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The definition of mechanical circulatory support (MCS) refers to a group of mechanical devices which can be added to the physiological circulation providing support or replacement of the heart and/or the lungs. This allows adequate blood flow and oxygenation in situations where pharmaceutical support is insufficient. To establish MCS we have several devices at our disposal which can be used as a stand-alone therapy or supplement each other depending on the clinical need. The ongoing technological development and especially radical miniaturization changes the playing field continuously. This article will briefly discuss some of the currently most used devices. [ABSTRACT FROM AUTHOR]

Background: In recent years, rapid advances in cardiac surgery and changes in attitude towards patients with cognitive disability have led to these patients receiving cardiac transplantation. Method: This is a retrospective report describing the experience of four patients with Down Syndrome who received heart transplantation in a single institution. Results: Anthracycline‐induced cardiomyopathy was the most common cause of heart failure in this group (3/4). Two patients were bridged to transplantation, one by using a combination of extra‐corporeal membrane oxygenation and biventricular assist device and the other by using a durable implantable left ventricular assist device. All the four patients are alive with the longest surviving patient 17 years after transplantation. Against strong hypothetical predictions, we observed no propensity for the development of post‐transplant infections or lymphoproliferative disorders. Conclusion: Down Syndrome should not be the sole contraindication to heart transplantation. The decision for transplantation should be on a case‐by‐case basis provided adequate social support is in place. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Ventricular assist device (VAD) for systemic right ventricular (RV) failure patients post-atrial switch, for transposition of the great arteries (TGA), and those with congenitally corrected TGA has proven useful to reduce transpulmonary gradient and bridge-to-transplantation. The purpose of this study is to describe our experience of VAD in systemic RV failure and our move towards concomitant tricuspid valve replacement (TVR). METHODS This is a single-centre retrospective study of consecutive adult patients receiving HeartWare VAD for systemic RV failure between 2010 and 2019. From 2017, concomitant TVR was performed routinely. Demographic, clinical variables and echocardiographic and haemodynamic measurements pre- and post-VAD implantation were recorded. Complications on support, heart transplantation and survival rates were described. RESULTS Eighteen patients underwent VAD implantation. Moderate or severe systemic tricuspid regurgitation was present in 83.3% of patients, and subpulmonic left ventricular impairment in 88.9%. One-year survival was 72.2%. VAD implantation was technically feasible and successful in all but one. Post-VAD, transpulmonary gradient fell from 16 (15–22) to 10 (7–13) mmHg (P = 0.01). Patients with TVR (n = 6) also demonstrated a reduction in mean pulmonary and wedge pressures. Furthermore, subpulmonic left ventricular end-diastolic dimension (44.3 vs 39.6 mm; P = 0.03) and function improved in this group. After 1 year of support, 72.2% of patients were suitable for transplantation. CONCLUSIONS VAD is an effective strategy as bridge-to-candidacy and bridge-to-transplantation in patients with end-stage systemic RV failure. Concomitant TVR at the time of implant is associated with better early haemodynamic and echocardiographic results post-VAD. [ABSTRACT FROM AUTHOR]

Background: Infections and thrombotic events remain life‐threatening complications in patients with ventricular assist devices (VAD). Methods: We describe the relationship between both events in our cohort of patients (n = 220) supported with the HeartWare VAD (HVAD). This is a retrospective analysis of patients undergoing HVAD implantation between July 2009 and March 2019 at the Freeman Hospital, Newcastle upon Tyne, United Kingdom. Results: Infection was the most common adverse event in HVAD patients, with 125 patients (56.8%) experiencing ≥ one infection (n = 168, 0.33 event per person year (EPPY)), followed by pump thrombosis (PT) in 61 patients (27.7%, 0.16 EPPY). VAD‐specific infections were the largest group of infections. Of the 125 patients who had an infection, 66 (53%) had a thrombotic event. Both thrombotic events and infections were related to the duration of support, though there was only limited evidence that infections predispose to thrombosis. Those with higher than median levels of C‐reactive protein during the infection were more likely to have an ischaemic stroke (IS) (34.5% vs 16.7%, p =.03), though not PT or a combined thrombotic event (CTE: first PT or IS). However, in multivariate analysis, there was no significant effect of infection predisposing to CTE. Conclusions: Infection and thrombotic events are significant adverse events related to the duration of support in patients receiving HVADs. Infections do not clearly predispose to thrombotic events. [ABSTRACT FROM AUTHOR]

