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Patients on femoral veno-arterial extracorporeal life support (VA-ECLS) are at risk of distal lower-limb hypoperfusion and ischemia of the cannulated leg. This study sought to evaluate the effect of using continuous non-invasive lower-limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on rates of leg ischemia requiring surgical intervention. We performed a retrospective analysis of patients placed on femoral VA-ECLS at our institution between 2010-2014 (pre-NIRS era) and 2017-2021 (NIRS era). Patients cannulated during the 2015-2016 transition era were excluded. Baseline characteristics, short-term outcomes, and ischemic complications requiring surgical intervention (fasciotomy, thrombectomy, amputation) were compared across the two cohorts. Of the 490 patients included in the study, 141 (28.8%) and 349 (71.2%) were cannulated before and after the routine use of NIRS to direct DPC placement, respectively. Patients in the recent cohort had greater rates of hyperlipidemia (53.7% vs 41.1%, P = 0.015) and hypertension (71.4% vs 60.0%, P = 0.020) at baseline, though they were less likely to have been supported with an intra-aortic balloon pump prior to ECLS cannulation (26.9% vs 37.6%, P = 0.026). These patients were also more likely to have cardiac arrest (22.9% vs 7.8%, P = <0.001) and pulmonary causes (5.2% vs 0.7%, P = 0.040) as indications for ECLS, with lower rates of ECLS initiated for acute myocardial infarction (15.8% vs 34.0%, P = <0.001). Patients in the NIRS cohort had a smaller arterial cannula size (P = <0.001) and greater duration of ECLS support (5.00 vs 3.25 days, P = <0.001) though significantly lower rates of surgical intervention for limb ischemia (2.6% vs 8.5%, P = 0.007) despite comparable rates of DPC placement (49.1% vs 44.7%, P = 0.427), with only 2 patients (1.1%) not identified by NIRS ultimately requiring surgical intervention. The use of smaller arterial cannulas (≤ 15 Fr) and continuous NIRS monitoring to guide selective insertion of DPCs may be a valid and effective strategy associated with a reduced incidence of ischemic events requiring surgical intervention. [ABSTRACT FROM AUTHOR]

Pre-operative assessment for LVAD patients often considers strong social support, counseling, and health literacy. Here, we examine how socioeconomic status (SES) plays a role in LVAD use and outcomes at a single institution. Patients were identified using the institution's medical records. The Distressed Communities Index (DCI) Score was utilized to assess for SES. The DCI incorporates education, poverty, unemployment, income, undomiciled status, and changes in employment or establishment. The score was used as both a continuous variable (from 0.0 to 100.0) and a categorical variable based on SES quintiles: Prosperous, Comfortable, Mid-Tier, At-Risk, and Distressed. Pre- and post-implantation characteristics and outcomes were analyzed. There were 426 patients who received a durable LVAD during 2012-2019. Patients were identified by DCI quintile: Prosperous (n=132), Comfortable (n=101), Mid-Tier (n=87), At-Risk (n=73), and Distressed (n=33), (p<0.001). The median DCI score for the cohort was 34.5 (Comfortable Quintile). The median age of the cohort was 60 (IQR 49-67) and was significantly different between groups. More men received durable LVAD (81.5%) and were more likely to have a higher SES. White race was associated with prosperous SES and black race with distressed SES. Higher rates of smoking and prior coronary artery bypass existed among higher SES groups (p<0.01 and 0.01, respectively). Univariable binary logistic and Poisson regression revealed that DCI score did not have a significant association with rates of orthotopic heart transplantation (OR, 1.0; 95% CI, 0.99-1.01), one-year mortality (OR 0.99; 95% CI, 0.99-1.01), or number of readmissions (Coeff., 0.002; 95% CI, -0.001-0.005, p=0.19). Patients with higher SES were more likely to receive an LVAD as treatment for refractory heart failure. Differences in socioeconomic status did not have an association with post-implantation outcomes. [ABSTRACT FROM AUTHOR]

Our study assesses the ability of conventional body mass index (cBMI) and modified body mass index (mBMI) to predict mortality after pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We retrospectively analyzed 270 patients with CTEPH who had PTE performed at our institution between January 2010 and December 2021. cBMI was separated into 4 groups following the World Health Organization (WHO) classification scheme: underweight (<18.5 kg/m^2), normal (18.5 to 24.9 kg/m^2), overweight (25 to 29.9 kg/m^2) and obese (> 30 kg/m^2). mBMI was calculated as 10*cBMI*albumin. Cubic-spline functions were generated to examine the behavior of various outcomes (mortality, postoperative in-hospital events, and readmissions) with respect to mBMI. Baseline characteristics and outcomes were assessed. The primary outcome was in-hospital mortality. Of 270 patients, 238 (88.1%) had preoperative BMI and albumin data in the electronic medical record. According to the results of the spline functions, continuous mBMI was dichotomized into two categories (< 1000 and >=1000) and used in analyses afterwards. Whereas cBMI groupings were not predictive of in-hospital mortality when examined using a logistic regression model, high mBMI was associated with improved odds of survival (OR= 0.339, 95% CI = [0.117, 0.941], p=0.039). Kaplan-Meier analysis demonstrated that the high mBMI cohort had a higher survival rate at 2 years compared to the low mBMI cohort (92.7% vs. 83.2%, p=0.018). In contrast, cBMI did not reveal significant stratification of patient survival groups (p=0.27). Low mBMI but not cBMI is associated with increased in-hospital and two-year mortality after PTE in CTEPH patients. [ABSTRACT FROM AUTHOR]

We sought to determine the temporal patterns, causes, and predictors of readmission after HeartMate 3 (HM3) implantation and compare them with those of HeartMate II (HMII). We retrospectively reviewed hospital readmission data for HM3 recipients at our institution between 2014 and 2019. As a historical control, HMII recipients between 2010 and 2014 were used for comparison. The Fine-Gray method was used to generate cumulative incidence functions for readmissions with death as a competing risk and the Nelson non-parametric method was used to generate mean cumulative functions for readmissions. A total time restricted multivariable Fine-Gray competing risk regression with a robust sandwich covariance estimator was used to determine risk factors for readmission while accounting for repeated events within patients. There were 207 HMII and 182 HM3 patients. The average number of readmissions per patient was 2.14 and 1.73 for HMII and HM3 (p=0.09), respectively. Leading causes of readmission for HMII were bleeding (21%), infection (20%), and device malfunction (12%), while those for HM3 were infection (22%), bleeding (11%), and arrhythmia (10%). The mean cumulative number of readmissions and temporal pattern of readmissions in patients receiving HMII and HM3 did not differ significantly (Figure 1a and b). Risk factors for readmission in patients implanted with HM3 included age (HR = 1.011, 95% CI = 1.001-1.021, p = 0.03) and postoperative urinary tract infection (HR = 1.453, CI = 1.094-1.928, p = 0.01). Overall readmission burden was similar for patients implanted with HMII and HM3. Postoperative urinary tract infection may be a risk factor for readmissions, but further studies are needed to determine additional risk factors. [ABSTRACT FROM AUTHOR]

