AbstractAimsIntra‐aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF‐CS), including those with out‐of‐proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short‐term haemodynamic changes in patients with HF‐CS following IABP support stratified by baseline PAPi.Methods and resultsThis is a single‐centre study of 67 consecutive patients with HF‐CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72 h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72 h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59 years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF‐CS. Thirty‐eight (56%) patients had a PAPi <2.0. Following 72 h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12 mmHg, P < 0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5 mmHg, P = 0.001), and an increase in PAPi (1 to 1.6, P = 0.001). No significant change in cardiac index (CI; 2 to 2.1 L/min/m2, P = 0.31) was observed. The PAPi ≥2.0 group (N = 29) had no observed significant change in CVP (10 to 8 mmHg, P = 0.47), or PAPi (2.6 to 2.8, P = 0.92), but there was a significant improvement in CI (1.9 to 2.5 L/min/m2, P = 0.004) along with reduction in mPA (37 to 29 mmHg, P = 0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P = 0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P = 0.07) compared with the PAPi ≥2.0 group at 72 h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P = 0.02), with no overall significant differences observed in escalation to veno‐arterial extracorporeal membrane oxygenation, 30‐day mortality, renal replacement therapy post‐IABP, or rates of heart transplantation.ConclusionsIABP devices in those with HF‐CS and low or abnormal PAPi may provide modest short‐term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.

PurposeEnd-stage heart failure patients are at an increased risk of severe disease and complications from coronavirus disease-2019 (COVID-19). Additionally, the disease increases perioperative risks The purpose of this study was to describe the clinical course following left ventricular assist device (LVAD) implantation in patients with COVID-19.MethodsA single-center, retrospective review between March 2020 and March 2021 identified 6 patients with a history of COVID-19 who subsequently underwent LVAD implantation. Baseline characteristics, clinical course, and outcomes were examined.ResultsPatients were male (83%), Black (67%), and implanted with a Heartmate 3 for destination therapy. The time from COVID-19 diagnosis to LVAD surgery ranged from 3 days to 6 months (median 40 days, [IQR 12-114 days]). All patients were supported with an intra-aortic balloon pump (IABP) and high-dose inotropes prior to implant. The median age was 60 years (IQR 57-61 years) and body mass index 30 kg/m2 (IQR 24-31 kg/m2). Following implantation, 5 patients (83%) had respiratory failure greater than 7 days on ventilator support, 2 (33%) required tracheostomy, and 2 (33%) were reintubated before successful extubation. Two patients (33%) required temporary right ventricular assist device (RVAD) support, 4 patients (67%) needed continuous renal replacement therapy (CRRT), and 3 patients (50%) suffered ischemic strokes: two patients on postoperative day 1, and the other on postoperative day 5. The median length of hospital stay following surgery ranged from 16 to 73 days (median 53 days, [IQR 35-67 days]). Five patients (83%) were discharged from the hospital, 2 to acute inpatient rehab, 1 to a subacute rehabilitation facility, and 2 to home. Two patients (33%) were readmitted within 30 days for gastrointestinal bleeding and neuropathic pain. There was one (17%) 30-day hospital mortality due to multisystem organ failure following a stroke and the decision to withdraw care. End-stage heart failure patients are at an increased risk of severe disease and complications from coronavirus disease-2019 (COVID-19). Additionally, the disease increases perioperative risks The purpose of this study was to describe the clinical course following left ventricular assist device (LVAD) implantation in patients with COVID-19. A single-center, retrospective review between March 2020 and March 2021 identified 6 patients with a history of COVID-19 who subsequently underwent LVAD implantation. Baseline characteristics, clinical course, and outcomes were examined. Patients were male (83%), Black (67%), and implanted with a Heartmate 3 for destination therapy. The time from COVID-19 diagnosis to LVAD surgery ranged from 3 days to 6 months (median 40 days, [IQR 12-114 days]). All patients were supported with an intra-aortic balloon pump (IABP) and high-dose inotropes prior to implant. The median age was 60 years (IQR 57-61 years) and body mass index 30 kg/m2 (IQR 24-31 kg/m2). Following implantation, 5 patients (83%) had respiratory failure greater than 7 days on ventilator support, 2 (33%) required tracheostomy, and 2 (33%) were reintubated before successful extubation. Two patients (33%) required temporary right ventricular assist device (RVAD) support, 4 patients (67%) needed continuous renal replacement therapy (CRRT), and 3 patients (50%) suffered ischemic strokes: two patients on postoperative day 1, and the other on postoperative day 5. The median length of hospital stay following surgery ranged from 16 to 73 days (median 53 days, [IQR 35-67 days]). Five patients (83%) were discharged from the hospital, 2 to acute inpatient rehab, 1 to a subacute rehabilitation facility, and 2 to home. Two patients (33%) were readmitted within 30 days for gastrointestinal bleeding and neuropathic pain. There was one (17%) 30-day hospital mortality due to multisystem organ failure following a stroke and the decision to withdraw care. Table 1.Table 1Characteristics of LVAD implantation in COVID-19 patientsCharacteristicsPT 1PT 2PT 3PT 4PT 5PT 6Age, years566459476161SexMMMFMMBMI373230311922Race/EthnicityBlackWhiteBlackBlackHispanicBlackHypertensionYYYYYYDiabetesYYNYNNLung DiseaseYNYNNYChronic Kidney DiseaseNYYYYNPrior StrokeYNNNNNINTERMACS Profile333333Time from +SARS-COV-2 PCR to LVAD, days7201321861194Duration on LVAD support, days1943317224345140Days from implant to discharge503071551673Days from implant to extubation73071551673TracheostomyNYYNNNRVAD SupportYNNYNNCRRTYYYYNNStrokeNYNYNYAlive at end of follow-upYNYYYY Open table in a new tab

