Heart transplantation in children after mechanical circulatory support: comparison of heart transplantation with ventricular assist devices and elective heart transplantation

Heart transplantation (HTx) is an ultimate treatment for children with end-stage heart failure or inoperable congenital heart disease. The supply of hearts is inadequate; therefore, different mechanical support systems must be used as bridge to HTx in pediatric patients with postoperative low output. The use of ventricular assist devices (VADs) as bridge to HTx in children is limited because of size differences. The purpose of this study was to evaluate the overall long-term outcome of pediatric circulatory support before pediatric HTx. From 1989 through 2004, 91 pediatric patients underwent isolated HTx. Seven of them required mechanical support before transplantation. We reviewed retrospectively the course of 91 children (mean age 14.7 years) who underwent HTx. Group A consisted of elective HTx patients who were treated as outpatients before HTx, whereas group B was the VAD-HTx bridging group (n=7; mean age 12.31 +/- 2.8 years). Mean duration of VAD support was 108 +/- 98 days (minimum 1 day, maximum 258 days). Overall survival rate after HTx was 80% at 1 year without significant differences between groups. Five of seven patients survived and could be discharged after successful HTx, for a survival rate of 77%. The mean follow-up period was 16.76 +/- 10.6 months. No differences in posttransplantation long-term survival and rejection episodes occurred between patients transplanted with or without VAD. VAD therapy can keep pediatric patients with end-stage heart failure alive until successful HTx, and bridge to HTx is a safe procedure in pediatric patients. After HTx, survival rates of these children are similar to those of patients awaiting elective HTx.     

Overweight is advantageous for heart-transplant candidates to survive the period of critically ill status

Although extreme obesity and being underweight are both known as risk factors for mortality in patients with ventricular assist devices (VAD) and in those listed for urgent heart transplantation (HTx), the risk in patients between these extremes is controversial. We investigate the risk of mortality after their progression to critically ill status (i.e., urgency listing or VAD implantation) in patients stratified by body mass index (BMI). Risk of mortality on the waiting list was studied in group N (n = 134), normal weight, BMI: 18.5-24.9 kg/m(2); group OWt (n = 112), overweight, BMI: 25.0-29.9 kg/m(2); and group OB-I (n = 39), obesity class I, BMI: 30.0-34.9 kg/m(2). Patients' 1 year survival rate on the waiting list in group N (62.2%) and group OB-I (50.6%) was significantly lower than in group OWt (74.3%, p = 0.036 and p = 0.022, respectively). After adjustment for age, gender, serum creatinine, and primary use of VAD, group OB-I (hazard ratio [HR] 1.971, 95% confidence interval [CI] 1.062-3.659, p = 0.032) and group N (HR 1.792, 95% CI 1.058-3.036, p = 0.030) were at higher risk of mortality compared with group OWt. Overweight HTx candidates have the best prognosis on the waiting list. Obesity class I patients are encouraged to reduce their body weight to at least overweight.     

Bosentan improved persistent pulmonary hypertension in a case after implantation of a left ventricular assist device

No medical treatment has been established to ameliorate pulmonary hypertension (PH) due to left heart disease. Heart transplantation (HTx) is thus far the definitive therapy for stage D heart failure, but concomitant PH is one of the major risk factors for death after HTx. Recently, implantation of a left ventricular assist device (LVAD) has been reported to improve PH and has become a major bridge tool for HTx. We experienced a rare case with persistent PH even after the implantation of a continuous-flow LVAD. The administration of an endothelin receptor antagonist, bosentan, significantly decreased pulmonary vascular resistance. Combination therapy with LVAD implantation and anti-PH medication may be useful for patients with stage D heart failure complicated with severe PH.     