Left atrial appendage occlusion (LAAO) at time of implantation was previously shown to reduce thromboembolic events (TEs) in continuous flow left ventricular assist devices (LVADs); however, the efficacy of LAAO in HM3 recipients is unknown. This study aims to assess the clinical impact of LAAO in HM 3 patients. Adults receiving first HM3 implantation from November 2014 through December 2019 at our center were retrospectively reviewed. TEs included device thrombosis and ischemic strokes. Patients were classified by whether they received LAAO or not. Incidence of TEs was compared between groups using cumulative incidence curves with competing risks (death and heart transplant) and risk factors for TEs were assessed with Fine and Gray competing risk regression. 182 patients received HM 3s during the study period. Ninety-nine HM3 patients (54%) received LAAO versus 83 (46%) who did not. Zero LAAO patients (0%) had prior coronary artery bypass grafting, compared to 35 patients (42%) who did not receive LAAO (p < 0.001). Forty-six LAAO patients (48%) had a past medical history of atrial fibrillation, which was similar to the 45 patients (55%) who did not receive LAAO (p = 0.48). There were 14 thromboembolic events, including 13 strokes (7%) and one pump thrombosis (0.5%). Cumulative incidence of TEs was similar in both groups (less than 10% at three years). LAAO was not associated with TEs (p = 0.35) in Fine and Gray competing risk regression and no statistically significant risk factors for TEs were identified. A low number of TEs was observed in HM3 recipients. LAAO did not further reduce the rate of TEs in this patient population. [ABSTRACT FROM AUTHOR]

The use of extracorporeal life support (ECLS) for patients in cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of gender-associated differences in outcomes. Our study assesses differences between male and female patients placed on venoarterial ECLS (VA-ECLS) for cardiogenic shock at numerous centers worldwide. This is a multicenter retrospective study conducted on 9888 patients from the Extracorporeal Life Support Organization database. We looked at adult patients (> 18 years old) who were placed on VA-ECLS between January 1st, 2011 and December 31st, 2019 for cardiogenic shock. We only looked at patients' first ECLS runs, excluding subsequent ECLS runs for patients who received ECLS multiple times. The primary endpoint was in-hospital mortality. Patients who were transferred to outside hospitals after ECLS placement were excluded. Secondary endpoints include postoperative bleeding, infection, cardiac arrhythmia, cardiac arrest, limb ischemia, compartment syndrome, fasciotomy requirement, stroke, renal replacement therapy, and metabolic acidosis. There were 6747 male patients and 3141 female patients. In an unadjusted comparison, male patients were more likely to have prior myocardial infarction (29.5% vs 20.9%, p<0.001), coronary artery disease (23.1% vs 15.6%, p<0.001), diabetes (10.6% vs 9.2%, p=0.038), chronic kidney disease (7.7% vs 5.2%, p<0.001), and CHF (23.9% vs 21.4%, p=0.006). Female patients were more likely to be centrally cannulated (23% vs 18.5%, p<0.001). There was no difference in in-hospital mortality between male and female patients (57.2% vs 55.7%, p=0.169). Female patients were more likely to have limb ischemia as a complication (7.0% vs 4.6%, p<0.001), whereas male patients were more likely to require renal replacement therapy (43.5% vs 38.6%, p<0.001) and have arrhythmias (15.2 vs 13.1, p=0.008) after ECLS. There were no other differences in the secondary outcomes between male and female patients. Compared with male patients, female patients were more likely to centrally cannulated and experience limb ischemia as a complication of ECLS, potentially due to their smaller vessel size. Varying cannulation approach based on biologic sex may be warranted to reduce ECLS complication rates in female patients. [ABSTRACT FROM AUTHOR]

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used for post-cardiotomy shock (PCS). Its application to post-aortic surgical patients is challenging. We report our experience of VA-ECMO support for PCS following aortic surgery. A total of 126 adult patients required VA-ECMO for PCS from Jan 2007 to Feb 2017. Of this group, 27 patients underwent aortic surgery (Group AO). Outcomes were examined, as well as risk factors for mortality, and this group was compared to those requiring ECMO for PCS following coronary artery bypass graft (CABG) and/or valve procedures (Group CV, n=65). Fifteen patients had acute type A aortic dissection and 6 had ascending and/or root aneurysm. Root replacement was performed in 13 patients, ascending in 11, and arch replacement 2, with concomitant procedures in 17 patients. Mean cardiopulmonary bypass time was 280±125 minutes and mean aortic cross-clamp time was 153±79 minutes. In-hospital mortality was 51.8%. Significant bleeding, new hemodialysis requirement, and neurological complications occurred in 59%, 37%, and 11% of patients, respectively. Risk factors for in-hospital mortality in logistic regression analysis included coronary artery disease (OR 7.3, 95% CI 1.3-60.3, p=0.034), aortic cross-clamp time >150 minutes (OR 6.0, 95% CI 1.2-41.1, p=0.048), lactate > 6 mg/dL at 24 hours post-ECMO initiation (OR 12.0, 95% CI 1.6-255.6, p=0.037) and bleeding complication (OR 5.9, 95% CI 1.2-37, p=0.041). Compared to Group CV, Group AO had significantly longer bypass and cross-clamp times, and a greater proportion of patients underwent ECMO cannulation via the axillary artery. In-hospital mortality was not significantly different (51.8% vs. 63.1%, p=0.356). ECMO support for aortic surgical patients provides survival comparable to that for CABG and/or valve patients. [ABSTRACT FROM AUTHOR]

