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Magnitude of Bleeding and Blood Product Utilization Predict Early Right Ventricular Implantation in LVAD Recipients
Abstracts exchange (PE). We thought to characterize indication and outcomes of LVAD PE in our institution. Methods: A total of 240 continuous flow LVAD were implanted between 2011 and July 2018. We performed a retrospective analysis of 24 LVAD PE performed on 20 patients, including indication for LVAD PE, time on support to first and second pump exchange, pump type, surgical approach, and operative outcomes. Results: Of 240 CF LVAD implants performed over 7 years, 24 (10%) represented pump exchange. Patient age was 47 (17-86) years at time of first implant, and all patients were male. A total of 24 LVAD PE were performed on 20 patients. Time on support until first LVAD PE was 548.3 days (41-1345), and to second LVAD PE was 225 days (13-456). Indications included pump thrombosis in 18 (90%) patients, and pump malfunction in 2 (10%) patients.Type of LVAD PE included 15 / 169 Heart Mate II (HMII)(8.8%), and 9 / 69 HeartWare (HW) (13%) (p<0.05). Time on support to first pump exchange was 516 days (411221), and 603 days (357-1345) for HMII and HW respectively.Operative approach involved median sternotomy on 11 (45%), subcostal approach on 10 (41%), and limited left thoracotomy on 3 (14%) patients. Postoperative survival to hospital discharge was 95% after first LVAD PE, and 100% after second LVAD PE. Major postoperative complications included surgical bleeding requiring open chest with delayed closure (n=4), renal insufficiency requiring hemodialysis (n=5), and recurrence of driveline infection (n=6). Of 19 patients discharged after first LVAD PE, 5 (26%) underwent heart transplantation after LVAD PE, and 5 of the remaining 14 patients (36%) were alive at 2 years after first LVAD PE. Conclusion: LVAD PE is a safe and effective therapy for patients presenting pump thrombosis or device malfunction. About 20% of patients will require a second LVAD PE within a year. 912 How Do Mechanical Circulatory Support Patients Die? Autopsy Findings for Bridge to Transplant LVAD/TAH Patients Who Do Not Survive to Transplant N.K. Bart,1 K. Muthiah,1 P.C. Jansz,2 and C.S. Hayward.1 1Heart Transplant and Failure, St Vincents Hospital, Sydney, Australia; and the 2 Cardiothoracic Surgery, St Vincents Hospital, Sydney, Australia. Purpose: Despite being life saving for end-stage heart failure patients, permanent mechanical circulatory support (MCS) is often the proximate cause of death in those that do not make it to transplant. Autopsy is the gold standard for causes of mortality, and is a vital tool for better understanding of pathology in this patient cohort. The aim of this study was to determine the frequency and outcomes of autopsy investigations over the course of a MCS program in a single center. Methods: The autopsy findings of all patients who had a left ventricular assist device (LVAD) and total artificial heart (TAH) inserted between June 1994 and December 2016 as a bridge to transplant but subsequently died on pump were reviewed. Results: A total of 187 patients had an LVAD or TAH implanted during the study. The cohort who died on pump (n=59; M=45, F=14) had an average age at implant of 53 § 14 yrs, average INTERMACS score of 2, and average time on pump of 325 § 316 days. Autopsies were conducted in 24/59 (41%) of patients. At autopsy, 8 patients had infection sited as cause of/contributing to the cause of death, one with purulent material obstructing the function of the pump. Six had explant swabs available. These were positive for MRSA, candida glabrata, pseudomonas fluorescens, scedosporium in 4 patients respectively, and 3/6 had positive explant swabs for pseudomonas aeruginosa. Lung injury was common, with 4 patients having acute respiratory distress syndrome, and 5 patients with diffuse alveolar damage. Four patients had intracranial hemorrhage, 2 patients had other bleeding (small bowel, haemopericardium), 1 patient had pump thrombus, 1 active myocarditis, and there was 1 accidental disconnection of the driveline. Conclusion: Over an observational period of 22 years, the frequency of autopsies ordered was low. In order to keep patients alive to transplant, clinicians require a better understanding of causes of death. Patients with mechanical circulatory support have complex physiology and are at high risk of infection and bleeding complications.
