pleural effusions. Patients with or without RBC were compared to assess differences in outcomes. Results: We observed a diagnosis of RBC in 39 patients (51%). Of these, 33 had re-exploration for bleeding leading in 26 delayed closure, 6 had hemothorax, 10 had drained pleural effusions, 3 had pericardial drainage, and 16 had placement of CT in the postoperative period (patients had multiple events). RBC incidence was comparable between devices (HMII: 25 of 49 (51%) vs. HVAD 13 of 28 (46%), p= 0.55). Preoperative characteristics were comparable between groups. RBC group had longer cardiopulmonary bypass time (116 vs. 87, p= 0.05). Patients with RBC had a statistically higher mortality (23% vs. 0%, p = 0.002). Early outcomes revealed RBC patients had higher total CT outputs (24 hours) (4.8L vs. 1.9L, p< 0.001). Patients with RBS were more likely to receive transfusions (87% vs. 53%, p< 0.001), and factor VII (20% vs. 0%, p= 0.004). RBC group had longer ICU stays (425 vs. 167 hours, p< 0.001), longer time on ventilation (30 vs. 9 hours, p< 0.001), and higher incidence of tracheostomy (33% vs. 0%, p= 0.006). RBC group had more complications (72% vs. 40%): higher incidence of renal failure/dialysis (26% vs. 0%, p< 0.001), more frequent tamponade (10% vs. 0%, p= 0.04), and increased arrhythmias (56% vs. 34%, p= 0.05). Total length of stay was longer in RBC group (28 vs. 22 days, p< 0.001). Conclusion: RBS is frequent after LVAD implantation and is associated with increased mortality and morbidity. Active blood clearance systems should be considered for this high-risk population to improve outcomes and reduce resource utilization. Larger randomized studies are needed to clarify the implications of RBS. 7( 20) RV Longitudinal Strain Predicts RV Failure and Other Adverse Events Post LVAD Implantation M. Gibson , F. Sliwinski, J. Silva, E. Adler. UC San Diego Medical Center, San Diego, CA.
Purpose: To determine the utility of preoperative RV function echocardiographic assessment in predicting post operative RV failure (RVF) and clinical outcomes in patients undergoing left ventricular assist device (LVAD) implantation. Methods: 65 consecutive patients were analyzed. Clinical, hemodynamic, and echocardiographic data at baseline and post LVAD implantation were retrospectively collected. RV failure was defined as the need for an RV assist device, use of iNO for more than 48h or use of intropic agents > 14 days. Standard assessment of RV function included qualitative and quantitative assessment, including RV free wall strain, Tricuspid Annular Plane Systolic Excursion (TAPSE) and severity of tricuspid regurgitation (TR). RV strain was calculated retrospectively using EchoInsight Epsilon Imaging software. Results: RV failure developed in 22 patients (34%). RV free wall longitudinal strain preoperatively was significantly associated with RV failure post-operatively (-9.9% +/- 5.0 in patients with RVF vs. -13.4%+/- 4.0 in patients without RVF, p= 0.002) whereas other markers of RV function were not (TAPSE, 1.2+/- 0.6 in patients with RVF vs 1.9+/-3.1 in patients without RVF, p = 0.25, Severity of TR, RVF vs no RVF: mild 12 (55%) vs 20(46%), moderate 6 (27%) vs 16(37%), severe 3(14%) vs 1(2.3%), p= 0.16). An RV strain ≥ -14.5 was predictive of RVF with a sensitivity of 81.8%, specificity of 39.5%, and negative predictive value of 81%. RV strain was associated with several other adverse clinical outcomes, including prolonged length of stay postoperatively and need for dialysis. Conclusion: Preoperative assessment of RV strain is a useful parameter for predicting adverse outcomes post LVAD. Other parameters of RV function such as severity of TR or TAPSE were not predictive of RV failure. Furthermore, RV strain could be quickly ascertained using software designed for this purpose, even if it was not calculated at the time of the echocardiogram.