Purpose: There are marked gender differences in all etiologies of advanced heart failure. We sought to determine whether there is evidence of gender‐specific decision making for transplant assessments, and how gender effects outcomes. Methods: Retrospective analysis of adult heart transplant assessments at a single UK center between April 2015 and March 2020. Results: Females were 32% of referrals (N = 137 females, 285 males), with marked differences between diagnoses – 11% ischemic and 43% of adult congenital. Females were younger, shorter, weighed less, and had lower pulmonary pressures. Females were much less likely to receive a ventricular assist device (13%). Blood type "O" females were relatively more likely compared to males to receive a transplant (45%). Comparing males and females who received a ventricular assist device, both had similar levels of high pulmonary pressures, indicating consistent decision‐making based on hemodynamics to implant a device. Overall survival was better for females (in noncongenital patients), and this was due to female patients who were not accepted for transplant or a ventricular assist device being more often "too well for transplant," rather than in males when they were more often "unsuitable." Conclusions: Marked gender differences exist at all stages of the heart transplant assessment pathway. Appropriate decision‐making based on clinical grounds is shown with less transplants in male blood type "O"s and hemodynamic criteria for ventricular assist device implantation in both genders. Further studies are needed to determine if there is a wider community bias in advanced heart failure treatments for females. [ABSTRACT FROM AUTHOR]

Aims: Continuous‐flow left ventricular assist devices (LVADs) as destination therapy (DT) are a recommended treatment by National Institute for Health and Care Excellence England for end‐stage heart failure patients ineligible for cardiac transplantation. Despite the fact that DT is frequently used as an LVAD indication across other major European countries and the United States, with consistent improvements in quality‐of‐life and longevity, National Health Service (NHS) England does not currently fund DT, mainly due to concerns over cost‐effectiveness. On the basis of the recently published ENDURANCE Supplemental Trial studying DT patients, we assessed for the first time the cost‐effectiveness of DT LVADs compared with medical management (MM) in the NHS England. Methods and results: We developed a Markov multiple‐state economic model using NHS cost data. LVAD survival and adverse event rates were derived from the ENDURANCE Supplemental Trial. MM survival was based on Seattle Heart Failure Model estimates in the absence of contemporary clinical trials for this population. Incremental cost‐effectiveness ratios (ICERs) were calculated over a lifetime horizon. A discount rate of 3.5% per year was applied to costs and benefits. Deterministic ICER was £46 207 per quality‐adjusted life year (QALY). Costs and utilities were £204 022 and 3.27 QALYs for the LVAD arm vs. £77 790 and 0.54 QALYs for the MM arm. Sensitivity analyses confirmed robustness of the primary analysis. Conclusions: The implantation of the HeartWare™ HVAD™ System in patients ineligible for cardiac transplantation as DT is a cost‐effective therapy in the NHS England healthcare system under the end‐of‐life willingness‐to‐pay threshold of £50 000/QALY, which applies for VAD patients. [ABSTRACT FROM AUTHOR]

The use of continuous-flow mechanical circulatory support in preschool children remains anecdotal. This case report describes the sequel to the implantation with a HeartWare HVAD system (Medtronic, Minneapolis, MN) in a 3-year old child. A 3-year-old boy with myocarditis-related cardiomyopathy underwent implantation with a HeartWare device. After an uncomplicated postoperative course, the patient was discharged home. Serial echocardiography showed progressive left ventricular recovery. After 6 months, the device was decommissioned, and the outflow graft was tied off. Six years after insertion, the device was explanted uneventfully. The HeartWare ventricular assist device offers viable long-term mechanical circulatory support in selected children that results in sustainable care and good quality of life. [ABSTRACT FROM AUTHOR]

