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Ann Thorac Surg 2010;89:522-529. doi:10.1016/j.athoracsur.2009.11.016
© 2010 The Society of Thoracic Surgeons
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Jay K. Bhama
Prasad S. Adusumilli
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Kenneth R. McCurry
Robert L. Kormos
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Right arrow Mechanical Circulatory Assistance

Original Articles: Adult Cardiac

Impact of Abdominal Complications on Outcome After Mechanical Circulatory Support

Jay K. Bhama, MDa,*, Steven Rayappa, BSa, Diana Zaldonis, MPH, BSNa, Prasad S. Adusumilli, MDa, Aditya Bansal, MDa, Elizabeth A. Genovese, BSa, Jeffrey J. Teuteberg, MDb, Yoshiya Toyoda, MD, PhDa, Michael P. Siegenthaler, MDa, Christian A. Bermudez, MDa, Kenneth R. McCurry, MDa, Robert L. Kormos, MDa

a Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
b Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication November 3, 2009.

Abbreviations and Acronyms AC = abdominal complication; AW = abdominal wall; Bi-PVAD = biventricular paracorporeal ventricular assist device; GI = gastrointestinal; GT = gastrointestinal tract; HR = hazard ratio; IC = intracorporeal; L-IVAD = left intracorporeal ventricular assist device; L-PVAD = left paracorporeal ventricular assist device; MCS = mechanical circulatory support; PC = paracorporeal; RV = right ventricular; SO = solid organ

* Address correspondence to Dr Bhama, Department of Surgery, Heart, Lung and Esophageal Surgery Institute, Division of Cardiac Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-900, Pittsburgh, PA 15213 (Email: bhamajk{at}upmc.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
Background: Mechanical circulatory support (MCS) is life sustaining for patients with end-stage heart failure. Most devices require abdominal wall transgression, creating a potential for abdominal complications. The incidence and impact of these relatively underreported complications are unknown.

Methods: A retrospective review was performed on 179 patients who received MCS therapy from 1999 to 2008. Abdominal complications were grouped as abdominal wall, gastrointestinal tract, and solid organ.

Results: Ninety-eight patients (55%) experienced 157 abdominal complications. These involved the abdominal wall in 69 (44%), the gastrointestinal tract in 52 (33%), and the solid organs in 36 (23%). Surgical intervention was required in 36% of patients with abdominal wall complications, 19% of patients with gastrointestinal tract complications, and 14% of patients with solid organ complications. Multivariate analysis identified diabetes mellitus (p < 0.001), emergent device placement (p = 0.019), and preimplant mechanical ventilation (p = 0.045) as independent risk factors for developing an abdominal complication. Kaplan-Meier survival while receiving MCS was significantly reduced for patients with abdominal complications versus those without (p = 0.0142). Multivariate analysis identified only solid organ abdominal complications (p = 0.001) as an independent risk factor for death while receiving device support.

Conclusions: Abdominal complications are common in patients supported with MCS devices and significantly reduce survival. Surgical intervention is more frequently required for complications related to the abdominal wall compared with other complications. Patients with significant comorbidities (diabetes mellitus, respiratory failure) requiring urgent or emergent device placement are at higher risk for the development of abdominal complications with an attendant reduction in device-related survival.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
It is estimated that more than 500,000 new cases of heart failure are diagnosed yearly in this country. Owing primarily to the paucity of available donors for cardiac transplantation, mechanical circulatory support (MCS) has emerged as a viable treatment option for those with end-stage heart failure, applied as a bridge to cardiac transplantation or also as permanent or "destination" therapy.

Mechanical circulatory support devices are positioned either in a paracorporeal position with cannulas that traverse the abdominal wall or, alternatively, in an intracorporeal position with the device sitting either within the peritoneum or abdominal wall itself. As most devices require some form of abdominal wall transgression for placement, there is a concomitant risk for abdominal complications that may be related to device placement. Additional factors associated with MCS devices such as anticoagulation, exposure of the blood to extravascular surfaces, and venous congestion attributable to right ventricular (RV) dysfunction may also contribute to visceral organ complications.

