Improved Approach With Subcostal Exchange of the HeartMate II Left Ventricular Assist Device: Difference in On and Off Pump?

Infection following CF-LVAD exchange for non-infectious indications: A systematic review and meta-analysis

Introduction:

Patients on continuous flow left ventricular assist devices (CF-LVADs) often require CF-LVAD exchange. The purpose of this study was to investigate the incidence of infection following CF-LVAD exchange performed for non-infectious indications.

Methods:

An electronic literature search was performed to identify all studies of patients undergoing CF-LVAD exchange for pump thrombosis or device malfunction. Of 2,698 articles identified, 6 studies with 81 total patients met the inclusion criteria. Cohort-level data were pooled for meta-analysis.

Results:

Mean patient age was 60 years (95% CI: 41–78), and 74% were male (95% CI: 61–84). Pump thrombosis was the most common indication for exchange in 70% of patients (95% CI: 47–86). Other indications were driveline fracture and electrical malfunction in 21% (95% CI: 5–56) and 12% (95% CI: 4–33) of patients, respectively. Prior to exchange, 95% of patients were on HeartMate II (HM2) LVADs (95% CI: 86–98) and average duration of support for these patients was 27.1 months (95% CI: 9.3–44.8). The majority were placed on a HM2 following exchange (88% (95% CI: 45–98)) versus HM3 (12% (95% CI: 2–55)). Follow-up was an average of 16.4 months (95% CI: 6.8–26.0). Following exchange, 16 of 81 patients developed infection, with pooled mean incidence of 24% (95% CI: 14–38). 30-day mortality was 14% (95% CI: 7–26). Survival at follow-up was 65% (95% CI: 52–76).

Conclusions:

Infection following CF-LVAD exchange can occur at rates higher than those observed with primary implantation; therefore, effective strategies need to implemented early and consistently to help lower infections rates and help improve outcomes following exchange.

Three year follow-up after less-invasive Left Ventricular Assist Device exchange to HeartMate 3

BACKGROUND

Device exchange to a newer generation left ventricular assist device (LVAD) offers the opportunity to benefit from improved adverse events profiles. We present the three year results of a patient cohort undergoing VAD upgrades to a new generation device focusing on outcomes and adverse events.

METHODS

We present the first series of patients who underwent LVAD upgrade to HeartMate 3. All operations were performed less invasively. Follow-up time was three years after LVAD exchange.

RESULTS

Overall four HeartMate II and two HVAD patients underwent LVAD upgrade. In five cases severe infection of the VAD led to device exchange (83%, 5/6). Three year survival after LVAD exchange was 100% (6/6). In the follow-up examinations one patient showed a single syncope and several low flow alarms (1/6). The remaining five patients showed no technical malfunctions of the LVAD or hemodynamic adverse events (5/6). Four out of five patients whose devices had to be changed due to an infection suffered a local re-infection (4/5), which, however, did not require any further surgical intervention. Four patients were successfully transplanted and two patients were still on device support at three years after LVAD exchange.

CONCLUSIONS

Three-year outcomes and adverse events after LVAD exchange to HeartMate 3 show excellent results. The superior hemocompatibility in terms of pump thrombosis makes the HM3 a favored choice in case of LVAD exchange due previous pump thrombosis. However, in cases of exchange due to device infection the risk of reinfection remains high.

Cardiac Emergencies in Patients with Left Ventricular Assist Devices

Continuous-flow left ventricular assist devices are frequently used for management of patients with advanced heart failure with reduced ejection fraction. Although technologic advancements have contributed to improved outcomes, several complications arise over time. These complications result from several factors, including medication effects, physiologic responses to chronic exposure to circulatory support that is minimally/entirely nonpulsatile, and dysfunction of the device itself. Clinical presentation can range from chronic and indolent to acute, life-threatening emergencies. Several areas of uncertainty exist regarding best practices for managing complications; however, growing awareness has led to development of new guidelines to reduce risk and improve outcomes.

HeartMate 3 pump exchange via sternal-sparing bilateral minithoracotomies

As median survival for left ventricular assist device (LVAD) patients increases, the incidence of adverse events requiring device exchange is likely to increase as well. Less invasive surgical approaches for device exchange of older generation pumps have demonstrated multiple potential benefits compared with median sternotomy. However, there remains a paucity of data in regard to less invasive surgical techniques for the exchange of the newest generation intrapericardial devices. In this report we describe a complete sternal-sparing technique for the LVAD exchange of a HeartMate 3 via bilateral minithoracotomies.

Outcomes following left ventricular assist device exchange

INTRODUCTION

Left ventricular assist device (LVAD) exchange has been historically associated with a significant risk of morbidity and mortality. It is unknown, however, whether these outcomes have improved. We aimed to compare clinical outcomes following LVAD exchange to those following initial LVAD implant in a contemporary patient cohort.

METHODS

A total of 115 LVAD patients were enrolled between 2014 and 2017 and followed for 1 year. Of these, 15 patients (54.5 ± 13.3 years old, 87% male) underwent LVAD exchange at 277 (IQR 191-597) days following LVAD implantation and 100 patients (57.5 ± 12.3 years old, 76% male) did not undergo an LVAD exchange (non-exchange group).

RESULTS

One-year survival rate following LVAD exchange tended to be higher than the non-exchange patients (93% vs 76%, P = .15). Readmission rates for each comorbidity did not significantly differ between the two groups (P > .05 for all) except for the higher rate of pump thrombosis in the LVAD exchange group (P < .05).

DISCUSSION

LVAD exchange cohorts seem to have comparable clinical outcome with the non-exchange cohorts.

CONCLUSION

LVAD exchange might be an increasingly appropriate therapeutic option for the management of pump thrombosis, although careful monitoring for recurrent pump thrombosis is required.