How to evaluate the outflow tract of LVAD after minimally invasive implantation by 3D CT-scan

During a minimally invasive implantation technique, the outflow graft of left ventricular assist device (LVAD) is tunnelled blindly through the pericardium or left pleura, with an inability to assess for twisting or malposition. Three-dimensional computed tomography scan (CT-scan) has a role in qualitative evaluation of the different outflow tract configurations. The different surgical minimally invasive approaches include: (a) mini-sternotomy and left mini-thoracotomy, (b) right mini-thoracotomy and left mini-thoracotomy, (c) subclavian artery access and left mini-thoracotomy. The outflow graft could be anastomosed to the left axillary artery or the ascending aorta. CT-scan reconstruction using syngo InSpace4D (Siemens, Muenchen, Germany) was used to provide fast segmentation and high-resolution images. The 3D reconstructions permit an evaluation of different anastomosis configurations and to assess the route of outflow graft.     

Validation of mitral regurgitation reversibility in patients with HeartMate 3 LVAD implantation

The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3 years. Of 135 LVAD patients (with severe MR, n = 33; with none, mild, or moderate MR, n = 102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1 month postoperatively, and at 1, 2, and 3 years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P < .001), right ventricular end-diastolic diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), and estimated pulmonary artery pressure (P < .001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2 years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P = .073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.     

Superior trans‐septal approach for minimally invasive mitral valve surgery via right small thoracotomy

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long‐shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans‐septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the “drawer‐case technique.” In conclusion, MIMVS via right thoracotomy using the superior trans‐septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.     

3D organ modeling with open‐source software

To date, 3D organ modeling has not reached widespread clinical use, despite showing promise in medical literature. The majority of anatomic modeling that is presented in the literature is performed with proprietary software, presenting certain barriers to use, such as price for usage rights. Open‐source software not only circumvents this barrier, but also often provides greater customization offered by global communities. In this proof‐of‐concept experiment, a HeartMate II LVAD inflow cannula was “virtually fit” in a patient’s left ventricle using only open‐source software. Open‐source programs provide a legitimate alternative to the proprietary software options.     

Long-term discontinuation of warfarin in a patient with HeartMate 3 left ventricular assist device without complication

A 38-year-old woman with peripartum cardiomyopathy underwent placement of a HeartMate 3 (HM3) left ventricular assist device (LVAD). Postoperatively, she refused warfarin therapy and was maintained on aspirin monotherapy for 19 months. She did not experience thrombotic or thromboembolic complications associated with lack of oral vitamin K antagonist anticoagulation. Our patient represents the longest reported duration of a patient with HM3 LVAD maintained without warfarin without evidence of thrombotic or thromboembolic events.     

Off‐pump,minimally invasive and robotic coronary revascularization yield improved outcomes over traditional on‐pump CABG

Coronary artery disease is a global health concern, with increasing morbidity and mortality. Surgical coronary artery bypass grafting has been performed on cardiopulmonary bypass for nearly four decades, with excellent long‐term durability. Beating‐heart coronary surgery has been increasing in frequency in an attempt to decrease cardiopulmonary bypass‐related morbidity. Furthermore, with increasing expertise and technology, minimally invasive and robotic techniques have been developed to enhance post‐operative recovery, patient satisfaction and cosmesis. Several clinical trials have demonstrated decreased morbidity and more rapid recovery following off‐pump, minimally invasive and robotic procedures when compared to on‐pump coronary artery bypass grafts (CABGs). An equivalent extent of revascularization and medium‐term anastomotic patency has been demonstrated among all approaches. Furthermore, for a large number of patients who do not have anatomy amenable to traditional coronary revascularization, adjunctive molecular therapies may provide alternative myocardial micro‐revascularization. Copyright © 2008 John Wiley & Sons, Ltd.     