Inotrope therapy can be utilized as palliation for patients with end stage heart failure who are not candidates for durable devices or transplant. We aim to compare survival and outcomes between patients with and without defibrillators who received palliative inotropes. We retrospectively analyzed 220 patients with American Heart Association Stage D heart failure discharged on palliative inotropes after January 1, 2010. Patients who underwent durable device support or transplant were excluded. Those with a permanent pacemaker (PPM), bi-ventricular pacemaker (BiV-P), or no device were assigned to the Pacer/None group. Patients with an implantable cardioverter defibrillator (ICD), BiV-defibrillator (BiV-D), or LifeVest (Zoll, Chelmsford, MA) were assigned to the Defibrillator group. Primary outcome was 2-year survival. Secondary outcomes were clinic visits and hospitalizations, complications such as infection or arrhythmia, and number of treated tachyarrhythmia episodes. Of 220 patients, 54 were in the Pacer/None group and 168 were in the Defibrillator group. We found no difference in age or gender. In both groups, more patients were placed on milrinone compared to dobutamine, but no difference in days on therapy was seen. Patients in the Defibrillator group were more likely to have hypertension. Patients in the Pacer/None group were more likely to have pulmonary hypertension (see Figure). We found no significant difference in our primary outcome of survival at 2-years post-discharge with 25.8% in the Pacer/None group compared to 26.3% in the Defibrillator group (see Kaplan-Meyer curve). No difference was found in PICC line infections and arrhythmias, number of hospitalizations, and clinic visits within 2-years. No difference was seen in the number of treated arrhythmic episodes within in the Defibrillator group. Those who expired or entered hospice, however, were found to have more treated episodes than those who survived to 2-years. Patients undergoing evaluation for defibrillator implantation are required to meet guidelines on indications and expected survival. As patients with palliative inotropes are living longer, consideration for protection against arrhythmic events is fundamental. Further studies with larger populations are needed to understand the utility of defibrillators in this population. Inotrope therapy can be utilized as palliation for patients with end stage heart failure who are not candidates for durable devices or transplant. We aim to compare survival and outcomes between patients with and without defibrillators who received palliative inotropes. We retrospectively analyzed 220 patients with American Heart Association Stage D heart failure discharged on palliative inotropes after January 1, 2010. Patients who underwent durable device support or transplant were excluded. Those with a permanent pacemaker (PPM), bi-ventricular pacemaker (BiV-P), or no device were assigned to the Pacer/None group. Patients with an implantable cardioverter defibrillator (ICD), BiV-defibrillator (BiV-D), or LifeVest (Zoll, Chelmsford, MA) were assigned to the Defibrillator group. Primary outcome was 2-year survival. Secondary outcomes were clinic visits and hospitalizations, complications such as infection or arrhythmia, and number of treated tachyarrhythmia episodes. Of 220 patients, 54 were in the Pacer/None group and 168 were in the Defibrillator group. We found no difference in age or gender. In both groups, more patients were placed on milrinone compared to dobutamine, but no difference in days on therapy was seen. Patients in the Defibrillator group were more likely to have hypertension. Patients in the Pacer/None group were more likely to have pulmonary hypertension (see Figure). We found no significant difference in our primary outcome of survival at 2-years post-discharge with 25.8% in the Pacer/None group compared to 26.3% in the Defibrillator group (see Kaplan-Meyer curve). No difference was found in PICC line infections and arrhythmias, number of hospitalizations, and clinic visits within 2-years. No difference was seen in the number of treated arrhythmic episodes within in the Defibrillator group. Those who expired or entered hospice, however, were found to have more treated episodes than those who survived to 2-years. Patients undergoing evaluation for defibrillator implantation are required to meet guidelines on indications and expected survival. As patients with palliative inotropes are living longer, consideration for protection against arrhythmic events is fundamental. Further studies with larger populations are needed to understand the utility of defibrillators in this population.

Patients on left ventricular assist device (LVAD) support may be susceptible to severe disease and complications from coronavirus disease-19 (COVID-19). The purpose of this study was to describe the clinical course of COVID-19 in LVAD patients. A retrospective review was performed at our center; 28 LVAD patients who developed COVID-19 between March 2020 and March 2021, and six patients with a prior COVID-19 infection who underwent LVAD implantation, were identified and examined. Of the 28 patients, nine (32%) died during the study period, five (18%) during their index hospitalization for COVID-19. Two patients (7%) presented with suspected pump thrombosis. In a nonadjusted binary regression logistic analysis, admission to the intensive care unit (unadjusted odds ratio, 7.6 [CI, 1.2-48], P = 0.03), and the need for mechanical ventilation (unadjusted odds ratio 14 [CI, 1.3-159], P = 0.03) were associated with mortality. The six patients who previously had COVID-19 and subsequently received a LVAD were on intra-aortic balloon pump and inotropic support at time of surgery. All six experienced a complicated and prolonged postoperative course. Three patients (50%) suffered from ischemic stroke, and there was one (17%) 30 day mortality. We observed an increased risk of morbidity and mortality in LVAD patients with COVID-19.