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Medium-Term Circulatory Support for Cardiogenic Shock in a Developing Country: Do We Need a Long-Term Device?
Abstracts S217
5( 80) Histopathological Analysis of the Mitral Valve After Long-Term Mechanical Circulatory Support H. Hata ,1 T. Fujita,1 H. Ishibashi-Ueda,2 T. Nakatani,3 J. Kobayashi.1 1Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan; 2Pathology, National Cerebral and Cardiovascular Center, Suita, Japan; 3Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan. Purpose: In Japan, destination therapy-use of left ventricular assisting device (LVAD) is not allowed; however, the LVAD support period of bridge to transplant-use is extremely long. The objective of this study was to investigate the pathological change of the mitral valve after long-term LVAD support. Methods: Forty-one hearts removed at heart transplantation were investigated. Five patients had undergone mitral valve repair or replacement. Thirty-four patients were supported by extracorporeal pulsatile device (Nipro-LVAD) and 7 patients by implantable devices (DuraHeart in 2 patients, EVAHEART in 2 patients, Heartmate II in 1 patient, Jarvik 2000 in 1 patient, Novacor in 1 patient). We compared the histological change of the mitral valve with the results of echocardiogram. Results: The mean duration of LVAD support until heart transplantation was 961+/-307 (ranged from 416 to 1697, median 927) days. Although the mean left ventricular end diastolic/systolic diameter (from 73/66 to 61/55mm) and left atrial diameter (from 46 to 33mm) significantly decreased and mitral regurgitation improved after LVAD implantation, the mitral annulus was still dilated (mean circumference length was 11.1cm, ranged from 8.3 to 14.5cm) in the 36 patients without mitral valve operation. Mitral leaflet became thinner and showed myxomatous degeneration with loose collagen fiber in these patients. In the patients with previous mitral annuloplasty, the mitral annular circumference length was kept normally, mean of 8.1cm. Statistically, there was no close correlation between circumference length of mitral annulus and left ventricular dimension, LVAD support duration time, the grade of mitral regurgitation, cardiac function, or etiology of heart failure. Conclusion: Although significant reverse remodeling of left ventricle was observed after long-term LVAD support, mitral annulus dilation still remained. Concomitant mitral valve surgery with LVAD implantation may be the procedure of choice. 5( 81) Medium-Term Circulatory Support for Cardiogenic Shock in a Developing Country: Do We Need a Long-Term Device? M.A. Villavicencio ,1 V. Rossel,2 R. Larrea,1 J.P. Peralta,1 E. Larrain,1 J.S. Lim,3 E. Donoso,3 F. Gajardo,3 M. Hurtado.1 1Unidad de Trasplante, Clinica Davila, Santiago, Chile; 2Departamento de Medicina, Universidad
de Chile, Santiago, Chile; 3Unidad de Trasplante, Instituto Nacional del Tórax, Santiago, Chile. Purpose: Bridge-to-transplant long-term devices are commonly not affordable for our health system and usually they are not suitable for critically ill patients. Centrimag® may be an alternative for a one-step bridge-to-transplant surgical procedure. Methods: Retrospective review of 28 patients subjected to Centrimag® implantation. Twenty-three (82%) were male, mean age 42+13 years. Etiology of heart failure was ischemic in 13(46%), dilated cardiomyopathy in 8(29%), and other 7(25%).All were INTERMACS class I, 27(96%) had multiorgan failure, and in 26(93%) the indication was failure of medical management. Twelve (43%) had previous cardiac arrest with a mean arrest time of 21+17 min. Circulatory support was biventricular: 25(89%), univentricular 3(11%), and in 9(32%) an oxygenator was interposed until respiratory recovery. Results: Thirty-day post-implant survival was 79% (22 patients). Bridge-totransplant or recovery: 20 (71%) patients. Mean support time was 40 days, and 12(43%) were supported > 4 weeks. The longest support was 292 days. Eight (29%) died before been bridged. Post-implant complications: re-exploration for bleeding 10(36%), neurologic dysfunction 4(14%), pneumonia 10(36%), bacteremia 5(36%) and acute dialysis 8(29%). Kaplan Meier two-year survival: 62+10%. Mean follow-up time: 21 months with a total of 579 months. All alive patients were in NYHA functional class I with normal biventricular function. Conclusion: Centrimag® is useful to provide medium-term support for cardiogenic shock in a developing country. Support longer than 4 weeks is feasible. A bridge-to-transplant long-term device may not be needed in the setting of a waiting time less than 3 months. 