7( 21) The Impact of LVAD Complications on Short-Term Outcomes after Heart Transplantation H. Shah ,1 M. Kahanda,1 J. Schilling,2 S. LaRue,2 J. Shuster,3 S. Sitner.3 1Internal Medicine, Barnes Jewish Hospital/Washington University, Saint Louis, MO; 2Cardiology, Barnes Jewish Hospital/ Washington University, Saint Louis, MO; 3Cardiology, Barnes Jewish Hospital, Saint Louis, MO. Purpose: LVADs play a critical role in supporting patients with end stage heart failure to transplant. Given the increased use of bridge to transplant LVADs, more patients awaiting an organ develop device complications leading to an upgrade in listing status. However, it remains unclear whether the presence of a device complication is a risk factor for worse outcomes early after transplant. Methods: We conducted a single center retrospective study of 188 patients who underwent heart transplant from 7/2009 to 1/2015. Of these, 51 (27%) had a LVAD complication (gastrointestinal bleeding, pump thrombosis/ failure, LVAD related infection, cerebrovascular accident, or LVAD related arrhythmia) leading to an upgrade of transplant listing status. We divided patients into those with LVAD complications (VAD-C) and all other transplants (n= 137). The primary outcome was hospital and ICU length of stay. Secondary outcomes included 1-year mortality, days on pressor and ventilator support, need for renal replacement therapy (RRT), and incidence of infection during index hospitalization.
Abstracts S265 Results: Prior to transplant, 125 patients (66%) were on LVAD support. The number of patients transplanted for LVAD complication increased from 3% in 2010 to 35% in 2014. With regard to the primary outcome, median hospital stay was 18 days for the VAD-C group and 16 days for the non-complication group (p= 0.18). Median ICU LOS was 7 days for both groups. For secondary outcomes, there was no difference in 1-year mortality, days on pressor/ventilator support, or incidence of infection during index hospitalization. There was a trend towards increased need for RRT in the VAD-C group compared to in the non-complication group with 43% vs. 28% requiring hemodialysis, respectively (p= 0.056). Conclusion: The number of patients undergoing heart transplant with a preceding LVAD complication is increasing over time. Although we hypothesized that LVAD complications would be associated with worse post-transplant outcomes, our findings suggest that these groups have similar rates of adverse events early after transplant. However, there may be an increased risk of renal failure requiring hemodialysis in those with prior LVAD complication. Additional analysis is warranted that includes larger numbers of patients to determine the impact of specific VAD complications on early and late post-transplant outcomes. 7( 22) Outflow Graft Obstruction of the Heart Ware HVAD Left Ventricular Assist Device: A Single Center Case Series R.K. Young , D.T. Majure, F.H. Sheikh, M.E. Rodrigo, G. Weigold, S.S. Najjar, S.W. Boyce. MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, MD. Purpose: LVAD malfunction is most commonly due to pump thrombosis. However, outflow graft obstruction (OGO) can also lead to impaired pump performance. The incidence of OGO in HVAD recipients is not well described. Methods: We conducted a retrospective review of all patients who received an HVAD at our Institution between 1/2010 and 9/2015. OGO was defined as any obstruction along the OG identified via imaging or surgical exploration. Results: A total of 162 HVADs were implanted during the study period. We identified 7 patients who had 8 OGO events. The mean time to development of OGO was 904±483 days. All patients presented with low flow alarms and only 1 patient had an elevation in LDH. All but 1 patient underwent high resolution Cardiac CT imaging, and 5 underwent cardiac catheterization. The etiologies of the OGO included stenosis at the outflow graft anastomotic site, intraluminal OG thrombus, and external compression of the graft. Treatment strategies included medical management, OG percutaneous stenting, LVAD exchange or surgical revision. There were 4 bleeding complications that were attributed to medical therapy. Five patients were alive at 6 months after the event, including 2 who required an LVAD exchange. Two patients died within 3 months after the OGO event. Conclusion: This is the first case series to describe OGO in patients with HVADs. In our single center experience, we observed a 4% incidence of OGO, that had several differing causes. OGO should be considered in patients presenting with low flows. Future studies should explore the optimal management strategies for these patients. 7( 23) Survival and Driveline Infection Rates in Patients on Chronic Immunosuppressive Therapy Who Undergo Left Ventricular Assist Device Implantation J.R. Spratt ,1 S. Roy,2 D. Plack,3 R. John,1 K. Liao,1 R.J. Cogswell.2 1Department of Surgery, University of Minnesota, Minneapolis, MN; 2Department of Medicine, University of Minnesota, Minneapolis, MN; 3University of Minnesota, Minneapolis, MN. Purpose: As use of LVADs for patients with end-stage heart failure grows, this therapy is now being considered in higher risk populations. There is a paucity of data on the outcomes of patients on chronic immunosuppressive therapy who have undergone LVAD implantation. Methods: A single center LVAD database (continuous flow, post 2005) was queried to identify patients on immunosuppressive therapy for greater than 1 month during LVAD support. For patients on chronic steroids, a dose greater than 20 mg daily for greater than 1 month was required for inclusion. Baseline characteristics were compared between immunosuppressed and immune competent patients. A Kaplan-Meier survival analysis was used to estimate survival in both groups. The cumulative incidence of driveline infection over the duration of LVAD support was also calculated.
