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De novo aortic insufficiency (AI) is a common adverse event after continuous-flow left ventricular assist device (LVAD) placement and is associated with morbidity and mortality. This study aims to compare the development of de novo AI between HeartMate 3 (Abbott) and HeartMate II LVAD recipients. A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year postimplantation) of HeartMate 3 patients implanted between November 2014 and March 2019 and of HeartMate II patients implanted between April 2004 and December 2015 at Columbia University Irving Medical Center. One hundred twenty-two patients were excluded from analysis for a history of aortic valve surgery, concomitant aortic valve surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as development of more than mild AI after LVAD implant. Included in the study were 121 HeartMate 3 patients and 270 HeartMate II patients. After accounting for competing risks of death and transplantation, there was no significant difference in the development of de novo AI by 1 year postimplantation between HeartMate II and HeartMate 3 patients (P =.68). There was no significant difference in severity of AI developed up to 1 year post-implantation between HeartMate II and HeartMate 3 patients. Development of de novo AI is comparable between HeartMate 3 and HeartMate II patients. There is no significant difference in severity of AI between HeartMate II and HeartMate 3 patients. [ABSTRACT FROM AUTHOR]

Vasoplegia is a frequent complication of left ventricular assist device (LVAD) implantation. We investigated the effectiveness of methylene blue (MB) for vasoplegia in LVAD recipients. Twenty-seven patients received MB for vasoplegia after LVAD implantation and met study criteria between March 2015 and May 2018. Propensity score inverse probability weighting identified 41 controls who did not receive MB for post-LVAD vasoplegia. Clinical outcomes were compared between control and MB groups and between patients who received doses during (n = 15) and after surgery (n = 12). Hemodynamics and vasopressor requirements were analyzed using analysis of covariance. Median total MB dose was 1.9 mg/kg (interquartile range, 1.2-2.2 mg/kg). Methylene blue recipients experienced a transient initial decline in norepinephrine requirement from 141 ng/kg per min (95% confidence interval [CI], 81-201 ng/kg per min) to 117 ng/kg per min (95% CI, 58-176 ng/kg per min; P =.022) and a delayed decline in vasopressin from 4.8 U/h (95% CI, 3.8-5.8 U/h) to 4.0 U/h (95% CI, 2.8-5.1 U/h) (P =.004). In-hospital mortality, postoperative complications, and end-organ dysfunction did not differ from those of controls. There were no observed differences in mean arterial pressure, vasopressor requirements, or outcomes between patients who received doses during or after surgery. Weighted overall mortality in the entire study cohort was 8.8%. Although MB may affect vasopressor requirements, clinical outcomes in vasoplegia after LVAD implantation did not improve and were not affected by the timing of administration. [ABSTRACT FROM AUTHOR]

Although extremely high pulmonary vascular resistance (PVR) is a relative contraindication for heart transplantation (HTx), recent data with continuous-flow left ventricular assist devices (LVADs) indicate HTx outcomes may be different when high PVR is managed with an LVAD. This study clarifies the contemporary association between PVR at HTx and posttransplant survival in LVAD vs non-LVAD cohorts. We reviewed the United Network for Organ Sharing registry for adults who received a transplant from 2008 to 2015. In those with continuous-flow LVADs and those with no VADs at HTx, (non-VAD), we grouped patients by low PVR (PVR <3), intermediate PVR (PVR 3 to <6), and high PVR (PVR ≥6) groups. Adjusted hazard ratios (aHRs) for death after HTx were calculated by Cox regression. The non-LVAD cohort included 6270 patients (4385 in low, 1643 in intermediate, and 242 in high PVR), and the LVAD cohort included 4111 patients (3227 in low, 798 in intermediate, and 86 in high PVR). The high PVR LVAD group had the worst survival, which was not significant, likely to low power (P =.300). The aHR for death in non-LVAD was 1.047 (95% confidence interval, 1.010-1.088) and in LVAD was 1.063 (95% confidence interval, 1.010-1.119). Cubic spline analysis demonstrated nonlinear associations between PVR and the aHR, especially in the LVAD cohort. There was no significant evidence to conclude the effect of pretransplant PVR on posttransplant survival is higher in LVAD vs non-LVAD patients, based on analysis of the United Network for Organ Sharing database. However, further investigations are indicated to clarify HTx candidacy in those with extremely high PVR even after LVAD. [ABSTRACT FROM AUTHOR]

