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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.

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.

Background Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. Methods Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve. Results Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P = .01) in predicting survival to discharge. Conclusions This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.

The rate of heart failure and subsequent placement of left ventricular assistive devices (LVADs) has been increasing. The extra-anatomic placement of the LVAD and outflow graft presents a challenging problem for repair when complications arise. The present report describes a case of a 63-year-old man who had presented with acute pseudoaneurysm of the outflow graft of his recently placed LVAD. Percutaneous access of the left subclavian artery and percutaneous, transthoracic access of the outflow graft was obtained to allow for sheath placement and stent deployment within the outflow graft. The patient underwent successful endovascular repair of the defect without complications.

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.

BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end-stage liver disease-excluding international normalized ratio (MELD-XI) scoring system has been shown to have prognostic value in other critically ill patient populations. MATERIALS AND METHODS A single-center retrospective review was performed for all adult patients managed on VA-ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD-XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD-XI in regard to in-hospital mortality. RESULTS Of the 187 patients, 74 (40%) patients had MELD-XI less than 14 (low-risk) and 113 (60%) had a MELD-XI of 14 or greater (high-risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high-risk MELD-XI group had significantly greater mortality during index hospitalization compared to the low-risk group (74% vs 39%; P

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.

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.

Right ventricular assist devices (RVADs) typically require groin cannulation or sternal re-entry which can be avoided by direct pulmonary artery implantation with an Impella. We report the first use of the Impella LD as a directly implanted RVAD.

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.

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.

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.

Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p

Background Anomalous left coronary artery from the pulmonary artery is a rare congenital abnormality that requires surgical correction. Case summary We describe the case of a 33-year-old female with a history of anomalous left coronary artery of the pulmonary artery who presents with exertional angina. She underwent a Takeuchi repair that was complicated by a baffle leak. She was successfully treated with left internal mammary artery-left anterior descending (LAD) bypass grafting and percutaneous baffle leak closure. Discussion The Takeuchi procedure involves the creation of an aortopulmonary window and an intrapulmonary tunnel that ‘baffles’ the aorta to the ostium of the anomalous left coronary artery. The most common late complication of the Takeuchi procedure is the presence of a baffle leak. Percutaneous baffle leak occlusion via vascular plug and coronary bypass of the LAD can successfully treat a baffle leak with excellent short-term follow-up.

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 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.

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.

Effects of extracorporeal membrane oxygenation (ECMO) treatment on brain health are currently unknown. For this study, we will noninvasively monitor these patients with diffuse correlation spectroscopy and transcranial doppler ultrasound during ECMO treatment.

Little is known about the temporal trends and outcomes for extra-corporeal membrane oxygenation (ECMO) in patients with high-risk pulmonary embolism (PE) in the United States. We queried the National Inpatient Sample (NIS) database from 2005 to 2013 to identify patients admitted with high-risk PE. Our objective was to determine trends for ECMO use in patients with high-risk PE. We also assessed in-hospital outcomes among patients with high-risk PE receiving ECMO. We evaluated 77,809 hospitalizations for high-risk PE. There was an upward trend in the utilization of ECMO from 0.07% in 2005 to 1.1% in 2013 ( p = 0.015). ECMO was utilized more in urban teaching hospitals and large hospitals. ECMO use was associated with lower mortality in patients with massive PE ( p < 0.001). In-hospital mortality for patients receiving ECMO was 61.6%, with no change over the observational period ( p = 0.68). Our investigation revealed several independent predictors of increased mortality in patients with high-risk PE using ECMO as hemodynamic support, including: age, female sex, obesity, congestive heart failure, and chronic pulmonary disease. ECMO, therefore, as a rescue strategy or bridge to definitive treatment, may be effective in the management of high-risk PE when selecting patients with favorable clinical characteristics.

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.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass that provides life-saving support to critically ill patients whose illness is progressing despite maximal conventional support. Use in adults is expanding, however neurological injuries are common. Currently, the existing brain imaging tools are a snapshot in time and require high-risk patient transport. Here we assess the feasibility of measuring diffuse correlation spectroscopy, transcranial Doppler ultrasound, electroencephalography, and auditory brainstem responses at the bedside, and developing a cerebral autoregulation metric. We report preliminary results from two patients, demonstrating feasibility and laying the foundation for future studies monitoring neurological health during ECMO.

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.