Executive cognitive dysfunction without stroke after long-term mechanical circulatory support

Among patients who receive heart transplantation (HTx) after long-term mechanical circulatory support (MCS), some show executive cognitive dysfunction without a history of stroke. Fifty HTx patients (19 patients on MCS for longer than 3 months before HTx and 31 patients without MCS as control group) were enrolled in the study. All subjects were men aged between 20 and 59 years without a history of stroke. Patients with MCS were divided into two groups: the AH-Thr group (n = 11), in which thrombus was detected in the left ventricular assist device (LVAD) and quickly removed (mean 3.3 times); and the AH group (n = 8), in which there was no detectable thrombus in the LVAD. The Trail Making Test (TMT) and the Wisconsin Card Sorting Test (WCST) were administered. The AH-Thr group showed poorer cognitive performance both in the TMT part B, with longer completion time (p < 0.05 versus the other two groups), and in the WCST, with more perseverative errors (p < 0.001 versus the other two groups). These data indicate that patients in the AH-Thr group showed executive cognitive dysfunction in set-shifting ability, suggesting frontal lobe damage. The conditions that facilitate thrombus formation in the LVAD may induce executive cognitive dysfunction without stroke.     

A heart transplant candidate with severe pulmonary hypertension and extremely high pulmonary vascular resistance

Fixed pulmonary hypertension (PH) is a contraindication for heart transplantation (HTx). Several studies showed that use of a left ventricular assist device (LVAD) in patients with fixed PH who were initially deemed ineligible for HTx effectively decreased pulmonary arterial pressure (PAP), thus permitting HTx. We recently encountered a candidate for HTx who had severe PH with extremely high pulmonary vascular resistance (PVR). A 27-year-old female who had been diagnosed with dilated-phase hypertrophic cardiomyopathy and who was approved for HTx at age 25 was referred to our institute because of severe fatigability with moderate dyspnea even at rest due to severe bilateral heart failure. Despite continuous inotrope infusion, the patient’s symptoms were not relieved. Right heart catheterization (RHC) disclosed a PAP of 62/40 mmHg with severely reduced cardiac output (1.8 l/min). A PVR of 15.9 Wood units suggested progressive worsening of left ventricular function with almost irreversible remodeling of the pulmonary vasculature, and the patient was thought to be contraindicated for HTx. Following 3 weeks of aggressive medical treatment, repeat RHC demonstrated PVR lowering to 8.16 Wood units. This suggested it was likely that PVR could be reversed, and the patient underwent LVAD implantation. RHC performed after LVAD implantation showed a fall in PVR from the initial, extremely high measurement of 15.9 Wood units to 3.4 Wood units at 2 months postoperatively, and to 2.2 Wood units at 1 year. The patient is currently awaiting HTx with favorable LVAD support.     

Development of implantable right ventricular assist device

Implantable ventricular assist devices (VADs) are indicated for long waiting periods before transplantation and also as a destination therapy. Meanwhile, right ventricular failure (RVF) is one of the four major complications observed in patients after left VAD (LVAD) implantation, with an incidence of approximately 20%. Preoperative prediction of the complication remains difficult, and the mortality is very high. To date, no implantable right VAD (RVAD) is available for the clinical situation. The possibility of realizing an implantable RVAD with Gyro centrifugal pump (PI-710 pump) was investigated. Eleven chronic animal experiments with LVAD and RVAD implantation were performed. Right heart bypass was established between right outflow and pulmonary trunk, and the pump was implanted in the preperitoneal space. The anatomic fit was good. The mean term of the experiments was 59 days, with excellent pump performance. Stable pulmonary hemodynamics and respiratory function were maintained during all of the experimental terms. No specific abnormal histologic findings of the lung were confirmed; however, tunica media hypertrophy was recognized in some cases. The PI-710 pump is feasible as a clinically implantable RVAD, but further study of histologic and pulmonary vascular changes after RVAD implantation is needed.     

