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9: Use of Mechanical Support Devices in Patients with Mechanical Mitral Valve Prosthesis
Abstracts Conclusions: NAEs occurred in 17% of total population and were associated with a worse outcome. Primary ICH was uncommon. In this population with multiple risks for NAEs, careful management of anticoagulation appears a key component to potentially reducing NAEs
S9 (36.6%) patients without AI (p⫽0.18). Patients with AI were older (63.7 vs 53.7 years, p⫽0.028) and trended to have a larger aortic root diameter at the time of implant (3.41 and 3.16 cm, p⫽0.07).[figure1]
7 The Columbia Experience with the Levitronix CentriMag as a Rescue Device in High Risk Patients B. Worku, H. Takayama, D. Van Patten, P. Pak, Y. Naka. Columbia University, New York, NY. Purpose: The Levitronix CentriMag heart pump has gained popularity in the last several years as rescue support for patients with decompensated heart failure. We have used the CentriMag device as a bridge to decision or bridge to recovery. We describe our experience with device placement, use, and outcomes. Methods and Materials: This is a retrospective study of patients who received a VAD between January 2007 and August 2009 with primary focus on those who received the CentriMag assist device for heart failure refractory to medical management. Results: Of 63 patients who underwent CentriMag device placement 43% (27) were for failure of medical management. Primary diagnoses were ICM (18), DCM (7), and other (2). Mean age was 47.1 years (7-72). Before the VAD, 89% of patients were on IABP support, 56% were on vasopressors, and 56% were on more than 1 inotrope. IMTERMACS score was 1 in 33% patients and 2 in 67%. Mean length of support was 15.9 days (2-48) and mean follow up was 308 days (3-907). Six patients were bridged to a long term mechanical assist device, 8 to transplantation, and 10 to recovery. Eighty-nine percent (24/27) of patients survived to explant and 74% (20/ 27) survived to hospital discharge, with a one year survival of 68%.Thromboembolic complications occurred in 10 patients, including 6 strokes. Compared to the patients who survived to discharge, those who died had a trend toward more frequent diagnosis of ICM (86% in non-survivors vs. 60% in survivors). No difference was observed in preoperative use of IABP or inotropes, median serum total bilirubin (1.25 vs. 1.7), or median creatinine (1.2 vs. 1.35) in non-survivors vs. survivors. Conclusions: The Levitronix CentriMag demonstrates promising results when used in patients with heart failure refractory to medical management. The diagnosis of ICM appears to carry a higher risk for poor outcomes. As many patients were successfully bridged either to recovery or directly to heart transplantation, the strategy of using the CentriMag rather than a long-term device appears to be reasonable option. 8 Development of Aortic Insufficiency in Patients Supported with a HeartMate II Left Ventricular Assist Device (LVAD) S.-W. Pak,2 N. Uriel,1 H. Takayama,2 B. Kachniarz,2 L.K. Murray,2 D. Mancini,1 Y. Naka,2 U.P. Jorde.1 1Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: LVADs providing continuous flow are increasingly used in end-stage heart failure patients and establish a novel physiology in the aortic root. We assessed the frequency of aortic insufficiency (AI) development after HeartMate II implantation. Methods and Materials: Preoperative (within 30 days) as well as all postoperative echocardiograms of 79 patients who underwent HeartMate II implantation at our center between 2004 and 2009 were retrospectively reviewed. AI was deemed significant if “mild to moderate” or greater. Results: Of the 79 patients, 76 had available preoperative echocardiographic reports. Over a mean observation time of 477 days, 12 patients (16%) developed significant AI (mild/moderate ⫽ 7, moderate ⫽ 4, moderate to severe ⫽ 1), with a mean/median onset time at 139/ 89 days. Prevalence of significant AI in patients who remained on support (i.e. alive and not transplanted) was 3% at 30 days and 13% at 100 days. Three of ten (30%) destination therapy patients compared to 9 of 42 (21.4%) bridge to transplantation patients developed AI. Ischemic cardiomyopathy was the etiology of heart failure in 7 of 12 (58%) patients with AI and in 15 of 41