S363 913 Psychosocial Evaluation of Candidates for Mechanical Circulatory Support and Risk for Adverse Post-Implantation Medical Outcomes M.A. Dew,1 J. Hollenberger,2 L.L. Obregon,3 G.W. Hickey,4 C.M. Sciortino,4 K.L. Lockard,4 N.M. Kunz,4 M.A. Mathier,4 R.N. Ramani,4 A. Kilic,4 D.M. McNamara,4 M.A. Simon,4 and R.L. Kormos.4 1University of Pittsburgh School of Medicine and Medical Center, Pittsburgh, PA; 2 Grove City College, Grove City, PA and University of Pittsburgh Medical Center, Pittsburgh, PA; 3Heart and Vascular Institute, University of Pittsburgh Medical Center, and Carnegie Mellon University, Pittsburgh, PA; and the 4Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: A psychosocial evaluation is required for candidates for longterm mechanical circulatory support (MCS). Despite guidelines and recommendations for elements to be included in this evaluation, few data indicate whether evaluation findings are prognostic for adverse outcomes after MCS implantation. We examined this issue with respect to post-implant survival time, rehospitalization, and adverse medical events (AEs). Methods: A single-site retrospective analysis was performed using prospectively collected data for all patients aged ≥18 receiving long-term MCS between 4/2004-12/2017. We coded pre-implant psychosocial evaluations with an established rating system (Psychosocial Assessment of Candidates for Transplantation, Modified for MCS; m-PACT). The m-PACT yields a Total score (calculated so that higher=less favorable; range=0-20) and scores for 10 components reflecting social support; mental health and substance use; ability to perform activities of daily living; and knowledge and adherence to current medical requirements. Competing risk models (competing risks: transplant, weaning from MCS) were estimated to determine associations of m-PACT Total and component scores with survival time on MCS, time to unscheduled rehospitalization, and time to any of 14 classes of AEs. Pre-implant demographic and clinical factors were controlled. Results: In 238 MCS patients (M§SD age 56§13, 81% male, 83% white, 62% bridge to transplant, median time on MCS=256 days), survival time and time to rehospitalization were not significantly associated with mPACT Total. However, for each 1-point m-PACT Total score increase, AE risk increased by 7% (hazard ratio, HR=1.07, CI: 1.01, 1.15, p=.028). The individual types of AEs most affected were cardiovascular dysfunction and device malfunctions. The m-PACT components accounting for the influence of m-PACT Total on AE risk were poorer medical adherence at the time of the evaluation (HR=1.74, CI: 1.14, 1.67, p=.001), and mental health problems (HR=1.20, CI: 1.02, 1.61, p=.035). Conclusion: The psychosocial evaluation may provide prognostic information for post-implant outcomes. Strategies to address psychosocial risk factors either before implant or as soon as possible post-implant may help to reduce AE risk and thereby promote patient well-being during MCS.
914 Magnitude of Bleeding and Blood Product Utilization Predict Early Right Ventricular Implantation in LVAD Recipients J. Conroy,1 H. Lamba,1 J. Ho,1 J. Kraus,2 S. Chatterjee,1 S. Fedson,1 S. Sattee,1 F. Cheema,1 A. Civitello,1 R. Delgado,1 A. Shafii,1 G. Loor,1 T. Rosengart,1 O. Frazier,1 J. Morgan,1 and A. Nair.1 1Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Texas Heart Institute at Baylor College of Medicine, Houston, TX; and the 2 Baylor College of Medicine, Houston, TX. Purpose: We assessed the impact of blood loss and transfusion volume on right ventricular failure (RVF) requiring right-sided mechanical circulatory support (R-MCS) after continuous flow left ventricular assist device (CFLVAD) implantation. Methods: Retrospective review of 434 patients with CF-LVAD implantation from 2003 to 2017. Intraoperative blood loss, postoperative blood loss, and intraoperative transfusion volume was assessed for patients requiring R-MCS. Results: Mean patient age was 55.2§13.6 years. Heartware HVAD was inserted in 100 (23.0%) and HeartMate II in 334 (77.0%) patients. Of these, 49 (11.3%) patients required R-MCS. R-MCS placed within 24 hours
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of CF-LVAD (N=20, 4.6%) had significantly more intraoperative and postoperative blood loss, and received a significantly higher quantity of intraoperative blood products compared to patients who did not require R-MCS within 24 hours (Table 1). HeartMate II patients had higher 24 hour blood loss (3398.3§3721.6 vs 1621.2§1243.4 ml, p<0.001) and transfusion requirements (26.4§ 28.3 vs 14.5§17.6 Units, p<0.001) compared to HVAD patients. Transfusion volume was an independent predictor of early RHF. Other independent predictors of early RHF included the ratio of preoperative mean right atrial pressure to pulmonary capillary wedge and increased body surface. Conclusion: Intraoperative and postoperative blood loss as well as intraoperative transfusions were associated with development of early RVF requiring R-MCS. This highlights the importance of reducing coagulopathy and its associated need for transfusions in patients at risk for early R-MCS.
