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Background Appropriate collection of quality of life (QOL) measurements for left ventricular assist device (LVAD) patients is challenging. Patient-Reported Outcomes Measurement Information System (PROMIS) is a popular tool that has been validated across multiple disciplines, but its applicability to the LVAD population remains unknown. Methods This single-center, retrospective review included LVAD patients that completed a PROMIS assessment and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey at clinical encounters postoperatively. Patients completed computer adaptive PROMIS assessments for physical function, pain interference and depression. All PROMIS domains are designed to follow a normal distribution (mean T-score 50, standard deviation 10) in the general population. Assessments were aggregated over time and correlation between the KCCQ-12 summary score and each PROMIS domain was assessed individually. Results A total of 178 LVAD patients were included in the study. The median time between LVAD implantation and PRO collection was 16.5 [interquartile range, 7.9-37.8] months. Patients typically had worse physical function (T-score 38.8 [33.6-44.2]) but comparable pain (51.1 [38.7-59.2]) and depression (49.9 [41.7-57.5]) as the general population. The KCCQ-12 was more strongly correlated to PROMIS physical function (Spearman’s ρ = 0.746) than pain (ρ = -0.539) or depression (ρ = -0.591). Conclusions PROMIS provides a robust QOL data collection system that can be implemented in a clinical setting without imposing a significant burden. Using this more holistic system may allow for better patient-centered care in order to address QOL limitations imposed by LVAD support that are not directly related to heart failure symptoms.

Driveline infection (DLI) is a significant source of morbidity and mortality during left ventricular assist device (LVAD) support yet limited studies are available to describe the center-level prevalence, preventive practices, and their potential effectiveness.We surveyed LVAD centers in the United States to determine program burden and preventive practices for DLI during HeartMate (HM) 3 support. An online, anonymous, question-based survey was sent to expert providers at implanting centers. Only a single respondent completed the survey for each center. As an exploratory analysis, we compared specific DLI preventive practices between centers with low (≤10%) and high (10%) reported prevalence of DLI.Seventy-eight centers responded to the survey (response rate: 50%). Respondents were comprised of 37 (47%) heart failure cardiologists, 27 (35%) LVAD coordinators, and 14 (18%) cardiothoracic surgeons. The prevalence of DLI during HM3 was reported as ≤10% by 27 (35%), 11%-25% by 36 (46%), and25% by 16 (19%) centers. Thirteen (17%) centers had a body mass index threshold for device placement, 29 (37%) utilized a counter incision, 66 (81%) placed an anchor stitch, and 69 (88%) used an external device to stabilize the DL. Proportionally, more centers with a low DLI prevalence used a wound vacuum 6 (22%) versus 3 (6%, p = 0.03) than those with high DLI.Variation exists in reported prevalence and practices of preventing and managing driveline infections across centers during HM3 support. Further studies are warranted to develop and assess the effectiveness of standardized preventive strategies.

Multidisciplinary Pulmonary Embolism Response Teams (PERTs) may improve the care of patients with a high risk of pulmonary embolism (PE). The impact of a PERT on long-term mortality has never been evaluated. An observational analysis was conducted of 137 patients before PERT implementation (between 2014 and 2015) and 231 patients after PERT implementation (between 2016 and 2019), presenting to the emergency department of an academic medical center with submassive and massive PE. The primary outcome was 6-month mortality, evaluated by univariate and multivariate analyses. PERT was associated with a sustained reduction in mortality through 6 months (6-month mortality rates of 14% post-PERT vs 24% pre-PERT, unadjusted hazard ratio of 0.57, Relative Risk Reduction of 43%, p = 0.025). There was a reduced length of stay following PERT implementation (9.1 vs 6.5 days, p = 0.007). Time from triage to a diagnosis of PE was independently predictive of mortality, and the risk of mortality was reduced by 5% for each hour earlier that the diagnosis was made. In conclusion, this study is the first to demonstrate an association between PERT implementation and a sustained reduction in 6-month mortality for patients with high-risk PE.

Background Historically, obesity was considered a relative contraindication to left ventricular assist device (LVAD) implantation with less invasive surgery (LIS). The present study aimed to compare the outcomes of obese patients who underwent LVAD implantation through LIS with those who received full sternotomy (FS) implantation. Methods We retrospectively reviewed all patients implanted with HeartMate 3 LVAD in our institution between September 2015 and June 2020. Obese patients (BMI ≥ 30 kg/m2 ) were included and dichotomized based on surgical approach into the FS or LIS cohort. Results Of 231 implanted patients, 107 (46%) were obese and included in the study. FS was performed in 26 (24%) patients and LIS approach in 81 (76%) patients. Preoperative patient characteristics were similar between the cohorts. Postoperatively, patients in LIS cohort had less bleeding (p = 0.029), fewer transfusions (p = 0.042), shorter duration of inotropic support ( p = 0.049), and decreased incidence of severe RV failure (11.1% vs 30.8%, p = 0.028). Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (91.4% LIS vs 76.9% FS, p = 0.079). More LIS patients were discharged home (60.0% vs 82.4%, p = 0.041) rather than to rehabilitation center . Conclusion Our results showed that the LIS approach in obese patients is associated with fewer postoperative complications and a trend towards better short-term survival. These results suggest that less invasive LVAD implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to substantiate these results.

Objective Bilateral internal thoracic artery (BITA) bypass can enable more complete arterial revascularization procedures. Minimally invasive cardiac surgery (MICS) can offer significant patient benefits. New minimally invasive technology for sternal retraction and tissue manipulation is needed to enable ergonomic and reliable minimally invasive ITA harvesting. The goal of this research was to develop technology and techniques, along with experimental testing and training models, for a sternal-sparing approach to in situ BITA harvesting through a small subxiphoid access site. Methods This study focused on optimizing custom equipment and methods for subxiphoid BITA harvesting initially in a porcine model (19 pig carcasses, 36 ITAs) and subsequently in 7 cadavers (14 ITAs). Results Fifty consecutive ITAs were successfully harvested using this remote access approach. The last 20 ITA specimens harvested from the porcine model were explanted and measured; the average length of the free ITA grafts was 12.8 ± 0.9 cm (range 10.8 to 14.2 cm) with a mean time of 23.3 ± 5.2 minutes (range 13 to 25 minutes) for each harvest. Conclusions Early results demonstrate that both ITAs can be reliably harvested in a skeletonized fashion in situ through sternal-sparing, small subxiphoid access in 2 experimental models. This innovative approach warrants further exploration toward facilitating complete arterial revascularization and the further adoption of minimally invasive coronary artery bypass graft surgery.

