scholarly journals Trends, risk factors and prognostic implications of postoperative stroke after heart transplantation: an analysis of the UNOS database

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
A Briasoulis ◽  
I Doulamis ◽  
P Kampaktsis ◽  
P Alvarez
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Cardiac Surgery ◽  
Heart Transplantation ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Ischemic Time ◽  
Perioperative Stroke ◽  
Postoperative Stroke ◽  
All Cause Mortality

Abstract Background Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HT) are limited. Methods We conducted a retrospective analysis of the UNOS database from 2009 to 2020 to identify adults who developed stroke after orthotropic HT. HT recipients were divided according to the presence or absence of postoperative stroke. The primary endpoint was all-cause mortality after HT. Results A total of 25,015 HT recipients were analyzed, including 719 (2.9%) patients who suffered perioperative stroke. The rates of stroke increased from 2.1% in 2009 to 3.7% in 2019 and the risk of stroke was higher after the implantation of the new allocation system (odds ratio 1.29, 1.29, 95% Confidence Intervals [CI] 1.06–1.56, p=0.01). HT recipients with postoperative stroke were older (p=0.008), with higher rates of prior cerebrovascular accident (CVA) (p=0.004), prior cardiac surgery (p<0.001), longer waitlist time (p=0.04), higher rates of extracorporeal membrane oxygenation support (ECMO) (p<0.001), left ventricular assist devices (LVAD) (p<0.001), mechanical ventilation (p=0.003) and longer ischemic time (p<0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischemic time and mechanical ventilation at the time of HT were independent predictors of postoperative stroke. Stroke was associated with increased risk of 30-day and all-cause mortality after HT (hazard ratio [HR] 1.49, CI 1.12–1.99, p=0.007). Conclusion Perioperative stroke after HT is infrequent but associated with higher mortality. Redo sternotomy, LVAD and ECMO support at HT are among the risk factors identified. FUNDunding Acknowledgement Type of funding sources: None. Risk factors for stroke

Anaesthesia for cardiac surgery

2017 ◽  
Author(s):  
Uwe Schirmer ◽  
Andreas Koster
Keyword(s):  
Heart Failure ◽  
Cardiac Surgery ◽  
Minimally Invasive ◽  
Heart Transplantation ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Cardiac Anaesthesia

Cardiac anaesthesia continues to develop as a specialized discipline within the wide field of clinical anaesthesia. A comprehensive knowledge of cardiovascular physiology and its improved monitoring with modern invasive and non-invasive devices is the basis for the pharmacological treatment of complex cardiovascular disorders. Excellent skills in intraoperative transoesophageal echocardiography have become essential. Rapid developments in cardiopulmonary bypass techniques and surgical devices have resulted in the speedy introduction of new surgical techniques which anaesthesia has to embrace. The developments in the field of (left) ventricular assist devices are expansive. By changing the paradigm of the indication of implantation from ‘bridging to heart transplantation’ to ‘destination therapy’, particularly in the large group of elderly patients with end-stage heart failure, these complex operations are no longer restricted to the small group of heart centres performing heart transplantation. This chapter provides a comprehensive review of modern cardiac anaesthesia in the contemporary world of quickly evolving cardiac surgery. The basics of anaesthesia management for the ‘cardiac’ patient are described and principles of extracorporeal circulation as well as diagnostic and treatment strategies of disturbances of the haemostatic system are highlighted. Pharmacological strategies to treat left- and right-heart failure and strategies for temporary mechanical support are outlined. Further areas of focus are the anaesthetic implications of modern less or minimally invasive procedures such as off-pump coronary artery bypass grafting and minimally invasive valve implantation/surgery and anaesthesia for implantation of ventricular assist devices and heart transplantation.

scholarly journals Prevalence and management of driveline infections in mechanical circulatory support - a single center analysis

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Andrzej Juraszek ◽  
Mikołaj Smólski ◽  
Piotr Kołsut ◽  
Jarosław Szymański ◽  
Paweł Litwiński ◽  
...  
Keyword(s):  
Risk Factors ◽  
Antibiotic Therapy ◽  
Heart Transplantation ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Single Center ◽  
Driveline Infection

