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Cardiac CT Parameters as Predictors of Aortic Insufficiency Post LVAD Implantation
Abstracts S195 echocardiographic aspects thought to influence aortic insufficiency (AI) in these patients were analyzed. AI was considered significant if more than mild. Results: Median LVAD support duration was 431 days. Significant AI were founded in 35 patients (29%). In 10 patients an AI had already shown before LVAD implantation. De novo AI occurred in median after 210 days of support. No patient presented severe AI. 11 patients had a prosthetic aortic valve with no significant AI developing in this group. Permanently closed aortic valve correlated with greater prevalence of aortic insufficiency when compared with complete or incomplete opening from aortic valve (P= 0.02). There was no significant difference between device flow in patients with or without aortic insufficiency. Etiology of the cardiomyopathy and the type of device had no significant influence to the development of aortic valve insufficiency. Conclusion: Aortic insufficiency has a high prevalence following assist device continuous flow support. Echocardiographic parameters are an integral part of ambulatory care of these patients and can guide the optimal setting from LVAD. Aortic valve that does not open should be avoided in order to prevent aortic insufficiency. Bioprosthetic aortic valve replacement is an adequate strategy for AI at VAD implantation. 5( 23) Aortic Valve Pathology in Patients Supported by a Continuous-Flow Left Ventricular Assist Device T. Saito ,1 E. Potapov,1 K. Wassilew,1 B. Gorodetski,2 T. Krabatsch,1 R. Hetzer.1 1Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Deutsches Herzzentrum Berlin, Berlin, Germany. Purpose: Continuous-flow left ventricular assist devices (CF-LVAD) alter the flow pattern in the ascending aorta and may induce pathological changes to the aortic wall and to the aortic valve. We aimed to assess histological changes of the relevant anatomic structures exposed to continuous-flow stress over time. Methods: A retrospective histological analysis of 36 explanted hearts supported with a CF-LVAD from heart transplant patients submitted between July 2003 and February 2013 was performed. Patients were divided into 4 groups according to duration of CF-LVAD support: group A (< 6 months), group B (6 to 12 months), group C (12 to 18 months) and group D (≥ 18 months). Sections of formalin-fixed paraffin-embedded tissue showing the continuity of aortic wall and left-sided valves were examined histologically. The length and thickness of aortic tubular portion, separately the thickness of the intima and media of the aortic root and the aorto-mitral continuity thickness were measured on EvG stained slides using specific software. The 3 layers of the aortic valve cusps (pars fibrosa, spongiosa and ventricularis) were measured individually and the thickness index (= thickness of free edge/ thickness of basal part) was calculated. Results: LVAD support time differed significantly in the groups [Group A: 9 patients, mean 76 days (range: 7 to 141 days), group B: 6 patients, 253 days (212 to 357 days), group C: 8 patients, 450 days (379 to 536 days), group D: 13 patients, 1079 days (709 to 2009 days)]. The mean thickness index of ventricularis layer was 1.13±0.72, (range 0.30 to 3.40) in group A, 1.37±0.96 (0.15 to 3.65) in group B, 0.91±0.44 (0.43 to 1.65) in group C and 0.68±0.41 (0.13 to 1.58) in group D. Group D patients exhibited a thinner ventricularis layer at the free edge of the cusp compared to group A (p= 0.015) and B (p= 0.034). The spongiosa and fibrosa layers showed no significant difference in thickness between the groups. Most of the aortic cusps showed nodular thickening (either due to myxoid degeneration or collagen accumulation) at the free margin independent of LVAD support duration. Conclusion: Long-term LVAD support appears to cause involution of the ventricularis layer of the aortic valve, especially at the free edge of the cusp, being consistent with more pronounced degenerative changes with longer LVAD exposure, which might be correlated with the continuous coaptation of the cusps. 5 ( 24) Cardiac CT Parameters as Predictors of Aortic Insufficiency Post LVAD Implantation K. Kancherla ,1 Z. Wang,2 D. Emerson,3 W.G. Weigold,2 D. Abramov,2 G. Ruiz,2 J.M. Steiner,4 M. Hofmeyer,2 D.T. Majure,2 F.H. Sheikh,2 R.D. Bannerman,2 E.J. Molina,5 S.W. Boyce,5 S.S. Najjar,2 G.
