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192: Predictors of Improvement in Right Ventricular Function after Placement of a Left Ventricular Assist Device
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
arrhythmias that were treated either by the ICD (7) or required external defibrillation (1, non-ICD patient). In 2 of the 8 patients the arrhythmia was asymptomatic but detected and treated by the ICD. In total the ICDs delivered 16 shocks to 4 patients. There were no inappropriate shocks. In one patient repeated ventricular tachycardia was treated by anti-tachy pacing alone. An episode of VT storm required radiofrequency ablation of an LV tachycardia in one patient. Conclusions: More than 1/3 of the patients on HMII had ventricular arrhythmias requiring treatment, and arrhythmias causing hemodynamic instability did occur. In 25% of the patients with events the arrhythmia did not cause symptoms. Prophylactic ICD implantation in patients supported with a continuous flow LVAD remains a standard treatment at our center.
192 Predictors of Improvement in Right Ventricular Function after Placement of a Left Ventricular Assist Device B.A. Boilson1, J.A. Schirger, I. Penev2, S.S. Kushwaha1, C.G.A. McGregor2, R.C. Daly2, L.C. Durham2, B.S. Edwards1, S.J. Park2 1Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN Purpose: End stage heart failure is increasing in prevalence and left ventricular assist device (LVAD) technology being used increasingly as a bridge to transplantation and also as destination therapy. Although LVAD placement is followed by left ventricular offloading and increase in systemic cardiac output, persistent right ventricular (RV) dysfunction is common.The aim of this study was to investigate the baseline characteristics which contribute most to improvement in right ventricular dysfunction after LVAD placement. Methods and Materials: All patients who underwent LVAD implantation at out institution between May 2003 and July 2008 were evaluated. The primary endpoint was improvement in RV function measured by echo. Secondary endpoints were improvement in measures of pulmonary hypertension by right heart catheterization and echo. Both bridge to transplant and destination therapy patients were included. Both continuous flow and pulsatile devices were included. Results: Fifty-seven patients were studied for a mean 230.5 days. The most powerful predictors of improvement in right ventricular function at last followup were baseline severity of mitral valve regurgitation (MR) (p⫽0.0006, R⫽-0.51), tricuspid valve regurgitation (TR) (p⫽0.01, R⫽-0.39) and pulmonary vascular resistance (PVR) (p⫽0.006, R⫽-0.42). Similarly, improvement in pulmonary hypertension was predicted by baseline MR (p⫽0.005, R⫽0.4), PCWP (p⫽0.002, R⫽0.44) and PVR (p⬍0.0001, R⫽0.53). Predictors of change in PVR were baseline PA pressure (p⫽0.0002, R⫽-0.5), MR severity (p⫽0.05, R⫽0.28) and PVR at baseline (p⬍0.0001, R⫽0.9). Conclusions: Improvement in RV function improves most after LVAD insertion when it occurs in the setting of severe MR. Dramatic offloading of the left ventricle and reduction in MR severity in these patients post LVAD placement results in a significant drop in RV afterload and PVR which facilitates recovery of RV function. RV dysfunction present at baseline in the absence of significant MR may not improve to the same degree post LVAD placement. 193 Long-Term Support with a Bi-Ventricular Assist Device – A Single Center Experience P. Sfirakis1, A. Gkouziouta2, L. Tsourelis1, D. Zarkalis1, E. Leontiadis3, L. Louca1, G. Stavridis1, P.A. Alivizatos1 1Onassis Cardiac Surgery Center, Athens, Greece; 2Onassis Cardiac Surgery Center, Athens, Greece; 3Onassis Cardiac Surgery Center, Athens, Greece
Abstracts
S133
Purpose: Low organ donation combined with delayed referral of advanced-stage cardiomyopathy patients necessitates biventricular assist device (BiVAD) support for extended periods of time. Reliable devices and close patient follow-up increase the survival likelihood. We report our experience with the Berlin Heart Excor BiVAD. Methods and Materials: Twenty one biventricular Berlin Heart Excor devices have been implanted since 2004. Patients’ ages ranged from 11 to 56 years (median age 40 years). Diagnoses included dilated (81%), ischemic (15%) and restrictive (4%) cardiomyopathies. All patients presented in severe biventricular failure (intravenous inotropes, 21; ventilated, 3; IABP, 13; mean: CI 1.9 L/min/m2; CVP 19 mmHg; total bilirubin 3.75 mg/dl; NT-proBNP, 25,500 pg/ml). Two patients needed a BiVAD after left ventricular assist device support of 439 and 295 days, respectively. Anticoagulation consisted of heparin, Vitamin K antagonist, aspirin, dipyridamole and occasionally clopidogrel. Results: Thirty day, 180 day, and 1 year survival after implantation (excluding transplanted patients) was 95%, 87% and 82% respectively. Thirteen patients (62%) were transplanted (11/13 successfully), and 5 (24%) are ongoing. Mean time on support was 319 days and 17 out