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“The Right Stuff”: Using a Caval Stent Valve to Mitigate the Effect of Right Heart Failure in LVAD Patients
S366
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
approved or CE certified plug is available for the explantation of newest generation HeartMate 3TM. Here, we present an individualized explantation strategy with an in-house developed patient-tailored silicone plug for the HeartMate 3TM LVAD avoiding (re-) sternotomy. Methods: Hemodynamic evaluation of two HeartMate 3TM patients was performed in order to assess cardiac recovery and hereby planning a LVAD explantation strategy avoiding (re-) sternotomy. A preoperative CT scan was used to define the ideal dimensions of the silicone plug fitting with a HeartMate 3TM mock apical ring. The cylindrical plug was made out of medical grade liquid silicone elastomer MED-4820 (NuSil Silicone Technology LLC, Carpinteria, USA) using a patient specific high quality surface casting mold and subsequently sterilized in a clinical standard process. Its geometry was defined by the inner diameter of the apical cuff and the patient’s CT data implementing one rounded end and a cylindrical head with cross-shaped suture guides on the other end. Results: Following CT scans of two HeartMate 3TM patients, individualized explantation of the LVAD was planned with a patient-tailored silicone plug. Both patients could be successfully weaned from VAD support and explanted with a lateral thoracotomy. No apical bleeding occurred after VAD removal and silicone plug insertion. The plugs could be inserted easily and reliably secured with crossing sutures. The patients were monitored on ICU and could be discharged home in the following days. Conclusion: The surgical removal of HeartMate 3TM is feasible using a patient-tailored silicone plug avoiding (re-) sternotomy. The medical grade liquid silicone elastomer allows perfect patient-specific fitting with preoperative CT-measured dimensions. 920 “The Right Stuff”: Using a Caval Stent Valve to Mitigate the Effect of Right Heart Failure in LVAD Patients R.R. Gonzalez,1 A.A. Grant,2 E. DeMarchena,3 A. Klima,3 M. Armor,3 A. Badiye,3 M. Loebe,3 M. Cohen,3 and A. Ghodsizad.3 1Surgery, Miami Transplant Institute University of Miami, Miami, FL; and the 2Miami Transplant Institute, Miami, FL. Purpose: Right heart failure following left ventricular assist device implantation is one of the major challenges in patients suffering from advanced heart failure. There is still no ideal right-sided support system available. Here we describe the implantation of a stent valve at the inferior cavoatrial junction to protect liver and kidney during right heart failure. Methods: The Medtronic Evolut Pro was delivered via the right jugular vein. Valves were placed in the inferior cavoatrial junction and pressures measured above and below the valve. After initiating biventricular heart failure in a porcine model, a cut down technique was used to access the right IJ. Using fluoroscopy, we then implanted the Evolut Pro valve through the right IJ in 3 animals. Results: Pressure measurements using a pigtail catheter were then taken above and below the stent valve to assess the effectiveness of stent valve in reducing pressure in the abdominal inferior vena cava. We successfully implanted a stent-valve using endovascular technique in the inferior cavoatrial junction. Pressures above and below the stent-valve were markedly different as shown during random Pressure measurements (Delta P > 5 mmHG) when the upper body part of the animal was elevated. Conclusion: Implantation of a stent-valve may prevent or slow the progression of multi-system organ failure that often accompanies right heart failure after LVAD implantation. This study demonstrates the feasibility of this technique though additional study is warranted.
