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Introduction Acute right ventricular failure (aRVF) is associated with high mortality and morbidity. Mechanical circulatory support (MCS) may be considered as an advanced treatment option. The ProtekDuo is a cannula that can be used to provide acute right ventricular support as part of a temporary percutaneous (tp) right ventricular assist device (RVAD) system. The primary objective of this systematic review is to describe patient survival and complications when the ProtekDuo cannula was used as part of an tpRVAD system. Methods MEDLINE, Embase, and Scopus were searched from database inception to August 26, 2022. Reference sections of studies were reviewed to screen for database omissions. Results Seven studies with 127 patients were eligible for inclusion. The studies included patients with aRVF from a variety of causes. Mean duration of support was between 10 and 58 days in five studies. Patient survival to discharge was between 60% and 85.2% in two studies. Four authors reported 30-day survival between 60% and 85.2%. Devicerelated and non-device related complications were low. Conclusions Patients treated with RVAD using the ProtekDuo cannula have comparable survival rates and complications to other tpRVAD systems. Several advantages exist compared to other RVAD systems.

Background: Acute myocardial infarction (AMI) complicated by cardiogenic shock (AMI-CS) or heart failure is associated with an unacceptably high in-hospital mortality of 33%–55% and a lost chance to accept PCI (Percutaneous Coronary Intervention). Aim: The aim of the study was to find out whether percutaneous hemodynamic support device Impella 2.5 improves prognosis of high-risk PCI patients or not. Methods: This study was a case series involving six patients who underwent a Left Ventricular Assist Device (LVAD, Impella 2.5, Abiomed, Danvers, MA) implantation after suffering from AMI with a very low ejection fraction and acute heart failure. The clinical experience and outcomes of the patients are hereby discussed. Results: All PCI procedures were safely completed under LVAD support. The hemodynamic parameters of all patients improved clinically over the next 30 days and following 12 months after Impella insertion except in two patients, of which one patient (Case number 6) died 4 days post-Impella protected PCI procedure due to acute left ventricle heart failure with cardiogenic shock and pulmonary oedema; and another one died at 12 months after Impella protected PCI procedure (Case number 4) due to decompensated heart failure and infected pneumonia. Conclusion: Percutaneous hemodynamic support is favorable and feasible during high risk Percutaneous Coronary Intervention (PCI). A bigger study is needed to substantiate the claims of the current study.

Introduction: Inherited thrombophilias represent a concerning risk factor due to a proclivity to an aberrant clot formation. However, in patients with left ventricular assist device (LVAD), their impact on bleeding and thrombotic complications remains still poorly understood. The aim of the present study was to evaluate the effect of thrombophilic mutation directed anticoagulation therapy on adverse clinical outcomes in LVAD patients. Materials and methods: About 138 consecutive patients indicated for LVAD implant (HeartMate II, Abbott, Plymouth, USA) were prospectively screened for three major thrombophilic mutations: factor II (prothrombin), factor V Leiden, and homozygous methylenetetrahydrofolate reductase (MTHFR). Subsequently, discordant individualized anticoagulation targets of INR 2.5–3.0 in thrombophilia positive and INR 1.8–2.2 in negative patients were established; notably without anti-platelet agents given the center standard of care. Results: Mean age was 50 ± 12.7 years, 83% male. Mean duration of support was 464.5 days (SD 482.9; SEM 41.1) and median of 310 days (IQR 162; 546). Full thrombophilia positive cohort analysis has not revealed any significant impact on event free survival. In contrast, detailed analysis of specific thrombophilias subsets has revealed Factor II prothrombin mutation as a significant predisposition for the pump thrombosis risk (SHR 10.48; p = 0.001) despite more aggressive prespecified anticoagulation target. Moreover, the incidence of bleeding events in prothrombin group was also significantly increased (SHR 6.0; p = 0.03). Conclusions: Our observations suggest that specific thrombophilias in LVAD patients may pose different intensity predisposition for thrombotic complications. Factor II (prothrombin) positive mutation was identified as significant risk factor associated with the pump thrombosis.

Outflow cannula occlusion is an infrequent complication occurring among recipients of continuous flow left ventricular assist devices. Hereby, we present a case of a 66-year-old man with a HeartMate 3 left ventricular assist device that presented 18 months after implantation and during his admission, evidence of poor left ventricular unloading and forward flow uncovered intrinsic and extrinsic outflow cannula obstruction. The patient’s course was complicated by cardiogenic shock, diffuse alveolar hemorrhage and multiorgan failure. Post-mortem examination suggested foreign body reaction as a potential contributor of outflow graft obstruction at the level of the bend relief.

Objective To report the initial clinical experience with the Impella 5.5® with SmartAssist®, a temporary left ventricular assist device that provides up to 6.2 L/min forward flow, with recent FDA approval for up to 14 days. Methods From October 2019 to March 2020, 200 patients at 42 US centers received the Impella 5.5 and entered into the IQ registry, a manufacturer-maintained quality database that captures limited baseline/procedural characteristics and outcomes through device explant. Post hoc subgroup analyses were conducted to assess the role of baseline and procedural characteristics on survival, defined as successful device weaning or bridge to durable therapy. Results Median patient age was 62 years (range, 13 to 83 years); 83.4% were male. The device was most commonly used for cardiomyopathy (45.0%), acute myocardial infarction complicated by cardiogenic shock (AMICS; 29.0%), and post cardiotomy cardiogenic shock (PCCS; 16.5%). Median duration of support was 10.0 days (range, 0.001 to 64.4 days). Through device explant, overall survival was 74.0%, with survival of 80.0%, 67.2%, 57.6%, and 94.7% in cardiomyopathy, AMICS, PCCS, and others (comprising high-risk revascularization, coronary artery bypass graft, electrophysiology/ablation, and myocarditis), respectively. Patients requiring extracorporeal membrane oxygenation and Impella support (35 patients, 17.5%) had significantly lower survival (51.4% vs 78.8%, P = 0.002). Conclusions In the first 200 US patients treated with the Impella 5.5, we observed overall survival to explant of 74%. Survival outcomes were improved compared to historic rates observed with cardiogenic shock, particularly PCCS. Prospective studies assessing comparative performance of this device to conventional strategies are warranted in future.

