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Bilateral Mini-Thoracotomy Versus Association of Upper-Mini-Sternotomy and Left Mini-Thoracotomy for LVAD Implantation: A Propensity Score Analysis
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The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Conclusion: Over 70% of the patients with fulminant myocarditis were rescued with aggressive MCS therapy. Endomyocardial biopsy is very important because immunosuppressive therapy carries promising outcomes in certain etiologies. 5( 94) Aortic Valve Interventions: Durability and Morbidity in Patients on Continuous Flow LVAD Support J.A. Cowger ,1 C. Salerno,2 F.D. Pagani,3 K.D. Aaronson,4 F. Billia,5 V. Rao.6 1Cardiovascular Medicine, St. Vincent Heart Center of Indiana, Indianapolis, IN; 2Cardiac Surgery, St. Vincent Heart Center of Indiana, Indianapolis, IN; 3Cardiac Surgery, University of Michigan, Ann Arbor, MI; 4Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; 5Cardiovascular Medicine, University of Toronto, Toronto, ON, Canada; 6Cardiac Surgery, University of Toronto, Toronto, CA; Toronto, ON, Canada. Purpose: Aortic valve repair or replacement (AVR) may reduce AI development after continuous flow (CF) LVAD implant and theoretically could reduce the risk of recurrent heart failure after LVAD, especially in those for whom long term support is anticipated. The aim herein is to evaluate the durability and morbidity associated with aortic valve (AV) interventions in CFLVAD patients. Methods: A retrospective, multicenter, analysis of CFLVAD patients with AV interventions was conducted. Kaplan-Meier estimates of survival were calculated. Cumulative frequencies of gastrointestinal bleeds (GIB), peripheral embolism, and VAD thrombosis were tallied. Severity of AI at last follow-up echocardiogram was measured. Results: Of the 37 patients studied, 35 underwent AV intervention at the time of CFLVAD implant and 2 had preexisting bioprosthetic AVR left unadultered. Median [25th, 75th] patient age was 61 [53,68] years and 51% were supported for destination therapy. Operative AV interventions at the time of VAD included 24 (65%) AV repairs, 7 bioprosthetic AVRs (19%), and 4 AV occlusions (11%) for prior mechanical AVRs. Over a median 304 (mean 510) days of patient support, there were 14 deaths with 1 and 2 year survivals of 71±8.5% and 58±11%. Freedom from VAD hemolysis at 1 year was 90±5.8% with an overall event rate of 0.17 per patient-year (PPY) of support. GIB and peripheral embolism occurred at events rates of 0.21 PPY and 0.12 PPY, respectively. Echocardiograms performed a median 306 [147,703] days after VAD implant showed the presence of mild-moderate AI in 1 patient and < = mild AI in the remaining patients. Conclusion: AV interventions are a durable means of reducing postLVAD AI. The requirement for AV intervention is associated with lower survival and increased device thrombosis. The benefits of VAD therapy in patients requiring AV intervention should be weighed against the increased risks associated with AV interventions. 5( 95) Bilateral Mini-Thoracotomy Versus Association of Upper-Mini-Sternotomy and Left Mini-Thoracotomy for LVAD Implantation: A Propensity Score Analysis J. Bejko , T. Bottio, M. Gallo, G. Bortolussi, R. Bianco, V. Tarzia, G. Gerosa. Cardiac Surgery, Padova, Italy. Purpose: The study aimed to compare the short-term results of LVAD implantation through two different minimally invasive approaches. Methods: This is a retrospective, observational, cohort study of prospectively collected data on 69 patients undergoing LVAD implantation between January-2009 to September-2014 (37 Jarvik 2000, and 32 Heartware). Fortyone-patients were performed through a minimally invasive approach (right anterior minithoracotomy or upper-ministernotomy associated to the left minithoracotomy), and 28 were conventionally performed in full-sternotomy or left-thoracotomy. By propensity score matching, 13 patients, who received the VAD through bilateral mini-thoracotomy (Group-A) were compared with 28 patients performed in upper-ministernotomy associated to the left minithoracotomy (Group-B). Results: The 2 groups were comparable in terms of preoperative characteristics (Age, Sex, Cardiomyopathy, INTERMACS, NYHA, EUROScore, ASA, Cardiac-function, Cardiac-rhythm, Pulmonary-artery-pressure, Chronic-renal-failure, Chronic-obstructive-pulmonary-disease, BSA,
