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606: Mechanical Circulatory Support in Patients with Heart Failure Secondary to Transposition of the Great Arteries
S276
Abstracts
The Journal of Heart and Lung Transplantation February 2009
Conclusions: Aggressive antibiotic treatment is not adequate in VAD infection due to MDR nosococomial pathogens. Heart transplantation, even at a pre-terminal stage, may offer reasonable chances of success. Patients’ Characteristics Patients
Infection Sites
MDR Pathogen
Treatment
Outcomes
HeartMate Pocket Acinetobacter Tygecycline/Colimycin TransplantedXVE Infection/Peritonitis/ baumanii Alive and well 22y.o Endocarditis Berlin Heart Pocket Infection/ Stenotrophomonas Tygecycline/TM/SMX TransplantedExcor Septicemia maltophilia Alive and well BiVAD45 y.o Berlin Heart Endocarditis Klebsiella Colimycin/Garamycin/ Transplanted/Excor Pneumoniae/ Tygecycline Alive and well BiVAD Ps.Aeruginosa 19y.o Novacor 23 Septicemia/ Acinetobacter Tygecycline/ Died y.o. Endocarditis baumanii Colimycin Berlin Heart Mediastinitis Candida Voriconazole/ TransplantedExcor parapsilosis Amphotericin B Alive and well BiVAD 46 y.o
605 Assessment of Recovery on Ventricular Assist Device Support C. Irving, J. Cassidy, R. Kirk, M. Griselli, A. Hasan, D. Crossland Freeman Hospital, Newcastle upon Tyne, United Kingdom Purpose: Ventricular assist device (VAD) aid to recovery is increasingly described although there is little data on assessment of improvement. We aimed to report our results in children explanted from the Berlin Heart Excor®VAD and review criteria of successful outcome. Methods and Materials: We reviewed clinical, histological data and results of our protocol for assessment of children who underwent elective VAD removal. Detailed echocardiograms are carried out monthly with VAD paused and when there is subjective evidence of near normal function a stress test is performed. This comprises echocardiogram with inotrope challenge in infants(⫹/- invasive haemodynamic monitoring)and previously, echocardiogram with exercise challenge alone in older children. Results: 16 children have been supported with the Berlin Heart Excor®VAD in our institution since 2005. 4 showed sufficient improvement for explantation. All had been ventilated on maximal inotropes. Our first was a 13 year old placed on VAD after mitral valve replacement. Histology showed fibrosis. She maintained her blood pressure (BP), with appropriate heart rate (HR) rise on exercise and was explanted after 107 days. She died 2 days later of low output cardiac failure. 3 children ages 16, 13 and 48 months with primary myocardial disease(2 myocarditis/1 cardiomyopathy, all with no fibrosis on histology)sustained cardiac output and function for an hour with VAD paused and hand pumped. There was appropriate increased HR, mean BP and contractility with dobutamine/isoprenaline. All had successful VAD removal after support times of 120, 67 and 50 days respectively. Cardiac function in all continued to improve and they are no longer listed for transplant. Conclusions: Long term support to recovery is achievable even in small children. In our early experience, primary myocardial disease without histological fibrosis and normal inotropic response appears to predict favourable outcome. Although exercise challenge in adults is well described to predict suitability for VAD removal we intend to include an inotrope challenge in children prior to explantation. 606 Mechanical Circulatory Support in Patients with Heart Failure Secondary to Transposition of the Great Arteries D.L. Joyce1, S.S. Crow2, J.D. St.Louis3, E.A. Braunlin4, L.A. Pyles4, P. Kofflin4, L.D. Joyce3 1Stanford University, Palo Alto, CA; 2Mayo Clinic, Rochester, MN; 3University of Minnesota, Minneapolis, MN; 4 University of Minnesota, Minneapolis, MN
Purpose: Advances in the palliation of congenital heart disease have resulted in more children surviving to adulthood. Many of these adults ultimately develop end stage heart failure with cardiac transplantation as their only option for continued survival. With the scarcity of donor organs, the prospect of using ventricular assist devices as a bridge to transplantation is appealing. Adapting an LVAD designed for the normal anatomical heart, to the anatomy of the heart with transposition of the great vessels requires creativity and an understanding of the potential anatomic obstacles to cannula placement. We report on the evolution of our surgical technique for implanting continuous flow LVADs (1 DeBakey, 2 HeartMate II) in three patients with TGA (one congenitally corrected ccTGA and two surgically corrected dTGA). Methods and Materials: Applying the standard left ventricle cannulation technique to the right ventricle led us too anteriorly in our first case creating obstruction by the huge trabeculae and moderator band. Division of the moderator band was helpful, but the cannula obstruction persisted from the anterior papillary muscle to the tricuspid valve and required repositioning of