915 Surgical Management for Heart Failure: A Comparison of Left Ventricular Repair and Ventricular Assist Device H. Kanemitsu, K. Minatoya, K. Yamazaki, K. Sakamoto, M. Kawatou, J. Sakai, M. Kudo, M. Nakamura, R. Yamamoto, Y. Kitagata, Y. Ide and T. Ikeda. Cardiovascular Surgery, Kyoto University, Kyoto, Japan. Purpose: Currently, in Japan, implantable ventricular assist devices (VAD) are limited to bridge to transplantation (BTT). Therefore, left ventricular repair (LVR) has been applied to patients with severe heart failure who were ineligible for cardiac transplantation. We compared the mid-term results of surgical management with LVR and VAD for advanced heart failure. Methods: We enrolled 19 patients with advanced heart failure to undergo LVR (n=13) or implantation of VAD (n=6) from 2008 to 2015 in our institute. Procedures in LVR group included papillary muscle approximation in 13 patients, Batista type left ventricular repair in 6, Overlap in 1, and septal anterior ventricular exclusion in 1. The VAD used in this study was HeartMateII (Thoratec, Pleasanton, CA). All patients had symptoms of New York Heart Association class IV but 9 patients class III in LVR group. Results: Patients in Group LVR were older than those in Group VAD (Group LVR 63§14 years old vs Group VAD 44§17, p = 0.036). There were no significant differences in preoperative LV EF (Group LVR 21.2§ 9.1 vs Group VAD 20.3§10.0 %, p = 0.83) or LV end-diastolic dimension (Group LVR 72§13 vs Group VAD 70§12 mm, p = 0.71) between the groups. There was no significant differences in preoperative BNP values (Group LVR 914§500 vs Group VAD 615§241, p = 0.11). Group LVR had 2 in-hospital death after surgery, but VAD had none. There were no significant differences in LV EF (Group LVR 20.2§910.8 vs Group VAD 27.6§19.2 %, p = 0.41) or LV end-diastolic dimension (Group LVR 65§ 6 vs Group VAD 57§14 mm, p = 0.18) between the groups, immediately after surgery. Follow-up was 2.1§1.8 years long. There were total 10 deaths in Group LVR, but no patients died in Group VAD and 1 patient had transplantation during follow-up. Group VAD had superior 5-year survival rates (Log-rank: Group LVR 9 % vs Group VAD 100 %, p = 0.010.) Conclusion: Treatment with VAD in patients with advanced heart failure significantly improved survival compared with LVR. VAD as destination therapy should be warranted in Japan.
916 Complete Sternal-Sparing LVAD Implantation Improves Mobility Compared to Full Sternotomy B.C. Ayers, K. Wood, S. Sheen, E. Morrison, H. Vidula, J. Alexis, S. Prasad and I. Gosev. University of Rochester, Rochester, NY. Purpose: Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several associated benefits. We hypothesized that the CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). Methods: We retrospectively reviewed all patients implanted with a commercial HeartMate 3 at our institution from September 2017 to August 2018 (N=52). Patients were grouped based on surgical technique, CSS or FS. Patients were excluded if they did not see a physical therapist within three weeks postoperatively. The Activity Measure for Post Acute Care (AM-PAC) short forms and Functional Independence Measure (FIM) scores were used to assess postoperative mobility and physical limitations. Results: A total of 43 patients were included in the study; 27 (63%) were implanted via the CSS approach and 16 (37%) underwent FS. Preoperative characteristics were similar between cohorts. By postoperative day 3 (POD3), the CSS cohort demonstrated improved mobility based on AMPAC scores compared to the FS group (Figure 1) with 40% of the CSS cohort versus 67% of the FS cohort remaining 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the FIM sit-to-stand metric (Figure 2) with 78% of the CSS cohort achieving modified or complete independence by POD15 compared to 21% of the FS patients. Conclusion: The CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and functional independence compared to FS.
