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Objective The present study assessed agreement between resting cardiac output estimated by inert gas rebreathing (IGR) and thermodilution methods in patients with heart failure and those implanted with a left ventricular assist device (LVAD). Methods and Results Hemodynamic measurements were obtained in 42 patients, 22 with chronic heart failure and 20 with implanted continuous flow LVAD (34 males, aged 50 ± 11 years). Measurements were performed at rest using thermodilution and IGR methods. Cardiac output derived by thermodilution and IGR were not significantly different in LVAD (4.4 ± 0.9 L/min vs 4.7 ± 0.8 L/min, P = .27) or patients with heart failure (4.4 ± 1.4 L/min vs 4.5 ± 1.3 L/min, P = .75). There was a strong relationship between thermodilution and IGR cardiac index (r = 0.81, P = .001) and stroke volume index (r = 0.75, P = .001). Bland–Altman analysis showed acceptable limits of agreement for cardiac index derived by thermodilution and IGR, namely, the mean difference (lower and upper limits of agreement) for patients with heart failure –0.002 L/min/m2 (–0.65 to 0.66 L/min/m2), and –0.14 L/min/m2 (–0.78 to 0.49 L/min/m2) for patients with LVAD. Conclusions IGR is a valid method for estimating cardiac output and should be used in clinical practice to complement the evaluation and management of chronic heart failure and patients with an LVAD.

We sought to determine hemodynamic mechanisms of exercise intolerance in a group of patients with the HeartWare ventricular assist device (VAD) compared to a group of heart failure patients. Twenty VAD and 22 heart failure patients underwent symptom-limited active straight leg raising exercise during right heart catheterization with thermodilution (TD), and upright cycling cardiopulmonary stress testing with cardiac output measurement by inert gas rebreathing (IGR) method. The TD and IGR exercise cardiac indexes were higher in VAD compared with heart failure group (both P < 0.05), although there was only a borderline increase in peak exercise oxygen consumption (VO2) (P = 0.06). Baseline and exercise right heart catheterization pressures were not significantly different between the two groups. The only significant independent predictors of peak VO2 in the heart failure group were exercise heart rate and cardiac index (both P < 0.05). In contrast, for the VAD group only, resting pulmonary arterial wedge and pulmonary arterial mean pressures were independently related to peak VO2 (both P < 0.05). Thus, in heart failure, exercise cardiac index is an important limitation to exercise capacity, and VADs increase exercise cardiac index. However, in VAD patients, this only produces limited benefits as increased pulmonary and pulmonary wedge pressures limit increases in exercise capacity.

Although left ventricular assist device (LVAD) improves functional capacity, on average LVAD patients are unable to achieve the aerobic capacity of normal healthy subjects or mild heart failure patients. The aim of this study was to examine if markers of right ventricular (RV) function influence maximal exercise capacity. This was a single-center prospective study that enrolled 20 consecutive HeartWare ventricular assist device patients who were admitted at the Freeman Hospital (Newcastle upon Tyne, United Kingdom) for a heart transplant assessment from August 2017 to October 2018. Mean peak oxygen consumption (Peak VO2) was 14.0 ± 5.0 ml/kg/min, and mean peak age and gender-adjusted percent predicted oxygen consumption (%VO2) was 40.0% ± 11.5%. Patients were subdivided into two groups based on the median peak VO2, so each group consisted of 10 patients (50%). Right-sided and pulmonary pressures were consistently higher in the group with poorer exercise tolerance. Patients with poor exercise tolerance (peak VO2 below the median) had higher right atrial pressures at rest (10.6 ± 6.4 vs. 4.3 mmHg ± 3.2; p = 0.02) and the increase with passive leg raising was significantly greater than those with preserved exercise tolerance (peak VO2 above the median). Patients with poor functional capacity also had greater RV dimensions (4.4 cm ± 0.5 vs. 3.7 cm ± 0.5; p = 0.02) and a higher incidence of significant tricuspid regurgitation (moderate or severe tricuspid regurgitation in five patients in the poor exercise capacity group vs. none in the preserved exercise capacity group; p = 0.03). In conclusion, echocardiographic and hemodynamic markers of RV dysfunction discriminate between preserved and nonpreserved exercise capacity in HeartWare ventricular assist device patients.

