Evaluation of cardiac arrhythmia in pediatric patients with Left Ventricular Assist Device (L-VAD).

OBJECTIVE: Pediatric heart failure is an important cause of morbidity and mortality in childhood. Left ventricular assist devices (L-VAD) are used for bridging to transplantation in patients with indications for heart transplantation. PATIENTS AND METHODS: The children included in the study were patients who underwent implantation of an L-VAD due to advanced heart failure at Ege University Faculty of Medicine Hospital between January 2009 and January 2023. RESULTS: Of the 33 patients who underwent L-VAD implantation, 16 (48.5%) were female and 17 (51.5%) were male. The median age at surgery was 13 years (IQR, 9.5-15). The median weight was 44 kg (IQR, 25.65-52), the median height was 158 cm (IQR, 134.5-168.5), and the median body surface area was 1.37 m2 (IQR, 0.95-1.51). All patients who underwent L-VAD implantation had an echocardiographic diagnosis of dilated cardiomyopathy. The patients underwent a median of 16 (IQR, 9-21) ECGs, and the median number of 24-hour Holter ECGs obtained was 3 (IQR, 2-5). Arrhythmias that occurred after L-VAD implantation were classified as atrial and ventricular. Ventricular arrhythmia included ventricular tachycardia (VT) lasting for more than 30 seconds (sustained VT), VT lasting for less than 30 seconds (nonsustained VT), and ventricular fibrillation. Atrial arrhythmias included atrial flutter, atrial fibrillation, supraventricular tachycardia, and atrial ectopic tachycardia. During the follow-up, atrial or ventricular arrhythmias were observed in 11 (33%) patients. The most common rhythm disturbances before L-VAD implantation were ventricular arrhythmias, while after the surgery, atrial arrhythmias were found to be the most frequent. A total of 5 patients underwent cardioversion (n=2) or defibrillation (n=3) due to arrhythmia. CONCLUSIONS: In patients undergoing L-VAD implantation, rhythm disorders that could normally lead to hemodynamic instability are frequently encountered. In these rhythm disorders, medical therapy should be attempted before resorting to cardioversion or defibrillation, and subsequently, more aggressive treatment methods should be considered.

Anesthetic Management for Left Ventricular Assist Device Implantation Through Left Thoracotomy: Evaluation of On-Pump Versus Off-Pump.

BACKGROUND: Ventricular assist devices (VADs) are alternative approaches to medical treatment in patients with acute or chronic heart failure. The goal of this study was to compare an anesthetic approach in patients undergoing implantation of a VAD with (on-pump) or without (off-pump) cardiopulmonary bypass (CPB) through left thoracotomy. METHODS: A total of 32 patients were divided into 2 groups: on-pump (group 1) and off-pump (group 2). A standard anesthesia protocol was used in all patients. Baseline characteristics of the patients, intraoperative hemodynamic and respiratory variables, anesthetic agents and vasoactive drugs administered, the amount of blood products, extubation, length of hospital stay and intensive care unit stay, and postoperative complications were recorded. RESULTS: Patients' mean age was 54.7 ± 13.3 years (range, 18-74 years). Eighteen patients underwent surgery with CPB. Demographic data of the patients, preoperative characteristics, intraoperative use of blood products, intraoperative complications, and anesthetic drugs used were similar between groups (P > .05). The duration of surgery (219 ± 23 vs 273 ± 56 minutes) and anesthesia (274 ± 38 vs 323 ± 57 minutes) were shorter in group 2; there was no difference between the 2 groups in terms of mechanical ventilation time, length of stay in the intensive care unit, and length of hospital stay. There was no decrease in postoperative oxygen parameters and an increase in patient lactate levels with the use of CPB. The use of fresh frozen plasma and platelet suspension in the postoperative period was significantly higher in group 1 (P < .05). The rate of complications and mortality rate were comparable between the 2 groups (P > .05). CONCLUSIONS: Our study results show that the use of CPB during VAD implantation via left thoracotomy increases operation time and use of blood products, while causing no change in the rate of complications.

Short-term Results of Heartmate 3 Ventricular Assist Device Implantation for End-Stage Heart Failure.

