A prospective comparison of mid-term outcomes in patients treated with heart transplantation with advanced age donors versus left ventricular assist device implantation.

OBJECTIVES: In Europe, the age of heart donors is constantly increasing. Ageing of heart donors limits the probability of success of heart transplantation (HTx). The aim of this study is to compare the outcome of patients with advanced heart failure (HF) treated with a continuous-flow left ventricular assist device (CF-LVAD) with indication as bridge to transplantation (BTT) or bridge to candidacy (BTC) versus recipients of HTx with the donor's age above 55 years (HTx with donors >55 years). METHODS: we prospectively evaluated 301 consecutive patients with advanced HF treated with a CF-LVAD (n = 83) or HTx without prior bridging (n = 218) in our hospital from January 2006 to January 2015. We compared the outcome of CF-LVAD-BTT (n = 37) versus HTx with donors >55 years (n = 45) and the outcome of CF-LVAD-BTT plus BTC (n = 62) versus HTx with donors >55 years at the 1- and 2-year follow-up. Survival was evaluated according to the first operation. RESULTS: The perioperative (30-day) mortality rate was 0% in the LVAD-BTT group vs 20% (n = 9) in the HTx group with donors >55 years (P = 0.003). Perioperative mortality occurred in 5% of the LVAD-BTT/BTC patients (n = 3) and in 20% of the HTx with donors >55 year group (P = 0.026). Kaplan-Meier curves estimated a 2-year survival rate of 94.6% in CF-LVAD-BTT vs 68.9% in HTx with donors >55 years [age- and sex-adjusted hazard ratio (HR) 0.25; 95% confidence interval (CI) 0.08-0.81; P = 0.02 in favour of CF-LVAD]. Considering the post-HTx outcome, a trend in favour of CF-LVAD-BTT was also observed (age- and sex-adjusted HR 0.45; 95% CI 0.17-1.16; P = 0.09 in favour of CF-LVAD), whereas CF-LVAD-BTT/BTC showed a similar survival at 2 years compared with HTx with donors >55 years, both censoring the follow-up at the time of HTx and considering the post-HTx outcome. CONCLUSIONS: Early and mid-term outcomes of patients treated with a CF-LVAD with BTT indication seem better than HTx with old donors. It must be emphasized that up to 19% of patients in the CF-LVAD/BTT group underwent transplantation in an urgent condition due to complications related to the LVAD. At the 2-year follow-up, CF-LVAD with BTT and BTC indications have similar outcome than HTx using old heart donors. These results must be confirmed in a larger and multicentre population and extending the follow-up.

Mid-term survival after continuous-flow left ventricular assist device versus heart transplantation.

There is a paucity of data about mid-term outcome of patients with advanced heart failure (HF) treated with left ventricular assist device (LVAD) in Europe, where donor shortage and their aging limit the availability and the probability of success of heart transplantation (HTx). The aim of this study is to compare Italian single-centre mid-term outcome in prospective patients treated with LVAD vs. HTx. We evaluated 213 consecutive patients with advanced HF who underwent continuous-flow LVAD implant or HTx from 1/2006 to 2/2012, with complete follow-up at 1 year (3/2013). We compared outcome in patients who received a LVAD (n = 49) with those who underwent HTx (n = 164) and in matched groups of 39 LVAD and 39 HTx patients. Patients that were treated with LVAD had a worse risk profile in comparison with HTx patients. Kaplan-Meier survival curves estimated a one-year survival of 75.5 % in LVAD vs. 82.3 % in HTx patients, a difference that was non-statistically significant [hazard ratio (HR) 1.46; 95 % confidence interval (CI) 0.74-2.86; p = 0.27 for LVAD vs. HTx]. After group matching 1-year survival was similar between LVAD (76.9 %) and HTx (79.5 %; HR 1.15; 95 % CI 0.44-2.98; p = 0.78). Concordant data was observed at 2-year follow-up. Patients treated with LVAD as bridge-to-transplant indication (n = 22) showed a non significant better outcome compared with HTx with a 95.5 and 90.9 % survival, at 1- and 2-year follow-up, respectively. Despite worse preoperative conditions, survival is not significantly lower after LVAD than after HTx at 2-year follow-up. Given the scarce number of donors for HTx, LVAD therapy represents a valid option, potentially affecting the current allocation strategy of heart donors also in Europe.

Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. These patients are also often affected by severe iliac-femoral arteriopathy, rendering the trans-femoral approach unusable. We report our experience with the direct-aortic approach to treat these patients. METHODS: From May 2008 to November 2013 two hundred and thirty-two patients (131 female, 56%) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were evaluated for TAVI at our department. Of these patients, 202 were deemed eligible for TAVI. Of this group, 50 underwent CoreValve implantation by the direct aortic approach through a right anterior mini-thoracotmy (28 female, 56%), mean age 81.2±6.9. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. RESULTS: Twenty-eight (56%) patients were female and 11 (22%) were redo at TAVI. We used a 23-mm CoreValve Evolute in 3 patients (6%), and the most used valve size was the 29mm in 46% of patients. Mean hemodynamic trans-aortic gradient was less than 5mmHg. The paravalvular regurgitation was ≤ grade 1 in 46 patients as assessed by peri-procedural transesophageal echocardiography (TEE). Seven patients (7/43, 16%) required a permanent pacemaker implantation; 30-day mortality was 6% (3 patients). Seven patients (14.8%) died during follow-up. Actuarial survival at 2years is 84.7±5.3%. CONCLUSIONS: Transcatheter aortic valve implantation with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure.

Current indications for heart transplantation and left ventricular assist device: a practical point of view.

Heart transplantation (HTx) is considered the "gold standard" therapy of refractory heart failure (HF), but it is accessible only to few patients because of the paucity of suitable heart donors. On the other hand, left ventricular assist devices (LVADs) have proven to be effective in improving survival and quality of life in patients with refractory HF. The challenge encountered by multidisciplinary teams in dealing with advanced HF lies in identifying patients who could benefit more from HTx as compared to LVAD implantation and the appropriate timing. The decision-making is based on clinical parameters, imaging-based data and risk scores. Current outcome of HF patients supported by LVAD (2-year survival around 70%) is rapidly improving and leads the way to a new therapeutic strategy. Patients who have a low likelihood to gain access to the heart graft pool could benefit more from LVAD implantation (defined as bridge to transplantation indication) than from remaining on HTx waiting list with the likely risk of clinical deterioration or removal from the list because patients are no longer suitable for transplantation. LVAD has also demonstrated to be effective in patients who are not considered eligible candidates for HTx with a destination therapy indication. HTx should be reserved to those patients for whom the maximum clinical benefit can be expected, such as young patients with no comorbidities. Here we discuss the current listing criteria for HTx and indications to implant of LVAD for patients with refractory acute and chronic HF based on the guidelines and the practical experience of our center.

[Proposal for updated listing criteria for heart transplantation and indications to implant of left ventricular assist devices]. / Evoluzione delle indicazioni al trapianto cardiaco e all'impianto di dispositivi di assistenza ventricolare sinistra.

Heart transplantation (HTx) is considered to be the gold standard treatment for advanced heart failure (HF) but it is available only for a minority of patients, due to paucity of donor hearts (278 HTx were performed in 2011 in Italy). Patients listed for HTx have a prolonged waiting time (that is about 2.3 years in the 2006-2010 time period in Italy) that is superior compared with patients who receive HTx (median time around 6 months), to underline the presence of an allocation system that prioritizes candidates in critical conditions. Patients listed for HTx have a poor quality of life and their annual mortality is around 8-10%. Another 10-15% of HTx candidates are removed from the waiting list each year because they are no longer suitable for transplantation. On the other hand, continuous-flow left ventricular assist devices (LVADs) have been demonstrated to improve survival and quality of life of patients with advanced/refractory HF. LVAD therapy can represent a valid alternative to HTx, and it is recommended for patients with advanced HF in the recent edition of the European Society of Cardiology guidelines on HF management. In the United States, a larger number of centers compared with European ones started to apply a strategy of LVAD implant for many patients who meet clinical criteria for listing for HTx. Data from our center concerning the last 6 years of LVAD implant (51 implants since 2006) reported a 75.5% survival rate at 1 year. In Italian series, as in our center, current HTx survival is only slightly superior (83% survival rate at 1 year), based on data from the Italian National Transplant Center. We report a proposal for updated listing criteria for HTx and indications for LVAD implant in patients with advanced acute and chronic HF. Criteria for identifying suitable patients for HTx and/or LVAD considering the shortage of donors are discussed.

