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Background: Women with congenital long QT syndrome (LQTS) experience increased cardiac event risk after the onset of adolescence, perhaps stemming from the known modulating effects of sex hormones on the cardiac potassium channels. Objective: We hypothesized that the effect of sex hormones on cardiac ion channel function may modify electrocardiographic (ECG) parameters associated with the propensity for ventricular tachyarrhythmias during the menstrual cycle in women with LQTS. Methods: We prospectively enrolled 65 women with congenital LQTS (type 1 LQTS [LQT1], n = 24 [36.9%]; type 2 LQTS [LQT2], n = 20 [30.8%]) and unaffected female relatives (n = 21 [32.3%]). Patients underwent three 7-day ECG recordings during their menstrual cycles. Simultaneous saliva testing of sex hormone levels was conducted on the first day of each 7-day ECG recording cycle. Results: The mean age was 35 ± 8 years, without a significant difference among the groups. In women with LQT2, linear mixed effects models showed significant inverse correlations of the corrected QT interval with progesterone levels (P < .001) and with the progesterone to estradiol ratio (P < .001). Inverse relationships of the R-R interval with estradiol levels (P = .003) and of the T-wave duration with testosterone levels (P = .014) were also observed in women with LQT2. In contrast, no significant associations were observed between ECG parameters and sex hormone levels in women with LQT1 or unaffected relatives. Conclusion: This is the first study to prospectively assess correlations between repolarization dynamics and sex hormone levels during the menstrual cycle in women with congenital LQTS. Our findings show genotype-specific unique corrected QT dynamics during the menstrual cycle that may affect the propensity for ventricular tachyarrhythmia in women with LQTS, particularly women with LQT2.

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.

The objective of this single-center, pilot, prospective, and historical control study is to evaluate safety and feasibility outcomes associated with left atrial appendage exclusion (LAAE) concomitant with left ventricular assist device (LVAD) implantation via less invasive surgery (LIS) as a stroke prevention strategy.A predefined number of 30 eligible subjects scheduled for LIS LVAD with LAAE were enrolled in the prospective arm between January 2020 and February 2021. Eligible retrospective LIS LVAD patients without LAAE were propensity-matched in a 1:1 ratio with the prospective arm subjects. The primary study objectives were to evaluate the safety, feasibility, and efficacy of the LAAE concomitant with LIS LVAD.Preoperative characteristics of patients in the Non-LAAE and LAAE groups were similar. LAAE was successfully excluded in all prospective patients (100%). Primary safety endpoints of chest tube output within the first 24 postoperative hours, Reoperation for bleeding within 48 h, and index hospitalization mortality demonstrated comparable safety of LAAE versus Non-LAAE with LIS LVAD. Cox proportional hazard regression demonstrated that LAAE with LIS LVAD was associated with 37% and 49% reduction in the risk of stroke and disabling stroke, respectively (p .05).Results from our pilot study demonstrated the safety and feasibility of LAAE concomitant with LIS LVAD as a stroke prevention strategy. This is the first prospective study describing LAAE performed concomitantly to less invasive LVAD implantation. The efficacy of LAAE in long-term stroke prevention needs to be confirmed in future prospective randomized clinical trials.

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 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.

Purpose A survival gap between weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) and the hospital discharge has been consistently reported. The aim of this study is to investigate the clinical features of patients who underwent successful VA-ECMO decannulation at our institution and to identify the major contributors responsible for adverse outcomes. Methods We retrospectively reviewed all patients supported with VA-ECMO in our institution between January 2013 and June 2020. Only patients that survived VA-ECMO and underwent successful decannulation were included and dichotomized based on survival to hospital discharge: non-survivors versus survivors. The primary study outcome was the cause of death after successful VA-ECMO decannulation. Results Of the 262 adult patients who underwent VA-ECMO decannulation, 72 (27.5%) patients did not survive to hospital discharge. Non-survivors were older (62 vs. 54 years, p Conclusion In our study, one-third of patients decannulated off VA-ECMO did not survive to hospital discharge due to end-stage heart failure, infections or neurological injury. The first 8 post-decannulation days were recognized as a critical period where thorough strategies to prevent acquired infections and cautious support of end-organ function should be warranted. Future large-scale trials are needed to confirm our results.

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.

We present the patient with severe aortic insufficiency (AI) 5 years post left ventricular assist device (LVAD) implantation. His management was complicated with unsuccessful percutaneous aortic valve closure attempt, transcatheter aortic valve replacement (TAVR) implantation with a severe paravalvular leak, eventual valve dislodgment into the left ventricle (LV), and LVAD inflow cannula occlusion. We utilized a mini-thoracotomy approach to successfully retrieve the dislodged valve through the LV apex while deploying a valve-in-valve TAVR under direct visualization and deep hypothermic cardiac arrest. This case can serve as an example of the serious pitfalls and potential resolution strategies when treating LVAD-associated AI.

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.

Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several potential benefits. We hypothesized that the CSS approach for HeartMate 3 (HM3) LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). We retrospectively reviewed patients who were implanted with a commercial HM3 at our institution from September 2017 to August 2018. The Activity Measure for Post-Acute Care short forms and Functional Independence Measure scores were used to assess the patient’s physical limitations postoperatively. A total of 43 patients were included in the study: 27 (63%) CSS patients and 16 (37%) FS patients. At postoperative day 3, the CSS cohort demonstrated improved mobility based on Activity Measure for Post-Acute Care scores compared to the FS group; 40% of the CSS cohort versus 67% of the FS cohort remained 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the Functional Independence Measure sit-to-stand metric with 78% of the CSS cohort achieving modified or complete independence by postoperative day 15 compared to only 21% of the FS patients. These early data suggest that the CSS approach for HM3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

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.

Purpose We sought to develop and implement a comprehensive enhanced recovery after surgery protocol for patients implanted with left ventricular assist device. Methods Our approach to the development and phased implementation of the ERAS protocol were described (Figure 1). We retrospectively reviewed prospectively collected LVAD implant data at our institution between February 2019 and August 2020. Patients were divided into 6-months period cohorts: Pre-ERAS cohort (which covered 6 months prior to ERAS initiation) and ERAS cohort. A time gap of 6 months between the cohorts was used to appreciate initial outcomes after implementing most of the protocol phases. Results Of the 115 LVAD implants, 38 patients were classified in pre-ERAS cohort and 46 in ERAS cohort. We reduced transfusions and discharge on opioids and show a trend towards reduced intubation times, ICU and overall length of stay (Table 1). Conclusion ERAS for advanced heart failure patients deemed candidates for LVAD therapy is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. We described details of the protocol, challenges faced as well as early positive changes in clinical outcomes. Further studies are needed to both assess provider satisfaction and evaluate benefits of an ERAS protocol in reduction of adverse events.

We present a complicated case of massive pulmonary embolism occurring 11 weeks after a craniotomy in a patient with multiple high-risk comorbidities. The patient underwent successful pulmonary artery surgical embolectomy via left mini-thoracotomy incision on peripheral venoarterial extracorporeal membrane oxygenation support. For this patient, avoiding a sternotomy allowed for greatly decreased postoperative morbidity and the use of venoarterial extracorporeal membrane oxygenation allowed for the avoidance of intraoperative anticoagulation. This case demonstrates the feasibility of off-pump surgical pulmonary embolectomy via left mini-thoracotomy as a treatment strategy for appropriate patients to improve patient-centred care.

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.