Temporary biventricular support with extracorporeal membrane oxygenation: a feasible therapeutic approach for cardiogenic shock with multiple organ failure

Various strategies using a ventricular assist device (VAD) are applied to rescue Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (Profile-1) patients. However, the optimal use of VAD in Profile-1 patients has not been completely elucidated. We retrospectively reviewed 23 Profile-1 patients [mean age 36.9 ± 16.6 years, 14 males; 11 with non-ischemic cardiomyopathy (NICM), 9 with fulminant myocarditis (FM), 2 with ischemic cardiomyopathy (ICM), and 1 with peripartum cardiomyopathy (PPCM); 18 with pre-operative percutaneous extracorporeal membrane oxygenation (p-ECMO) support] who underwent VAD implantation from 2011 to 2015 at our institution. Nine initially received left VAD (LVAD) alone (NICM in 9, ICM in 2 with ICM, and FM in 1), one with NICM received biventricular VAD (BiVAD; n = 1), and 10 received LVAD combined with right ventricular support using an ECMO circuit (BiVAD-ECMO) (FM in 8, NICM in 1, and PPCM in 1). Paracorporeal VAD was used in all patients. ECMO was used for the patients with severe pulmonary edema, inflammation, anemia, and thrombopenia. The BiVAD patient died 1.4 months after VAD implantation. The overall survival was comparable between patients with BiVAD-ECMO and LVAD (2-year survival, 80.0 and 75.0%, respectively). Three VAD strategies were initially applied in Profile-1 patients. Among them, the BiVAD-ECMO strategy is a promising therapeutic option to rescue Profile-1 patients with multiple organ failure.     

Four-year paracorporeal left ventricular assist device (LVAD) support for heart failure after Rastelli operation

It is well known that heart failure can occur after a conventional Rastelli operation (using an anatomical right ventricle as a systemic ventricle) in patients with congenitally corrected transposition of the great arteries (CCTGA). At present, heart transplantation (HTx) is the only definitive therapy known to save such patients. The left ventricular assist device (LVAD) has been employed for patients presenting with acute deterioration of chronic heart failure as a bridge to transplantation when early HTx is not feasible. LVAD implantation in postoperative cases and/or in patients with dextrocardia is often difficult because of the complex anatomy. We report the case of a 26-year-old male patient with CCTGA who presented with heart failure after a conventional Rastelli operation and in whom paracorporeal LVAD implantation was undertaken for the management of right (systemic) ventricular failure. The patient recovered from the heart failure and remained on the HTx list for approximately 4 years with LVAD support.     

Diagnosis,medical treatment,and stepwise mechanical circulatory support for fulminat myocarditis

Fulminant myocarditis is one of the most challenging diseases. We sought to examine the outcomes of our multidisciplinary treatment strategy for fulminant myocarditis. A retrospective review of consecutive 30 patients with fulminant myocarditis was conducted. Of the 30 patients, 25 required mechanical circulatory support (MCS). Percutaneous extracorporeal membrane oxygenation (ECMO) was the first-line therapy to rescue the patients and inserted in 23 of them. The other 2 were implanted with temporary ventricular assist device (t-VAD) with extracorporeal centrifugal pump(s). Sixteen of the ECMO-supported patients were later transitioned to t-VAD. Of the 18 patients who underwent t-VAD support, heart function recovered and the VAD was explanted in 10. Four patients were bridged to long-term VAD and the other 4 died on t-VAD. Two patients were directly bridged to long-term VAD by ECMO. Heart function recovered only with ECMO in 4 patients and 1 died on ECMO. Overall survival rate was 83.3%. The duration of ECMO support significantly correlated with total bilirubin level, which was a significant risk factor for mortality. Pathologically, 7 patients (23.3%) had eosinophilic myocarditis and 1 (3.3%) had giant-cell myocarditis, and all the 8 patients underwent immunosuppressive therapy including steroids. Heart function recovered to normal level in 7 of them (87.5%). Timely conversion from the percutaneous ECMO to the temporary VAD before elevation of total bilirubin level is crucial for improving the clinical outcomes. Endomyocardial biopsy is needed to be done as soon as possible, because immunosuppressive therapy carries promising outcomes in certain etiologies.     