Background: There is an ongoing debate about the influence of the female gender on postoperative outcomes after durable left ventricular assist device (LVAD) implantation. Despite the differences in pathophysiology of heart failure in females, therapy concepts are the same as in the male population. The aim of this study was to investigate the role of the female gender in surgical heart failure therapy. Materials and methods: Between August 2010 and January 2020, 207 patients were treated with durable LVAD at out institution. We matched 111 patients in two groups to compare the outcomes in male and female patients and to stratify the risk factors of mortality. Results: The groups were matched 2:1 and were comparable after matching. We found no difference in in-hospital and follow-up mortality between male and female patients. Postoperative adverse events and complications were found to be unvaried across male and female patients. Female patients had higher rates of postoperative LVAD-thrombosis compared to their male counterparts (13.5% vs 0, p = 0.001) and the rates of renal replacement therapy lasting over 90 days were also higher in the female group (33.8% vs 56.8%, p = 0.021). Furthermore, the female gender was not an independent predictor neither of in-hospital nor follow-up mortality. Conclusions: Durable continuous flow left ventricular assist devices as a bridge to transplantation or recovery in female patients are associated with a higher risk of acute kidney injury requiring RRT and are at a higher risk of LVAD-thrombosis. Nevertheless, survival rates between genders are similar.

The purpose of this research is to overcome the shortcomings of the current direct ventricular assist device in structure design, material selection and design a pneumatic flexible actuator that can be used to drive a fully flexible cup-shaped direct ventricular assist device according to the human heart shape. In this study, the structural parameters of the flexible actuator are initially determined based on the existing research, then the flexible actuator model is constructed with SOLIDWORKS, then the model is imported into ABAQUS for finite element simulation, lastly, the actuator structure is optimized according to the simulation results. The flexible actuator is made by molding, and its mold is made by 3D printing. Finally, the final structural plan is determined by testing the mechanical properties of the flexible actuator. The pneumatic flexible actuator designed in this research can be combined into the required direct ventricular assist device in a reasonable way, which will provide ideas for the design of a fully flexible direct ventricular assist device.

Loneliness is a risk factor for coronary heart disease, stroke, and hospital readmission, yet there are no studies to our knowledge examining loneliness in left ventricular assistance device (LVAD) patients. This study used a cross-sectional survey design on a convenience sample of LVAD patients ( n = 73). Logistic regression was used to identify demographic correlates of loneliness; linear regression was used to examine the relationship between loneliness and both stress and depression. Loneliness was measured via the loneliness item from the Center for Epidemiologic Studies Depression (CESD), depression via the CESD (excluding the loneliness item), and stress via the Perceived Stress Scale. In bivariate analyses, older age (OR per year = 0.958, 95%CI = 0.919–0.998) and being partnered (OR = 0.245, 95%CI = 0.083–0.724) were associated with less loneliness. In the multivariate model, there was an interaction effect between age and partnership ( p = 0.0212), where older age was protective against loneliness for non-partnered, but not partnered, patients. Higher loneliness was associated with higher stress (β = 0.484, B = 5.687, 95%CI = 3.195–8.178) and depression (β = 0.618, B = 7.544, 95%CI = 5.241–9.848). Patients who are not partnered and younger may be at increased risk of loneliness after LVAD. Loneliness in turn is associated with higher stress and depression. Longitudinal research is necessary to speak to direction of effects.

Objective We have observed that minimally invasive left ventricular assist device (LVAD) insertion leads to more facile re-entry and easier cardiac transplantation. We hypothesize minimally invasive LVAD implantation results in improved outcomes at the time of subsequent heart transplant. Methods All adults undergoing cardiac transplantation between October 2015 and March 2019 at our institution were retrospectively reviewed. Those bridged to transplantation with a HeartWare HVAD were identified and divided into 2 cohorts based upon the surgical approach: those who underwent HVAD placement by conventional sternotomy versus minimally invasive insertion via lateral thoracotomy and hemisternotomy (LTHS). Patient demographics, as well as perioperative transplant outcomes, including survival, length of stay (LOS), blood utilization, ischemic time, bypass time, and postoperative extracorporeal membrane oxygenation (ECMO) were compared between cohorts. Results Forty-two patients were bridged to heart transplant with a HVAD implanted via either sternotomy ( n = 22) or LTHS technique ( n = 20). Demographics were similar between groups. There was 1 predischarge death in the sternotomy group and none in the LTHS group. Body surface area, cardiopulmonary bypass time, ischemic time, ECMO utilization, and reoperation for bleeding were similar. Red blood cell units transfused were significantly lower in the LTHS cohort (3.0 [1.0-5.0] vs 6.0 [2.5-10.0] P = 0.046). The LTHS cohort had a significantly shorter hospital LOS (12.0 [11.0-28.0] vs 22.5 [15.7-41.7] P = 0.022) with a trend toward shorter intensive care unit LOS (6.0 [5.0-10.5] vs 11.0 [6.0-21.5] days P = 0.057). Conclusions Minimally invasive HVAD implantation improves outcomes at subsequent heart transplantation, resulting in shorter LOS and less red cell transfusion. Larger multi-institutional studies are necessary to validate these findings.

Implantable ventricular assist devices are used in heart failure therapy. These devices require real-time flow rate estimation for effective mechanical circulatory support. We previously developed a flow rate estimation method using the eccentric position of a magnetically levitated impeller to achieve real-time estimation. However, dynamic motion of the levitated impeller can compromise the method’s performance. Therefore, in this study, we investigated the effects of dynamic motion of the levitated impeller on the time resolution and estimation accuracy of the proposed method. The magnetically levitated impeller was axially suspended and radially restricted by the passive stability in a centrifugal blood pump that we developed. The dynamic motions of impeller rotation and whirling were analyzed at various operating conditions to evaluate the reliability of estimation. The vibration response curves of the impeller revealed that the resonant rotational speed was 1300–1400 revolutions per minute (rpm). The blood pump was used as a ventricular assist device with rotational speed (over 1800 rpm) sufficiently higher than the resonant speed. The rotor-dynamic forces on the impeller (0.03–0.14 N) suppressed the whirling motion of the impeller, indicating that the dynamic motion could be stable. Although the temporal responsiveness should be determined based on the trade-offs among the estimation accuracy and time resolution, the real-time estimation capability of the proposed method was confirmed.

