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Minimal-Invasive LVAD Implantation, Is It Safe or Even Better?
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
embolic CVA (p¼0.965), hemorrhagic CVA were comparable (10.3% HW group, 9.5%HMII group, p¼0.846). Thrombolysis, because of pump thrombosis, was performed in 3.1% in the HW group, 4.0% in the HMII group (n.s.), replacement was necessary in 3.1% of the HW patients vs 9.0% of the HMII patients (n.s.). One year mortality was 69.8% in the HW group vs 67.3% in The HMII group (n.s.). Conclusions: Despite more riskfactors for morbidity and mortality in the HW group (Ventilation, ECMO preoperatively), the results were comparable for the HW and the HMII group. Both devices are feasible, HW seems to have advantages in ECMO patiens and patients on ventilation. 135 Minimal-Invasive LVAD Implantation, Is It Safe or Even Better? A.L. Meyer, J. Hahn, P. von Samson-Himmelstjerna, J. Garbade, M. Barten, F.W. Mohr, M. Struber. Cardiac Surgery, Heart Center ¨ Leipzig, Leipzig, Germany. Purpose: The rotary blood pump (HVAD) from HeartWare is an established left ventricular assist device and usually implanted via sternotomy. To reduce the invasiveness of the implant procedure and to optimize the position of the inflow cannula we propose a different implant technique with an extrapericardial placement of the pump via left anterolateral minithoracotomy. Methods and Materials: In a time period of 7 months 28 of 42 patients were implanted with the HVAD using a minithoracotomy for pump placement in combination with an upper hemisternotomy for anastomosis of the outflow graft. In 11 of these patients implant procedure was performed without extracorporeal circulation. The implantation was in 31% a redo-procedures. The 25 male and 3 female patients were in mean 55 years old. Diagnosis was DCM in 15 and ICM in 13 patients. Implants were performed at Intermacs levels 1-4. Results: Mean follow up was 107 days. There was 1 death due to right heart failure in this patient cohort. One conversion to full sternotomy was required. Optimal positioning of inflow cannula was confirmed by 3D Echo. One pump thrombosis and two driveline infections were observed. Conclusions: Placement of the HVAD via thoracotomy is superior in terms of inflow position. Preservation of pericardium may reduce distention of the right heart. ‘‘Off pump’’ approach is feasible in patients without intraventricular thrombus. Optimal placement of inflow may have positive effect on pump performance and possibly adverse event rates in the follow up. 136 Donor Alcohol Abuse Increases the Risk for Graft Dysfunction in Lung Transplant Recipients E.M. Lowery, E. Kuhlmann, E. Mahoney, C. Wigfield, E.J. Kovacs. Medicine, Loyola University Medical Center, Maywood, IL. Purpose: Primary graft dysfunction (PGD) is a form of ischemia reperfusion lung injury that is a major cause of early morbidity and mortality after lung transplantation. Alcohol abuse is known to alter pulmonary immunity, promote alveolar epithelial dysfunction and increase the risk of acute lung injury. The effects of alcohol abuse in donors of lung allografts on transplant outcomes is unknown, and our aim was to examine the incidence of donor alcohol abuse and early effects on graft function following transplantation. Methods and Materials: We performed a single center cohort study of lung transplant recipients from 2007-2011, reviewing patient charts for donor information and lung transplant outcome data. Statistical analysis included student’s t-test and Mann-Whitney U test. Results: 195 lung transplant recipients were included in the cohort and 20.5% (N¼40) of the recipients had donors with significant alcohol use. Recipients of allografts from alcoholic donors spent more time on mechanical ventilation following transplant when compared to recipients whose donors had no reported alcohol abuse, mean 6.9⫾12.1 days versus 3.9⫾8.1 days on the ventilator, (p¼0.07). Gas exchange, represented as PaO2/FiO2, was significantly worse in recipients of donors with alcohol