S363 913 Psychosocial Evaluation of Candidates for Mechanical Circulatory Support and Risk for Adverse Post-Implantation Medical Outcomes M.A. Dew,1 J. Hollenberger,2 L.L. Obregon,3 G.W. Hickey,4 C.M. Sciortino,4 K.L. Lockard,4 N.M. Kunz,4 M.A. Mathier,4 R.N. Ramani,4 A. Kilic,4 D.M. McNamara,4 M.A. Simon,4 and R.L. Kormos.4 1University of Pittsburgh School of Medicine and Medical Center, Pittsburgh, PA; 2 Grove City College, Grove City, PA and University of Pittsburgh Medical Center, Pittsburgh, PA; 3Heart and Vascular Institute, University of Pittsburgh Medical Center, and Carnegie Mellon University, Pittsburgh, PA; and the 4Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: A psychosocial evaluation is required for candidates for longterm mechanical circulatory support (MCS). Despite guidelines and recommendations for elements to be included in this evaluation, few data indicate whether evaluation findings are prognostic for adverse outcomes after MCS implantation. We examined this issue with respect to post-implant survival time, rehospitalization, and adverse medical events (AEs). Methods: A single-site retrospective analysis was performed using prospectively collected data for all patients aged ≥18 receiving long-term MCS between 4/2004-12/2017. We coded pre-implant psychosocial evaluations with an established rating system (Psychosocial Assessment of Candidates for Transplantation, Modified for MCS; m-PACT). The m-PACT yields a Total score (calculated so that higher=less favorable; range=0-20) and scores for 10 components reflecting social support; mental health and substance use; ability to perform activities of daily living; and knowledge and adherence to current medical requirements. Competing risk models (competing risks: transplant, weaning from MCS) were estimated to determine associations of m-PACT Total and component scores with survival time on MCS, time to unscheduled rehospitalization, and time to any of 14 classes of AEs. Pre-implant demographic and clinical factors were controlled. Results: In 238 MCS patients (M§SD age 56§13, 81% male, 83% white, 62% bridge to transplant, median time on MCS=256 days), survival time and time to rehospitalization were not significantly associated with mPACT Total. However, for each 1-point m-PACT Total score increase, AE risk increased by 7% (hazard ratio, HR=1.07, CI: 1.01, 1.15, p=.028). The individual types of AEs most affected were cardiovascular dysfunction and device malfunctions. The m-PACT components accounting for the influence of m-PACT Total on AE risk were poorer medical adherence at the time of the evaluation (HR=1.74, CI: 1.14, 1.67, p=.001), and mental health problems (HR=1.20, CI: 1.02, 1.61, p=.035). Conclusion: The psychosocial evaluation may provide prognostic information for post-implant outcomes. Strategies to address psychosocial risk factors either before implant or as soon as possible post-implant may help to reduce AE risk and thereby promote patient well-being during MCS.
914 Magnitude of Bleeding and Blood Product Utilization Predict Early Right Ventricular Implantation in LVAD Recipients J. Conroy,1 H. Lamba,1 J. Ho,1 J. Kraus,2 S. Chatterjee,1 S. Fedson,1 S. Sattee,1 F. Cheema,1 A. Civitello,1 R. Delgado,1 A. Shafii,1 G. Loor,1 T. Rosengart,1 O. Frazier,1 J. Morgan,1 and A. Nair.1 1Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Texas Heart Institute at Baylor College of Medicine, Houston, TX; and the 2 Baylor College of Medicine, Houston, TX. Purpose: We assessed the impact of blood loss and transfusion volume on right ventricular failure (RVF) requiring right-sided mechanical circulatory support (R-MCS) after continuous flow left ventricular assist device (CFLVAD) implantation. Methods: Retrospective review of 434 patients with CF-LVAD implantation from 2003 to 2017. Intraoperative blood loss, postoperative blood loss, and intraoperative transfusion volume was assessed for patients requiring R-MCS. Results: Mean patient age was 55.2§13.6 years. Heartware HVAD was inserted in 100 (23.0%) and HeartMate II in 334 (77.0%) patients. Of these, 49 (11.3%) patients required R-MCS. R-MCS placed within 24 hours
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of CF-LVAD (N=20, 4.6%) had significantly more intraoperative and postoperative blood loss, and received a significantly higher quantity of intraoperative blood products compared to patients who did not require R-MCS within 24 hours (Table 1). HeartMate II patients had higher 24 hour blood loss (3398.3§3721.6 vs 1621.2§1243.4 ml, p<0.001) and transfusion requirements (26.4§ 28.3 vs 14.5§17.6 Units, p<0.001) compared to HVAD patients. Transfusion volume was an independent predictor of early RHF. Other independent predictors of early RHF included the ratio of preoperative mean right atrial pressure to pulmonary capillary wedge and increased body surface. Conclusion: Intraoperative and postoperative blood loss as well as intraoperative transfusions were associated with development of early RVF requiring R-MCS. This highlights the importance of reducing coagulopathy and its associated need for transfusions in patients at risk for early R-MCS.
