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Can a Minimally Invasive OFF-pump Implantation Strategy be Considered Safe for Selected Patients Undergoing HeartWare Ventricular Assist Device Implantation?
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
mortality of these patients occurred much sooner. Educational efforts to ensure timely referral for VAD are important to maximize the number of patients who may benefit from this therapy.
INTERMACS profile, LM, and MS models were predictive of RHF at the time of VAD implantation. Patients in this study were generally at a higher risk status, some of whom may have benefited from VAD therapy at an earlier stage. 1( 42) Can a Minimally Invasive OFF-pump Implantation Strategy be Considered Safe for Selected Patients Undergoing HeartWare Ventricular Assist Device Implantation? B. Sileshi , M.E. Davis, N.A. Haglund, H. Nian, J. Kennedy, R. Deegan, J. Stulak, K. Schelndorf, M.E. Keebler, S. Maltais. Vanderbilt University Medical Cente, Nashville, TN.
1( 41) Predicting Peri-operative Right Heart Failure, Post-implant Survival and Timing of Mechanical Ventricular Assistance M. Harb ,1 R. Lui,1 D. Robson,2 A. Jabbour,2 E. Kotlyar,2 A. Keogh,2 E. Granger,2 P. Spratt,2 P.S. Macdonald,2 P. Jansz,2 C.S. Hayward,2 K. Dhital.2 1St Vincent’s Hospital Clinical School, University of New South Wales, Sydney, Australia; 2Heart & Lung Transplant Unit, St Vincent’s Health Network, Sydney, Australia. Purpose: To assess the clinical utility of various heart failure (HF) risk stratification models in predicting peri-operative right heart failure (RHF), post-implant all-cause mortality, and in identifying high-risk status when patients may have benefited from ventricular assist device (VAD) therapy at an earlier stage. Methods: Pre-operative scores for several HF-related risk stratification models (ADHERE - Acute Decompensated Heart Failure National Registry, FS - Felker Score, INTERMACS - Interagency Registry for Mechanically Assisted Circulatory Support profiles, MS - Matthews Score, LM - LietzMiller score, and SHFM - Seattle Heart Failure Model), were calculated using retrospective data from all continuous flow (CF) VAD recipients between October 2004 to September 2012. 30-day, 60-day and 1-year mortality were assessed using Cox proportional hazards analysis and survival was modeled using Kaplan-Meier curves. Results: 92 CF VADs were implanted in 92 patients with a mean age of 49 ± 16 years. 90.2% (n= 83) of patients received a VAD as a bridge to transplantation. 39.1% (n= 36) of patients developed RHF. 30-day, 60-day and 1-year all-cause mortality rates were 3.3%, 5.5% and 20.1% respectively. None of the risk scores were predictive of mortality at these time points. Univariate analysis of component variables found higher haemoglobin (HR 0.96; 95% CI, 0.93 to 0.99) and higher haematocrit (HR 0.89; 95% CI, 0.81 to 0.98) to reduce the risk of 1-year mortality, while vasodilator therapy (HR 3.3; 95% CI, 1.16 to 9.60) increased 1-year mortality risk. Of the scores, INTERMACS (mean 1.40 ± 0.59), LM (11.99 ± 5.5) and MS (2.47 ± 2.76) were predictive of RHF (all p < 0.05) on univariate but not on multivariate analysis. Similarly, of younger age, lower haemoglobin, higher bilirubin, and lower albumin (all p< 0.05), only younger age was significant for RHF on multivariate analysis. Data from 6 months prior to VAD implantation shows patients declining in HF status using both the MS (p= 0.056) and SHFM scores (p= 0.053). Conclusion: HF risk stratification models used in this study failed to dichotomise our patients into high and low-risk for mortality. The