The literature regarding abdominal complications after MCS is limited, and the incidence and impact of these relatively underreported complications are, therefore, unknown. The purpose of this study is to characterize the types of abdominal complications that occur after MCS device placement and to determine their incidence and impact on outcomes.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Patients
Approval was obtained from the University of Pittsburgh Medical Center Institutional Review Board, and informed consent and permission for the release of information was obtained from each patient. A retrospective review was performed of our prospectively maintained MCS database. From 1999 to 2008, 179 patients were treated with MCS therapy. Relevant demographic and perioperative outcome data, including the development of abdominal complications as defined below, were collected for all patients. The MCS devices used for isolated left ventricular support included the HeartMate XVE, HeartMate II, VentrAssist, Thoratec paracorporeal ventricular assist device, or the Thoratec intracorporeal ventricular assist device. Biventricular assist was achieved with biventricular Thoratec ventricular assist devices.

Definition of Abdominal Complications
Each abdominal complication was grouped as follows: (1) abdominal wall (AW), (2) gastrointestinal tract (GT), and (3) solid organ (SO). Abdominal wall complications included (1) bleeding, dehiscence, or infection involving the abdominal portion of the wound or device pocket or infection of the drive line of an intracorporeal device, (2) bleeding or infection of the inflow or outflow cannula site of a paracorporeal device, (3) incisional hernias, and (4) retroperitoneal bleeding. Isolated mediastinitis was not considered an abdominal complication unless there was involvement of the abdominal wall or device pocket. Gastrointestinal tract complications included (1) upper or lower gastrointestinal (GI) bleeding, (2) bowel infarction, (3) bowel obstruction, (4) bowel perforation, (5) ileus, (6) infection with Clostridium difficile, (7) appendicitis, and (8) negative exploratory laparotomy. Solid organ complications included (1) transient hyperbilirubinemia (total bilirubin > 3 times the upper limit of normal), (2) hepatic insufficiency (total bilirubin, aspartate aminotransferase or alanine aminotransferase elevation to a level > 3 times the upper limit of normal), (3) pancreatitis (elevated lipase above the upper limit of normal) with or without pseudocyst formation, (4) cholecystitis, (5) choledocholithiasis, and (6) hemorrhage from spleen or liver.

Statistical Analysis
Statistical analysis was performed using Stata version 10 (StataCorp LP, College Station, TX). Descriptive statistics are reported as mean ± standard deviation. Fisher's exact test and independent Student's t test were used for qualitative and quantitative variable analysis, respectively. Actuarial survival estimates were calculated using Kaplan-Meier life table analysis. Patients were censored at the time of death while on the device, at heart transplantation, or after successful device removal. The log rank statistic was used to determine whether the survival curves differed with a probability value of less than 0.05 considered statistically significant.

Univariate and multivariate analyses with Cox proportional-hazards regression were used to determine independent preimplant risk factors for the development of an abdominal complication as well as independent postimplant risk factors for mortality while receiving MCS therapy. Exploration for high correlation between predictor variables was performed using two-sided Pearson correlation. Factors found to be significant by univariate analysis (p < 0.05) were subjected to multivariate analysis after excluding factors with significant correlation. The preimplant variables analyzed were age (>70 or <55 years), sex, race (white, African American, other), device mechanism (pulsatile versus nonpulsatile), device position (intracorporeal versus paracorporeal), body mass index ranges (<18.5, 18.5–25.9, 26–29.9, >30), diabetes mellitus, prior sternotomy, mechanical ventilation (at any point during the hospitalization before implant), hemodialysis, intraaortic balloon pump support, treatment intent (bridge to transplant, recovery support, permanent support), and treatment urgency (elective, urgent, emergent). The postimplant variables analyzed were number of abdominal complications (single, double, triple, multiple), type of abdominal complication (AW, GT, SO), cardiac arrhythmia, tracheostomy, reoperation for bleeding, need for RV MCS, renal insufficiency, hemodialysis, pneumonia, and bloodstream infection.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
Ninety-eight patients (52%) experienced 157 abdominal complications summarized in Table 1. Abdominal complications most commonly involved the AW (44%) followed by the GT (33%) and SO (23%). The need for major surgical intervention based on the complication group is also listed in Table 1. Figure 1 demonstrates the incidence and distribution of the major abdominal complication groups according to the specific MCS device.


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  		Table 1 Incidence of Various Abdominal Complications and the Need for Surgical Intervention After Mechanical Circulatory Support Therapy
 

Figure 1
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  		Fig 1. Distribution of major abdominal complication (AC) groups according to specific mechanical circulatory support device. (AW = abdominal wall; Bi-PVAD = biventricular paracorporeal ventricular assist device; GT = gastrointestinal tract; L-IVAD = left intracorporeal ventricular assist device; L-PVAD = left paracorporeal ventricular assist device; SO = solid organ.)