The HeartWare left ventricular assist device has been in use for over 12 years. We sought to determine how outcomes at our centre have improved over time.Review of electronic hospital records at the Freeman Hospital, Newcastle upon Tyne, United Kingdom.A total of 255 first time adult implants were divided into 2 eras: Era 1: 2009-2015 (N = 154) and Era 2: 2016-2020 (N = 101). We prospectively aimed to avoid higher risk Intermacs Classifications in Era 2, which resulted in significant changes in Intermacs class to lower risk in Era 2 (P 0.001). There was a significant improvement in survival in Era 2, with 1 year survival increasing from 70 to 80% (P 0.05). This was particularly associated with lower 30 day mortality in Era 2 (1.7 ± 2.3 vs 15.5 ± 7%, P 0.005). This was associated with better right ventricular function in Era 2, and there was a trend to more temporary right ventricular assist devices used in Era 2 (28 ± 13 vs 12 ± 14%, P = 0.06). Deaths from intracranial haemorrhage, sepsis and right heart failure were unchanged between eras, though there was a trend towards less deaths in Era 2 from combined thromboses deaths (stroke and device thrombosis; 3.3 ± 5.4 vs 11.1 ± 7.4%, P = 0.07).Better patient selection in association with more use of temporary right ventricular assist support has resulted in a significant improvement in survival. Intracranial haemorrhage, sepsis and right heart failure remain significant problems.

Purpose Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) post atrial switch for transposition of the great arteries (TGA) and congenitally corrected TGA (ccTGA) has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. The hemodynamic impact of severe tricuspid regurgitation (TR), potential role of systemic tricuspid valve replacement (TVR) and long-term outcomes are still unknown. The purpose of this study is to describe our experience of VAD in SRVF and our move towards concomitant TVR. Methods Single-centre retrospective study of consecutive adult patients receiving HeartWare-VAD for SRVF between 2010 and 2020. 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 24 patients underwent VAD implantation. Moderate or severe systemic TR was present in 83% of patients, and subpulmonic left ventricular (LV) impairment in 79%. One and two-year survival rates were 75% and 60% respectively. VAD implantation was technically feasible and successful in all but one. Post VAD, TPG fell from 16 (15-20) to 10 (7-13) mmHg; p=0.002. Patients with TVR (n=12) also demonstrated reduction in pulmonary and atrial pressures (figure). Subpulmonic LV end-diastolic dimension (50 vs 42mm; p=0.05) and systolic function improved in this group. On the other hand a high prevalence of subpulmonic LV failure was noted in the non TVR group (50% vs 8.3%; p=0.03) resulting in higher mortality. After six months on support, 63% of patients were suitable for transplantation. Conclusion VAD implantation for patients with SRVF in TGA or ccTGA is feasible, and significantly reduces the TPG to transplantable limits. Concomitant TVR at the time of implant associates better haemodynamic and echocardiographic results.

To manage myocardial recovery in patients with the HeartWare left ventricular assist device (HVAD), we describe a minimally invasive approach (decommissioning) that involves disconnecting the driveline and occluding the outflow tract through a small left thoracotomy incision, leaving the device in situ, in conjunction with optimal medical therapies and comprehensive assessment of left ventricular recovery. Nine patients (all male, 37 ± 12 years, all nonischemic dilated cardiomyopathy) had an HVAD implanted for 766 ± 343 days. When left ventricular function improved to mild impairment by echocardiography, patients underwent assessment at reduced flow (2578 ± 148 to 1822 ± 67 rpm) with documentation of compensated right heart hemodynamics and ejection fraction 52 ± 8%. Eight of nine patients underwent decommissioning, and 1 patient had a hybrid procedure of percutaneous occlusion of outflow graft and surgical division of driveline. Two patients died postoperatively at 413 days (sepsis) and 810 days (heart failure). In conclusion, in selected patients with nonischemic dilated cardiomyopathy, a prolonged period of HVAD support in conjunction with heart failure medications can lead to recovery of left ventricular function. Surgical decommissioning is then an option to remove these patients from support. These patients are, however, not cured and remain at risk for future deterioration in ventricular function and infections.

Introduction and objectives: Pump thrombosis is a serious left ventricular assist device complication, though there are no guidelines regarding its treatment. The main aim of this study was to describe a strategy of intravenous anticoagulation as the initial treatment in these patients and then to compare intravenous heparin with bivalirudin. Methods: All consecutive patients who received a HeartWare left ventricular assist device from July 2009 to March 2019 were retrospectively analysed. Patients developing a pump thrombosis were selected, and treatment, outcomes and complications were recorded. Results: During this period of time (116 months), 220 patients underwent HeartWare left ventricular assist device implantation and 57 developed pump thrombosis, with an incidence rate of first pump thrombosis of 0.17 events per patient-year of support (incidence rate of all episodes of pump thrombosis: 0.30 events per patient-year of support). All the patients were initially treated medically, predominantly with either intravenous heparin (n = 26) or bivalirudin (n = 16). Patients treated with bivalirudin during the first pump thrombosis episode had less subsequent re-thrombosis episodes (18.7% vs 57.7%, p Conclusion: Left ventricular assist device thrombosis is a serious life-threatening complication; hence, we propose an initial conservative management of pump thrombosis with enhanced intravenous anticoagulation with either intravenous heparin or bivalirudin, with surgery reserved for refractory cases.