Heart transplantation: 25 years' single-centre experience.

OBJECTIVES: Heart transplantation (HTx) is still one of the most effective therapies for end-stage heart disease for patients with no other medical or surgical therapy. We report the results of our 25-year orthotropic HTx single-centre experience. METHODS: From November 1985, 905 orthotopic heart transplants have been performed at our centre. We exclude from the present analysis 13 patients who underwent re-transplantation and 14 pediatric cases (age at HTx <15 years). RESULTS: The present study collected the data of 878 primary adult orthotopic HTx performed at our centre. Mean age at HTx was of 49.6 ±â€Š11.6 years. Mean donor age was 36.9 ±â€Š14.8 years. Hospital mortality was 11.6% (102 patients), early graft failure was the principal cause of death (58 patients) followed by infections (18 cases) and acute rejection (7 patients). Overall actuarial survival was 78.1% at 5 years and 63.8% and 47.5%, respectively, at 10 and 15 years from HTx. Mean survival was 10.74 years; 257 late deaths were reported (33.1%); main causes were neoplasm in 83 patients, and cardiac causes included coronary allograft vasculopathy in 78 patients. Freedom from any infection at 5, 10 and 15 years was 52.2, 44.1 and 40.1%, respectively. Freedom from rejection at 5 years was 36.2%, with 493 patients experiencing at last one episode of rejection, the majority occurring during the first 2 months after transplantation. The long-term survival of HTx recipients is limited in large part by the development of coronary artery vasculopathy and malignancies. In our experience freedom from coronary allograft vasculopathy at 10 years was 66.9%, and 85 patients underwent percutaneous coronary revascularization. In our study population, 44 patients experienced posttransplant lymphoproliferative disorder and 91 patients experienced a solid neoplasm, mean survival free from neoplasm was 12.23 years. CONCLUSION: Over the past four decades the field of HTx has evolved considerably, with improvements in surgical techniques and postoperative patients' care. A careful patient selection and treatment of candidates for transplantation as well as accurate clinical follow-up combined with real multidisciplinary teamwork that involved different heart failure specialists, allowed us to obtain our excellent long-term results.

Direct aortic access for transcatheter self-expanding aortic bioprosthetic valves implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for operation; however, these patients are also often affected by severe iliac-femoral arteriopathy that prohibits the transfemoral approach. METHODS: From May 2008 to January 2012, 400 patients were evaluated for TAVI at our center; of these, 141 patients (64 men; mean age 81.3±8 years) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were eligible for CoreValve (137 patients; Medtronic Inc, MN) or Sapien (Edwards Lifesciences, CA) implantation. Twenty-five patients (all affected by severe peripheral vasculopathy, including five re-do procedures), with a mean The Society of Thoracic Surgeons mortality score 11%±6%, underwent CoreValve implantation directly from the ascending aorta through a right anterior minithoracotomy. This case series was reviewed to evaluate the clinical outcomes of these patients. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. RESULTS: In all patients after valve deployment, the mean aortic gradient immediately dropped to 5 mm Hg or less, and the angiographic grade aortic insufficiency was 1 or less in 22 patients. One patient was converted to the transfemoral approach due to an extremely fragile aortic wall, but the patient died of abdominal aorta aneurysm rupture on postoperative day 1. Procedural success was obtained in the remaining 24 patients. A left ventricle tear in 1 patient was successfully surgically treated. Four patients required a permanent pacemaker implantation. Thirty-day mortality was 8% (2 patients). All discharged patients improved their New York Heart Association functional class and functional capacity, and echocardiograms demonstrated good valve performance up to 2 years (mean valve gradient, 9 mm Hg). During follow-up, 1 patient died of cachexia and another of bone marrow aplasia. CONCLUSIONS: TAVI with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure, and has emerged as a valuable alternative route to transapical access.