OBJECTIVE: To report our initial experience with Heartmate 3 ventricular assist device (HM3) in cases with end-stage heart failure (ESHF). METHODS: Charts of 8 ESHF patients who underwent HM3 implantation in our clinic from January to June 2016 (group 1) and 16 patients who underwent HM2 implantation during 2015 (group 2) were reviewed retrospectively. Demographics as well as pre- and early postoperative medical data were noted and statistically analyzed between the 2 groups. RESULTS: No statistical difference was found in age or sex distribution between groups (P > .05). Mean Interagency Registry for Mechanically Assisted Circulatory Support scores were 2.13 ± 0.99 and 3.38 ± 0.72 in groups 1 and 2, respectively (P = .020). Mean cardiopulmonary bypass time, and chest tube drainage fluid volume and blood product requirement during intensive care unit (ICU) stay were 64.0 ± 13.9 minutes, 1,112.5 ± 516.7 mL, and 318.8 ± 271.2 mL, respectively, in group 1 and 89.0 ± 33.3 minutes, 2,081.3 ± 1,696.0 mL, and 1,118.8 ± 1,010.8 mL in group 2 (P = .027, P = .019, and P = .040, respectively). Need for surgical revision and early mortality were not evident for group 1, although 4 cases (25.0%) required revision surgery, and early mortality was seen in 3 cases (18.8%) in group 2 (P = .121 and P = .190, respectively). Mean durations of ICU stay and total postoperative hospitalization were 5.9 ± 2.0 and 18.3 ± 5.5 days, respectively in group 1 and 6.2 ± 4.3 and 18.0 ± 6.9 days in the surviving 13 patients of the group 2 (P = .645 and P = .697, respectively). CONCLUSIONS: With its shorter implantation time and reduced blood product requirement in the early postoperative period, the HM3 system was found to be safe and effective in ESHF treatment.

Effects of Thickness on the Metal-Insulator Transition in Free-Standing Vanadium Dioxide Nanocrystals.

Controlling solid state phase transitions via external stimuli offers rich physics along with possibilities of unparalleled applications in electronics and optics. The well-known metal-insulator transition (MIT) in vanadium dioxide (VO2) is one instance of such phase transitions emerging from strong electronic correlations. Inducing the MIT using electric field has been investigated extensively for the applications in electrical and ultrafast optical switching. However, as the Thomas-Fermi screening length is very short, for considerable alteration in the material's properties with electric field induced MIT, crystals below 10 nm are needed. So far, the only way to achieve thin crystals of VO2 has been via epitaxial growth techniques. Yet, stress due to lattice mismatch as well as interdiffusion with the substrate complicate the studies. Here, we show that free-standing vapor-phase grown crystals of VO2 can be milled down to the desired thickness using argon ion-beam milling without compromising their electronic and structural properties. Among our results, we show that even below 4 nm thickness the MIT persists and the transition temperature is lowered in two-terminal devices as the crystal gets thinner. The findings in this Letter can be applied to similar strongly correlated materials to study quantum confinement effects.

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey.

INTRODUCTION: HeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center. METHODS: Twenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation. RESULTS: Mean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus. DISCUSSION: Mechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Anesthetic Management for Left Ventricular Assist Device Implantation Without Using Cardiopulmonary Bypass: Case Series.