921 Results of Minimally Invasive HVAD Insertion in a Large Cohort of Unselected Patients D.J. Kaczorowski,1 Z.N. Kon,2 E.N. Sorensen,1 S.M. Pham,3 C. Pasrija,1 L.M. Dees,1 R.J. Madathil,1 V. Ton,1 E.D. Feller,1 and B.P. Griffith.1 1University of Maryland, Baltimore, MD; 2NYU Langone Medical Center, New York, NY; and the 3Mayo Clinic Florida, Jacksonville, FL. Purpose: Prior reports on minimally invasive LVAD insertion have focused on smaller and/or highly selected populations. Since 2016 we have used the lateral thoracotomy-hemisternotomy (LTHS) technique and the Heartware HVAD as our default approach for all patients. We compare these outcomes to our results with conventional sternotomy (CS). Methods: Since April 2016, 58/61 HVAD patients (representing 61/62 total LVAD insertions) underwent LTHS. Two patients had CS due to stem-cell trial restrictions; one had a posterolateral thoracotomy due to hostile sternum. Outcomes of 60 LTHS procedures were compared to 52 CS dating to 2011. Results: Preoperative characteristics (Table 1) were similar except for more males in the LTHS group. No patient was excluded from LTHS due to low Intermacs profile, presence of PFO/ASD, or high RV failure risk. Postoperative outcomes are shown in Table 2. Operative time was longer for LTHS. However, cardiopulmonary bypass (CPB) time, RVAD use, intraoperative red blood cell (RBC) transfusion ≥4U, reoperation for bleeding, operative mortality, and hospital length of stay (LOS) were all lower. One-year Kaplan-Meier estimated survival was 90% LTHS vs 65% CS (p=0.003). Conclusion: Improved perioperative and long-term outcomes were observed when employing LTHS as the default technique in a large group of unselected patients.
Table 1.
Preoperative Characteristics
Age Male White Ischemic CMP ECMO/temp. VAD or Intermacs 1 TR ≥ moderate PAPi < 2.0 CVP:PCWP ≥ 0.63 Prior Sternotomy
CS (n=52)
LTHS (n=60)
p-value
52 § 15 38 (73%) 18 (35%) 15 (28%) 13 (25%) 23 (44%) 18/50 (36%) 12/49 (24%) 9 (17%)
54 § 13 55 (92%) 29 (48%) 20 (33%) 16 (27%) 24 (40%) 15/58 (26%) 15/58 (26%) 12 (20%)
0.70 0.01 0.18 0.68 1.00 0.57 0.69 1.00 0.68
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
approved or CE certified plug is available for the explantation of newest generation HeartMate 3TM. Here, we present an individualized explantation strategy with an in-house developed patient-tailored silicone plug for the HeartMate 3TM LVAD avoiding (re-) sternotomy. Methods: Hemodynamic evaluation of two HeartMate 3TM patients was performed in order to assess cardiac recovery and hereby planning a LVAD explantation strategy avoiding (re-) sternotomy. A preoperative CT scan was used to define the ideal dimensions of the silicone plug fitting with a HeartMate 3TM mock apical ring. The cylindrical plug was made out of medical grade liquid silicone elastomer MED-4820 (NuSil Silicone Technology LLC, Carpinteria, USA) using a patient specific high quality surface casting mold and subsequently sterilized in a clinical standard process. Its geometry was defined by the inner diameter of the apical cuff and the patient’s CT data implementing one rounded end and a cylindrical head with cross-shaped suture guides on the other end. Results: Following CT scans of two HeartMate 3TM patients, individualized explantation of the LVAD was planned with a patient-tailored silicone plug. Both patients could be successfully weaned from VAD support and explanted with a lateral thoracotomy. No apical bleeding occurred after VAD removal and silicone plug insertion. The plugs could be inserted easily and reliably secured with crossing sutures. The patients were monitored on ICU and could be discharged home in the following days. Conclusion: The surgical removal of HeartMate 3TM is feasible using a patient-tailored silicone plug avoiding (re-) sternotomy. The medical grade liquid silicone elastomer allows perfect patient-specific fitting with preoperative CT-measured dimensions. 