Abstract Background Driveline infections in continuous-flow left ventricular assist devices (cf-LVAD) remain the most common adverse event. This single-center retrospective study investigated the risk factors, prevalence and management of driveline infections. Methods Patients treated after cf-LVAD implantation from December 2014 to January 2020 were enrolled. Baseline data were collected and potential risk factors were elaborated. The multi-modal treatment was based on antibiotic therapy, daily wound care, surgical driveline reposition, and heart transplantation. Time of infection development, freedom of reinfection, freedom of heart transplantation, and death in the follow-up time were investigated. Results Of 75 observed patients, 26 (34.7%) developed a driveline infection. The mean time from implantation to infection diagnosis was 463 (±399; range, 35–1400) days. The most common pathogen was Staphylococcus aureus (n = 15, 60%). First-line therapy was based on antibiotics, with a primary success rate of 27%. The majority of patients (n = 19; 73.1%) were treated with surgical reposition after initial antibiotic therapy. During the follow-up time of 569 (±506; range 32–2093) days, the reinfection freedom after surgical transposition was 57.9%. Heart transplantation was performed in eight patients due to resistant infection. The overall mortality for driveline infection was 11.5%. Conclusions Driveline infections are frequent in patients with implanted cf-LVAD, and treatment does not efficiently avoid reinfection, leading to moderate mortality rates. Only about a quarter of the infected patients were cured with antibiotics alone. Surgical driveline reposition is a reasonable treatment option and does not preclude subsequent heart transplantation due to limited reinfection freedom.

scholarly journals Heart Transplantation of Patients with Ventricular Assist Devices: Impact of Normothermic Ex-Vivo Preservation Using Organ Care System Compared with Cold Storage

2020 ◽  
Author(s):  
Zhuldyz Nurmykhametova ◽  
Rymbay Kaliyev ◽  
Timur Lesbekov ◽  
Serik Bekbossynov ◽  
Makhabbat Bekbossynova ◽  
...  
Keyword(s):  
Heart Transplantation ◽  
Cold Storage ◽  
Mechanical Circulatory Support ◽  
Ex Vivo ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Ischemic Time ◽  
Significant Difference ◽  
Care System

Abstract Background: Organ Care System (OCS) minimizes the cold ischemic time and allows for optimization of logistics and meticulous recipient preparation. Impact of normothermic ex-vivo preservation using OCS compared with cold storage (CS) for prolonged heart preservation especially beneficial for high-risk recipients bridged to transplantation with Mechanical Circulatory Support (MCS). Methods: Between 2012 and 2018, we performed a retrospective single-center review of prospectively collected data. All patients who underwent heart transplantation with MCS using the OCS Heart (n=25) versus standard cold storage were included in this study. Results: During this period, 300 patients were implanted with left ventricular assisted device (LVAD) and 35 (11.6 %) were bridged to heart transplantation. There was no significant difference in donor and recipient characteristics and risk factors. The Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was a trend towards higher estimated risk of death at 1y in the OCS group (14.2 vs. 10.8% p= 0.083). Mean total ischemic time during preservation was statistically significantly longer in CS vs OCS group (210 (23) Vs 74.6 (13) min p=0.001). Median ex vivo normothermic heart perfusion time in OCS was 348.4(132; 955) min. There was significant difference in total out of body time between OCS group 423(67) Vs CS group 210(23) min p=0.002). The allografts were reperfused for 73 (33) vs 121 (45) minutes (p=0.01) before disconnection from cardiopulmonary bypass in OCS vs CS group. All patients were alive on the 30th days post implant in CS groups and 96% in OCS group (p=0.5). Conclusion: Normothermic ex-vivo preservation of the allograft during transportation with the organ care system might be beneficial for long-time out of body organ preservation in comparison of cold storage especially for recipients on mechanical circulatory support.

scholarly journals Heart transplantation of patients with ventricular assist devices: impact of normothermic ex-vivo preservation using organ care system compared with cold storage

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Rymbay Kaliyev ◽  
Timur Lesbekov ◽  
Serik Bekbossynov ◽  
Zhuldyz Nurmykhametova ◽  
Makhabbat Bekbossynova ◽  
...  
Keyword(s):  
Heart Transplantation ◽  
Cold Storage ◽  
Mechanical Circulatory Support ◽  
Ex Vivo ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Ischemic Time ◽  
Significant Difference ◽  
Care System

