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LVAD Implantation in Patients on ECLS
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
hemodynamics post-LVAD implantation as compared to pre-LVAD time point (Figure, panel A). Post-heart transplant, the reversal in pulmonary hypertension was similarly sustained in the two groups (Figure, panel B). Use of vasodilatory medications, before and after heart transplantation, was comparable between the groups. Conclusion: Both types of CF-LVADs (AX and CR) seem to exert a comparable effect on the degree and sustainability of pulmonary hypertension reversal before and after heart transplantation.
8( 94) LVAD Implantation in Patients on ECLS M.J. Morshuis ,1 A. Koster,2 M. Schönbrodt,1 J. Gummert.1 1Cardiothoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany; 2Anaesthesiology, Heart Center NRW, Bad Oeynhausen, Germany. Purpose: ECLS implantation in end stage refractory cardiac failure is increasing in a bridge to bridge setting. If LVAD implantation is indicated, we developed a technique for implantation on femoro-femoral ECLS support. Methods: Systems used for femoro-femoral ECLS support were Thoratec® centrimag©, Medos© Deltastream© and Maquet® Cardiohelp©. All systems were installed by seldinger-technique over the femoral artery and vein. A shunt to avoid limb ischemia was installed in all cases. If recovery did not occur and LVAD implantation was indicated, this was performed on ECLS if no additional procedure was planned in patients receiving HeartWareTM. The anastomis between outflow graft and aorta was performed first, then the coring of the left ventricle. The device was de-aired retrogradely and could be installed. Bloodloss was avoided as much as possible. A needlevent connected to a cell saver was installed in the ascending aorta for de-airing during the startup procedure of the LVAD. In case additional procedures like ASD closure, tricuspid reconstruction or aortic valve replacement was indicated a heart lung machine (HLM) was installed. HeartMate II® was implanted with HLM in all cases. Results: Between September 2006 and August 2015, 93 patients were receiving LVAD therapy after ECLS support. 41 Patients (group A) were implanted under ECLS support, in 52 patients (group B) the ECLS was converted to HLM for implantation of the LVAD. The 30 days mortality in group A was 9.8% (n= 4). In group B the 30 day mortality was 26.9% (n= 14) (Chi-Quadrat-Test p= 0.084, NS) Conclusion: LVAD implantation after ECLS support can be performed on ECLS without HLM. In case of additional procedures a HLM has to be installed. Although this study has limitations, LVAD implantation on ECLS support seems to be a safe option which could reduce 30 day mortality.
8( 95) Is the Diameter of the Outflow Graft the Crucial Difference in Stroke Rates Between Heartmate II and HVAD? A Computational Fluid Dynamics Study K. Balakrishnan ,1 S. Bhat,2 J. Mathew,2 R. Krishnakumar.2 1Cardiac Surgery, Fortis Malar Hospital, Chennai, India; 2Engineering Design, Indian Institute of Technology, Chennai, India. Purpose: We hypothesised that the difference in stroke rates observed in the ENDURANCE trial between HVAD and Heartmate II could be attributed to the difference in outflow graft diameters. Cerebral blood flow (CBF) patterns in the neck vessels was compared between 1. Normal pulsatile blood flow 2. A continuous flow pump (CFP) with a 10 mm outflow graft 3. CFP with a 14 mm outflow graft Methods: CT scan of a patient was converted into a 3D geometric model using Image Segmentation and Registration tool kit and a mesh for fluid structure interaction was prepared with four noded shell elements for the aortic wall and a tetrahedral fluid element. The complete human arterial tree model was built in Simulink .A CFP output of 5.8 Ltr/min and completely closed aortic valve condition was considered in the computational fluid dynamics analysis and the flow in the cerebral vessels was a DERIVED parameter and NOT given as an input. we studied CBF in 1. Normal pulsatile blood flow 2. Flow through a 10 mm and a 14 mm graft attached to the aorta at an angle of 30 and 45 degrees 3. Influence of aortic incompetence on CBF 4. Impact of varying blood pressures for the same VAD flow Results: Compared to pulsatile flow, the CBF velocities are significantly lower in CFP. 2. Due to a jet effect, a 10 mm graft has a lot of eddies and stasis as compared with a 14 mm graft which mimics normal flow much more closely 3. The angle of insertion also seems more crucial in a 10 mm but not in a 14 mm graft with the worst results at an angle of 45 degrees in a 10 mm graft 4. There is a disproportionate drop in CBF with the onset of aortic incompetence 5. Blood pressure had no independent effect on CBF as long as pump flows were unchanged Conclusion: A 14 mm outflow graft has more favourable CBF characteristics than a 10 mm graft Aortic incompetence has an adverse effect on CBF out of proportion to the degree of aortic leak. These findings might explain the observed differences in stroke rates in the two pumps. More studies are needed validate these findings.
