Epicardial cavernous haemangioma; A case report of a unique incidental finding

Background

Primary cardiac tumours are rare, accounting for only 0.002-0.03% at autopsy. Cardiac haemangiomas are benign vascular tumours and constitute for 0.28% of all primary cardiac tumours. Cavernous haemangiomas, capillary haemangiomas, and arteriovenous haemangiomas are three distinct types. Cardiac haemangiomas are often misdiagnosed as myxomas and must be differentiated from malignant angiosarcomas.

Case summary

We present a 44-year-old Mediterranean male patient with a cavernous haemangioma in the inferior vena cava and right atrium, detected on transthoracic echocardiography. The patient experienced palpitations and dyspnoea on exertion. Computed tomography (CT) angiography revealed a 7.5 × 6 × 5 cm mass suspected to be perfused by the distal right coronary artery. A watch-and-wait approach was suggested, leading to a cardiac magnetic resonance imaging (MRI) with contrast 6 months later. T1 mapping exhibited a prolonged relaxation time and isointensity to the myocardium. T2 mapping revealed a homogenous hyperintense mass with heterogenous late enhancement. Surgical excision was performed using a bicaval cannulation technique on cardiopulmonary bypass. Intraoperatively, no connection to the coronaries was noted. At 1 year follow-up, the patient reported restored physical resilience, with no evidence of tumour recurrence.

Discussion

Clinical symptoms of cardiac cavernous haemangiomas are unspecific and become evident once the tumour grows. To investigate the nature and vascular involvement of the tumour, a contrast-enhanced CT angiography or MRI can be performed. Cardiac haemangiomas are often misdiagnosed and must be differentiated from malignant angiosarcomas. Clear guidelines for the treatment of cardiac haemangiomas in adult patients are lacking. Primary cardiac tumours require thorough investigation, and surgical intervention should be tailored to the individual's case.

Early and late outcomes after minimally invasive direct coronary artery bypass vs. full sternotomy off-pump coronary artery bypass grafting

Objectives

Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years.

Patients and methods

From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years.

Results

MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22).

Conclusion

MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.

Pulmonary Vascular Resistance to Predict Right Heart Failure in Patients Undergoing Left Ventricular Assist Device Implantation

Right heart failure (RHF) is associated with poor outcomes, especially in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to identify predictors of RHF after LVAD implantation. Of 129 consecutive patients (mean age 56 ± 11 years, 89% male) undergoing LVAD implantation, 34 developed RHF. Compared to patients without RHF, those with RHF required longer invasive mechanical ventilation and had longer intensive care unit and hospital stays (p < 0.01). One-year all-cause mortality was significantly higher in patients with versus without RHF after LVAD implantation (29.4% vs. 1.2%; hazard ratio 35.4; 95% confidence interval 4.5-277; p < 0.001). Mortality was highest in patients with delayed RHF after initial LVAD-only implantation (66.7%). Patients who did versus did not develop RHF had significantly higher baseline pulmonary vascular resistance (PVR; 404 ± 375 vs. 234 ± 162 dyn/s/cm5; p = 0.01). PVR > 250 dyn/s/cm5 was a significant predictor of survival in patients with RHF after LVAD implantation. These data confirm the negative impact of RHF on morbidity and mortality after LVAD implantation. Preoperative PVR > 250 dyn/s/cm5 determined using invasive right heart catheterization was an independent predictor of developing RHF after LVAD implantation, and of subsequent mortality, and could be used for risk stratification in the setting for deciding between single or biventricular support strategy.

CD14highCD16+ monocytes are the main producers of Interleukin-10 following clinical heart transplantation

Introduction

Following heart transplantation, a cascade of immunological responses is initiated influencing the clinical outcome and long-term survival of the transplanted patients. The anti-inflammatory cytokine interleukin-10 (IL-10) was shown to be elevated in the blood of heart transplant recipients directly after transplantation but the releasing cell populations and the composition of lymphocyte subsets following transplantation have not been thoroughly studied.

Methods

We identified immune cells by immunophenotyping and analyzed intracellular IL-10 production in peripheral blood mononuclear cells (PBMC) of heart transplanted patients (n= 17) before, directly after and 24h post heart transplantation. The cells were stimulated with lipopolysaccharide or PMA/Ionomycin to enhance cytokine production within leukocytes in vitro.

Results and discussion

We demonstrate that intermediate monocytes (CD14highCD16+), but not CD8+ T cells, CD4+ T cells, CD56+ NK cells or CD20+ B cells appeared to be the major IL-10 producers within patients PBMC following heart transplantation. Consequently, the absolute monocyte count and the ratio of intermediate monocytes to classical monocytes (CD14+CD16-) were specifically increased in comparison to pre transplant levels. Hence, this population of monocytes, which has not been in the focus of heart transplantation so far, may be an important modulator of clinical outcome and long-term survival of heart transplant recipients. Alteration of blood-circulating monocytes towards a CD14highCD16+ phenotype could therefore shift the pro-inflammatory immune response towards induction of graft tolerance, and may pave the way for the optimization of immunosuppression.

Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies

Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.

The Role of Daily Implant-Based Multiparametric Telemonitoring in Patients with a Ventricular Assist Device

The telemonitoring of heart failure (HF) patients is becoming increasingly important. This study aimed to evaluate the benefit of telemonitoring in end-stage HF patients with a ventricular-assistance device (VAD). A total of 26 HF-patients (66 ± 11 years, 88% male) on VAD therapy with an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization defibrillator (CRT-D) including telemonitoring function were enrolled. The long-term follow-up data (4.10 ± 2.58 years) were assessed. All the patients (n = 26, 100%) received daily ICD/CRT-D telemonitoring. In most of the patients (73%, n = 19), the telemedical center had to take action for a mean of three times. An acute alert due to sustained ventricular arrhythmias (VAs) occurred in 12 patients (63%) with 50% of them (n = 6) requiring ICD shock delivery. Eight patients (67%) were hospitalized due to symptomatic VAs. In 11 patients (92%), immediate medication adjustments were recommended. Relevant lead issues were revealed in thirteen patients (50%), with six patients (46%) undergoing consecutive lead revisions. Most of the events (83%) were detected within 24 h. Daily telemonitoring significantly reduced the number of in-hospital device controls by 44% (p < 0.01). The telemonitoring ensured that cardiac arrhythmias and device/lead problems were identified early, allowing pre-emptive and prompt interventions. In addition, the telemonitoring significantly reduced the number of in-hospital device controls in this cohort of HF patients.