Background The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a life-supporting therapy has increased exponentially over the last decade. As more patients receive and survive ECMO, there are a number of unanswered clinical questions about their long-term prognosis and organ function including the need for long-term dialysis. Methods We aimed to utilize over 208 patient-years of follow-up data from our large institutional cohort of VA-ECMO patients to determine the incidence of requiring VA-ECMO support on the need for renal replacement therapy after discharge (LT-dialysis). This retrospective review included all adult VA-ECMO patients at our institution from January 2014 to October 2018 (N = 283). Results Out of the 99 (35%) survivors, 88 (89%) did not require LT-dialysis of any duration after discharge from the index hospitalization. Patients who required VA-ECMO for decompensated cardiogenic shock were more likely to need LT-dialysis (p = .034), and those who required renal replacement therapy during VA-ECMO (N = 27) also had a higher incidence of LT-dialysis (33%). Conclusion Overall, these data suggest there is a low incidence of long-term dialysis dependence among survivors of VA-ECMO support. Worries about the potential long-term detrimental effect of VA-ECMO should not preclude patients from receiving this life-saving support.

Right ventricular failure (RVF) remains one of the major causes of morbidity and mortality after left ventricular assist device (LVAD) implantation. We sought to compare immediate postoperative invasive hemodynamics and the risk of RVF following two different surgical approaches: less invasive surgery (LIS) versus full sternotomy (FS).The study population comprised all 231 patients who underwent implantation of a HeartMate 3 (Abbott) LVAD at our institution from 2015 to 2020, utilizing an LIS (n = 161; 70%) versus FS (n = 70; 30%) surgical approach. Outcomes included postoperative invasive hemodynamic parameters, vasoactive-inotropic score (VIS), RVF during index hospitalization, and 6-month mortality.Baseline clinical characteristics of the two groups were similar. Multivariate analysis showed that LIS, compared with FS, was associated with the improved cardiac index (CI) at the sixth postoperative hour (p = .036) and similar CI at 24 h, maintained by lower VIS at both timepoints (p = .002). The LIS versus FS approach was also associated with a three-fold lower incidence of in-hospital severe RVF (8.7% vs. 28.6%, p .001) and need for RVAD support (5.0% vs. 17.1%, p = .003), and with 68% reduction in the risk of 6-month mortality after LVAD implantation (Hazard ratio, 0.32; CI, 0.13-0.78; p = .012).Our findings suggest that LIS, compared with FS, is associated with a more favorable hemodynamic profile, as indicated by similar hemodynamic parameters maintained by lower vasoactive-inotropic support during the acute postoperative period. These findings were followed by a reduction in the risk of severe RVF and 6-month mortality in the LIS group.

Background Studies of long-term inotrope use in advanced HF have previously provided limited and conflicting results. This study aimed to evaluate the safety and efficacy of long-term milrinone use and identify predictors of failure to bridge to orthotropic heart transplant (OHT) in a cohort of end-stage heart failure (HF) patients listed for heart transplantation and receiving inotrope therapy. Methods The study included 150 adults listed for OHT at a single center from 2001 to 2017 who received milrinone therapy for ≥30 days. Multivariate Cox proportional hazards models were used to identify factors associated with “failure” (left ventricular assist device, intra-aortic balloon pump, status downgrade due to instability, death) vs. “success” (OHT, recovery) during bridging to OHT. Results “Failure” occurred in 33 (22%) patients. Factors independently associated with failure included male sex (HR = 7.6; p = 0.004), no implantable cardioverter-defibrillator (HR = 3.8; p = 0.009), and lack of guideline-directed medical therapy (GDMT) with a beta-blocker (HR = 7.8; p = 0.002) or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (HR = 6.3; p Conclusions Our findings suggest that long-term milrinone therapy in selected patients is associated with a high rate of successful bridging to OHT and a low rate of adverse events. Patients intolerant of GDMT are more likely to fail to bridge to OHT without mechanical support. Sex differences in outcomes associated with milrinone therapy should be explored.

Background Despite limited evidence, systemic anticoagulation is the current standard of care for patients supported on venoarterial-extracorporeal membrane oxygenation (VA-ECMO). We hypothesized that not anticoagulating patients on VA-ECMO would decrease complications. Methods We retrospectively reviewed adult patients supported on VA-ECMO at our institution. Patients were stratified based on anticoagulation strategy. The primary outcome was a composite of hemorrhagic and thrombotic complications. Secondary outcomes included blood product use, incidence of heparin-induced thrombocytopenia (HIT), hospital length of stay, and in-hospital mortality. Results From May 2011 through January 2018, there were 203 eligible patients supported on VA-ECMO, 35% (75 patients) were not anticoagulated. Overall complication rates were significantly lower for the no anticoagulation group (57% versus 76%; P = .007) including a trend toward fewer hemorrhagic complications (53% versus 63%; P = .178) without increased risk of thrombosis (13% versus 21%; P = .147). The anticoagulated group required more transfusions of packed red blood cells (12.8 versus 1.09; P = .002) and platelets (3.0 versus 1.3; P = .009) and showed a higher incidence of HIT (8% versus 0%; P = .015). No difference was found in overall mortality (72% versus 62%; P = .165). Conclusions The absence of routine systemic anticoagulation for patients supported on VA-ECMO is not associated with higher mortality, pump failure, or thrombotic complications. Patients had a lower requirement for blood product transfusions, and there was no incidence of HIT. Patients supported on VA-ECMO without other indications for anticoagulation can be treated without systemic anticoagulation during their VA-ECMO course.

OBJECTIVES History of prior cardiac surgery has traditionally been considered a risk factor for subsequent cardiac procedures. The aim of this study was to investigate the outcomes of patients implanted with a left ventricular assist device via redo sternotomy. METHODS Prospectively collected data were reviewed for all patients implanted with a continuous-flow left ventricular assist device at a single institution from December 2006 through June 2018. Patients were separated into 2 cohorts: those with a history of prior cardiac surgery (redo sternotomy) and those undergoing primary sternotomy at the time of left ventricular assist device implantation. The primary outcome was overall survival. RESULTS Of the 321 patients included in the study, 77 (24%) were implanted via redo sternotomy and 244 (76%) via primary sternotomy. The redo sternotomy cohort was generally older (59 ± 10 vs 57 ± 12 years, P = 0.050) and had a higher incidence of ischaemic disease (70% vs 49%, P = 0.002). The Kaplan–Meier survival analysis demonstrated that overall survival was not significantly different between the redo sternotomy and primary sternotomy groups (6-month survival: 86% vs 92%; 5-year survival: 53% vs 51%; log-rank P = 0.590 for overall difference during follow-up). The propensity score analysis consistently showed that redo sternotomy was not significantly associated with mortality risk (hazard ratio 1.19, 95% confidence interval 0.73–1.93; P = 0.488). Redo sternotomy patients were more likely to require rehospitalization during their first year postoperatively (P = 0.020) and spent less time out of the hospital during the first year (P = 0.046). CONCLUSIONS The redo sternotomy cohort represents a more technically challenging patient population, but overall survival similar to that of primary sternotomy patients can be achieved.