Weissman.2 1Medstar Health Research Institute, Washington, DC; 2Cardiology, Medstar Washington Hospital Center, Washington, DC; 3Department of Surgery, Medstar Georgetown University Hospital, Washington, DC; 4Medicine, Medstar Georgetown University Hospital, Washington, DC; 5Cardiothoracic Surgery, Medstar Washington Hospital Center, Washington, DC. Purpose: Prior studies have documented development aortic insufficiency (AI) post left ventricular device (LVAD) insertion. This may have clinical implications. There is no data evaluating the utility of cardiac CT (CCT) parameters in predicting post implant AI. We hypothesized that aortic dimensions and outflow cannula (OC) position may predict the presence of AI. Methods: We performed a retrospective single center study. Of 192 LVAD implants between 01/2007 - 09/2013, 63 had CCT (median time to CT 254 days (interquartile range 109,511)). Diameter of the aortic annulus (AoAn), sinuses of Valsalva (SV), sinotubular junction (STJ), ascending aorta (AsAo), as well as AoAn eccentricity (1-(short axis diameter/long axis diameter)), AoAn to OC distance, insertion angle (IA) of the OC to AsAo, and the hypothetical flow angle (FA) between flow from the OC to the opposite wall of the AsAo (figure) were measured in diastole. Transthoracic echo was evaluated for presence of AI and regurgitant jet ratio (JR) (AI jet width/LV outflow tract diameter). Results: AI was present in 18 patients (29%). JR < 0.2 was seen in 10 patients (16%) vs. JR > 0.2 in 8 (13%). CT findings are in table. Aortic diameters, AoAn eccentricity, and AoAn to OC distance did not differ between AI / no AI groups. The IA and FA were more acute in the AI group (OC relatively tilted towards the distal AsAo). There were no differences between < 0.2 JR vs. > 0.2 JR groups. Conclusion: In our study aortic diameters and OC distance do not correlate to the presence of AI post LVAD implant. Orientation of the OC insertion to the AsAo was correlated with the presence of AI. The clinical significance of this finding is not defined.
NO AI(N= 45) AI(N= 18)
P Value Jet ratio
Jet ratio > 0.20 (N= 8)
P Value
AoAn Mean (mm) 27.4±4.04
27.78±3.14
0.69
27.28±3.59
28.51±2.42
0.41
Eccentricity of AoAn
0.23±0.10
0.20±0.11
0.49
0.21±0.10
0.19±012
0.69
SV Mean (mm)
32.31±3.69
32.64±2.50
0.68
32.64±2.32
32.65±2.93
0.98
STJ Mean (mm)
29.96±3.51
29.35±3.13
0.51
29.27±2.93
29.46±3.63
0.90
OC-AoAn Distance(mm)
43.54±8.13
44.34±6.60
0.69
43.14±7.46
46.05±5.19
0.35
AsAo diameter (mm)
31.73±4.30
31.29±3.89
0.79
30.75±4.78
32.31±2.41
0.41
Insertion Angle
92.43±22.86
80.53±20.33
0.05
85.66±14.62
74.76±25.06 0.30
Flow Angle
71.40±21.19
52.34±28.72
0.02
53.74±30.19
50.54±28.98 0.83
S196
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
5( 25) Efficacy and Durability of Central Oversewing for Treatment of Aortic Valve Insufficiency in Patients with Continuous Flow Left Ventricular Assist Devices M.A. Schechter ,1 J.T. Joseph,1 J. Finet,2 A. Krishnamoorthy,2 A.M. Ganapathi,1 A.J. Lodge,1 C.B. Patel,2 C.A. Milano.1 1Department of Surgery, Duke University Medical Center, Durham, NC; 2Department of Medicine, Duke University Medical Center, Durham, NC. Purpose: Aortic insufficiency (AI) in patients supported with continuous flow left ventricular assist devices (CF-LVAD) results in regurgitant volume returning from the aorta to the left ventricle, increased LVAD pump volume, and reduced systemic cardiac output. One common strategy to address AI during CF-LVAD support is central oversewing of the aortic valve, which allows some opening between the valve leaflets laterally. However, the long-term durability of this technique has not been extensively described. We therefore describe the outcomes of a group of patients who underwent CF-LVAD insertion with either a concomitant or delayed central oversewing procedure. Methods: All patients undergoing CF-LVAD between 01/2006 and 03/2013 were retrospectively evaluated, and those who underwent central oversewing of the valve were included in this analysis. Pre-procedure and post-procedure intraoperative transesophageal echoacrdiograms (TEE) were reviewed to determine the initial efficacy of the surgical technique. All subsequent transthoracic echocardiograms (TTE) for each patient were also reviewed to assess durability. Aortic regurgitation severity was grated using the vena contracta (VC) width and the ratio between the VC and left ventricular outflow tract (LVOT) diameter. Clinical outcomes evaluated included survival, incidence of post-operative neurological events, hemolysis, and re-hospitalizations for gastrointestinal bleeding. Results: A total of 19 consecutive cases with central aortic valve oversewing were identified and included. Median follow-up to most recent echo was 560 days (range: 46 - 954 days). All but one patient had their aortic insufficiency reduced to “none/trace”, based upon the reduction in both VC and VC/LVOT ratio on post-operative TEE. There was no statistically significant increase in the VC width and VC/LVOT ratio between the first and last follow-up echocardiograms (p = 0.13 and p = 0.08, respectively). Only two patients developed more than mild aortic insufficiency after central oversewing (time to development: 45 and 120 days). Central oversewing of the aortic valve did not adversely affect outcomes following LVAD implantation. Conclusion: Central oversewing of the aortic valve is an effective and durable means of addressing greater than mild AI in patients with CF-LVADs. 5( 26) Neurologic Complications After Implantation of Total Artificial Heart I. Tchoukina , M.T. Hassanein, V. Kasirajan, D.G. Tang, K.B. Shah. Virginia Commonwealth University, Richmond, VA. Purpose: Neurologic complications (NC) occur after implantation of mechanical circulatory support devices. The incidence of the NC has been reported to be low in previous studies with the total artificial heart (TAH) and continuous flow left ventricular assist devices (CFLVAD). We sought to compare the incidence of NC in patients receiving support with TAH to those with CFLVAD. Methods: We retrospectively reviewed data on all patients who received TAH or CFLVAD at our institution between April 2006 and September 2013. NC was defined as transient ischemic attack, ischemic cerebrovascular accident (CVA) or hemorrhagic CVA. The incidence and timing of the first NC after the implant were compared between the device groups. Results: The TAH (n= 74) and CFLVAD (n= 126) groups were similar with regards to age (48.9 vs. 52.2 years, p= 0.1), ethnicity (p= 0.41) and BSA (2.12 vs. 2.11 m2, p= 0.7), however TAH patients were more likely to be male (87.8% vs. 71.4%, p= 0.007) and have a history of nonischemic cardiomyopathy (77% vs. 54.8%, p= 0.002). The median follow up duration was 84.5 days (range: 1 - 1,014) in the TAH group and 238.5 days (range: 1 - 1,471) in the CFLVAD group (p< 0.001). NC developed in 9 patients in the TAH group and 13 patients in the CFLVAD group (12.2% vs. 10.3%, p= 0.7). Four (5.4%) TAH patients and 7 (5.6%) CFLVAD patients developed permanent disability or died (p= 1.0), while the remaining had resolution of neurological deficits. The incidence of NC per patient-years (ppy) was low, but higher in the TAH patients compared to CFLVAD patients (0.346 vs. 0.112 events ppy, p= 0.02). The majority of the events occurred
early post device implant in TAH and CFLVAD patients (median time to event 42 vs. 44 days, p= 1.0, FIGURE). Conclusion: Despite difference in design, the incidence of NC was similar for TAH and CFLVAD. The risk was highest early post device implantation. A large proportion of patients with either device survived NC without permanent disability.