peripheral-arterial-vascular disease, metabolic-disease). In Group-A we observed a faster post-operative recovery because of significantly reduced duration of surgery (min. 150±33 vs 187±62, p< 0.05), anesthesia (min. 165±42 vs 242±56, p< 0.05), mechanical-ventilation (hrs. 3.1±0.2 vs 6,7±3.4, p< 0.05), ICU (days 2.8±0.4 vs 3,4±1,3 p< 0.05) and in Hospital-stay (days 13.8±2.5 vs 18.5±9 p< 0.05), and finally by accelerating the time to first mobilization (p< 0.05). Additionally, bilateral-thoracotomy-approach offered significantly reduced need for plasma and platelet transfusions. A lower incidence of new onset postoperative atrial fibrillation was recorded in Group A (17% vs 31%, p< 0.05). Major and minor postoperative complications and overall in-hospital mortality were not significantly different between groups. Conclusion: Our experience shows that bilateral-thoracotomy-approach for LVAD surgery is a reproducible, safe, and effective procedure, offers a faster post-operative recovery, and reduces the need for blood product transfusion. 5( 96) Palliative Care Effectively Guides Transition to Inpatient Hospice, Home Hospice or Home Services for End-of-Life Care of LVAD Patients S. Nakagawa,1 C. Blinderman,1 B. Cagliostro,1 M. Flannery,1 V.K. Topkara,2 K. Takeda,3 H. Takayama,3 Y. Naka ,3 P.C. Colombo,2 M. Yuzefpolskaya.2 1Columbia University, New York, NY; 2Medicine, Columbia University, New York, NY; 3Surgery, Columbia University, New York, NY. Purpose: A Palliative Care specialist (PC) is now mandated by Center for Medicare and Medicaid Services (CMS) to be integrated as a member of the multidisciplinary team for the care patients implanted with left ventricular assist devices (LVADs) as destination therapy. However, the role of PC in gauging end-of-life options for LVAD patients and, thereby, reducing length of stay in the hospital has not been previously described. The purpose of this case series is to illustrate our single center experience in end-of-life care of LVAD patients. Methods: Between January 2014 and October 2014, 35 LVAD patients received PC consults with the objective to provide advanced care planning (ACP) and goals of care discussion (GOC). “End of life” was defined as a clinical condition where further curative options are considered more harmful than beneficial. The following end-of-life options were discussed by the PC team: termination of device support, inpatient hospice, home hospice and home/PC services. Results: 8/35 (23%) LVAD patients were deemed “end of life’ based on: i) overwhelming infection in 4/8 (50%), ii) profound debilitation 3/8 (25%) and iii) terminal neurologic event 1/8 (12.5%). End-of-life options included: i) transition to inpatient facility with hospice in 2 patients (25%); ii) transition to home with hospice in 2 patents (25%); iii) transition to home with PC services in 1 patient (12.5%); and iv) turning off the device during the index hospitalization in 3 patients (37.5%) . Median out-of-the-hospital survival of patients who were transitioned to hospice or home/PC services was 77 days (range, 16-173 days). Of note, 4 patients transitioned from ACP to GOC during the course of follow up with PC. Conclusion: PC consultation is essential in clarifying goals of care and available treatment options in LVAD patients at the end-of-life. This could result in successful (and possibly earlier) discharge from the hospital, thus reduced (projected) length of stay, and even improved survival. 5( 97) Demography and Outcome Data of the Bern VAD-Program Retrieved From the Euromacs Registry M. Susac ,1 K. Zuk,1 T.M. de By,2 B. Gahl,3 D. Reineke,3 L. Englberger,3 B. Hugi-Mayr,3 J. Zuber-Zibung,1 J. Gummert,4 R. Hetzer,5 P.J. Mohacsi,1 T. Carrel.3 1Cardiology, University Hospital, Bern, Switzerland; 2Euromacs Association, Berlin, Germany; 3Cardiovascular Surgery, University Hospital, Bern, Switzerland; 4Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany; 5German Heart Institute Berlin, Euromacs Association, Berlin, Germany. Purpose: Euromacs was created 2009. The Bern University Hospital reported all patients (pts), who received a VAD between 2011 and 2014 to Euromacs. We present for the first time an example of a comparison of outcome data of a single institution with the entire Euromacs database.