Results: Of the 303 patients in our LVAD database, 19 patients were on chronic immunosuppression. The indications for immunosuppressive therapy were rheumatoid arthritis (5), other inflammatory arthritis (4), prior solid organ transplant (2 kidney, 1 heart), sarcoidosis (2), and inflammatory bowel disease (2). In this small sample, immunosuppressed patients did not differ significantly from immune competent subjects with regard to age, sex, BMI, INTERMACS score, diabetes status, or kidney function. Among the immunosuppressed patients, 7/19 (37%) were destination therapy vs. 60/283 (21%) in the immune competent group (p= 0.08). Among immunosuppressed patients, survival was 66% (95% CI: 39 - 83%) at 1 year and 49% (95% CI: 17-76%) at 4 years. Survival among immune competent patients was 81% (95% CI: 75-85%) at 1 year and 53% (95% CI: 44-61%) at 4 years, but the difference was not statistically significant (log rank p= 0.78). The incidence of driveline infection over 4 years of LVAD support was 29.4% in the immunosuppressed patients and 18.6% in immune competent patients (p= 0.27). Conclusion: The point estimates for mortality and cumulative infection were higher in patients on chronic immunosuppression after LVAD in this single center case series. However, this study was not powered to detect a statistically significant difference between the two groups. Larger scale studies are needed to fully understand the risks and outcomes of patients on chronic immunosuppression undergoing LVAD implantation. 7( 24) Fatal Flaw - Driveline Fracture as a Rare but Serious Complication of Mechanical Circulatory Support with Left Ventricular Assist Devices Y. Boyechko , T. Tribble, M. Guglin. Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY. Purpose: Both bridge-to-transplant and destination therapy patient populations have seen decreased 1-year mortality due to mechanical circulatory support with left ventricular assist devices (LVAD). Regardless of such outcomes, many complications still exist and remain a significant cause of morbidity and mortality. Our purpose is to study the prevalence, clinical course, and outcomes specifically of patients with LVAD driveline (DL) fractures. Methods: This single-center, retrospective review included all patients at our institution who experienced DL fracture/injury from January 2012 - September 2015. Results: Eleven of 140 LVAD patients (7.9%) had DL fractures (see Table). Time from implant to time of fracture was 21+/-15.9 months. The majority of fractures were external (64%), due to trauma (i.e. cut during dressing change). Internal injury, proximal to the cutaneous exit site, occurred in 36% of patients, usually due to unknown causes. Only one patient (9%) survived on LVAD support. One survived LVAD explant, another underwent pump exchange, and three others underwent heart transplantation. The remaining 5 expired. All patients with untreated internal fractures died (75%). Conclusion: Driveline fracture is a rare complication of LVAD and is often lethal when it occurs. Only one patient in our cohort survived without the need for heart transplant, LVAD exchange, or explant. Internal driveline fractures portend a very high mortality. Driveline fracture, especially one that cannot be promptly repaired or if internal fracture is suspected, requires immediate pump exchange or listing for heart transplant.
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
and CP groups are shown below. No significant differences were observed in LDH or pf-Hb levels across any time point within 3 days of device implant. Conclusion: This is the first study to establish normative LDH and pf-Hb levels among patients receiving the Impella series of axial flow catheters for hemodynamic support. Clinically severe hemolysis was rare.