Heart transplantation across preformed donor-specific antibody barriers using a perioperative desensitization protocol

Heart transplantation across preformed donor-specific HLA-antibody barriers is associated with impaired short- and long-term survival. Therefore, in recipients with preformed anti-HLA antibodies, waiting for crossmatch-negative donors is standard practice. As an alternative strategy, recipients with preformed anti-HLA donor specific antibodies have been managed at our institutions with a perioperative desensitization regimen. A retrospective analysis was performed comparing heart transplant recipients with preformed donor-specific HLA-antibodies to recipients without donor-specific antibodies. Recipients with a positive virtual crossmatch received a perioperative desensitization protocol including tocilizumab intraoperatively, plasma exchange and rituximab followed by a six-month course of IgGAM. Among the 117 heart-transplanted patients, 19 (16%) patients underwent perioperative desensitization, and the remaining 98 (84%) patients did not. Cold ischemic time, posttransplant extracorporeal life support for primary graft dysfunction, and intensive care unit stay time did not differ between groups. At 1-year follow-up, freedom from pulsed steroid therapy for presumed rejection and biopsy-confirmed acute cellular or humoral rejection did not differ between groups. One-year survival amounted to 94.7% in the treated patients and 81.4% in the control group. Therefore, heart transplantation in sensitized recipients undergoing a perioperative desensitization appears safe with comparable postoperative outcomes as patients with a negative crossmatch.

Bacteriophage-Enriched Galenic for Intrapericardial Ventricular Assist Device Infection

We report a case of severe outflow graft infection following left ventricular assist device (LVAD) implantation. A 51-year old male LVAD patient was readmitted to our hospital presenting signs of systemic infection. One year previously, LVAD implantation (HeartMate3, Abbott, Chicago, IL, USA) with concomitant patent foramen ovale closure had been performed in the context of end-stage heart failure due to dilative cardiomyopathy (INTERMACS III). The indication for LVAD-therapy was bridge-to-candidacy, since the patient did not instantly fulfill all criteria for cardiac transplantation. At admission, a PET-CT scan unveiled fluid accumulation, encircling the outflow-graft prosthesis (SUVmax 10.5) with contrast-enhancement involving the intrathoracic driveline (SUVmax 11.2). Since cardiac transplantation was not feasible, the patient underwent surgical revision. In the first step, redo sternotomy was performed with local debridement, including jet lavage. Intraoperative swabs confirmed bacterial infection with staphylococcus aureus. Following this, the patient underwent negative pressure wound therapy (NPWT) with instillation using the V.A.C. VERAFLO system (KCI-3M, San Antonio, TX, USA) for a total of 19 days. Due to the severity of infection, local bacteriophage application was performed within the wound closure. In order to concentrate phage therapy at the infection site, phages were applied using a novel semi-fluid galenic. After wound closure, the patient was discharged with an uneventful course. A control PET-CT scan 3 months after discharge showed a significant decrease in infection (outflow graft: SUVmax 7.2, intrathoracic driveline: SUVmax 3.0) correlated with contrast enhancement. Bacterial infection of intrathoracic VAD components represents a severe and potentially life-threatening complication. If cardiac transplantation is not feasible, complex wound management strategies are required. Local bacteriophage therapy might be a promising addition to already established therapeutical options. In order to improve bacteriophage retention at the wound site, application of a viscous galenic might be beneficial.

The HeartWare Ventricular Assist Device (HVAD): A Single Institutional 10-Year Experience

OBJECTIVES

 The aim of this study was to analyze our 10-year experience with the HVAD in a real-world scenario in a high-volume German heart center.

METHODS

 We retrospectively analyzed outcomes of adults (≥18 years) with terminal heart failure (HF), who underwent HVAD implantation for durable LVAD therapy in our center between October 2009 and March 2020. Primary and secondary end points were all-cause death after implantation and LVAD-associated complications, respectively. We focused the distinct analyses on risk profiles at the time of implantation and implant strategies, i.e., bridge-to-transplant (BTT) or destination therapy (DT).

RESULTS

 A total of 510 patients were included, with 229 and 281 individuals in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 1 (45%) and 2 to 4, respectively. Median follow-up was 26 months (IQR: 5-54 months). Overall survival at 1, 3, and 5 years after HVAD implantation was 66% (95% CI; 61.7-70%), 49.4% (95% CI; 44.9-53.8%), and 37.4% (95% CI; 32.8-42%), not censored for LVAD exchange, LVAD explantation, or heart transplantation. INTERMACS level 1 and peri-operative temporary right heart assistance were independent risk factors for survival. Survival was best in BTT patients undergoing heart transplantation at any time during follow-up. The INTERMACS level at time of HVAD implantation did not affect survival after heart transplantation. Freedom from the combined end point of any device-associated severe complication and death was 44.5% (95% CI; 40-48.8%) at 1-year after implantation.

CONCLUSION

 The HVAD is a reliable pump for durable mechanical circulatory support even in high-risk patients. Still, heart transplantation outperforms durable MCS therapy for a superior long-term survival.

Left ventricular unloading during extracorporeal life support for myocardial infarction with cardiogenic shock: surgical venting versus Impella device

OBJECTIVES

Patients in cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) may experience severe complications from reduced left ventricular (LV) unloading and increased cardiac afterload. These effects are usually modified by adding a percutaneous direct Impella vent or surgical LV vent on top of VA-ECMO in selected patients. However, direct comparisons between 2 LV unloading strategies in patients with cardiogenic shock due to myocardial infarction are lacking. Therefore, we sought to investigate the impact of these 2 different approaches.

METHODS

We enrolled 112 patients treated with an Impella or surgical LV vent during VA-ECMO support between January 2014 and February 2020. The primary endpoint was 30-day mortality. Secondary endpoints included rates of myocardial recovery or transition to durable mechanical circulatory support. Additionally, we assessed adverse events such as peripheral ischaemic complications requiring intervention, sepsis and ischaemic stroke.

RESULTS

At 30 days, 38 patients in the Impella group (54%) and 26 patients in the surgical LV vent group (63%) had died (relative risk with Impella 0.78, 95% confidence interval 0.47-1.30; P = 0.35). Impella group and the surgical LV vent group differed significantly with respect to the secondary end points including rates of myocardial recovery (24% and 7%, respectively; P = 0.022) and rates of durable mechanical circulatory support (17% and 42%, P = 0.012). Complication rates were not statistically different between the 2 groups.