of 18 (94%) patients with adult-sized pumps were discharged home with a mobile driver. One patient exceeded 2 years of uncomplicated support before he was transplanted. Nine patients were on support for ⬎1 year. One patient with renal failure and dialysis dependence lives at home 1.5 years after implantation. Complications included infection (n ⫽ 6), bleeding requiring reexploration (n⫽3), and thromboembolic events (n ⫽ 4). Three patients died, 1 of an accidentally ruptured cannula (after 365 days), 1 of multiorgan system failure (119 days), and 1 of sepsis (18 days). Conclusions: Reliability of components and strict utilization of patient-care protocols leads to excellent survival in this extremely sick population. Meticulous multi-disciplinary management by experienced personnel is essential. 194 Effect of Continuous Flow Left Ventricular Assist Devices on Left Ventricular Size and Severity of Mitral Regurgitation S.A. Mandras, S. Joseph, I.M. Saeed, T.J. Guthrie, S.V. Arnold, I.-W. Wang, N. Moazami, G.A. Ewald Washington University in Saint Louis, Saint Louis, MO Purpose: Pulsatile Ventricular Assist Devices (VADs) allow for maximum unloading of the left ventricle (LV) and offer the potential for ventricular recovery because of their mode of operation. In contrast, little data exists regarding the effect of continuous flow pumps on LV unloading and reverse remodeling. The purpose of this study was to investigate the effect of continuous flow rotary devices on LV size and severity of mitral regurgitation (MR). Methods and Materials: Echocardiograms were reviewed in 21 patients (8 ischemic, 13 nonischemic) implanted with Heartmate II (n⫽14) and Ventrassist (n⫽7) LVADs. Mean time from heart failure diagnosis to VAD placement was 3.3 years. Left ventricular enddiastolic diameters (LVEDD) and MR severity were compared from baseline to 1 and 6 months after VAD placement using paired t-test and chi-square respectively. Results: The use of the continuous flow VADs resulted in a reduction in LVEDD at 1 month post VAD from 6.83 ⫾ 1.31 to 5.52 ⫾ 1.36 (p⫽0.0001). In the 12 patients who reached 6 month follow up (11 Heartmate II, 1 Ventrassist), this reduction was maintained (p⫽0.025). MR severity was also reduced at 1 month, and maintained at 6 months (p⫽ 0.0034 and 0.0014 respectively.) Conclusions: Continuous flow VADs result in an early improvement in LV size and MR severity which appears to be sustained without further change up to 6 months after VAD placement. Further research is needed to determine if these echocardiographic indicators of reverse remodeling correlate with clinical recovery.
arrhythmias that were treated either by the ICD (7) or required external defibrillation (1, non-ICD patient). In 2 of the 8 patients the arrhythmia was asymptomatic but detected and treated by the ICD. In total the ICDs delivered 16 shocks to 4 patients. There were no inappropriate shocks. In one patient repeated ventricular tachycardia was treated by anti-tachy pacing alone. An episode of VT storm required radiofrequency ablation of an LV tachycardia in one patient. Conclusions: More than 1/3 of the patients on HMII had ventricular arrhythmias requiring treatment, and arrhythmias causing hemodynamic instability did occur. In 25% of the patients with events the arrhythmia did not cause symptoms. Prophylactic ICD implantation in patients supported with a continuous flow LVAD remains a standard treatment at our center.
192 Predictors of Improvement in Right Ventricular Function after Placement of a Left Ventricular Assist Device B.A. Boilson1, J.A. Schirger, I. Penev2, S.S. Kushwaha1, C.G.A. McGregor2, R.C. Daly2, L.C. Durham2, B.S. Edwards1, S.J. Park2 1Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN Purpose: End stage heart failure is increasing in prevalence and left ventricular assist device (LVAD) technology being used increasingly as a bridge to transplantation and also as destination therapy. Although LVAD placement is followed by left ventricular offloading and increase in systemic cardiac output, persistent right ventricular (RV) dysfunction is common.The aim of this study was to investigate the baseline characteristics which contribute most to improvement in right ventricular dysfunction after LVAD placement. Methods and Materials: All patients who underwent LVAD implantation at out institution between May 2003 and July 2008 were evaluated. The primary endpoint was improvement in RV function measured by echo. Secondary endpoints were improvement in measures of pulmonary hypertension by right heart catheterization and echo. Both bridge to transplant and destination therapy patients were included. Both continuous flow and pulsatile devices were included. Results: Fifty-seven patients were studied for a mean 230.5 days. The most powerful predictors of improvement in right ventricular function at last followup were baseline severity of mitral valve regurgitation (MR) (p⫽0.0006, R⫽-0.51), tricuspid valve regurgitation (TR) (p⫽0.01, R⫽-0.39) and pulmonary vascular