Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: A Society of Thoracic Surgeons database analysis

Robertson, Jason O.; Grau‐Sepulveda, Maria V.; Okada, Shoichi; O’Brien, Sean M.; Brennan, J. Matthew; Shah, Ashish S.; Itoh, Akinobu; Damiano, Ralph J.; Prasad, Sunil; Silvestry, Scott C.

doi:10.1016/j.healun.2014.01.861

Cited by 85 publications

(62 citation statements)

References 23 publications

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“…Concomitant TVR, however, was not associated with RVAD risk in the INTERMACS registry. This finding is similar to those from the Society for Thoracic Surgeons (STS) 25 and HeartWare bridge-to-transplant (ADVANCE) trial datasets 23 . Among patients with severe TR undergoing implantation of a centrifugal-flow LVAD, those who received concomitant TVR were less likely to develop late RHF 23 .…”

Section: Discussionsupporting

confidence: 84%

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Kiernan

Grandin

Brinkley

et al. 2017

Circ: Heart Failure

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Background To investigate pre-implant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) surgery. Methods and Results Patients in the INTERMACS registry who underwent primary CF-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined endpoint of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9,976 patients undergoing CF-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Pre-implant characteristics associated with RVAD use included INTERMACS patient profiles 1 and 2, the need for preoperative ECMO or renal replacement therapy, severe pre-implant tricuspid regurgitation, history of prior cardiac surgery, and concomitant procedures other than TV repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (AUC 0.78) and the combined end-point of RVAD or death within 14 days (AUC 0.73). Compared to patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9% respectively (p<0.0001 for both). Conclusions The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction and profiles of hemodynamic instability.

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Section: Discussionsupporting

confidence: 84%

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Kiernan

Grandin

Brinkley

et al. 2017

Circ: Heart Failure

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“…It is common surgical practice to repair moderate-severe TR at the time of CF-LVAD implantation to decrease the chances of a sudden increase in preload. 24 However, a recent meta-analysis 28 on concomitant tricuspid valve procedures in patients with severe preoperative TR undergoing LVAD implantation showed worse early postoperative outcomes and no reduction in early death or the need for early right-sided mechanical circulatory support.…”

Section: Surgical Managementmentioning

confidence: 99%

Predictors and Management of Right Heart Failure after Left Ventricular Assist Device Implantation

Fida¹,

Loebe²,

Estep³

et al. 2015

Methodist DeBakey Cardiovascular Journal

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Early recognition and improved outcomes of ischemic heart disease has resulted in an aging population and a global increase in the prevalence of heart failure (HF).1 Consequently, the burden of stage D heart failure (HF), which is unresponsive to conventional medical therapy, has surpassed the availability of the finite donor organ pool. 2 Significant advances in the field of mechanical circulatory support has made destination therapy (DT) with left ventricular assist devices (LVADs) a promising alternative to heart transplantation, with 1-year postimplant actuarial survival at about 80% with a continuous flow LVAD (CF-LVAD). 3However, despite newer technology and greater familiarity with patient management, physicians continue to be confronted by early and/or late right ventricular failure (RVF) that significantly impacts survival post-LVAD implantation. As none of the current mechanical circulatory support (MCS) devices are approved for DT for solitary right heart support or biventricular support, it is critical to identify preoperative predictors of right heart failure post-LVAD implant. Definition and Incidence of Right Ventricular Failure after LVAD PlacementIn the absence of a universally agreed-upon definition of RVF after LVAD placement, its reported incidence varies with the institutional practice, the United Network for Organ Sharing (UNOS) indication for MCS, the device type, and the criteria used to define failure. Additionally, it is now recognized that RVF is a progressive condition that can occur beyond the immediate postoperative period. However, this emerging concept of "late RVF" remains ill-defined and difficult to predict. The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) defines RVF as persistent signs and symptoms of RV dysfunction evident by central venous pressure (CVP) > 18 mm Hg with a cardiac index (CI) < 2.0 L/min/m 2 in the absence of increased left atrial filling pressure/pulmonary capillary wedge pressure (PCWP) > 18 mm Hg, cardiac tamponade, ventricular arrhythmias, and/or pneumothorax requiring either right ventricular assist device (RVAD) implantation or inhaled nitric oxide or inotropic therapy for ≥ 14 days after LVAD implantation. 4 According to INTERMACS, RVF severity is described as follows:• Severe, when there is a need for RVAD; • Moderate, when inotropes or intravenous or inhaled pulmonary vasodilators are used; and • Mild, when a combination of ≥ 2 signs and symptoms are present but without the need for RVAD or inotropic and/ or vasodilator support. Signs and symptoms include CVP > 18 mm Hg, CI < 2.3 L/min/m 2 , ascites, moderate to severe peripheral edema, or evidence of high CVP on physical exam or transthoracic echocardiogram.The incidence of severe RVF necessitating RVAD placement after LVAD or preemptive BiVAD support is reported to be anywhere from 9.4% to 37.0%. [5][6][7][8][9] Most studies have reported the incidence encompassing the need for inotropic support with or without RVAD (≥ 14 days) after LVAD implant, with a range of b...

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“…A recent study demonstrated performing a TVP did not reduce early death or requirement for RVAD, and was associated with worse early inhospital postoperative outcomes. 16 Some investigators have reported a more aggressive approach to tricuspid valve annuloplasty in patients with LVAD placement. 12,17,18 We believe that the evidence supporting this approach remains unclear.…”

Section: Tricuspid Insufficiencymentioning

confidence: 99%

Outcomes After Concomitant Procedures with Left Ventricular Assist Device Implantation: Implications by Device Type and Indication

Maltais

Haglund

Davis³

et al. 2016

ASAIO Journal

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Guidelines for performing concomitant procedures (CPs) in patients undergoing continuous flow-left ventricular assist device (CF-LVAD) implantation are unclear. The impact of an increased surgical complexity outside the constraint of landmark clinical trials has not been reported. From May 2004 to December 2013, 614 patients (499 males, 81%) underwent CF-LVAD implant at our institutions. Median age was 57 ± 13 years and 364 (59%) were bridge to transplantation (BTT). Survival and device-related complications were analyzed and stratified based on the surgical intervention. A total of 398 patients (65%) underwent CF-LVAD implantation without CPs. The remaining patients (35%, n = 216) were grouped according to various CPs. Survival was comparable between groups and not influenced by the CP, device type, or indication for implant. Time-to-first device-related adverse event was shorter in patients with CPs. Regression analysis revealed only increased age (p = 0.03), increase in baseline creatinine (p = 0.002), cardiopulmonary bypass time (p = 0.03), and decreased body mass index (p = 0.03) were predictors of mortality, whereas only age (p = 0.006) and prior sternotomy (p = 0.02) were related to adverse device-related events. Performing CPs leads to comparable survival and device-related outcomes after implant. The decision to perform CPs should be balanced with age, preoperative renal dysfunction, and projected complexity of surgery.

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Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: A Society of Thoracic Surgeons database analysis

Cited by 85 publications

References 23 publications

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Predictors and Management of Right Heart Failure after Left Ventricular Assist Device Implantation

Outcomes After Concomitant Procedures with Left Ventricular Assist Device Implantation: Implications by Device Type and Indication

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