Introduction and purpose Pump thrombosis (PT) is a serious left ventricular assist device (LVAD) complication, though there are no guidelines regarding its treatment. We have adopted a strategy of intravenous anticoagulation as the initial treatment strategy in these patients. Methods All consecutive patients who received a HeartWare LVAD from July-2009 to January-2018 were retrospectively analyzed. Patients developing a PT were selected, and treatment, outcomes and complications were recorded. Results 197 patients underwent HVAD, and 49 developed PT. All the patients were initially treated medically, though during the first PT 26.5% of the patients needed surgery [VAD exchange (n=6), transplant (n=6), or decommissioning (n=1)]. The overall survival at 1 year was 63.3%. Patients were treated predominantly with either intravenous heparin or bivalirudin. There were no significant differences neither in complications nor in survival between the 2 treatments (Figure 1); however, patients treated with bivalirudin during the first PT episode had less subsequent re-thrombosis episodes (18.2% vs 57.7%, p Table 1. Comparison of baseline characteristics and outcomes between Heparin and Bivalirudin Heparin (n=26) Bivalirudin (n=11) p-value Male, gender n (%) 20 (76.9) 9 (81.8) 1.00 Age when implant (years) 48±11.8 49.8±11.4 0.67 AF n (%) 9 (34.6) 6 (54.5) 0.50 Diagnosis: Dilated cardiomyopathy n (%) 13 (50) 7 (63.6) Ischemic heart disease n (%) 12 (46.2) 3 (27.3) Congenital heart disease n (%) 1 (3.8) 1 (9) 0.50 Thrombolysis (+ alteplase) n (%) 19 (73.1) 4 (36.4) 0.08 Treatment duration (days) 11.5±7.2 15.3±6.5 0.15 % Time in range 36.3±7.1 59.7±4.2 0.009 Hospitalisation (days) 19.1±16.4 31.9±18.2 0.06 Complications: Ischemic Stroke n (%) 2 (7.7) 4 (36.4) 0.09 Intracraneal bleeding n (%) 2 (7.7) 0 (0) 0.88 Gastrointestinal bleeding n (%) 1 (3.8) 0 (0) 1.00 Serious bleeding n (%) 5 (19.2) 0 (0) 0.29 Any bleeding n (%) 7 (26.9) 2 (18.2) 0.88 LDH Baseline 271.7±79.3 221.6±41.3 0.10 Admision 727.8±448.2 517.5±171.3 0.21 Maximum 827.1±424.7 1217.6±1004 0.03 Discharge 334.9±135.9 308.6±111.8 0.70 Time to normalisation (days) 10.2±4.5 17.2±2.6 0.004 Outcomes: Transplant (total) n (%) 7 (26.9) 2 (18.2) 0.88 VAD Exchange (total) n (%) 8 (30.8) 4 (36.4) 1.00 Mortality at 2 years n (%) 15 (57.7) 5 (45.4) 0.831 Rethrombosis: Rethrombosis n (%) 15 (57.7) 2 (18.2) 0.03 Number of episodes of rethrombosis 0.15 +1 n=6 n=1 +2 n=4 n=1 +3 n=4 n=0 +4 n=1 n=0 Figure 1 Conclusion VAD thrombosis is a serious life threatening complication, though an initial strategy with enhanced intravenous anticoagulation is an acceptable strategy with either intravenous heparin or bivalirudin. Acknowledgement/Funding N. Bouzas-Cruz would like to thank the Spanish Society of Cardiology (Sociedad Española de Cardiología), for her research grant and fellowship.

Background Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is a significant cause of morbidity and mortality. While multiple predictors of early RHF have been described, information on late RHF is scarce. The aim of this study was to identify predictors of late RHF in LVAD patients. Methods A retrospective analysis of all adult patients who underwent HeartWare-VAD implantation for ischemic heart disease or non-ischemic dilated cardiomyopathy in a single centre was performed. Late RHF was defined as RHF requiring hospitalization and medical treatment after 30 days of LVAD implantation. Results A total of 16 (10.3%) patients from 156 implantations developed late RHF. Patients developing late RHF were older at time of surgery, 56.7±6.9 vs 49.5±12.5 years; p Multivariate Cox proportional-hazards analysis for late right heart failure Variable Hazard ratio 95% confidence interval P-value Tricuspid regurgitation- moderate or severe 5.50 1.34–22.58 0.02 Mitral regurgitation (discharge)- moderate or severe 3.54 1.14–11.02 0.03 Age 1.07 1.01–1.14 0.03 Right ventricular basal diameter 1.14 0.43–3.03 0.79 Right ventricular fractional area change 0.98 0.87–1.10 0.79 Multivariate analysis showing predictors of late right heart failure according to a multivariate model. Late RHF according to TR severity Conclusions Pre-operative significant tricuspid regurgitation and mitral regurgitation after implantation predict the occurrence of late RHF. Prospective studies are needed to determine whether tricuspid valve interventions may reduce late RHF.