Minimal data exists regarding the impact of extracorporeal life support (ECLS) flow on incidence of acute kidney injury (AKI). This study examines the predictive role of ECLS flow and other risk factors in the development of AKI. We performed a retrospective analysis of 519 patients placed on ECLS at our institution between January 2015 and December 2020 for cardiogenic shock (CS). We calculated ECLS flow index using average flow 72 hours post-cannulation and body surface area. Stages of AKI were determined according to KDIGO guidelines. ECLS flow index, baseline characteristics, and outcomes were compared between patients that did and did not develop AKI. Of the included cohort, 180 (38.1%) patients developed AKI: 41 (22.8%) had Stage 1 AKI, 26 (14.4%) had Stage 2 AKI, and 113 (62.8%) had Stage 3 AKI. Patients who developed AKI had lower rates of survival to hospital discharge (39.4% vs. 61.3%, p<0.001) and 1-year survival (28.8% vs. 50.0%, p<0.001) compared to those who did not. Stage 3 AKI was the only stage of AKI that was predictive of 1-year mortality (HR=1.59, p=0.001). ECLS flow index ranged from 0.71-3.03 lpm/mm2 with a median of 1.61 lpm/mm2. Patients with Stage 3 AKI had a higher median flow index than the other groups of patients (1.69 vs. 1.57 lpm/mm2, p=0.015). There was no association between flow index and Stage 2 AKI or Stage 1 AKI, while flow index was specifically predictive of Stage 3 AKI (OR=2.01, p=0.021). Patients with higher flow index were more likely to experience neurological adverse events (OR=1.92, p=0.022) and infection (OR=1.80, p=0.043) and less likely to undergo myocardial recovery (OR=0.43, p=0.002). Patients newly initiated on renal replacement therapy (RRT) had higher median flow index (1.69 vs 1.58 lpm/mm2, p=0.018) and patients with Stage 3 AKI on RRT had the lowest 1-year survival compared to patients with Stage 3 AKI who did not receive RRT, Stage 2 AKI, and Stage 1 AKI (19.0% vs 35.0% vs 43.5% vs 38.2%, p=0.047). In our cohort, AKI is common and Stage 3 AKI is associated with worse outcomes compared to all other stages of AKI. In this study, higher ELCS flow indices were associated with increased likelihood of Stage 3 AKI and RRT incidence, suggesting that baseline sickness rather than ECLS flow has a significant impact on AKI development. These results indicate that lower flow indices may not pose increased risk of renal injury. [ABSTRACT FROM AUTHOR]

The global shortage of available donor organs and the poor clinical outcomes of re-transplant patients raise the ethical and economic concerns. In this study, we examined the difference in post-transplant survival of re-transplant (re-HTx) patients with and without the use of marginal donor hearts. The United Network of Organ Sharing database was retrospectively queried from January 2000 to March 2020 to identify adult (17 > years) patients underwent re-HTx. Recipients were divided into early (≦6 months after previous transplant)and late (>6 months after previous transplant) groups based on the timing of re-transplantation. Demographic data and outcomes were compared with and without the use of marginal donors in each group. Marginal donors were those who met at least one of the following characteristics: age greater than 55 years, cocaine or other intravenous drug use, hepatitis C positive, ejection fraction less than 0.45, and donor: recipient weight less than 0.8. There were 111 early and 1133 late re-transplantation.10-year mortality was significantly higher in the early transplantation compared with the late transplantation (Early 61.0% vs. Late 44.9%, log-rank P<0.001). There was no difference in preoperative patient background between the Marginal and non-Marginal groups in the early transplant group, while the Marginal group had a higher BMI (p<0.001), higher PRA (p=0.005), and longer total waiting time (0.018) than non-marginal group in the late transplant group. There was no significant difference in 10-year mortality between the marginal and non-marginal groups in either the early or late transplant groups. (Early: non-MD 58.5% vs. MD 62.0%, log-rank P=0.827; Late: non-MD 43.2% vs. MD 46.6%, log-rank P=0.699). Utilization of marginal donor in patients undergoing re-HTx is not associated with worse outcomes both for early and late graft failure. [ABSTRACT FROM AUTHOR]

Our study assesses factors associated with postoperative acute kidney injury (AKI) following pulmonary thromboendarterectomy (PTE) and its impact on outcomes. We retrospectively analyzed 249 patients who underwent PTE at our institution between June 2009 and December 2020. The primary end point was development of postoperative AKI using the KDIGO definition. Secondary endpoints include length of hospital stay, hospital mortality, and two-year mortality. Patients with stage 0 and stage 1 AKI were combined into the No/Mild AKI group, and patients with stage 2 and stage 3 AKI were combined into the Mod/Severe AKI group. Univariable logistic regression and random forests were used to determine factors associated with AKI, of which preoperative hemoglobin, cardiogenic shock, prior MI, creatinine, and age were used for multivariable logistic regression. There were a total of 249 patients, of which 123 (49.4%) developed postoperative AKI. 126 patients (50.6%) had no AKI, 91 (36.5%) had stage 1 AKI, 21 (8.4%) had stage 2 AKI, and 11 (4.4%) had stage 3 AKI. CPB time and circulatory arrest time were similar between the Mod/Severe and No/Mild AKI groups (211 [179-251] vs 235 [191.5-270.8], p=0.132 and 38 [30-44] vs 42 [35.3-45.8], p=0.177). Multivariable analysis showed that prior diagnosis of cardiogenic shock is associated with Mod/severe AKI (3.68 CI [1.27-10.70], p=0.017). Patients who developed Mod/Severe AKI had higher in-hospital (4.1% vs 15.6%, p=0.022) and 2-year mortality. Length of stay was longer for the Mod/Severe AKI group (19 days [15-41.3] vs 14 days [10-21], p<0.001). Figure 1 shows the Kaplan-Meier Curve of two-year survival between the two groups. Prior diagnosis of cardiogenic shock, but not CPB or cross clamp time, is a predictor of Mod/severe AKI after PTE. Development of stage 2 or 3 AKI after PTE is associated with increased mortality, as well as longer hospital stay. [ABSTRACT FROM AUTHOR]