Does the cardioplegic solution have an effect on early outcomes following heart transplantation?

OBJECTIVE: The choice of cardioplegic solution for myocardial preservation in heart transplantation (HT) remains debated. We analysed our experience with three different cardioplegic solutions in adult HT performed during past 5 years, in terms of non-immunological intraoperative biventricular graft failure (BVF) and in-hospital mortality. METHODS: A total of 133 patients underwent HT at our hospital from January 2006 to December 2010. Patients were divided into three groups, according to the solution adopted in the donor: HTK-Custodiol (n = 61), Celsior (n = 38) and St Thomas (n = 34). For each patient, solution was chosen according to surgeon's preference. RESULTS: Recipient and donor mean age was 48.2 ± 12.7 and 43.8 ± 13.6 years, respectively. Twenty-four patients (18.0%) were in Status 1 at the transplant. The mean ischaemic time was 187.9 ± 52.6 min. Intraoperative BVF was observed in 18 cases (13.5%). Patients with BVF, and their respective donors, were older than the other patients (patients: 53.3 vs 47.4 years, P = 0.06; donors: 49.4 vs 42.9 years, P 0.06), and experienced significantly higher in-hospital mortality (47.3 vs 7.8%, P = 0.0001). The combination of patients aged 60 years or older with donors aged 60 years or older carried a mortality of 66.6% (6 out of 9). The three groups of patients did not differ significantly in terms of preoperative and intraoperative features and outcomes, including biventricular graft failure and death. At multivariate analysis, predictors of in-hospital death were a combination of both a recipient and a donor aged ≥ 60 years (OR 27.9), intraoperative BVF (OR 14.8) and previous cardiac surgery (OR 13.0). Cardioplegic solution did not predict mortality. CONCLUSIONS: We did not observe a significant effect of the kind of cardioplegic solution on the early HT outcomes. The combination between both a recipient and a donor aged ≥ 60 years, reoperation and BVF are strong predictors of in-hospital death.

Twenty-five year outcomes of tricuspid valve replacement comparing mechanical and biologic prostheses.

BACKGROUND: Tricuspid valve replacement (TVR) has historically been associated with high mortality and morbidity, and current knowledge of long-term results of TVR is limited. This study reviewed our experience from a consecutive series at 2 institutions. METHODS: Ninety patients (65 women [72%]; mean age, 53.8 ± 14.2 years; mean body surface area, 1.6 ± 0.2 m(2)) underwent TVR between January 1980 and December 2005. The etiology was secondary to left-heart valve disease in 56 patients (62%), degenerative disease in 16 (18%), Ebstein anomaly in 7 (8%), and endocarditis in 11 (12%). Seventy patients (78%) were in New York Heart Association class III or IV. Sixty patients (67%) underwent redo procedures. TVR was with a mechanical valve in 46 patients (51%) and a biologic prosthesis in 44 (49%). RESULTS: The overall operative mortality was 17.7% (16 patients). During follow-up, 16 of the 74 survivors died. Kaplan-Meier survival at 5, 10, and 15 years was, respectively, 72%, 65%, and 63%. During follow-up, 16 patients (21.6%) underwent reoperation; among them, 8 with a mechanical valve underwent reoperation for tricuspid valve thrombosis and 6 with a biologic prosthesis for tricuspid valve deterioration. However, freedom from reoperation at 5 and 10 years was similar between mechanical (86% and 76%) and bioprostheses (97% and 83%). All 16 patients survived the reoperation. CONCLUSIONS: The present experience suggests that the type of implanted prosthesis in the tricuspid position does not affect early and long-term outcomes or the reoperation rate. Timely referral before end-stage cardiac impairment develops could determine further outcomes improvement.