Introduction Left Ventricular Assist Devices (LVAD) improve survival and functional capacity in patients with advanced heart failure (HF). However, there are potential complications. Purpose We sought to determine parameters of exercise intolerance in a group of patients with the HeartWare LVAD (HVAD) compared to a group of HF patients. Methods This was a single-centre parallel prospective group-study. Briefly, echocardiograms, right heart catheterisation (RHC) and cardiopulmonary exercise tests were performed in forty-two patients admitted for a heart transplant assessment between August2017 and October2018.Of them 20 belonged to the HVAD group and 22 to the HF group. Results In our study, HVAD patients had a better exercise capacity than HF patients, although no significant differences were noted (14.0±5.0 ml/kg/min vs 11.3±3.9 ml/kg/min, p=0.06). To determine exercise tolerance, both HVAD and HF groups were subdivided into 2 groups based on the median peak exercise oxygen consumption (peakVO2) for that group. The table shows the comparison between preserved and non-preserved exercise tolerance in HF and HVADpatients. First of all, in the HVADgroup, all resting RHC pressures were significantly lower in the preserved exercise capacity group. However, in HFpatients there were no statistically significant differences between both subgroups in right-sided pressures, but Thermodilution exercise-induced change in cardiac output (ΔCO) and cardiac index (ΔCI) was significantly higher in the patients with preserved exercise tolerance. Secondly, in the HVADgroup the right ventricle was significantly larger in the reduced exercise tolerance subgroup. Moreover, patients with lower peak VO2 had more significant tricuspid regurgitation. Nevertheless, in HFpatients none of the echocardiographic parameters were related to the exercise capacity. HF HVAD > Median Peak V02 < Median Peak V02 p > Median Peak V02 < Median Peak V02 p Thermodilution CO, l/min: • Rest 4.3±1.0 4.4±1.8 0.82 4.8±0.8 4.2±1.2 0.21 • Exercise 5.6±1.7 4.8±1.8 0.36 7.1±3.2 4.8±0.8 0.05 • ΔCO 1.26±1.0 0.26±0.7 0.02 2.2±2.5 0.4±0.7 0.05 Right Atrium pressure, mmHg 7.0±4.5 6.8±4.10 0.92 4.3±3.2 10.6±6.40 0.02 Mean Pulmonary Artery pressure, mmHg 26.4±12.6 26.5±10.9 0.97 16.8±5.4 30.5±12.5 0.01 Tricuspid Regurgitation, n (%): • None 1 (9) 1 (9) 1 (12) 0 (0) • Mild 7 (64) 8 (73) 7 (88) 4 (44) • Moderate 2 (18) 0 (0) 0 (0) 4 (44) • Severe 1 (9) 2 (18) 0.36 0 (0) 1 (12) 0.03 Right Ventricle Basal Diastolic Diameter, cm 4.0±1.0 4.1±1.0 0.83 3.7±0.5 4.4±0.5 0.02 Conclusion Right-sided parameters in the echocardiogram and RHC pressures discriminate between preserved and non-preserved exercise capacity in HVADpatients, but not in HFpatients. In these last patients only ΔCO and ΔCI were statistically correlated with peak exercise oxygen consumption Acknowledgement/Funding N. Bouzas-Cruz would like to thank the Spanish Society of Cardiology (Sociedad Española de Cardiología), for her research grant and fellowship