Outcomes of pediatric patients bridged to heart transplantation from extracorporeal membrane oxygenation support

Extracorporeal membrane oxygenation (ECMO) is used as a salvage therapy in children with irreversible myocardial failure who may be candidates for heart transplantation (HTx) (at the Hospital for Sick Children). We retrospectively assessed outcomes of children wait-listed for HTx from ECMO, and risk factors for patients (pts) bridged to HTx from January 1990 through December 2005. Of 205 patients supported with cardiac ECMO, 46 were wait-listed for HTx. Sixteen patients died before HTx: eight died while wait-listed on ECMO; eight were delisted (clinical deterioration; all died); five were delisted (improved), and 25 (54%) underwent HTx from ECMO. Of 25 patients who underwent HTx (median age 7.0 years [10 days to 17 years]), 13 had myocarditis or cardiomyopathy, and 12 had congenital heart disease. Median ECMO duration was 6.7 days (3-18 days). Median follow-up was 4.3 years (0.2-10.6 years). Four patients died <1 week post-HTx, and 21 survived until hospital discharge (84%). Post-transplant survival was 67% and 52% at 1 and 5 years, respectively. Risk factors for early death were older age, higher body surface area, higher creatinine before and during ECMO, fungal infections, and exposure to blood products. In summary, few risk factors preclude HTx candidacy from ECMO. The impact of newer assist technology on ECMO, wait-list mortality, and HTx outcomes remains to be elucidated.     

Inflammatory response after implantation of a left ventricular assist device: comparison between the axial flow MicroMed DeBakey VAD and the pulsatile Novacor device

The implantation of a ventricular assist device (VAD) is associated with a stimulation of the inflammatory system. We compared changes in the inflammatory response after implantation of a pulsatile Novacor left (L) VAD and the axial flow MicroMed DeBakey VAD. Six consecutive patients after implantation of a Novacor LVAD (NC) and six patients after implantation of a MicroMed DeBakey VAD (MD) were included in the investigation. Patients received LVADs for medically non treatable end-stage heart failure. Tumor necrosis factor alpha (TNF), C3a, C5a, interleukin 6 (IL-6), and neutrophil elastase were measured twice a week over a period of 3 months after implantation of the device. All tests were performed with an enzyme-linked immunosorbent assay. There was no significant difference in the clinical course of the two groups. All inflammatory parameters were elevated in both groups during the entire period of the investigation. There was no difference in TNF, polynuclear leukocyte elastase, or C3a levels between the two groups; however, IL-6 (NC: 23.6+/-37.6 pg/ml vs. MD: 63+/-114 pg/ml, p < 0.001) and C5a (NC: 708+/-352 microg/L vs. MD: 1,745+/-1,305 microg/L, p < 0.001) were increased significantly more in patients following implantation of the axial flow MicroMed DeBakey VAD. Compared with the pulsatile Novacor device, the implantation of the axial flow MicroMed DeBakey LVAD seems to be associated with an increased stimulation of one part of the inflammatory system. Further investigations are necessary for evaluation of the pathophysiologic mechanism and clinical implications of these findings.     

Preliminary report on the cost effectiveness of ventricular assist devices

The aim of the present study was to perform a cost-effectiveness analysis (CEA) of ventricular assist devices (VAD) implantation surgery in the Japanese medical reimbursement system. The study group consisted of thirty-seven patients who had undergone VAD implantation surgery for dilated cardiomyopathy (n = 25; 67.6 %) or hypertrophic cardiomyopathy (n = 4; 10.8 %), and others (n = 8; 21.6 %). Quality-adjusted life years (QALYs) were calculated using the utility score and years of life. Medical reimbursement bills were chosen as cost indices. The observation period was the 12-month period after surgery. Then, the incremental cost-effectiveness ratio was calculated according to the VAD type. In addition, the prognosis after 36 months was estimated on the basis of the results obtained using the Markov chain model. The mean preoperative INTERMACS profile score was 2.35 ± 0.77. Our results showed that the utility score, which indicates the effectiveness of VAD implantation surgery, improved by 0.279 ± 0.188 (ΔQALY, p < 0.05). The cost of VAD implantation surgery was 313,282 ± 25,275 (ΔUS$/year) on the basis of medical reimbursement bills associated with therapeutic interventions. The calculated result of CEA was 364,501 ± 190,599 (ΔUS$/QALY). The improvement in the utility score was greater for implantable versus extracorporeal VADs (0.233 ± 0.534 vs. 0.371 ± 0.238) and ICER was 303,104 (ΔUS$/ΔQALY). Furthermore, when we estimated CEA for 36 months, the expected baseline value was 102,712 (US$/QALY). Therefore, VAD implantation surgery was cost effective considering the disease specificities.     