7( 19) Retained Blood Syndrome Impacts Outcomes after Left Ventricular Assist Device Implantation S. Maltais ,1 E.M. Boyle,2 M.E. Davis,3 J.M. Stulak,1 L.P. Perrault,4 N.A. Haglund.3 1Mayo Clinic, Rochester, MN; 2St-Charles Medical Center, Bend, OR; 3Vanderbilt, Nashville, TN; 4Montreal Heart, Montreal, QC, Canada. Purpose: Chest tubes are utilized to remove retained mediastinal blood in the early postoperative period. Inadequate blood evacuation often requires additional procedures to remove retained blood effusions. We sought to define retained blood syndrome (RBS) in patients undergoing LVAD implantation and its impact on outcomes. Methods: From March 2009 to September 2014, 77 patients (63 males; aged 53 years) underwent primary LVAD implantation. HeartMate II (HMII) was implanted in 49 patients (64%) and HeartWare VAD (HVAD) in 28 (36%). Composite retained blood complex (RBC) outcome consisted of reoperation or delayed closure for bleeding, pericardial or hemothorax drainage, or identification of pleural effusions. Patients with or without RBC were compared to assess differences in outcomes. Results: We observed a diagnosis of RBC in 39 patients (51%). Of these, 33 had re-exploration for bleeding leading in 26 delayed closure, 6 had hemothorax, 10 had drained pleural effusions, 3 had pericardial drainage, and 16 had placement of CT in the postoperative period (patients had multiple events). RBC incidence was comparable between devices (HMII: 25 of 49 (51%) vs. HVAD 13 of 28 (46%), p= 0.55). Preoperative characteristics were comparable between groups. RBC group had longer cardiopulmonary bypass time (116 vs. 87, p= 0.05). Patients with RBC had a statistically higher mortality (23% vs. 0%, p = 0.002). Early outcomes revealed RBC patients had higher total CT outputs (24 hours) (4.8L vs. 1.9L, p< 0.001). Patients with RBS were more likely to receive transfusions (87% vs. 53%, p< 0.001), and factor VII (20% vs. 0%, p= 0.004). RBC group had longer ICU stays (425 vs. 167 hours, p< 0.001), longer time on ventilation (30 vs. 9 hours, p< 0.001), and higher incidence of tracheostomy (33% vs. 0%, p= 0.006). RBC group had more complications (72% vs. 40%): higher incidence of renal failure/dialysis (26% vs. 0%, p< 0.001), more frequent tamponade (10% vs. 0%, p= 0.04), and increased arrhythmias (56% vs. 34%, p= 0.05). Total length of stay was longer in RBC group (28 vs. 22 days, p< 0.001). Conclusion: RBS is frequent after LVAD implantation and is associated with increased mortality and morbidity. Active blood clearance systems should be considered for this high-risk population to improve outcomes and reduce resource utilization. Larger randomized studies are needed to clarify the implications of RBS. 7( 20) RV Longitudinal Strain Predicts RV Failure and Other Adverse Events Post LVAD Implantation M. Gibson , F. Sliwinski, J. Silva, E. Adler. UC San Diego Medical Center, San Diego, CA.
Purpose: To determine the utility of preoperative RV function echocardiographic assessment in predicting post operative RV failure (RVF) and clinical outcomes in patients undergoing left ventricular assist device (LVAD) implantation. Methods: 65 consecutive patients were analyzed. Clinical, hemodynamic, and echocardiographic data at baseline and post LVAD implantation were retrospectively collected. RV failure was defined as the need for an RV assist device, use of iNO for more than 48h or use of intropic agents > 14 days. Standard assessment of RV function included qualitative and quantitative assessment, including RV free wall strain, Tricuspid Annular Plane Systolic Excursion (TAPSE) and severity of tricuspid regurgitation (TR). RV strain was calculated retrospectively using EchoInsight Epsilon Imaging software. Results: RV failure developed in 22 patients (34%). RV free wall longitudinal strain preoperatively was significantly associated with RV failure post-operatively (-9.9% +/- 5.0 in patients with RVF vs. -13.4%+/- 4.0 in patients without RVF, p= 0.002) whereas other markers of RV function were not (TAPSE, 1.2+/- 0.6 in patients with RVF vs 1.9+/-3.1 in patients without RVF, p = 0.25, Severity of TR, RVF vs no RVF: mild 12 (55%) vs 20(46%), moderate 6 (27%) vs 16(37%), severe 3(14%) vs 1(2.3%), p= 0.16). An RV strain ≥ -14.5 was predictive of RVF with a sensitivity of 81.8%, specificity of 39.5%, and negative predictive value of 81%. RV strain was associated with several other adverse clinical outcomes, including prolonged length of stay postoperatively and need for dialysis. Conclusion: Preoperative assessment of RV strain is a useful parameter for predicting adverse outcomes post LVAD. Other parameters of RV function such as severity of TR or TAPSE were not predictive of RV failure. Furthermore, RV strain could be quickly ascertained using software designed for this purpose, even if it was not calculated at the time of the echocardiogram.