Remote Monitoring of Left Ventricular Assist Device Parameters After HeartAssist‐5 Implantation

Although several left ventricular assist devices (LVADs) have been used widely, remote monitoring of LVAD parameters has been available only recently. We present our remote monitoring experience with an axial‐flow LVAD (HeartAssist‐5, MicroMed Cardiovascular, Inc., Houston, TX, USA). Five consecutive patients who were implanted a HeartAssist‐5 LVAD because of end‐stage heart failure due to ischemic (n = 4) or idiopathic (n = 1) cardiomyopathy, and discharged from hospital between December 2011 and January 2013 were analyzed. The data (pump speed, pump flow, power consumption) obtained from clinical visits and remote monitoring were studied. During a median follow‐up of 253 (range: 80–394) days, fine tuning of LVADs was performed at clinical visits. All patients are doing well and are in New York Heart Association Class‐I/II. A total of 39 alarms were received from three patients. One patient was hospitalized for suspected thrombosis and was subjected to physical examinations as well as laboratory and echocardiographic evaluations; however, no evidence of thrombus washout or pump thrombus was found. The patient was treated conservatively. Remaining alarms were due to insufficient water intake and were resolved by increased water consumption at night and summer times, and fine tuning of pump speed. No alarms were received from the remaining two patients. We believe that remote monitoring is a useful technology for early detection and treatment of serious problems occurring out of hospital thereby improving patient care. Future developments may ease troubleshooting, provide more data from the patient and the pump, and eventually increase physician and patient satisfaction. Despite all potential clinical benefits, remote monitoring should be taken as a supplement to rather than a substitute for routine clinical visits for patient follow‐up.     

Device exchange versus nonexchange modalities in left ventricular assist device‐specific infections: A systematic review and meta‐analysis

No standardized treatment algorithm exists for the management of continuous‐flow left ventricular assist device (CF‐LVAD)‐specific infections. The aim of this systematic review and meta‐analysis was to compare the outcomes of CF‐LVAD‐specific infections as managed by device exchange to other treatment modalities not involving device exchange. Electronic search was performed to identify all studies in the English literature relating to the management of CF‐LVAD‐specific infections. All identified articles were systematically assessed for selection criteria. Thirteen studies with 158 cases of CF‐LVAD‐specific infection were pooled for analysis. Overall, 18/158 (11.4%) patients underwent CF‐LVAD exchange, and 140/158 (88.6%) patients were treated with non‐exchange modalities. The proportion of patients with isolated driveline infections or pump or pocket infections did not differ significantly between the groups. During a mean follow‐up of 290 days, there were no significant differences in the overall mortality [exchange 17.6% (4.3–50.6) vs. non‐exchange 23.3% (15.8–32.9), P = 0.67] and infection recurrence rates [exchange 26.7% (8.7–58.0) vs. non‐exchange 38.6% (15.4–68.5), P = 0.56]. In the setting of CF‐LVAD‐specific infections, device exchange does not appear to confer an advantage in the overall mortality and infection recurrence as compared to non‐exchange modalities.     

Impact of the HeartMate 3 continuous-flow left ventricular assist device in patients with small body size

Open in a separate window OBJECTIVESLimited data are available for use of the HeartMate 3 (HM 3) left ventricular assist device in patients with a small body surface area (BSA). Because the HM 3 is currently the sole device available worldwide, we conducted a single-centre retrospective study of patients with a small BSA (<1.5 m²) who underwent HM 3 implantation to better understand the operative and postoperative management.METHODSThis study enrolled 64 consecutive patients who had undergone HM 3 implantation from August 2018 to July 2021. The patients were divided into 2 groups based on their BSA before the operation: BSA of <1.5 m² (small BSA group, n = 18) and BSA of ≥1.5 m² (regular BSA group, n = 46). The primary study endpoint was survival free of events such as disabling stroke and pump failure. The secondary endpoint was the frequency of adverse events.RESULTSThe average BSA was 1.38 m² in the small BSA group. The overall event-free survival rate at 12 months was 100% and 86.7% in the small BSA group and regular BSA group, respectively, and no significant difference was found between the 2 groups (log-rank P = 0.2). The number of cumulative adverse events of death, stroke of any severity, driveline infection, pump infection, ventricular arrhythmia, gastrointestinal Haemorrhage and pump failure was similar between the 2 groups.CONCLUSIONSThe HM 3 was safely implanted in patients with a small BSA, and postoperative outcomes were acceptable regardless of BSA. However, further research is needed to confirm the indications for HM 3 implantation in even smaller patients.