Purpose: In the past less invasive and OFF-pump implantation strategies have been anecdotally reported using the HeartWare ventricular assist device (HVAD). We describe our experience with a left thoracotomy minimally invasive OFF-pump implantation technique (OFF-P), and compare early inhospital outcomes to patients undergoing conventional ON-pump implantation (ON-P). Methods: Between January 2013 and November 2013, 49 patients underwent HVAD implantation, of whom seven (6 males, 85.7%) were approached with OFF-P, while 42 (34 males, 81%) were implanted using ON-P. Multivariate analysis was used to compare surgical techniques after adjusting for age, INTERMACS, Kormos and Lietz-Miller scores, using propensity score modeling. Results: All patients were implanted as a bridge-to-transplantation. Overall survival was 92% (n= 45). All patients in the OFF-P survived to discharge. When compared to ON-P, OFF-P patients had higher Kormos scores (0.58 vs. 0.41, p= 0.04), while all other preoperative characteristics were comparable (all p> 0.05). Intraoperative and postoperative blood product requirement averaged 1.71±0.95 and 0.86±1.2 units respectively for OFF-P, versus 7.55±11.8 and 3.54±8.1 units for ON-P (p= 0.35 and p= 0.48). Days on inotropes averaged 4.1±4.0 for OFF-P (6.2±3.6 for ON-P, p= 0.15). Mean ICU length of stay (LOS) and total in-hospital LOS for OFF-P was 7.3±5.2 and 13.6±4.1 days, respectively, compared to 6.6±5.2 and 13.4±5.5 for ON-P (p= 0.54 and p= 0.65). Propensity score multivariate analysis revealed comparable early outcomes between groups (Table 1). Conclusion: A minimally invasive left thoracotomy OFF-pump implantation strategy can be safely utilized in selected patients undergoing HVAD implantation. Despite higher Kormos score in OFF-P, encouraging comparable outcomes between the two techniques were observed. Further collaborative studies are needed to identify differences between implant strategies.
1( 43) Mechanical Circulatory Support for Failing Systemic Right Ventricle Using Left Ventricular Assist Device - An Option To Decide and Bridge? E. Peng ,1 M. Griselli,1 J. O’Sullivan,1 D. Crossland,1 M. Chaudhari,1 N. Wrightson,1 T. Butt,1 C. Roysam,2 G. Parry,1 G.A. MacGowan,1 S. Schueler,1 A. Hasan.1 1Cardiopulmonary Transplant, Freeman Hospital, Newcastle Upon Tyne, United Kingdom; 2Cardiothoracic Anaesthesia, Freeman Hospital, Newcastle Upon Tyne, United Kingdom. Purpose: The systemic morphological right ventricle (RV) in congenital corrected transposition (ccTGA) or following atrial switch is associated with late failure and cardiac transplantation becomes the only treatment option. Although the role of using left ventricular device (LVAD) to support failing
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
mortality of these patients occurred much sooner. Educational efforts to ensure timely referral for VAD are important to maximize the number of patients who may benefit from this therapy.
INTERMACS profile, LM, and MS models were predictive of RHF at the time of VAD implantation. Patients in this study were generally at a higher risk status, some of whom may have benefited from VAD therapy at an earlier stage. 1( 42) Can a Minimally Invasive OFF-pump Implantation Strategy be Considered Safe for Selected Patients Undergoing HeartWare Ventricular Assist Device Implantation? B. Sileshi , M.E. Davis, N.A. Haglund, H. Nian, J. Kennedy, R. Deegan, J. Stulak, K. Schelndorf, M.E. Keebler, S. Maltais. Vanderbilt University Medical Cente, Nashville, TN.
1( 41) Predicting Peri-operative Right Heart Failure, Post-implant Survival and Timing of Mechanical Ventricular Assistance M. Harb ,1 R. Lui,1 D. Robson,2 A. Jabbour,2 E. Kotlyar,2 A. Keogh,2 E. Granger,2 P. Spratt,2 P.S. Macdonald,2 P. Jansz,2 C.S. Hayward,2 K. Dhital.2 1St Vincent’s Hospital Clinical School, University of New South Wales, Sydney, Australia; 2Heart & Lung Transplant Unit, St Vincent’s Health Network, Sydney, Australia. Purpose: To assess the clinical utility of various heart failure (HF) risk stratification models in predicting peri-operative right heart failure (RHF), post-implant all-cause mortality, and in identifying high-risk status when patients may have benefited from ventricular assist device (VAD) therapy at an earlier stage. Methods: Pre-operative scores for several HF-related risk stratification models (ADHERE - Acute Decompensated Heart Failure National Registry, FS - Felker Score, INTERMACS - Interagency Registry for Mechanically Assisted Circulatory Support profiles, MS - Matthews Score, LM - LietzMiller score, and SHFM - Seattle Heart Failure Model), were calculated using retrospective data from all continuous flow (CF) VAD recipients between October 2004 to September 2012. 