Introduction: Heart transplantation is the definitive treatment for end-stage heart failure. Left ventricular assist devices (LVADs) are a continually improving technology that extends life for some candidates on the heart transplant waiting list. Research Questions: Our objective is to compare Black-White differences in LVAD implantation and heart transplant outcomes during a period of technological innovation when the pulsatile flow LVAD was largely replaced by the continuous flow LVAD between 1999-2014. Design: We used transplant registry data from the United Network for Organ Sharing (N = 5,550) to identify Black and White patients with heart failure who used an LVAD as a bridge-to-transplant (BTT). Using logistic regression, we compared Black-White differences in access to newer LVAD technology and timing of implantation relative to wait listing for heart transplantation. We used competing-risks event history models to predict transplant outcomes across race, LVAD type, and timing of LVAD implantation. Results: Black and White candidates were equally likely to receive newer continuous flow LVADs, but Black candidates received LVADs later in the disease course (i.e. after transplant listing). This later timing of technological intervention contributed to poorer wait list outcomes among black transplant candidates, including lower likelihood of receiving a heart transplant and greater likelihood of being removed from the wait list due to worsening health. Discussion: Delayed LVAD implantation is more common among Black patients and is associated with poorer transplant outcomes.

Thrombosis and its related events have become a major concern during the development and optimization of ventricular assist devices (VADs, also called blood pumps), and limit their clinical use and economic benefits. Attempts have been made to model the thrombosis formation, considering hemodynamic and biochemical processes. However, the complexities and computational expenses are prohibitive. Blood stasis is one of the key factors which may lead to the formation of thrombosis and excessive thromboembolic risks for patients. This study proposed a novel approach for modeling blood stasis, based on a two-phase flow principle. The locations of blood residual can be tracked over time, so that regions of blood stasis can be identified. The blood stasis in an axial blood pump is simulated under various working conditions, the results agree well with the experimental results. In contrast, conventional hemodynamic metrics such as velocity, time-averaged wall shear stress (TAWSS), and relative residence time (RRT), were contradictory in judging risk of blood stasis and thrombosis, and inconsistent with experimental results. We also found that the pump operating at the designed rotational speed is less prone to blood stasis. The model provides an efficient and fast alternative for evaluating blood stasis and thrombosis potential in blood pumps, and will be a valuable addition to the tools to support the design and improvement of VADs.

Enlarged cardiac structures, especially those on left side have the potential to cause airway compression in pediatric patients with chronic heart failure, owing to their proximity to and impact on the trachea-bronchial tree. Ventricular assist devices are effective in decompressing such hearts thereby alleviating airway problems. Aortopexy serves as an effective airway decompressive measure in cases with persistent airway compression despite effective cardiac decompression by ventricular assist devices. We report a case of 1-year-old male patient with dilated cardiomyopathy in whom airway compression persisted despite ventricular assist device implantation. Aortopexy was effective in relieving airway compression allowing for subsequent extubation and successful heart transplantation.

We describe a successful bridge to recovery by coronary reimplantation and Berlin Heart EXCOR left ventricular assist device in a child with left main coronary artery ostial atresia and severe ischemic cardiomyopathy.

Background: Ventricular assist device (VAD) patients are at high risk for morbidities and mortality. One potentially beneficial component of the Joint Commission VAD Certification process is the requirement that individual VAD programs select 4 performance measures to improve and optimize patients’ clinical outcomes. Problem Statement: Review of patient data after our program’s first certification visit in 2008 showed that, compared to national recommendations and published reports, our patients had suboptimal outcomes in 4 areas after device implantation: length of hospital stay, receipt of early (Methods: Plan-Do-Study-Act processes were implemented to shorten length of stay, increase patient receipt of early physical therapy, decrease driveline infection incidence, and improve nutritional status. With 2008 as our baseline, we deployed interventions for each outcome area across 2009 to 2017. Performance improvement activities included staff, patient, and family didactic, one-on-one, and hands-on education; procedural changes; and outcomes monitoring with feedback to staff on progress. Descriptive and inferential statistics were examined to document change in the outcomes. Outcomes: Across the performance improvement period, length of stay decreased from 40 to 23 days; physical therapy consults increased from 87% to 100% of patients; 1-year driveline infection incidence went from 38% to 23.5%; and the percentage of patients with prealbumin within the normal range increased from 84% to 90%. Implications: Performance improvement interventions may enhance ventricular assist device patient outcomes. Interventions’ sustainability should be evaluated to ensure that gains are not lost over time.

Background: The seasonal variation of incidence and severity of heart failure is well known. However, the impact of seasonal variation on clinical outcomes following left ventricular assist device (LVAD) implantation remains unknown. Methods: We retrospectively reviewed consecutive patients who received LVAD implantation between January 2014 and December 2016 along with their first year of post-implant outcomes. Clinical outcomes were compared between those with winter LVAD implantation (between October and March) and those with non-winter LVAD implantation. Results: 168 patients with a median age of 57 years and 130 males were included. There was no seasonal difference in the number of LVAD implantations. One-year survival free from major adverse events was significantly lower in the winter implant group ( n = 88) compared to the non-winter group ( n = 80) (44% vs 61%) with an adjusted hazard ratio of 1.81 (95% confidence interval 1.11–2.90, p = 0.014), largely due to a higher rate of heart failure readmission in the winter implant patients (incidence rate ratio 2.29, 95% confidence interval 0.89–5.84). Conclusion: Patients who underwent LVAD implantation during the winter season had a higher heart failure readmission rate. A detailed mechanism and therapeutic strategy given our findings warrant further investigation.

Background Mechanical cardiac support (MCS) is a lifesaving therapy option in patients with heart failure and other medical disorders. However, there is an associated risk of gastrointestinal bleeding (GIB). The goal of this study was to determine GIB incidence and associated risk factors. Methods All patients at one institution from 2009 to 2018 under durable and nondurable support were retrospectively reviewed for GIB during their MCS period. Clinical records were evaluated for patient demographics, GIB characteristics, and interventions. Univariate and multivariate analyses were performed to compare patient groups. Results A total of 427 patients were reviewed, with 111 (25.9%) patients representing 218 episodes of GIB during our study period. The incidence rate from support initiation to GIB was 44.9% by 6 months and 60.6% in 12 months, occurring at a mean of 216.7 days. Higher rates of bleeding were found in patients with hypertension (82% vs 71.5%; P = .03) and diabetes mellitus (62.2% vs 38.3%; P < .0001), as well as pulmonary (48.7% vs 35.4%; P = .014), hepatic (21.6% vs 10.4%; P = .003), and renal disease (48.7% vs 37.3%; P = .037). Endoscopy revealed an upper GI source in 56% (n = 123) of bleeds. The most common etiology of bleeding included angiodysplasia/vascular malformation (35.7%). Therapeutic intervention was performed in 109 (50%) cases, with only 1 surgical intervention. Discussion Overall, GIB can be a significant adverse event in patients under mechanical cardiac support, so proper management of anticoagulation and early endoscopy evaluation remains of great importance.