CONCLUSIONS

The use of Impella device as therapeutic unloading therapy during VA-ECMO did not significantly reduce 30-day mortality compared to surgical LV vent in patients with cardiogenic shock due to acute myocardial infarction.

Bacteriophages for the Treatment of Graft Infections in Cardiovascular Medicine

Bacterial infections of vascular grafts represent a major burden in cardiovascular medicine, which is related to an increase in morbidity and mortality. Different factors that are associated with this medical field such as patient frailty, biofilm formation, or immunosuppression negatively influence antibiotic treatment, inhibiting therapy success. Thus, further treatment strategies are required. Bacteriophage antibacterial properties were discovered 100 years ago, but the focus on antibiotics in Western medicine since the mid-20th century slowed the further development of bacteriophage therapy. Therefore, the experience and knowledge gained until then in bacteriophage mechanisms of action, handling, clinical uses, and limitations were largely lost. However, the parallel emergence of antimicrobial resistance and individualized medicine has provoked a radical reassessment of this approach and cardiovascular surgery is one area in which phages may play an important role to cope with this new scenario. In this context, bacteriophages might be applicable for both prophylactic and therapeutic use, serving as a stand-alone therapy or in combination with antibiotics. From another perspective, standardization of phage application is also required. The ideal surgical bacteriophage application method should be less invasive, enabling highly localized concentrations, and limiting bacteriophage distribution to the infection site during a prolonged time lapse. This review describes the latest reports of phage therapy in cardiovascular surgery and discusses options for their use in implant and vascular graft infections.

Donor-recipient risk assessment tools in heart transplant recipients: the Bad Oeynhausen experience

AIMS

Some risk assessment tools have been developed to categorize mortality risk in heart transplant recipients, but it is unclear whether these tools can be used interchangeable in different transplant regions.

METHODS AND RESULTS

We performed a retrospective single-centre study in 1049 adult German heart transplant recipients under jurisdiction of Eurotransplant. Univariable and multivariable Cox regression analysis was used to generate a risk scoring system. C-statistics were used to compare our score with a US score and a French score regarding their ability to discriminate between 1 year survivors and non-survivors within our study cohort. Of 38 parameters assessed, seven recipient-specific parameters [age, height, dilated cardiomyopathy (DCM), ischaemic cardiomyopathy (ICM), total bilirubin, extracorporeal membrane oxygenation (ECMO), and biventricular assist device/total artificial heart (BVAD/TAH) implant], one donor-specific parameter (cold ischaemic time), and one recipient-independent and donor-independent other parameter (late transplant era) were statistically significant in predicting 1 year mortality. The initial score was generated by using the regression coefficients from the multivariable analysis as follows: 1.70 * ln age - 4.0 * ln height - 0.9 * diagnosis (= 1 if diagnosis = DCM) - 0.67 * diagnosis (= 1 if diagnosis = ICM) + 0.33 * ln total bilirubin + 1.74 * ln cold ischaemic time + 0.98 * mechanical circulatory support (MCS) implant (= 1 if MCS implant = ECMO) + 0.47 * MCS implant (= 1 of MCS implant = BVAD/TAH) - 0.66 * transplant era (= 1 if transplant era = 2017-2018). The initial score was converted into the Bad Oeynhausen (BO) score as a positive integer variable by means of the following formula: BO score = (initial score + 8) * 3. In patients scoring 2 to <7 points (n = 112), 7 to <11 points (n = 580), 11 to <15 points (n = 339), and 15 to 20 points (n = 18), 1 year survival was 93.1%, 84.2%, 66.9%, and 27.8%, respectively. The c-index of our score was 0.73 [95% confidence interval (CI): 0.69-0.77]. Values were in our cohort for the US and French scores 0.66 (95% CI: 0.62-0.70) and 0.63 (95% CI: 0.59-0.67), respectively.

CONCLUSIONS

Data indicate that our score, but also risk assessment tools from other transplant regions, may be used as a reliable support for risk-adjusted organ allocation and potentially help to improve outcomes in heart transplantation. Further developments will have to include as yet unaccounted risk factors for even more reliable predictions.

Identification of distinct secretory patterns and their regulatory networks of ischemia versus reperfusion phases in clinical heart transplantation

BACKGROUND

Ischemia/reperfusion injury (IRI) is associated with inflammatory responses contributing to the development of primary graft dysfunction (PGD) and rejection. Here, we investigated the pathophysiology of IRI and the early phase after heart transplantation (HTx) regarding its cytokine/chemokine and endothelial networks.

METHODS

Using multiplex technology, we assessed protein concentrations in plasma samples of HTx recipients (n = 11) pre-, postoperatively, 24 h and 3 weeks after HTx. The same proteins were quantified in organ storage solutions at the end of heart storage (n = 10). Unsupervised cluster, principal component analysis (PCA), K-nearest neighbor (KNN) network classifier analysis, ANOVA and Spearman correlation analyses were performed to identify specific patterns for IRI and individual kinetics of important soluble factors in HTx.

RESULTS

Unique patterns of soluble factors were identified in plasma of HTx patients. KNN analysis defined IL-10, IL-6, sIL-6Rα, IL-1RA, IL-16, sVEGFR-1, IGFBP-1, HGF and sHer-2 as strongest signals directly post-Tx declining 24 hrs after HTx. By contrast, MIF, osteopontin (OPN), sVCAM-1 and sICAM-1, IGFBP-1, SCGF-ß, HGF were highly enriched in organ storage solutions, reflecting distinct ischemic (storage solution) vs. reperfusion (plasma) signatures.

CONCLUSIONS

We identified specific inflammatory signatures for ischemic vs. reperfusion phases of HTx, associated with pro- as well as anti-inflammatory and endothelial biomarker candidates for IRI. These signatures might help to identify potential danger factors and their networks at both the ex situ (ischemic) as well as the reperfusion phase in the recipient after implantation.

Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting

OBJECTIVES

Recent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort.

METHODS

A total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis.

RESULTS

In the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87-1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32-0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47-0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87-1.08; P = 0.59 and HR 1.01, 95% CI 0.90-1.13; P = 0.91, respectively).

CONCLUSIONS

Data do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.

Cardiac recovery following left ventricular assist device therapy: experience of complete device explantation including ventricular patch plasty

OBJECTIVES

Myocardial recovery is a rare phenomenon in left ventricular assist device (LVAD) therapy. Surgical LVAD removal is associated with the risk of cardiac failure, and the individual evaluation of sufficient myocardial recovery is crucial. Thus, complete device explantation is not consistently performed to minimize perioperative risk. However, the remaining ventricular assist device components bear significant risks of infection or thrombosis. Therefore, we developed this study to evaluate a complete LVAD explantation protocol.