 
Demographics, comorbidities, and preoperative hemodynamics for patients with and without abdominal complications are compared in Table 2. Both groups were similar with regard to preoperative age, sex, diagnosis, and comorbidities including diabetes, hypertension, prior cardiac surgery, and renal insufficiency. Patients who experienced abdominal complications had a significantly higher incidence of having preoperative respiratory failure requiring mechanical ventilation at some point during their admission for device placement and lower mean pulmonary artery pressures. They also underwent urgent and emergent device placement and received intracorporeal devices more frequently. There was no difference between groups regarding the specific type of device placed or the treatment intent, with the majority of patients being treated as a bridge to transplantation. Multivariate Cox regression analysis revealed diabetes mellitus, emergent device placement, and mechanical ventilation to be preoperative risk factors independently predictive of developing an abdominal complication (Table 3).


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  		Table 2 Demographic Characteristics
 

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  		Table 3 Multivariate Analysis of Preimplantation Risk Factors a
 
Postoperative adverse events experienced by this cohort of patients are compared in Table 4. The incidence of postoperative cardiac arrhythmias, prolonged mechanical ventilation requiring tracheostomy, RV failure requiring MCS, renal insufficiency, and infection were higher in patients who experienced abdominal complications. Multivariate Cox regression analysis revealed SO abdominal complications to be the only postoperative adverse event independently predictive of mortality while receiving MCS therapy (Table 5).


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  		Table 4 Postoperative Adverse Events
 

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  		Table 5 Multivariate Analysis of Postimplantation Adverse Events a
 
Kaplan-Meier survival analysis comparing device survival in patients with and without abdominal complications is demonstrated in Figure 2. Survival was significantly reduced for patients who experienced an abdominal complication versus those who did not. Survival analysis based on the type of abdominal complication experienced is shown in Figure 3. Patients who experienced SO complications or multiple abdominal complications had significantly worse survival than those who experienced no abdominal complications (Fig 3A). Patients who experienced GT complications trended toward worse survival, but this was not statistically significant (Fig 3B). There was no difference in survival for patients who experienced AW complications compared with those who experienced no AW complication (Fig 3B).


Figure 2
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  		Fig 2. Overall Kaplan-Meier survival while receiving mechanical circulatory support therapy based on the development of an abdominal complication (AC).

 

Figure 3
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  		Fig 3. Kaplan-Meier survival while receiving mechanical circulatory support comparing patients without abdominal complications (AC) with those who experienced solid organ (SO) or multiple abdominal complications (A) and those who experienced abdominal wall (AW) or gastrointestinal tract (GT) complications (B).

 

   Comment
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
The present study demonstrates that the incidence of abdominal complications after MCS therapy is higher than previously reported and significantly reduces survival while on the device. Meticulous attention to surgical technique may limit complications related to abdominal wall transgression (ie, device pocket infection, visceral organ trauma, bowel obstruction); however, numerous physiologic pathways may also contribute to the development of abdominal complications after MCS therapy. Organ ischemia related to poor end-organ perfusion as well as a systemic inflammatory response related to cardiopulmonary bypass and blood contact with extravascular surfaces may contribute to the development of intraabdominal organ dysfunction. Coexisting RV dysfunction may also contribute to organ failure by venous congestion.

The incidence of abdominal complications after MCS therapy has not been specifically defined. Reports in the literature are limited largely to case reports and small cases series [1–5] largely describing mechanical or bleeding complications after MCS device placement. Most large series have focused on device-related infectious complications but have failed to provide information regarding other abdominal complications, especially those related to the solid organs and gastrointestinal tract. Constantini and colleagues [6] reported the only other large series of abdominal complications after MCS therapy. In that study, which also focused largely on infectious complications, the incidence of abdominal complications in 100 patients treated with MCS therapy was 11%, with a pretransplant mortality rate of 36%. Patients without an abdominal complication experienced a mortality rate of 17%, although this was not a statistically significant difference. Hardware infection was the most common and serious complication in that series of patients followed by nearly equivalent rates of other complications including hernia, bleeding, pancreatitis, and cholecystitis. The overall incidence of abdominal complications reported by Constantini and colleagues [6] is lower than what we report here, likely related to our more liberal definition for what constitutes an abdominal complication. In addition to the typical abdominal complications that were investigated by Constantini and colleagues [6], we also included SO problems such as transient hyperbilirubinemia, hepatic insufficiency, and pancreatitis, as well as GT problems such as upper or lower GI bleeding, and C difficile infection. Given that these complications have been noted to have a major impact on postoperative recovery as well as outcomes and that other studies have failed to tabulate their incidence, we believe we are justified in including them as significant abdominal complications [7].