Introduction: We describe a patient who developed severe aortic regurgitation following Impella left ventricular assist device implantation requiring aortic valve replacement. Case report: A previously healthy 34-year-old female presented with chest pain and flu-like symptoms. Electrocardiogram showed widespread ST elevation and serum troponin was raised, consistent with myocarditis. Coronary angiography was normal but the right coronary artery dissected. Subsequent cardiogenic shock required veno-arterial extracorporeal membrane oxygenation and Impella implantation. Myocardial function recovered, but upon removal of the Impella, severe aortic regurgitation was present and she underwent aortic valve replacement, making a full recovery. Discussion: Aortic regurgitation is a rare complication of Impella implantation, and to our knowledge, this is the first reported case successfully treated with aortic valve replacement. Veno-arterial extracorporeal membrane oxygenation and Impella used in tandem are relatively novel, and may add synergistic benefit to strategies for acute cardiogenic shock. Conclusion: Echocardiography must include frequent assessment of both valvular and myocardial function after Impella removal.

Long-term using continuous flow ventricular assist devices could trigger complications associated with diminished pulsatility, such as valve insufficiency and gastrointestinal bleeding. One feasible solution is to produce pulsatile flow assist with speed regulation in continuous flow ventricular assist devices. A third-generation blood pump with pulsatile operation control algorithm was first characterized alone under pulsatile mode at various speeds, amplitudes, and waveforms. The pump was then incorporated in a Mock circulation system to evaluate in vitro hemodynamic effects when using continuous and different pulsatile operations. Pulsatility was evaluated by surplus hemodynamic energy. Results showed that pulsatile operations provided sufficient hemodynamic assistance and increased pulsatility of the circulatory system (53% increment), the mean aortic pressure (65% increment), and cardiac output (27% increment). The pulsatility of the system under pulsatile operation support was increased 147% compared with continuous operation support. The hemodynamic performance of pulsatile operations is susceptible to phase shifts, which could be a tacking angle for physiological control optimization. This study found third-generation blood pumps using different pulsatile operations for ventricular assistance promising.

Since the use of continuous flow blood pumps as ventricular assist devices is standard, the problems with haemolysis have increased. It is mainly induced by shear stress affecting the erythrocyte membrane. There are many investigations about haemolysis in laminar and turbulent blood flow. The results defined as threshold levels for the damage of erythrocytes depend on the exposure time of the shear stress, but they are very different, depending on the used experimental methods or the calculation strategy. Here, the results are resumed and shown in curves. Different models for the calculation of the strengths of erythrocytes are discussed. There are few results reported about tests of haemolysis in blood pumps, but some theoretical approaches for the design of continuous flow blood pumps according to low haemolysis have been investigated within the last years.

Implantable ventricular assist devices are a type of mechanical circulatory support for assisting the pumping of the heart. Accurate estimation of the flow rate through such devices is critical to ensure effective performance. A novel method for estimating the flow rate using the passively stabilized position of a magnetically levitated impeller was developed by our group. However, the performance of the method is affected by the gravity vector, which depends on the patient’s posture. In this study, the effects of gravity on the flow estimation method are analyzed, and a compensation method is proposed. The magnetically levitated impeller is axially suspended and radially restricted by passive stability in a centrifugal blood pump developed by our group. The gravity effects were evaluated by analyzing the relationships between the radial position of the magnetically levitated impeller and the flow rate with respect to the gravity direction. Accurate estimation of the flow rate could not be achieved when the direction of gravity with respect to impeller was unknown. A mean absolute error of up to 4.89 L/min was obtained for flow rate measurement range of 0–5 L/min. However, analysis of the equilibrium of forces on the passively stabilized impeller indicated that the effects of gravity on the flow estimation could be compensated by performing additional measurements of the gravity direction with respect to impeller. The method for compensating the effects of gravity on the flow estimation should improve the performance of therapy with the implantable ventricular assist devices.

Objective Despite improvement in outcomes after left ventricular assist device (LVAD) implantation over the past 2 decades, high-risk recipients continue to have a prohibitive rate of morbidity and mortality. We hypothesized that a less invasive approach to LVAD implantation would be associated with improved survival compared to a conventional approach in this high-risk cohort. Methods All consecutive LVAD recipients (2013 to 2017) that underwent centrifugal LVAD implantation were retrospectively reviewed. Patients were classified as high-risk if INTERMACS 1 or required temporary VAD/venoarterial extracorporeal membrane oxygenation prior to durable VAD implantation. Patients were stratified into 3 groups: left thoracotomy with hemi-sternotomy (LTHS) high-risk, conventional sternotomy (CS) high-risk, and non-high-risk. The primary outcome was 1-year survival. Results A total of 57 patients (LTHS high-risk: 11, CS high-risk: 12, non-high-risk: 34) were identified. Preoperative right ventricular failure scores, HeartMate-II mortality scores, and end-organ dysfunction were similar between the 2 high-risk groups. While operative time was similar between the 3 groups, cardiopulmonary bypass time was significantly shorter in the LTHS high-risk group compared to other groups. There was a trend toward decreased intensive care unit length of stay and ventilator time in LTHS high-risk compared to CS high-risk patients. Moreover, between these 2 groups, there was a significant decrease in temporary right VAD support (50% vs 0%, P = 0.014), and 1-year survival was significantly higher in the LTHS group (42% vs 91%, P = 0.025). Conclusions Less invasive LVAD implantation appears to be associated with improved survival compared to conventional LVAD implantation in high-risk patients.

This review focuses on the literature published from January 2019 to February 2020 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period, and 59 peer-reviewed articles are discussed.

Background. Despite demonstrated efficacy, patient decision aids (DAs) are rarely used in clinical practice in the absence of coverage mandates. Deciding whether to pursue a left ventricular assist device (LVAD) is a major, preference-sensitive decision—ideal for exploring implementation of a DA. Methods. We conducted a type II effectiveness-implementation hybrid trial at 6 LVAD programs using a stepped-wedge cluster-randomized design. Using the RE-AIM framework, we collected both quantitative and qualitative outcomes, including a checklist collected by study staff for each enrolled patient regarding DA use and interviews with LVAD program clinicians preintervention, 6 months postintervention, and at the conclusion of the study. Results. From June 2015 to January 2017, 248 patients and their caregivers were enrolled. A total of 69 interviews were conducted with 48 clinicians at 3 time points. The DA reached 95% of eligible patients. Adoption was 100%, as all sites approached agreed to participate in the trial. Interviews revealed several themes related to the implementation of the DA: clinicians had a strong desire to ensure patients were informed and embraced the DA. Despite this, they reported communication challenges among their team that impeded implementation. Five of the 6 sites have maintained use of the DA following the trial; 1 site reported concerns about decreased procedural volume with use of the DA as a reason for discontinuation. Conclusions. In this hybrid trial, a DA for patients considering LVADs and their caregivers demonstrated high reach. Adoption and implementation were facilitated by a strong desire to ensure that patients were well informed. Future dissemination research and practice should attend to concerns about procedure volume and coverage mandates and facilitate ongoing communication at sites using the DA.

