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Purpose Vascular endothelial growth factor (VEGF) has been implicated in gastrointestinal angiodysplasias (GIADs). Bevacizumab (Avastin) is a humanized monoclonal antibody against VEGF and confers potent antiangiogenic properties. We sought to examine the safety and efficacy of intravenous bevacizumab in a small group of LVAD patients with refractory GI bleeding due to GIADs. Methods We conducted a pilot study between January, 2017 and March, 2018 at a large institution to examine the efficacy and safety of intravenous bevacizumab administration in patients supported with continuous flow LVAD who presented with refractory GIADs-related bleeding, defined as endoscopy-proven GIADs that failed both conventional medical and endoscopic therapies. We assessed response to therapy based on changes in number of GI bleeding hospitalizations, blood transfusions, and scoping procedures. Results Five LVAD patients (mean age 67 years, all male, all HeartMate II) with refractory GIADs-associated bleeding were treated with intravenous bevacizumab for a total of 8 cycles according to our institutional protocol. The median (interquartile range [IQR]) of follow up while on LVAD was 11.0 (2.6, 25.5) and 11.2 (10.2, 13.5) months pre and post bevacizumab initiation, respectively. Intravenous bevacizumab administration resulted in a remarkable decrease in the annual number of blood transfusions (45.8 [13.6, 133.8] vs. 6.0 [3.7, 12.2]), hospitalizations for GI bleeding (5.6 [3.1, 11.7] vs. 1.7 [0.40, 2.8]), and scoping interventions (10.6 [4.7, 41.7] vs. 2.3 [0, 5.1]) (Figure). All patients tolerated bevacizumab therapy without serious side effects. Conclusion Intravenous bevacizumab is an effective and safe treatment option for LVAD patients with refractory GI bleeding due to GIADs. Further studies are warranted to examine its long-term efficacy and safety in a large LVAD population. [ABSTRACT FROM AUTHOR]

Purpose Increasingly, patients undergoing LVAD implantation have had previous cardiac surgery, and re-operative sternotomy LVAD implantation can pose certain technical challenges. The approval of the thoracotomy approach for LVAD implantation potentially offers increased flexibility of access and may mitigate some of these technical challenges. Thus we reviewed our series of patients with previous sternotomy and who underwent left thoracotomy and upper hemisternotomy LVAD implantation. Methods Data were compiled on all patients who had consented to be included in the Advanced Heart Failure Registry, at Vanderbilt University Medical Center, between January 2013 and October 2018. Patients who had had previous sternotomy and thoracotomy HeartWareTM HVAD LVAD implantation were included in the analysis. Patients who had undergone thoracotomy HeartMate II (N=3), or off-pump thoracotomy HVAD implantation (N = 9) were excluded from the analysis. The operative technique for all patients involved a limited left anterolateral thoracotomy with an upper hemi-sternotomy anastomosis to the ascending aorta. Preoperative, Intra-operative and post-operative clinical and VAD specific variables were reported. Data regarding clinical end points were analyzed at 30 days and one year following implant. Results 19 patients satisfied the inclusion criteria, and their characteristics are described in Table 1. One patient died 11 days post LVAD implantation due to multi-system organ failure. This patient was INTERMACS 1 at implant with multi-organ failure pre-operatively. All other patients were either transplanted or still on LVAD support one year following implant. Conclusion The use of the left thoracotomy upper hemisternotomy approach for LVAD implantation in patients with previous sternotomy is a safe alternative to re-operative sternotomy. [ABSTRACT FROM AUTHOR]

Purpose Landmark work has demonstrated that hemocompatibility-related adverse event (HRAE) burden is significant lower with the newest centrifugal flow pump compared to the established axial flow pump. No study has compared HRAE among the approved centrifugal and axial flow pumps. The objective of this study was to evaluate the burden of HRAE between HeartMate II (HMII) and HeartWare HVAD (HW). Methods We performed a retrospective analysis of hemocompatibility related adverse events (nonsurgical bleeding, thromboembolic event, pump thrombosis, or neurological event) in patients following implantation of HMII or HW through 6 months follow-up. HRAE were categorized by type and severity of adverse event and assigned a hemocompatibility score (HCS) of 0-4 for no HRAE through life ending or disabling HRAE, respectively. Statistical analysis included assessment of survival free from HRAE from implantation to 6-month follow-up using Kaplan-Meier and Cox proportional-hazard models and comparison of net hemocompatibility score using proportional odds regression. Results The study cohort included 331 patients with 268 patients (81%) in the HMII group and 63 patients (19%) in HW group. Overall median age was 62.2 years; HMII patients were older (median 63.5 versus 58.1years, p<0.001). Freedom from HRAE at 6 months was similar between the groups, 69% in HMII and 61% in HW (HR 0.74, 95% CI 0.4-1.2, p=0.2). Net HCS was also similar between the groups, reported as mean± standard deviation total HCS per patient, in HMII was 0.7±1.4 compared to 0.5±1.2 in HW, p=0.36 (Figure A). Relative hazard of HRAE at 6 months correlated with patient age rather than VAD (Figure B). Conclusion Freedom from and burden of HRAE were not significantly different between the HeartMate II and HeartWare HVAD which is distinct from findings in the MOMENTUM trial. This indicates that hemocompatibility may differ significantly among available centrifugal flow technology and direct comparison of centrifugal flow pumps is required. [ABSTRACT FROM AUTHOR]

Purpose Following implantation of continuous-flow left ventricular assist devices (CF-LVADs), mechanical offloading results in improved resting hemodynamics; however peak exercise capacity generally does not increase substantially. The present study evaluated CF-LVAD supported patients who were invasively monitored during exercise to define parameters that underpin exercise capacity and outcomes. Methods A review of all CF-LVAD patients who underwent supine cycle ergometry exercise testing with measurement of pulmonary gas exchange during right heart catheterization (RHC) for evaluation of dyspnea at one institution between 2007 and 2018 was performed (n=22). In addition to the complete resting and exercise RHC data, additional data was extracted from the medical record including: baseline demographics, echocardiographic data, cardiopulmonary exercise testing (CPET) data, six-minute walk test (6MWT) distances, and pulmonary function test data (PFT). Results The primary outcome was death or heart failure hospitalization. Although resting filling pressures were relatively preserved, resting cardiac index (Fick) was low (2.1 ± 0.5 mL/kg/min). An impaired cardiac output reserve was present in 75% of patients. On univariate modeling, patients with exercise-induced hypoxemia (arterial oxygen saturation < 90%) experienced worse event-free survival (unadjusted HR 11.0, CI 2.4-57.2, p=0.003), which persisted after adjustment for RHC peak VO 2 and peak cardiac output (adjusted HR 25, CI 3.6-322, p=0.001). Conclusion Our findings suggest that exercise RHC provides additional prognostic utility over resting RHC in the CF-LVAD population. [ABSTRACT FROM AUTHOR]