PURPOSE: Ventricular assist devices are an alternative to medical treatment in patients with hemodynamic disturbances related to acute or chronic congestive heart failure. In this case series, we present our anesthesia management for implantation of left ventricular assist device (LVAD) with thoracotomy. METHOD: Sixteen patients with end-stage heart failure undergoing LVAD implantation via thoracotomy between November 2012 and August 2014 were analyzed prospectively. Preoperative characteristics, intraoperative hemodynamic and respiratory parameters, use of anesthetic and blood products, and durations of mechanical ventilation, hospital, and intensive care stays were recorded. RESULTS: Sixteen patients (mean age, 54.6 ± 13 years) were investigated. Single-lung ventilation was applied to 2 patients. Cardiopulmonary bypass (CPB) was required in 5 patients. Intraoperative ketamine, midazolam, fentanyl, and rocuronium requirements were 112 ± 63 mg, 5.5 ± 3.5 mg, 438 ± 187 µg, and 179 ± 49 mg, respectively. Requirements of fresh donor blood, fresh frozen plasma, and thrombocyte and erythrocyte suspension were 1.19 ± 1, 1 ± 0.8, 0.44 ± 0.5, and 0.25 ± 0.7 U, respectively. Durations of mechanical ventilation, intensive care unit, and hospital stay were 46 ± 53 hours, 8.2 ± 6.6 days, and 20.5 ± 11.6 days, respectively. Twelve patients were discharged from hospital with full recovery and 2 patients died; 2 patients are still receiving treatment in the hospital. CONCLUSION: A left thoracotomy approach can be used without CPB, because it reduces the incidences of pump complications and blood transfusion. In addition, this case series showed that the implantation of LVAD by thoracotomy can be implemented securely with single-lumen endotracheal tube without single-lung ventilation.

Transthoracic echocardiographic and cardiopulmonary exercise testing parameters in Eisenmenger's syndrome. Association with six-minute walk test distance.

OBJECTIVE: The six-minute walk test (6MWT) evaluates the functional exercise capacity in patients with cardiopulmonary disease. We aimed to investigate the association between 6MWT distance and transthoracic echocardiographic (TTE) findings as well as cardiopulmonary exercise testing (CPET) parameters in Eisenmenger's syndrome (ES) patients waiting for heart-lung transplantation on their initial admission to our center. PATIENTS AND METHODS: A total of 23 patients with ES (12 women, 11 men; mean age, 28.2 ± 8.1 years) were included in the study. The correlation between 6MWT distance and CPET and TTE findings was retrospectively analyzed. RESULTS: The most frequent underlying heart diseases were ventricular septal defect (VSD) with complex congenital heart disease (n = 10, 43 %) and isolated VSD (n = 7, 30 %). The 6MWT distance was 349.7 ± 77.4 m in the study group. An inverse correlation was found between 6MWT distance and systolic pulmonary arterial pressure (SPAP) measured with TTE (r = - 0.445; p = 0.03). All patients underwent CPET at the first visit. Mean VO2 max was 14.9 ± 3.3 ml/kg/min and the VE/VCO2 rate was 50.4 ± 9.2 %. No significant correlation was observed between 6MWT and CPET findings. SPAP, which did not display any correlation with CPET findings, was the only independent predictor of 6MWT distance. CONCLUSION: We suggest that 6MWT distance may be more suitable than CPET in the follow-up of ES patients. Further prospective, randomized, controlled trials are necessary to make more robust interpretations of this issue.

Efficacy of the cardiac rehabilitation program in patients with end-stage heart failure, heart transplant patients, and left ventricular assist device recipients.

OBJECTIVE: The objective of this study was to assess the effects of cardiac rehabilitation on the functional capacity, pulmonary functions, quality of life, and psychological state of patients who had heart failure (HF), heart transplantation (HTx), or a left ventricular assist device (LVAD). METHODS: An 8-week exercise program was undertaken by 46 patients diagnosed with end-stage heart failure, 40 of whom had a heart transplantation and 11 were implanted with an LVAD. The patients' functionality was assessed with a maximal oxygen consumption test (pVO2), their psychological state with the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI), their quality of life (QOL) with the Short Form 36 (SF 36), and their pulmonary condition with pulmonary function tests (PFTs). RESULTS: A significant improvement was observed in all forced vital capacity (%), forced expiratory volume in 1 second (%), pVO2, BDI, and most of the subscores of the SF 36 scores at the end of the exercise, compared with the pre-exercise period (P < .05). The intergroup evaluations showed no significant differences among the 3 groups in terms of all assessed changes (P > .05). CONCLUSION: An 8-week supervised exercise program was observed to improve functional capacity, PFT, QOL, and depression among patients who had HF, HTx, or LVAD. Supervised exercise should be recommended for every patient included in a heart transplant program.

Anesthesia for cardiac transplantation: experience from a single center.