Orthotopic heart transplantation with donors greater than or equal to 60 years of age: a single-center experience.

OBJECTIVES: Heart transplantation is the best therapeutic option for patients suffering from end-stage heart failure, but donor organ availability still represents a major problem. This had led to a shift toward extended donor criteria. The aim of the present study is to analyze the short- and long-term results of heart transplantation in patients with donor age ≥ 60 years. METHODS: Since November 1985, 890 patients have been transplanted at our center. We consider, for the present study, only primary adult heart transplantations performed after 1990, totaling 761 patients, mean age at transplantation 49.8 years, and 616 patients being male (81%). We compare the short- and long-term results of patients transplanted with donors younger than 60 years or ≥ 60 years. RESULTS: Since 1990, at our center, 711 patients have been heart transplanted with a donor younger than 60 years, while 50 patients received a heart from a donor older than 60 years. No differences have been reported in the etiology of cardiomyopathy, previous surgery, or mean ischemic time. Patients transplanted with donors ≥ 60 years of age were significantly older compared to the younger donors' group. Donor cause of death was a cerebrovascular accident in 82% of donors ≥ 60 years versus 41% in younger donors. Patients' heart transplanted with donors ≥ 60 years had a higher incidence of acute graft failure with a hospital mortality of 32% (16 patients) significantly higher compared with 10.2% for the other group. No differences were noticed in the incidence of renal failure, acute rejection treated, coronary allograft vasculopathy, and neoplasm during long-term follow-up. CONCLUSIONS: It was possible to expand the cardiac donor pool by accepting allografts from donors ≥ 60 years of age in selected cases by performing a coronary angiogram. A meticulous donor evaluation and a careful risk assessment between the risk of death on the waiting list and probable increased hospital mortality are needed.

Off-pump coronary revascularization in chronic dialysis-dependent patients: early outcomes at a single institution.

INTRODUCTION: Atherosclerotic vascular disease is the leading cause of morbidity and mortality in patients with end-stage renal disease. Several authors reported that chronic dialytic patients have a high operative risk when submitted to coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB) whereas little information exists about off-pump myocardial revascularization in these patients. MATERIAL AND METHODS: Between January 2000 and December 2008, 17 consecutive patients (12 men, mean age of 62.3 +/- 12.3 years) with end-stage renal failure maintained on chronic hemodialysis underwent isolated off-pump CABG at our center. To evaluate this approach we compared the outcomes of off-pump revascularization with those obtained in the same period in 23 patients (20 men, mean age of 64.0 +/- 9.7 years), with the same preoperative features, who underwent conventional CABG on the arrested heart using CPB. RESULTS: Off-pump revascularization in end-stage renal disease patients showed a satisfactory incidence of mortality and morbidity rates. When compared with conventional CPB CABG group, off-pump patients had a lower incidence of bleeding, transfusions, ventilation support time, length of inotropic support and perioperative myocardial infarction. Also ICU and hospital stay and incidence of new-onset atrial fibrillation were lower in off-pump CABG patients. CONCLUSION: In our experience, avoidance of CPB in end-stage renal disease patients was associated with an acceptable incidence of postoperative complications and of major adverse events. Off-pump CABG is a safe and effective method of myocardial revascularization in chronically dialyzed patients that should strongly be taken in consideration when planning the surgical strategy in this selected cohort of patients, although multicentric prospective randomized controlled trials are strongly recommended.

Early expression of pro- and anti-inflammatory cytokines in left ventricular assist device recipients with multiple organ failure syndrome.

