Health status analysis is comparable in HM3 patients with different preoperative grades of mitral regurgitation.

BACKGROUND: The guidelines for mechanical circulatory support of the International Society for Heart and Lung Transplantation do not recommend the routine replacement or repair of the mitral valve at the time point of left ventricular assist device (LVAD) implantation. We investigated different parameters of health status including exercise capacity, anxiety and depression after LVAD implantation in patients with different preoperative grades of mitral regurgitation (MR). METHODS: A single-center analysis of health status was performed including 45 patients with HeartMate 3 (HM 3) implantation using the 12-items Short Form Health Survey (SF-12) and the Hospital Anxiety and Depression Score (HADS) questionnaires. The study groups were classified according to echocardiographically defined preoperative grade of MR. The group without severe MR comprised 33 patients; the group with severe MR comprised 12 patients. RESULTS: Demographic and preclinical characteristics as well as LVAD complications such as thrombosis and bleeding events were comparable between LVAD patients with severe and not severe MR (p > 0.05). Severe MR resolved in all patients after LVAD implantation and improved to moderate, mild or no MR in both groups in a period ranging from 6 months until 2 years. The analyses of SF-12 questionnaire revealed that the physical (p = 0.44) and mental health (p = 0.64) was comparable. The grade of anxiety (p = 0.34) and depression (p = 0.44) was comparable between the groups. Exercise capacity measured by the 6 min walk test correlated positively with the SF-12-determined physical health (p < 0.01, r = 0.518) and negatively with the HADS anxiety (p = 0.01, r = -0.399) and depression (p < 0.01, r = -0.570) scores. CONCLUSIONS: Our data showed that the health status is comparable in HM 3 patients with different preoperative MR severities in the post-LVAD period. Preoperative severe MR resolves in the majority of patients early after LVAD implantation and is not associated with concomitant mitral valve repair or replacement at the time of LVAD implantation.

The Impact of Obesity on T and NK Cells after LVAD Implantation.

INTRODUCTION: Infections are a major problem after left ventricular assist device (LVAD) implantation that affects morbidity, mortality, and the quality of life. Obesity often increases the risk for infection. In the cohort of LVAD patients, it is unknown if obesity affects the immunological parameters involved in viral defense. Therefore, this study investigated whether overweight or obesity affects immunological parameters such as CD8+ T cells and natural killer (NK) cells. METHODS: Immune cell subsets of CD8+ T cells and NK cells were compared between normal-weight (BMI 18.5-24.9 kg/m2, n = 17), pre-obese (BMI 25.0-29.9 kg/m2, n = 24), and obese (BMI ≥30 kg/m2, n = 27) patients. Cell subsets and cytokine serum levels were quantified prior to LVAD implantation and at 3, 6, and 12 months after LVAD implantation. RESULTS: At the end of the first postoperative year, obese patients (31.8% ± 2.1%) had a lower proportion of CD8+ T cells than normal-weight patients (42.4% ± 4.1%; p = 0.04), and the percentage of CD8+ T cells was negatively correlated with BMI (p = 0.03; r = -0.329). The proportion of circulating NK cells increased after LVAD implantation patients in normal-weight (p = 0.01) and obese patients (p < 0.01). Patients with pre-obesity showed a delayed increase (p < 0.01) 12 months after LVAD implantation. Further, obese patients showed an increase in the percentage of CD57+ NK cells after 6 and 12 months (p = 0.01) of treatment, higher proportions of CD56bright NK cells (p = 0.01), and lower proportions of CD56dim/neg NK cells (p = 0.03) 3 months after LVAD implantation than normal-weight patients. The proportion of CD56bright NK cells positively correlated with BMI (p < 0.01, r = 0.403) 1 year after LVAD implantation. CONCLUSIONS: This study documented that obesity affects CD8+ T cells and subsets of NK cells in patients with LVAD in the first year after LVAD implantation. Lower proportions of CD8+ T cells and CD56dim/neg NK cells and higher proportion of CD56bright NK cells were detected in obese but not in pre-obese and normal-weight LVAD patients during the first year after LVAD implantation. The induced immunological imbalance and phenotypic changes of T and NK cells may influence viral and bacterial immunoreactivity.

New Wound Management of Driveline Infections with Cold Atmospheric Plasma.