5( 27) Cerebrovascular Accidents and End of Life Admissions Contribute Most to the Cost in Patients With Continuous Flow Left Ventricular Assist Devices G. Ashrith , F. Kotun, A.M. Cordero-Reyes, A. Bhimaraj, B.H. Trachtenberg, M. Loebe, G. Torre-Amione, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Continuous flow Left ventricular assist devices (LVAD) have proven to prolong life and quality of life in patients with end stage heart failure. However their cost effectiveness is still low compared to life prolonging therapies for other medical conditions. It is well known that the device and implantation contributes to the cost, but the contribution of readmissions to the overall cost is unknown. Methods: We retrospectively reviewed the readmission cost (in US Dollars) during the first year after implant of continuous flow device in 119 patients during years 2008-11 at The Methodist Hospital, Houston. There were a total of 226 readmissions during that time period (1-year post implant or death). Kruskal-Wallis one way ANOVA was used to compare differences between groups. Results: There were 14 admissions for cerebrovascular accidents (CVA), 36 for gastrointestinal (GI) bleeding, 67 for infections, 10 for arrhythmias, 27 for heart failure, 9 for VAD related mechanical issues, and 63 admissions for other medical problems. Average cost of readmission, cost per day and length of stay for each medical reason is given in Table. Stroke related readmission costs were significantly higher compared to all other conditions (Table). Twelve of 16 patients who expired after index implant admission, during the first year of follow up, died in our hospital. Admissions leading to demise were considerably expensive compared to any other hospital admission (USD 428,843+/-383,687 vs. 95023+/-56,888; p< 0.0001). Conclusion: CVAs in patients with LVADs incur most cost when compared to any other cause of readmission. Admission during which the patient expires adds considerably to the overall cost of the device. Better strategies to manage CVA and better end of life planning may reduce overall cost in patients with LVADs.
5( 28) Effectiveness of Continuous Flow Left Ventricular Assist Device Exchange for Recurrence of Major Drive Line and Pump Pocket Infection M.F. Masood , M. Romano, J.W. Haft, R. Hasan, K. Aaronson, F. Pagani. Cardiac Surgery, University of Michigan, Ann Arbor, MI.
Weissman.2 1Medstar Health Research Institute, Washington, DC; 2Cardiology, Medstar Washington Hospital Center, Washington, DC; 3Department of Surgery, Medstar Georgetown University Hospital, Washington, DC; 4Medicine, Medstar Georgetown University Hospital, Washington, DC; 5Cardiothoracic Surgery, Medstar Washington Hospital Center, Washington, DC. Purpose: Prior studies have documented development aortic insufficiency (AI) post left ventricular device (LVAD) insertion. This may have clinical implications. There is no data evaluating the utility of cardiac CT (CCT) parameters in predicting post implant AI. We hypothesized that aortic dimensions and outflow cannula (OC) position may predict the presence of AI. Methods: We performed a retrospective single center study. Of 192 LVAD implants between 01/2007 - 09/2013, 63 had CCT (median time to CT 254 days (interquartile range 109,511)). Diameter of the aortic annulus (AoAn), sinuses of Valsalva (SV), sinotubular junction (STJ), ascending aorta (AsAo), as well as AoAn eccentricity (1-(short axis diameter/long axis diameter)), AoAn to OC distance, insertion angle (IA) of the OC to AsAo, and the hypothetical flow angle (FA) between flow from the OC to the opposite wall of the AsAo (figure) were measured in diastole. Transthoracic echo was evaluated for presence of AI and regurgitant jet ratio (JR) (AI jet width/LV outflow tract diameter). Results: AI was present in 18 patients (29%). JR < 0.2 was seen in 10 patients (16%) vs. JR > 0.2 in 8 (13%). CT findings are in table. Aortic diameters, AoAn eccentricity, and AoAn to OC distance did not differ between AI / no AI groups. The IA and FA were more acute in the AI group (OC relatively tilted towards the distal AsAo). There were no differences between < 0.2 JR vs. > 0.2 JR groups. Conclusion: In our study aortic diameters and OC distance do not correlate to the presence of AI post LVAD implant. Orientation of the OC insertion to the AsAo was correlated with the presence of AI. The clinical significance of this finding is not defined.