Left ventricular assist devices are routinely used to treat patients with advanced heart failure as a bridge to transplant or a destination therapy. However, non-physiological shear stress generated by left ventricular assist devices damages blood cells. The continued development of novel left ventricular assist devices is essential to improve the left ventricular assist device therapy for heart failure patients. The CH-VAD is a new maglev centrifugal left ventricular assist device. In this study, the CH-VAD pump was numerically analyzed and compared with the HVAD and HeartMate II pumps under two clinically relevant conditions (flow: 4.5 L/min, pressure head: normal ~80 and hypertension ~120 mmHg). The velocity and shear stress fields, washout, and hemolysis index of the three pumps were assessed with computational fluid dynamics analysis. Under the same condition, the CH-VAD hemolysis index was two times lower than the HVAD and HeartMate II pumps; the CH-VAD had the least percentage volume with shear stress larger than 100 Pa (i.e. normal condition: 0.4% vs HVAD 1.0%, and HeartMate II 2.9%). Under the normal condition, more than 98% was washed out of the three pumps within 0.4 s. The washout times were slightly shorter under the hypertension condition for the three pumps. No regions inside the CH-VAD or HVAD had extremely long residential time, while areas near the straightener of the HeartMate II pump had long residential time (>4 s) indicating elevated risks of thrombosis. The computational fluid dynamics results suggested that the CH-VAD pump has a better hemolytic biocompatibility than the HVAD and HeartMate II pumps under the normal and hypertension conditions.

This study aimed to evaluate a newly designed circulatory mock loop intended to model cardiac and circulatory hemodynamics for mechanical circulatory support device testing. The mock loop was built with dedicated ports suitable for attaching assist devices in various configurations. This biventricular mock loop uses two pneumatic pumps (Abiomed AB5000™, Danvers, MA, USA) driven by a dual-output driver (Thoratec Model 2600, Pleasanton, CA, USA). The drive pressures can be individually modified to simulate a healthy heart and left and/or right heart failure conditions, and variable compliance and fluid volume allow for additional customization. The loop output for a healthy heart was tested at 4.2 L/min with left and right atrial pressures of 1 and 5 mm Hg, respectively; a mean aortic pressure of 93 mm Hg; and pulmonary artery pressure of 17 mm Hg. Under conditions of left heart failure, these values were reduced to 2.1 L/min output, left atrial pressure = 28 mm Hg, right atrial pressure = 3 mm Hg, aortic pressure = 58 mm Hg, and pulmonary artery pressure = 35 mm Hg. Right heart failure resulted in the reverse balance: left atrial pressure = 0 mm Hg, right atrial pressure = 30 mm Hg, aortic pressure = 100 mm Hg, and pulmonary artery pressure = 13 mm Hg with a flow of 3.9 L/min. For biventricular heart failure, flow was decreased to 1.6 L/min, left atrial pressure = 13 mm Hg, right atrial pressure = 13 mm Hg, aortic pressure = 52 mm Hg, and pulmonary artery pressure = 18 mm Hg. This mock loop could become a reliable bench tool to simulate a range of heart failure conditions.

Intraventricular flow patterns during left ventricular assist device support have been investigated via computational fluid dynamics by several groups. Based on such simulations, specific parameters for thrombus formation risk analysis have been developed. However, computational fluid dynamic simulations of complex flow configurations require proper validation by experiments. To meet this need, a ventricular model with a well-defined inflow section was analyzed by particle image velocimetry and replicated by transient computational fluid dynamic simulations. To cover the laminar, transitional, and turbulent flow regime, four numerical methods including the laminar, standard k-omega, shear-stress transport, and renormalized group k-epsilon were applied and compared to the particle image velocimetry results in 46 different planes in the whole left ventricle. The simulated flow patterns for all methods, except renormalized group k-epsilon, were comparable to the flow patterns measured using particle image velocimetry (absolute error over whole left ventricle: laminar: 10.5, standard k-omega: 11.3, shear–stress transport: 11.3, and renormalized group k-epsilon: 17.8 mm/s). Intraventricular flow fields were simulated using four numerical methods and validated with experimental particle image velocimetry results. In the given setting and for the chosen boundary conditions, the laminar, standard K-omega, and shear–stress transport methods showed acceptable similarity to experimental particle image velocimetry data, with the laminar model showing the best transient behavior.

Driveline infection is the most common infectious complication in patients with left ventricular assist devices. Minimum inhibitory concentration changes are not well described in relapsed driveline infections. This retrospective descriptive epidemiology study of patients with left ventricular assist device implantation between January 1, 2013, and August 1, 2017, who developed driveline infection with positive cultures aimed to describe minimum inhibitory concentration changes. Of the 330 patients underwent left ventricular assist device implantation, 30 (9%) met criteria for driveline infection. Median duration of follow-up was 26 months (interquartile range 16, 39) and time to first driveline infection was 171 days (interquartile range 83, 403). There were 74 driveline infections: 40 new and 34 relapsed. Staphylococcus aureus was most common in new and relapsed driveline infection. Thirteen patients comprised the 34 relapsed infections, 9 of which experienced a minimum inhibitory concentration change. Median time to first minimum inhibitory concentration change was 56 days (interquartile range 36–88), and type of minimum inhibitory concentration change was an increase in five cases, decrease in two cases, and both increase and decrease in two cases. Minimum inhibitory concentration changes did not result in resistance in S. aureus but did in Pseudomonas aeruginosa and Mycobacterium fortuitum relapsed driveline infection. Time to first relapse from initial infection was longer in those who received suppressive therapy, 60 days versus 83 days, p = 0.047. Relapsed driveline infections were most common with S. aureus. Minimum inhibitory concentration changes were quite variable and may not be the major contributor to relapsed infection in gram-positive driveline infection.