The pediatric mechanical circulatory support program in Innsbruck, Austria, and the impact of such programs on lack of donor hearts in Europe

Strategy and results of the Innsbruck Mechanical Circulatory Support Program are presented, and the impact of such programs on pediatric heart transplantation (HTX) in Europe is discussed. Venoarterial extracorporeal membrane oxygenation (vaECMO) and ventricular assist devices (VADs) were used in 21 pediatric patients (median age 3.3 years, 2 days to 17 years) for acute heart failure (AHF) following a bridge or bridge-to-bridge strategy. Twelve patients were treated with vaECMO: eight were weaned after 2-10 days, two died, and two were switched to a VAD. Of the last, one was weaned 47 days later and the other underwent HTX 168 days later. In nine patients, VAD was implanted without preceding vaECMO. One such patient died (cerebral hemorrhage) after 236 days; of the remaining eight patients three were weaned and five underwent HTX. Waiting time for HTX (high-urgency status) varied from 4 to 372 days. Fifteen patients were discharged (follow up: 2-74 months); 14 are doing very well (New York Heart Association (NYHA) Functional Classification Class I, neurologically normal), whereas one suffers from severe neurologic damage, presumably from resuscitation before vaECMO. Data from Eurotransplant on pediatric HTX in 2004, 2005, and 2006 (33, 49, and 34 transplanted hearts, respectively; recipients <16 years of age) are discussed. Mechanical circulatory support (MCS) substantially improves survival with AHF in pediatric patients. Medium-term support (up to 400 days in our patients) is possible and outcome of survivors is excellent. Wide spread use of MCS might slightly aggravate the lack of donor organs, which could result in longer support times.     

Pathological findings in cardiac apex removed during implantation of left ventricular assist devices (LVAD) are non-specific: 13-year-experience at a German Heart Center

Background and aim: Ventricular assist devices (VAD) have become an established therapy for patients with end-stage heart failure. The two main reasons for this development are the shortage of appropriate donor organs and the increasing number of patients waiting for heart transplantation (HTX). Furthermore, the enormous advances in the technical equipment and the rising clinical experience have improved the implantation technique, the durability and the long-term patient outcomes. Methods: We reviewed all cases of left ventricular assist device (LVAD) implantation at our Erlangen Heart Center during January 2000-July 2013. The main aim of this study was to analyze the underlying pathology from the cardiac apex removed during the implantation. From all patients, we created a follow-up, analyzed the pathological features with the clinical diagnoses and described the overall outcome. Results: VAD implantation was performed in 266 cases at our center in the last 13 years (2.2% of the total of 12254 cardiac surgical operations in that period). From these patients, 223 underwent LVAD or biventricular (BVAD) implantation; the remaining received a right (RVAD) implantation. The most frequent underlying clinical diagnoses were dilated (n = 84, 37.7%, DCM) or ischemic (n = 61, 27.4%, ICM) cardiomyopathy. The pathological findings in the apex biopsy were generally non-specific and showed variable interstitial myocardial fibrosis with evidence of fibre loss, fatty degeneration and variable irregular atrophy of muscle fibres, consistent with dilated and ischemic cardiomyopathies as the most frequent causes of heart failure in these patients. Only a few cases showed other specific features such as myocarditis and AL-amyloidosis. Conclusions: Pathological findings in cardiac apex removed during LVAD implantation are rather non-specific and they generally reflect the late stage or consequences of chronic myocardial damage in cases of dilated or ischemic cardiomyopathies. Variable patchy chronic inflammatory changes may be observed in cardiomyopathies as a non-specific reaction caused by myocardial fiber damage and should not lead to misinterpretation as evidence of myocarditis or revision of original diagnosis.     