METHODS

All patients in our institution who had an LVAD explanted were enrolled in the study. Explant surgery involved removal of the driveline, pump housing, sewing ring and outflow graft. The ventricular wall was reconstructed by double patch plasty. Our analysis focused on surgical and postoperative outcome parameters, including all-cause mortality and major adverse cardiac and cerebrovascular events.

RESULTS

A total of 12 patients (HVAD, n = 5; HeartMate II, n = 3; HeartMate 3, n = 4) had myocardial recovery and qualified for our LVAD explantation study protocol [median age: 40 years, interquartile range (IQR) 33-52 years; 50% men]. Primary heart failure aetiology: myocarditis (n = 5), dilated cardiomyopathy (n = 4), toxic cardiomyopathy (n = 2) and valvular heart failure (n = 1). The median average duration on LVAD was 10 months (25-75%: IQR 8.5-30 months). The median left ventricular ejection fraction was 15% (IQR 13-18%) at LVAD implantation and 50% (IQR 45-50%) before LVAD explantation (P = 0.0025).The 30-day survival was 100%. The 1-year survival was 91.7%. All patients were discharged after a median 13 days (IQR 10-18 days) postoperatively. No patient had major adverse cardiac and cerebrovascular events. The New York Heart Association functional class remained consistent during the follow-up period (median New York Heart Association functional class: II, IQR II-II class) including preservation of ventricular function.

CONCLUSIONS

Complete LVAD explantation with ventricular patch plasty is feasible and has consistent long-term results.

First-in-human high-density epicardial mapping and ablation through a left anterior minithoracotomy in an LVAD patient presenting in electrical storm: a case report

Background

Despite substantial technical improvements in long-term mechanical circulatory support, ventricular tachycardia (VT) remains a major challenge in left ventricular assist device (LVAD) patients. Recurrent VTs in LVAD patients are not only associated with limited quality of life, but also increased mortality. Although LVAD therapy improves VT tolerance of the left ventricle, haemodynamical deterioration of the right ventricle is the limiting factor in these patients.

Case summary 

We present a case report of a hybrid epicardial VT ablation of incessant VTs in a 53-year-old man with advanced heart failure and St.p. LVAD implantation. With this unique clinical case report, we describe an epicardial VT ablation using secondary surgical open-heart access in a patient with therapy-refractory VTs combing left-sided minithoracotomy with high-density (HD) mapping and catheter ablation.

Discussion 

To the best of our knowledge, the presented approach is the first interdisciplinary case of epicardial VT ablation using secondary surgical open-heart access in an LVAD patient with therapy-refractory VTs. By combing left-sided minithoracotomy with HD mapping and catheter ablation, we could to demonstrate that even in these complex patients epicardial VT ablations can be performed safely and improve quality of life of LVAD patients with recurrent implantable cardioverter-defibrillator shock therapies.

Exercise capacity in patients implanted with left ventricular assist devices for end-stage heart failure treatment

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular assist device (LVAD) is an expanding therapy in end-stage heart failure today. Although LVAD therapy bears the potential to normalize cardiac output, a majority of patients show a severely impaired physical condition at the time of LVAD implantation. To date, no validated standardized training protocol is available, and established practices to effectively improve LVAD patients’ exercise tolerance is lacking. This study sought to investigate exercise capacity quantified by cardiopulmonary exercise testing (CPX) and a standardized six-minute walk test (6MWT) in patients after LVAD implantation.

Methods

We enrolled 30 end-stage heart failure patients who had received an LVAD implantation 20.7 ± 7.6 days prior to examination, mean age 54.9 ± 7.8 years, 26 males (87 %). Exercise tolerance was assessed using cardiopulmonary exercise testing (CPX) for maximal and submaximal exercise capacity, followed by a standardized (6MWT).

Results

Patients showed peak oxygen uptake values of 8.3 ± 2.4 ml/min/kg at a mean workload of 46.7 ± 11.3 watts and a mean anaerobic threshold of 6.7 ± 1.7 ml/min/kg at a workload of 32.6 ± 6.9 watts. Mean standardized 6-minute walking distance was at 183.8 ± 71.4 meters. There were no adverse events during exercise testing.

Conclusions

Cardiopulmonary exercise testing (CPX) and standardized 6MWT show severely impaired cardiopulmonary exercise capacity in patients after LVAD implantation, warranting further studies for dedicated training protocols, specifically focusing on LVAD patients to improve exercise tolerance at an acceptable safety profile.

Secondary aortic valve replacement in continuous flow left ventricular assist device therapy

The purpose of the study was to investigate the outcome of secondary surgical aortic valve replacement (sSAVR) in patients with severe aortic regurgitation (AR) in the context of ventricular assist device (VAD) therapy. From 2009 to 2020, 792 patients underwent cf-LVAD implantation [HVAD (Medtronic, USA), n = 585, and HM 3 (Abbott, USA), n = 207]. All cf-LVAD patients with severe AR requiring secondary AVR were enrolled in this study. A total of six patients (median, 40 years, IQR; 34-61 years, 50% male) underwent secondary surgical aortic valve replacement (sSAVR) after cf-LVAD implantation. Median time of previous LVAD support was 26 months (IQR: 21-29 months). Two patients required additional tricuspid valve repair (TVR) and one patient underwent SAVR after failed TAVR. Four patients needed temporary right ventricular assist device (RVAD) with a median of 30 days (IQR; 29-33 days). Three patients were bridged to urgent heart transplantation due to persevering right heart failure, whereas two destination therapy (DT) candidates survived without any associated complications. An additional DT patient died of pneumonia 1 month after sSAVR. Secondary surgical aortic valve replacement in ongoing LVAD patients is an advanced procedure for a complex cohort. In our series, sSAVR was safely performed and effective, but involved a high-risk for subsequent right heart failure, requiring urgent heart transplantation. In LVAD patients with severe AR requiring treatment where TAVR is not feasible, sSAVR can be evaluated as salvage option for bridge to transplant patients or selected destination therapy candidates.

Identification of characteristics, risk factors, and predictors of recurrent LVAD thrombosis: conditions in HeartWare devices

Background

Redictors of repetitive left-ventricular assist device (LVAD)-thrombosis have not been studied yet.