8( 96) Minimally Invasive Heartware HVAD Implantation with Outflow Graft Anastomosis to the Left Subclavian Artery J. Riebandt ,1 D. Wiedemann,1 T. Haberl,1 T. Schloeglhofer,2 R. Moayedifar,1 K. Dimitrov,1 G. Laufer,1 D. Zimpfer.1 1Cardiac Surgery, Medical Univ Vienna, Vienna, Austria; 2Medical Physics and Biomedical Engineering, Medical Univ Vienna, Vienna, Austria. Purpose: The implantation of a left ventricular assist device has become a standard treatment option for terminal heart failure. We present our institutional experience with an alternative less invasive surgical approach for the Heartware HVAD with outflow graft anastomosis to the left subclavian artery. Methods: A left sided mini-thoracotomy in the fourth or fifth intercostal space is performed for apical exposure; the subclavian artery is accessed by an incision below and parallel to the left clavicle. The outflow graft is then tunneled through the thoracic cavity and first intercostal space. Implantation can
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
hemodynamics post-LVAD implantation as compared to pre-LVAD time point (Figure, panel A). Post-heart transplant, the reversal in pulmonary hypertension was similarly sustained in the two groups (Figure, panel B). Use of vasodilatory medications, before and after heart transplantation, was comparable between the groups. Conclusion: Both types of CF-LVADs (AX and CR) seem to exert a comparable effect on the degree and sustainability of pulmonary hypertension reversal before and after heart transplantation.
8( 94) LVAD Implantation in Patients on ECLS M.J. Morshuis ,1 A. Koster,2 M. Schönbrodt,1 J. Gummert.1 1Cardiothoracic Surgery, Heart Center NRW, Bad Oeynhausen, Germany; 2Anaesthesiology, Heart Center NRW, Bad Oeynhausen, Germany. Purpose: ECLS implantation in end stage refractory cardiac failure is increasing in a bridge to bridge setting. If LVAD implantation is indicated, we developed a technique for implantation on femoro-femoral ECLS support. Methods: Systems used for femoro-femoral ECLS support were Thoratec® centrimag©, Medos© Deltastream© and Maquet® Cardiohelp©. All systems were installed by seldinger-technique over the femoral artery and vein. A shunt to avoid limb ischemia was installed in all cases. If recovery did not occur and LVAD implantation was indicated, this was performed on ECLS if no additional procedure was planned in patients receiving HeartWareTM. The anastomis between outflow graft and aorta was performed first, then the coring of the left ventricle. The device was de-aired retrogradely and could be installed. Bloodloss was avoided as much as possible. A needlevent connected to a cell saver was installed in the ascending aorta for de-airing during the startup procedure of the LVAD. In case additional procedures like ASD closure, tricuspid reconstruction or aortic valve replacement was indicated a heart lung machine (HLM) was installed. HeartMate II® was implanted with HLM in all cases. Results: Between September 2006 and August 2015, 93 patients were receiving LVAD therapy after ECLS support. 41 Patients (group A) were implanted under ECLS support, in 52 patients (group B) the ECLS was converted to HLM for implantation of the LVAD. The 30 days mortality in group A was 9.8% (n= 4). In group B the 30 day mortality was 26.9% (n= 14) (Chi-Quadrat-Test p= 0.084, NS) Conclusion: LVAD implantation after ECLS support can be performed on ECLS without HLM. In case of additional procedures a HLM has to be installed. Although this study has limitations, LVAD implantation on ECLS support seems to be a safe option which could reduce 30 day mortality.