7( 21) The Impact of LVAD Complications on Short-Term Outcomes after Heart Transplantation H. Shah ,1 M. Kahanda,1 J. Schilling,2 S. LaRue,2 J. Shuster,3 S. Sitner.3 1Internal Medicine, Barnes Jewish Hospital/Washington University, Saint Louis, MO; 2Cardiology, Barnes Jewish Hospital/ Washington University, Saint Louis, MO; 3Cardiology, Barnes Jewish Hospital, Saint Louis, MO. Purpose: LVADs play a critical role in supporting patients with end stage heart failure to transplant. Given the increased use of bridge to transplant LVADs, more patients awaiting an organ develop device complications leading to an upgrade in listing status. However, it remains unclear whether the presence of a device complication is a risk factor for worse outcomes early after transplant. Methods: We conducted a single center retrospective study of 188 patients who underwent heart transplant from 7/2009 to 1/2015. Of these, 51 (27%) had a LVAD complication (gastrointestinal bleeding, pump thrombosis/ failure, LVAD related infection, cerebrovascular accident, or LVAD related arrhythmia) leading to an upgrade of transplant listing status. We divided patients into those with LVAD complications (VAD-C) and all other transplants (n= 137). The primary outcome was hospital and ICU length of stay. Secondary outcomes included 1-year mortality, days on pressor and ventilator support, need for renal replacement therapy (RRT), and incidence of infection during index hospitalization.
Abstracts S265 Results: Prior to transplant, 125 patients (66%) were on LVAD support. The number of patients transplanted for LVAD complication increased from 3% in 2010 to 35% in 2014. With regard to the primary outcome, median hospital stay was 18 days for the VAD-C group and 16 days for the non-complication group (p= 0.18). Median ICU LOS was 7 days for both groups. For secondary outcomes, there was no difference in 1-year mortality, days on pressor/ventilator support, or incidence of infection during index hospitalization. There was a trend towards increased need for RRT in the VAD-C group compared to in the non-complication group with 43% vs. 28% requiring hemodialysis, respectively (p= 0.056). Conclusion: The number of patients undergoing heart transplant with a preceding LVAD complication is increasing over time. Although we hypothesized that LVAD complications would be associated with worse post-transplant outcomes, our findings suggest that these groups have similar rates of adverse events early after transplant. However, there may be an increased risk of renal failure requiring hemodialysis in those with prior LVAD complication. Additional analysis is warranted that includes larger numbers of patients to determine the impact of specific VAD complications on early and late post-transplant outcomes. 7( 22) Outflow Graft Obstruction of the Heart Ware HVAD Left Ventricular Assist Device: A Single Center Case Series R.K. Young , D.T. Majure, F.H. Sheikh, M.E. Rodrigo, G. Weigold, S.S. Najjar, S.W. Boyce. MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, MD. Purpose: LVAD malfunction is most commonly due to pump thrombosis. However, outflow graft obstruction (OGO) can also lead to impaired pump performance. The incidence of OGO in HVAD recipients is not well described. Methods: We conducted a retrospective review of all patients who received an HVAD at our Institution between 1/2010 and 9/2015. OGO was defined as any obstruction along the OG identified via imaging or surgical exploration. Results: A total of 162 HVADs were implanted during the study period. We identified 7 patients who had 8 OGO events. The mean time to development of OGO was 904±483 days. All patients presented with low flow alarms and only 1 patient had an elevation in LDH. All but 1 patient underwent high resolution Cardiac CT imaging, and 5 underwent cardiac catheterization. The etiologies of the OGO included stenosis at the outflow graft anastomotic site, intraluminal OG thrombus, and external compression of the graft. Treatment strategies included medical management, OG percutaneous stenting, LVAD exchange or surgical revision. There were 4 bleeding complications that were attributed to medical therapy. Five patients were alive at 6 months after the event, including 2 who required an LVAD exchange. Two patients died within 3 months after the OGO event. Conclusion: This is the first case series to describe OGO in patients with HVADs. In our single center experience, we observed a 4% incidence of OGO, that had several differing causes. OGO should be considered in patients presenting with low flows. Future studies should explore the optimal management strategies for these patients. 