920 “The Right Stuff”: Using a Caval Stent Valve to Mitigate the Effect of Right Heart Failure in LVAD Patients R.R. Gonzalez,1 A.A. Grant,2 E. DeMarchena,3 A. Klima,3 M. Armor,3 A. Badiye,3 M. Loebe,3 M. Cohen,3 and A. Ghodsizad.3 1Surgery, Miami Transplant Institute University of Miami, Miami, FL; and the 2Miami Transplant Institute, Miami, FL. Purpose: Right heart failure following left ventricular assist device implantation is one of the major challenges in patients suffering from advanced heart failure. There is still no ideal right-sided support system available. Here we describe the implantation of a stent valve at the inferior cavoatrial junction to protect liver and kidney during right heart failure. Methods: The Medtronic Evolut Pro was delivered via the right jugular vein. Valves were placed in the inferior cavoatrial junction and pressures measured above and below the valve. After initiating biventricular heart failure in a porcine model, a cut down technique was used to access the right IJ. Using fluoroscopy, we then implanted the Evolut Pro valve through the right IJ in 3 animals. Results: Pressure measurements using a pigtail catheter were then taken above and below the stent valve to assess the effectiveness of stent valve in reducing pressure in the abdominal inferior vena cava. We successfully implanted a stent-valve using endovascular technique in the inferior cavoatrial junction. Pressures above and below the stent-valve were markedly different as shown during random Pressure measurements (Delta P > 5 mmHG) when the upper body part of the animal was elevated. Conclusion: Implantation of a stent-valve may prevent or slow the progression of multi-system organ failure that often accompanies right heart failure after LVAD implantation. This study demonstrates the feasibility of this technique though additional study is warranted.
921 Results of Minimally Invasive HVAD Insertion in a Large Cohort of Unselected Patients D.J. Kaczorowski,1 Z.N. Kon,2 E.N. Sorensen,1 S.M. Pham,3 C. Pasrija,1 L.M. Dees,1 R.J. Madathil,1 V. Ton,1 E.D. Feller,1 and B.P. Griffith.1 1University of Maryland, Baltimore, MD; 2NYU Langone Medical Center, New York, NY; and the 3Mayo Clinic Florida, Jacksonville, FL. Purpose: Prior reports on minimally invasive LVAD insertion have focused on smaller and/or highly selected populations. Since 2016 we have used the lateral thoracotomy-hemisternotomy (LTHS) technique and the Heartware HVAD as our default approach for all patients. We compare these outcomes to our results with conventional sternotomy (CS). Methods: Since April 2016, 58/61 HVAD patients (representing 61/62 total LVAD insertions) underwent LTHS. Two patients had CS due to stem-cell trial restrictions; one had a posterolateral thoracotomy due to hostile sternum. Outcomes of 60 LTHS procedures were compared to 52 CS dating to 2011. Results: Preoperative characteristics (Table 1) were similar except for more males in the LTHS group. No patient was excluded from LTHS due to low Intermacs profile, presence of PFO/ASD, or high RV failure risk. Postoperative outcomes are shown in Table 2. Operative time was longer for LTHS. However, cardiopulmonary bypass (CPB) time, RVAD use, intraoperative red blood cell (RBC) transfusion ≥4U, reoperation for bleeding, operative mortality, and hospital length of stay (LOS) were all lower. One-year Kaplan-Meier estimated survival was 90% LTHS vs 65% CS (p=0.003). Conclusion: Improved perioperative and long-term outcomes were observed when employing LTHS as the default technique in a large group of unselected patients.
Table 1.
Preoperative Characteristics
Age Male White Ischemic CMP ECMO/temp. VAD or Intermacs 1 TR ≥ moderate PAPi < 2.0 CVP:PCWP ≥ 0.63 Prior Sternotomy
CS (n=52)
LTHS (n=60)
p-value
52 § 15 38 (73%) 18 (35%) 15 (28%) 13 (25%) 23 (44%) 18/50 (36%) 12/49 (24%) 9 (17%)
54 § 13 55 (92%) 29 (48%) 20 (33%) 16 (27%) 24 (40%) 15/58 (26%) 15/58 (26%) 12 (20%)
0.70 0.01 0.18 0.68 1.00 0.57 0.69 1.00 0.68