Can long-term ventricular assist devices be safely implanted in low-volume, non-heart transplant centres?

More than 20 years' experience of left ventricular assist device implantation at a non-transplant Centre

OBJECTIVES

Over recent decades implantable left ventricular assist devices (LVAD) have increased the possibility of improved survival in patients with advanced heart failure who also benefit from a better quality of life. The aim of this retrospective survey was to review the clinical results of LVAD implantation at a low-volume non-transplant centre (Linköping, Sweden) between 1993 and 2016. Our aim was also to assess the mortality and morbidity rates associated with implantation of three LVAD versions at our centre, and to compare our results with those from transplant centres.

DESIGN

A retrospective cohort study was performed examining the medical records of patients who had a HeartMate^® (HMI, HMII, HMIII) LVAD implanted as a bridge to heart transplantation (BTT) or as destination therapy (DT) at the University Hospital, Linköping.

RESULTS

Our main finding was a survival to heart transplantation rate of 82% among our BTT LVAD patients. The most common adverse event among our patients was infection. A higher frequency of temporary dialysis was seen in the HMII group compared to the HMI group, and the frequency of right ventricular failure was higher in our HMII material.

CONCLUSIONS

Our data suggests that patients requiring long-term LVAD support can safely have their device implanted and cared for at a non-transplant centre.

Safety and Feasibility of Laparoscopic Abdominal Surgery in Patients With Mechanical Circulatory Assist Devices

Objectives Increasing number of mechanical circulatory assist devices (MCADs) are being placed in heart failure patients. Morbidity from device placement is high and the outcome of patients who require noncardiac surgery after, is unclear. As laparoscopic interventions are associated with decreased morbidity, we examined the impact of such procedures in these patients. Methods A retrospective review was conducted on 302 patients who underwent MCAD placement from 2005 to 2012. All laparoscopic abdominal surgeries were included and impact on postoperative morbidity and mortality studied. Results Ten out of 16 procedures were laparoscopic with 1 conversion to open. Seven patients had a HeartMate II, 2 had Total Artificial Hearts, and 1 had CentriMag. Four patients had devices for ischemic cardiomyopathy and 6 cases were emergent. Surgeries included 6 laparoscopic cholecystectomies, 2 exploratory laparoscopies, 1 laparoscopic colostomy takedown, and 1 laparoscopic ventral hernia repair with mesh. Median age of the patients was 63 years (range, 29-79 years). Median operative time was 123 minutes (range, 30-380 minutes). Five of 10 patients were on preoperative anticoagulation with average intraoperative blood loss of 150 mL (range, 20-700 mL). There were 3 postoperative complications; acute respiratory failure, acute kidney injury and multisystem organ failure resulting in death not related to the surgical procedure. Conclusion The need for noncardiac surgery in post-MCAD patients is increasing due to limited donors and due to more durable and longer support from newer generation assist devices. While surgery should be approached with caution in this high-risk group, laparoscopic surgery appears to be a safe and successful treatment option.

Laparoscopic nephroureterectomy in a patient with a left ventricular assist device

Left ventricular assist device (LVAD) therapy is an established treatment option for select patients with advanced heart failure. Advances in technology and patient management have resulted in improved post-implant outcomes. Consequently, more patients with LVADs are presenting for evaluation and care of non-cardiac surgical disease. However, there is a paucity of literature regarding the optimal perioperative and surgical management of such patients. We present the case of a 71-year-old male with a HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD, who underwent a laparoscopic left nephroureterectomy for an upper urinary tract transitional cell carcinoma. His perioperative course was uneventful due to the multidisciplinary efforts of cardiac surgery, cardiac anesthesia, nephrology and urology. To our knowledge, this is the first reported case of a laparoscopic nephroureterectomy in a patient with a HeartMate II LVAD.