Short‐to‐shield (STS) is a potential complication for left ventricular assist device (LVAD) patients supported by the HeartMate II (HMII) pump. This phenomenon occurs when a damaged internal wire within the driveline makes contact with the surrounding sheath, resulting in insufficient power delivery to the motor when connected to a grounded power base unit (PBU). An ungrounded cable can be used to negate these effects, but the long‐term safety of this treatment strategy is unknown. In this case series, we present our institutional experience treating 17 STS patients with an ungrounded cable. In total, we present 4922 patient‐days (13.4 patient‐years) of ungrounded cable support after primary STS treatment. There were no deaths or complications related to STS. These data suggest that the long‐term use of an ungrounded cable is a reasonable treatment option for patients who cannot or do not wish to undergo pump exchange or splice repair., Patients that experience short‐to‐shield can be safely managed with an ungrounded cable long‐term with careful monitoring.

BACKGROUND Left ventricular assist devices (LVADs) have improved outcomes for selected patients with advanced heart failure, but alternative optimal surgical techniques remain to be defined. We aim to describe our initial experience in using a sternal-sparing (SS) technique for implantation of a magnetically levitated LVAD, the HeartMate 3 (HM3) pump. METHODS This retrospective, single-center study included consecutive patients implanted with the HM3 LVAD between September 2015 and September 2018. Patients were compared based on surgical approach: SS or traditional sternotomy (TS). The primary outcome was overall survival at 6 months. Secondary outcomes included peri-operative complications, blood product utilization, and hospital readmissions. RESULTS Of 105 patients implanted with the HM3 LVAD, 41 (39%) were implanted via SS and 64 (61%) via TS approach. There were no intraoperative conversions. The SS patients were younger; otherwise, all other characteristics were similar between cohorts. The SS cohort demonstrated a significantly lower incidence of severe right ventricular failure (7% vs 28%, p = 0.012), fewer blood-product transfusions (41% vs 86%, p < 0.001), and shorter index hospital length of stay (15.5 vs 21 days, p = 0.018). Six-month survival was 93% for the SS cohort. CONCLUSIONS In this single-center observational study, we have demonstrated that the SS approach may be a safe and effective surgical technique for implantation of the HM3 LVAD in well-selected patients. The potential benefits compared with TS require further inquiry.

We present the successful use of surgical embolectomy (SE) without systemic anticoagulation to treat a complicated case of pulmonary embolism. The patient presented with an embolic cerebrovascular accident and subsequently developed a massive pulmonary embolism. Because of the risk of hemorrhagic transformation, the decision was made to proceed with emergent SE on venoarterial extracorporeal membrane oxygenation support without anticoagulation. The surgery was performed without complication. The potential to perform SE without anticoagulation could potentially decrease the incidence of surgical bleeding and make SE a therapeutic option for patients with contraindications to anticoagulation. Further research is needed to substantiate the efficacy of this treatment strategy.

Background: Advancements in left ventricular assist device (LVAD) technology have improved long-term survival for properly selected patients with advanced heart failure. However, the subset of patients in critical cardiogenic shock remain difficult to treat with persistently high patient morbidity and mortality. The goal of this study is to describe our institutional experience utilizing extracorporeal membrane oxygenation (ECMO) as a bridge to LVAD for patients in cardiogenic shock comparing the less invasive complete sternal-sparing (CSS) surgical technique to median sternotomy. Methods: Data was collected as a single center retrospective review of patients implanted with a continuous-flow LVAD directly off ECMO from 2012 to 2018. Patients were stratified by LVAD surgical technique. The primary outcome was survival to discharge. Secondary outcomes included postoperative complications, resource utilization and survival at 6-months. Results: Of the 37 patients implanted directly off ECMO, 26 (70%) patients were implanted via median sternotomy and 11 (30%) patients by the CSS approach. Median time on ECMO support was 8 days (range, 2–29 days). Preoperative characteristics were similar between groups. Survival to discharge was 78% overall (73% vs . 91% CSS, P=0.391). The CSS cohort had fewer postoperative complications, including fewer transfusions (P=0.044) and trend towards less right ventricular (RV) failure (62% vs . 27% CSS, P=0.079). Both cohorts required similar median length of stay (LOS) in the intensive care unit (ICU) (11 vs . 12 days, P=0.695) and similar overall hospital LOS (34 vs . 22 days, P=0.242). Overall survival was 74% at six months (68% vs . 89% CSS, P=0.386). Conclusions: VA ECMO can be used effectively as a bridge-to-LVAD for patients in cardiogenic shock. The less invasive CSS approach demonstrates potential advantages to median sternotomy. Further study is needed to better understand the benefits of less invasive surgical techniques.

Current treatment for end-stage cardiac disease has benefitted greatly from the development of left ventricular assist devices (LVADs). However, as the prevalence of LVADs increased, so too did the number of patients with complications. The smaller size of the HeartMate III (HMIII) device allows for it to be placed completely intrathoracic. This requires a new reconstructive strategy when deep pocket infection and hardware exposure ensue. We report our first case of flap coverage of an exposed HMIII after deep pocket infection and discuss the reconstructive challenges associated with this fully intrathoracic device. A 31-year-old female with worsening postpartum non-ischemic cardiomyopathy was transferred to our facility in end-stage heart failure. She underwent complete sternal-sparing placement of a HMIII via bilateral anterior thoracotomies, and eventually developed a deep pocket infection with intrathoracic abscess. Plastic Surgery reconstructed the wounds using bilateral pectoralis major muscle flaps. The patient enjoyed an uneventful postoperative course and was discharged home 2 weeks later on intravenous antibiotics. HMIII devices are completely intrathoracic, occupying the pericardial space anteriorly, which can make an infection difficult to access. Wound location largely dictated which flaps would be acceptable for reconstruction following debridement. Close cooperation between cardiac and reconstructive surgeons will once again be paramount to evolving the surgical care of HMIII patients with deep pocket infection. Level of Evidence: Level V, therapeutic study.

INTRODUCTION: The concept of a Pulmonary Embolism Response Team (PERT) is multidisciplinary, with the hope that it may positively impact patient care, hospital efficiency, and outcomes in the treatment of patients with intermediate and high risk pulmonary embolism (PE). METHODS: Clinical characteristics of a baseline population of patients presenting with submassive and massive PE to URMC between 2014 and 2016 were examined (n=159). We compared this baseline population before implementation of a PERT to a similar population of patients at three-month periods, and then as a group at 18 months after PERT implementation (n=146). Outcomes include management strategies and efficiency of the emergency department (ED) in diagnosing, treating, and dispositioning patients. RESULTS: Before PERT, patients with submassive and massive PE were managed fairly conservatively: heparin alone (85%), or additional advanced therapies (15%). Following PERT, submassive and massive PE were managed as follows: heparin alone (68%), or additional advanced therapies (32%). Efficiency of the ED in managing high risk PE significantly improved after PERT compared with before PERT; where triage to diagnosis time was reduced (384 vs. 212 minutes, 45% decrease, p=0.0001), diagnosis to heparin time was reduced (182 vs. 76 minutes, 58% decrease, p=0.0001), and the time from triage to disposition was reduced (392 vs. 290 minutes, 26% decrease, p

