Lipid-In, Sugar-Out: Early Results of Treatment with additional Ketogenic Parenteral Nutrition in Left Ventricle Assist Device Patients.

Background and Aims: Right ventricle failure (RVF) can be a fatal complication following left ventricle assist device (LVAD) implant. Careful intra and postoperative management is becoming increasingly important. Unfortunately, the attempts are limited to the prediction and not to the treatment. There are no data on Ketogenic parenteral nutrition (KPN) for the targeted treatment of RVF. The aim of our retrospective observational case-control study is to determine whether KPN may play a role as additional treatment to conventional therapy after LVAD implantation.Material and Methods: This is a retrospective single center analysis of a case series on prospectively collected data. From February 2012 to April 2021, 192 patients have been implanted with an LVAD. All the patients were managed with optimal medical and surgical therapy. One-hundred-seven patients were treated with additional KPN as adjuvant therapy against and in prevention of acute RVF (KPN-Group), defined according to International Society Heart and Lung Transplantation (ISHLT) guidelines. The remaining 85 patients, managed without KPN, constituted our control group (No-KPN-Group).Results: In KPN-Group acute-RVF occurred in 31 patients (29%), while causing death in 14 patients (13%). In the No-KPN-Group acute-RVF was observed in 32 patients (37.6%), while causing death in 20 patients (23.5%). According to echocardiographic and hemodynamic results, the majority of KPN-Group patients responded with RV function improvement (range 4–60% of TAPSE increase, p < 0.05) with recovery of RV function in 85% of the patients (91/107). In No-KPN-Group RV functional recovery was observed in 65 patients (76.4%). Overall intra-hospital mortality was 23.4% (25) and 27.1% (23) in KPN-Group and No-KPN-Group, respectively (p = 0.337). While Intensive Care Unit (ICU) stay was comparable (p = 0.078), ward-stay was significantly shorter in KPN-Group (p = 0.03).Conclusion: KPN was well tolerated. A complete recovery of the RV function was achieved in the majority of the patients and results lasted beyond the duration of KPN. Future research to understand the underlying mechanism, and identification of suitable patients and treatment duration is necessary.

Abstract 15339: Prediction of Severe Right Ventricular Failure After Left Ventricle Assist Device Using Echocardiographic Right Ventricular Dp/dt

Introduction: Right ventricular failure (RVF) remains a major cause of morbidity and mortality after continuous flow Left Ventricle Assist Device (CF-LVAD) implantation. Previous risk assessments using pre-operative data to predict RVF have performed only modestly well. Methods: We retrospectively studied the potential of echocardiographic RV dP/dt - a non-invasive measure of right ventricular contractility derived from the Doppler signal of tricuspid regurgitation, to predict post-LVAD RVF in patients who were inotrope-independent and those who were on inotropic therapy prior to LVAD. Sixty-five consecutive CF-LVAD recipients at Vanderbilt University Medical Center from 2013-2019 who had a baseline echocardiogram without inotrope support within 3 months prior to LVAD implantation were included. Forty patients from the cohort were started on inotropes prior to LVAD implantation. Baseline off-inotrope and on-inotrope RV dP/dt data were analyzed. Severity of post-LVAD RVF was defined by INTERMACS criteria. Results: Of the 65 studied patients, 30 patients had none or mild RVF, 17 had moderate RVF, and 18 had severe RVF. Patients with severe RVF had markedly poorer survival outcome than no/mild and moderate RVF patients. Baseline RV dP/dt was significantly lower in patients who developed post-LVAD severe RVF. A baseline off-inotrope, or on-inotrope RV dP/dt ≥ 300 mmHg/s predicted a low risk of severe RVF with high sensitivity (89% and 80%, respectively) and negative predictive value (91% and 88% respectively); while the presence of both off-inotrope and on-inotrope RV dP/dt < 300 mmHg/s was associated with a high likelihood of post-LVAD RVF (OR 10.5, 95% 1.8-59.4 compared to the rest of the cohort on inotrope therapy). Conclusion: Echocardiographic RV dP/dt may be a valuable adjunct tool for prediction of post-LVAD severe RVF in patients undergoing evaluation for LVAD implantation.

Effects of implanting a long-term left ventricle assist device on post-transplant outcomes

Background: An increasing number of patients are receiving left ventricle assist devices as a bridge to heart transplantation. The aim of this study was to determine the difference between patients who received transplants from a left ventricle assist device and those who underwent heart transplantation without a prior left ventricle assist device implantation. Material and methods: The study included patients who underwent heart transplantation in our institute between January 2010 and November 2018. The following clinical variables were evaluated: donor characteristics, patient’s pre-transplant demographical data, post-transplant data, and patient survival. Cardiac allograft vasculopathy progression was prospectively examined (after 1 month and 12 months after heart transplantation) by coronary optical coherence tomography. We were interested in the difference in 1- and 5-year survival between the left ventricle assist device and non-left ventricle assist device groups. Results: A total of 248 patients were identified; out of them, 48 patients received a left ventricle assist device before heart transplantation, whereas 200 had transplants with no prior left ventricle assist device implantation. There were no significant differences in any donor characteristics. The mean duration of cardiopulmonary bypass time in the non-left ventricle assist device group was 156 versus 175 min in the left ventricle assist device group ( p = 0.009), blood loss was 650 versus 1045 mL ( p < 0.001), the need to implant an extracorporeal membrane oxygenation was 10% versus 23% ( p = 0.02). There was no difference in cardiac allograft vasculopathy progression between the groups 1 year after heart transplantation ( p = 0.528). The 1- and 5-year survival, according to Kaplan–Meier, was 80% and 70% in the left ventricle assist device group, compared to 80% and 73%, respectively, in the non-left ventricle assist device group (Log-rank test: p = 0.945). Conclusion: Our results indicate that patients undergoing heart transplantation from left ventricle assist devices suffer significantly more from intraoperative and post-operative complications; however, only insignificant cardiac allograft vasculopathy progression and survival differences between the two groups were observed.