Heart transplantation is an established treatment for end-stage heart failure. Due to the increase in demand and persistent scarcity of organ, mechanical circulatory devices have played a major role in therapy for advanced heart failure. Usage of left ventricular assist device (LVAD) has gone up from 6% in 2006 to 43% in 2013 as per the United Network of Organ Sharing database. Majority of patients presenting for a heart transplantation are often bridged with an assist device prior for management of heart failure while on wait-list. On one hand, it is well established that LVADs improve survival on wait-list; on the other hand, the effect of LVAD on morbidity and survival after a heart transplantation is still unclear. In this article, we review the available literature and attempt to infer the outcomes given the risks and benefits of heart transplantation with prior LVAD patients.

Objectives: The main aim was a systematic evaluation of the current evidence on outcomes for patients undergoing right ventricular assist device (RVAD) implantation following left ventricular assist device (LVAD) implantation. Methods: This systematic review was registered on PROSPERO (CRD42019130131). Reports evaluating in-hospital as well as follow-up outcome in LVAD and LVAD/RVAD implantation were identified through Ovid Medline, Web of Science and EMBASE. The primary endpoint was mortality at the hospital stay and at follow-up. Pooled incidence of defined endpoints was calculated by using random effects models. Results: A total of 35 retrospective studies that included 3260 patients were analyzed. 30 days mortality was in favour of isolated LVAD implantation 6.74% (1.98–11.5%) versus 31.9% (19.78–44.02%) p = 0.001 in LVAD with temporary need for RVAD. During the hospital stay the incidence of major bleeding was 18.7% (18.2–19.4%) versus 40.0% (36.3–48.8%) and stroke rate was 5.6% (5.4–5.8%) versus 20.9% (16.8–28.3%) and was in favour of isolated LVAD implantation. Mortality reported at short-term as well at long-term was 19.66% (CI 15.73–23.59%) and 33.90% (CI 8.84–59.96%) in LVAD respectively versus 45.35% (CI 35.31–55.4%) p ⩽ 0.001 and 48.23% (CI 16.01–80.45%) p = 0.686 in LVAD/RVAD group respectively. Conclusion: Implantation of a temporary RVAD is allied with a worse outcome during the primary hospitalization and at follow-up. Compared to isolated LVAD support, biventricular mechanical circulatory support leads to an elevated mortality and higher incidence of adverse events such as bleeding and stroke.

Background: Heart failure is one of the most expensive chronic diseases, as it leads to considerable expenses due to increasing hospitalisation rates. In addition to the implications of the demographic transition and the lack of available organs for transplantation, a major challenge in this context is that conservative treatment options are limited. This has led to the research and development of mechanical circulatory assist systems. Telemonitoring is anticipated to be an effective tool in outpatient management, which may be a key to improved outcomes of left ventricular assist devices therapy. In patients with chronic cardiac diseases, telemedicine is already used and has been shown to reduce premature mortality. This study aims to provide insights into the left ventricular assist device–specific requirements for telemonitoring and infrastructural translation from caregivers’ and patients’ points of view. Method: A qualitative investigation based on guided interview and focus group techniques was conducted at two German heart centres. The study included 15 patients and 7 caregivers (4 cardiac surgeons, 3 ventricular assist device coordinators). Qualitative content analysis was used for data analysis. The categories for analysis were (1) benefits for patients, (2) benefits for hospitals and the healthcare system, (3) acceptance and causative factors and (4) infrastructural implementation. Results: Patients and experts expect the following benefits for telemonitored patients: added safety, early detection of complications, rapid intervention in case of emergency, regular inspection of pump parameters, fewer outpatient clinic visits and the ability to provide more informed feedback and instructions to the family members who take care of the patient. However, the expected acceptance of telemonitoring in left ventricular assist device therapy differed among the interviewed groups. Alongside the aforementioned expected benefits, patients and clinical experts criticised the reduced self-determination for the patient, probable large amounts of time/effort required of the patient and caregiver and data protection/integrity issues (data misuse, device manipulation and mistransfer). Interviewees expected easy handling, proper education and safe data transmission to be necessary factors leading to acceptance. Complication rate reduction, fewer hospitalisations and cost reductions were benefits recorded for the healthcare system and clinics. Clinical experts preferred a telemonitoring centre run by ventricular assist device coordinators. Conclusion: Although positive expectations are associated with the use of telemonitoring in left ventricular assist device therapy, further action is needed. For example, software and infrastructure developers will need to address issues such as variations among patients and may need to find a balance between designing individualised solutions for compliant patients and a safe and easy-to-handle set-up. In addition, proper elucidation of users will contribute to the successful implementation of a left ventricular assist device telemonitoring programme among patients and caregivers.

The use of left ventricular assist device (LVAD) in patients with mechanical aortic valves may result in thromboembolic events due to blood stasis around the valve and intermittent valve opening. Mechanical aortic valves encountered during LVAD implantation are managed by replacement with a tissue valve, or closure of the valve with a patch. Closure of the valve carries the risk of sudden death in cases of LVAD stoppage. Replacing the whole mechanical valve conduit is time consuming and carries a significant risk of bleeding and right ventricular (RV) failure. We describe an alternative technique of replacing a mechanical aortic valve by breaking its inner leaflets and sewing a tissue valve on top of the mechanical valve ring.

A 50-year-old male with a history of nonischemic dilated cardiomyopathy presented in cardiogenic shock and ultimately underwent durable left ventricular assist device implantation. He recovered well initially but developed persistent bacteremia. His indwelling pacemaker leads were extracted due to evidence of vegetation. Shortly thereafter, around 3 months post–left ventricular assist device, he succumbed to a massive intracranial hemorrhage due to ruptured cerebral mycotic aneurysm. This case highlights the potential importance of brain imaging in left ventricular assist device patients with persistent bacteremia to avoid this likely catastrophic complication.

Objective: In vitro performance verification of ventricular assist devices using a mock circulatory loop is a prominent step to guarantee the system responses and the device performance and safety before the in vivo tests and ultimately clinical trials. Methods: In this article, we performed a comprehensive literature research to establish a verification matrix consisting of 12 test cases, defined by a set of physiological parameters which are commonly used to characterize a physiological condition. The clinical hemodynamic indicators for defining successful mechanical support were used as the acceptance criteria. A mock circulatory loop was customized to simulate the test cases, and a full verification protocol was described in details. An example left ventricular assist device was incorporated in the loop to accomplish a standard ventricular assist device performance verification. Result: The test cases based on clinical data with sufficient safety margin represent our understanding in defining the extremes of operation. The mock circulatory loop was capable of generating the test conditions in the verification matrix and reproducing the Frank–Starling law of the native heart. The effect of the left ventricular assist device assistance (characterized by the total systemic flow, mean aortic pressure, and left atrial pressure) was well verified by the proposed protocol and acceptance criteria. Conclusion: To date, all left ventricular assist devices made in China have been evaluated according this protocol and some of them have entered the clinical trial stage. We are closely observing the clinical data in order to further improve the performance of the platform and encourage more advances in mechanical circulatory assist devices.