Paracorporeal ventricular assist device as a bridge to transplant candidacy in the era of implantable continuous-flow ventricular assist device

Ventricular assist devices (VADs) have long been used as bridge to transplant therapy (BTT). Nipro-Toyobo paracorporeal pulsatile-flow VAD (nt-VAD) was the only device available until April 2011, when implantable continuous-flow VADs (cf-VADs) became available. Although cf-VADs are central to BTT, nt-VAD remains a necessary option. We aimed to clarify the role of nt-VAD in an era of increasing cf-VAD use. We retrospectively reviewed patients who underwent VAD implantation at the National Cerebral and Cardiovascular Center from May 2011 to March 2013. Characteristics were compared between the nt-VAD and cf-VAD groups. Twenty-nine patients (mean age 37.7 ± 11.1 years, 23 males) underwent VAD implantation. Fifteen patients initially received nt-VADs, although 4 were converted to cf-VADs. Of these 15 patients, 3 were too small for cf-VADs and 2 needed bilateral ventricular support. The remaining 10 patients received nt-VADs (7 patients at INTERMACS level 1 and 3 at level 2). The nt-VAD group patients had significantly more preoperative mechanical circulatory support and were in a more critical condition before VAD implantation than the cf-VAD group. The 2-year survival rate was not significantly different. Despite the critical conditions of nt-VAD patients, their overall survival is not statistically inferior to that of cf-VAD patients. nt-VAD is a good option as a BTC for the patient with urgent and critical condition.     

Heart transplantation in adults with congenital heart disease: experience with 15 patients

End-stage congenital heart disease (CHD) is an important indication for pediatric heart transplantation (HTx) as well as transplantation in adult populations. The purpose of this retrospective analysis was to compare the survival rate of adults who underwent HTx for end-stage CHD with those who underwent HTx for other causes. To find out whether HTx is a viable therapeutic option for adult patients with preoperated CHD, data from 15 adult patients with different forms of CHD, who had previously undergone different corrective and palliative procedures, were retrospectively analyzed and compared with the HTx data of 1400 adult patients (>15 years old) whose indications for HTx were other than end-stage CHD. From 1989 to 2005, 15 adult patients (eight men/seven women) were given transplantation for end-stage CHD. Ten patients had been preoperated once, five patients twice. Their mean age was 34.06 +/- 3.9 years. In five cases, patients had development of acute renal failure. One female patient died 40 days after surgery, after having a cerebral infarction; one male patient died 4 years after HTx for OKT 3 monoclonal antibody-resistant rejection; and two patients died as the result of multiple organ failure at 4 days and 30 days after HTx, respectively; 11 patients are still alive. The cumulative survival rate at 1 year is 80% versus 80% in patients given transplantation for noncongenital indications. Heart transplantation in adults with end-stage CHD can be performed with a good long-term prognosis. Previous palliative operations do not affect outcome after HTx.     

Ventricular assist device implantation in the pediatric population: does pump size selection and associated hemodynamics impact outcomes?