Abstract Background Organ Care System (OCS) minimizes the cold ischemic time and allows for optimization of logistics and meticulous recipient preparation. Impact of normothermic ex-vivo preservation using OCS compared with cold storage (CS) for prolonged heart preservation especially beneficial for high-risk recipients bridged to transplantation with Mechanical Circulatory Support (MCS). Methods Between 2012 and 2018, we performed a retrospective single-center review of prospectively collected data. All patients who underwent heart transplantation with MCS using the OCS Heart (n = 25) versus standard cold storage (n = 10) were included in this study. Results During this period, 353 patients were implanted with left ventricular assisted device (LVAD) and 35 (10%) were bridged to heart transplantation. There was no significant difference in donor and recipient characteristics and risk factors. The Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was a trend towards higher estimated risk of death at 1y in the OCS group (14.2 vs. 10.8% p = 0.083). Mean total ischemic time during preservation was statistically significantly longer in CS vs OCS group (210 (23) Vs 74.6 (13) min p = 0.001). Median ex vivo normothermic heart perfusion time in OCS was 348.4(132; 955) min. There was significant difference in total out of body time between OCS group 423(67) Vs CS group 210(23) min p = 0.002). All patients were alive on the 30th days post implant in CS groups and 96% in OCS group (p = 0.5). Conclusion Normothermic ex-vivo preservation of the allograft during transportation with the organ care system might be beneficial for long-time out of body organ preservation in comparison of cold storage especially for recipients on mechanical circulatory support.

scholarly journals Heart transplantation of patients with ventricular assist devices: impact of normothermic ex-vivo preservation using organ care system compared with cold storage

2020 ◽  
Author(s):  
Rymbay Kaliyev ◽  
Timur Lesbekov ◽  
Serik Bekbossynov ◽  
Zhuldyz Nurmykhametova ◽  
Makhabbat Bekbossynova ◽  
...  
Keyword(s):  
Heart Transplantation ◽  
Cold Storage ◽  
Mechanical Circulatory Support ◽  
Ex Vivo ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Ischemic Time ◽  
Significant Difference ◽  
Care System

Abstract Background: Organ Care System (OCS) minimizes the cold ischemic time and allows for optimization of logistics and meticulous recipient preparation. Impact of normothermic ex-vivo preservation using OCS compared with cold storage (CS) for prolonged heart preservation especially beneficial for high-risk recipients bridged to transplantation with Mechanical Circulatory Support (MCS).Methods: Between 2012 and 2018, we performed a retrospective single-center review of prospectively collected data. All patients who underwent heart transplantation with MCS using the OCS Heart (n=25) versus standard cold storage (n=10) were included in this study. Results: During this period, 353 patients were implanted with left ventricular assisted device (LVAD) and 35 (10 %) were bridged to heart transplantation. There was no significant difference in donor and recipient characteristics and risk factors. The Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was a trend towards higher estimated risk of death at 1y in the OCS group (14.2 vs. 10.8% p= 0.083). Mean total ischemic time during preservation was statistically significantly longer in CS vs OCS group (210 (23) Vs 74.6 (13) min p=0.001). Median ex vivo normothermic heart perfusion time in OCS was 348.4(132; 955) min. There was significant difference in total out of body time between OCS group 423(67) Vs CS group 210(23) min p=0.002). All patients were alive on the 30th days post implant in CS groups and 96% in OCS group (p=0.5).Conclusion: Normothermic ex-vivo preservation of the allograft during transportation with the organ care system might be beneficial for long-time out of body organ preservation in comparison of cold storage especially for recipients on mechanical circulatory support.