abuse following transplant compared to recipients with no donor alcohol abuse (Fig 1). Conclusions: Lung transplant recipients who received allografts from alcoholic donors had evidence of graft dysfunction following transplant. We speculate that alcoholic donor allografts may be susceptible to damage from formation of reactive oxygen species, which is exaggerated by the ischemia-reperfusion of transplantation, resulting in an increased rate of PGD. 137 Disparities in Lung Transplantation before and after Introduction of the Lung Allocation Score K.M. Wille,1 K.F. Harrington,1 J.A. deAndrade,1 S. Vishin,1 R.A. Oster,1 R.A. Kaslow.2 1Medicine, University of Alabama at Birmingham, Birmingham, AL; 2Epidemiology, University of Alabama at Birmingham, Birmingham, AL. Purpose: In May 2005 the lung allocation score (LAS) became the primary method for determining allocation of lungs for organ transplantation for those at least 12 years of age in the United States. During the pre-LAS period, patients of African-American ancestry were more likely than those of white ancestry to become too sick or die while awaiting transplant. The association between gender and lung transplant outcomes has not been widely studied. We hypothesized that racial and gender disparities would be modified with implementation of the LAS. Methods and Materials: Black and white patients Z18 years of age registered on the UNOS lung transplantation waiting list from January 1, 2000-May 3, 2005 (pre-LAS, n¼8765) and May 4, 2005-September 13, 2010 (LAS, n¼8806) were included. Lung transplantation was the primary outcome measure. Multivariable analyses were performed within each time period to determine the odds of dying or receiving a lung transplant within three years of listing. Results: In the pre-LAS era, black patients were more likely than white to become too sick for transplantation or die within three years of wait list registration (43.8% vs. 30.8%;odds ratio [OR] 1.84; po0.001). Race was not associated with death or becoming too sick while listed for transplantation in the LAS era (14.0% vs. 13.3%;OR 0.93; p¼0.74). Black patients were less likely to undergo transplantation in the pre-LAS era (56.3% vs. 69.2%;OR 0.54; po0.001) but not in the LAS era (86.0% vs. 86.7%;OR 1.07; p¼0.74). Women were more likely than men to die or become too sick for transplantation within three years of listing in the LAS era (16.1% vs. 11.3%;OR 1.58; po0.001), as compared to the pre-LAS era (33.4% vs. 30.7%;OR 1.19; p¼0.08). Conclusions: Racial disparities in lung transplantation have decreased with the implementation of LAS as the method of organ allocation; however, gender disparities may have actually increased in the LAS era. 138 Candidates Listed for Both Single and Double Lung Do Not Have Improved Post-Transplant Survival with Double Lung Transplant N. Shariati, S.M. Studer, C. Migliore, S. Schultz, M. Hur, E. Johnson, M.J. Russo. Lung Center, Barnabas Health Heart and Lung Institute, Newark, NJ.
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
embolic CVA (p¼0.965), hemorrhagic CVA were comparable (10.3% HW group, 9.5%HMII group, p¼0.846). Thrombolysis, because of pump thrombosis, was performed in 3.1% in the HW group, 4.0% in the HMII group (n.s.), replacement was necessary in 3.1% of the HW patients vs 9.0% of the HMII patients (n.s.). One year mortality was 69.8% in the HW group vs 67.3% in The HMII group (n.s.). Conclusions: Despite more riskfactors for morbidity and mortality in the HW group (Ventilation, ECMO preoperatively), the results were comparable for the HW and the HMII group. Both devices are feasible, HW seems to have advantages in ECMO patiens and patients on ventilation. 135 Minimal-Invasive LVAD Implantation, Is It Safe or Even Better? A.L. Meyer, J. Hahn, P. von Samson-Himmelstjerna, J. Garbade, M. Barten, F.W. Mohr, M. Struber. Cardiac Surgery, Heart Center ¨ Leipzig, Leipzig, Germany. Purpose: The rotary blood pump (HVAD) from HeartWare is an established left ventricular assist device and usually implanted via sternotomy. To reduce the invasiveness of the implant procedure and to optimize the position of the inflow cannula we propose a different implant technique with an extrapericardial placement of the pump via left anterolateral minithoracotomy. Methods and Materials: In a time period of 7 months 28 of 42 patients were implanted with the HVAD using a minithoracotomy for pump placement in combination with an upper hemisternotomy for anastomosis of the outflow graft. In 11 of these patients implant procedure was performed without extracorporeal circulation. The implantation was in 31% a redo-procedures. The 25 male and 3 female patients were in mean 55 years old. Diagnosis was DCM in 15 and ICM in 13 patients. Implants were performed at Intermacs levels 1-4. Results: Mean follow up was 107 days. There was 1 death due to right heart failure in this patient cohort. One conversion to full sternotomy was required. Optimal positioning of inflow cannula was confirmed by 3D Echo. One pump thrombosis and two driveline infections were observed. Conclusions: Placement of the HVAD via thoracotomy is superior in terms of inflow position. Preservation of pericardium may reduce distention of the right heart. ‘‘Off pump’’ approach is feasible in patients without intraventricular thrombus. Optimal placement of inflow may have positive effect on pump performance and possibly adverse event rates in the follow up. 136 Donor Alcohol Abuse Increases the Risk for Graft Dysfunction in Lung Transplant Recipients E.M. Lowery, E. Kuhlmann, E. Mahoney, C. Wigfield, E.J. Kovacs. Medicine, Loyola University Medical Center, Maywood, IL. Purpose: Primary graft dysfunction (PGD) is a form of ischemia reperfusion lung injury that is a major cause of early morbidity and mortality after lung transplantation. Alcohol abuse is known to alter pulmonary immunity, promote alveolar epithelial dysfunction and increase the risk of acute lung injury. The effects of alcohol abuse in donors of lung allografts on transplant outcomes is unknown, and our aim was to examine the incidence of donor alcohol abuse and early effects on graft function following transplantation. Methods and Materials: We performed a single center cohort study of lung transplant recipients from 2007-2011, reviewing patient charts for donor information and lung transplant outcome data. Statistical analysis included student’s t-test and Mann-Whitney U test. Results: 195 lung transplant recipients were included in the cohort and 20.5% (N¼40) of the recipients had donors with significant alcohol use. Recipients of allografts from alcoholic donors spent more time on mechanical ventilation following transplant when compared to recipients whose donors had no reported alcohol abuse, mean 6.9⫾12.1 days versus 3.9⫾8.1 days on the ventilator, (p¼0.07). Gas exchange, represented as PaO2/FiO2, was significantly worse in recipients of donors with alcohol
abuse following transplant compared to recipients with no donor alcohol abuse (Fig 1). Conclusions: Lung transplant recipients who received allografts from alcoholic donors had evidence of graft dysfunction following transplant. We speculate that alcoholic donor allografts may be susceptible to damage from formation of reactive oxygen species, which is exaggerated by the ischemia-reperfusion of transplantation, resulting in an increased rate of PGD. 137 Disparities in Lung Transplantation before and after Introduction of the Lung Allocation Score K.M. Wille,1 K.F. Harrington,1 J.A. deAndrade,1 S. Vishin,1 R.A. Oster,1 R.A. Kaslow.2 1Medicine, University of Alabama at Birmingham, Birmingham, AL; 2Epidemiology, University of Alabama at Birmingham, Birmingham, AL. Purpose: In May 2005 the lung allocation score (LAS) became the primary method for determining allocation of lungs for organ transplantation for those at least 12 years of age in the United States. During the pre-LAS period, patients of African-American ancestry were more likely than those of white ancestry to become too sick or die while awaiting transplant. The association between gender and lung transplant outcomes has not been widely studied. We hypothesized that racial and gender disparities would be modified with implementation of the LAS. Methods and Materials: Black and white patients Z18 years of age registered on the UNOS lung transplantation waiting list from January 1, 2000-May 3, 2005 (pre-LAS, n¼8765) and May 4, 2005-September 13, 2010 (LAS, n¼8806) were included. Lung transplantation was the primary outcome measure. Multivariable analyses were performed within each time period to determine the odds of dying or receiving a lung transplant within three years of listing. Results: In the pre-LAS era, black patients were more likely than white to become too sick for transplantation or die within three years of wait list registration (43.8% vs. 30.8%;odds ratio [OR] 1.84; po0.001). Race was not associated with death or becoming too sick while listed for transplantation in the LAS era (14.0% vs. 13.3%;OR 0.93; p¼0.74). Black patients were less likely to undergo transplantation in the pre-LAS era (56.3% vs. 69.2%;OR 0.54; po0.001) but not in the LAS era (86.0% vs. 86.7%;OR 1.07; p¼0.74). Women were more likely than men to die or become too sick for transplantation within three years of listing in the LAS era (16.1% vs. 11.3%;OR 1.58; po0.001), as compared to the pre-LAS era (33.4% vs. 30.7%;OR 1.19; p¼0.08). Conclusions: Racial disparities in lung transplantation have decreased with the implementation of LAS as the method of organ allocation; however, gender disparities may have actually increased in the LAS era. 138 Candidates Listed for Both Single and Double Lung Do Not Have Improved Post-Transplant Survival with Double Lung Transplant N. Shariati, S.M. Studer, C. Migliore, S. Schultz, M. Hur, E. Johnson, M.J. Russo. Lung Center, Barnabas Health Heart and Lung Institute, Newark, NJ.