The Society for Cardiovascular Angiography and Interventions (SCAI) recently introduced a staging schema for cardiogenic shock (CS) based on exam findings, lab markers, and hemodynamics. We applied the SCAI schema to CS patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess clinical relevance. We retrospectively reviewed patients receiving VA-ECMO for CS at our institution from January 2015 to December 2019. Patients with post-cardiotomy shock and non-cardiac shock etiologies were excluded. Patients were classified to a SCAI stage A-E based on device and drug initiation, hemodynamics, CPR use, and levels of lactate and creatinine. Outcomes included in-hospital mortality, myocardial recovery, and adverse events during ECMO course. A total of 245 patients met the inclusion criteria, with median age of 59 years [IQR: 48-67]. One hundred fifty-nine patients (65%) were male. The number of patients in SCAI stages was 0 (0%) in A, 0 (0%) in B, 34 (14%) in C, 82 (33%) in D, and 129 (53%) in E. Of the E patients, 88 (68%) were undergoing CPR. Underlying CS etiologies of acute decompensated heart failure (C: 53%, D: 43%, E: 17%, p<0.001) and ventricular fibrillation (C: 9%, D: 0%, E: 3%, p<0.001) were greater in C. Median ECMO duration decreased with stage (C: 7 [4-14], D: 6 [3-9], E: 4 [1-8] days, p<0.001). In-hospital mortality increased (C: 35%, D: 56%, E: 71%, p<0.001) and myocardial recovery decreased (C: 68%, D: 37%, E: 30%, p<0.001) with stage. Adverse events varied in terms of acute kidney injury (C: 35%, D: 45%, E: 54%, p=0.045) and infection (C: 35%, D: 28%, E: 16%, p=0.004). Kaplan-Meier analysis revealed E had worse survival than C and D (Figure 1). Outcomes were similar between E,CPR+ and E,CPR- patients (68% vs. 73%, p=0.76). In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification. [ABSTRACT FROM AUTHOR]

The United States OPTN implemented changes in the adult heart allocation system to reduce waitlist mortality and to minimize regional variation in organ availability. We sought to examine regional pattern of waitlist and short-term post-transplant survival for status 1 and status 2 patients across the eleven organ procurement organization (OPO) regions. Deidentified data from the UNOS database were retrospectively analyzed and identified patients listed between October 2018 and June 2022 were used. Temporal trends in waitlist time across geographic regions were assessed using cumulative incidence functions and compared with the Fine-Gray test. Competing events assessed were transplantation, death or de-list or remained waitlisted over 30-days. We further adjusted for age, gender, BMI, ethnicity, blood type, exception status, and allocation status. Post-transplant 30-day mortality was examined with mulitvariable logistic regression. A total of 7,440 patients were included (879 status 1 and 6,561 status 2). The median days for a status 1 patient was 5 patient-days and ranged from 3 to 6 patient-days across regions while the median days for a status 2 patient was 12 patient-days and ranged from 7 to 16 patient-days across regions. There was significant variation in transplantation across the 11 regions for both status 1 and status 2 patients for both time to transplantation and time to death or delisting over 30 days (Figure 1). After adjusting for covariates, region remained significantly associated with variation in transplantation and death or delisting (p <0.001). Post-transplant 30-day mortality did not differ across region (p=0.08). While the allocation change was meant to minimize regional variation in organ availability, there remains significant variation in outcomes for patients on the waiting list. These findings may help to inform future modifications that may result in a more equitable distribution of available organs. [ABSTRACT FROM AUTHOR]

We aimed to compare 5-year survival and readmissions of patients who received HeartMate 3 (HM3) left ventricular assist device (LVAD) or orthotopic heart transplantation (OHT) as primary treatment for advanced heart failure. We retrospectively analyzed 501 adult patients who received HM3 or OHT between January 2014 and March 2021. To minimize crossover bias, OHT patients with prior LVAD were excluded and HM3 patients were censored at time of transplant. Cohorts were propensity score-matched (PSM) to reduce selection bias using a nearest-neighbor algorithm with the following baseline characteristics: age, sex, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), serum creatinine, serum albumin, pulmonary artery (PA) systolic pressure, etiology, cardiac device history, and surgery after the 2018 UNOS allocation change. Primary outcome was 5-year survival, evaluated by Kaplan-Meier survival curves with log-rank testing for significance. Secondary outcome was mean cumulative, all-cause, unplanned readmission up to five years of follow-up. Our cohort consisted of 219 (65%) HM3 patients and 118 (35%) OHT. PSM matched 72 patients in each cohort, with a SMD < 0.1 for all parameters, except for device history (SMD = 0.102) and surgery after UNOS change (SMD = 0.168). After PSM, there was no statistical difference in 2-year (HM3 89.6% vs. OHT 89.7%, P = 0.88) and 5-year survival (HM3 67.2% vs. OHT 84.0%, P = 0.76) (Figure 1A). HM3 patients ages 18-58 had superior survival compared to those ages 59 and older (84.7% vs 58.9 %, P = 0.0039), resembling that of OHT overall (Figure 1B). Mean cumulative readmission at 5-years was significantly higher in the HM3 cohort (5.89 vs 2.99, P < 0.05) (Figure 1C). Our data suggests that HM3 provided comparable long-term survival to OHT as a primary treatment for heart failure, especially in younger patients but had significantly increased readmissions. [ABSTRACT FROM AUTHOR]

Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Race and socioeconomic based disparities in PTE outcomes have not been well studied. We retrospectively reviewed all patients who underwent PTE for CTEPH at our institution from June 2009 to July 2019, tracking patient demographic information including self-identified race, preoperative variables, and 5-year mortality. SES was assessed using the zip code-linked Distressed Communities Index, a validated holistic measure of community well-being. Survival was estimated with Kaplan-Meier and compared using the log-rank test. Factors associated with mortality were estimated using Cox proportional hazards analysis. Of the 235 patients that underwent PTE during the study period, 100 (42.5%) were white and 88 (37.4%) were black. Out of our 47 (20.1%) patients who were not white or black, we had too few patients of other races to analyze. White patients had a higher median age at surgery than black patients (57 vs 52 years, p = 0.043). There was no difference in 5-year mortality after PTE between black and white patients (p = 0.54, Figure 1). SES (HR 0.97, 95% CI [0.94,0.996], p=0.02) was significantly associated with mortality, while race (HR 0.78, 95% CI [.213, 2.891], p=0.78) was not. SES but not race was not associated with mortality following PTE at our center. However, additional studies with larger sample sizes are warranted. [ABSTRACT FROM AUTHOR]