5( 82) Subclinical Hemorrhagic Cerebral Lesions Are Prevalent in Patients With Long Term Continuous-Flow LVAD Support D. Yoshioka ,1 K. Toda,1 T. Nakamura,1 S. Miyagawa,1 Y. Yoshikawa,1 S. Fukushima,1 S. Saito,1 T. Saito,2 Y. Sawa.1 1Cardiovascular surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; 2Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan. Purpose: Continuous-flow left ventricular assist device (cLVAD) provides sufficient clinical results for heart failure patients, however cerebrovascular accident (CVA) is still critical complications in patients with cLVAD and it is important to evaluate accurate etiology of CVA to decrease CVA in cLVAD patients. In this study, we evaluated the prevalence of asymptomatic small cerebrovascular complication during cLVAD support. Methods: Among 31 patients who underwent heart transplantation at Osaka University Hospital since 2011, 24 patients had continuous-flow LVAD support (DuraHeart: 16, HeartMateII: 3, HeartWare: 2, Jarvik2000: 3) of mean duration of 2.50 ± 0.95 years. In these 24 patients, excluding one patient who died of primary graft failure, we performed brain magnetic resonance imaging (MRI) before the first discharge after heart transplantation. The prevalence of symptomatic and asymptomatic cerebral lesions in these 23 patients was analyzed. An ischemic lesion was defined as high density signal in fluid-attenuated inversion recovery (FLAIR) -MR imaging, whereas a hemorrhagic lesion was defined as low density signal in T2-weighted gradient-echo imaging. Results: During cLVAD support, 2 patients had symptomatic cerebral infarction and 3 patients had symptomatic intracranial hemorrhage (2: intracerebral hemorrhage, 1: subarachnoid hemorrhage) which were detected by computed tomography scan. Among all 23 patients, 11 patients (48%) had silent ischemic lesion with FLAIR image (mean maximum size: 9.1 ± 6.5 mm, mean counts 1.6 ± 1.0). On the other hand, all 23 patients (100%) had silent cerebral microbleeds (CMBs) lesions (mean maximum size: 8.6 ± 6.2 mm, mean counts 13.7 ± 24.7) with T2-weighted gradient-echo imaging. Counts of CMBs was 0 ~4 in 9 patients, 5 ~ 10 in 5 patients, 11~20 in 4 patients, over 21 in 4 patients. Eight of 23 (35%) had CMBs larger than 5mm. All three patients who had bacteremia during cLVAD support had CMBs with a mean number of 17.0 counts which was significantly higher than patients without bacteremia. No patients had intracranial aneurysm which was detected by MR angiography.
5( 80) Histopathological Analysis of the Mitral Valve After Long-Term Mechanical Circulatory Support H. Hata ,1 T. Fujita,1 H. Ishibashi-Ueda,2 T. Nakatani,3 J. Kobayashi.1 1Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan; 2Pathology, National Cerebral and Cardiovascular Center, Suita, Japan; 3Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan. Purpose: In Japan, destination therapy-use of left ventricular assisting device (LVAD) is not allowed; however, the LVAD support period of bridge to transplant-use is extremely long. The objective of this study was to investigate the pathological change of the mitral valve after long-term LVAD support. Methods: Forty-one hearts removed at heart transplantation were investigated. Five patients had undergone mitral valve repair or replacement. Thirty-four patients were supported by extracorporeal pulsatile device (Nipro-LVAD) and 7 patients by implantable devices (DuraHeart in 2 patients, EVAHEART in 2 patients, Heartmate II in 1 patient, Jarvik 2000 in 1 patient, Novacor in 1 patient). We compared the histological change of the mitral valve with the results of echocardiogram. Results: The mean duration of LVAD support until heart transplantation was 961+/-307 (ranged from 416 to 1697, median 927) days. Although the mean left ventricular end diastolic/systolic diameter (from 73/66 to 61/55mm) and left atrial diameter (from 46 to 33mm) significantly decreased and mitral regurgitation improved after LVAD implantation, the mitral annulus was still dilated (mean circumference length was 11.1cm, ranged from 8.3 to 14.5cm) in the 36 patients without mitral valve operation. Mitral leaflet became thinner and showed myxomatous degeneration with loose collagen fiber in these patients. In the patients with previous mitral annuloplasty, the mitral annular circumference length was kept normally, mean of 8.1cm. Statistically, there was no close correlation between circumference length of mitral annulus and left ventricular dimension, LVAD support duration time, the grade of mitral regurgitation, cardiac function, or etiology of heart failure. Conclusion: Although significant reverse remodeling of left ventricle was observed after long-term LVAD support, mitral annulus dilation still remained. Concomitant mitral valve surgery with LVAD implantation may be the procedure of choice. 5( 81) Medium-Term Circulatory Support for Cardiogenic Shock in a Developing Country: Do We Need a Long-Term Device? M.A. Villavicencio ,1 V. Rossel,2 R. Larrea,1 J.P. Peralta,1 E. Larrain,1 J.S. Lim,3 E. Donoso,3 F. Gajardo,3 M. Hurtado.1 1Unidad de Trasplante, Clinica Davila, Santiago, Chile; 2Departamento de Medicina, Universidad