30-day, 60-day and 1-year mortality were assessed using Cox proportional hazards analysis and survival was modeled using Kaplan-Meier curves. Results: 92 CF VADs were implanted in 92 patients with a mean age of 49 ± 16 years. 90.2% (n= 83) of patients received a VAD as a bridge to transplantation. 39.1% (n= 36) of patients developed RHF. 30-day, 60-day and 1-year all-cause mortality rates were 3.3%, 5.5% and 20.1% respectively. None of the risk scores were predictive of mortality at these time points. Univariate analysis of component variables found higher haemoglobin (HR 0.96; 95% CI, 0.93 to 0.99) and higher haematocrit (HR 0.89; 95% CI, 0.81 to 0.98) to reduce the risk of 1-year mortality, while vasodilator therapy (HR 3.3; 95% CI, 1.16 to 9.60) increased 1-year mortality risk. Of the scores, INTERMACS (mean 1.40 ± 0.59), LM (11.99 ± 5.5) and MS (2.47 ± 2.76) were predictive of RHF (all p < 0.05) on univariate but not on multivariate analysis. Similarly, of younger age, lower haemoglobin, higher bilirubin, and lower albumin (all p< 0.05), only younger age was significant for RHF on multivariate analysis. Data from 6 months prior to VAD implantation shows patients declining in HF status using both the MS (p= 0.056) and SHFM scores (p= 0.053). Conclusion: HF risk stratification models used in this study failed to dichotomise our patients into high and low-risk for mortality. The
Purpose: In the past less invasive and OFF-pump implantation strategies have been anecdotally reported using the HeartWare ventricular assist device (HVAD). We describe our experience with a left thoracotomy minimally invasive OFF-pump implantation technique (OFF-P), and compare early inhospital outcomes to patients undergoing conventional ON-pump implantation (ON-P). Methods: Between January 2013 and November 2013, 49 patients underwent HVAD implantation, of whom seven (6 males, 85.7%) were approached with OFF-P, while 42 (34 males, 81%) were implanted using ON-P. Multivariate analysis was used to compare surgical techniques after adjusting for age, INTERMACS, Kormos and Lietz-Miller scores, using propensity score modeling. Results: All patients were implanted as a bridge-to-transplantation. Overall survival was 92% (n= 45). All patients in the OFF-P survived to discharge. When compared to ON-P, OFF-P patients had higher Kormos scores (0.58 vs. 0.41, p= 0.04), while all other preoperative characteristics were comparable (all p> 0.05). Intraoperative and postoperative blood product requirement averaged 1.71±0.95 and 0.86±1.2 units respectively for OFF-P, versus 7.55±11.8 and 3.54±8.1 units for ON-P (p= 0.35 and p= 0.48). Days on inotropes averaged 4.1±4.0 for OFF-P (6.2±3.6 for ON-P, p= 0.15). Mean ICU length of stay (LOS) and total in-hospital LOS for OFF-P was 7.3±5.2 and 13.6±4.1 days, respectively, compared to 6.6±5.2 and 13.4±5.5 for ON-P (p= 0.54 and p= 0.65). Propensity score multivariate analysis revealed comparable early outcomes between groups (Table 1). Conclusion: A minimally invasive left thoracotomy OFF-pump implantation strategy can be safely utilized in selected patients undergoing HVAD implantation. Despite higher Kormos score in OFF-P, encouraging comparable outcomes between the two techniques were observed. Further collaborative studies are needed to identify differences between implant strategies.
1( 43) Mechanical Circulatory Support for Failing Systemic Right Ventricle Using Left Ventricular Assist Device - An Option To Decide and Bridge? E. Peng ,1 M. Griselli,1 J. O’Sullivan,1 D. Crossland,1 M. Chaudhari,1 N. Wrightson,1 T. Butt,1 C. Roysam,2 G. Parry,1 G.A. MacGowan,1 S. Schueler,1 A. Hasan.1 1Cardiopulmonary Transplant, Freeman Hospital, Newcastle Upon Tyne, United Kingdom; 2Cardiothoracic Anaesthesia, Freeman Hospital, Newcastle Upon Tyne, United Kingdom. Purpose: The systemic morphological right ventricle (RV) in congenital corrected transposition (ccTGA) or following atrial switch is associated with late failure and cardiac transplantation becomes the only treatment option. Although the role of using left ventricular device (LVAD) to support failing