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Impact of Concomitant Valvular Surgery on Patients Undergoing LVAD Implantation
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
supported with Impella died within three days of LVAD implant and was excluded from analysis. Post LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared to 43% of those without Impella (13 of 30) [p = 0.038]. There was no difference in severity or incidence of AI based on type of Impella device or type of LVAD used. Conclusion: In our cohort, patients supported with Impella as a bridge to durable LVAD have higher risk of developing AI. Further studies are needed to identify risk factors and develop strategies to mitigate this risk as the use of Impella becomes more widespread.
Table
Rates of AI based on Pre LVAD Mechanical Support Less than Mild AI
Pre Implant 3 Impella (n = 12) No Impella prior 17 to implant (n = 30)
Mild to Moderate AI 9 (82%)
p = 0.038
13 (43%)
155 Impact of Concomitant Valvular Surgery on Patients Undergoing LVAD Implantation K.Y. Mulumba,1 P. Kasinpila,1 R. Fong,1 S. Kong,1 L. Hecker,1 R. Nissan,1 D. Banerjee,2 J. Teuteberg,2 Y. Shudo,1 Y. Woo,1 and W. Hiesinger.1 1Cardiothoracic Surgery, Stanford University, Palo Alto, CA; and the 2Cardiology, Stanford University, Palo Alto, CA. Purpose: Concomitant valvular surgery at the time of left ventricular device (LVAD) implantation remains controversial. This study aims to evaluate outcomes of these patients compared to the isolated-LVAD cohort. Methods: We examined 309 adult LVAD patients (2009-2018) at Stanford and identified those who underwent concomitant aortic, mitral, or tricuspid valve surgery. Pre- and post-operative data were analyzed and compared with those who underwent LVAD implantation alone. We also performed a case-control study to compare the concomitant valve-LVAD patients to those with ≥ 3+ or 4+ regurgitation (moderate and severe, respectively) who only received an LVAD. Continuous variables were analyzed using student’s t test and reported as mean § standard deviation (SD), and Wilcoxon rank-sum test with median and 1st and 3rd quartile values (Q1 and Q3). Categorical variables were analyzed using Fisher’s exact test (n, %). All p-values are two tailed with <0.05 corresponding to statistical significance. Results: Twenty-two patients had valvular intervention at the time of LVAD placement: 10 aortic, 11 tricuspid, and 1 mitral. Preop demographics were similar across all groups. Expectedly, intraop data showed that patients with concomitant valve surgery had greater cardiopulmonary bypass (CPB) time than those without valve surgery. They also had higher rates of OR take-backs for bleeding, tracheostomy, dialysis, post-op stroke, and overall mortality. Furthermore, patients undergoing both LVAD-TVR and LVAD-AVR subsets had longer CPB time, but the LVAD-TVR group alone was at higher risk for bleeding, tracheostomy, dialysis, longer hospital stay, and lower overall survival. (Table 1 does not include LVAD-AVR and MVR data.) Conclusion: Patients undergoing concomitant valve surgery at time of LVAD placement have higher risk for increased complications and mortality when compared to the isolated-LVAD cohort. However, these risks are more apparent only in patients undergoing LVAD-TVR and not in the LVAD-AVR or MVR cohorts.
Table 1: Table comparing data between valve-LVAD outcomes VS LVAD alone Concomitant valve surgery (n=22) LVAD without valve surgery (n=287) p-value LVAD+tricuspid valve (n=11) Patients with mod to severe TR (N=121) p-value Age (mean § SD) 60.8 §13.7 55.2§14.3 0.076 54.9 § 16.0 55.6 § 13.3 0.987 Gender, male, n (%) 15(68.12%) 221 (77%) 0.348 7 (63.6%) 98 (81%) 0.2346 Body Mass Index (kg/m2), (mean § SD) 27.57§ 6.2 27.42§6.32 0.915 27.8 § 7.85 26.5 § 6.65 0.5234 Previous cardiac surgery, n (%) 9 (40.9%) 71 (25%) 0.102 3 (27.3%) 31 (25.8%) 1 INTERMACS class (mean § SD) 2.68 §1.4 2.59§1.4 0.69 2.45 § 1.75 2.51 § 0.95 0.2748 BTT LVAD indication, n (%) 10 (45.5%) 143 (50.5%) 0.646 6 (60%) 56 (47.5%) 0.5981 CPB, minutes (median; Q1, Q3) 131 (100.5, 164) 67 (49.5, 97) <0.00001 131 (80, 152) 62.5 (46, 94.8) 0.0015 Total product transfusion in 1 week, units (mean § SD) 10.59 § 11.59 12.82 § 17.39 0.555 11.1 § 12.4 14.8 § 16.8 0.6383 Dialysis, n (%) 9 (40.9%) 62 (21.8%) 0.04 7 (63.6%) 28 (23.1%) 0.0078 Take back to OR for bleeding, n (%) 10 (45.5%) 70 (24.6%)
(continued)
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
supported with Impella died within three days of LVAD implant and was excluded from analysis. Post LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared to 43% of those without Impella (13 of 30) [p = 0.038]. There was no difference in severity or incidence of AI based on type of Impella device or type of LVAD used. Conclusion: In our cohort, patients supported with Impella as a bridge to durable LVAD have higher risk of developing AI. Further studies are needed to identify risk factors and develop strategies to mitigate this risk as the use of Impella becomes more widespread.