The use of pediatric ventricular assist devices (VADs) continues to evolve with the availability of smaller blood pumps. We examine the correlation of implanting appropriate sized blood pumps with a lower incidence of VAD related complications (VADRC). A 7-year retrospective review was undertaken for all pediatric VAD patients. Optimal VAD hemodynamics were defined as cardiac index of 2.7 L/m2 and rate of 80 beats per minute (bpm) with complete fill/empty of the blood pump. Patient/blood pump size match, VAD rate and fill/empty ratios were calculated (optimum = 1.0) and then correlated with incidence of VADRC. The study included 22 patients, mean age 9.77 years (6 mo-18 yrs) and mean body surface area (BSA) of 1.14 m2 (0.14 m2-2.32 m2), who underwent VAD implantation. VADRC included death while on support (n = 5), bleeding requiring reoperation (n = 8), hemolysis (n = 2), neurologic events (n = 2), thrombus formation (n = 3), and infection (n = 3). Six patients were bridged to transplant without any VADRC. This subset of patients had a mean blood pump size match ratio of 0.98, VAD rate ratio of 0.92 and fill/empty ratio of 1.00. Patients with VADRC (n = 16) were found to have a mean blood pump size match ratio of 0.72, VAD rate ratio of 0.72 and fill/empty ratio of 0.78. We report a series of pediatric patients with wide ranging BSA receiving VAD implantation. Selection of appropriate sized blood pumps can be correlated with decreased VADRC.     

Ethical considerations for ventricular assist device support: a 10-point model

The potential for long-term support on a ventricular assist device (VAD) in the bridge-to-transplant (BTT) and destination therapy (DT) settings has created unprecedented ethical challenges for patients and caregivers. Concerns include the patient's adaptation to life on a device and the ethical, clinical, and practical issues associated with living on mechanical support. On the basis of our experience treating 175 consecutive VAD patients, we have developed a model to address the ethical and psychosocial needs of patients undergoing VAD implantation. Patient preparation for VAD implantation encompasses three phases: 1) initial information regarding the physical events involved in implantation, risks and benefits of current device technology, and the use of VAD as a rescue device; 2) preimplant preparation including completion of advance directives specific to BTT/DT, competency determination, and identifying a patient spokesperson, multidisciplinary consultants, and cultural preferences regarding device withdrawal; and 3) VAD-specific end-of-life issues including plans for device replacement and palliative care with hospice or device withdrawal. This three-phase 10-point model addresses the ethical and psychosocial issues that should be discussed with patients undergoing VAD support.     

Less-invasive off-pump ventricular assist device implantation in regional paravertebral analgesia

We describe the clinical course and treatment of a 58-year-old male with a primary cardiogenic shock, who underwent a minimally invasive off-pump ventricular-assist-device (VAD) implantation with the aid of paravertebral regional analgesia. He was extubated soon after the procedure, in the operating room, with the aim to reduce the right ventricle impairment. We illustrate how a minimally invasive implant may improve the clinical outcomes of VAD patients shortening their return time to active life.     

Ventricular assist device implantation using a right thoracotomy

Most patients needing implantation of a ventricular assist device (VAD) require repeated sternotomy; some after cardiac surgery, and others later for heart transplantation. The purpose of this study was to establish the right thoracotomy technique as an alternative for VAD implantation to reduce repeated sternotomy-related morbidity and mortality. We performed a right thoracotomy in animals, preclinical cadaver fitting tests, and a clinical case. A total of 20 various animals underwent right thoracotomy for implantation of bi-VAD (BVAD, n = 17) and left VAD (LVAD, n = 3). The right chest cavity was entered through the fourth intercostal space with partial resection of the fifth rib. There was no procedure-related morbidity or mortality, except for one calf with right anterior leg paralysis. Preclinical fitting tests were performed on 7 human cadavers to observe the anatomical feasibility of BVAD cannulation from the right side of the heart. In humans, the ascending aorta, interatrial groove, right atrium, and main pulmonary artery were identified as optimal cannula insertion sites for BVAD implantation. A patient with cardiogenic shock underwent a right thoracotomy for implantation of an external LVAD. Cardiac function recovered after 3 weeks, and the device was successfully explanted through a repeat right thoracotomy. In conclusion, a right thoracotomy can be an alternative method to the standard median sternotomy for patients who need repeated sternotomy because of previous cardiac surgery, transplantation at a later date, or those with mediastinal infections.