The use of short-term mechanical circulatory support (ST-MCS) has increased for refractory cardiogenic shock. However, there are scant data about bridge-to-recovery patients. We retrospectively reviewed 502 patients with cardiogenic shock who received venoarterial extracorporeal membrane oxygenation or a temporary surgical ventricular assist device as ST-MCS between 2010 and 2016. There were 178 patients (35.5%) who survived through device explantation. Of these, 149 patients (29.7%) survived to discharge and were included for analysis. The primary outcome was midterm survival without undergoing heart replacement therapy. In our bridge-to-recovery cohort, 101 patients (67.8%) were men, and the median age was 59 years (interquartile range, 51 to 67 years). Etiology of cardiogenic shock included postcardiotomy shock in 35.6% of patients (n = 53), allograft failure in 26.8% (n = 40), acute myocardial infarction (AMI) in 24.2% (n = 36), and other acute decompensated heart failure in 14.4% (n = 20). There were 24 major events (16.1%) recorded, including 21 patients who died and 3 patients who received heart replacement therapy during median follow-up of 306 days (interquartile range, 58.25 to 916.75 days). Overall freedom from event at 3 years was 74.2%. In subgroup analysis, AMI patients had a significantly worse freedom-from-event rate at 40.4% (p < 0.001). By univariate Cox analysis, AMI etiology (p = 0.003), length of ST-MCS (p = 0.06), blood urea nitrogen (p = 0.012), and left ventricular ejection fraction (p = 0.005) at discharge were predictors for adverse events. The overall midterm outcome of patients explanted from ST-MCS is favorable except for AMI patients. [ABSTRACT FROM AUTHOR]

Background Blood type O heart transplant recipients wait longer than non-O recipients and frequently require bridging left ventricular assist devices (LVADs). However, rarely has the effect of this disparity been shown in a large registry. This study used Markov simulation to clarify the outcome difference between O and non-O candidates and how allocation change could affect survival. Methods We reviewed the United Network for Organ Sharing registry for adults listed for heart transplantation from 2008 to 2015. Cumulative incidences of death or transplant and survival after listing were compared between O and non-O using propensity matching. A four-state Markov model—waiting without LVAD, waiting with LVAD, transplantation, and death—was created to simulate survival after listing. Sensitivity analysis was performed to see how the percentage of O hearts in non-O recipients would affect survivals. Results A total of 8,187 O and non-O candidates were included after matching. The cumulative incidence of transplantation was lower in O (p < 0.001), and death after listing was significantly higher (p < 0.001). During a median follow-up of 2.1 years, 69.6% of non-O candidates were transplanted, compared with 54.9% of O candidates (p < 0.001). Despite this disparity, 19% of non-O recipients received O hearts. Our simulated survival demonstrated that decreasing the O heart percentage in non-O recipients from the current 19% to 5% would provide similar survival in O and non-O after listing. Conclusions Under the current strategy, there are death and transplant rate differences between O and non-O candidates. Our simulation-based allocation strategy might aid in mitigating this discrepancy across blood types. [ABSTRACT FROM AUTHOR]