Background: Asphyxia is one of the most common causes of pediatric cardiac arrest, and becoming a more frequently recognized cause in adults. Periodic acceleration (pGz) is a novel method of cardiopulmonary resuscitation (CPR). pGz is achieved by rapid motion of the supine body headward-footward that generates adequate perfusion and ventilation during cardiac arrest. In a swine ventricular fibrillation cardiac arrest model, pGz produced a higher return of spontaneous circulation (ROSC), superior neurological outcome, less echocardiography evidence of post resuscitation myocardial stunning, and decreased indices of tissue injury. In contrast to standard chest compression CPR, pGz does not produce rib fractures. We investigated the feasibility of pGz in severe asphyxia cardiac arrest and assessed whether beneficial effects seen in the VF model of cardiac arrest could be realized. Methods and Results: Sixteen swine weight 4+/-1 kg were anesthetized, tracheally intubated, and instrumented to measure, hemodynamics and echocardiography. Asphyxia was induced by occlusion of the tracheal tube. After loss of aortic pulsations (median time 10 min) animals were observed for three additional minutes following which all were in cardiac arrest. The animals were then randomized to receive 10 min of pGz or standard chest compression ventilation performed with a commercial device (Thumper). A single dose of epinephrine (adrenaline) and sodium bicarbonate were given and defibrillation attempted if appropriate for a maximum of 10 min. Both groups received fractional inspired O2 concentration of 100% during CPR and after resuscitation. Four animals in each group (50%) had an initial ROSC, however only two of the four initial survivors remained alive 3h after ROSC. There were no significant differences in blood pressure, coronary perfusion pressure during CPR and after early ROSC between groups. pGz treated animals had significantly lower pulmonary artery pressure; 20+/-4 mmHg compared to Thumper 46+/-5 mmHg, 30 min after ROSC (p<0.01). Surviving animals in both groups had severe myocardial dysfunction at 30 min after ROSC. At necropsy, 25% of the Thumper treated animals had rib fractures, while none occurred in the pGz group. Conclusions: In a lethal model of asphyxia cardiac arrest, pGz is equivalent to standard CPR, with respect to acute outcomes and resuscitation survival rates but is associated with significantly lower pulmonary artery pressures and does not produce traumatic rib fractures. [ABSTRACT FROM AUTHOR]

However, due to the insidious nature of the tumor margin nearly 25-35% of patients with iCCA have R1 resections in comparison to only 10% of patients with other liver tumors. The iCCA patients who had undergone OLT and had over 30 days of follow-up (n=7) were matched 1:3 for iCCA patients undergoing resection based on explant pathology- matching for most significant oncologic risk factors first. Resection margin was positive in 14% of patients undergoing resection vs none in the transplants. [Extracted from the article]

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. The aim of this study is to investigate the prognostic significance of FMR and AF in patients with LVAD. We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We excluded patients who had previous or concomitant mitral valve procedure and patients who had insufficient quality of echocardiographic images. We defined significant FMR as MR color jet area / left atrial area > 0.2 and AF as persistent AF at LVAD implantation. 427 patient's charts were reviews (125 patients had previous or concomitant mitral valve procedure and 31 patients had insufficient quality of echocardiographic images). 271 were included in this analysis. Mean age of cohort was 57.1 +/-13.0 years, and 84% were male. Of all, 110 (41%) patients had significant FMR and 51 (19%) patients had persistent AF. Patients were divided into 4 groups: no AF and no significant FMR (Group1, n=136), no AF and significant FMR (Group 2, n=84), AF and no significant FMR(Group 3, n=25), and AF and significant FMR (Group 4, n=26). Forty-four (16%) patients died within 2years. Kaplan-Meier curve analysis demonstrated 2-year survival of 77% in Group 1, 87% in Group 2, 92% in Group 3, and 47% in Group 4 (P=0.0006). On the multivariate Cox proportional hazard model Group 4 was significant predictor of mortality [hazard ratio (HR), 2.62; 95% confidence interval (CI),1.27-5.41; P =0.009], independently of other parameters. Coexistence of significant FMR and AF is a poor prognostic marker in patients undergoing LVAD implantation. [ABSTRACT FROM AUTHOR]

Aortic insufficiency (AI) is common following continuous flow left ventricular assist device (CFLVAD) and is associated with morbidity and mortality. This study aims to assess the incidence of de novo AI in HeartMate 3 (HM 3) LVAD recipients and compare the outcomes with HeartMate II (HM II) patients. A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year post implant) of 151 HM 3 patients implanted between Nov. 2014 and March 2019, as well as of 270 HM II patients implanted between April 2004 and Dec. 2015 at our center. Patients (n=30) were excluded from analysis for a history of aortic valve (AV) surgery, concomitant AV surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as more than mild AI. In the HM 3 cohort, mean age was 58 ± 12 and 84% were male. 74% received HM 3 as destination therapy. Incidence and degree of de novo AI in each group is summarized in Figure 1. 4 patients were readmitted due to significant AI and heart failure symptoms. Cumulative incidence curves showed that the probability of de novo AI at 1 year was 8.4% in the HM 3 cohort vs. 13% in the HM II cohort (Figure 2, p=0.29). In both cohorts, patients who had AV opening on echocardiogram at 1 month post implant were significantly less likely to develop de novo AI (100% freedom from de novo AI at 1 year for HM 3 with open AV vs. 84% for HM 3 with closed AV, 97% for HM II with open AV vs. 76% for HM II with closed AV). The incidence of de novo AI is low and comparable between HM 3 and HM II patients at our center. AV opening at 1 month post implant appears to be protective of this complication. [ABSTRACT FROM AUTHOR]

Previous studies have shown remarkable decrease in severity of functional mitral regurgitation (FMR) after left ventricular assist device (LVAD) implantation with mechanical unloading. This study aimed to identify the change of FMR and mitral geometry in LVAD patients. We retrospectively reviewed all patients who underwent LVAD implantation and had significant FMR without mitral valve procedure between January 2010 and December 2017. All patients underwent echocardiographic examination preoperatively and 1 month after LVAD implantation. We defined significant FMR as MR color jet area / left atrial area > 0.2. We measured mitral annular diameter (MAD) and posterior (Dp) and apical (Da) displacement of the coaptation point of mitral leaflets on echocardiogram. Patients were divided into 2 groups, patients with and without AF. 106 patients were identified, 82 with no AF and 24 with AF. Mitral geometry significantly changed after LVAD insertion in both groups (table). Preoperative MAD was smaller in patients without AF (39.0 +/-4.5 vs. 41.2 +/-3.8mm; P=0.04) and reduced following LVAD in both postoperative (30.3+/-5.4 vs. 36.5 +/-4.1mm; P<0.0001), however, the changes of MAD before and after surgery were larger in patients with no AF (8.8 +/-5.0 vs. 4.7 +/-3.2 mm; P=0.0003). There were no significant differences in Da between groups. Patients with AF had a higher prevalence of significant FMR at 1 month after LVAD implantation than patients with no AF (4% vs. 17%; P =0.03). LVAD implantation significantly changed mitral geometry, however, the changes were less in patients with AF resulting in greater residual FMR. [ABSTRACT FROM AUTHOR]

