20 Developing comprehensive mechanical circulatory support in singapore

Abstract

Heart transplantation was initiated in Singapore in 1990. Three to six heart transplants are performed annually. The waiting list mortality was about 30%. Hence, mechanical circulatory support was initiated with HeartMate I in 2001. Extracorporeal membrane oxygenation (ECMO) for acute life support became available by 2003. Durable implantable rotary left ventricular assist device (LVAD) with HeartMate IITM (HMII) was introduced in 2007, followed by HeartWareTM HVADTM in 2012 and HeartMate 3TM (HM3) in 2015. 90 consecutive durable implantable devices (58 HMII, 21 HVAD and 11 HM3), were placed from May 2009 to December 2017. Of these, 65 were placed as bridge-to-transplant. Overall perioperative mortality was 7 (7.7%). 26 were INTERMACS level 1 patients, bridged with ECMO without perioperative mortality. Median ICU stay and hospital stay were 8 and 31 days, respectively. Mean duration of support was 907 days. The longest support was 8.6 years. 45 had been on ongoing support, and 23 were transplanted. Late mortality occurred in 13 patients, 5 due to stroke. Driveline infection developed in 28.7%. 57.1% were associated with driveline trauma. Pocket infection developed in 5 patients. In the initial 78 patients, 17 (21.7%) experienced gastrointestinal bleeding (GIB); 11 with recurrent GIB were successfully treated with thalidomide. 6 developed aortic regurgitation, 5 underwent modified Park stitch. Implantable cardioverter defibrillator placement pre-LVAD did not confer mortality benefit. Issues with hardware occurred in 60%. Cardiac recovery occurred in 2 and their LVADs were decommissioned. Overall survival at 5 years was 84.4%, compared with INTERMACS registry data of 48%.