the pump. Subsequent use of epicardial ECHO as well as transesophageal ECHO allowed for intra-operative localization of the moderator bands and papillary muscles and identification of the optimal cannulation site. This location is usually much more on the diaphragmatic surface of the right ventricle than one would expect. Results: The acute angle of the inflow cannula on the DeBakey LVAD required flipping the device 180 degrees. The HeartMate II device could be shifted towards the midline. One patient was successfully transplanted and two are home waiting for a donor organ. Conclusions: The left ventricular assist device offers additional options for adults with congenital heart disease who experience end stage cardiac failure. Echocardiography guidance to optimal LVAD cannula placement ensures successful cardiac support for patients with surgically palliated TGA. 607 Use of a CardioWest TAH-t for High Risk Patients Reduces Complications and Improves Survival M. Flattery, L. Ohler, K. Doolin, M. Hess, R. Cooke, S. Harton, V. Kasirajan Virginia Commonwealth University Health System, Richmond, VA Purpose: Evaluating risk as part of patient selection for mechanical circulatory assist devices (MCAD) can be an effective method for predicting mortality and morbidity in patients with end stage heart failure. The purpose of this retrospective analysis was to determine the effectiveness of a risk assessment tool to predict outcomes of patients requiring MCAD. Methods and Materials: Twenty-five patients received implants with either a left ventricular assist device (LVAD) or total artificial heart (TAH-t) between January 2006 and September 2008. The risk assessment tool, which was validated in the post REMATCH era, assigns weights to 13 biologic and hemodynamic factors including platelet count, body surface area, creatinine clearance, white blood cell count, mean pulmonary artery pressure, INR, serum albumin, hematocrit, serum transaminase, history of arrhythmia, and the use of vasodilator, inotropic or beta blocker therapy. Data were extracted from medical records. Values included for analysis were obtained within 72 hours prior to device implant. To determine if the tool could be used effectively to predict outcomes, we compared the risk assessment scores of the 25 patients implanted with an LVAD or TAH-t. Results: Eleven patients received the CardioWest TAH-t, 13 patients were implanted with the Thoratec Heartmate XVE and 1 patient with the Jarvik 2000. Fifty-four percent of the LVAD patients were classified as high risk and 57% of the TAH-t patients were classified as high
Abstracts
The Journal of Heart and Lung Transplantation February 2009
Conclusions: Aggressive antibiotic treatment is not adequate in VAD infection due to MDR nosococomial pathogens. Heart transplantation, even at a pre-terminal stage, may offer reasonable chances of success. Patients’ Characteristics Patients
Infection Sites
MDR Pathogen
Treatment
Outcomes
HeartMate Pocket Acinetobacter Tygecycline/Colimycin TransplantedXVE Infection/Peritonitis/ baumanii Alive and well 22y.o Endocarditis Berlin Heart Pocket Infection/ Stenotrophomonas Tygecycline/TM/SMX TransplantedExcor Septicemia maltophilia Alive and well BiVAD45 y.o Berlin Heart Endocarditis Klebsiella Colimycin/Garamycin/ Transplanted/Excor Pneumoniae/ Tygecycline Alive and well BiVAD Ps.Aeruginosa 19y.o Novacor 23 Septicemia/ Acinetobacter Tygecycline/ Died y.o. Endocarditis baumanii Colimycin Berlin Heart Mediastinitis Candida Voriconazole/ TransplantedExcor parapsilosis Amphotericin B Alive and well BiVAD 46 y.o
605 Assessment of Recovery on Ventricular Assist Device Support C. Irving, J. Cassidy, R. Kirk, M. Griselli, A. Hasan, D. Crossland Freeman Hospital, Newcastle upon Tyne, United Kingdom Purpose: Ventricular assist device (VAD) aid to recovery is increasingly described although there is little data on assessment of improvement. We aimed to report our results in children explanted from the Berlin Heart Excor®VAD and review criteria of successful outcome. Methods and Materials: We reviewed clinical, histological data and results of our protocol for assessment of children who underwent elective VAD removal. Detailed echocardiograms are carried out monthly with VAD paused and when there is subjective evidence of near normal function a stress test is performed. This comprises echocardiogram with inotrope challenge in infants(⫹/- invasive haemodynamic monitoring)and previously, echocardiogram with exercise challenge alone in older children. Results: 16 children have been supported with the Berlin Heart Excor®VAD in our institution since 2005. 4 showed sufficient improvement for explantation. All had been ventilated on maximal inotropes. Our first was a 13 year old placed on VAD after mitral valve replacement. Histology showed fibrosis. She maintained her blood pressure (BP), with appropriate heart rate (HR) rise on exercise and was explanted after 107 days. She died 2 days later of low output cardiac failure. 