Introduction: Chronic heart failure is characterized by reduced exercise capacity. Invasive exercise hemodynamics are not routinely performed unless patients undergo transplant or left ventricular assist devices (LVAD) assessment, though now with readily available noninvasive devices, exercise hemodynamics are easily obtained. Our contention is that this is a valuable opportunity to acquire a more accurate measure of cardiac status in heart failure. Exercise hemodynamic measures such as cardiac power output can be carried out cheaply and effectively. Recent studies have highlighted the added value of exercise hemodynamics in prognostication of heart failure, and their role in assessing myocardial recovery in LVADs. Areas covered: In this review, we explore the literature available on Medline until 2019 focusing on resting and exercise hemodynamics alongside the methods of assessment (invasive and noninvasive) in heart failure with reduced ejection fraction and patients with implanted LVADs. Expert opinion: Hemodynamics measured both at rest and exercise are expected to play a significant role in the work up of transplant and LVAD patients. Furthermore, there is the potential to utilize noninvasive assessment in a complimentary fashion to support patient selection and improve the monitoring of response to treatment across the full cohort of heart failure patients. [ABSTRACT FROM AUTHOR]

Objective: To study the survival and patient outcome in a population of UK patients supported by an implantable left ventricular assist device (LVAD) as a bridge to heart transplantation.Methods: Data on all adult patients (n=342) who received a HeartMate II or HVAD as a first long-term LVAD between January 2007 and 31 December 2013 were extracted from the UK Ventricular Assist Device (VAD) Database in November 2015. Outcomes analysed include survival on a LVAD, time to urgent listing, heart transplantation and complications including those needing a pump exchange.Results: 112 patients were supported with the Thoratec HeartMate II and 230 were supported with the HeartWare HVAD. Median duration of support was 534 days. During the study period, 81 patients required moving to the UK urgent waiting list for heart transplantation. Of the 342 patients, 85 (24.8%) received a heart transplant, this included 63 on the urgent list. Thirty-day survival was 88.9%, while overall patient survival at 3 years from LVAD implant was 49.6%. 156 patients (46%) died during LVAD support; the most common cause of death on a VAD was a cerebrovascular accident. There was no significant difference between the two devices used in any outcome.Conclusions: In a population of patients with advanced heart failure, who have a very poor prognosis, support with an implantable LVAD allowed a quarter to receive a heart transplant in a 3-year period. Overall survival of the cohort was about 50%. With improvement in technology and in post-LVAD management, it is likely that outcomes will improve further. [ABSTRACT FROM AUTHOR]

Introduction: The incidence of postoperative thrombocytopenia after aortic valve replacement (AVR) with the Perceval S Sutureless bioprosthesis remains unclear. The aim of this study was to report thrombocytopenia associated with the use of sutureless AVR. Methods: The data was collected retrospectively for patients who had isolated AVR with sutureless Perceval S valve (Group A: 72 patients) and was compared with patients who underwent isolated sutured AVR with Perimount Magna Ease Bioprosthesis (Group B: 101 patients) in our institution between June 2014 and January 2017. Results: Cardiopulmonary bypass and cross-clamp time were significantly shorter in group A. Maximum drop in platelet count was 58% mean (day 2.3) in group A versus 44% mean (day 1.7) in group B (P=0.0001). Absolute platelet count on postoperative day 1-6 in group A was significantly less than in group B (P≤0.05). Platelet count recovered to preoperative value in 44% patients in group B versus only in 26% patients in group A at discharge (P=0.018). Moderate thrombocytopenia occurs more often in group A (41% vs. 26%) (P=0.008) while severe thrombocytopenia (<50 x 109) was observed in 6% in group A but never in group B. Platelets (P=0.007) and packed red blood cells (P=0.009) transfusion was significantly higher in the group A. Conclusion: The implantation of sutureless Perceval aortic valves was associated with a significant drop in platelet count postoperatively with slow recovery and higher platelets and packed red blood cells transfusion requirements. A prospective randomised trial is needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Objective: The aim of this retrospective study was to compare early postoperative outcomes after aortic valve replacement (AVR) with sutureless bioprostheses and conventional stented bioprostheses implanted through median sternotomy. Methods: From January 2011 to December 2016, 763 patients underwent aortic valve replacement with bioprostheses; of these, 139 received a Perceval S sutureless valve (Group A) and 624 received a Perimount Magna Ease valve (Group B). These groups were further divided into A1 (isolated Perceval AVR), A2 (Perceval AVR with coronary artery bypass grafting [CABG]), B1 (isolated conventional stented bioprosthesis), and B2 (conventional stented bioprosthesis + CABG). Results: Patients in Group A were older (mean 74 years vs. 71 years; P<0.0001), predominantly women (53% vs. 32%; P<0.0001), had a higher logistic EuroSCORE (3.26 vs. 2.43; P<0.001), more preoperative atrial fibrillation (20% vs. 13%; P=0.03), and had a lower reopening rate for bleeding (2.1% vs. 6.7%; P=0.04). Compared to Group B1, Group A1 had shorter cross-clamp (mean 40 min vs. 57 min; P≤0.0001) and bypass times (mean 63 min vs. mean 80 min; P=0.02), and they bled less postoperatively (mean 295 ml vs. mean 393 ml; P=0.002). The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm2. Conclusion: In our retrospective study of 763 patients, sutureless valve group patients are older, mostly women, more symptomatic preoperatively, and have higher logistic EuroSCORE. They have shorter cross-clamp and bypass times, less postoperative bleeding, and reduced incidence of reopening. Further studies are needed to evaluate the clinical benefits in short, mid, and long-terms. [ABSTRACT FROM AUTHOR]