915 Surgical Management for Heart Failure: A Comparison of Left Ventricular Repair and Ventricular Assist Device H. Kanemitsu, K. Minatoya, K. Yamazaki, K. Sakamoto, M. Kawatou, J. Sakai, M. Kudo, M. Nakamura, R. Yamamoto, Y. Kitagata, Y. Ide and T. Ikeda. Cardiovascular Surgery, Kyoto University, Kyoto, Japan. Purpose: Currently, in Japan, implantable ventricular assist devices (VAD) are limited to bridge to transplantation (BTT). Therefore, left ventricular repair (LVR) has been applied to patients with severe heart failure who were ineligible for cardiac transplantation. We compared the mid-term results of surgical management with LVR and VAD for advanced heart failure. Methods: We enrolled 19 patients with advanced heart failure to undergo LVR (n=13) or implantation of VAD (n=6) from 2008 to 2015 in our institute. Procedures in LVR group included papillary muscle approximation in 13 patients, Batista type left ventricular repair in 6, Overlap in 1, and septal anterior ventricular exclusion in 1. The VAD used in this study was HeartMateII (Thoratec, Pleasanton, CA). All patients had symptoms of New York Heart Association class IV but 9 patients class III in LVR group. Results: Patients in Group LVR were older than those in Group VAD (Group LVR 63§14 years old vs Group VAD 44§17, p = 0.036). There were no significant differences in preoperative LV EF (Group LVR 21.2§ 9.1 vs Group VAD 20.3§10.0 %, p = 0.83) or LV end-diastolic dimension (Group LVR 72§13 vs Group VAD 70§12 mm, p = 0.71) between the groups. There was no significant differences in preoperative BNP values (Group LVR 914§500 vs Group VAD 615§241, p = 0.11). Group LVR had 2 in-hospital death after surgery, but VAD had none. There were no significant differences in LV EF (Group LVR 20.2§910.8 vs Group VAD 27.6§19.2 %, p = 0.41) or LV end-diastolic dimension (Group LVR 65§ 6 vs Group VAD 57§14 mm, p = 0.18) between the groups, immediately after surgery. Follow-up was 2.1§1.8 years long. There were total 10 deaths in Group LVR, but no patients died in Group VAD and 1 patient had transplantation during follow-up. Group VAD had superior 5-year survival rates (Log-rank: Group LVR 9 % vs Group VAD 100 %, p = 0.010.) Conclusion: Treatment with VAD in patients with advanced heart failure significantly improved survival compared with LVR. VAD as destination therapy should be warranted in Japan.
916 Complete Sternal-Sparing LVAD Implantation Improves Mobility Compared to Full Sternotomy B.C. Ayers, K. Wood, S. Sheen, E. Morrison, H. Vidula, J. Alexis, S. Prasad and I. Gosev. University of Rochester, Rochester, NY. Purpose: Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several associated benefits. We hypothesized that the CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). Methods: We retrospectively reviewed all patients implanted with a commercial HeartMate 3 at our institution from September 2017 to August 2018 (N=52). Patients were grouped based on surgical technique, CSS or FS. Patients were excluded if they did not see a physical therapist within three weeks postoperatively. The Activity Measure for Post Acute Care (AM-PAC) short forms and Functional Independence Measure (FIM) scores were used to assess postoperative mobility and physical limitations. Results: A total of 43 patients were included in the study; 27 (63%) were implanted via the CSS approach and 16 (37%) underwent FS. Preoperative characteristics were similar between cohorts. By postoperative day 3 (POD3), the CSS cohort demonstrated improved mobility based on AMPAC scores compared to the FS group (Figure 1) with 40% of the CSS cohort versus 67% of the FS cohort remaining 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the FIM sit-to-stand metric (Figure 2) with 78% of the CSS cohort achieving modified or complete independence by POD15 compared to 21% of the FS patients. Conclusion: The CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and functional independence compared to FS.