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Usefulness of Implantable Cardioverter Defibrillators in Patients Supported With Ventricular Assist Devices
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The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Methods: We reviewed data for consecutive adult HF patients receiving VAD as a bridge to transplantation from 2003 to 2013. The primary outcome was survival to transplantation. Results: A total of 97 VADs were implanted [34 left ventricular (LVAD), 63 biventricular (BIVAD), mean age 40 ± 12 years, 90% male, left ventricular ejection fraction 18 ± 9%, 74% dilated cardiomyopathy]. Mean length of support was 740 days (range 30-1460); 53 patients survived to transplantation. Sixty patients had an ICD (22 LVAD, 38 BIVAD). More LVAD patients had an appropriate ICD shock before implantation than after (16 vs 7; P = .02). There was a trend toward higher shock frequency before LVAD implant than after (3.3 ± 5.2 vs 1.1 ± 3.8 shocks/y; P = .06). Mean time to first shock after VAD implant was 129 ± 109 days. LVAD-supported patients with an ICD were significantly more likely to survive to transplantation [1-y actuarial survival to transplantation: LVAD: 91% with ICD vs 57% without ICD; BIVAD: 54% vs 47%. ICD shocks on VAD support when appropriate and frequent predicted adverse outcomes and hospitalizations such as aortic regurgitation or right heart failure when on LVAD support. Conclusion: Shock frequency decreases after VAD implantation, likely owing to ventricular unloading, but appropriate ICD shocks still occur in VAD patients. An ICD is associated with improved survival in LVAD-supported HF patients.
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Radiologic Assessment of HeartMate II Position: Minimal Pump Migration After Long Term Support R.M. Adamson ,1 B.S. Bower,2 K.S. Sundareswaran,3 D.J. Farrar,3 W.P. Dembitsky.1 1Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA; 2Radiology, Sharp Memorial Hospital, San Diego, CA; 3Research and Scientific Affairs, Thoratec, Pleasanton, CA.
Utility of Cardiac Computed Tomography in Detecting Malposition of Left Ventricular Assist Devices Associated With Pump Thrombosis M. Kassi, R. Adigun, S. Choi, A.M. Cordero-Reyes, A. Bhimaraj, B.H. Trachtenberg, G. Ashrith, M. Loebe, G. Torre-Amione, S. Chang, J.D. Estep . Cardiology, Houston Methodist Hospital, Houston, TX.
Purpose: Surgical positioning of the HeartMate II LVAD (HMII) assuring a durable, unobstructed blood flow path is essential for optimal device function and hemodynamic support. Recent reports have demonstrated that malpositioned pumps have increased thrombus rates yet no systematic review of immediate positioning and migration has been reported. We report a noninvasive radiologic assessment of immediate and long-term HMII position and adverse event rates. Methods: We reviewed 126 consecutive, single center patients (age 64± 11; 87% male; 43 % destination therapy) implanted with the HMII from Jan 2009-Dec 2012 and followed for up to 4 years. Implant technique was consistent in all patients. A radiologist measured pump position, pocket depth, and cannula angles on available chest radiographs. Changes over time were determined in 64 of these patients who had pairs of acceptable radiographs with measurements made immediately after implant and at an average of 2.0± 0.7 years follow-up. Survival and adverse events potentially associated with pump malposition or obstructed blood flow including; stroke, pump thrombosis, and right heart failure were determined in all 126 patients. Results: The axis of the pump relative to the spine was 92 ± 10° at baseline and 94 ± 9° at 2 years (n= 64, p= ns), and inflow cannula angles averaged 21 ± 13° from vertical at baseline and 20 ± 12° at 2 years (p= ns). More than 91% of angle measurements showed less than 15° movement over the follow-up durations. There was a small but significant superior pump migration from a depth of 12.7 ± 2.7 cm to 10.4 ± 2.6 cm (p< 0.001), but did not result in pump malposition. The 30-day operative mortality was 3.6%. There were no inflow cannula obstructions, explorations for device repositioning or RVAD use. Prolonged inotrope dependence occurred in 5.6% (7/126), and low rate of pump thrombosis 0.019 events/ pt-yr. (0 at 3 months) and stroke 0.074 events/pt-yr. were noted. Conclusion: Non-invasive radiographic measurements verify appropriate HMII anatomic placement with minimal migration over an average of 2 years. No malpositioned placements were identified which may contribute to the low adverse events observed. 5( 44) Usefulness of Implantable Cardioverter Defibrillators in Patients Supported With Ventricular Assist Devices A. Gkouziouta , S. Adamopoulos, A. Kostopoulou, G. Theodorakis, P. Sfirakis. Heart Failure, MCS and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece. Purpose: Implantable cardioverter-defibrillators (ICDs) reduce mortality in heart failure (HF). In patients requiring a ventricular assist device (VAD), the benefit from ICD therapy is not well established. The aim of this study was to define the impact of ICD on outcomes in VAD-supported patients.