Right-sided heart failure (RHF) after left ventricular assist device implantation is a significant cause of morbidity and mortality. Although multiple predictors of early RHF have been described, information on late RHF is scarce. The aim of this study was to identify predictors of late RHF in left ventricular assist device patients. A retrospective analysis of all adult patients who underwent HeartWare-ventricular assist device implantation as a bridge to transplantation in a single-centre was performed. Late RHF was defined as RHF requiring rehospitalization after 30 days of implantation. A total of 16 (10.3%) patients from 156 implantations developed late RHF. Median time to late RHF onset was 182.5 (interquartile range 105 to 618) days. Patients developing late RHF were older at surgery. A significantly higher rate of moderate or severe tricuspid regurgitation before implantation was found in patients presenting with late RHF (81.2% vs 33.5%; p0.001). Several echocardiographic parameters at discharge postimplant, such as significant mitral regurgitation, demonstrated a strong association with late RHF. A multivariate Cox regression analysis revealed that significant preoperative tricuspid regurgitation was the strongest predictor of late RHF (hazard ratio 5.50, 95% confidence interval [1.34 to 22.58]; p = 0.02). Significant mitral regurgitation postimplantation and older age also significantly predicted late RHF. In conclusion, preoperative significant tricuspid regurgitation and mitral regurgitation after implantation predict the occurrence of late RHF.

Left ventricular assist devices (LVADs) have become an established treatment for advanced heart failure, although with long-term support these patients are potentially exposed to serious complications. Our purpose was to assess the role of the neutrophil to lymphocyte ratio (NLR) in LVAD complications and to evaluate if higher values of NLR after 4-6 months on LVAD support (NLR 4_6m) are associated with worse prognosis. All consecutive patients who received a HeartWare LVAD (N = 188, age 50 ± 13 years), as bridge to transplant from December 2009 to January 2018 were included. Neutrophil to lymphocyte ratio was recorded pre-LVAD, post-LVAD, after 4-6 months on support and in case of a first adverse event to occur after the 4-6 months NLR was recorded. Median NLR values were pre-LVAD 4.26 (interquartile range [IQR], 3.1-6.9), at 1 day postoperative 11.6 (IQR, 8.3-16.6), and NLR 4_6m 4.4 (IQR, 3.0-6.4) (p < 0.001). Neutrophil to lymphocyte ratio increased significantly when patients had an infection, stroke, or pump thrombosis, as compared with the NLR 4_6m (all p < 0.05). Patients with NLR 4_6m ≥ median had higher rates of stroke and mortality. Survival time was shorter among patients with NLR 4_6m ≥ 4.4 (log-rank test p = 0.006). Neutrophil to lymphocyte ratio 4_6m was found to be predictive of increased mortality (area under the curve of 0.62, p = 0.007). After multivariate analysis, NLR 4_6m remained independently associated with increased mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.03-2.7; p = 0.037). Neutrophil to lymphocyte ratio 4_6m values significantly increase in association with adverse events on LVAD support and are independently associated with mortality. This association suggests presence of inflammation adversely affects LVAD outcomes.

Purpose Management of RV failure at the time of LVAD implantation is often difficult, and institution of emergency RVAD support leads to poor outcomes in these patients. We want to share our experience of a simplified, less traumatic temporary surgical RVAD support during LVAD implant, which allows safe post-operative care and rehabilitation, as well as allow an easy removal under local anaesthetic (LA). Methods Between 2012-2020, we identified 178 patients undergoing LVAD implantation in our unit. In 41 patients (23%), temporary RVAD support was needed due to failure to wean from CPB. Patients who required delayed RVAD support were excluded (n=12). The RVAD implant consisted of a 8 mm outflow graft onto the main pulmonary artery, and tunnelled via the left chest. The venous inflow via the sapheno-femoral junction. This technique allowed safe mobilization of the patient during their post-operative rehabilitation. The decannulation is performed under LA without resternotomy. Results A total of 29 patients were included in this study. There were 23 males and 6 females with a mean age of 51.1 years (range 12-68). Pre-operative diagnosis was DCM in 17 (58.6%), ICM in 8 (27.6%), giant cell myocarditis in 2 (6.9%) and others in 4 (13.7%). The median INTERMACS class was 2. 22/29 patients (75.8%) were successfully weaned from RVAD support. In those that failed to wean, five (17.2%) were transplanted super-urgently while another two patients (6.9%) died of multi-organ failure. Median RVAD support was 7 days (range 3-28). Post-operative complications occurred in 20/29 patients (68.9%). Bleeding/tamponade occured in 11/29 (37.9%) - six patients required re-exploration. One patient (3.4%) had bleeding from the PA graft - he was reopened after his RVAD was weaned off. RVAD support was reinstituted for a further 13 days. Median ICU LOS was 12 days (range 5-33) and median hospital LOS was 40 days (range 5-149). 25/29 patients (86.2%) were discharged home and the 30-day survival was 89.6%. Conclusion Our simplified temporary RVAD technique is a safe and less invasive surgical approach to allow for successful LVAD implant in patients with severe RV failure. This allows significant improvement in perioperative management including rehabilitation on ICU. The rate of complications is low and the explant procedure easy with minimal trauma.