Methods

We identified predictors of recurrent LVAD thrombosis in HeartWare (HVAD) patients in a long-term study from 2010 until 2020. We included all patients with two or more thrombolysis treatments for repetitive HVAD thrombosis and effectiveness of thrombolytic therapy was defined as freedom from stroke, death, another HVAD thrombosis, or surgical device exchange within 30 days after the event. Study endpoints also include all-cause mortality and heart transplantation.

Results

A total of 534 HVAD implantations have been screened, and 73 patients (13.7%) developed first HVAD thrombosis after a median of 10 months (IQR; 6–21 months). 46 of these patients had effective thrombolysis in 71.7% (n = 33/46). After a median of 14 months (IQR 4–32 months) follow-up, 17 patients (51.5%) had developed a second HVAD thrombosis and all were treated with t-PA therapy again, resulting in effectiveness in 76.5% (n = 13/17). The four patients with ineffective t-PA therapy underwent subsequent surgical HVAD exchange. Multiple Cox regression model analysis revealed time interval between HVAD implantation and first thrombosis as an independent risk factor of recurrent thrombosis (HR, 0.93, 95% CI 0.87–0.99, p = 0.031). Kaplan–Meier analysis at 3 year follow-up showed no significant difference in overall survival for recurrent vs non-recurrent thrombosis groups (log-rank test, p = 0.959).

Conclusion

Recurrent HVAD thrombosis mostly appears within 12 months after first thrombosis. Systemic t-PA therapy for recurrent pump thrombosis seems safe, achieving comparable effectiveness rates to initial t-PA therapy. Survival does not differ between patients with or without recurrent HVAD thrombosis.

Patients with ventricular assist device and cerebral entrapment-Supporting skullcap reimplantation

Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all-cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge-to-transplantation LVAD patients [median age at LVAD implantation: 32.5 years (IQR: 24.8-39.5 years); four male, HVAD, n = 3; HM II, n = 1; HM 3, n = 2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n = 2), dilated (n = 2), or ischemic (n = 2). Median INTERMACS class was 1.5 (IQR; 1.0-2.8). Median time on LVAD support to DC procedure was 33 months (IQR: 16-48 months). The indication for DC was intraparenchymal hemorrhage (n = 4), subdural hematoma (n = 1), and malignant middle cerebral artery infarction (n = 1). After a median time of 4 months (IQR: 3.3-4.0 months, range; 2.0-10 months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26 months (IQR: 21-42 months) follow-up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis.

Mechanical circulatory support as a bridge to candidacy in adults with transposition of the great arteries and a systemic right ventricle

OBJECTIVES

Clinical experience with continuous flow ventricular assist devices (VADs) in patients with transposition of the great arteries (TGA) including dextro-TGA and congenitally corrected TGA is rare, and indications as well as potential benefits or specific hurdles remain unclear. Therefore, our goal was to report on our experience regarding VAD therapy in adult patients with TGA as a bridge to candidacy.

METHODS

We performed a single-centre retrospective study of all adult patients with TGA with systemic right ventricular failure who had continuous flow VAD implants between 2010 and 2018. Study end points were all causes of death, major cardiac and cerebrovascular adverse events or pump thrombosis. Follow-up continued until the time of the heart transplant.

RESULTS

A total of 6 patients (4 men) had a continuous flow VAD implanted in the context of a failing systemic right ventricle (dextro-TGA after the Mustard procedure: n = 3; congenitally corrected TGA: n = 3). Demographics: mean age 32 ± 5.7 years; median Interagency Registry for Mechanically Assisted Circulatory Support: level II (range 1-4), mean pulmonary artery 48 ± 13 mmHg, mean pulmonary vascular resistance 5.6 ± 3.5 Wood units. Postoperative data: intensive care unit stay: 16 ± 9.7 days; in-hospital survival: 100%; no early VAD-related complications occurred. Mean follow-up: 33 ± 18 months; persistent left-side paresis: n = 1; minor (non-disabling) stroke: n = 2. Post-VAD pulmonary artery: 19 ± 3.4 mmHg; P < 0.005; post-VAD pulmonary resistance: 2.2 ± 0.55 Wood units; P = 0.066. Four patients had heart transplants after a mean waiting time of 30 months after the VAD was implanted; 2 patients are still on the waiting list (waiting time: 52 and 24 months).

CONCLUSIONS

Continuous flow VAD therapy is a feasible therapeutic option in adult patients with TGA and a failing systemic right ventricle as a bridge to candidacy and a bridge to a heart transplant.

Clinical characteristics and outcomes of patients with adult congenital heart disease listed for heart and heart‒lung transplantation in the Eurotransplant region

BACKGROUND

The therapeutic success in patients with congenital heart disease (CHD) leads to a growing number of adults with CHD (adult CHD [ACHD]) who develop end-stage heart failure. We aimed to determine patient characteristics and outcomes of ACHD listed for heart transplantation.

METHODS

Using data from all the patients with ACHD in 20 transplant centers in the Eurotransplant region from 1999 to 2015, we analyzed patient characteristics, waiting list, and post-transplantation outcomes.

RESULTS

A total of 204 patients with ACHD were listed during the study period. The median age was 38 years, and 62.3% of the patients were listed in high urgency (HU), and 37.7% of the patients were in transplantable (T)-listing status. A total of 23.5% of the patients died or were delisted owing to clinical worsening, and 75% of the patients underwent transplantation. Median waiting time for patients with HU-listing status was 4.18 months and with T-listing status 9.07 months. There was no difference in crude mortality or delisting between patients who were HU status listed and T status listed (p = 0.65). In multivariable regression analysis, markers for respiratory failure (mechanical ventilation, hazard ratio [HR]: 1.41, 95% CI: 1.11-1.81, p = 0.006) and arrhythmias (anti-arrhythmic medication, HR: 1.42, 95% CI: 1.01-2.01, p = 0.044) were associated with a higher risk of death or delisting. In the overall cohort, post-transplantation mortality was 26.8% after 1 year and 33.4% after 5 years.

CONCLUSIONS

Listed patients are at high risk of death without differences in the urgency of listing. Respiratory failure requiring invasive ventilation and possibly arrhythmias requiring anti-arrhythmic medication indicate worse outcomes on waiting list.