7( 23) Survival and Driveline Infection Rates in Patients on Chronic Immunosuppressive Therapy Who Undergo Left Ventricular Assist Device Implantation J.R. Spratt ,1 S. Roy,2 D. Plack,3 R. John,1 K. Liao,1 R.J. Cogswell.2 1Department of Surgery, University of Minnesota, Minneapolis, MN; 2Department of Medicine, University of Minnesota, Minneapolis, MN; 3University of Minnesota, Minneapolis, MN. Purpose: As use of LVADs for patients with end-stage heart failure grows, this therapy is now being considered in higher risk populations. There is a paucity of data on the outcomes of patients on chronic immunosuppressive therapy who have undergone LVAD implantation. Methods: A single center LVAD database (continuous flow, post 2005) was queried to identify patients on immunosuppressive therapy for greater than 1 month during LVAD support. For patients on chronic steroids, a dose greater than 20 mg daily for greater than 1 month was required for inclusion. Baseline characteristics were compared between immunosuppressed and immune competent patients. A Kaplan-Meier survival analysis was used to estimate survival in both groups. The cumulative incidence of driveline infection over the duration of LVAD support was also calculated.
Results: Of the 303 patients in our LVAD database, 19 patients were on chronic immunosuppression. The indications for immunosuppressive therapy were rheumatoid arthritis (5), other inflammatory arthritis (4), prior solid organ transplant (2 kidney, 1 heart), sarcoidosis (2), and inflammatory bowel disease (2). In this small sample, immunosuppressed patients did not differ significantly from immune competent subjects with regard to age, sex, BMI, INTERMACS score, diabetes status, or kidney function. Among the immunosuppressed patients, 7/19 (37%) were destination therapy vs. 60/283 (21%) in the immune competent group (p= 0.08). Among immunosuppressed patients, survival was 66% (95% CI: 39 - 83%) at 1 year and 49% (95% CI: 17-76%) at 4 years. Survival among immune competent patients was 81% (95% CI: 75-85%) at 1 year and 53% (95% CI: 44-61%) at 4 years, but the difference was not statistically significant (log rank p= 0.78). The incidence of driveline infection over 4 years of LVAD support was 29.4% in the immunosuppressed patients and 18.6% in immune competent patients (p= 0.27). Conclusion: The point estimates for mortality and cumulative infection were higher in patients on chronic immunosuppression after LVAD in this single center case series. However, this study was not powered to detect a statistically significant difference between the two groups. Larger scale studies are needed to fully understand the risks and outcomes of patients on chronic immunosuppression undergoing LVAD implantation. 7( 24) Fatal Flaw - Driveline Fracture as a Rare but Serious Complication of Mechanical Circulatory Support with Left Ventricular Assist Devices Y. Boyechko , T. Tribble, M. Guglin. Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY. Purpose: Both bridge-to-transplant and destination therapy patient populations have seen decreased 1-year mortality due to mechanical circulatory support with left ventricular assist devices (LVAD). Regardless of such outcomes, many complications still exist and remain a significant cause of morbidity and mortality. Our purpose is to study the prevalence, clinical course, and outcomes specifically of patients with LVAD driveline (DL) fractures. Methods: This single-center, retrospective review included all patients at our institution who experienced DL fracture/injury from January 2012 - September 2015. Results: Eleven of 140 LVAD patients (7.9%) had DL fractures (see Table). Time from implant to time of fracture was 21+/-15.9 months. The majority of fractures were external (64%), due to trauma (i.e. cut during dressing change). Internal injury, proximal to the cutaneous exit site, occurred in 36% of patients, usually due to unknown causes. Only one patient (9%) survived on LVAD support. One survived LVAD explant, another underwent pump exchange, and three others underwent heart transplantation. The remaining 5 expired. All patients with untreated internal fractures died (75%). Conclusion: Driveline fracture is a rare complication of LVAD and is often lethal when it occurs. Only one patient in our cohort survived without the need for heart transplant, LVAD exchange, or explant. Internal driveline fractures portend a very high mortality. Driveline fracture, especially one that cannot be promptly repaired or if internal fracture is suspected, requires immediate pump exchange or listing for heart transplant.