Background Hospital readmissions have an adverse effect on the quality of life in patients with end-stage heart failure. We examined the temporal pattern, predictors, and outcomes of readmission in continuous flow left ventricular assist device–supported patients. Methods We retrospectively reviewed inpatient data of 350 consecutive patients who received a continuous-flow left ventricular assist device at our center between May 2004 and December 2014. A total time–restricted model was used to estimate hazard ratios for readmission, and the Nelson nonparametric method was used to estimate mean cumulative function for each cause of readmission. Results The mean age was 57 ± 13 years, 82.6% received a HeartMate II (Abbott Laboratories, Chicago, IL), and 26.3% were destination therapy. The 30-day readmission rate was 21.7%, and 264 readmissions (41.1%) occurred within the first 6 months of support. The leading cause of readmission was bleeding (0.74 mean cumulative events per person), followed by infection (0.7), device failure (0.52), arrhythmia (0.3), and right heart failure (0.28) at 3 years. The number of readmissions did not have an adverse effect on survival (hazard ratio, 1.03; 95% confidence interval, 0.92 to 1.17; p = 0.58). Increase in each body mass index unit was associated with 1.029 times the rate of overall readmission ( p = 0.041). Patients with a body mass index of 30 kg/m 2 or higher had increased readmissions for device failure ( p = 0.008) and right heart failure ( p = 0.03). Conclusions Readmission burden is highest during the first few months of continuous-flow left ventricular assist device support, but survival is not affected. Patients with an elevated body mass index are at increased risk for readmissions for device failure and right heart failure. [ABSTRACT FROM AUTHOR]

Background Optimal anticoagulation strategy remains uncertain in patients with heparin-induced thrombocytopenia (HIT) and undergoing left ventricular assist device (LVAD) implantation. We describe our protocol of abciximab and heparin in these patients. Methods Our protocol is to administer abciximab, 0.25 mg/kg loading dose, followed by continuous infusion of 0.125 μg · kg −1 · min −1 throughout cardiopulmonary bypass. Full-dose heparin is then given with subsequent additional doses to maintain an activated clotting time of 400 seconds or longer. The abciximab infusion is stopped 15 minutes after heparin reversal with protamine, and platelets are transfused. Results Six patients underwent LVAD implantation with this protocol in our program. HIT was confirmed in 4 patients was suspected in 2, which was negative after the operation. One patient received a HeartMate XVE (Thoratec Corp, Pleasanton, CA) and the others received HeartMate II (Thoratec Corp). There were no thromboembolic complications. One patient required chest reexploration for bleeding and temporary right VAD support. Postoperative anticoagulation with argatroban was restarted on median postoperative day 3 (range, days 1 to 6) and warfarin was started on day 5 (range, days 3 to 12). Median postoperative intensive care unit stay was 9 days (range, 5 to 76 days), and hospital stay was 22 days (range, 18 to 132 days). After the initial LVAD implantation, 1 patient required HeartMate XVE LVAD exchange to HeartMate II and subsequent heart transplant, both of which were performed with the abciximab/heparin protocol. A HeartMate II device was explanted in another patient after myocardial recovery. The remaining 4 patients are alive on device support. Conclusions This is the first report of a novel abciximab/heparin protocol for LVAD implantation in patients with HIT. The preliminary results suggest the feasibility and safety of this protocol. [ABSTRACT FROM AUTHOR]

Background Few studies have evaluated the long-term effects of continuous blood flow with reduced pulsatility on end-organ function. Methods Between May 2004 and December 2015, 469 patients underwent continuous-flow left ventricular assist device (LVAD) implantation at our center. Our study included 59 (13%) patients who were supported with an LVAD for a minimum of 3 years. We evaluated postoperative renal function and hepatic function at 1 and 6 months, and 1, 2, and 3 years after implantation in those 59 patients. Results The patients’ mean age was 63 ± 13 years, 81% were male, 53% had an ischemic cause of heart failure, and 68% underwent LVAD implantation as destination therapy. All laboratory determinations showed significant improvements at 1 month after the procedure. Hepatic values remained in a normal range for up to 3 years, although renal function improvement was predominantly transient. One month after implantation, the mean estimated glomerular filtration rate (eGFR) was improved from 58.2 ± 27.9 to 77.7 ± 33.5 mL/min/1.73 m 2 . However, 46 (78%) patients showed a gradual decline in eGFR to only 1.7% above the preoperative value after 3 years ( p = 0.67 vs baseline). The risk factors for impaired renal function after long-term support were age 60 years or older, ischemic cause, and late right heart failure. Conclusions Continuous-flow LVAD improves renal and hepatic functions in patients with advanced heart failure. However, in most, the initial improvement in renal function is largely transient and returns to baseline after a prolonged support period. [ABSTRACT FROM AUTHOR]