Abdominal wall complications are the most commonly described abdominal complication after MCS therapy and have been the focus of most large studies describing postoperative outcomes. We found similar results in our study, with AW complications accounting for 44% of the abdominal complications. Our approach to the management of these complications has included prompt surgical intervention in cases of bleeding and facial dehiscence. Infection has been managed based on its degree of invasiveness and whether actual hardware infection was suspected. When any infection is suspected, antibiotic coverage is initiated on an empiric basis until culture and sensitivity data are available to further guide treatment. If there is significant drainage from the wound, surgical exploration with irrigation and drainage is performed. In certain cases, we have used omental transposition flaps or bilateral pectoralis major advancement flaps in surgically addressing these infections [8].

The second most commonly encountered abdominal complication in this study involved the GT and consisted largely of C difficile infection and GI bleeding. Gastrointestinal bleeding is a common occurrence in critically ill, intensive care unit–bound patients. Recently, studies have suggested that an association exists between MCS therapy and the development of intestinal arteriovenous malformations, especially with continuous-flow MCS devices [4]. Gastrointestinal bleeding accounted for 13% of abdominal complications in our series, and the device-specific incidences were as follows: HeartMate XVE (7%), HeartMate II (24%), Thoratec left paracorporeal ventricular assist device (17%), Thoratec biventricular paracorporeal ventricular assist device (12%), Thoratec left intracorporeal ventricular assist device (0%), and VentrAssist (11%). It remains unclear whether the varying rates of GI bleeding relate to device -specific mechanical characteristics, such as lack of pulsatility, or rather to device-related patterns of anticoagulation. Our approach to GI bleeding in MCS patients has relied heavily on urgent endoscopy for both diagnosis and treatment of this complication, leaving surgical intervention as the last resort for patients who fail endoscopic therapy. We typically hold all anticoagulation and correct any underlying coagulopathy with appropriate blood products. Minimization of blood product administration is important to avoid problems related to immunologic sensitization, which may complicate future heart transplantation. In our experience, patients can tolerate withholding or minimizing anticoagulation for 48 to 72 hours to address the GI bleeding without thromboembolic complication; nonetheless, vigilance is required if anticoagulation needs to be withheld for longer periods.

The high incidence of GI tract infection with C difficile seen in this series establishes this as a significant morbidity in patients receiving MCS therapy. Diarrhea associated with C difficile infection may lead to dehydration, poor device flow, and renal insufficiency. There have been no previous reports documenting the incidence of this often troublesome complication. Constantini and colleagues [6] reported one case in 100 patients in their series and attributed its development to the prolonged use of antibiotic therapy beyond 24 hours. Immune system dysfunction associated with MCS therapy [9] coupled with prolonged use of antibiotic therapy typical in patients with MCS devices may explain the high incidence of C difficile infection seen in this group of patients. Until newer devices, such as those with totally implantable power sources, are available that reduce the overall incidence of infection and need for antibiotics, patients and their physicians will continue to battle this problem [10]. Owing to the significant incidence of C difficile infection in this population of patients, our protocol limits postoperative surgical antibiotic prophylaxis to 48 hours after device implantation. Additionally, we have initiated routine C difficile prophylaxis therapy during the entire hospital stay (metronidazole, 250 mg orally twice daily).

Solid organ injury was the least common complication seen after MCS in this series, accounting for 23% of abdominal complications. Hepatic insufficiency as noted by total bilirubin and hepatic enzyme elevation accounted for the majority of these incidents; fewer patients experienced pancreatitis or combined pancreatitis with hepatic insufficiency. Other complications such as transient hyperbilirubinemia, biliary tract infection, and SO bleeding were less common. Unfortunately, the development of a SO complication had a profoundly adverse impact on survival after MCS and was an independent predictor of mortality while receiving device support. The pathophysiology of hepatic dysfunction after MCS therapy was recently reviewed by Wadia and associates [11], who emphasized that there are multiple pathways by which the liver can be injured including forward failure related to ischemia or hypoxia and backward failure related to venous congestion from RV dysfunction. Splanchnic vasoconstriction and gut-related gram-negative sepsis may also contribute to a systemic inflammatory response that leads to intrahepatic cholestasis and subsequent hepatic insufficiency. Patients receiving MCS therapy are uniquely predisposed to hepatic injury along these multiple pathways given their poor cardiac function before MCS institution, their propensity for infection as previously discussed, and their often extremely debilitated condition just before treatment. The development of RV failure early after left-sided support may further predispose these patients to both hepatic and intestinal congestion, which may amplify hepatic injury. We have advocated early RV MCS in this setting [12].