BACKGROUND: Cardiac transplantation has become the established therapeutic modality in patients with end-stage heart failure. This article presents our institution's clinical experience in the anesthetic management of patients who underwent cardiac transplantation between February 1998 and August 2012. METHODS: In our institution, 175 patients (136 males and 39 females) diagnosed as having end-stage heart failure have undergone cardiac transplantation between February 1998 and August 2012. A retrospective review performed on this series of patients sought to analyze elements of perioperative anesthetic care, including preoperative characteristics, general anesthia, and blood product usage. RESULTS: The patients were diagnosed as having either nonischemic cardiomyopathy (n = 128; 73%) or ischemic cardiomyopathy (n = 47; 27%). Seventy-three of them had undergone previous cardiac surgery. Invasive arterial, central venous, and pulmonary arterial pressures were monitored as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 158/175 patients (average dose, 18.67 ± 1.91 mg). The average intraoperative fentanyl dose was 898.85 ± 211.65 µg. Anesthesia was maintained with either end-tidal 2%-4% sevoflurane (n = 132) or 4%-6% desflurane (n = 43). Dopamine, dobutamine, and epinephrine were used after weaning from cardiopulmonary bypass and continued upon exiting the operating room in 168, 159, and 143 patients, respectively. Inhaled nitric oxide (20-40 ppm) was used in 37 patients (21%). The total amount of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 2.95 ± 2.05 (range, 1-15), 1.29 ± 0.97 (range, 0-6), and 1.23 ± 2.29 (range; 0-12) units, respectively. On average, patients were extubated 16 hours after arrival in the intensive care unit where they remained to day 6. A total of 67 patients (38%) died during the follow-up; infection and right ventricular failure were the most common causes. CONCLUSION: Anesthesia for cardiac transplantation requires an appreciation of heart failure pathophysiology, invasive monitoring, and skillful anesthetic and postoperative care.

Anesthesia for ventricular assist device placement: experience from a single center.

BACKGROUND: Circulatory support with ventricular assist systems has become a treatment alternative for patients with end-stage heart failure owing to the donor shortage. In this report, we have presented our institution's clinical experience in the anesthetic management of ventricular assist device (VAD) implantation. METHODS: Between April 2007 and August 2012, VAD implantation was performed in 84 adult patients with end-stage heart failure. The group included 75 male and 9 female patients of overall mean age, 47.6 ± 13.4 years. Our retrospective review analyzed elements of perioperative anesthetic care, including preoperative characteristics, general anesthetic care, and blood product usage. RESULTS: The indications for VAD implantation were dilated (n = 59; 70%) or ischemic cardiomyopathy (n = 25; 30%). An intra-aortic balloon pump had been placed in 16 patients. We monitored invasive arterial and central venous pressures as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 79 of 84 patients (average dose, 18.75 ± 1.40 mg). Intraoperative fentanyl dose was 939.69 ± 212.44 µg. Anesthesia was maintained with sevoflurane (n = 55) or desflurane (n = 29). Dopamine, dobutamine, epinephrine, norepinephrine, and levosimendan were used in 74, 79, 60, 14, and 32 patients, respectively. Inhaled nitric oxide was administered to 38 subjects (45%). The amounts of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 3.96 ± 2.78, 1.91 ± 1.21, 1.80 ± 2.48 u, respectively. On average, patients were extubated 13 hours after arrival in the intensive care unit and discharged therefrom on day 8. Thirty-one patients were successfully bridged to heart transplantation. While 27 patients (32%) died during the follow-up period, 26 are still living on VAD support. CONCLUSION: Among patients undergoing VAD implantation, the anesthesiologist should become familiar with the device and consider the severity of cardiac and other end-organ dysfunction.

Anesthesia for ventricular assist device placement in pediatric patients: experience from a single center.