Background Left ventricular assist device (LVAD) therapy has been the standard of care for selected patients with advance heart failure. Even though considerable strides have been achieved with the introduction of the newest centrifugal pump, therapy is still burdened with significant perioperative complications. Smaller devices, along with improved techniques and instruments, have encouraged the adoption of minimally invasive cardiac surgery (MICS) techniques for LVAD implantation to improve perioperative outcomes. Methods We describe a technique for complete sternal-sparing (CSS) HeartMate 3 (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) implantation using bilateral thoracotomies and discuss early clinical outcomes of the first ten consecutive patients who underwent CSS implantation of the HeartMate 3 LVAD at our institution. Results The median length of stay in the intensive care unit was 3.5 days. No patients required reexploration for postoperative bleeding. There was no incidence of right ventricle failure, stroke, renal failure, hepatic failure, or myocardial infarction. The median length of hospitalization after LVAD implantation was 14.5 days (interquartile range, 12 to 17 days). Conclusions Our early outcomes suggest that the CSS approach may reduce the incidence of right ventricular failure, bleeding, intubation time, and intensive care unit length of stay. Further studies are needed to fully elucidate the advantages of CSS LVAD implantation compared with median sternotomy.

Introduction: We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD). Methods and results: In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04 ; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups. Conclusions: ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible ; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

Introduction: Multidisciplinary Pulmonary Embolism Response Teams (PERTs) improve the care of patients with high risk pulmonary embolism (PE). The effect of a PERT on long-term mortality has never been evaluated. Hypothesis: We assessed the hypothesis that PERT would improve mortality of patients with high risk PE. Methods: An observational analysis was conducted of patients before PERT (pre-PERT, N = 137, between 2014 and 2015) after PERT (post-PERT, N = 231, from 2016 to 2019) presenting to the emergency department of a large academic medical center with submassive and massive PE. The primary outcome was six-month mortality with univariate and multivariate analyses. Results: PERT was associated with a sustained reduction in Kaplan-Meier mortality estimates (Figure) through six months (six-month mortality rates of 14% post-PERT vs. 24% pre-PERT, unadjusted HR of 0.57, RRR of 43%, NNT of 10, log-rank p=0.025). A Cox proportional hazards model demonstrated no difference in mortality from diagnosis through 1 month after presentation (HR 1.11 vs pre-PERT, 95% CI 0.55-2.26, p=0.766), but confirmed a reduction in mortality 1-6 months after diagnosis post-PERT (HR 0.42 vs pre-PERT, 95% CI 0.19-0.95, p=0.037). There was a reduced length of stay post-PERT (9.1± 10.8 vs 6.5 ± 9.8 days pre-PERT, P=0.007). Time from triage to diagnosis of PE was independently predictive of mortality, and the risk of mortality was reduced by 4.6% for each hour earlier that the diagnosis was made. Conclusions: In conclusion, this study is the first to demonstrate an association between PERT implementation and reduction in 6-month mortality in patients with high risk PE. This effect of reduced time to PE diagnosis associated with a multidisciplinary PERT may be a mechanism for the reduction in mortality.

As median survival for left ventricular assist device (LVAD) patients increases, the incidence of adverse events requiring device exchange is likely to increase as well. Less invasive surgical approaches for device exchange of older generation pumps have demonstrated multiple potential benefits compared with median sternotomy. However, there remains a paucity of data in regard to less invasive surgical techniques for the exchange of the newest generation intrapericardial devices. In this report we describe a complete sternal-sparing technique for the LVAD exchange of a HeartMate 3 via bilateral minithoracotomies.

Objective Early reports of less invasive techniques for left ventricular assist device (LVAD) implantation have demonstrated promising results. We sought to investigate the safety and feasibility of implementing the complete sternal-sparing (CSS) approach for LVAD implantation in patients with a history of prior cardiac operation. Methods This was a retrospective review of prospectively collected data for all patients implanted with a fully magnetically levitated LVAD from April 2017 through December 2018. Patients were dichotomized based on surgical approach: CSS or full median sternotomy (FS). Perioperative complications and overall survival were compared between cohorts. Results Of the 29 eligible patients, 15 (52%) were implanted via the CSS approach and 14 (48%) via FS. Preoperative characteristics were similar between cohorts. Overall survival to discharge was 93% for CSS compared to 71% for FS ( P = 0.169). The CSS cohort demonstrated fewer postoperative complications, including fewer cases of severe right ventricular failure ( P = 0.006) and less blood product utilization ( P = 0.015). Median hospital length of stay was significantly shorter for the CSS cohort (median 13 vs 32.5 days, P = 0.016). Neither cohort had any 30-day readmissions. Conclusions Early data suggest that the CSS technique is a safe and effective technique for patients with a history of prior sternotomy. Further studies are needed to validate this single-center experience.

Purpose Right ventricular failure (RVF) remains one of the major cause of morbidity and mortality after left ventricular assist device (LVAD) surgery. The purpose of this study was to investigate the incidence of RVF after less invasive surgery (LIS) LVAD surgery compared to median sternotomy. Methods The study population comprised of 231 patients who underwent HeartMate 3 LVAD implantation in our institution between September 2015 and June 2020. Patients were compared based on surgical approach: full sternotomy (FS) or LIS. The primary outcome was RVF as defined by INTERMACS. Index hospitalization major complications and survival were secondary outcomes. Results LIS approach was used in 161 (69.7%) patients and FS approach in 70 (30.3%) of our LVAD patients. Baseline patient characteristics were similar between cohorts apart from LIS patients being younger (54±14 vs 60±11, p= 0.003). Postoperatively, LIS patients had decreased postoperative bleeding (p=0.001) and shorter time on mechanical ventilation (p Conclusion Less invasive LVAD implantation is associated with improved perioperative outcomes compared to median sternotomy, including a lower incidence of severe right heart failure and need for temporary mechanical circulatory support. Further research is needed to elucidate the mechanism of the less invasive approach in preserving RV function.

OBJECTIVES There are various strategies in the use of temporary mechanical circulatory support following orthotopic heart transplant (OHT). We sought to examine the outcomes following different temporary mechanical circulatory support strategies for acute graft failure. METHODS Patients who received an OHT between 2001 and 2015 at a single institution were retrospectively reviewed. Patients were divided into 2 groups based on the need for temporary mechanical circulatory support (TMCS). RESULTS A total of 9.9% (19 of 192) of patients required TMCS following OHT. There were no significant differences in the preoperative demographics between groups. Six patients (32%) required a biventricular assist device, 9 patients (47%) required a right ventricular assist device and 4 patients (21%) required a veno-arterial extracorporeal membrane oxygenator. Perioperative morbidity was comparable between all groups. Our entire TMCS cohort had 94.7% 30-day and 61.1% 1-year survival. When compared with the OHT patients with no TMCS (97.1% at 30 days and 92.8% at 1 year), survival was inferior in TMCS patients ( P = 0.01 at 30 days, P