Purpose: Pump thrombosis is a potentially life-threatening event that currently presents a diagnostic challenge. We therefore sought to explore the diagnostic utility and the association of measured cardiac computed tomography (CT) parameters in patients with LVAD malfunction due to pump thrombosis. Methods: From 2009 to 2013, 150 patients underwent placement of Heart Mate II continuous flow pump at our institution. Of these 52 patients, underwent cardiac CT with contrast either as part of a prospective protocol or for suspected malfunction. 14 patients had pump thrombosis per the INTERMACS criteria and the remaining were used as controls. Rigorous linear and area measurements for the inflow and outflow tracts of LVADs were performed with CT, and X-ray measurements were extrapolated from previously published data. Results: The mean age of the population was 55 ± 11, 36 were male, and 28 had ischemic cardiomyopathy. Results are shown in figure 2. For inflow cannula, measurement of axial area shown in figure 1, was significantly higher in the pump thrombosis group compared to the control group 31±16 mm2 vs 20 ± 12 mm2 (p= .02). Although, the difference in the acute angle for the inflow cannula relative to the perpendicular axis between the midpoint of the mitral annulus and tip of inflow cannulas was not significantly different between the two groups, there was a trend towards greater angulation in the pump thrombosis group (60 ± 6 vs 53 ± 15) and there was a positive correlation between both measurements r= 0.513, p-value= 0.003. There were no significant differences in X-ray measured parameters. Conclusion: Area in the axial view of the ventricle at the site of the inflow cannula tip may be a surrogate for off axis placement of the cannula. This area may be helpful in predicting pump thrombosis in patients with CF-LVADs. X-ray measurement did not shown significant differences in this patient population.
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Methods: We reviewed data for consecutive adult HF patients receiving VAD as a bridge to transplantation from 2003 to 2013. The primary outcome was survival to transplantation. Results: A total of 97 VADs were implanted [34 left ventricular (LVAD), 63 biventricular (BIVAD), mean age 40 ± 12 years, 90% male, left ventricular ejection fraction 18 ± 9%, 74% dilated cardiomyopathy]. Mean length of support was 740 days (range 30-1460); 53 patients survived to transplantation. Sixty patients had an ICD (22 LVAD, 38 BIVAD). More LVAD patients had an appropriate ICD shock before implantation than after (16 vs 7; P = .02). There was a trend toward higher shock frequency before LVAD implant than after (3.3 ± 5.2 vs 1.1 ± 3.8 shocks/y; P = .06). Mean time to first shock after VAD implant was 129 ± 109 days. LVAD-supported patients with an ICD were significantly more likely to survive to transplantation [1-y actuarial survival to transplantation: LVAD: 91% with ICD vs 57% without ICD; BIVAD: 54% vs 47%. ICD shocks on VAD support when appropriate and frequent predicted adverse outcomes and hospitalizations such as aortic regurgitation or right heart failure when on LVAD support. Conclusion: Shock frequency decreases after VAD implantation, likely owing to ventricular unloading, but appropriate ICD shocks still occur in VAD patients. An ICD is associated with improved survival in LVAD-supported HF patients.
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Radiologic Assessment of HeartMate II Position: Minimal Pump Migration After Long Term Support R.M. Adamson ,1 B.S. Bower,2 K.S. Sundareswaran,3 D.J. Farrar,3 W.P. Dembitsky.1 1Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA; 2Radiology, Sharp Memorial Hospital, San Diego, CA; 3Research and Scientific Affairs, Thoratec, Pleasanton, CA.
Utility of Cardiac Computed Tomography in Detecting Malposition of Left Ventricular Assist Devices Associated With Pump Thrombosis M. Kassi, R. Adigun, S. Choi, A.M. Cordero-Reyes, A. Bhimaraj, B.H. Trachtenberg, G. Ashrith, M. Loebe, G. Torre-Amione, S. Chang, J.D. Estep . Cardiology, Houston Methodist Hospital, Houston, TX.