Objective: The aim of this retrospective study is to evaluate the safety and performance of the Perceval sutureless valve in patients undergoing aortic valve replacement. We report the 30-day clinical outcomes of 139 patients. Methods: From January 2014 to December 2016, 139 patients underwent sutureless aortic valve replacement. Their operation notes, National Adult Cardiac Surgery Database and perioperative transoesophageal echocardiography findings were studied retrospectively. Results: Ninety-two patients underwent isolated aortic valve replacement (group A) with Perceval valve and 47 patients had combined procedures of aortic valve replacement and coronary artery bypass grafting (group B). The patients received a size S (n=23), M (n=39), L (n=42) or XL (n=35) prosthesis. Perceval valve was successfully implanted in 135 (97.1%) patients. Mean cross-clamping time and bypass time were 40 and 63 minutes for isolated cases, while 68 and 107 minutes for combined cases. Three (2.1%) patients died within 30 days. Four patients suffered stroke and 5 patients went into acute renal failure. Median intensive care unit and hospital stay was 2 and 8.5, respectively. Four valves were explanted due to significant paravalvular leak after surgery. Five patients had permanent pacemaker as a result of complete heart block and mean postoperative drainage was 295 mL for isolated case and 457 mL for combined cases. The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm2. Conclusion: Early postoperative results showed that Perceval valve is safe. Further follow up is needed to evaluate the long-term outcome with this bioprosthesis. [ABSTRACT FROM AUTHOR]

OBJECTIVES: With the scarcity of organs, a durable, reliable ventricular assist device (VAD) is required. The Berlin Heart EXCOR® (BH) remains the most established VAD in the paediatric population. Implantable continuous flow (CF) VADs have been introduced to the paediatric field with encouraging early results. In this study, we compared the results of a newly introduced CF VAD (HeartWare VAD [HVAD]VR) to results in a matched group of BH recipients. METHODS: The study included patients aged <16 years who received mechanical left VAD (LVAD) support between December 2005 and January 2016. The preimplant characteristics and postimplant outcomes of patients who received the HVAD were compared with those of a matched group who received the BH. Patients with congenital heart disease were excluded. RESULTS: Thirty patients were included in the study: 13 had received the HVAD and were matched with 17 patients who had received the BH LVAD. The only difference in preimplant characteristics was the need for higher inotropic support in the BH group. There was no difference in the need for right ventricular (RV) support (58.8% for BH vs 53.8% for HVAD, P = 1.00) or in the incidence of cerebrovascular accidents (12.5% vs 7.7%, respectively, P = 1.00), though the BH group showed prolonged mechanical ventilation (31.3% vs 0%, P = 0.047). There were no deaths while on VAD support in either group. Patients with the HVAD showed a bimodal distribution for the primary end point (transplant/explant): All HVAD recipients who also required early RV support reached this end point within 30 days of receiving the implant. CONCLUSIONS: Our early experience with the CF intracorporeal LVAD system (HVAD) indicates outcomes comparable to those with the well-established pulsatile flow paracorporeal LVAD (BH). The theoretical durability of the CF device, which might also allow for the possibility of hospital discharge and better quality of life, is yet to be proven. [ABSTRACT FROM AUTHOR]