The new impella intracardiac microaxial pump for treatment of right heart failure after orthotopic heart transplantation

The Journal of Heart and Lung Transplantation Volume 21, Number 1 Purpose: The clinical features and outcome of patients who underwent orthotopic cardiac transplantation (OCT) after a failing Fontan circulation is still debated. Methods and Results: Twelve patients were submitted to OCT in our Institution for failing Fontan-type operations. Five were female, the mean age was 16,6 ⫾ 7,25 years, mean period from Fontan procedure to transplant was 9 years (range 1-16 yrs). Four previous cardiac operations were performed in one pts, three operations in five pts and two operations in six pts. The indications for cardiac transplantation were protein-losing enteropathy (PLE) in six cases, heart failure and/or intractable arrhythmia’s in six patients. All the pts received as basic immunosuppressive therapy cyclosporine and azathioprine and four patients had a short period (3 to 6 months) of steroid therapy for repeated acute rejections. In a high percentage of pts (six) azathioprine was definitively stopped for adverse events. There were two hospital deaths: one pts died after 10 days for low output syndrome (preoperative NYHA IV and undersized donor heart) and one died in 17TH p.o. day after acute neurological event. One patient died 2 years later for acute rejection and another pts died seven years later for chronic rejection and endocarditis. One patient was successfully operated one year later for pulmonary vein obstruction. All the 8 survivors with a mean follow-up of 60 months (range 104-14 months) are in NYHA class I and one delivered a healthy baby. Normalisation of the protein titres was observed in all the cases after a mean period of 7 months. Conclusion: The results show that cardiac transplantation is a good option for patients with a failed Fontan operation; we documented the reversibility of PLE in all the cases; the risk of previous operation didn’t increase significantly the hospital mortality. 167 HEART TRANSPLANT AND LVAD CHARGES ARE SIMILAR P.L. DiGiorgi, E.H. Burton, M.C. Oz, Surgery, Columbia University, New York, NY Background: Despite increasing clinical success of left ventricular assist devices (LVADs), physicians need to measure device cost efficacy in order to determine the societal value of this technology. Today’s large clinical volume allows comparison of the costs of this innovation compared to orthotopic heart transplant (OHT). Methods: We evaluated the hospital charges for patients who were discharged after LVAD implantation and returned to the hospital for OHT. Length of stays (LOS), readmissions, and outpatient services were analyzed including their respective hospital charges. Equal time periods were analyzed for both LVAD and OHT. Results: From the LVAD population at Columbia Presbyterian, 49 patients were discharged following HeartMate implantation and readmitted for OHT. The average charges for LVAD vs. OHT over an equal period of time were $244,468.41 ⫾ $139,200.07 vs. $204,921.18 ⫾ $85,686.67 (p⫽0.09). The average postoperative LOSs were 35.3 ⫾ 23.8 vs. 18.7 ⫾ 12.1 days for the LVAD and OHT respectively (p⬍0.001). LVADs were implanted for an average of 118 ⫾ 72 days. Lastly, the average number of outpatient services needed during the LVAD period was 2.7 ⫾ 4.5 vs. 10.1 ⫾ 7.6 (OHT), generating an average total service cost of $20,326.11 ⫾

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$27,068.57 vs. 15,701.34 ⫾ $11,097.03 (LVAD inpatient rehabilitation considered an outpatient service) (p⫽0.27). Conclusions: LVAD implantation is associated with similar costs to that of OHT. In addition, OHT is associated with a greater number of outpatient services. These data show LVAD therapy, at least in the short term, is similar in cost to OHT. 168 THE NEW IMPELLA INTRACARDIAC MICROAXIAL PUMP FOR TREATMENT OF RIGHT HEART FAILURE AFTER ORTHOTOPIC HEART TRANSPLANTATION J. Martin,1 C. Yerebakan,1 C. Benk,1 M. Krause,1 G. Derjung,2 F. Beyersdorf,1 1Department of Cardiovascular Surgery, AlbertLudwigs-University, Freiburg, Germany; 2Impella Kardiotechnik AG, Aachen, Germany Right heart failure is a common problem after heart transplantation and may result in graft failure. The use of available assist devices in this situation is associated with a high incidence of complications due to hemorrhage and infections. Smaller and less invasive assist systems could minimize the risk and improve the outcome of the patients. The new Impella system is a miniaturized axial pump (diameter 19.2 F) for intracardiac support. Different catheter types for left and right ventricular support are available. The right ventricular assist device has a right angled shape (Fig.1). It is introduced via a dacron vascular graft(A)into the pulmonary artery (B) and through the pulmonary valve with the top of the pump in the right ventricle (C). To provide safe bleeding control the pump was introduced via a 10 mm vascular Dacron graft. To induce right heart failure pig hearts were transplanted orthotopically with an ischemic time of 24 hours. One hour after start of reperfusion the right ventricular impella system was inserted and weaning from cardiopulmonary bypass was attempted. Right ventricular circulatory support was maintained by the Impella pump for 5 hours. The assist system provided continuous blood flow of 2.5 - 4.5 l/min over the observation period. Introduction, handling, and removal of the system was safe and easy. Animals maintained good oxygenation and diuresis. One hour after weaning from the assist system hemodynamics remained stable with epinephrine at 0.1 ␮g/kg/ min. Introduction of these device into the clinical arena could open a new approach to prevention and treatment of right heart failure after heart transplantation.