Purpose Patient acuity as assessed by INTERMACS profile is significantly correlated to postoperative outcomes for patients undergoing LVAD implantation via median sternotomy. The prognostic utility of INTERMACS profile for the sternal-sparing (SS) approach has yet to be determined. Methods This retrospective, single center study included consecutive patients implanted with a fully magnetically levitated LVAD via the SS approach between February 2018 through June 2019. Patients were compared based on preoperative INTERMACS profile: higher risk (HR) profiles one and two versus lower risk (LR) profiles three or higher. The primary outcome was six-month survival free from disabling stroke or pump exchange. Results Of the 97 total patients implanted via the SS technique, 40 (41%) were HR and 57 (59%) were LR. Besides INTERMACS profile, baseline patient characteristics were similar between cohorts including age (p=0.558), gender (p>0.999) and etiology of heart failure (p=0.224). Postoperatively, the LR cohort had fewer complications and were more likely to be discharged to home (Table 1). Time in the ICU and overall postoperative hospital length of stay were significantly shorter for the LR cohort. Primary outcome was achieved in 96.5% LR vs 82.5% HR cohorts (p=0.015). Conclusion Preoperative INTERMACS profile is correlated with postoperative outcomes for the sternal-sparing approach. Lower risk patients who undergo sternal-sparing implantation demonstrate low rates of complications with excellent mid-term survival. Further research is needed to define the optimal timing of LVAD implantation.

Several risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). Right ventricular (RV) dysfunction, which is common to intermediate and high risk PE, is an independent predictor of mortality and may be a faster and simpler way to assess patient risk in acute care settings. We evaluated 571 patients presenting with acute PE as the primary diagnosis, stratifying them by the Pulmonary Embolism Severity Index (PESI), by the BOVA score, orcategoricallyas low risk (no RV dysfunction by imaging), intermediate risk (RV dysfunction by imaging), or high risk PE (RV dysfunction by imaging with sustained hypotension). Using imaging data to firstly define the presence of RV dysfunction, and plasma cardiac troponin T (cTnT) and NT-proBNP as additional evidence for myocardial strain, we evaluated the PESI and BOVA scoring systems compared to categorical assignment of PE as low risk, submassive, and massive PE. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% C.I. 0.73 – 0.95, p< 0.0001), and 0.88 (95% C.I. 0.79-0.97, p< 0.0001), respectively, and low risk from massive PE with an area under the curve (AUC) of 0.89 (95% C.I. 0.78 – 1.00, p< 0.0001), and 0.89 (95% C.I. 0.82-0.95, p< 0.0001), respectively. Predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality for submassive PE by a two-fold order of magnitude. These data suggest the presence of RV dysfunction in the context of acute PE is sufficient for the purposes of risk stratification, while more complicated risk stratification algorithms may under-estimate short-term mortality risk.

BACKGROUND Less-invasive techniques for left ventricular assist device (LVAD) implantation have shown promising outcomes but are associated with significant postoperative pain. We aim to investigate the use of ultrasound-guided regional nerve blocks to improve pain management during these procedures. METHODS We retrospectively reviewed patients implanted with a HeartMate 3 LVAD via complete sternal-sparing (CSS) approach at our institution from February 2018 to July 2018. Patients were grouped based on their postoperative pain management plan-those who received a regional nerve block plus multimodal analgesia and a control group who received standard multimodal analgesia alone. Pain scores and analgesic use were recorded for all patients during the initial 72 hours postoperatively. RESULTS Preoperative characteristics were similar between cohorts. Of the 28 patients included in the study, 15 (54%) received a postoperative regional nerve block. Patients who received a nerve block had significantly lower pain scores and required a lower dose of opioid analgesics (70.7 ± 13.9 vs 124.6 ± 19.3 morphine equivalents, P = 0.029) during the first 72 hours postoperatively. There was no difference in time to extubation, intensive care unit length of stay, or hospital length of stay. CONCLUSIONS Optimizing postoperative analgesia using a regional nerve block is associated with decreased opioid use and decreased postoperative pain after CSS LVAD implantation. Regional nerve blocks should be included as part of a protocol-based postoperative pain management program.

Purpose The present study aimed to compare the outcomes of obese patients who underwent HeartMate 3 implantation through less invasive surgery (LIS) with those who received full sternotomy (FS) implantation. We hypothesized that LIS is a safe and effective technique for LVAD implantation in obese patients. Methods We performed a retrospective review of all patients implanted with HeartMate 3 LVAD in our institution from September 2015 through Jun 2020. Obese patients (BMI≥ 30 kg/m2) were included in the study and dichotomized based on surgical approach into the full sternotomy (FS) cohort or LIS. Primary outcomes were index hospitalization and 30-day survival. Secondary outcomes were incidence of index hospitalization major complications. Results Of 231 patients implanted patients, 107 (46.3%) were obese and included in the study. FS was used in 26 (24.3%) patients and LIS approach in 81 (75.7%) patients. Preoperative patient characteristics were similar between the cohorts (Table 1). In the immediate postoperative course, fewer patients in the LIS cohort received units of packed red blood cells (34.6% vs 57.7%, p=0.042) and fresh frozen plasma (19.8 vs 46.2%, p=0.011). Duration of postoperative inotropic support was shorter in LIS cohort (p=0.049). The incidence of major complications was similar between the groups. Decreased incidence of severe RV failure (30.8% vs 11.1% LIS, p=0.028) and need for RVAD implantation (p=0.037) were observed in LIS cohort. Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (76.9% FS vs 91.4% LIS, p=0.079). Conclusion These data demonstrate multiple potential benefits of the less invasive surgical technique, including fewer postoperative complications and a trend towards better survival to discharge. This study suggests that less invasive HeartMate 3 implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to confirm our data.

Purpose The purpose of the present study is to examine the effect of operative time of day on outcomes in orthotopic heart transplant (OHT) recipients. We hypothesized that nighttime OHT operations would be associated with increased 1-year mortality when compared to daytime OHT operations. Methods We performed a retrospective analysis of adult heart transplant recipients in the United Network for Organ Sharing (UNOS) database from January 2000 to December 2019. Operative time of day was derived from the donor cross-clamp time (night, 6 pm-4 am; day, 4 am-6 pm). The primary outcome was survival at 1 year. Kaplan-Meier curves and log-rank statistics were generated to compare the effect of operative time and were further stratified by age, transplant center yearly volume (low volume, Results Of the 42,007 patients included in the study, 24,200 (57.6%) underwent nighttime and 17,807 (42.4%) daytime OHT (Table 1). Preoperative patient characteristics were similar between cohorts. 1-year survival (Figures 1) was not different between the cohorts (89.7 vs 89.5%, p=0.630). When further stratified by age, center volume, or VAD status, 1-year survival between operative times still remained insignificant. Conclusion There is no significant association between nighttime operations and 1-year post-transplant survival in adult heart transplant recipients.