de Chile, Santiago, Chile; 3Unidad de Trasplante, Instituto Nacional del Tórax, Santiago, Chile. Purpose: Bridge-to-transplant long-term devices are commonly not affordable for our health system and usually they are not suitable for critically ill patients. Centrimag® may be an alternative for a one-step bridge-to-transplant surgical procedure. Methods: Retrospective review of 28 patients subjected to Centrimag® implantation. Twenty-three (82%) were male, mean age 42+13 years. Etiology of heart failure was ischemic in 13(46%), dilated cardiomyopathy in 8(29%), and other 7(25%).All were INTERMACS class I, 27(96%) had multiorgan failure, and in 26(93%) the indication was failure of medical management. Twelve (43%) had previous cardiac arrest with a mean arrest time of 21+17 min. Circulatory support was biventricular: 25(89%), univentricular 3(11%), and in 9(32%) an oxygenator was interposed until respiratory recovery. Results: Thirty-day post-implant survival was 79% (22 patients). Bridge-totransplant or recovery: 20 (71%) patients. Mean support time was 40 days, and 12(43%) were supported > 4 weeks. The longest support was 292 days. Eight (29%) died before been bridged. Post-implant complications: re-exploration for bleeding 10(36%), neurologic dysfunction 4(14%), pneumonia 10(36%), bacteremia 5(36%) and acute dialysis 8(29%). Kaplan Meier two-year survival: 62+10%. Mean follow-up time: 21 months with a total of 579 months. All alive patients were in NYHA functional class I with normal biventricular function. Conclusion: Centrimag® is useful to provide medium-term support for cardiogenic shock in a developing country. Support longer than 4 weeks is feasible. A bridge-to-transplant long-term device may not be needed in the setting of a waiting time less than 3 months. 5( 82) Subclinical Hemorrhagic Cerebral Lesions Are Prevalent in Patients With Long Term Continuous-Flow LVAD Support D. Yoshioka ,1 K. Toda,1 T. Nakamura,1 S. Miyagawa,1 Y. Yoshikawa,1 S. Fukushima,1 S. Saito,1 T. Saito,2 Y. Sawa.1 1Cardiovascular surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; 2Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan. Purpose: Continuous-flow left ventricular assist device (cLVAD) provides sufficient clinical results for heart failure patients, however cerebrovascular accident (CVA) is still critical complications in patients with cLVAD and it is important to evaluate accurate etiology of CVA to decrease CVA in cLVAD patients. In this study, we evaluated the prevalence of asymptomatic small cerebrovascular complication during cLVAD support. Methods: Among 31 patients who underwent heart transplantation at Osaka University Hospital since 2011, 24 patients had continuous-flow LVAD support (DuraHeart: 16, HeartMateII: 3, HeartWare: 2, Jarvik2000: 3) of mean duration of 2.50 ± 0.95 years. In these 24 patients, excluding one patient who died of primary graft failure, we performed brain magnetic resonance imaging (MRI) before the first discharge after heart transplantation. The prevalence of symptomatic and asymptomatic cerebral lesions in these 23 patients was analyzed. An ischemic lesion was defined as high density signal in fluid-attenuated inversion recovery (FLAIR) -MR imaging, whereas a hemorrhagic lesion was defined as low density signal in T2-weighted gradient-echo imaging. Results: During cLVAD support, 2 patients had symptomatic cerebral infarction and 3 patients had symptomatic intracranial hemorrhage (2: intracerebral hemorrhage, 1: subarachnoid hemorrhage) which were detected by computed tomography scan. Among all 23 patients, 11 patients (48%) had silent ischemic lesion with FLAIR image (mean maximum size: 9.1 ± 6.5 mm, mean counts 1.6 ± 1.0). On the other hand, all 23 patients (100%) had silent cerebral microbleeds (CMBs) lesions (mean maximum size: 8.6 ± 6.2 mm, mean counts 13.7 ± 24.7) with T2-weighted gradient-echo imaging. Counts of CMBs was 0 ~4 in 9 patients, 5 ~ 10 in 5 patients, 11~20 in 4 patients, over 21 in 4 patients. Eight of 23 (35%) had CMBs larger than 5mm. All three patients who had bacteremia during cLVAD support had CMBs with a mean number of 17.0 counts which was significantly higher than patients without bacteremia. No patients had intracranial aneurysm which was detected by MR angiography.