Purpose ISHLT guidelines recommend serial right heart catheterization (RHC) to survey pulmonary hypertension in patients awaiting heart transplant. In LVAD as BTT patients the ideal surveillance frequency is unknown in those without prior pulmonary hypertension or whose pre-LVAD PVR normalized after surgery. Here, we review the utility of our surveillance RHC protocol. Methods Between January 2017 and July 2018, 69 patients who received an LVAD as BTT were studied. Routine RHC was performed every six months irrespective of prior PVR. Hemodynamic variables were retrospectively collected and reviewed. Results In 69 patients, 217 RHCs were analyzed. The median age was 55 years (IQR=15), and 55 (80%) were male. Median follow-up period was 18.4 months, and hemodynamic variables were largely unchanged post-LVAD (Table). Post-LVAD, overall PVR decreased from 3.5 ± 2.1 to 2.4 ± 1.0 Wood units (p = 7.2e-5) at six months and stabilized below 3 at all time points. Thirty-three patients (48%) had PVR ≤ 3 (1.8 ± 0.7), and 36 patients (52%) had PVR > 3 (4.9 ± 2.0) pre-LVAD. Both groups exhibited stabilization of PVR with mean < 3 at all post-LVAD time points (Figure). Of the 16 patients (23%) who had PVR > 3 at any point after LVAD implantation, 13 (81%) had a pre-LVAD PVR > 3. No patients with a PVR ≤ 3 six months post-LVAD implantation presented with a PVR > 3 at any subsequent RHC. Of the 40 patients (58%) transplanted, one patient developed severe primary graft dysfunction with right ventricular failure. Conclusion Routine RHC every six months may not be necessary for BTT patients, particularly for those with PVR ≤ 3 six months post LVAD. [ABSTRACT FROM AUTHOR]

Purpose Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial given the paucity of clear evidence for improved outcomes and a lack of clarity on appropriate candidacy in time-sensitive arrest situations. We set out to investigate what factors predicted successful outcomes in ECPR patients. Methods Between March 2007 and August 2018, 112 patients were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for ECPR at our institution. Primary outcomes of interest were survival to decannulation and survival to hospital discharge. Patients were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was performed to identify pre-cannulation predictors of in-hospital mortality. Results Among 112 patients, 44 (39%) survived to decannulation with 31 (28%) surviving to discharge. The median age was 60 (IQR 45-72 years) with a median duration of ECMO support of 2.2 days (IQR 0.6-5.1). There were no differences in age, comorbidities, or year of cannulation between those who survived to decannulation and those who did not. Patients who survived to discharge had a lower prevalence of chronic kidney disease than those who died in-hospital (19% vs. 41%, p=0.046) with lower baseline creatinine levels (median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p=0.008). Median time from CPR initiation to cannulation was 40 minutes (IQR 30-50) with no differences between survivors and non-survivors (p=0.453). When controlling for age and CPR duration, multivariable logistic regression identified pre-arrest serum creatinine as predictive of mortality (OR 3.25 (95% CI: 1.22-8.70), p=0.019) while higher pre-arrest serum albumin was protective (OR 0.32 (95% CI: 0.14-0.74), p=0.007). Conclusion Despite high mortality rates, ECPR affords the opportunity to rescue patients in cardiac arrest. Reduced pre-cannulation renal function and higher serum albumin levels may have value in determining the likelihood of ECPR survival. [ABSTRACT FROM AUTHOR]

Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Disparities in PTE outcomes between sexes have not been well studied. We retrospectively reviewed all patients who underwent PTE for CTEPH at our center from June 2009 to July 2019, tracking preoperative variables including patient age at surgery, last creatinine before surgery, ejection fraction, and sex, as well as patient mortality. We assessed differences in outcomes based on sex. Survival was estimated with Kaplan-Meier and compared using the log-rank test. Risk factors for mortality after PTE were determined with multivariable Cox proportional hazards analysis. Of the 235 patients that underwent PTE during the study period, 107 were male (59%) and 128 were female (41%). Male patients had a higher median age at time of surgery (59 versus 50 years, p = 0.004), and higher median preoperative creatinine (1.1 versus 0.86, p < 0.001). There was no difference in 5-year survival after PTE between male and female patients (p = 0.69, Figure 1). Patient age (HR 1.049, 95% CI [1.013-1.087], p = 0.008) was significantly associated with mortality in multivariable analysis, while sex was not (HR 0.594 for male sex, 95% CI [0.224-1.573], p = 0.29). Sex was not associated with mortality following PTE at our center. Further study with larger sample sizes are warranted. [ABSTRACT FROM AUTHOR]