Purpose Driveline infection (DLI) is a significant source of morbidity and mortality during left ventricular assist device (LVAD) support yet limited data are available to describe preventive practices and their potential effectiveness. Methods We surveyed LVAD centers within the United States to assess local practices for driveline stabilization and preventive approaches towards DLIs. An online, anonymous, question-based survey was created and sent to expert providers at implanting centers. Respondents were participants in FLIGHT and IDEAL heart failure (HF) working groups and only a single respondent completed the survey for each center. As an exploratory analysis, we compared specific DLI preventive practices between centers with low (≤10%) and high (>10%) reported rates of DLI. Results Representatives from 55 centers responded to the survey. Respondents comprised of 37 HF cardiologists, 14 cardiothoracic surgeons, 2 LVAD advanced practitioners and 2 LVAD RNs. The response rate was 95%. Centers were geographically well distributed throughout the United States and 80% reported implanting over 20 LVADs per year. Forty-five (81%) centers reported usage of an anchor stitch, 48 (87%) used an external device to stabilize the driveline, while 7 (13%) utilized a wound vacuum after device placement. Eighteen centers (33%) reported a low DLI rate in comparison to 37 (66%) reporting a high rate. Centers with low DLI rates trended to utilize an anchor stitch (94% vs. 76%, p=0.09) and wound vacuum (22% vs. 8%, p=0.14) more often than those with high DLI rates (figure 1). Conclusion Variation exists in preventive practices and DLI rates across centers. Although no significant differences were noted for assessed practices between centers with high and low DLI rates, further studies are warranted to determine the effectiveness of an anchor stitch and wound vacuum placement for preventing DLIs.

Purpose Prior study has suggested an association between angulation of the inflow cannula and outcomes following left ventricular assist device (LVAD) implantation. A potential benefit of the sternal-sparing LVAD implantation technique is superior visualization of the apex in its natural anatomic position. Our hypothesis was the sternal-sparing technique would result in more consistent angle of LVAD implantation. Methods This single-center, retrospective review included consecutive patients implanted from September 2015 through September 2019. Patients were stratified via surgical technique: sternal-sparing or median sternotomy. The coronal angle of the inflow cannula relative to the horizontal line was measured on the first available postoperative anterior-posterior chest radiograph (Figure 1). All measurements were calculated by trained radiologists. A randomly selected subgroup of patients was repeated by multiple readers to assess interrater reliability. Results Of the 161 patients included in the study, 102 (63%) were implanted via the sternal-sparing approach. Preoperative patient characteristics were similar between cohorts. The inflow cannula angle was significantly different between cohorts (Figure 1, p=0.020). The sternal-sparing cohort had a more consistent angle (median [IQR], 18 [6-29] degrees) compared to the sternotomy patients (25 [10-42] degrees, p=0.020). Significantly more sternal-sparing patients had an angle ≤65 degrees (100% vs 93%, p=0.017), which has previously been associated with improved patient outcomes with a different model pump. Conclusion Our data suggests the angle of the inflow cannula after LVAD implantation is more consistently reproduced when utilizing the sternal-sparing approach compared to median sternotomy. Further research is needed to examine the relationship between inflow cannula angle and patient outcomes to determine the ideal inflow cannula angle for the fully magnetically levitated pump.

Purpose Thromboembolic events (TEs) remain common adverse events for left ventricular assist device (LVAD) patients. There is early evidence that left atrial appendage occlusion (LAAO) at the time of LVAD implantation may reduce the incidence of TEs, but the feasibility of LAAO during less invasive LVAD implantation is unknown. Methods Patients who underwent LAAO during LVAD implantation via the complete sternal-sparing (CSS) approach were retrospectively reviewed. LAAO was performed through the left thoracotomy incision using a commercially available left atrial appendage exclusive device. Preoperative patient characteristics, intraoperative data, and postoperative complications were collected. The primary outcome was incidence of intraoperative complications. Secondary outcomes included operative time, successful placement of exclusion device, and incidence of postoperative TEs. Results A total of 8 patients underwent concurrent LAAO at the time of CSS LVAD implantation. Average age was 62 ±12 years and five (63%) patients were male. Two patients (25%) were INTERMACS Profile 1, five (63%) Profile 3, and one (12%) was Profile 4. Four patients (50%) had evidence of preoperative left ventricular thrombus, and six (75%) had a history of arrhythmia. All patients received a fully magnetically levitated LVAD. There were no intraoperative complications and all patients had evidence of complete atrial appendage occlusion on intraoperative transesophageal echocardiogram. Performing LAAO did not significantly increase operative time compared to CSS implantation without concomitant LAAO. Median postoperative length of stay was 12 [10-13] days. During a total of 587 patient-days of follow-up, one patient suffered a non-disabling thrombotic stroke with no residual defects and one patient died from unrelated causes. Conclusion LAAO is feasible via the left thoracotomy incision during CSS LVAD implantation. Early evidence suggests the procedure is safe and effective at occluding the left atrial appendage. Further research is needed to determine potential long-term benefits.

Purpose The purpose of this study was to examine the association between surgical implantation technique and the incidence of postoperative severe right heart failure (RHF). Methods We performed a retrospective review of all patients implanted with a continuous flow left ventricular assist device (LVAD) at our institution from May 2008 through June 2019. Patients were dichotomized based on surgical implantation technique: sternal-sparing (SS) or median sternotomy. Multivariate logistic regression was performed to adjust for preoperative patient characteristics. The primary outcome was the incidence of severe RHF during the index hospitalization as defined by INTERMACS. Results Of the 426 total patients, 103 (24%) were implanted via sternal-sparing approach and 323 (76%) via median sternotomy. Preoperative patient characteristics were similar between cohorts except for younger age in the SS cohort (53 ±14 vs 57 ±12 years, p=0.016). A large proportion of both cohorts presented as INTERMACS Profile 1 (39% SS vs 37% sternotomy, p =0.726). Intraoperatively, both cohorts had similar cardiopulmonary bypass times (117±51 vs 108±46 minutes, p=0.065). Postoperatively, there was a lower incidence of severe RHF in the SS cohort (9% vs 23%, p=0.001), including fewer cases requiring a right ventricular assist device (3% vs 15%, p=0.001). In a multivariate model, sternal-sparing approach (Odds Ratio 0.36 (0.17-0.78), p=0.010) and INTERMACS Profile ≥3 (Odds Ratio 0.15 (0.07-0.30), p Conclusion Sternal-sparing LVAD implantation is associated with a lower incidence of severe right heart failure compared to median sternotomy. Further research is needed to elucidate the mechanism of the sternal-sparing approach in preserving RV function.