Conclusions: A significant number of patients developed AI during support with a continuous flow pump. More comprehensive preoperative aortic root geometry assessment may identify patients at highest risk who might benefit from surgical aortic valve manipulation at the time of implant. 9 Use of Mechanical Support Devices in Patients with Mechanical Mitral Valve Prosthesis A. Goda,1 H. Takayama,2 S.-W. Pak,2 J. Ulrich,1 D. Mancini,1 Y. Naka.2 1 Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: Use of Left Ventricular Assist Devices (LVAD) in patients with mechanical valves may carry an increased risk of thromboemblism, however, clinical information is lacking. This study describes the use of LVAD in patients with mechanical mitral valve prosthesis at a single large university center. Methods and Materials: A retrospective analysis of LVAD patients from 1996 to 2008 was performed. Results: Nine patients with a mechanical mitral valve (averaged age 53⫾ 9 years old) were identified (Table). In all patients, the indication for LVAD was as a bridge to transplant. At the time of LVAD implant, no intervention to the mitral valve was performed. Several different types of mechanical support were used. Five patients were received warfarin, and 1 patient was on heparin. Eight patients were successfully transplanted an average of 83 days post implant and 1 died after 48 days from multiorgan failure. No clinical thromboembolic event was observed. No intracardiac thrombus was detected by echocardiogram or on pathology of the explanted hearts. Two patients had bleeding event (GI bleeding, bleeding from aortic graft).[table1]
1 2 3 4 5 6 7 8 9
Age
Period from valve rep to VAD
Etiology of HF
Type of VAD
52 34 59 57 61 52 54 62 45
2y 2y 1y 6y 8d 3d 5y 9d 45d
CAD DCM CAD VHD CAD CAD CAD CAD DCM
HM I ⫹ RVAD HM II HM I HM I Thoratec IVAD HM I HM I HM I CentriLVAD3HMII
Conclusions: Our case series suggests placement of mechanical support device in patients with mechanical mitral prosthesis appears safe and well tolerated. Observations in a larger patient cohort will be needed to confirm our findings.
S9 (36.6%) patients without AI (p⫽0.18). Patients with AI were older (63.7 vs 53.7 years, p⫽0.028) and trended to have a larger aortic root diameter at the time of implant (3.41 and 3.16 cm, p⫽0.07).[figure1]
7 The Columbia Experience with the Levitronix CentriMag as a Rescue Device in High Risk Patients B. Worku, H. Takayama, D. Van Patten, P. Pak, Y. Naka. Columbia University, New York, NY. Purpose: The Levitronix CentriMag heart pump has gained popularity in the last several years as rescue support for patients with decompensated heart failure. We have used the CentriMag device as a bridge to decision or bridge to recovery. We describe our experience with device placement, use, and outcomes. Methods and Materials: This is a retrospective study of patients who received a VAD between January 2007 and August 2009 with primary focus on those who received the CentriMag assist device for heart failure refractory to medical management. Results: Of 63 patients who underwent CentriMag device placement 43% (27) were for failure of medical management. Primary diagnoses were ICM (18), DCM (7), and other (2). Mean age was 47.1 years (7-72). Before the VAD, 89% of patients were on IABP support, 56% were on vasopressors, and 56% were on more than 1 inotrope. IMTERMACS score was 1 in 33% patients and 2 in 67%. Mean length of support was 15.9 days (2-48) and mean follow up was 308 days (3-907). Six patients were bridged to a long term mechanical assist device, 8 to transplantation, and 10 to recovery. Eighty-nine percent (24/27) of patients survived to explant and 74% (20/ 27) survived to hospital discharge, with a one year survival of 68%.Thromboembolic complications occurred in 10 patients, including 6 strokes. Compared to the patients who survived to discharge, those who died had a trend toward more frequent diagnosis of ICM (86% in non-survivors vs. 60% in survivors). No difference was observed in preoperative use of IABP or inotropes, median serum total bilirubin (1.25 vs. 1.7), or median creatinine (1.2 vs. 1.35) in non-survivors vs. survivors. Conclusions: The Levitronix CentriMag demonstrates promising results when used in patients with heart failure refractory to medical management. The diagnosis of ICM appears to carry a higher risk for poor outcomes. As many patients were successfully bridged either to recovery or directly to heart transplantation, the strategy of using the CentriMag rather than a long-term device appears to be reasonable option. 