Clearly, patients receiving MCS therapy who are already deconditioned with significant end-organ dysfunction are at particular risk for the development of abdominal complications as well as the other adverse events that accompany these complications. These data suggest that careful patient selection for the institution of MCS therapy is mandated, especially for those with significant preoperative comorbidities such as diabetes, renal failure, and respiratory failure. We advocate earlier institution of MCS before the development of significant end-organ dysfunction, which often necessitates emergent device placement.

Although this study provides valuable new data regarding the incidence and impact of abdominal complications on outcome after MCS therapy, this information must be taken in the context of numerous limitations. This was a retrospective study spanning a 10-year period and including a variety of devices, both pulsatile and nonpulsatile, and having varying hemodynamic and physiologic properties that may affect end-organ function differently. Additionally, there was a wide heterogeneity in the number of devices, with fewer nonpulsatile devices (20%) than pulsatile devices (80%). However, the devices evaluated represent a cross section of devices that are currently available and remain in use. This provides an important benchmark against which newer generation devices currently under study may be compared.

In conclusion, abdominal complications are far more common after MCS therapy than previously documented and have a profoundly adverse impact on overall survival. Surgical intervention is more frequently required for complications resulting from abdominal wall transgression for device implantation, although medical management is sufficient when complications result from shock, congestion, or anticoagulation. Nonetheless, complications related to shock or congestion such as hepatic insufficiency may still have a profound impact on survival. Patients with significant comorbidities and end-organ dysfunction who require emergent device placement are at particular risk for experiencing abdominal complications. These findings have important implications for the development of future devices and implant technique, as well as patient selection and timing of surgical intervention.


   Discussion
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR JOHN V. CONTE (Baltimore, MD): Congratulations on a nice study. I think I would be remiss if I didn't acknowledge the role that your colleagues, particularly Dr Kormos at Pittsburgh, have played in the development of this field over the last 20 years, certainly have made huge contributions. My feeling is that this field is going to be one of the most important areas of our specialty going forward, and I personally think that in the next 10 years we are going to see mechanical circulatory support replace heart transplantation as a gold standard treatment for the treatment of end-stage heart disease. However, that is going to be incumbent upon those in industry to figure out ways that we can have power sources that do not rely on a percutaneous drive line. I will tell you as a mechanical device guy that drive line is the bane of my existence, and I think if we didn't have that you probably wouldn't be presenting this paper today.

I think it is incumbent upon us until we get the perfect pump to figure out who the right candidates are, what devices to put in these people, and, most importantly, how to treat those complications that come up. I laud your attempt to try and do this, but I almost wonder if you haven't bitten off a bit more than you can chew by trying to undertake this huge experience that you have had at Pittsburgh. You know, 20 years of devices, you have used several different devices: some pulsatile, some pneumatic, some electric, some laminar flow, some devices aren't even used anymore. So it is hard for me to know how to interpret all this data, and I wonder if the complications we see aren't just a surrogate of those patients who were the sicker patients who need to be done most urgently.

A couple of observations. Do you think that those complications such as infection—and you had a very high incidence of C difficile colitis—are really a reflection of those sicker patients that you may have had to operate on in the distant past, in the early experience, say from 1990 on, as opposed to those from 2000 on? We don't see that much today because I think we do a better job of preparing our patients for surgery. Do you think that has played a role, number one?

Number two, we have noticed in the HeartMate II population, which is really the only population we have been able to really scrutinize the continuous-flow pump for a protracted period of time, that there is a very high incidence of GI (gastrointestinal) bleeding. That is the number one GI complication we have seen. And in many of our patients they have been due to AV (arteriovenous) malformations, and we had 3 or 4 patients we have actually had to do bowel resections and other patients we have had to embolize to try and take care of these malformations. Do you have any insight as to whether that is in your experience related to the continuous-flow pumps or do you think there is an equal incidence of GI bleeding in the pulsatile pumps?