Purpose Although Left Ventricular Assist Device (LVAD) improves functional capacity, on average LVAD patients are unable to achieve the aerobic capacity of normal healthy subjects or mild heart failure patients. The aim of this study was to examine if markers of right ventricular (RV) function influence maximal exercise capacity. Methods This was a single-centre prospective study that enrolled 20 consecutive HeartWare ventricular assist device (HVAD) patients who were admitted at the Freeman Hospital (Newcastle upon Tyne, United Kingdom) for a heart transplant assessment from August 2017 to October 2018. Results Mean peak oxygen consumption (Peak VO2) was 14.0 ± 5.0 ml/kg/min, and mean peak age and gender-adjusted percent predicted oxygen consumption (%VO2) was 40.0 ± 11.5 %. Patients were subdivided into 2 groups based on the median peak VO2, so each group consisted of 10 patients (50%). Right-sided and pulmonary pressures were consistently higher in the group with poorer exercise tolerance. Patients with poor exercise tolerance (peak VO2 below the median) had higher right atrial pressures at rest (10.6mmHg ± 6.4 versus 4.3mmHg ± 3.2, p= 0.02) and the increase with passive leg raising was significantly greater than those with preserved exercise tolerance (peak VO2 above the median). Patients with poor functional capacity also had greater RV dimensions (4.4 cm ± 0.5 versus 3.7 cm ± 0.5, p= 0.02) and a higher incidence of significant tricuspid regurgitation (TR) (moderate or severe TR in 5 patients in the poor exercise capacity group versus none in the preserved exercise capacity group, p=0.03). Conclusion Echocardiographic and hemodynamic markers of RV dysfunction discriminate between preserved and non-preserved exercise capacity in HVAD patients.

Purpose To determine parameters of exercise intolerance in a group of patients with HeartWare Ventricular Assist Device(HVAD) compared to a group of heart failure(HF)patients Methods This was a single-centre parallel prospective group-study.Echocardiograms,right heart catheterisation(RHC) and cardiopulmonary exercise tests were performed in 42patients admitted for a heart transplant assessment between August2017 and October2018:20 belonged to the HVAD group and 22 to the HF group Results HVADpatients had a better exercise capacity than HFpatients, although no significant differences were noted(14.0±5.0ml/kg/min vs 11.3±3.9ml/kg/min, p=0.06).To determine exercise tolerance,both HVAD and HFgroups were subdivided into 2 groups based on the median peakVO2.The table shows the comparison between preserved and non-preserved exercise tolerance in HF and HVADpatients. In the HVAD group,all resting RHC pressures were significantly lower in the preserved exercise capacity group.However,in HFpatients there were no statistically significant differences between both subgroups in right-sided pressures,but Thermodilution exercise-induced change in cardiac output(ΔCO) and cardiac index(ΔCI) was significantly higher in the patients with preserved exercise tolerance.In the HVADgroup the right ventricle was significantly larger in the reduced exercise tolerance subgroup.Patients with lower peakVO2 had more significant tricuspid regurgitation.Nevertheless,in HFpatients none of the echocardiographic parameters were related to the exercise capacity Conclusion Right-sided parameters in the echocardiogram and RHC pressures discriminate between preserved and non-preserved exercise capacity in HVADpatients,but not in HFpatients.In these last patients only ΔCO and ΔCI were statistically correlated with peak exercise oxygen consumption.

Purpose A new app-based programme for INR reporting was introduced in our cohort of patients with the aim of improving compliance and patient satisfaction. A comparison between the app-based programme and our current conventional method of telephone reporting was undertaken. Methods From a cohort of 52 durable MCS patients, 17 patients were enrolled onto the INR app. The remainder of the cohort continued to report their INR by telephoning the VAD nurse specialist. All patients were given the opportunity to submit their INR between 8am-1pm on the day requested, either via the app or telephone. Patients who did not contact within this time, were then contacted by the nurse specialist to chase the INR result. Compliance over a 15-day period was reviewed. Results An average of 9 INR submissions were made via the app, per day; with a 96.5% compliance within the allocated time period. Comparatively, the traditional method of reporting by phone showed an average of 14 INR submissions per day, with only an 87% compliance in the telephone group. Of the 17 INR app users, 23.5% of that patient group had a history of poor compliance in reporting their INR. A patient satisfaction survey showed 93.75% of respondents stated that they preferred using the app. All patients who previously had issues with compliance preferred the app and all patients strongly agreed the app was easy to use and had saved them time. Conclusion Compliance in the app group was found to be higher compared to patients who reported their INR by phone. Introduction of the INR app has not only reduced nurse workload, but also saved the patients’ time. Patients have responded very positively to the introduction of the app, justifying further enrolment of the remaining patient cohort onto the app.