resistance (PVR) (p⫽0.006, R⫽-0.42). Similarly, improvement in pulmonary hypertension was predicted by baseline MR (p⫽0.005, R⫽0.4), PCWP (p⫽0.002, R⫽0.44) and PVR (p⬍0.0001, R⫽0.53). Predictors of change in PVR were baseline PA pressure (p⫽0.0002, R⫽-0.5), MR severity (p⫽0.05, R⫽0.28) and PVR at baseline (p⬍0.0001, R⫽0.9). Conclusions: Improvement in RV function improves most after LVAD insertion when it occurs in the setting of severe MR. Dramatic offloading of the left ventricle and reduction in MR severity in these patients post LVAD placement results in a significant drop in RV afterload and PVR which facilitates recovery of RV function. RV dysfunction present at baseline in the absence of significant MR may not improve to the same degree post LVAD placement. 193 Long-Term Support with a Bi-Ventricular Assist Device – A Single Center Experience P. Sfirakis1, A. Gkouziouta2, L. Tsourelis1, D. Zarkalis1, E. Leontiadis3, L. Louca1, G. Stavridis1, P.A. Alivizatos1 1Onassis Cardiac Surgery Center, Athens, Greece; 2Onassis Cardiac Surgery Center, Athens, Greece; 3Onassis Cardiac Surgery Center, Athens, Greece
Abstracts
S133
Purpose: Low organ donation combined with delayed referral of advanced-stage cardiomyopathy patients necessitates biventricular assist device (BiVAD) support for extended periods of time. Reliable devices and close patient follow-up increase the survival likelihood. We report our experience with the Berlin Heart Excor BiVAD. Methods and Materials: Twenty one biventricular Berlin Heart Excor devices have been implanted since 2004. Patients’ ages ranged from 11 to 56 years (median age 40 years). Diagnoses included dilated (81%), ischemic (15%) and restrictive (4%) cardiomyopathies. All patients presented in severe biventricular failure (intravenous inotropes, 21; ventilated, 3; IABP, 13; mean: CI 1.9 L/min/m2; CVP 19 mmHg; total bilirubin 3.75 mg/dl; NT-proBNP, 25,500 pg/ml). Two patients needed a BiVAD after left ventricular assist device support of 439 and 295 days, respectively. Anticoagulation consisted of heparin, Vitamin K antagonist, aspirin, dipyridamole and occasionally clopidogrel. Results: Thirty day, 180 day, and 1 year survival after implantation (excluding transplanted patients) was 95%, 87% and 82% respectively. Thirteen patients (62%) were transplanted (11/13 successfully), and 5 (24%) are ongoing. Mean time on support was 319 days and 17 out of 18 (94%) patients with adult-sized pumps were discharged home with a mobile driver. One patient exceeded 2 years of uncomplicated support before he was transplanted. Nine patients were on support for ⬎1 year. One patient with renal failure and dialysis dependence lives at home 1.5 years after implantation. Complications included infection (n ⫽ 6), bleeding requiring reexploration (n⫽3), and thromboembolic events (n ⫽ 4). Three patients died, 1 of an accidentally ruptured cannula (after 365 days), 1 of multiorgan system failure (119 days), and 1 of sepsis (18 days). Conclusions: Reliability of components and strict utilization of patient-care protocols leads to excellent survival in this extremely sick population. Meticulous multi-disciplinary management by experienced personnel is essential. 194 Effect of Continuous Flow Left Ventricular Assist Devices on Left Ventricular Size and Severity of Mitral Regurgitation S.A. Mandras, S. Joseph, I.M. Saeed, T.J. Guthrie, S.V. Arnold, I.-W. Wang, N. Moazami, G.A. Ewald Washington University in Saint Louis, Saint Louis, MO Purpose: Pulsatile Ventricular Assist Devices (VADs) allow for maximum unloading of the left ventricle (LV) and offer the potential for ventricular recovery because of their mode of operation. In contrast, little data exists regarding the effect of continuous flow pumps on LV unloading and reverse remodeling. The purpose of this study was to investigate the effect of continuous flow rotary devices on LV size and severity of mitral regurgitation (MR). Methods and Materials: Echocardiograms were reviewed in 21 patients (8 ischemic, 13 nonischemic) implanted with Heartmate II (n⫽14) and Ventrassist (n⫽7) LVADs. Mean time from heart failure diagnosis to VAD placement was 3.3 years. Left ventricular enddiastolic diameters (LVEDD) and MR severity were compared from baseline to 1 and 6 months after VAD placement using paired t-test and chi-square respectively. Results: The use of the continuous flow VADs resulted in a reduction in LVEDD at 1 month post VAD from 6.83 ⫾ 1.31 to 5.52 ⫾ 1.36 (p⫽0.0001). In the 12 patients who reached 6 month follow up (11 Heartmate II, 1 Ventrassist), this reduction was maintained (p⫽0.025). MR severity was also reduced at 1 month, and maintained at 6 months (p⫽ 0.0034 and 0.0014 respectively.) Conclusions: Continuous flow VADs result in an early improvement in LV size and MR severity which appears to be sustained without further change up to 6 months after VAD placement. Further research is needed to determine if these echocardiographic indicators of reverse remodeling correlate with clinical recovery.