BACKGROUND: The use of a ventricular assist device (VAD) as a bridge to heart transplantation in the pediatric population has evolved over the past decades This article presents our institution's clinical experience in the anesthetic management of pediatric patients with end-stage heart failure who underwent implantation of a VAD between June 2009 and August 2012. METHODS: Between February 2011 and August 2012, implantation of a VAD was performed in 10 children of mean age 8.6 years. This retrospective review analyzed their perioperative anesthetic care. RESULTS: All patients had end-stage heart failure due to dilated cardiomyopathy. We used invasive arterial and central venous pressure monitoring and intraoperative transesophageal echocardiography in conjunction with intravenous administration of either ketamine (1 mg/kg) and midazolam (n = 3) or thiopental (3-5 mg/kg; n = 7). The mean intraoperative fentanyl dose was 434 ± 264.27 µg. Anesthesia was maintained with sevoflurane. Dopamine, dobutamine, and epinephrine were infused in 8, 10, and 5 patients, respectively. Inhaled nitric oxide was administered to all patients. The amounts of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were be 2.3 ± 0.82 (range, 1-4), 1.6 ± 0.69 (range, 1-3), and 2.4 ± 1.42 (range, 0-4) units, respectively. On average, patients were extubated 23 hours after arrival in the intensive care unit and exited there on day 6. Six patients were successfully bridged to heart transplantation, 2 died during the follow-up, and 2 patients remain on VAD support. CONCLUSION: VAD is increasingly being used as a bridge to heart transplantation in the pediatric population. Anesthesiologists must be vigilant about the pathophysiology of heart failure, the operative procedure, and the implanted device.

Long-term paracorporeal ventricular support systems: a single-center experience.

BACKGROUND: The Berlin Heart EXCOR is a first-generation paracorporeal, pneumatic ventricular assist device that creates pulsatile flow. It can be used for long-term support of the left and/or right ventricule during end-stage heart failure. The aim of this study was to share our clinical experience in 54 patients. METHODS: Between April 2007 and August 2012, 54 patients with end-stage heart failure underwent Berlin Heart EXCOR ventricular assist device implantation, including 5 females and 9 children. Twenty-four patients (44%) were in Intermacs level 1, 11 (21%) in level 2, and 19 (35%) in level 3. Biventricular support was applied to 13 patients. Device implantation was performed with an "on pump" beating heart technique while 6 other patients underwent intervention operations while the aortic valve has under cross-clamp. Tricuspid annuloplasty was performed in 6 patients. RESULTS: There was no peroperative death. Nine patients (17%) underwent re-exploration because of hemorrhage in the early postoperative period. Heart transplantation was performed in 32 patients (59%), while 10 (19%) are still under pump support with a mean follow-up of 13 months. Although 1 was successfully weaned from the system, 11 patients (20%) died during the support. Pump-head exchange was required 19 times in 17 patients because of visible thrombus or fibrin deposit in the pump head or due to membrane rupture. DISCUSSION: The use of long-term paracorporeal assist devices has decreased in recent years because of the increased popularity of implantable devices that permit longer survival and a better quality of life. We believe that the Berlin Heart EXCOR has a special role because it can be used in pediatric patients and especially in critical conditions like Intermacs levels 1 and 2.

Left ventricular assist device implantation in heart failure patients with a left ventricular thrombus.

BACKGROUND: In this report, we share our experience with left ventricular assist device (LVAD) implantation in cases with a left ventricular (LV) thrombus. METHOD: Over the 3 years, more than 100 end-stage heart failure cases have been treated with LVAD implantation in our center, including 6 patients with a LV thrombus. Three were detected using preoperative transthoracic echocardiography. Fifty percent of the patients had dilated cardiomyopathy and the remaining cases had an ischemic etiology. Double inotropic support with dopamine and dobutamine was used in all, with 3 drugs with the addition of adrenaline in 2 patients. In 4 cases we implanted the HeartWare Ventricular Assist System (HeartWare, Inc., Miramar, Fla, United States) and in the remaining 2 patients, the Berlin Heart EXCOR ventricular assist device (Berlin Heart AG, Berlin, Germany) for biventricular support. In 1 patient the apical ventriculotomy was extended to remove an intertrabecular thrombosis and ventricular septal surface covered with a dacron patch to minimize the thrombogenic potential. RESULTS: Two patients died due to sepsis and multiorgan failure. None of the patients experienced a neurological event, pump thrombosis, or pump malfunction. Two subjects underwent re-explorations due to hemorrhage. Two candidates underwent successfull transplantation without any evidence of thrombosis in the explanted heart or device. CONCLUSION: We believe that patients with a LV thrombus and preserved right ventricular function are good candidates for implantation of a LVAD after removing the intracavitary thrombus.

