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Perforation of the Pneumatic Driveline in Patients Converted to a Portable Driver for the Total Artificial Heart
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
to simultaneously record hemodynamic data in the pressure-volume and pressure-time domains respectively. After recording baseline data with the MVAD activated at 16,000 RPM, 2 different QPulse settings were studied. A second pig was studied using the same protocol after percutaneous balloon occlusion of the left circumflex artery for 60 minutes, followed by reperfusion and implantation of the MVAD. Results: Changes in LV and aortic parameters across 5 consecutive beats per condition are shown in Table 1. The impact of QPulse on MVAD parameters is shown in Figure 1A. Changes in pressurevolume loops in a non-injured heart with QPulse are shown in Figure 1B. In the injured pig LV, both QPulse settings increased dP/dT max (190⫾12 vs 447⫾21, Low-QPulse Off vs On, po0.01; 206⫾9 vs 497⫾15, High-QPulse Off vs On, po0.01) and LV stroke work (26⫾4 vs 137⫾32, Low-QPulse Off vs On, po0.01; 19⫾6 vs 111⫾26, HighQPulse Off vs On, po0.01). Conclusions: Hemodynamic data demonstrate that QPulse promotes aortic valve operation and modulates LV loading conditions. Future studies are needed to explore the short and long term impact of this novel software algorithm in the next generation MVAD. 125
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Perforation of the Pneumatic Driveline in Patients Converted to a Portable Driver for the Total Artificial Heart K.B. Shah,1 R.A. Volman,1 S.C. Harton,1 D.G. Tang,2 V. Kasirajan.2 1 Division of Cardiology, Virginia Commonwealth University, Richmond, VA; 2Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA.
Aortic Valve Commissural Fusion during Continuous-Flow Left Ventricular Assist Device Support Is Associated with Continuous Valve Closure; a Correlation Study between Valve Histopathology and Clinical Patient Characteristics J. Martina,1 M. Schipper,2 N. de Jonge,3 R. de Weger,4 J. Lahpor,5 A. Vink.6 1Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands; 2Pathology, University Medical Center Utrecht, Utrecht, Netherlands; 3Cardiology, Utrecht Medical Center Utrecht, Utrecht, Netherlands; 4Missing affiliation four; 5Missing affiliation five; 6 Missing affiliation six.
Purpose: With the introduction of portable drivers (PD), patients (pts) with the total artificial heart (TAH) no longer are required to remain tethered to a massive in-hospital driver (IHD). With increased mobility pts may introduce torque and stress the pneumatic drivelines. We examined the incidence of driveline fracture (Fx) in pts on PD. Methods and Materials: We conducted a single-center retrospective study of consecutive pts who received a TAH (2006-2012). Baseline characteristics and laboratory data were compared with a chi-squares and independent t-tests. Results: Sixty-six pts were implanted with the TAH and 16(24%) were converted to PD. Pts on both drivers were of similar age and body surface area, however PD pts were on support for a longer duration of time (median[range]:216[73–694] vs 75[1–379], Po0.001). Five pts (8%) experienced Fx of the driveline requiring repair. Two pts reported fault alarms from the driver, the other 3 noticed a hissing sound from the Fx. All Fxs occurred in pts after transfer to the PD while no pts who stayed on the IHD experienced a driveline fracture (31% vs. 0%, Po0.001). The pts who suffered a Fx had longer times on TAH support (483[271-694] vs 89[1-460], Po0.001,) and 5/7 pts on device 49 months required repair. The Fx was repaired with mechanical excision in 2 pts and covered with vulcanizing tape in the remaining 3. None of the Fx resulted in death. Conclusions: Fx of the pneumatic TAH driveline was observed only in pts converted to the PD. Factors contributing to this potentially fatal complication include increased duration on TAH support and mechanical stress from increased activity and mobility. Durability of the TAH driveline may limit successful long-term support with the device.
Purpose: Continuous-flow Left Ventricular Assist Devices (cf-LVADs) may induce commissural fusion of the aortic valve leaflets. The factors associated with this occurrence of commissural fusion are unknown. Therefore, the aim of this study was to examine the association between cf-LVAD-induced aortic valve commissural fusion and clinical characteristics. Methods and Materials: Gross and histopathological examinations were performed on 15 hearts from patients supported by either Heartmate II (n¼13) or Heartware (n¼2) cf-LVADs and related to clinical characteristics (10 heart transplantation, 5 autopsy). Results: 9/15 (60%) aortic valves showed fusion of single or multiple commissures (total fusion length 11 mm [2.5-24] (median [Interquartile range]) per valve, some leading to noticeable nodular displacements or considerable lumen diameter narrowing. Multiple fenestrations were observed in one valve. Histopathological examination confirmed commissural fusion, with minor and prominent changes in valve layer structure without evidence of inflammatory infiltration at the site of fusion. Commissural fusion was associated with continuous aortic valve closure during cf-LVAD support (p¼0.05). LVAD-induced aortic valve insufficiency developed in all patients with commissural fusion and in 50% of patients without fusion. Age, duration of cf-LVAD support and aetiology of heart failure (ischemic versus dilatated cardiomypathy) were not associated with the amount of fusion.
