Impact of Polytetrafluoroethylene Coverage of Left Ventricular Assist Device on Blood Product Utilization During Subsequent Explant and Heart Transplant
Presented During:
Friday, September 20, 2024: 5:00PM - 6:30PM
Omni King Edward Hotel
Abstract No:
10101
Submission Type:
Abstract Submission
Authors:
Chen Chia Wang (1), Mark Petrovic (1), John Trahanas (2), Jennifer Garcia (1), Emma Ye (1), Yuliya Tipograf (2), Alexandra Debose-Scarlett (2), Swaroop Bommareddi (2), Duc Nguyen (2), Hasan Siddiqi (2), Christina Jelly (2), Aditi Balakrishna (2), Kelly Schlendorf (2), Ashish Shah (2), Brian Lima (2)
Institutions:
(1) Vanderbilt University School of Medicine, Nashville, TN, (2) Vanderbilt University Medical Center, Nashville, TN
Submitting Author:
Chen Chia Wang
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Vanderbilt University School of Medicine
Vanderbilt University School of Medicine
Co-Author(s):
Mark Petrovic
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Vanderbilt University School of Medicine
Vanderbilt University School of Medicine
John Trahanas
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Jennifer Garcia
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Vanderbilt University School of Medicine
Vanderbilt University School of Medicine
Emma Ye
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Vanderbilt University School of Medicine
Vanderbilt University School of Medicine
Yuliya Tipograf
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Alexandra Debose-Scarlett
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Swaroop Bommareddi
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Duc Nguyen
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Hasan Siddiqi
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Christina Jelly
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Aditi Balakrishna
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Kelly Schlendorf
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
*Ashish Shah
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
♦Brian Lima
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Vanderbilt University Medical Center
Vanderbilt University Medical Center
Presenting Author:
Chen Chia Wang
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Abstract:
Objective: Left ventricular assist device (LVAD) explant at the time of heart transplantation (HT) remains technically challenging and can be associated with perioperative hemorrhage. Techniques such as wrapping the outflow graft and/or chassis with polytetrafluoroethylene (PTFE) during implantation may facilitate hemostasis during redo sternotomy and adhesiolysis. However, these safeguards are not universally adopted or formally evaluated. In this study, we investigated the association between PTFE coverage of LVAD components and intraoperative and postoperative blood requirements during the subsequent LVAD explant-HT.
Methods: From November 2018 to December 2023, a total of 623 HTs were performed at a single institution. Of these, only patients with intrathoracic, fully magnetically levitated centrifugal-flow LVAD explants were included in our study. Patients were divided into four groups based on coverage during implantation: no PTFE coverage, chassis coverage only, outflow graft coverage only, and complete coverage. Intraoperative blood requirement was calculated as the sum of all intraoperative packed red blood cell (pRBC), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusions. Postoperative blood requirement was the sum of all pRBC, platelet, and FFP transfusions within 48 hours of HT. Multivariate linear regression models were used to control for other factors associated with blood product use, such as multi-organ transplant and history of multiple sternotomies. Other outcomes included cumulative 48-hour postoperative chest tube output, rates of reoperation for bleeding, extracorporeal membrane oxygenation (ECMO) requirement, and 30-day and one-year mortality.
Results: There were 104 qualifying VAD-explant HT during the study period, of which 18 had no PTFE coverage, 24 had only outflow graft coverage, 3 had only chassis coverage, and 59 had complete coverage. Donor and recipient demographics, cold ischemic time, and predicted heart mass ratio were similar between groups. Recipient baseline platelets, international normalized ratio, number of prior sternotomies, and rates of multi-organ transplant were also comparable. Patients with both outflow graft and chassis covering had significantly lower cumulative chest tube output (1838 vs 3191mL, p=0.037) compared to patients with no PTFE covering, but no significant difference compared to patients with only outflow graft (p=0.848) or chassis (p=0.948) covering. Linear regression adjusting for prior sternotomies and multi-organ transplants demonstrated that, relative to LVADs with both outflow graft and chassis covered, LVADs with no PTFE coverage had significantly higher intraoperative (estimate 2367 mL, SD 768, p=0.003) and postoperative transfusion requirements (estimate 2677 mL, SD 983, p=0.008). Rates of reoperation for bleeding, ECMO at 24 hours post HT, and mortality at 30 days and one year were comparable between the study groups.
Conclusions: LVAD implant techniques are currently heterogeneous in clinical practice, and difficult explants pose a major risk for hemorrhage during and after HT. This study demonstrated that PTFE coverage of the outflow graft and chassis during implant of the LVAD type examined is associated with substantially lower intraoperative and postoperative blood products utilization. Adopting this technique as standard of care during implants could greatly reduce the risk for patients requiring LVAD implant as a bridge to HT.
Methods: From November 2018 to December 2023, a total of 623 HTs were performed at a single institution. Of these, only patients with intrathoracic, fully magnetically levitated centrifugal-flow LVAD explants were included in our study. Patients were divided into four groups based on coverage during implantation: no PTFE coverage, chassis coverage only, outflow graft coverage only, and complete coverage. Intraoperative blood requirement was calculated as the sum of all intraoperative packed red blood cell (pRBC), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusions. Postoperative blood requirement was the sum of all pRBC, platelet, and FFP transfusions within 48 hours of HT. Multivariate linear regression models were used to control for other factors associated with blood product use, such as multi-organ transplant and history of multiple sternotomies. Other outcomes included cumulative 48-hour postoperative chest tube output, rates of reoperation for bleeding, extracorporeal membrane oxygenation (ECMO) requirement, and 30-day and one-year mortality.
Results: There were 104 qualifying VAD-explant HT during the study period, of which 18 had no PTFE coverage, 24 had only outflow graft coverage, 3 had only chassis coverage, and 59 had complete coverage. Donor and recipient demographics, cold ischemic time, and predicted heart mass ratio were similar between groups. Recipient baseline platelets, international normalized ratio, number of prior sternotomies, and rates of multi-organ transplant were also comparable. Patients with both outflow graft and chassis covering had significantly lower cumulative chest tube output (1838 vs 3191mL, p=0.037) compared to patients with no PTFE covering, but no significant difference compared to patients with only outflow graft (p=0.848) or chassis (p=0.948) covering. Linear regression adjusting for prior sternotomies and multi-organ transplants demonstrated that, relative to LVADs with both outflow graft and chassis covered, LVADs with no PTFE coverage had significantly higher intraoperative (estimate 2367 mL, SD 768, p=0.003) and postoperative transfusion requirements (estimate 2677 mL, SD 983, p=0.008). Rates of reoperation for bleeding, ECMO at 24 hours post HT, and mortality at 30 days and one year were comparable between the study groups.
Conclusions: LVAD implant techniques are currently heterogeneous in clinical practice, and difficult explants pose a major risk for hemorrhage during and after HT. This study demonstrated that PTFE coverage of the outflow graft and chassis during implant of the LVAD type examined is associated with substantially lower intraoperative and postoperative blood products utilization. Adopting this technique as standard of care during implants could greatly reduce the risk for patients requiring LVAD implant as a bridge to HT.
Mechanical Support and Thoracic Transplantation Summit:
ECMO/Mechanical Support
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