To assess whether the combined evaluation of total Sequential Organ Failure Assessment (t-SOFA) score and pro- and anti-inflammatory cytokine profiles early after left ventricular assist device (LVAD) implant discriminates patients at high risk for multiple organ failure syndrome (MOFS) in the first month post-LVAD, we analyzed plasma interleukin (IL)-6, IL-8, IL-10, IL-1ra, IL-1beta, tumor necrosis factor-alpha (TNF-alpha), and urine neopterin levels before (day 0) and at 4 hours, 1, 3, 7, 14, and 30 days after LVAD implant in 23 recipients. Eight patients died of MOFS between days 7 and 30 (nonsurvivors). At preimplant, only blood urea nitrogen and age were higher in nonsurvivors than survivors. At 4 hours, IL-8, IL-10, and IL1-ra levels were higher in nonsurvivors than in survivors; t-SOFA was also higher and peaked on day 3 in nonsurvivors. Only IL-8 levels on day 1 were significantly associated with a t-SOFA > or =10 on day 3 (odds ratio 1.10, 95% confidence interval 1.01-1.21, p = 0.04). Neopterin, marker of monocyte activation, increased significantly only in nonsurvivors (p < 0.001). These findings suggest that an activated inflammatory system soon after LVAD implant is implicated in MOFS development. Early monitoring of inflammatory mediators and t-SOFA score may be a valuable tool for outcome prediction in LVAD recipients.

Failure and off-pump replacement of Incor LVAD system.

An Incor (Berlin Heart AG, Berlin) left ventricular assist device (LVAD) was implanted; 6 months later the patient was admitted to our department for intravenous antibiotic therapy for a driveline infection. Two days after admission under direct echocardiographic monitoring, the pump failure was noted to be entirely dependent on the position of the cable. The pump was successfully replaced without cardiopulmonary bypass as a matter of urgency.

Noncardiac surgical procedures in patient supported with long-term implantable left ventricular assist device.

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly used as bridges to transplantation or as destination therapy. As sicker and older patients are more frequently considered for mechanical support, general surgical problems are expected to increase in these patients. METHODS: Anesthesia records and clinical charts were reviewed for 11 recipients of LVADs undergoing 12 general surgical procedures between January 1988 and March 2007. RESULTS: Eight patients underwent major surgical procedures: 1 intracranial hematoma drainage, 1 right hemicolectomy with ileocolostomy, 1 splenectomy, 1 surgical repair of an iliac-femoral artery pseudoaneurysm, 2 cholecystectomies, 1 pyelolithotomy, and 1 coil embolization of a femoral side-branch disruption. Four patients underwent minor surgical procedures. The mean duration of LVAD support before surgery was 58.7 +/- 45.6 days. All patients survived the procedures. CONCLUSION: Noncardiac surgery in LVAD recipients is feasible, without significant morbidity or mortality. Intraoperative coagulation management has a key role in safely performing these procedures.

Long-term results of lung cancer after heart transplantation: single center 20-year experience.

OBJECTIVE: The present study analyses, long-term lung cancer survival rate in the Niguarda heart transplant population and the results of surgical treatments. METHODS: From November 1985 to December 2006, 786 heart transplants were performed in our Center; we underwent a retrospective review of patients developing primary lung cancer. RESULTS: Among 660 heart transplant recipients valuable in this study, 22 (3.3%) developed a primary lung cancer (20 male, 91%), their mean age at time of heart transplant was 54.5+/-5.2 years (range, 42-65). The mean time from transplantation to lung cancer diagnosis was 73.7+/-30 months. Eleven patients (50%) were in stage IIIB or higher at the time of presentation. The 5-year survival rate of the entire study population was 21.4%, with a median survival time (MST) of 10.1 months. Ten patients underwent surgical resection (9 lobectomies and 1 wedge resection) and demonstrated improved long-term survival with 5-year survival of 56% and MST 70.4 months, compared to patients who did not undergo any surgical procedure, all of whom died during follow-up, with 1-year survival of 33%. CONCLUSIONS: Long-term results following lung cancer surgery in heart transplant recipients are satisfactory when performed at the early stage of the disease. Preventive computed tomography screen should be considered as a routine method for early diagnosis in this group of high-risk patients.