And finally, what is the role of debridement at your program for drive line or pocket infections? I think with the continuous-flow pumps we are not really going to have pocket infections anymore because we don't really have pockets the way we used to have. What role is debridement playing in your management of these patients, because in our hands, debridement has allowed us to take these complications and make them chronic problems as opposed to life-threatening problems.

Again, congratulations on this undertaking, and I look forward to hearing your response.

DR BHAMA: Thank you, Dr Conte. I appreciate your comments. With regards to your first question, I do agree that this is a large study spanning a long period of time, including a number of patients, and numerous devices. As I tried to point out in the limitations section of this paper, it is very difficult to make definitive conclusions, especially since this does cover a large period of time and definitely reflects somewhat of a learning curve with this technology.

With regards to your second question regarding the HeartMate II and our incidence of GI bleeding, we did experience similar problems with the HeartMate II, but we had it with the other devices as well. I think that part of the problem is that these complications just haven't really been properly reported for some of the other devices. If you look, there are some studies out there, largely case reports, but these complications have not really been looked at very carefully in previous studies. In this study we found it to occur at similar rates with most all of the devices.

With regards to the role for debridement for drive line or pocket infections, your third question, we divided these up by whether they involved the drive line or the abdominal wall/pocket. I would agree with you that for the drive line it probably doesn't play as much of a role in treating the problem, whereas for the abdominal wall/pocket we do end up utilizing surgical techniques, as you saw in the presentation, for patients who have those problems. But it has less of a role, at least in our hands, for problems with the drive line.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Mouly-Bandini A, Chalvignac V, Collart F, et al. Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD J Heart Lung Transplant 2002;21:1144-1146.[Medline]
  2. Saito S, Matsumiya G, Ichikawa H, Matsue H, Sekiya N, Sawa Y. Abdominal fascial enlargement to relieve obstruction of the duodenum caused by Novacor left ventricular assist system J Heart Lung Transplant 2007;26:759-762.[Medline]
  3. Chandra D, Gupta S, Reddy RM, Gregoric ID, Kar B. Gastric volvulus after ventricular assist device explantation and cardiac transplantation Tex Heart Inst J 2007;34:112-114.[Medline]
  4. Letsou GV, Shah N, Gregoric IG, Myers TJ, Delgado R, Frazier OH. Gastrointestinal bleeding from arteriovenous malformation in patients supported by the Jarvik 2000 axial-flow left ventricular assist device J Heart Lung Transplant 2005;24:105-109.[Medline]
  5. Chatterjee S, Williams NN, Ohara ML, Twomey C, Morris JB, Acker MA. Diaphragmatic hernias associated with ventricular assist devices and heart transplantation Ann Thorac Surg 2004;77:2111-2114.[Abstract/Free Full Text]
  6. Constantini TW, Taylor JH, Beilman GJ. Abdominal complications of ventricular assist device placement Surg Infect 2005;6:409-418.
  7. Rakhit A, Nurko S, Gauvreau K, Mayer JE, Blume ED. Gastrointestinal complications after pediatric cardiac transplantation J Heart Lung Transplant 2002;21:751-759.[Medline]
  8. Sajjadian A, Valerio IL, Acurturk MA, et al. Omental transposition flap for salvage of ventricular assist devices Plast Reconstr Surg 2006;118:919-927.[Medline]
  9. Kimball PM, Flatter M, McDougan F, Kasirajan V. Cellular immunity impaired among patients on left ventricular assist device for 6 months Ann Thorac Surg 2008;85:1656-1661.[Abstract/Free Full Text]
  10. Conte J. Invited commentary: cellular immunity impaired among patients on left ventricular assist device for 6 months Ann Thorac Surg 2008;85:1661.[Free Full Text]
  11. Wadia Y, Etheridge W, Smart F, Wood RP, Frazier OH. Pathophysiology of hepatic dysfunction and intrahepatic cholestasis in heart failure and after left ventricular assist device support J Heart Lung Transplant 2005;24:361-370.[Medline]
  12. Bhama JK, Kormos RL, Toyoda Y, McCurry KR, Teuteberg J, Siegenthaler MP. Clinical experience utilizing the Levitronix CentriMag system for temporary right ventricular mechanical circulatory support J Heart Lung Transplant 2008;28:971-976.



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