Background: The role of antiplatelet agents in the modulation of arterial disease is well described, but a paucity of data exists regarding their role in chronic venous insufficiency (CVI). We hypothesize that platelet responses to various antiplatelet agents are altered when comparing platelet function within refluxing and non-refluxing vein segments. Additionally, changes in platelet phenotype may alter vein wall biology. Methods: Isolated platelets were obtained simultaneously from the patient antecubital vein (ACV) and a refluxing greater saphenous vein (GSV) during surgical phlebectomy and compared to platelets from healthy individuals. Non-refluxing GSV was harvested for coronary bypass. Platelet surface receptor activation was assessed through P2Y12 (clopidogrel), PAR1 (vorapaxar), and thromboxane (aspirin) pathways by flow cytometry for p-selectin. Immunoblotting assessed CD41 (platelet) and CD45 (WBC) within the wall of vein samples. Results: Platelets from refluxing GSV showed a significant increase in reactivity via all platelet signaling pathways, especially P2Y12 and thromboxane when compared to platelets from the ACV in the same patient. Conversely, platelets collected from the ACV in CVI patients showed a significant decrease in reactivity to all agonists compared to ACV in healthy individuals without CVI. Most notably, GSV from a patient with CVI had a reduction in CD41 content, but a seven-fold increase in the CD45:CD41 ratio, compared to GSV from healthy people (Figure). Conclusions: Platelet activation by these clinically relevant pathways is enhanced locally in the refluxing GSV, yet systemic, circulating platelets isolated from CVI patients are 2-3-fold less active than systemic platelets from healthy people. Our data suggest that reflux may locally alter the circulating platelet phenotype and in turn also have a role in remodeling the vein wall.

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 Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several associated benefits. We hypothesized that the CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). Methods We retrospectively reviewed all patients implanted with a commercial HeartMate 3 at our institution from September 2017 to August 2018 (N=52). Patients were grouped based on surgical technique, CSS or FS. Patients were excluded if they did not see a physical therapist within three weeks postoperatively. The Activity Measure for Post Acute Care (AM-PAC) short forms and Functional Independence Measure (FIM) scores were used to assess postoperative mobility and physical limitations. Results A total of 43 patients were included in the study; 27 (63%) were implanted via the CSS approach and 16 (37%) underwent FS. Preoperative characteristics were similar between cohorts. By postoperative day 3 (POD3), the CSS cohort demonstrated improved mobility based on AM-PAC scores compared to the FS group (Figure 1) with 40% of the CSS cohort versus 67% of the FS cohort remaining 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the FIM sit-to-stand metric (Figure 2) with 78% of the CSS cohort achieving modified or complete independence by POD15 compared to 21% of the FS patients. Conclusion The CSS approach for HeartMate 3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

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.

A 74-year-old man with a past medical history of diabetes mellitus, hypertension, severe aortic stenosis, coronary artery disease status post-coronary artery bypass surgery with left internal mammary artery, vein graft, and aortic valve replacement with a Rapid Deployment Edwards 23-mm Intuity Elite

Background Management of existing aortic insufficiency (AI) and mechanical aortic valves in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. Surgical options to address these issues include closure, repair or replacement of the valve. Methods Continuous-flow LVAD/biventricular VAD patients entered into the INTERMACS database between June 2006 and December 2012 were included ( n = 5,344) in this analysis. Outcomes were compared between patients who underwent aortic valve (AV) closure ( n = 125), repair ( n = 95) and replacement ( n = 85). Results Among patients who underwent an AV procedure, actuarial survival was significantly reduced for AV closures (63.2%) compared with AV repairs (76.8%) and replacements (71.8%) ( p = 0.0003). Differences were greater between groups when only INTERMACS Level 1 or 2 patients were analyzed ( p = 0.003). After multivariate adjustment, AV closure remained a significant risk factor for mortality (hazard ratio=1.87, 95% confidence interval 1.39 to 2.53, p p Conclusions AV closure was associated with increased mortality when compared with repair or replacement in patients with AI who underwent LVAD insertion. The reasons for this association require further investigation. This is the largest study to date to examine concomitant AV procedures in patients undergoing LVAD insertion.

This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)-supported patients.Use of ESAs in patients with LVADs may minimize blood transfusions and decrease allosensitization. ESAs increase thrombotic events, which is concerning because LVADs are sensitive to pump thrombosis (PT).We retrospectively reviewed 221 patients at our center who received a HeartMate II (Thoratec Corp., Pleasanton, California) LVAD between January 1, 2009 and June 6, 2013. Patients were divided into those who received ESAs during index admission (n = 121) and those who did not (n = 100). Suspected PT was defined as evidence of thrombus in the LVAD or severe hemolysis (lactate dehydrogenase1,000 mg/dl or plasma-free hemoglobin40 mg/dl). Outcomes were compared between cohorts using inverse probability-weighted analyses.During a mean follow-up of 14.2 ± 11.9 months, suspected PT occurred in 37 patients (ESA 23%, no ESA 12%; p =0.03). The ESA cohort received ESAs 13.9 ± 60.9 days after LVAD implantation. At 180 days, event-free rates for suspected PT were ESA 78.6% versus no ESA 94.5% (p 0.001). ESA use had higher rates of suspected PT (hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 1.38 to 4.00; p = 0.002). For every 100-unit increase in cumulative ESA dosage, the hazard of suspected PT increased by 10% (HR: 1.10; 95% CI: 1.04 to 1.16; p 0.001). After inverse probability weighting, ESA use was associated with a significantly higher rate of all-cause mortality (HR: 1.62; 95% CI: 1.12 to 2.33; p = 0.01).ESA use in LVAD patients is associated with higher rates of suspected PT.