8 Development of Aortic Insufficiency in Patients Supported with a HeartMate II Left Ventricular Assist Device (LVAD) S.-W. Pak,2 N. Uriel,1 H. Takayama,2 B. Kachniarz,2 L.K. Murray,2 D. Mancini,1 Y. Naka,2 U.P. Jorde.1 1Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: LVADs providing continuous flow are increasingly used in end-stage heart failure patients and establish a novel physiology in the aortic root. We assessed the frequency of aortic insufficiency (AI) development after HeartMate II implantation. Methods and Materials: Preoperative (within 30 days) as well as all postoperative echocardiograms of 79 patients who underwent HeartMate II implantation at our center between 2004 and 2009 were retrospectively reviewed. AI was deemed significant if “mild to moderate” or greater. Results: Of the 79 patients, 76 had available preoperative echocardiographic reports. Over a mean observation time of 477 days, 12 patients (16%) developed significant AI (mild/moderate ⫽ 7, moderate ⫽ 4, moderate to severe ⫽ 1), with a mean/median onset time at 139/ 89 days. Prevalence of significant AI in patients who remained on support (i.e. alive and not transplanted) was 3% at 30 days and 13% at 100 days. Three of ten (30%) destination therapy patients compared to 9 of 42 (21.4%) bridge to transplantation patients developed AI. Ischemic cardiomyopathy was the etiology of heart failure in 7 of 12 (58%) patients with AI and in 15 of 41
Conclusions: A significant number of patients developed AI during support with a continuous flow pump. More comprehensive preoperative aortic root geometry assessment may identify patients at highest risk who might benefit from surgical aortic valve manipulation at the time of implant. 9 Use of Mechanical Support Devices in Patients with Mechanical Mitral Valve Prosthesis A. Goda,1 H. Takayama,2 S.-W. Pak,2 J. Ulrich,1 D. Mancini,1 Y. Naka.2 1 Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: Use of Left Ventricular Assist Devices (LVAD) in patients with mechanical valves may carry an increased risk of thromboemblism, however, clinical information is lacking. This study describes the use of LVAD in patients with mechanical mitral valve prosthesis at a single large university center. Methods and Materials: A retrospective analysis of LVAD patients from 1996 to 2008 was performed. Results: Nine patients with a mechanical mitral valve (averaged age 53⫾ 9 years old) were identified (Table). In all patients, the indication for LVAD was as a bridge to transplant. At the time of LVAD implant, no intervention to the mitral valve was performed. Several different types of mechanical support were used. Five patients were received warfarin, and 1 patient was on heparin. Eight patients were successfully transplanted an average of 83 days post implant and 1 died after 48 days from multiorgan failure. No clinical thromboembolic event was observed. No intracardiac thrombus was detected by echocardiogram or on pathology of the explanted hearts. Two patients had bleeding event (GI bleeding, bleeding from aortic graft).[table1]
1 2 3 4 5 6 7 8 9
Age
Period from valve rep to VAD
Etiology of HF
Type of VAD
52 34 59 57 61 52 54 62 45
2y 2y 1y 6y 8d 3d 5y 9d 45d
CAD DCM CAD VHD CAD CAD CAD CAD DCM
HM I ⫹ RVAD HM II HM I HM I Thoratec IVAD HM I HM I HM I CentriLVAD3HMII
Conclusions: Our case series suggests placement of mechanical support device in patients with mechanical mitral prosthesis appears safe and well tolerated. Observations in a larger patient cohort will be needed to confirm our findings.