In selected patients with left ventricular assist device–associated infection or malfunction, pump exchange may become necessary after conservative treatment options fail and heart transplantation is not readily available. We examined the survival and complication rate in patients (⩾19 years of age) who underwent HeartMate II to HeartMate II exchange at our institution from 1 January 2010 to 28 February 2018. Clinical outcomes were analyzed and compared for patients who underwent exchange for pump thrombosis (14 patients), breach of driveline integrity (5 patients), and device-associated infection (2 patients). There were no differences in 30-day mortality (p = 0.58), need for temporary renal replacement therapy (p = 0.58), right ventricular mechanical support (p = 0.11), and postoperative stroke (p = 0.80) among groups. Survival at 1 year was 90% ± 7% for the whole cohort and 85% ± 10% for those who underwent exchange for pump thrombosis. In patients exchanged for device thrombosis, freedom from re-thrombosis and survival free from pump re-thrombosis at 1 year were 49% ± 16% and 42% ± 15%, respectively. No association of demographic and clinical variables with the risk of recurrent pump thrombosis after the first exchange was identified. Survival after left ventricular assist device exchange compares well with published results after primary left ventricular assist device implantation. However, recurrence of thrombosis was common among patients who required a left ventricular assist device exchange due to pump thrombosis. In this sub-group, consideration should be given to alternative strategies to improve the outcomes.

Introduction: To better understand the forensic implications of death with a left ventricular assist device (LVAD), we reviewed all deaths that were reported to a regional medical examiner jurisdiction involving patients who had an LVAD. Methods: Medical examiner case files between January 2012 and September 2018 were searched for “LVAD” and “left ventricular assist device” to identify deaths that were reported to the medical examiner involving a decedent who had an LVAD at the time of death. Results: During the study period, a total of 14 deaths were reported to the regional medical examiner involving decedents who had an implanted LVAD at the time of death. The average age at death was 64 years, with a range from 40 to 81 years. The underlying cardiac disease leading to LVAD implantation was ischemic heart disease (n = 9), nonischemic dilated cardiomyopathy (n = 4), and chemotherapy-related cardiotoxicity (n = 1). Of these 14 deaths, 2 deaths were due to loss of power to the LVAD, 1 death was due to traumatic subdural hemorrhage occurring in the setting of anticoagulation therapy required by LVAD implantation, and 1 death was due to femur fracture following a fall. Discussion: Medical examiners should be familiar with the potential complications of LVADs, especially those complications that may prompt consideration of non-natural manners of death. Medical examiners should also be aware of the tools and investigative strategies that may assist in the investigation of LVAD-related deaths.

Background: Right ventricular stroke work index is a useful but invasively measured parameter that can be used to predict right heart failure following continuous-flow left ventricular assist device implantation. Right ventricular contraction pressure index is a novel parameter that was developed to measure right ventricular stroke work index with echocardiography. We aimed to investigate the clinical usefulness of right ventricular contraction pressure index to predict short-term mortality and right heart failure in patients who underwent continuous-flow left ventricular assist device implantation. Methods: A total of 49 patients who participated in institutional advanced heart failure registry and underwent continuous-flow left ventricular assist device implantation with a bridge-to-candidacy indication were analyzed retrospectively. Right ventricular contraction pressure index was calculated using offline measurements. Demographic, clinical and outcome data were obtained from the registry data. Patients were grouped according to right ventricular contraction pressure index quartiles. Results: Patients within the lowest right ventricular contraction pressure index quartile had a trend toward higher short-term mortality (46.2%, p = 0.056) and combined short-term mortality and definitive right heart failure (53.8%, p = 0.054) at 15th day postoperatively. Similarly, short-term survival or survival free of definite right heart failure were significantly lower in the lowest right ventricular contraction pressure index quartile (log-rank p = 0.045 and log-rank p = 0.03, respectively). In a proportional hazards model that included echocardiographic parameters, right ventricular contraction pressure index was an independent predictor for short-term mortality (odds ratio: 6.777, 95% confidence interval: 1.118–41.098, p = 0.037), but not for combined short-term mortality and definite right heart failure. No such associations were found for long-term mortality. Right ventricular contraction pressure index had a statistically significant correlation with invasively measured pulmonary capillary wedge pressure, pulmonary vascular resistance, mean pulmonary pressure, and right ventricular stroke work index. Conclusion: Right ventricular contraction pressure index was found as a useful parameter for determining short-term postoperative mortality in patients undergoing continuous-flow left ventricular assist device implantation.

Left ventricular assist devices (LVADs) are an important therapeutic option for patients with end-stage heart failure waiting for heart transplantation or in older patients as definite therapy for heart failure. Interestingly, about 62% of patients receiving LVADs do not have an automatic implantable cardioverter-defibrillator (AICD) at the time of implantation, although these patients have increased risk of being confronted with dangerous arrhythmia. Therefore, an LVAD system including AICD function is a reasonable alternative for such heart failure patients thereby avoiding a second surgical intervention for AICD implantation. In this article, a newly developed system including LVAD and AICD function is introduced, and we also report its first in vitro testing.

Bloodstream infection is the leading cause of mortality in left ventricular assist device. Bloodstream infection is a risk factor for intracranial hemorrhage. We report three left ventricular assist device recipients who presented with bloodstream infection and developed subarachnoid hemorrhage. Case 1, a 37-year-old male with non-ischemic cardiomyopathy with HeartMate II, presented with confusion and found to have serratia bloodstream infection and left frontal lobe subarachnoid hemorrhage. Cerebral angiogram showed a right M3/M4 branch infectious intracranial aneurysm. He was treated with coil embolization and underwent device exchange. Case 2, a 41-year-old male with non-ischemic cardiomyopathy with HeartMate II presented with confusion and found to have methicillin-resistant staphylococcus aureus bloodstream infection and bilateral frontal convexity subarachnoid hemorrhage. Cerebral angiogram showed left M3 and left A3 infectious intracranial aneurysms, which were treated with antibiotics alone. Case 3, a 58-year-old female with ischemic cardiomyopathy with HeartMate II presented with fever, found to have candida albicans bloodstream infection and a parieto-occipital enhancing lesion concerning for cerebral abscess. Repeat computed tomography brain a week later showed a new right frontal subarachnoid hemorrhage. Cerebral angiogram showed a M4/M5 junction infectious intracranial aneurysm; patient was not a surgical candidate and was transitioned to hospice. This case series emphasizes that left ventricular assist device–associated subarachnoid hemorrhage may be caused by infectious intracranial aneurysms when acute bloodstream infections are present.