NO AI(N= 45) AI(N= 18)
P Value Jet ratio
Jet ratio > 0.20 (N= 8)
P Value
AoAn Mean (mm) 27.4±4.04
27.78±3.14
0.69
27.28±3.59
28.51±2.42
0.41
Eccentricity of AoAn
0.23±0.10
0.20±0.11
0.49
0.21±0.10
0.19±012
0.69
SV Mean (mm)
32.31±3.69
32.64±2.50
0.68
32.64±2.32
32.65±2.93
0.98
STJ Mean (mm)
29.96±3.51
29.35±3.13
0.51
29.27±2.93
29.46±3.63
0.90
OC-AoAn Distance(mm)
43.54±8.13
44.34±6.60
0.69
43.14±7.46
46.05±5.19
0.35
AsAo diameter (mm)
31.73±4.30
31.29±3.89
0.79
30.75±4.78
32.31±2.41
0.41
Insertion Angle
92.43±22.86
80.53±20.33
0.05
85.66±14.62
74.76±25.06 0.30
Flow Angle
71.40±21.19
52.34±28.72
0.02
53.74±30.19
50.54±28.98 0.83
S196
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
5( 25) Efficacy and Durability of Central Oversewing for Treatment of Aortic Valve Insufficiency in Patients with Continuous Flow Left Ventricular Assist Devices M.A. Schechter ,1 J.T. Joseph,1 J. Finet,2 A. Krishnamoorthy,2 A.M. Ganapathi,1 A.J. Lodge,1 C.B. Patel,2 C.A. Milano.1 1Department of Surgery, Duke University Medical Center, Durham, NC; 2Department of Medicine, Duke University Medical Center, Durham, NC. Purpose: Aortic insufficiency (AI) in patients supported with continuous flow left ventricular assist devices (CF-LVAD) results in regurgitant volume returning from the aorta to the left ventricle, increased LVAD pump volume, and reduced systemic cardiac output. One common strategy to address AI during CF-LVAD support is central oversewing of the aortic valve, which allows some opening between the valve leaflets laterally. However, the long-term durability of this technique has not been extensively described. We therefore describe the outcomes of a group of patients who underwent CF-LVAD insertion with either a concomitant or delayed central oversewing procedure. Methods: All patients undergoing CF-LVAD between 01/2006 and 03/2013 were retrospectively evaluated, and those who underwent central oversewing of the valve were included in this analysis. Pre-procedure and post-procedure intraoperative transesophageal echoacrdiograms (TEE) were reviewed to determine the initial efficacy of the surgical technique. All subsequent transthoracic echocardiograms (TTE) for each patient were also reviewed to assess durability. Aortic regurgitation severity was grated using the vena contracta (VC) width and the ratio between the VC and left ventricular outflow tract (LVOT) diameter. Clinical outcomes evaluated included survival, incidence of post-operative neurological events, hemolysis, and re-hospitalizations for gastrointestinal bleeding. Results: A total of 19 consecutive cases with central aortic valve oversewing were identified and included. Median follow-up to most recent echo was 560 days (range: 46 - 954 days). All but one patient had their aortic insufficiency reduced to “none/trace”, based upon the reduction in both VC and VC/LVOT ratio on post-operative TEE. There was no statistically significant increase in the VC width and VC/LVOT ratio between the first and last follow-up echocardiograms (p = 0.13 and p = 0.08, respectively). Only two patients developed more than mild aortic insufficiency after central oversewing (time to development: 45 and 120 days). Central oversewing of the aortic valve did not adversely affect outcomes following LVAD implantation. Conclusion: Central oversewing of the aortic valve is an effective and durable means of addressing greater than mild AI in patients with CF-LVADs. 