Upper-body cannulation for midterm mechanical circulatory support: A novel bridging strategy to cardiac retransplantation

Heart retransplantation remains a controversial issue, due to the overall shortage of donor organs. Many patients put on the waiting list for retransplantation, decompensate rapidly, and do not survive. The use of veno-arterial extracorporeal life support remains an option in such emergency situations as bridge-to-recovery or bridge-to-transplantation therapy. In peripheral femoral configuration, veno-arterial extracorporeal life support improves the patient's condition by relieving low-cardiac output but immobilizes him or her for an uncertain period of time. The upper-body cannulation is an alternative approach, which allows to maintain the patient awake and mobile. We present two cases of midterm circulatory support as a bridge to heart retransplantation, using upper-body cannulation veno-arterial extracorporeal life support. Two male patients, presenting with progressive cardiac decompensation due to severe graft rejection, were placed on upper-body veno-arterial extracorporeal life support. The stabilization of hemodynamics and improvement of end-organ perfusion could be achieved after extracorporeal life support initiation. After 48 and 40 days, respectively, on extracorporeal life support with active physical therapy and no major adverse events, both patients received a cardiac retransplantation and were eventually discharged home. The presented cases are the first reported where a successful cardiac retransplant was performed following prolonged upper-body extracorporeal life support.

Heart transplantation after SynCardia® total artificial heart implantation

Background

The SynCardia total artificial heart (TAH)^® is the only approved TAH device. This report summarizes our single-center experience with the SynCardia TAH^® with particular focus on the outcome after subsequent heart transplantation.

Methods

We retrospectively analysed the outcome of all transplanted SynCardia TAH^® patients at our center between 2001 and 2019 in comparison to transplanted left ventricular assist device (LVAD) and biventricular assist device (BVAD) patients and to transplanted patients without prior durable mechanical circulatory support (non-MCS).

Results

Only a fraction (n=69; 37.3%) of all SynCardia TAH^® patients (n=193) were transplanted. The majority (81.2%) of those were in high-urgency status at the time of transplantation. Survival in transplanted SynCardia TAH^® patients was significantly poorer when compared to LVAD-, BVAD- and non-MCS patients (P=0.008).

Conclusions

Heart transplantation in SynCardia TAH^® patients requires distinct risk stratification to improve outcomes.

Early surgical myocardial revascularization in non-ST-segment elevation acute coronary syndrome

Background

In non-ST-elevation myocardial infarction (NSTEMI) there is no consensus regarding optimal time point for coronary artery bypass grafting (CABG). Recent findings suggest that long-term outcomes are improved in early-revascularized NSTEMI patients. However, it has been stated that early surgery is associated to increased operative risk. In this study, we wanted to elucidate if early CABG in non-ST-elevation acute coronary syndrome can be performed safely.

Methods

We performed a monocentric-prospective observational study within a 2-year interval. A total of 217 consecutive patients (41 female, age 68.9±10.2, ES II 6.62±8.56) developed NSTEMI and underwent CABG. Patients were divided into two groups according to the time point of coronary artery bypass after symptom onset (group A: <72 h; group B: >72 h). Endpoints included 6-month mortality and incidence of MACE (death, stroke or re-infarction).

Results

There were no differences regarding mortality between both groups (30 days: group A 2.4% vs. group B 3.7%; P=0.592; 6 months: 8.4% vs. 6.0%; P=0.487). Incidence of MACE in the 6-month follow-up was also similar in both groups (group A: 9.6% vs. 9.7%, P=0.982). Regression analysis revealed as independent risk factors for mortality in the entire cohort ES II OR 1.045 (95% CI: 1.004-1.088). ES II remained an independent prognostic factor in group A OR 1.043 (95% CI: 1.003-1.086) and group B OR 1.032 (95% CI: 1.001-1.063).

Conclusions

Early revascularized patients showed a higher level of illness. However, results of early CABG were comparable to those following delayed revascularization. Moreover, EuroSCORE II was determined as independent risk factors for mortality.

[Heart failure: ventricular assist devices and cardiac transplantation : A review of current surgical innovations]

BACKGROUND

End-stage heart failure is one of the leading causes of death in Germany. Cardiac transplantation is still considered the gold standard for the treatment of terminal heart failure; however, there is a discrepancy between patients on the waiting list and yearly performed transplantations. As an alternative, ventricular assist devices have achieved a high level of importance but treatment is still associated with challenges. Novel systems as well as innovative surgical techniques contribute to improving the safety and effectiveness of the treatment.

OBJECTIVE

To generate an overview of current surgical innovations in cardiac transplantation and mechanical circulatory support.

MATERIAL AND METHODS

A Medline search was conducted regarding innovations in cardiac transplantation and mechanical circulatory support.

RESULTS AND CONCLUSION

Not only the number of yearly performed cardiac transplantations has changed but also recipient profiles. While in the pioneering era of transplantation the typical candidate was young, not previously operated on and with lower levels of comorbidities, today's patients are significantly older, have been fitted with ventricular assist devices and have increased operative risk profiles. Modern methods of organ preservation enable longer transportation and operation times as well as an improved assessment of graft function and perspectives for graft optimization in the future. In the area of ventricular assist devices, advances in the reduction of the stroke rate seem to have been achieved by the latest generation devices. From a surgical perspective, less invasive surgical techniques with promising initial results have been established at numerous centers.

Prognostic Value of the Nutritional Risk Index in Candidates for Continuous Flow Left Ventricular Assist Device Therapy

INTRODUCTION AND OBJECTIVES

Malnutrition has been shown to affect clinical outcomes in patients with heart failure. The aim of this study was to analyze the impact of preoperative nutritional status assessed by the nutritional risk index (NRI) on the prognosis of patients with a continuous-flow left ventricular assist device (cf-LVAD).

METHODS

We performed a retrospective study of 279 patients who underwent cf-LVAD implantation between 2009 and 2015 in our center. Preoperative NRI was calculated and the patients were followed-up for 1 year. The association between preoperative NRI and postoperative clinical events was analyzed using multivariable logistic regression.

RESULTS

The prevalence of severe (NRI <83.5), moderate (83.5 ≤ NRI <97.5) and mild (97.5 ≤ NRI <100) nutritional risk was 5.4%, 21.5%, and 9.3%. Mortality rates 1 year after cf-LVAD implantation in these 3 categories were 53.3%, 31.7%, 23.1% vs 18.0% (P <.001) in patients with a normal IRN. A normal preoperative NRI value was an independent predictor of lower risk of death from any cause during follow-up (aHR per 1 unit, 0.961; 95%CI, 0.941-0.981; P <.001) was and a predictor for a lower risk of postoperative infections (aOR, 0.968; 95%CI, 0.946-0.991; P=.007), respiratory failure (aOR, 0,961; 95%CI, 0.936-0.987; P=.004), and right heart failure (aOR, 0.963; 95%CI, 0.934-0.992; P=.014).