Table
Rates of AI based on Pre LVAD Mechanical Support Less than Mild AI
Pre Implant 3 Impella (n = 12) No Impella prior 17 to implant (n = 30)
Mild to Moderate AI 9 (82%)
p = 0.038
13 (43%)
155 Impact of Concomitant Valvular Surgery on Patients Undergoing LVAD Implantation K.Y. Mulumba,1 P. Kasinpila,1 R. Fong,1 S. Kong,1 L. Hecker,1 R. Nissan,1 D. Banerjee,2 J. Teuteberg,2 Y. Shudo,1 Y. Woo,1 and W. Hiesinger.1 1Cardiothoracic Surgery, Stanford University, Palo Alto, CA; and the 2Cardiology, Stanford University, Palo Alto, CA. Purpose: Concomitant valvular surgery at the time of left ventricular device (LVAD) implantation remains controversial. This study aims to evaluate outcomes of these patients compared to the isolated-LVAD cohort. Methods: We examined 309 adult LVAD patients (2009-2018) at Stanford and identified those who underwent concomitant aortic, mitral, or tricuspid valve surgery. Pre- and post-operative data were analyzed and compared with those who underwent LVAD implantation alone. We also performed a case-control study to compare the concomitant valve-LVAD patients to those with ≥ 3+ or 4+ regurgitation (moderate and severe, respectively) who only received an LVAD. Continuous variables were analyzed using student’s t test and reported as mean § standard deviation (SD), and Wilcoxon rank-sum test with median and 1st and 3rd quartile values (Q1 and Q3). Categorical variables were analyzed using Fisher’s exact test (n, %). All p-values are two tailed with <0.05 corresponding to statistical significance. Results: Twenty-two patients had valvular intervention at the time of LVAD placement: 10 aortic, 11 tricuspid, and 1 mitral. Preop demographics were similar across all groups. Expectedly, intraop data showed that patients with concomitant valve surgery had greater cardiopulmonary bypass (CPB) time than those without valve surgery. They also had higher rates of OR take-backs for bleeding, tracheostomy, dialysis, post-op stroke, and overall mortality. Furthermore, patients undergoing both LVAD-TVR and LVAD-AVR subsets had longer CPB time, but the LVAD-TVR group alone was at higher risk for bleeding, tracheostomy, dialysis, longer hospital stay, and lower overall survival. (Table 1 does not include LVAD-AVR and MVR data.) Conclusion: Patients undergoing concomitant valve surgery at time of LVAD placement have higher risk for increased complications and mortality when compared to the isolated-LVAD cohort. However, these risks are more apparent only in patients undergoing LVAD-TVR and not in the LVAD-AVR or MVR cohorts.
Table 1: Table comparing data between valve-LVAD outcomes VS LVAD alone Concomitant valve surgery (n=22) LVAD without valve surgery (n=287) p-value LVAD+tricuspid valve (n=11) Patients with mod to severe TR (N=121) p-value Age (mean § SD) 60.8 §13.7 55.2§14.3 0.076 54.9 § 16.0 55.6 § 13.3 0.987 Gender, male, n (%) 15(68.12%) 221 (77%) 0.348 7 (63.6%) 98 (81%) 0.2346 Body Mass Index (kg/m2), (mean § SD) 27.57§ 6.2 27.42§6.32 0.915 27.8 § 7.85 26.5 § 6.65 0.5234 Previous cardiac surgery, n (%) 9 (40.9%) 71 (25%) 0.102 3 (27.3%) 31 (25.8%) 1 INTERMACS class (mean § SD) 2.68 §1.4 2.59§1.4 0.69 2.45 § 1.75 2.51 § 0.95 0.2748 BTT LVAD indication, n (%) 10 (45.5%) 143 (50.5%) 0.646 6 (60%) 56 (47.5%) 0.5981 CPB, minutes (median; Q1, Q3) 131 (100.5, 164) 67 (49.5, 97) <0.00001 131 (80, 152) 62.5 (46, 94.8) 0.0015 Total product transfusion in 1 week, units (mean § SD) 10.59 § 11.59 12.82 § 17.39 0.555 11.1 § 12.4 14.8 § 16.8 0.6383 Dialysis, n (%) 9 (40.9%) 62 (21.8%) 0.04 7 (63.6%) 28 (23.1%) 0.0078 Take back to OR for bleeding, n (%) 10 (45.5%) 70 (24.6%)
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