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
to simultaneously record hemodynamic data in the pressure-volume and pressure-time domains respectively. After recording baseline data with the MVAD activated at 16,000 RPM, 2 different QPulse settings were studied. A second pig was studied using the same protocol after percutaneous balloon occlusion of the left circumflex artery for 60 minutes, followed by reperfusion and implantation of the MVAD. Results: Changes in LV and aortic parameters across 5 consecutive beats per condition are shown in Table 1. The impact of QPulse on MVAD parameters is shown in Figure 1A. Changes in pressurevolume loops in a non-injured heart with QPulse are shown in Figure 1B. In the injured pig LV, both QPulse settings increased dP/dT max (190⫾12 vs 447⫾21, Low-QPulse Off vs On, po0.01; 206⫾9 vs 497⫾15, High-QPulse Off vs On, po0.01) and LV stroke work (26⫾4 vs 137⫾32, Low-QPulse Off vs On, po0.01; 19⫾6 vs 111⫾26, HighQPulse Off vs On, po0.01). Conclusions: Hemodynamic data demonstrate that QPulse promotes aortic valve operation and modulates LV loading conditions. Future studies are needed to explore the short and long term impact of this novel software algorithm in the next generation MVAD. 125
126
Perforation of the Pneumatic Driveline in Patients Converted to a Portable Driver for the Total Artificial Heart K.B. Shah,1 R.A. Volman,1 S.C. Harton,1 D.G. Tang,2 V. Kasirajan.2 1 Division of Cardiology, Virginia Commonwealth University, Richmond, VA; 2Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA.
Aortic Valve Commissural Fusion during Continuous-Flow Left Ventricular Assist Device Support Is Associated with Continuous Valve Closure; a Correlation Study between Valve Histopathology and Clinical Patient Characteristics J. Martina,1 M. Schipper,2 N. de Jonge,3 R. de Weger,4 J. Lahpor,5 A. Vink.6 1Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands; 2Pathology, University Medical Center Utrecht, Utrecht, Netherlands; 3Cardiology, Utrecht Medical Center Utrecht, Utrecht, Netherlands; 4Missing affiliation four; 5Missing affiliation five; 6 Missing affiliation six.
Purpose: With the introduction of portable drivers (PD), patients (pts) with the total artificial heart (TAH) no longer are required to remain tethered to a massive in-hospital driver (IHD). With increased mobility pts may introduce torque and stress the pneumatic drivelines. We examined the incidence of driveline fracture (Fx) in pts on PD. Methods and Materials: We conducted a single-center retrospective study of consecutive pts who received a TAH (2006-2012). Baseline characteristics and laboratory data were compared with a chi-squares and independent t-tests. Results: Sixty-six pts were implanted with the TAH and 16(24%) were converted to PD. Pts on both drivers were of similar age and body surface area, however PD pts were on support for a longer duration of time (median[range]:216[73–694] vs 75[1–379], Po0.001). Five pts (8%) experienced Fx of the driveline requiring repair. Two pts reported fault alarms from the driver, the other 3 noticed a hissing sound from the Fx. All Fxs occurred in pts after transfer to the PD while no pts who stayed on the IHD experienced a driveline fracture (31% vs. 0%, Po0.001). The pts who suffered a Fx had longer times on TAH support (483[271-694] vs 89[1-460], Po0.001,) and 5/7 pts on device 49 months required repair. The Fx was repaired with mechanical excision in 2 pts and covered with vulcanizing tape in the remaining 3. None of the Fx resulted in death. Conclusions: Fx of the pneumatic TAH driveline was observed only in pts converted to the PD. Factors contributing to this potentially fatal complication include increased duration on TAH support and mechanical stress from increased activity and mobility. Durability of the TAH driveline may limit successful long-term support with the device.
Purpose: Continuous-flow Left Ventricular Assist Devices (cf-LVADs) may induce commissural fusion of the aortic valve leaflets. The factors associated with this occurrence of commissural fusion are unknown. Therefore, the aim of this study was to examine the association between cf-LVAD-induced aortic valve commissural fusion and clinical characteristics. Methods and Materials: Gross and histopathological examinations were performed on 15 hearts from patients supported by either Heartmate II (n¼13) or Heartware (n¼2) cf-LVADs and related to clinical characteristics (10 heart transplantation, 5 autopsy). Results: 9/15 (60%) aortic valves showed fusion of single or multiple commissures (total fusion length 11 mm [2.5-24] (median [Interquartile range]) per valve, some leading to noticeable nodular displacements or considerable lumen diameter narrowing. Multiple fenestrations were observed in one valve. Histopathological examination confirmed commissural fusion, with minor and prominent changes in valve layer structure without evidence of inflammatory infiltration at the site of fusion. Commissural fusion was associated with continuous aortic valve closure during cf-LVAD support (p¼0.05). LVAD-induced aortic valve insufficiency developed in all patients with commissural fusion and in 50% of patients without fusion. Age, duration of cf-LVAD support and aetiology of heart failure (ischemic versus dilatated cardiomypathy) were not associated with the amount of fusion.