CONCLUSIONS

Malnourished patients are at increased risk for postoperative complications and death after cf-LVAD implantation. Assessment of nutritional risk could improve patient selection and the early initiation of nutritional support.

First series of left ventricular assist device exchanges to HeartMate 3

OBJECTIVES

Left ventricular assist device (LVAD) exchange is becoming a standard surgical procedure. The exchange procedure is an opportunity to upgrade patients to a new generation pump that offers advanced reduction of adverse events or longer battery hours.

METHODS

We performed an analysis of 6 consecutive patients who underwent LVAD exchange to HeartMate 3 either from a HeartWare or HeartMate (HM) II device. Minimally invasive operations were performed through a lateral thoracotomy. Follow-up time was 6 months after LVAD exchange.

RESULTS

We present 4 patients with the HM II and 2 patients with the HeartWare ventricular assist device (HVAD) who underwent LVAD exchange to HM III. The average age was 57.5 years. At the time of the LVAD exchange, all patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support level 3. In 5 cases, LVAD infection led to LVAD exchange (83%, 5/6). The remaining patient underwent LVAD exchange due to pump thrombosis (16%, 1/6). The 6-month survival rate after LVAD exchange was 100% (6/6). None of the patients was postoperatively supported by extracorporeal membrane oxygenation. No patient experienced postoperative relevant bleeding. One patient suffered minor cerebral bleeding (16.6%, 1/6). At the 6-month follow-up examination, 1 patient reported a single syncope and several low-flow alarms (1/6). The remaining 5 patients showed no adverse events or technical malfunctions of the VAD (5/6).

CONCLUSIONS

LVAD exchanges from HM II as well from HVAD to HM 3 are proven to be technically feasible. Due to the advantages and technical improvements of the new-generation pumps, this procedure is an excellent opportunity to give patients access to a superior generation of assist device.

Left Ventricular Assist Device Therapy for Destination Therapy: Is Less Invasive Surgery a Safe Alternative?

INTRODUCTION AND OBJECTIVES

The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients.

METHODS

We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26).

RESULTS

There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05).

CONCLUSIONS

Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.

Transplantation of purified iPSC-derived cardiomyocytes in myocardial infarction

Background

Induced pluripotent stem cells (iPSC) can be differentiated into cardiomyocytes and represent a possible autologous cell source for myocardial repair. We analyzed the engraftment and functional effects of murine iPSC-derived cardiomyocytes (iPSC-CMs) in a murine model of myocardial infarction.

Methods and results

To maximize cardiomyocyte yield and purity a genetic purification protocol was applied. Murine iPSCs were genetically modified to express a Zeocin^™ resistance gene under control of the cardiac-specific α-myosin heavy chain (α-MHC, MYH6) promoter. Thus, CM selection was performed during in vitro differentiation. iPSC-CM aggregates (“cardiac bodies”, CBs) were transplanted on day 14 after LAD ligation into the hearts of previously LAD-ligated mice (800 CBs/animal; 2-3x10⁶ CMs). Animals were treated with placebo (PBS, n = 14) or iPSC-CMs (n = 35). Myocardial remodeling and function were evaluated by magnetic resonance imaging (MRI), conductance catheter (CC) analysis and histological morphometry. In vitro and in vivo differentiation was investigated. Follow up was 28 days (including histological assessment and functional analysis). iPSC-CM purity was >99%. Transplanted iPSC-CMs formed mature grafts within the myocardium, expressed cardiac markers and exhibited sarcomeric structures. Intramyocardial transplantation of iPSC-CMs significantly improved myocardial remodeling and left ventricular function 28 days after LAD-ligation.

Conclusions

We conclude that iPSCs can effectively be differentiated into cardiomyocytes and genetically enriched to high purity. iPSC derived cardiomyocytes engraft within the myocardium of LAD-ligated mice and contribute to improve left ventricular function.

First experiences with HeartMate 3 follow-up and adverse events

BACKGROUND

The novel HeartMate 3 (HM3) left ventricular assist device (LVAD) received its CE mark in October 2015. It is a new compact LVAD featuring fully magnetically levitated pump, artificial pulse, large pump gaps, and a modular driveline. Here, we present outcomes and adverse events of a single-center cohort 6 months after HM3 implantation.

METHODS

We retrospectively studied a patient cohort of 27 patients who were supported with the HM3 at a single institution. We excluded patients with biventricular assist devices and other types of assist devices as well as LVAD exchange and re-operative procedures.

RESULTS

Twenty-seven patients were enrolled into the study. Within 1 year after HM3 implantation, 1 patient received a heart transplant and 3 patients died. Thirty-day survival was 88.9% and 6 months 85.2%. No pump thrombosis and no strokes were observed within 6 months. Right heart failure was diagnosed in 1 patient after HM3 implantation (3.7%). No technical complications of the pump were documented. No pump exchanges were necessary.

CONCLUSIONS

The novel LVAD HM3 has already shown good CE mark trial results. Within this first report after the CE mark trial, the 6-month survival after HM3 implantation was 85.2%. The HM3 showed excellent midterm results with 0% stroke and 0% pump thrombosis rates 6 months after implantation.

Does the surgeon's experience have an impact on outcome after total arterial revascularization with composite T-grafts? A risk factor analysis

OBJECTIVES

When composite T-grafting is performed, total arterial revascularization (TAR) can be accomplished with only two grafts. There is the belief that composite grafting poses a risk of graft failure due to its single inflow via the left internal thoracic artery (LITA). High surgical quality is essential for left internal thoracic artery preparation, T-grafting and length estimation. We investigated whether the surgeon's experience influences postoperative outcome.

METHODS

We analysed the data of 1080 consecutive patients (88% male, age: 62 ± 9 years) who underwent composite T-grafting between 1996 and 2011 in our institution. Patients were operated on either by experienced surgeons (Group A) or by surgeons early on in their career (Group B). Primary end-points were mortality, myocardial ischaemia, graft dysfunction and low cardiac output syndrome. Secondary end-points were persistent neurologic deficits (PNDs), blood transfusions and re-thoracotomy. Logistic regression analysis was performed to reveal independent risk factors for adverse outcome.