Effect of aortic valve movements on gastrointestinal bleeding that occured in continuous flow left ventricular assist device patients.

BACKGROUND: Gastrointestinal (GI) bleeding is one of the recently reported complications with continuous flow left ventricular assist devices (LVAD). The pathophysiology and etiology are unclear. We sought to describe the relationship between aortic valve movements and GI bleeding among patients with a new generation of LVAD. METHODS: We evaluated the data of 30 patients who underwent LVAD (HeartWare VAD) implantation from December 2010 to September 2012. The most common etiologic diagnosis was dilated cardiomyopathy. Patients were considered to show GI bleeding if they had hematemesis, melena, or hematochezia. RESULTS: Among 3 patients, 2 displayed upper GI bleeding and 1 had lower GI bleeding based on endoscopic and colononoscopic examinations. Pathological reports showed arteriovenous malformations in patients diagnosed with upper GI bleeding. The absence of aortic valve movements and a history of previous GI bleeding were significant risk factors (P = .021 and P = .007, respectively). CONCLUSION: In addition to aortic valve movements, we believe that a GI bleeding history was an equally important factor predisposing to this complication.

Clinical characteristics of obstructive sleep apnea syndrome in heart transplant recipients.

AIM: We investigated the prevalence and clinical characteristics of obstructive sleep apnea syndrome (OSAS) among heart transplantation patients. METHODS: Among 86 surviving patients of mean age 43.07 ± 13.23 years including 35 men transplanted from April 1999 to November 2010, 43 (50%) agreed to participate in this study. Patients with apnea-hypopnea index (AHI) < 5 were labeled as "normal", with an AHI > 5, as obstructive surgeon (OSA). According to the AHI, subjects were classified as with OSA (group 1; n = 25 of mean age 49.0 ± 12.1 years and including 21 men versus non OSA group 2; n = 18) of mean age 34.8 ± 10.1 years with 14 men. We recorded patient demographic features, medications, polysomnographi observations, laboratory measurements, as well as echocardiographic and angiographic parameters. RESULTS: Prevalence of OSA (AHI > 5) was 58% (n = 25) with 30% (n = 14) as moderate or severe OSA (AHI > 15) OSA patients were significantly older, and showed a greater value of body mass index (BMI) and waist circumference. Echocardiographic findings revealed the only significant difference to be systolic arterial pressure. The apnea-hypopnea index showed significant correlation with age, BMI, waist circumference, neck circumference, Epworth score, duration of apnea episode, time of SaO(2) under 90% and systolic arterial pressure (SPAP). An inverse correlation was observed between AHI and sleep efficiency, oxygen saturation, and percentage of time in random eye movement (REM) sleep. Multivariate backward logistic regression analysis indicated waist circumference, sleep efficiency, percentage of time in REM sleeps and duration of apnea episode to be independent predictors of AHI. CONCLUSION: OSA is prevalent among heart transplantation patients. Obesity is a risk factor and waist circumference, and independent predictor for OSA.

Changing face of heart failure surgery.

BACKGROUND: Heart failure is a serious disease ending with death if untreated. Although heart transplantation is the best therapy for end-stage heart failure, most candidates die in the waiting period due to the lack of donor organs. This condition represent a new era of heart failure surgery. METHODS: We retrospectively investigated 159 patients from 1998 to 2011 with a mean age of 40.0 years (range = 5-65), who were mostly diagnosed as dilated cardiomyopathy (n = 113). After April 2007, 67 patients underwent vascular assist device (VAD) implantation surgery for acute or chronic end-stage heart failure. We performed 69 heart transplantation with 27 on VAD systems before transplantation. RESULTS: Early mortality was 13.3% with 21 patients after the heart transplantation. The 67 patients supported with VAD did not experience an intraoperative death. The mean support time was 214 days (range = 3-1035). Twenty-four patients (35.8%) are still on pump support. The overall survival until transplantation or weaning was 77.6% at mean of 250.7 days survival reached 90% with Heartware (Hartware Inc, Miramar, Fla, USA) continuous flow pumps. CONCLUSION: After the introduction of VAD in 2007, the overall picture has been restructured radically for heart failure surgery, reducing patient loss on the waiting list. Especially, since 2009 nearly 80% of donor hearts were used for patients on mechanical circulatory support.