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Conclusion: Over 70% of the patients with fulminant myocarditis were rescued with aggressive MCS therapy. Endomyocardial biopsy is very important because immunosuppressive therapy carries promising outcomes in certain etiologies. 5( 94) Aortic Valve Interventions: Durability and Morbidity in Patients on Continuous Flow LVAD Support J.A. Cowger ,1 C. Salerno,2 F.D. Pagani,3 K.D. Aaronson,4 F. Billia,5 V. Rao.6 1Cardiovascular Medicine, St. Vincent Heart Center of Indiana, Indianapolis, IN; 2Cardiac Surgery, St. Vincent Heart Center of Indiana, Indianapolis, IN; 3Cardiac Surgery, University of Michigan, Ann Arbor, MI; 4Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; 5Cardiovascular Medicine, University of Toronto, Toronto, ON, Canada; 6Cardiac Surgery, University of Toronto, Toronto, CA; Toronto, ON, Canada. Purpose: Aortic valve repair or replacement (AVR) may reduce AI development after continuous flow (CF) LVAD implant and theoretically could reduce the risk of recurrent heart failure after LVAD, especially in those for whom long term support is anticipated. The aim herein is to evaluate the durability and morbidity associated with aortic valve (AV) interventions in CFLVAD patients. Methods: A retrospective, multicenter, analysis of CFLVAD patients with AV interventions was conducted. Kaplan-Meier estimates of survival were calculated. Cumulative frequencies of gastrointestinal bleeds (GIB), peripheral embolism, and VAD thrombosis were tallied. Severity of AI at last follow-up echocardiogram was measured. Results: Of the 37 patients studied, 35 underwent AV intervention at the time of CFLVAD implant and 2 had preexisting bioprosthetic AVR left unadultered. Median [25th, 75th] patient age was 61 [53,68] years and 51% were supported for destination therapy. Operative AV interventions at the time of VAD included 24 (65%) AV repairs, 7 bioprosthetic AVRs (19%), and 4 AV occlusions (11%) for prior mechanical AVRs. Over a median 304 (mean 510) days of patient support, there were 14 deaths with 1 and 2 year survivals of 71±8.5% and 58±11%. Freedom from VAD hemolysis at 1 year was 90±5.8% with an overall event rate of 0.17 per patient-year (PPY) of support. GIB and peripheral embolism occurred at events rates of 0.21 PPY and 0.12 PPY, respectively. Echocardiograms performed a median 306 [147,703] days after VAD implant showed the presence of mild-moderate AI in 1 patient and < = mild AI in the remaining patients. Conclusion: AV interventions are a durable means of reducing postLVAD AI. The requirement for AV intervention is associated with lower survival and increased device thrombosis. The benefits of VAD therapy in patients requiring AV intervention should be weighed against the increased risks associated with AV interventions. 5( 95) Bilateral Mini-Thoracotomy Versus Association of Upper-Mini-Sternotomy and Left Mini-Thoracotomy for LVAD Implantation: A Propensity Score Analysis J. Bejko , T. Bottio, M. Gallo, G. Bortolussi, R. Bianco, V. Tarzia, G. Gerosa. Cardiac Surgery, Padova, Italy. Purpose: The study aimed to compare the short-term results of LVAD implantation through two different minimally invasive approaches. Methods: This is a retrospective, observational, cohort study of prospectively collected data on 69 patients undergoing LVAD implantation between January-2009 to September-2014 (37 Jarvik 2000, and 32 Heartware). Fortyone-patients were performed through a minimally invasive approach (right anterior minithoracotomy or upper-ministernotomy associated to the left minithoracotomy), and 28 were conventionally performed in full-sternotomy or left-thoracotomy. By propensity score matching, 13 patients, who received the VAD through bilateral mini-thoracotomy (Group-A) were compared with 28 patients performed in upper-ministernotomy associated to the left minithoracotomy (Group-B). Results: The 2 groups were comparable in terms of preoperative characteristics (Age, Sex, Cardiomyopathy, INTERMACS, NYHA, EUROScore, ASA, Cardiac-function, Cardiac-rhythm, Pulmonary-artery-pressure, Chronic-renal-failure, Chronic-obstructive-pulmonary-disease, BSA,
