Risk factors for adverse outcomes after left ventricular assist device implantation and extracorporeal cardiopulmonary resuscitation.

Left ventricular assist device implantation following extracorporeal cardiopulmonary resuscitation has been associated with ambivalent results. In a series of patients who underwent left ventricular assist device implantation after extracorporeal cardiopulmonary resuscitation, we investigated whether the outcome can be predicted by preoperative risk factors or established risk scores. Primary endpoint was a composite of mortality and severe neurological disabling over 1 year of follow-up. To assess predictors of the primary endpoint, we performed univariate and multivariable Cox regression analyses. Of the 40 patients included, 24 patients (60%) experienced the primary endpoint. Renal replacement therapy and the Vasoactive-Inotropic Score were independently associated regarding the primary endpoint with a hazard ratio for renal replacement therapy of 2.50 (95% confidence interval: 1.09-5.70; P = 0.021) and for the Vasoactive-Inotropic Score of 1.02 per unit (95% confidence interval: 1.00-1.03; P = 0.040). The risk of experiencing an unfavorable outcome during follow-up in patients with a Vasoactive-Inotropic Score of 20 who needed renal replacement therapy or did not need renal replacement therapy was 78% and 54%, respectively. Our data indicate that a decision to implant a left ventricular assist device in patients requiring renal replacement therapy and revealing a high Vasoactive-Inotropic Score after extracorporeal cardiopulmonary resuscitation should be reached with caution.

Extracorporeal resuscitation as a further modifier of clinical outcome in patients with left ventricular assist device implantation and Interagency Registry for Mechanically Assisted Circulatory Support level 1.

In cardiogenic shock patients with Interagency Registry for Mechanical Circulatory Support (INTERMACS) level 1, the need for temporary circulatory support is a predictor and modifier of patient outcome. Because this group includes patients with and without cardiopulmonary resuscitation (CPR) and is thus very heterogeneous, we investigated whether a further subclassification is useful. We compared 30-day and 1-year mortality of patients who underwent left ventricular assist device implantation after extracorporeal CPR with the aid of an extracorporeal life support system (CPR+ group; n = 40) with cardiogenic shock patients in which the extracorporeal life support system was implanted under non-CPR conditions (CPR- group, n = 68). In the CPR+ and CPR- groups, 30-day mortality was 27.5% (n = 11) and 8.8% (n = 6), respectively (P = 0.014). The values for 1-year mortality were 57.5% (n = 23) and 36.8% (n = 25), respectively (P = 0.023). The age- and gender-adjusted hazard ratios of 30-day and 1-year mortality for the CPR+ group versus the CPR- group were 3.88 (95% confidence interval 1.29-11.7; P = 0.016) and 1.79 (95% confidence interval 1.01-3.17; P = 0.045), respectively. In conclusion, our data show that left ventricular assist device implantation with extracorporeal life support following CPR is associated with high 30-day and 1-year mortality. Further multicentre studies are needed to confirm these results and potentially add CPR as a new modifier to the INTERMACS profile.

Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients.

OBJECTIVES: The proportion of minimally invasive approaches is rising in cardiac surgery, in part driven by increasing patient demand. This study aimed to perform a risk-adjusted comparison of mortality, rate of stroke and perioperative morbidity of aortic valve replacement (AVR) conducted through either partial mini-sternotomy or conventional sternotomy. METHODS: Between July 2009 and July 2012, data from 984 consecutive patients undergoing isolated AVR were prospectively recorded. In 44.3% (n = 436), the less invasive partial mini-sternotomy was used. Propensity score matching was performed based on 15 preoperative risk factors to correct for selection bias. In-hospital mortality, stroke rate as well as other major complications in the minimally invasive group and conventional sternotomy group were compared in 404 matched patient pairs (total 808). RESULTS: In-hospital mortality and rate of postoperative intra-aortic balloon pump use were identical for propensity-matched patients, 1.0% (4 in each group). The rate of stroke [OR (95% confidence interval (CI)): 0.80 (0.22-2.98)], perioperative myocardial infarction [OR (95% CI): 2.00 (0.18-22.06)], low-output syndrome [OR (95% CI): 0.90 (0.37-2.22)], new onset of dialysis [OR (95% CI): 1.25 (0.49-3.17)] and re-exploration for bleeding [OR (95% CI): 0.88 (0.50-1.56)] were similar. Likewise, resource utilization (operation time, duration of stay in the intensive care unit and in-hospital stay) and valve selection (type and size) was not affected by the surgical approach either. CONCLUSIONS: AVR can be safely conducted through a partial mini-sternotomy. This approach is not associated with an increased rate of complications. However, wide CIs reflect the still prevailing statistical uncertainty in estimates, not excluding patient-relevant differences between approaches. Large trials, which also address end points, such as postoperative pain, duration of postoperative recovery and quality of life, are needed to clarify the role of minimally invasive AVR.

Suicide after ventricular assist device implantation.

Depression and anxiety are well documented in patients with end-stage heart failure and correlate with a higher risk of suicide. We report a 69-year-old depressed patient who committed suicide by disconnecting the driveline of his left ventricular assist device almost 3 years after implantation. We provide the medical, psychologic, and psychiatric background of this unique case. This report highlights the importance of pre-implant psychologic screening, the need for regular and long-term psychologic support for this vulnerable patient population, and the need for more qualitative research on patients' views on living with a left ventricular assist device, together with research exploring risk profiles for depression and suicide.