Purpose Less invasive techniques for left ventricular assist device (LVAD) implantation have shown promising outcomes but are associated with significant postoperative pain. We aimed to investigate the use of ultrasound-guided regional nerve blocks to improve pain management during these procedures. Methods We retrospectively reviewed patients implanted with a HeartMate 3 LVAD via complete sternal-sparing approach at our institution from February 2018 to July 2018. Patients were grouped based on their postoperative pain management plan - those who received a regional nerve block plus multi-modal analgesia and a control group who received standard multi-modal analgesia alone. Pain scores and analgesic use were recorded for all patients during the initial 72 hours postoperatively. Results Preoperative characteristics were similar between cohorts. Of the 28 patients included in the study, 15 (54%) received a postoperative regional nerve block. Patients who received a nerve block had significantly lower pain scores (Figure 1) and required a lower dose of opioid analgesics (70.7 ± 13.9 vs 124.6 ± 19.3 morphine equivalents, p = 0.029) during the first 72 hours postoperatively (Figure 2). There was no difference in time to extubation, intensive care unit length of stay or hospital length of stay. Conclusion Optimizing postoperative analgesia using a regional nerve block is associated with decreased opioid use and decreased postoperative pain after complete sternal-sparing LVAD implantation. Regional nerve blocks should be included as part of a protocol-based postoperative pain management program.

Purpose Previous studies have demonstrated poor survival for patients supported by extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) implantation. We hypothesize that ECMO can be used as an effective strategy for bridge to LVAD. Methods We retrospectively reviewed all patients implanted with a HeartMate 3 (HM3) at our institution from September 2017 through September 2018. Patients preoperatively supported by ECMO were identified and patient characteristics, intraoperative data and postoperative outcomes were recorded. A sub-group analysis was performed comparing outcomes for patients implanted via a complete sternal-sparing (CSS) approach versus full sternotomy (FS). Results A total of 16 (25%) patients were supported by ECMO preoperatively. Nine (56%) patients also required an intra-aortic balloon pump or Impella for additional support (Table). CSS was utilized in 9 (56%) patients and FS in 7 (44%). Median intensive care unit length of stay was 6 days [IQR, 4-18.5] with median total hospital length of stay of 20.5 days [13-37.5]. Survival to discharge was achieved in 81% of patients with 63% of the patients being discharged to home. The subgroup analysis showed a trend in improved outcomes for the CSS compared to FS cohort, including less postoperative chest tube drainage (1095.5 [878.5-1850] vs 2295 [1470-2800], p = 0.037) and less time on mechanical ventilation support (26 [13-134] vs 96 [49-456] hours, p = 0.039). There was no difference in intensive care unit length of stay, hospital length of stay or overall mortality between cohorts. Conclusion ECMO is a viable and effective strategy to stabilize critically ill patients as a bridge to long term mechanical support. The less invasive CSS approach demonstrates a trend towards favorable perioperative outcomes compared to traditional FS and warrants further study.

Purpose Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an important but resource intensive therapy for refractory cardiogenic shock. We aimed to identify the utility of early elevated lactate levels as a predictor of ECMO mortality. Methods We retrospectively reviewed patients supported by VA-ECMO from 2011-2018 (N=247). Patients were grouped into a mortality cohort consisting of patients that died during index hospitalization and a survival cohort of those that survived to hospital discharge. Patient characteristics, comorbidities and lactate levels during index hospitalization were compared between cohorts. Results Of the 247 patients, 80 survived (33%). Lactate levels were significantly higher in the mortality cohort at multiple time points including: average lactate before ECMO (7.08 vs 4.25 mmol/L, p Conclusion Mean lactate level during the initial 12h of VA-ECMO support is both a sensitive and specific predictor of mortality. Early lactate levels can assist with the often difficult decisions associated with VA-ECMO. More research is necessary to develop a robust prediction model to aid in the clinical decision making early after ECMO initiation.

Purpose Severe early right heart failure is a life-threatening complication of left ventricular assist device (LVAD) implantation that may require unplanned temporary right ventricular assist device (RVAD) support. There are limited data on the association between the need for early RVAD support and long-term survival following LVAD implantation. Methods We studied 348 patients who underwent continuous-flow LVAD implantation in a single center Registry. Forty-eight (14%) patients received an unplanned temporary RVAD within 48 hours following LVAD implantation. Multivariate Cox proportional hazards regression modeling was used to assess long-term mortality in patients who did vs. did not receive a RVAD. Results Patients (mean age 57 years, 80% male) were supported by a LVAD for a mean of 2.5 years, and 137 (39%) patients died during the follow-up period. Multivariate analysis showed that RVAD use was associated with a significant 3-fold increase in the risk of short-term (6-month) mortality (HR 2.99 [95% CI: 1.39-6.43]). However, among early RVAD patients who survived to 6 months, the risk for subsequent long-term mortality was significantly reduced (HR 0.41 [95% CI 0.14-1.14]; p value for the difference in mortality-risk associated with early RVAD support before and after 6 months = 0.002 [figure]). Conclusion Temporary, unplanned RVAD use within 48 hours of LVAD implantation is independently associated with increased short-term (6-month) mortality. However, the mortality risk associated with the need for RVAD support is significantly attenuated thereafter during long-term follow-up.

Purpose The purpose of this study was to evaluate early outcomes for INTERMACS Profile 3 and 4 patients implanted with the complete sternal-sparing Heartmate 3 surgical technique. Methods Retrospective analysis of prospectively collected data was performed on 53 consecutive patients implanted with left ventricular assist devices between February and September 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (3 patients), underwent pump exchange (5 patients), or were implanted with the HeartWare device (4 patients). Early clinical outcomes and survival at 30-days were evaluated for all INTERMACS Profile 3 and 4 patients. Results Of the 41 total patients, 18 (44%) were INTERMACS 3 or 4 at time of implantation and were included in this study. All patients underwent complete sternal-sparing HeartMate3 implantation with no conversions to full sternotomy. Average age was 54.6 ±16.1 years and 67% were male (Table). One patient (6%) returned to the operating room for bleeding. No patients required RVAD support. Median intubation time was 16 [IQR=7-34] hours. Median intensive care unit and hospital length of stay were 3 [IQR=2-4] days and 14 [IQR=12-18] days, respectively. One patient (6%) was readmitted within 30-days for gastrointestinal bleeding. Thirty-day survival was 100% (18/18). Conclusion In our single center experience, complete sternal-sparing HeartMate 3 implantation of INTERMACS 3 and 4 patients is safe with a low complication rate and excellent perioperative outcomes. Multicenter studies are required to further validate this less invasive surgical technique.

Purpose Patients with a history of previous sternotomy often pose difficult surgical challenges for subsequent cardiac procedures. We hypothesized that the less invasive complete sternal-sparing approach would demonstrate favorable outcomes compared to full sternotomy (FS) for patients with a history of previous sternotomy. Methods We retrospectively reviewed all patients implanted with a HeartMate 3 (HM3) at our institution from September 2017 through September 2018 (n=63). Patients were included if they had history of prior sternotomy and separated into groups based on LVAD implantation technique: CSS versus re-operative sternotomy. Preoperative characteristics and postoperative outcomes were compared between cohorts. Results Of the 17 (30%) HM3 patients with a history of previous sternotomy, 10 (59%) were implanted via CSS and 7 (41%) by re-operative sternotomy. The CSS cohort tended to be older (65±6 vs 56±11 years, p = 0.055) and more likely to have undergone CABG (80% vs 14%, p = 0.015) while the FS cohort was more likely to have undergone previous aortic valve replacement (71% vs 10%, p = 0.035) (Table). The CSS cohort demonstrated fewer overall complications (30% vs 86%, p = 0.050) including a decreased incidence of severe right ventricular failure (0% vs 57%, p = 0.015). There was a trend towards shorter ICU length of stay (median, [IQR]; 4 [3-6] vs 14 [4.5-32] days, p = 0.218), total hospital length of stay (13 [12-24] vs 32.5 [20.5-61.5] days, p = 0.104) and improved 30-day survival (90% vs 57%, p = 0.250) in the CSS cohort. Conclusion LVAD implantation via CSS approach demonstrates fewer complications and decreased incidence of severe right ventricular failure in patients undergoing re-operative cardiac surgery. The CSS approach is our preferred surgical implantation technique for this patient population.