3 children ages 16, 13 and 48 months with primary myocardial disease(2 myocarditis/1 cardiomyopathy, all with no fibrosis on histology)sustained cardiac output and function for an hour with VAD paused and hand pumped. There was appropriate increased HR, mean BP and contractility with dobutamine/isoprenaline. All had successful VAD removal after support times of 120, 67 and 50 days respectively. Cardiac function in all continued to improve and they are no longer listed for transplant. Conclusions: Long term support to recovery is achievable even in small children. In our early experience, primary myocardial disease without histological fibrosis and normal inotropic response appears to predict favourable outcome. Although exercise challenge in adults is well described to predict suitability for VAD removal we intend to include an inotrope challenge in children prior to explantation. 606 Mechanical Circulatory Support in Patients with Heart Failure Secondary to Transposition of the Great Arteries D.L. Joyce1, S.S. Crow2, J.D. St.Louis3, E.A. Braunlin4, L.A. Pyles4, P. Kofflin4, L.D. Joyce3 1Stanford University, Palo Alto, CA; 2Mayo Clinic, Rochester, MN; 3University of Minnesota, Minneapolis, MN; 4 University of Minnesota, Minneapolis, MN
Purpose: Advances in the palliation of congenital heart disease have resulted in more children surviving to adulthood. Many of these adults ultimately develop end stage heart failure with cardiac transplantation as their only option for continued survival. With the scarcity of donor organs, the prospect of using ventricular assist devices as a bridge to transplantation is appealing. Adapting an LVAD designed for the normal anatomical heart, to the anatomy of the heart with transposition of the great vessels requires creativity and an understanding of the potential anatomic obstacles to cannula placement. We report on the evolution of our surgical technique for implanting continuous flow LVADs (1 DeBakey, 2 HeartMate II) in three patients with TGA (one congenitally corrected ccTGA and two surgically corrected dTGA). Methods and Materials: Applying the standard left ventricle cannulation technique to the right ventricle led us too anteriorly in our first case creating obstruction by the huge trabeculae and moderator band. Division of the moderator band was helpful, but the cannula obstruction persisted from the anterior papillary muscle to the tricuspid valve and required repositioning of the pump. Subsequent use of epicardial ECHO as well as transesophageal ECHO allowed for intra-operative localization of the moderator bands and papillary muscles and identification of the optimal cannulation site. This location is usually much more on the diaphragmatic surface of the right ventricle than one would expect. Results: The acute angle of the inflow cannula on the DeBakey LVAD required flipping the device 180 degrees. The HeartMate II device could be shifted towards the midline. One patient was successfully transplanted and two are home waiting for a donor organ. Conclusions: The left ventricular assist device offers additional options for adults with congenital heart disease who experience end stage cardiac failure. Echocardiography guidance to optimal LVAD cannula placement ensures successful cardiac support for patients with surgically palliated TGA. 607 Use of a CardioWest TAH-t for High Risk Patients Reduces Complications and Improves Survival M. Flattery, L. Ohler, K. Doolin, M. Hess, R. Cooke, S. Harton, V. Kasirajan Virginia Commonwealth University Health System, Richmond, VA Purpose: Evaluating risk as part of patient selection for mechanical circulatory assist devices (MCAD) can be an effective method for predicting mortality and morbidity in patients with end stage heart failure. The purpose of this retrospective analysis was to determine the effectiveness of a risk assessment tool to predict outcomes of patients requiring MCAD. Methods and Materials: Twenty-five patients received implants with either a left ventricular assist device (LVAD) or total artificial heart (TAH-t) between January 2006 and September 2008. The risk assessment tool, which was validated in the post REMATCH era, assigns weights to 13 biologic and hemodynamic factors including platelet count, body surface area, creatinine clearance, white blood cell count, mean pulmonary artery pressure, INR, serum albumin, hematocrit, serum transaminase, history of arrhythmia, and the use of vasodilator, inotropic or beta blocker therapy. Data were extracted from medical records. Values included for analysis were obtained within 72 hours prior to device implant. To determine if the tool could be used effectively to predict outcomes, we compared the risk assessment scores of the 25 patients implanted with an LVAD or TAH-t. Results: Eleven patients received the CardioWest TAH-t, 13 patients were implanted with the Thoratec Heartmate XVE and 1 patient with the Jarvik 2000. Fifty-four percent of the LVAD patients were classified as high risk and 57% of the TAH-t patients were classified as high