The blood damage prediction in rotary blood pumps is an important procedure to evaluate the hemocompatibility of such systems. Blood damage is caused by shear stresses to the blood cells and their exposure times. The total impact of an equivalent shear stress can only be taken into account when turbulent stresses are included in the blood damage prediction. The aim of this article was to analyze the influence of the turbulent stresses on the damage prediction in a rotary blood pump’s flow. Therefore, the flow in a research blood pump was computed using large eddy simulations. A highly turbulence-resolving setup was used in order to directly resolve most of the computed stresses. The simulations were performed at the design point and an operation point with lower flow rate. Blood damage was predicted using three damage models (volumetric analysis of exceeded stress thresholds, hemolysis transport equation, and hemolysis approximation via volume integral) and two shear stress definitions (with and without turbulent stresses). For both simulations, turbulent stresses are the dominant stresses away from the walls. Here, they act in a range between 9 and 50 Pa. Nonetheless, the mean stresses in the proximity of the walls reach levels, which are one order of magnitude higher. Due to this, the turbulent stresses have a small impact on the results of the hemolysis prediction. Yet, turbulent stresses should be included in the damage prediction, since they belong to the total equivalent stress definition and could impact the damage on proteins or platelets.

WOS: 000476186400001, Background: Ventricular assist devices, improve morbidity and survival in patients with end-stage heart failure. Objectives: To evaluate the major causes of emergency department admissions in patients with ventricular assist device support. Methods: The charts of 200,000 adult patients who presented to our emergency department between January 2016 and January 2018 were reviewed retrospectively. A total of 444 emergency department visits made by 99 patients with ventricular assist device were included in the study. Results: The annual incidence of emergency department admissions of patients with ventricular assist device was 0.1%. The mean age was 55.5 +/- 11.1 years and 85.9% of the study population were men. The most commonly encountered diagnoses were abnormal international normalized ratio or international normalized ratio follow-up (18.2%); heart failure, non-specific chest pain, and chronic obstructive pulmonary disease (15.3%); minor/major bleeding (12.1%); neurological disorders such as ischemic stroke, transient ischemic attack, vertigo, migraine, and syncope (11.2%); non-device related infections (10.8%); ventricular tachycardia/fibrillation episode (8.5%); musculoskeletal disorders (7.2%); and device-related complications such as driveline infection and pump thrombosis (6.3%). Of the patients with bleeding, 31.1% had intracranial bleeding, 31.1% had epistaxis, 24% had gastrointestinal bleeding, 11.1% had hematuria, and 1.8% had gingival hemorrhage. Of the 15 patients who died, 73.3% were diagnosed with intracranial hemorrhage. Conclusion: Even though the mortality rates of patients with ventricular assist device tends to decrease, these patients still have significant morbidity due to the increase in the prevalence of ventricular assist device use. Except for device-related problems, emergency department management of this patient group does not differ much from other patient groups. As early diagnosis of any device-related problems is mandatory for decreasing mortality, emergency department physicians should be familiar with mechanical support systems.

Current left ventricular assist devices are designed to reestablish patient’s hemodynamics at rest but they lack the suitability to sustain the heart adequately during physical exercise. Aim of this work is to assess the performance during exercise of a left ventricular assist device with flatter pump pressure-flow characteristic and increased pressure sensitivity (left ventricular assist device 1) and to compare it to the performance of a left ventricular assist device with a steeper characteristic (left ventricular assist device 2). The two left ventricular assist devices were tested at constant rotational speed with a verified computational cardiorespiratory simulator reproducing an average left ventricular assist device patient response to exercise (EXE↑) and a left ventricular assist device patient with no chronotropic and inotropic response (EXE→). According to the results, left ventricular assist device 1 pumps a higher flow than left ventricular assist device 2 both at EXE↑ (6.3 vs 5.6 L/min) and at EXE→ (6.7 vs 6.1 L/min), thus it better unloads the left ventricle. Left ventricular assist device 1 increases the power delivered to the circulation from 0.63 W at rest to 0.67 W at EXE↑ and 0.82 W at EXE→, while left ventricular assist device 2 power shows even a minimal decrease. Left ventricular assist device 1 better sustains exercise hemodynamics and can provide benefits in terms of exercise performance, especially for patients with a poor residual left ventricular function, for whom the heart can hardly accommodate an increase of cardiac output.

Background: To investigate whether preoperative short-term extracorporeal life support therapy in patients undergoing continuous-flow left ventricular assist device implantation has an impact on the outcome regarding survival and adverse events. Methods: Between January 2011 and May 2018, 100 consecutive patients received HeartMate II, HeartWare, or HeartMate III for end-stage heart failure. Mean age was 64.2 ± 10.3 years. Three patient groups were identified: without preoperative extracorporeal life support (non-extracorporeal life support group, n = 80), with preoperative extracorporeal life support due to postcardiotomy shock after conventional cardiac surgery (postcardiotomy shock group, n = 9), and with preoperative extracorporeal life support without previous surgery (non-postcardiotomy shock group, n = 11). The primary endpoint was overall survival after device implantation. Secondary endpoints were adverse events during the follow-up period. Results: Survival was significantly different between the groups (p Conclusion: Continuous-flow left ventricular assist device implantation with prior extracorporeal life support appears to have a worse outcome regarding survival, right heart failure, renal and respiratory dysfunction (p

With the increasing prevalence of the left ventricular assist device (LVAD) in patients with end-stage cardiomyopathies, an increasing number of these patients are dying of noncardiac conditions. It is likely that the palliative care clinician will have an ever-increasing role in managing end of life for patients with LVADs, including discontinuation of LVAD support. There exists a paucity of literature describing strategies for effective delivery of palliative care in patients requesting discontinuation of LVAD therapy. Here, we present a case of a patient with metastatic cancer who requested LVAD discontinuation. Because of practical concerns and patient preference, the patient did not have intravenous (IV) access and medications requiring IV administration could not be used. Therefore, a strategy using intranasal midazolam and sufentanil was applied, the LVAD was deactivated, and the patient died comfortably. This case is, to our knowledge, the first to describe a strategy for delivery of palliative care in patients requesting discontinuation of LVAD support, particularly in the absence of IV access. Such a strategy may be applicable to patients wishing to die at home, and therefore allow greater latitude for patients and clinicians in their approach to the end of life.