Heart failure is affecting an increasing number of people in the UK. Some patients who have severe heart failure only have heart transplant as an option, and with prolonged waiting times on the transplant list, many may die waiting. To bridge these patients until a suitable organ is available, patients are being fitted with left ventricular assist devices (LVAD). These devices are mechanical pumps that assist weakened hearts in circulating blood around the body. An LVAD pump requires close monitoring of the pump's readings, exit site and anticoagulation while in hospital and once the patient has been discharged home. By creating a specialist nurse post to introduce a weekly telephone call to this caseload of patients, the authors' institute was able to reduce the amount of patients admitted by 15.5% and the amount of days spent in hospital was reduced by 20.9% over the same period.

OBJECTIVES Third-generation ventricular assist devices (VADs) are associated with improved outcomes, though in recent clinical trials bridge-to-transplant (BTT) rates are ∼30% at 6 months, so that transplantation can be used as a ‘bail out’ for serious complications. In the UK, there was a significant reduction in heart transplantation rates over the last decade, so that transplantation from VADs is much less frequent. The objective of this study was to determine outcomes and their predictors in this situation of low BTT rates, and as patients were exposed to long-term support, the incidence and outcomes of VAD thrombosis. METHODS We analysed outcomes for 102 consecutive patients between 2009 and 2013 (mean age 47 ± 13; VentrAssist n = 6 and HeartWare n = 96). The median duration of support was 462 ± 426 days. RESULTS Survival rates on the device were 75 and 66% at 1 and 2 years, respectively. Older age and more acute INTERMACS groups were significantly related to reduced survival within the first 90 days (P = 0.030 and 0.010, respectively). Poor preoperative right ventricular (RV) function had a negative effect on survival after 1 year (P = 0.009), though not earlier. VAD thrombosis (n = 24 HeartWare and n = 1 VentrAssist) occurred at 0.18 events per patient-year for HeartWare and 0.07 for VentrAssist devices at a median time of onset at 404 ± 281 days. There was no significant effect of VAD thrombosis on survival. Only 14 of 102 patients were transplanted at a median of 334 ± 347 days, and only 3 were transplanted within the first 6 months. CONCLUSIONS Third-generation left ventricular assist device implants with a low rate of transplantation have similar survival to destination therapy, and are susceptible to long-term complications of VAD thrombosis and right heart failure.

Purpose Long term VAD therapy is a highly complex treatment modality, posing significant challenges to patients, medical teams and allied health professionals. Traditionally lack of social support and social isolation for patients has raised concerns for hospital teams. We have reviewed our cohort of patients at a single centre to determine if lack of social support and isolation affects patients’ long term survival. Methods A total of 315 patients were reviewed, having undergone continuous flow VAD as a bridge to transplantation. 50 patients were identified as having a lack of social support at the time of implant and during their VAD journey. This was defined as patients who lived alone, with little or no carers. Survival data was reviewed at yearly intervals at year 1, 2 and 3. Data was censored if the VAD therapy was discontinued during this period at time of death, time of transplant or time of myocardial recovery at decommission. Results 86% of patients were still alive at year 1, with no transplants or decommissioning occurring in this period. (see table 1). Year 2 survival was 58% with 5 deaths, 3 transplants and 1 decommissioning and year 3 was 64% survival with 2 transplants occurring in that period. This was then compared to overall survival data at our own centre and the national average for VAD survival as detailed in the NHSBT report 2016. The results were favourable for the lack of social support in comparison to the national survival data, with 1 year survival higher in the lack of social support cohort at 86% compared with national % of survival ranging from 62-83% per centre. Year 2 survival at 58% compared to 56-73% respectively and year 3 survival at 64% compared with 48-65 %. Conclusion Our data shows that a lack of social support group should not prohibit the introduction of VAD therapy. Careful monitoring of all patients should be provided long term to enhance all patient survival

Purpose Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is a significant cause of morbidity and mortality. Multiple factors have been identified in order to predict early RHF, though information is scarce regarding late RHF. The aim of this study was to analyse and identify predictors of late RHF in LVAD patients. Methods A retrospective analysis of adult patients who underwent HeartWare-VAD implantation from 2009 to 2017 in a single-centre was performed. Late RHF was defined as RHF after 30 days of implantation requiring hospital admission. Clinical data, echocardiographic and haemodynamic parameters before implantation, data regarding the early post-operative phase and echocardiographic parameters at discharge were analysed. Results A total of 22 (10.7%) patients from 206 implantations developed late RHF during follow-up. Time to first RHF admission was 202.5 (IQR 130-682) days. Patients presenting with late RHF had a higher incidence of pre-operative significant tricuspid regurgitation (p Conclusion Late RHF was more prevalent in patients with dilated cardiomyopathy or congenital heart disease, and is not predicted by early RHF. Significant tricuspid regurgitation at discharge post-implantation predicted the occurrence of late RHF. Prospective studies are needed to determine whether tricuspid valve interventions may reduce late RHF.