Pulmonary thromboendarterectomy (PTE) is a standard procedure for the treatment of chronic thromboembolic pulmonary hypertension. PTE decreases pulmonary hypertension, though its effect on secondary tricuspid regurgitation (TR) is unclear. We retrospectively reviewed patients who received PTE from June 2009 to July 2019 at our center. Echocardiographic assessments of tricuspid regurgitation peak valve gradient (TRPG), right ventricular (RV) systolic dysfunction, and degree of TR were tracked longitudinally after PTE (1 month, 6 months, 12 months, 24 months, 36 months). Mixed effects longitudinal analysis was used to determine changes in echocardiographic parameters and risk factors for residual TR. The effect of moderate-severe TR on survival was assessed by cox proportional hazards analysis. In the 235 patients that underwent PTE, the mean pulmonary artery pressure at time of surgery was 43 +/- 14 mmHg. Preoperatively, 54 patients (23%) had trace TR, 59 (25%) mild, 42 (18%) mild-moderate, 50 (21%) moderate, 19 (8%) moderate-severe, and 9 (4%) severe. TR decreased at all time points postoperatively (p < 0.001). The mean preoperative TPRG was 64 mmHg (IQR 46 - 79) and significantly decreased after PTE below 40 mmHg at all time points (p < 0.001). TRPG was significantly correlated with degree of TR (p < 0.001 at each time point). Preoperative moderate-severe RV systolic dysfunction and female sex were associated with residual TR in multivariable analysis (p = 0.011 and p = 0.007, respectively). Preoperative moderate-severe TR was associated with decreased survival after PTE in multivariable analysis (HR 3.42, p = 0.005, Figure 1). Residual TR at six months postoperatively was not (p = 0.47). TR improved significantly three years after PTE with the exception of patients with residual pulmonary hypertension, preoperative RV dysfunction, and female sex. Preoperative but not postoperative TR may be a marker of poor prognosis after PTE. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) distention is a feared complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. LV unloading could be achieved with concomitant intra-aortic balloon pump (IABP) or Impella. We sought to assess the clinical and hemodynamic effects of IABP and Impella on patients supported with VA-ECMO We conducted a retrospective review of patients who received VA-ECMO at our institution between January 2015 and June 2020. Patients with post-cardiotomy shock were excluded. Patients were categorized as having received either ECMO alone or ECMO+LV unloading. LV unloading was further characterized as either ECMO+IABP, or ECMO+Impella. We recorded baseline characteristics, post-operative complications, and hemodynamic changes associated with device initiation. During the study period, 142 patients received ECMO alone, 76 received ECMO+IABP, and 76 received ECMO+Impella. The ECMO+LV unloading group had more male patients compared to ECMO alone (70.4% vs 57.5%, p=0.026). 39.4% of ECMO alone patients survived to discharge, compared to 44.4% of ECMO+LV unloading patients (p=0.12). The ECMO+LV unloading group showed a greater decrease in mean pulmonary diastolic pressures compared to ECMO alone after 24 hours of support (-6.0 ± 8.4 mmHg vs -0.1 ± 10.8 mmHg, p = 0.032). ECMO+Impella patients had a higher incidence of bleeding events compared to ECMO alone or ECMO+IABP (52.6% vs 37.3% vs 20.8%, p = 0.0003). Kaplan Meier analysis revealed that ECMO+IABP had better survival compared to ECMO alone and ECMO+Impella (Figure 1). In a multivariable Cox-hazard analysis, age (HR= 1.02), male sex (HR=0.57), baseline lactate (HR =1.05), baseline creatinine (HR=1.06), need for ECPR (HR=2.21) and presence of IABP (HR=0.48) were independent predictors for mortality. Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock. [ABSTRACT FROM AUTHOR]

Obesity may complicate the effective cannulation and delivery of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). With rising global body mass indices (BMI), obesity is becoming an increasingly more prevalent comorbidity in severe cardiogenic shock yet its impact on outcomes is not well-described. This study examined the relationship between BMI and VA-ECMO outcomes to better inform clinical decision making. Clinical data from all 574 cardiogenic shock patients who received VA-ECMO at our institution from March 2008 to January 2019 were analyzed. Patients were dichotomized into two groups: BMI ≥35kg/m2 (n=91) and BMI<35kg/m2 (n=483). The primary outcome of interest was survival to hospital discharge. Multiple logistic regression was performed to identify variables associated with survival-to-discharge and Kaplan Meier curves were generated to identify differences in survival between the WHO BMI categories. Median BMI was 28.4 kg/m2 (IQR 24.6-32.5) with a range of 14.0-69.1kg/m2. Patients with BMI≥35kg/m2 were significantly more likely to be younger, less likely to be male, and had a significantly higher rate of type 2 diabetes. Overall cohort survival to discharge was 46% (n=267/574), and was not different between the obese and non-obese cohorts (46% vs. 46% p=1.00). Obese patients were more likely to need CVVH while in-hospital (45% vs. 34%, p=0.046). Controlling for preoperative risk factors, multivariable logistic regression identified being underweight (BMI<18.5kg/m2) as the only negative BMI predictor of failure to survive-to-discharge (OR: 0.228, 95% CI: 0.055-0.950, p=0.042). There was no significant difference in one-year survival between the WHO BMI categories (p=0.51, Figure). Clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring VA-ECMO. The results of this study suggest that being underweight, rather than obese, portends a poorer prognosis for these patients. [ABSTRACT FROM AUTHOR]

A fully magnetically levitated centrifugal-flow left ventricular assist device can be placed in either the intra-thoracic cavity or the intra-pericardial cavity. This study aimed to investigate the clinical impact of pump location in patients following fully magnetically levitated left ventricular assist device (LVAD) placement. We retrospectively reviewed 161 patients who received fully magnetically levitated centrifugal-flow LVAD at our center between November 2014 and August 2019. Pump location was determined from the operative record and CT scan images if available. We identified 77 patients (48%) with intra-thoracic placement (Group T) and 84 patients (52%) with intra-pericardial placement (Group P). Clinical outcomes were compared between the groups. Patients in Group T were older (61 vs. 57 years, p=0.05), more likely to have prior sternotomy (27% vs. 11%, p=0.008), and more frequently INTERMACS class I (21% vs. 5.9%, p=0.008) compared with patients in Group P. Incidence of perioperative right ventricular assist device (RVAD) was significantly lower in Group T (23% vs. 38%, p=0.045). In-hospital mortality was 8.6% in Group T vs. 3.6% in Group P (p=0.15). Kaplan-meier curve analysis showed 2-year survival of 83% in Group T and 93% in Group P (p=0.15). Multivariate logistic regression analysis demonstrated INTERMACS class I was an independent predictor of RVAD use (OR 16.9, 95% CI 5.09-56.2, p<0.01) but Group P was not a predictor (p=0.2). In our study, intrathoracic vs. intrapericardial fully magnetically levitated centrifugal-flow pump placement did not affect overall clinical outcomes. [ABSTRACT FROM AUTHOR]

The use of extracorporeal membrane oxygenation (ECMO) for patients in cardiogenic shock has significantly increased over the past decade. However, there is a paucity of data examining gender-associated differences in the current mechanical circulatory support era. We assessed the impact of gender on outcomes in patients on venoarterial ECMO for cardiogenic shock. We retrospectively analyzed 574 adult patients who were placed on venoarterial ECMO for cardiogenic shock at our institution between Jan 2007- Dec 2018. Baseline risk factors and outcomes were assessed to compare male and female patients. Propensity score matching (PSM) was used to compare outcomes. The primary endpoint was in-hospital mortality. Secondary outcomes included limb ischemia (LI) defined as recommendation for distal perfusion cannula (DPC) or other interventions, LI interventions, DPC, stroke, bleeding, and continuous venovenous hemofiltration (CVVH) initiation. There were 394 male patients (69%) and 180 female patients (31%). In an unadjusted comparison, male patients were more likely to have coronary artery disease and hyperlipidemia and less likely to have COPD. Etiologies of shock were similar between the two groups. Male patients were also less likely to be be cannulated centrally for ECMO, though this difference was not seen after PSM. PSM compared 176 male patients to 176 female patients. There was no difference seen between men and women in in-hospital mortality (46.0% vs 42.6%, p=.59), LI (41.5% vs. 45.5%, p=0.52), LI surgery (15.3% vs. 12.5%, p=0.54), bleeding (44.3% vs. 48.9%, p=0.46), CVVH initiated (37.5% vs. 33.0%, p=0.44), and stroke (9.1% vs. 9.7%, p=1.00). Our data suggests that men who receive ECMO for cardiogenic shock are more likely to have pre-existing coronary artery disease and hyperlipidemia while women are more likely to have COPD. After correcting for such differences, there is no significant difference in outcome between male and female patients. [ABSTRACT FROM AUTHOR]