8( 95) Is the Diameter of the Outflow Graft the Crucial Difference in Stroke Rates Between Heartmate II and HVAD? A Computational Fluid Dynamics Study K. Balakrishnan ,1 S. Bhat,2 J. Mathew,2 R. Krishnakumar.2 1Cardiac Surgery, Fortis Malar Hospital, Chennai, India; 2Engineering Design, Indian Institute of Technology, Chennai, India. Purpose: We hypothesised that the difference in stroke rates observed in the ENDURANCE trial between HVAD and Heartmate II could be attributed to the difference in outflow graft diameters. Cerebral blood flow (CBF) patterns in the neck vessels was compared between 1. Normal pulsatile blood flow 2. A continuous flow pump (CFP) with a 10 mm outflow graft 3. CFP with a 14 mm outflow graft Methods: CT scan of a patient was converted into a 3D geometric model using Image Segmentation and Registration tool kit and a mesh for fluid structure interaction was prepared with four noded shell elements for the aortic wall and a tetrahedral fluid element. The complete human arterial tree model was built in Simulink .A CFP output of 5.8 Ltr/min and completely closed aortic valve condition was considered in the computational fluid dynamics analysis and the flow in the cerebral vessels was a DERIVED parameter and NOT given as an input. we studied CBF in 1. Normal pulsatile blood flow 2. Flow through a 10 mm and a 14 mm graft attached to the aorta at an angle of 30 and 45 degrees 3. Influence of aortic incompetence on CBF 4. Impact of varying blood pressures for the same VAD flow Results: Compared to pulsatile flow, the CBF velocities are significantly lower in CFP. 2. Due to a jet effect, a 10 mm graft has a lot of eddies and stasis as compared with a 14 mm graft which mimics normal flow much more closely 3. The angle of insertion also seems more crucial in a 10 mm but not in a 14 mm graft with the worst results at an angle of 45 degrees in a 10 mm graft 4. There is a disproportionate drop in CBF with the onset of aortic incompetence 5. Blood pressure had no independent effect on CBF as long as pump flows were unchanged Conclusion: A 14 mm outflow graft has more favourable CBF characteristics than a 10 mm graft Aortic incompetence has an adverse effect on CBF out of proportion to the degree of aortic leak. These findings might explain the observed differences in stroke rates in the two pumps. More studies are needed validate these findings.
8( 96) Minimally Invasive Heartware HVAD Implantation with Outflow Graft Anastomosis to the Left Subclavian Artery J. Riebandt ,1 D. Wiedemann,1 T. Haberl,1 T. Schloeglhofer,2 R. Moayedifar,1 K. Dimitrov,1 G. Laufer,1 D. Zimpfer.1 1Cardiac Surgery, Medical Univ Vienna, Vienna, Austria; 2Medical Physics and Biomedical Engineering, Medical Univ Vienna, Vienna, Austria. Purpose: The implantation of a left ventricular assist device has become a standard treatment option for terminal heart failure. We present our institutional experience with an alternative less invasive surgical approach for the Heartware HVAD with outflow graft anastomosis to the left subclavian artery. Methods: A left sided mini-thoracotomy in the fourth or fifth intercostal space is performed for apical exposure; the subclavian artery is accessed by an incision below and parallel to the left clavicle. The outflow graft is then tunneled through the thoracic cavity and first intercostal space. Implantation can