Purpose The incidence of MSSA bacteraemia continues to plague clinicians, with trends continually rising in the UK (Darzi, 2018). This is echoed in the MCS community. We aim to demonstrate how we have significantly reduced the incidence of this infection at our centre. Methods Following several root cause analyses exploring MSSA bacteraemia in our patient cohort, several practice developments were incorporated into our local and regional guidance, in conjunction with advice from our microbiologists. The changes included:Strategic: Root cause analysis for all VAD associated MSSA/MRSA bacteraemia, Review of health care acquired infections at Trust Serious Infection Review meetings. Operational: VAD MSSA policy Introduction of MSSA screening at intervals of pre operatively, weekly for all inpatients, and at all clinic visits. MSSA Eradication therapy. Robust aseptic non touch technique training for all clinicians and competency assessments. Universal anti-microbial washes. Antibiotic suppression for MSSA colonised patients. Driveline management: regular reviews, change of dressings, audits of appropriate dressing, timely surgical intervention. Results 160 patient records were reviewed retrospectively, with a total of 31 MSSA bacteremia being identified between 2011-2017. (Table 1) As seen in Table 1, a peak in MSSA bacteraemia was identified in 2012-2013 prior to the introduction of the practice developments. In subsequent years our rate of MSSA bacteraemia has fallen sharply. The total number of annual LVAD implants have stayed consistent around 30 per annum. Table 1 . Time period Number of MSSA bacteremia 2011 3 2012 11 2013 7 2014 4 2015 3 2016 2 2017 1 Conclusion With the introduction of our practice developments we have almost completely eliminated MSSA bacteremia in our LVAD community.

Background This study examined whether aortic valve opening (AVO) and other echocardiographic parameters influence outcomes in patients on left ventricular (LV) assist device (LVAD) support. Pump thrombosis (PT) and ischemic stroke (IS) are known complications of LVAD, but mechanisms that could influence them are not completely understood. Methods This was a retrospective analysis of 147 patients who received a HeartWare Ventricular Assist Device ( HeartWare International) as a bridge to transplant or to candidacy between July 2009 and August 2015, of whom 126 had at least 30 days of follow-up before the first event (30-days-out cohort). Outcomes included survival, PT, IS, and PT+IS (combined thrombotic event; CTE). Results Median time on support was 518 days. Of the 30-days-out cohort, 29% had a first PT and 19% a first IS. AVO was associated with longer survival on device (1,081 vs 723 days; p = 0.01) in the entire cohort. In the 30-days-out cohort, the aortic valve was more frequently closed in patients with lower ejection fractions on support (14% ± 6% vs 18% ± 9%; p = 0.009), more dilated pre-event echocardiogram (LV end-diastolic diameter, 66 ± 12 mm vs 62 ± 10 mm; p = 0.04), and pre-implant LV end-diastolic diameter (70 ± 10 mm vs 66 ± 9 mm; p = 0.06). CTE-free survival on the device was lower with a closed aortic valve (897 vs 1,314 days; p = 0.003) as was PT-free survival on the device (1,070 vs 1,457 days; p = 0.02). Cox regression analysis showed that AVO was an independent predictor of CTE ( p = 0.03) Conclusions Thrombotic events are relatively frequent in patients on long-term LVAD support. A closed aortic valve was associated with decreased overall survival, thrombosis-free survival, and poorer LV function on support. These are high-risk patients, so whether they require more intense anti-coagulation or prioritizing for transplantation requires further research.

The aim of this study was to determine the effects of the HeartWare left ventricular assist device (HVAD) (HeartWare International, Inc, Framingham, MA) on hemodynamics, ventricular function, and exercise capacity. Between July 2009 and March 2011, 46 patients with advanced heart failure had implantation of the HVAD. Of these patients, 30 had subsequent assessments for transplantation and these patients formed the study cohort. Thirty patients had assessments at a mean of 201±86 days and 13 went on to have a second assessment at 351±86 days. There were marked improvements in hemodynamics and exercise capacity at both assessments, with significant decreases in right and left heart filling pressures; increases in cardiac index, New York Heart Association class, and peak exercise oxygen consumption; and reduction in pulmonary vascular resistance (all P