5( 26) Neurologic Complications After Implantation of Total Artificial Heart I. Tchoukina , M.T. Hassanein, V. Kasirajan, D.G. Tang, K.B. Shah. Virginia Commonwealth University, Richmond, VA. Purpose: Neurologic complications (NC) occur after implantation of mechanical circulatory support devices. The incidence of the NC has been reported to be low in previous studies with the total artificial heart (TAH) and continuous flow left ventricular assist devices (CFLVAD). We sought to compare the incidence of NC in patients receiving support with TAH to those with CFLVAD. Methods: We retrospectively reviewed data on all patients who received TAH or CFLVAD at our institution between April 2006 and September 2013. NC was defined as transient ischemic attack, ischemic cerebrovascular accident (CVA) or hemorrhagic CVA. The incidence and timing of the first NC after the implant were compared between the device groups. Results: The TAH (n= 74) and CFLVAD (n= 126) groups were similar with regards to age (48.9 vs. 52.2 years, p= 0.1), ethnicity (p= 0.41) and BSA (2.12 vs. 2.11 m2, p= 0.7), however TAH patients were more likely to be male (87.8% vs. 71.4%, p= 0.007) and have a history of nonischemic cardiomyopathy (77% vs. 54.8%, p= 0.002). The median follow up duration was 84.5 days (range: 1 - 1,014) in the TAH group and 238.5 days (range: 1 - 1,471) in the CFLVAD group (p< 0.001). NC developed in 9 patients in the TAH group and 13 patients in the CFLVAD group (12.2% vs. 10.3%, p= 0.7). Four (5.4%) TAH patients and 7 (5.6%) CFLVAD patients developed permanent disability or died (p= 1.0), while the remaining had resolution of neurological deficits. The incidence of NC per patient-years (ppy) was low, but higher in the TAH patients compared to CFLVAD patients (0.346 vs. 0.112 events ppy, p= 0.02). The majority of the events occurred
early post device implant in TAH and CFLVAD patients (median time to event 42 vs. 44 days, p= 1.0, FIGURE). Conclusion: Despite difference in design, the incidence of NC was similar for TAH and CFLVAD. The risk was highest early post device implantation. A large proportion of patients with either device survived NC without permanent disability.
5( 27) Cerebrovascular Accidents and End of Life Admissions Contribute Most to the Cost in Patients With Continuous Flow Left Ventricular Assist Devices G. Ashrith , F. Kotun, A.M. Cordero-Reyes, A. Bhimaraj, B.H. Trachtenberg, M. Loebe, G. Torre-Amione, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Continuous flow Left ventricular assist devices (LVAD) have proven to prolong life and quality of life in patients with end stage heart failure. However their cost effectiveness is still low compared to life prolonging therapies for other medical conditions. It is well known that the device and implantation contributes to the cost, but the contribution of readmissions to the overall cost is unknown. Methods: We retrospectively reviewed the readmission cost (in US Dollars) during the first year after implant of continuous flow device in 119 patients during years 2008-11 at The Methodist Hospital, Houston. There were a total of 226 readmissions during that time period (1-year post implant or death). Kruskal-Wallis one way ANOVA was used to compare differences between groups. Results: There were 14 admissions for cerebrovascular accidents (CVA), 36 for gastrointestinal (GI) bleeding, 67 for infections, 10 for arrhythmias, 27 for heart failure, 9 for VAD related mechanical issues, and 63 admissions for other medical problems. Average cost of readmission, cost per day and length of stay for each medical reason is given in Table. Stroke related readmission costs were significantly higher compared to all other conditions (Table). Twelve of 16 patients who expired after index implant admission, during the first year of follow up, died in our hospital. Admissions leading to demise were considerably expensive compared to any other hospital admission (USD 428,843+/-383,687 vs. 95023+/-56,888; p< 0.0001). Conclusion: CVAs in patients with LVADs incur most cost when compared to any other cause of readmission. Admission during which the patient expires adds considerably to the overall cost of the device. Better strategies to manage CVA and better end of life planning may reduce overall cost in patients with LVADs.
5( 28) Effectiveness of Continuous Flow Left Ventricular Assist Device Exchange for Recurrence of Major Drive Line and Pump Pocket Infection M.F. Masood , M. Romano, J.W. Haft, R. Hasan, K. Aaronson, F. Pagani. Cardiac Surgery, University of Michigan, Ann Arbor, MI.