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 The ENDURANCE and ENDURANCE Supplemental Trials were designed to study the safety and efficacy of the HeartWare LVAD (HVAD) to support patients with advanced heart failure ineligible for transplant compared to the control HM2 device. There is increasing interest in the “less sick” patient with advanced heart failure. It is reasonable to assume that the total length of post-implant hospital stay would be correlated with less perioperative morbidity. Methods The ENDURANCE Trial prospectively randomized 465 patients with advanced heart failure to receive the HVAD (N=296) or the HM2 Control (n=149), and the ENDURANCE Supplemental Trial prospectively enrolled 465 patients (308 HVAD versus 157 control, HM2) with added improved blood pressure management. Data from these trials supported the FDA approval of the HVAD System for destination therapy in advanced heart failure patients. We now present a retrospective analysis of the total length of hospital stay (LOS) following LVAD implant. We separated the patients into 3 groups based on their total hospital stay, and performed Kaplan-Meier analysis as well as freedom from major LVAD-related adverse events over the 24 months post-implant Results There was an inverse relationship between total length of post-implant LOS and survival (p Conclusion The finding that total length of post-implant hospital stay is inversely related to survival is important especially considering the lack of difference in the freedom from bleeding, infection, stroke, and thrombotic events in these subgroups. These data suggest that LOS and subsequent survival is not necessarily related to VAD-related complications, but perhaps to underlying patient baseline condition.

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 Patient-Reported Outcomes Measurement Information System (PROMIS) is a computerized assessment that has been validated across multiple disciplines and chronic disease states. There is limited use of PROMIS in the heart failure patient population. We describe PROMIS scores in a large LVAD patient cohort and compare functional domain measurement to the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Methods LVAD patients completed the PROMIS computer adaptive test for physical function, pain and depression in addition to the KCCQ-12 survey at outpatient visits. PROMIS instruments are standardized to a mean score of 50 for the general population. Only KCCQ-12 completed within 90 days of a PROMIS score were included in the analysis. The nonparametric Spearman's rank correlation measure was used to estimate the strength of the relationship between the PROMIS function score and the KCCQ-12 measure. Results From June 2017 to August 2018, 271 PROMIS scores were completed from 132 different LVAD patients (55 ± 11 years old; 81% male; 58% BTT). Time since LVAD implantation ranged from 32 days to over 8 years (median 945 days). Compared to the general population, LVAD patients reported worse functional status but similar levels of pain and depression (Figure 1). KCCQ-12 was captured for 73 different patients and demonstrated significant positive correlation between the instruments (0.713, p Conclusion The PROMIS score shows a good correlation with the KCCQ-12 in LVAD patients. Further study is needed to determine its utility in predicting outcomes.

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.

Background Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm of endothelial origin with clinical behavior intermediate between hemangioma and angiosarcoma. The natural history of EHE is highly variable. This study uses an Internet registry to identify clinical patterns with prognostic significance in EHE. Methods Cases from the International Hemangioendothioma, Epithelioid Hemangioendothelioma, and Related Vascular Disorders (HEARD) Support Group were evaluated based on demographics, organ involvement, disease progression, presence or absence of pleural effusion, and treatment. Survival among various cohorts was compared using log-rank analysis of Kaplan-Meier plots. Results Two hundred sixty-four patients were identified from April 2004 to November 2009. Fifty-eight cases were excluded because of inadequate information or wrong diagnosis. EHE was more common in female patients (61%). Male gender and age ≥ 55 years were associated with decreased survival. The most commonly affected organs were liver, lung, and bone. No specific organ or combination of organ involvement differentially affected survival, and survival was no different between patients with multiple vs single organ involvement. However, pattern B, defined as lesions without distinct borders (eg, pulmonary infiltrates, pleural effusion, ascites), hemoptysis, or involvement of more than two bones adversely affected survival in all cohorts. Conclusion A novel staging system with prognostic value for EHE is proposed. Pleural effusion or other signs of uncontained tumor growth, hemoptysis, and osseous involvement of more than two bones implied worse survival than did localized and discrete tumors, regardless of number of organs involved. A lay registry can provide useful insights into the clinical behavior of a rare cancer.