Cerebrovascular Events in Patients with Centrifugal-Flow Left Ventricular Assist Devices: A Propensity Score Matched Analysis from the Intermacs Registry

Circulation ◽  
2021 ◽  
Author(s):  
Sung-Min Cho ◽  
J. Hunter Mehaffey ◽  
Susan L. Myers ◽  
Ryan S. Cantor ◽  
Randall C. Starling ◽  
...  
Keyword(s):  
Risk Factors ◽  
Propensity Score ◽  
Secondary Analysis ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

Background: Ischemic and hemorrhagic cerebrovascular accidents (ICVA and HCVA, respectively) remain common among patients with centrifugal-flow left ventricular assist devices (CF-LVADs), despite improvements in survival and device longevity. Therefore, the incidence of neurological adverse events (NAEs) associated with two contemporary CF-LVADs, the Abbott HeartMate3 ® (HM3) and the Medtronic HeartWare ™ HVAD ® (HVAD), were compared. Methods: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a CF-LVAD as a primary isolated implant between 1/1/2017 and 9/30/2019. Major NAEs were defined as transient ischemic attack (TIA), ICVA, and HCVA. The association of HVAD with risk of NAE in the first year post implant was evaluated using propensity score matching to balance for pre-implant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. Results: Of 6,205 included patients, 3,076 (49.6%) received the HM3 and 3,129 (50.4%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD). HVAD patients had more major NAEs (16.4% vs. 6.4%, p <0.001), as well as each subtype (TIA: 3.3% vs. 1.0%, p <0.001; ICVA: 7.7% vs. 3.4%, p <0.001; and HCVA: 7.2% vs. 2.0%, p <0.001), than did HM3 patients. A propensity-matched cohort balanced for pre-implant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE: 82% vs. 92%, p <0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio: 5.71, confidence interval: 3.90-8.36). Conclusions: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early post-implantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

Abstract 18639: Implantable Cardioverter-defibrillator Use is Associated With Improved Survival on the Waitlist for Heart Transplantation: A UNOS/ OPTN Registry Analysis of 36,397 Patients

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Kairav Vakil ◽  
Rebecca Cogswell ◽  
Sue Duval ◽  
Wayne Levy ◽  
Peter Eckman ◽  
...  
Keyword(s):  
Heart Transplantation ◽  
Cox Regression ◽  
Left Ventricular ◽  
Total Artificial Heart ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Cox Regression Analysis ◽  
End Stage ◽  
The Impact ◽  
Waitlist Mortality

Background: Current guidelines do not support routine use of implantable cardioverter-defibrillators (ICDs) in patients (pts) with end-stage heart failure (HF), unless these pts are awaiting advanced HF therapies such as left ventricular assist devices (LVADs) or a heart transplantation (HT). Whether ICDs improve survival in end-stage HF pts awaiting HT has not been previously examined in a large, multicenter cohort. Hypothesis: Presence of ICDs at time of listing for HT is associated with lower waitlist mortality. Methods: The United Network for Organ Sharing registry was used to identify adults (≥18 years) listed for HT between January 4, 1999 & September 30, 2014. Pts with congenital heart disease, total artificial heart, restrictive cardiomyopathy, prior HT, or missing covariates were excluded. Cox regression analysis was used to assess the impact of an ICD at the time of listing on waitlist mortality. Results: The analysis included 36,397 pts (mean age 53±12; 77% males) listed for HT. The prevalence of ICDs at listing has steadily increased over time before reaching a plateau in 2006 (27% in 1999, and range 76-82% between 2006-2014). In the unadjusted model, ICD use was associated with a 36% reduction in waitlist mortality (HR 0.64, 95% CI 0.60-0.68, p<0.001). After adjustment for covariates such as age, sex, race, creatinine, ischemic cardiomyopathy, and listing status, this association was nearly unchanged (HR 0.67, 95% CI 0.62-0.72, p<0.001). Test for interaction by listing era (pre- and post-2006) was non-significant (p=0.28). In the final adjusted model, that included listing era and LVAD status in addition to the above listed covariates, ICD use continued to remain associated with a mortality benefit on the waitlist for HT (HR 0.84, 95% CI 0.78-0.91, p<0.001). Conclusion: ICDs are increasingly prevalent in pts listed for HT; however many pts are still listed for HT without these devices. The presence of an ICD at the time of listing is associated with lower mortality on the waitlist. Although the magnitude of ICD efficacy diminishes slightly, its benefit continues to remain significant even after adjustment for listing era and LVAD use. Further analyses are required to identify specific sub-groups of pts where ICD use is most beneficial and appropriate.

Sign in / Sign up

Export Citation Format

Share Document