peripheral-arterial-vascular disease, metabolic-disease). In Group-A we observed a faster post-operative recovery because of significantly reduced duration of surgery (min. 150±33 vs 187±62, p< 0.05), anesthesia (min. 165±42 vs 242±56, p< 0.05), mechanical-ventilation (hrs. 3.1±0.2 vs 6,7±3.4, p< 0.05), ICU (days 2.8±0.4 vs 3,4±1,3 p< 0.05) and in Hospital-stay (days 13.8±2.5 vs 18.5±9 p< 0.05), and finally by accelerating the time to first mobilization (p< 0.05). Additionally, bilateral-thoracotomy-approach offered significantly reduced need for plasma and platelet transfusions. A lower incidence of new onset postoperative atrial fibrillation was recorded in Group A (17% vs 31%, p< 0.05). Major and minor postoperative complications and overall in-hospital mortality were not significantly different between groups. Conclusion: Our experience shows that bilateral-thoracotomy-approach for LVAD surgery is a reproducible, safe, and effective procedure, offers a faster post-operative recovery, and reduces the need for blood product transfusion. 5( 96) Palliative Care Effectively Guides Transition to Inpatient Hospice, Home Hospice or Home Services for End-of-Life Care of LVAD Patients S. Nakagawa,1 C. Blinderman,1 B. Cagliostro,1 M. Flannery,1 V.K. Topkara,2 K. Takeda,3 H. Takayama,3 Y. Naka ,3 P.C. Colombo,2 M. Yuzefpolskaya.2 1Columbia University, New York, NY; 2Medicine, Columbia University, New York, NY; 3Surgery, Columbia University, New York, NY. Purpose: A Palliative Care specialist (PC) is now mandated by Center for Medicare and Medicaid Services (CMS) to be integrated as a member of the multidisciplinary team for the care patients implanted with left ventricular assist devices (LVADs) as destination therapy. However, the role of PC in gauging end-of-life options for LVAD patients and, thereby, reducing length of stay in the hospital has not been previously described. The purpose of this case series is to illustrate our single center experience in end-of-life care of LVAD patients. Methods: Between January 2014 and October 2014, 35 LVAD patients received PC consults with the objective to provide advanced care planning (ACP) and goals of care discussion (GOC). “End of life” was defined as a clinical condition where further curative options are considered more harmful than beneficial. The following end-of-life options were discussed by the PC team: termination of device support, inpatient hospice, home hospice and home/PC services. Results: 8/35 (23%) LVAD patients were deemed “end of life’ based on: i) overwhelming infection in 4/8 (50%), ii) profound debilitation 3/8 (25%) and iii) terminal neurologic event 1/8 (12.5%). End-of-life options included: i) transition to inpatient facility with hospice in 2 patients (25%); ii) transition to home with hospice in 2 patents (25%); iii) transition to home with PC services in 1 patient (12.5%); and iv) turning off the device during the index hospitalization in 3 patients (37.5%) . Median out-of-the-hospital survival of patients who were transitioned to hospice or home/PC services was 77 days (range, 16-173 days). Of note, 4 patients transitioned from ACP to GOC during the course of follow up with PC. Conclusion: PC consultation is essential in clarifying goals of care and available treatment options in LVAD patients at the end-of-life. This could result in successful (and possibly earlier) discharge from the hospital, thus reduced (projected) length of stay, and even improved survival. 5( 97) Demography and Outcome Data of the Bern VAD-Program Retrieved From the Euromacs Registry M. Susac ,1 K. Zuk,1 T.M. de By,2 B. Gahl,3 D. Reineke,3 L. Englberger,3 B. Hugi-Mayr,3 J. Zuber-Zibung,1 J. Gummert,4 R. Hetzer,5 P.J. Mohacsi,1 T. Carrel.3 1Cardiology, University Hospital, Bern, Switzerland; 2Euromacs Association, Berlin, Germany; 3Cardiovascular Surgery, University Hospital, Bern, Switzerland; 4Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany; 5German Heart Institute Berlin, Euromacs Association, Berlin, Germany. Purpose: Euromacs was created 2009. The Bern University Hospital reported all patients (pts), who received a VAD between 2011 and 2014 to Euromacs. We present for the first time an example of a comparison of outcome data of a single institution with the entire Euromacs database.