Valvular procedures during ventricular assist device implantation.

BACKGROUND: Increased experience and success with ventricular assist devices (VAD) has permitted more aggressive use in patients formerly believed to be inappropriate for mechanical circulatory support (MCS). There is no clearly proven policy to manage end-stage heart failure patients with valvular pathologies. The aim of this report was to analysis our experience with combined approach of VAD implantation and valvular procedures among patients with valvular heart disease and end-stage heart failure. METHODS: We evaluated the clinical records of 67 patients who underwent MCS from April 2007 to September 2011. We identified 12 patients (17.9%) who received concomitant valvular procedures, four of whom had significant aortic insufficiency and received a simple coaptation stitch at the center to approximate the fibrous nodules of Arantius. The mechanical aortic valve was replaced with a stentless bioprosthesis in three patients. Mitral valve commissurotomy was performed in one patient with mitral stenosis and seven patients underwent tricuspit valve repair using an annuloplasty ring. RESULTS: All 12 patients were males, of mean age 50.3 ± 11.5 years (range = 25-66). Eleven of them (91.6%) survived the early and late postoperative periods. Ten subjects (83.3%) continue to be supported with VAD; 1 (8.3%) was successfully bridged to transplantation. Each study participant regression of the valvular pathologies by early echocardiography demonstrated. CONCLUSION: Concomitant valve surgery during VAD implantation appeared to be a reasonable option in end-stage heart failure patients with valvular heart disease.

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation.

BACKGROUND: Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure. METHODS: Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL). RESULTS: Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000). CONCLUSION: The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.

To bridge or not to bridge?

OBJECTIVE: Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs. METHODS: Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support. RESULTS: Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥ 130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar. CONCLUSION: Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.

New circulatory support system: heartware.

INTRODUCTION: Through the new developments in medicine, heart failure therapy has advanced to mechanical circulatory support systems. The HeartWare Ventricular Assist System HVAD; HeartWare, Inc.; Miramar, Fla, USA) is a new device that is a centrifugal, intracorporeal, miniaturized and continuous flow pump that serves simple patient use and enhanced life quality. This article reports the midterm results of patients who underwent the heartware support system. MATERIALS AND METHODS: We retrospectively compiled our data from December 2010, including 10 patients of mean age 51.8 years with 90% males, 70% of the overall patient cohort had dilated cardiomyopathy and remaining ones, ischemic disease. Mean left ventricular ejection fraction was 20.1% and mean systolic pulmonary artery pressure was 49.2 mm Hg. A single patient was grade 1; seven were grade 2; and remaining ones, grade 3 according to the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale. All patients were operated with cardiopulmonary bypass (CPB) with moderate hypothermia. Tricuspid ring annuloplasty was performed in 3 (30%) patients. In one patient we removed a left ventricular thrombus. In a case with severe aortic regurgitation, we placed a simple coaptation stitch at the central portion of the three aortic cusps under the aortic cross clamp. The mean CPB duration was 95.5 minutes. RESULTS: There was no operative or in-hospital mortality. Mean support time was 250.67 days. During the early postoperative period, one patient experienced a minor hemorrhagic neurological event also requiring a tracheostomy due to pneumonia. This patient has completely healed and on follow-up continues a normal life. All patients were asymptomatic regarding heart failure. One patient unfortunately died because of possible pancreatic cancer and sepsis. Two patients underwent transplantations on days 159 and 172 of support. CONCLUSION: The HVAD system provided effective circulatory support for patients with end-stage heart failure with low adverse event rates. Long-term results are needed particularly for destination therapy candidates.