Purpose: Surgical positioning of the HeartMate II LVAD (HMII) assuring a durable, unobstructed blood flow path is essential for optimal device function and hemodynamic support. Recent reports have demonstrated that malpositioned pumps have increased thrombus rates yet no systematic review of immediate positioning and migration has been reported. We report a noninvasive radiologic assessment of immediate and long-term HMII position and adverse event rates. Methods: We reviewed 126 consecutive, single center patients (age 64± 11; 87% male; 43 % destination therapy) implanted with the HMII from Jan 2009-Dec 2012 and followed for up to 4 years. Implant technique was consistent in all patients. A radiologist measured pump position, pocket depth, and cannula angles on available chest radiographs. Changes over time were determined in 64 of these patients who had pairs of acceptable radiographs with measurements made immediately after implant and at an average of 2.0± 0.7 years follow-up. Survival and adverse events potentially associated with pump malposition or obstructed blood flow including; stroke, pump thrombosis, and right heart failure were determined in all 126 patients. Results: The axis of the pump relative to the spine was 92 ± 10° at baseline and 94 ± 9° at 2 years (n= 64, p= ns), and inflow cannula angles averaged 21 ± 13° from vertical at baseline and 20 ± 12° at 2 years (p= ns). More than 91% of angle measurements showed less than 15° movement over the follow-up durations. There was a small but significant superior pump migration from a depth of 12.7 ± 2.7 cm to 10.4 ± 2.6 cm (p< 0.001), but did not result in pump malposition. The 30-day operative mortality was 3.6%. There were no inflow cannula obstructions, explorations for device repositioning or RVAD use. Prolonged inotrope dependence occurred in 5.6% (7/126), and low rate of pump thrombosis 0.019 events/ pt-yr. (0 at 3 months) and stroke 0.074 events/pt-yr. were noted. Conclusion: Non-invasive radiographic measurements verify appropriate HMII anatomic placement with minimal migration over an average of 2 years. No malpositioned placements were identified which may contribute to the low adverse events observed. 5( 44) Usefulness of Implantable Cardioverter Defibrillators in Patients Supported With Ventricular Assist Devices A. Gkouziouta , S. Adamopoulos, A. Kostopoulou, G. Theodorakis, P. Sfirakis. Heart Failure, MCS and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece. Purpose: Implantable cardioverter-defibrillators (ICDs) reduce mortality in heart failure (HF). In patients requiring a ventricular assist device (VAD), the benefit from ICD therapy is not well established. The aim of this study was to define the impact of ICD on outcomes in VAD-supported patients.
Purpose: Pump thrombosis is a potentially life-threatening event that currently presents a diagnostic challenge. We therefore sought to explore the diagnostic utility and the association of measured cardiac computed tomography (CT) parameters in patients with LVAD malfunction due to pump thrombosis. Methods: From 2009 to 2013, 150 patients underwent placement of Heart Mate II continuous flow pump at our institution. Of these 52 patients, underwent cardiac CT with contrast either as part of a prospective protocol or for suspected malfunction. 14 patients had pump thrombosis per the INTERMACS criteria and the remaining were used as controls. Rigorous linear and area measurements for the inflow and outflow tracts of LVADs were performed with CT, and X-ray measurements were extrapolated from previously published data. Results: The mean age of the population was 55 ± 11, 36 were male, and 28 had ischemic cardiomyopathy. Results are shown in figure 2. For inflow cannula, measurement of axial area shown in figure 1, was significantly higher in the pump thrombosis group compared to the control group 31±16 mm2 vs 20 ± 12 mm2 (p= .02). Although, the difference in the acute angle for the inflow cannula relative to the perpendicular axis between the midpoint of the mitral annulus and tip of inflow cannulas was not significantly different between the two groups, there was a trend towards greater angulation in the pump thrombosis group (60 ± 6 vs 53 ± 15) and there was a positive correlation between both measurements r= 0.513, p-value= 0.003. There were no significant differences in X-ray measured parameters. Conclusion: Area in the axial view of the ventricle at the site of the inflow cannula tip may be a surrogate for off axis placement of the cannula. This area may be helpful in predicting pump thrombosis in patients with CF-LVADs. X-ray measurement did not shown significant differences in this patient population.