The use of ventricular assist devices as a bridge to transplant or as destination therapy has increased. Wound complications increase morbidity in this cohort. Cold atmospheric plasma is a source of reactive oxygen and nitrogen species and can reduce the microbial load in skin wounds without negative effects on the surrounding tissue. We evaluated our cold atmospheric plasma treatment for LVAD driveline infections in a retrospective single-center study for peri- and postintervention outcome analysis. Between April 2019 and September 2019, 15 male patients were included (5 HVAD, 10 HeartMate III). The wounds were treated for a mean of 368.5 s with a reduction of bacterial load in treated wounds in 60% of patients, regardless of the pathogen. The most common pathogen was staphylococcus aureus (n = 8 patients). There was a significant reduction of the wound scale (scale 2.80 vs. 1.18; p < 0.001) plus a significant reduction in size (16.08 vs. 1.90 cm3; p = 0.047). Seven patients (46.6%) were free from any signs of local or systemic infection during 1-year follow-up. Five patients (33%) received a heart transplantation. Cold atmospheric plasma treatment is a potent, safe, and painless adjuvant technique for treating driveline infection without the need for repeating surgical interventions.

Long-term paracorporeal pulsatile mechanical circulatory support in adolescent and adult patients.

OBJECTIVES: Our goal was to analyse adverse events in adolescent and adult patients with the Berlin Heart EXCOR and to assess the outcome of a subsequent heart transplant (HTX). METHODS: From 2006 to 2020, a total of 58 patients (12-64 years old) received a biventricular assist device (BIVAD) at our institution and were included in this study. RESULTS: The causes of biventricular heart failure were nonischaemic cardiomyopathy (62.1%), ischaemic cardiomyopathy (22.4%) and myocarditis (15.5%). The median INTERMACS score was I (I-III). The median age was 49 years (interquartile range, 34-55 years), and 82.8% were male. Causes of death were multiorgan failure (25.0%), septic shock (17.9%), cerebral haemorrhage (14.3%), bleeding (14.3%) and embolic events (14.3%). Major bleeding was more frequent in the patients who died while on BIVADs (60.7 vs 6.7%, P < 0.001). Wound infections were more prevalent in HTX recipients (n = 21, 70.0%). After BIVAD thrombosis, 104 chamber exchanges were performed in 28 patients (48.3%). HTXs were performed in 52.6% of the patients after a BIVAD support time of 316 ± 240 days. The mean time to follow-up of 30 HTX recipients was 1722 ± 1368 days. One-, 6- and 12-month survival after an HTX were 96.7%, 90.0% and 76.7%, respectively. Long-term survival after 5 and 10 years was 69.7%. CONCLUSIONS: Pump thrombosis, infections and bleeding after receiving a BIVAD did not preclude a successful HTX. Although only 50% of patients with BIVADs were successfully given a transplant, long-term survival after an HTX in patients with BIVAD was noninferior compared to that of other recipients.

Novel Plug Device for HeartMate 3 Explantation: First Multicenter Experience.

Patients undergoing explantation of left ventricular assist devices (LVADs) after improvement of myocardial function remain a minority. Nevertheless, considering the growing population of LVAD patients, increasing demand for new explantation strategies is expected. Herein, we present a retrospective review of seven patients undergoing HeartMate3 explantation with the use of a custom-made apical ring plug in four medical centers. The primary outcome was status at intensive care unit discharge. Secondary outcomes included perioperative complications and transfusions. Six out of seven patients were males. The median age at explantation and time on LVAD support was 35 years (range:13-73) and 10 months (range:9-24), respectively. No technical difficulties were experienced during plug implantation via a conventional sternotomy or through a left lateral thoracotomy, either with or without cardiopulmonary bypass. Perioperative transfusions ranged from 0 to 3 units/patient. No re-operations for bleeding, hemorrhagic, embolic, or plug-related infective events were observed. Heparin was started 6 hours after surgery as a bridge to oral anticoagulation (international normalized ratio: 2-2.5). All patients were discharged alive from intensive care unit. This novel plug device for HeartMate3 explantation was successfully and safely implanted in this first patient series. Notwithstanding, its use should still be considered off-label and larger studies are required to investigate its long-term results.

HeartMate II implantation in patients with heparin-induced thrombocytopenia type II.

Diverse anticoagulation protocols are used in patients after implantation of ventricular assist devices. No consensus exists, especially in patients with heparin-induced thrombocytopenia type II. In a patient with heparin-induced thrombocytopenia type II, we implanted a left ventricular assist device (HeartMate XVE; Thoratec, Pleasanton, CA). Thirteen months later the device had to be replaced due to mechanical failure with a HeartMate II left ventricular assist device. We report on our successful protocol of perioperative anticoagulation management using heparin and iloprost during surgery and argatroban thereafter.

Implantation of a left ventricular assist device in a patient with primary antiphospholipid syndrome.

The antiphospholipid syndrome is characterized by arterial and venous thrombosis and is associated with the presence of circulating antiphospholipid antibodies. Arterial thrombosis can result in myocardial infarction, which may potentially lead to end-stage heart failure. Here we report our anticoagulation protocol for patients with antiphospholipid syndrome that undergo axial-flow left ventricle assist devices (HeartMate II; Thoratec, Pleasanton, CA) implantation.