Purpose Severe early right heart failure is a life-threatening complication of left ventricular assist device (LVAD) implantation that may require unplanned temporary right ventricular assist device (RVAD) support. There are limited data on preoperative predictors of RVAD use within only 48 hours of LVAD implantation. Methods We studied 343 patients who underwent continuous-flow LVAD implantation at a single center. Forty-eight (14%) received unplanned temporary RVAD support within 48 hours following LVAD placement. Multivariate logistic regression was used to identify independent predictors for the need of early RVAD support. Results Patients who required early temporary RVAD support had significantly different preoperative clinical characteristics compared to those who did not require support, including a younger age (53 vs. 58 years, respectively), a higher proportion of women (33% vs. 18%, respectively) and higher risk INTERMACS Profile of 1 or 2 (50% vs. 15%, respectively; p 2-fold risk-increase); INTERMACS Profile 1 or 2 (>4-fold risk-increase); the need for IABP or ECMO before LVAD implantation (>3-fold risk-increase); and increased AST levels (4% risk-increase per 10-unit increment). Conclusion Preoperative predictors of temporary, unplanned RVAD use within 48 hours of LVAD implantation include clinical and laboratory markers of hemodynamic instability and end-organ dysfunction. Female gender is a risk factor for RVAD use in this analysis and requires further study in a larger cohort.

Purpose The purpose of this study was to evaluate discharge patterns, days spent out of hospital and 90-day readmission rates after utilizing the complete sternal-sparing technique for HeartMate3 implantation. Methods Retrospective analysis of prospectively collected data was performed on 36 consecutive patients implanted with left ventricular assist devices between February and July 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (1 patient), were a pump exchange (5 patients), or were implanted with the HeartWare device (2 patients). Results A total of 28 patients were included in the study, all of which underwent complete sternal-sparing HeartMate 3 implantation. Two patients died during the initial hospitalization. Average age was 56.0±11.7 years, 77% were male and 50% were INTERMACS Profile 1. Intensive care unit and hospital length of stay were 4.5 days (IQR=2-7 days) and 15 days (IQR=12-31days), respectively. Seventeen patients (65%) were discharged home, and nine patients (35%) were discharged to acute rehab. After hospital discharge, patients spent 97% of their time out of the hospital. Three patients (12%) were readmitted to the hospital, one of whom was readmitted twice. Reasons for readmissions included gastrointestinal bleed, bacteremia, anemia and syncope. Ninety-day survival was 26/28 (93%). Conclusion In our single center experience, two thirds of patients were discharged home after HeartMate 3 implantation using less invasive surgical techniques. Along with short hospital stays, we observed a low 90-day readmission rate. Multicenter studies are required to further validate the benefits of less invasive HeartMate 3 implantation.

Purpose Obese patients supported by continuous flow left ventricular assist devices (LVADs) have comparable outcomes to those with a normal BMI. However, cardiac surgery in obese patients is associated with increased procedural complexity and morbidity. We describe our early outcomes using the complete sternal-sparing (CSS) approach for HeartMate 3 (HM3) implantation in obese patients. Methods We retrospectively reviewed all commercial HM3 implants at our institution through September 2018. Patients were separated into two groups based on BMI Results Of the 41 patients who underwent complete sternal sparing HM3 implantation, 18 (44%) were obese. The non-obese cohort had an average BMI of 24.8 ±2.8 compared to the obese cohort average BMI of 37.2 ±5.9. Six patients (15%) were extremely obese (BMI >40) (Figure). Preoperative characteristics and illness severity were similar between patient cohorts including > 39% of INTERMACS 1 patients in each group (Table). There was no significant difference in intraoperative data or early clinical outcomes. Both obese and non-obese patients demonstrated similar intensive care unit and hospital lengths of stay. There was no difference in 30-day survival or 30-day readmission rate. Conclusion The CSS approach is a safe and effective technique for LVAD implantation in obese patients. There is no increased risk of morbidity or mortality between obese and non-obese patients implanted with the HM3 LVAD using the CSS approach.

Purpose The purpose of this study was to analyze early outcomes, safety and reproducibility of the less invasive HeartMate 3 implantation technique. Methods Retrospective review of prospectively collected data was performed on 53 consecutive patients implanted with left ventricular assist devices between February and September 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (3 patients), were a pump exchange (5 patients) or were implanted with the HeartWare device (4 patients). Safety outcomes included return to the operating room and overall survival. Results A total of 41 patients were included in the study. Thirty-nine patients were implanted with the complete sternal-sparing technique while two had an upper hemi-sternotomy with small left anterior thoracotomy. Average age was 53.6±13.9 years, 76% were male and 41% were INTERMACS Profile 1. Twelve patients (29%) had a right ventricular stoke work index less than 400. Nine patients (22%) were implanted off VA ECMO and 10 patients (24%) had previous cardiac surgery. All patients that qualified for the procedure were implanted using a less invasive technique. No patients required conversion to full sternotomy. Two patients (5%) returned to the operating room for bleeding. Twenty patients (49%) received a perioperative packed red blood cell transfusion within 24 hours of surgery. Median blood loss in the first 24-hours was 1042 mL (IQR=768-1307 mL). 2 patients (5%) requiring RVAD support. Median intubation time was 16 hours (IQR=9-34 hours). Median intensive care unit and hospital length of stay were 4 days (IQR=2-6 days) and 15.5 days (IQR=12-23 days), respectively. Thirty-day survival was 39/41 (95%). Conclusion Less invasive HeartMate 3 implantation in our single center setting is safe and reproducible with excellent outcomes. Multicenter studies are required to further validate this technique.

Heparin-induced thrombocytopenia (HIT) is a rare side effect of heparin therapy that can result in life threatening thrombosis. It presents a therapeutic challenge in patients undergoing HeartMate 3 (HM3) left ventricular assist device (LVAD) implantation. Patient 1: A 69 year old male with

Cardiomyopathy (CM) is generally treated with generic heart failure medications, namely diuretics, beta blockers and afterload reduction. Extracorporeal membrane oxygenation (ECMO) can be used in patients with cardiogenic shock (CS) who do not respond to conventional therapy. A 32 year old female