RESULTS

Patients in Group B had a lower logistic EuroSCORE (2.8 vs 2.3%; P < 0.05), longer operative times (cross-clamp time: 41 ± 11 vs 47 ± 14 min; P < 0.001) and received less anastomoses (3.2 ± 0.7 vs 3.1 ± 0.7, P = 0.005). Mortality was low in both groups (Group A 0.6% vs Group B 0.4%; P = 1.0). Myocardial ischaemia occurred in 2.3% (Group A) and 2.5% (Group B; P = 0.82). Graft dysfunction was seen in 0.6% (Group A) and 1.4% (Group B; P = 0.25). Incidence of postoperative low cardiac output syndrome was comparable (Group A 1.4% vs Group B 0.7%; P = 0.53). Both groups showed similar incidence of secondary end-points (persistent neurologic deficit: Group A 2.9 vs 3.2% in Group B; P = 0.84; re-thoracotomy: 1.6% in Group A vs 1.8% in Group B, P = 1.0). Blood transfusions were more common in Group B (P = 0.005). Less surgical experience could only be identified as an independent risk factor for blood transfusion (P = 0.001).

CONCLUSIONS

Total arterial revascularization with composite T-grafts can be performed safely by surgeons with different surgical experience. Despite differences in surgical performance parameters (e.g. operation times, blood transfusions), complication rates were extremely low, irrespective of the surgeon's operative experience. Surgeons can be introduced to these procedures in an early phase of training.

Transplantation Effectiveness of Induced Pluripotent Stem Cells Is Improved by a Fibrinogen Biomatrix in an Experimental Model of Ischemic Heart Failure

OBJECTIVES

The aim of this study was to investigate whether a fibrinogen biomatrix improves the transplantation effectiveness of induced pluripotent stem cells (iPSCs) in a model of myocardial infarction.

BACKGROUND

Early retention, engraftment, and cell proliferation are important factors for successful cardiac stem cell therapy. Common transplantation techniques involve the direction injection of cells in aqueous media. However, this approach yields low retention and variable cell biodistribution, leading to reduced grafts that are unable to sufficiently regenerate damaged myocardium. Biologically compatible scaffolds that improve the retention of injected cells can improve cardiac stem cell therapy.

METHODS

Murine iPSCs were transfected for luciferase reporter gene expression. First, in vitro experiments were performed comparing cell viability in fibrinogen and medium. Second, iPSCs were transplanted intramyocardially by direct injection into ischemic myocardium of immunodeficient mice, following permanent left coronary artery ligation. Cells were delivered in medium or fibrinogen. Follow-up included graft assessment by bioluminescence imaging, the evaluation of cardiac function by magnetic resonance imaging, and histology to evaluate graft size and determine the extent of myocardial scarring.

RESULTS

In vitro experiments showed proliferation of iPSCs in fibrinogen from 6.4×10(3)±8.0×10(2) after 24 h to 2.1×10(4)±3.2×10(3) after 72 h. Early cardiac cell amount in control group animals was low (23.7%±0.7%) with massive cell accumulation in the right (46.3%±1.0%) and the left lung (30.0%±0.6%). When iPSCs were injected applying the fibrinogen biomatrix, intramyocardial cell amount was increased (66.3%±0.9%) with demonstrable graft proliferation over the experimental time course. Left ventricle-function was higher in the fibrinogen group (42.9%±2.8%), also showing a higher fraction of refilled infarcted-area (66.9%±2.7%).

CONCLUSIONS

The fibrinogen biomatrix improved cardiac iPSc retention, sustaining functional improvement and cellular refill of infarcted myocardium. Therefore, fibrinogen can be considered an ideal biological scaffold for intramyocardial stem cell transplantations.

HeartWare left ventricular assist device for the treatment of advanced heart failure

The importance of mechanical circulatory support in the therapy of advanced heart failure is steadily growing. The rapid developments in the field of mechanical support are characterized by continuous miniaturization and enhanced performance of the assist devices, providing increased pump durability and prolonged patient survival. The HeartWare left ventricular assist device system (HeartWare Inc., Framingham, MA, USA) is a mechanical ventricular assist device with over 8000 implantations worldwide. Compared with other available assist devices it is smaller in size and used in a broad range of patients. The possibility of minimally invasive procedures is one of the major benefits of the device – allowing implants and explants, as well as exchanges of the device with reduced surgical impact. We present here a review of the existing literature on the treatment of advanced heart failure using the HeartWare left ventricular assist device system.

Minimally-invasive LVAD Implantation: State of the Art

Nowadays, the worldwide number of left ventricular assist devices (LVADs) being implanted per year is higher than the number of cardiac transplantations. The rapid developments in the field of mechanical support are characterized by continuous miniaturization and enhanced performance of the pumps, providing increased device durability and a prolonged survival of the patients. The miniaturization process enabled minimally-invasive implantation methods, which are associated with generally benefitting the overall outcome of patients. Therefore, these new implantation strategies are considered the novel state of the art in LVAD surgery.

In this paper we provide a comprehensive review on the existing literature on minimally-invasive techniques with an emphasis on the different implantation approaches and their individual surgical challenges.

First series of mechanical circulatory support in non-compaction cardiomyopathy: Is LVAD implantation a safe alternative?

BACKGROUND

Left ventricular non-compaction (LVNC) is a rare cardiac disorder characterized by prominent trabeculae and deep recesses of the ventricular myocardium. Patients with LVNC may develop severe congestive heart failure refractory to medical therapy. However, heart transplantation is strongly limited due to donor organ shortage. Thus mechanical circulatory support by left ventricular assist devices (LVADs) is a promising alternative. Nevertheless, hypertrabeculation and proarrhythmogenic potential in LVNC might represent important hurdles for success of LVAD therapy in these patients.

METHODS AND RESULTS

We retrospectively analyzed the data of a total of 5 patients (3 HVAD, Heartware®; 2 HeartMate II, Thoratec®) with LVNC who underwent LVAD implantation in our institution between 2010 and 2014. Mean follow-up time was 86.5weeks. 30-day survival was 100% without major intrahospital complications. During follow-up, 3 patients developed pump thrombosis requiring pump replacement. Arrhythmias were not detected during follow-up as assessed by ICD interrogation.

CONCLUSIONS

LVAD implantation in LVNC can be performed with low intrahospital complication rates. However, we observed a high incidence of pump thrombosis during follow-up, possibly related to thromboembolic predisposition by the underlying LVNC. Therefore, careful management of anticoagulation appears to be critical in these patients.