Clinical outcome and bridge to transplant rate of left ventricular assist device recipient patients: comparison between continuous-flow and pulsatile-flow devices.

BACKGROUND: Long-term implantable continuous axial-flow pumps are increasingly used in bridging heart failure patients to heart transplant. Compared to pulsatile left ventricular assist devices (LVADs), they offer smaller dimensions, less surgical trauma and less thromboembolisms. However concerns still remain about the long-term effects of continuous-flow on patients' outcome. The aim of this study was to review our mechanical bridge to transplant experience to compare pre- and post-transplant outcomes between pulsatile and continuous-flow LVAD recipients. METHODS: Thirty-six patients with a continuous-flow device (Micromed DeBakey, Houston, TX or InCor Berlin Heart, Berlin, Germany--group A) were compared with 41 patients supported with a pulsatile device (Novacor, WorldHeart, Oakland, CA--group B). RESULTS: Mean age (48.6+/-12.4 vs 47.2+/-12.5) and LVAD duration (119.3+/-115.4 vs 128.3+/-198.3) were similar in the two groups. Group A recipients were smaller compared to group B (mean body surface area=1.77+/-0.18 vs 1.93+/-0.16; p<0.001). Idiopathic dilated cardiomyopathy was not significantly greater between the two groups (78% vs 58.3%; p=0.085). Successful bridging to transplantation was similar in group A compared to group B (52.8% vs 63.4%; p=non significant). On-VAD mortality was similar between the two groups (A vs B=33.3% vs 36.6%; p=non significant). Thirty-day mortality after HTx in group A was 10.5% compared to 7.7% in group B (p=non significant). First year post-transplant incidence of treated rejections (36.8% vs 46%; p=non significant) as the mean number of rejection/patient (0.38+/-0.5 vs 0.53+/-0.83; p=non significant) were similar in group A compared to group B. CONCLUSIONS: In our experience, when compared to pulsatile LVAD, continuous-flow pumps are similarly effective in transplant rate and post-transplant outcome.

Influence of inflow cannula length in axial-flow pumps on neurologic adverse event rate: results from a multi-center analysis.

BACKGROUND: The application of axial-flow pumps in patients with end-stage heart failure reveals a significantly reduced infectious complication rate as compared with rates observed with pulsatile devices. The remaining adverse event rate relates mainly to thromboembolic complications with neurologic consequences. We investigated the dependence of the neurologic adverse event rate on the length of the inflow cannula. METHODS: A total of 216 consecutive patients with an axial-flow pump (INCOR; Berlin Heart GmbH, Berlin, Germany) were included in a retrospective multi-center analysis. In 138 patients, a short inflow cannula (24-mm tip length into the left ventricle), and in 78 patients a long inflow cannula (tip length 34 mm) was applied. RESULTS: Patients with a long inflow cannula (LC) demonstrated a better survival rate than those with a short inflow cannula (SC) at the end of the observation period (LC, 63.4%; SC, 52.9%; p = 0.05). The thromboembolic adverse event rate was also significantly lower. Only 3 of the 78 patients (3.8%) with an LC had a thromboembolic adverse event (thromboembolic events per patient-year = 0.11) as compared with 32 (23.2%) of SC patients (thromboembolic events per patient-year = 0.50, p < 0.001). CONCLUSIONS: Patients with a long inflow cannula had a better survival rate and a lower incidence of cerebrovascular adverse events than patients with a short inflow cannula.

Successful emergent surgical revascularization and retrieval of entrapped drug eluting stent.

We report the case of a 61-year-old man who was treated with percutaneous coronary intervention (PCI) for unstable angina. Seven days after the procedure, he voluntary suspended double anti-aggregant therapy and experienced acute coronary thrombotic occlusion. A repeat PCI procedure was undertaken but the stent and the balloon remained entrapped in the proximal left main-left anterior descending coronary artery. After ineffective attempt of stent removal using an Amplatz goose neck catheter, the patient that was hemodynamically stable underwent uneventful emergency coronary artery bypass grafting and removal of the damaged stent and Amplatz goose neck.