Introduction:
Right ventricular failure (RVF) and ventricular tachyarrhythmias (VA) are common causes of poor outcome and mortality in patients with left ventricular assist device (LVAD). VA can precipitate RVF and inotropic therapy can further exacerbate VA. The purpose of this observational study was to investigate the individual and combined impact of RVF and VA on mortality in the early postoperative period after LVAD.
Methods:
We performed a retrospective analysis of patients undergoing implantation of an LVAD between 2014 to 2017 (N=110). Telemetry tracings and device interrogations were reviewed. Early VA was defined as any ventricular tachycardia and ventricular fibrillation within the first month after LVAD associated with hemodynamic compromise that required device therapy, catheter ablation, and/or antiarrhythmic therapy. Kaplan-Meier statistics with the Mantel-Cox log-rank test was used to analyze survival.
Results:
We identified 110 LVAD patients, age 57±13 years, 80 males (73%), ischemic cardiomyopathy n=54 (49%), (HeartWare (n=44), HeartMate II (n=44), and HeartMate III (n=22)). Patients were categorized into group A - early VA and severe RVF (n=14); group B - early VA without RVF (n=16); group C - severe RVF without early VA (n=33); and group D - neither VA nor RVF (n=47). The 1-year survival of group A, B, C, and D was 50%, 69%, 73%, and 89%, respectively (p=0.001 comparing each group to the other groups, enclosed figure). The presence of early VA did not relate to RVF (p=0.7). Pre-operative VA was related to post-LVAD VA (RR 9.4, p=0.003).
Conclusions:
Patients without early VA or severe RVF demonstrated the best survival. Both, VA and severe RVF decreased survival. The presence of both, VA and RVF appears to potentiate mortality. Pre-operative VA is related to post-LVAD VA. These data raise the question if intra-operative ablative therapy in patients undergoing LVAD implantation could improve post-operative mortality, VA, and RVF.
Objective: Few reports have evaluated postoperative continuous thoracic epidural analgesia on patients who received a lung transplant. This analgesic modality may facilitate extubation, early ambulation, and achieve adequate pain control with minimization of opioid use. An opioid sparing technique could minimize the side effects of opioids such as ileus, constipation, and somnolence.Methods: A retrospective chart review following local IRB approval was performed. A total of 97 patients’ charts were collected, from April 2015 to March 2017. Forty-eight patients received T6-7 epidural, and forty-nine patients received standard intravenous (IV) analgesia. Outcome measures collected included length of intensive care unit stay, total duration of hospitalization, need for reintubation or noninvasive intermittent positive pressure ventilation (NIPPV), need for IV lidocaine gtt, and total narcotics consumption during hospitalization in milligrams of morphine equivalents (MME).Results: Both groups were comparable in age, BMI, and race/gender distribution. Additionally, patient pain requirements were comparable between groups. However, a significantly smaller proportion of thoracic epidural patients required NIPPV post-operatively, (20.4%, 53.2%: p = .0015). Further, the number of patients requiring reintubation was almost halved, (12.5%, 21.3%: NS). Patients receiving thoracic epidural also experienced shorter ICU times (p = .0335) and on average, an overall reduced length of stay by six days.Conclusions: For patients undergoing lung transplant, epidural analgesia is a viable alternative to IV pain control. Further, it significantly reduced respiratory depression and length of stay in the ICU. More refined comparisons can be made by conducting a precise prospective study with a more structured protocol in place.
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