We analyzed the position of a fully magnetically levitated centrifugal-flow left ventricular assist device (LVAD) on serial radiographs to assess positional change and possible correlation with adverse events. We retrospectively analyzed 59 LVAD recipients who had serial chest radiographs at 1 month, 6 months, and 12 months after implantation between November 2014 and June 2018. We measured pump angle, pump-spine distance, and pump-diaphragm depth (figure) and investigated their relationship to a composite outcome of heart failure readmission, low flow alarms, or inflow/outflow occlusion requiring surgical repositioning through recurrent event survival modeling. There were 26 patients who experienced the composite outcome; in these patients, the median 1 month pump angle was 66.2 degrees (IQR 54.5-78.0) as compared to 59.0 degrees (IQR 47.0-65.0) in the 33 patients who did not have adverse events (p = 0.04). Pump depth and pump-spine distance at 1 month were not associated with the composite outcome. Between 1 month and 6 months, the absolute pump-spine distance changed by 10.00 mm (p<0.01) and the absolute pump-diaphragm depth changed by 18.80 mm (p<0.01). These parameters did not change significantly between 6-12 months post-implantation. Pump angle did not change significantly over any time period. Change in pump depth between 1-6 months (HR = 1.019; 95%CI = 1.000-1.039; p = 0.05) and between 6-12 months (HR = 1.020; 95%CI = 1.000-1.040; p = 0.05) were weakly associated with the composite outcome. Larger pump angles are associated with the composite outcome of heart failure readmission, low flow alarm, or inflow/outflow obstruction. At 6 months, the absolute values of pump-spine distance change and pump-diaphragm depth change are significant. Movement in pump depth is weakly associated with the composite outcome. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is common in patients with the left ventricular assist device (LVAD), but the little is known about the impact of AF on clinical outcomes. The aim of this study is to investigate the impact of AF on outcomes in patients with the HeartMate 3 (HM3) LVAD. We retrospectively reviewed 113 patients (December 2014 to June 2018) who underwent HM 3 implantation at Columbia University Medical Center. We divided patients into 3 cohorts: no AF, paroxysmal AF (PAF), or persistent AF (PeAF). The primary endpoint was a death at 2-year and a composite of death and hospital readmission due to recurrent heart failure, stroke, and gastrointestinal bleeding. AF was present in 61 patients (54%). Forty-three (38%) patients had PAF and 18 (16%) patients had PeAF at the time of LVAD implantation. Patients with PeAF were more likely to be older and have larger left atrial dimension. Patients with PAF or PeAF had higher incidence of perioperative right heart ventricular assist device support compared to patients with no AF (P=0.03). Kaplan-Meier analysis showed that patients with PeAF were significantly worse survival at 2-years (PeAF 65%, PAF 93%, no AF 93%, P=0.007). Composite event at 2-year occurred in 54% in PeAF, 75% in PAF, 69% in no AF (P=0.049). PeAF was associated with significantly worse clinical outcomes in patients with the HM 3 LVAD. Patient undergoing HM 3 may require additional intervention to reduce AF burden. [ABSTRACT FROM AUTHOR]

This study sought to determine the incidence and cause of readmission due to persistent low flow alarms after HM3 LVAD implantation. We retrospectively reviewed 135 patients who received HM3 LVAD between November 2014 and December 2018 in our single center. Patients who required readmission due to persistent low flow alarms were identified and analyzed. Cumulative incidence function curve was constructed for probability of low flow alarm readmission. Twenty-three patients (17.4%) required 28 readmissions due to persistent low flow alarms during median follow up of 11.2 months. The incidence of readmissions with persistent low flow alarms was 1.31 person-years. The probability of low flow alarm readmission was 17.7% at 1-year. Of 23 patients, 4 patients (17.4%) required multiple readmissions. The etiology of persistent low flow alarms is summarized in Table: Hypovolemia was present in 11 (39.3%) and hypertension was present in 16 (17.8%). Inflow or outflow obstruction requiring surgical intervention was present in 5 (17.8%). The reason for the alarm was not identified in 5 patients (17.8%). No patients had an electrical issue with the pump or a driveline disruption identified. Readmission due to low flow alarms is relatively common after HM3 LVAD. Hypovolemia was the most frequent etiology of low flow alarms. Obstruction of the inflow cannula or outflow graft is a serious complication that can present with low flow alarms and requires reoperation. [ABSTRACT FROM AUTHOR]

Purpose Primary graft dysfunction (PGD) in orthotopic heart transplant (OHT) carries a large morbidity and mortality. We have previously reported a dose-dependent association with pre-transplant amiodarone usage and PGD in patients with OHT. We conducted a prospective study to elucidate if preoperative serum amiodarone level could predict PGD. Methods Since 2017, we began to monitor serum amiodarone and amiodarone metabolite levels in the peri-operative period prior transplantation. Degree of PGD was determined for each patient post-operatively using the ISHLT Diagnostic Criteria and Classification of PGD. The data was prospectively collected in 54 patients. The risk of PGD was calculated with linear regression. Results The median age for the cohort was 54.5 (IQR 45-65) and 77.8% were male. Baseline height and BMI were 172.7cm (IQR 167- 178) and 27.5 kg/m2 (24.6- 30.8), respectively. Forty-one patients (75.9%) were bridged to transplant. Median cardiopulmonary bypass and ischemic times were 132 (IQR 118- 154) and 163 min (IQR 120- 208), respectively. Median intraoperative inotrope score was 6.9 (3.7-12.6). Twenty-six patients (48.2%) were taking amiodarone prior to OHT with a median dose of 200 mg daily, and the median total serum amiodarone level was 1.7μg/mL (1.2-2.1). Two patients (3.7%) experienced mild PGD. One (1.9%) and eleven (20.4%) patients experienced moderate and severe PGD, respectively. The risk of developing PGD was not correlated with amiodarone level (r = 0.31, 95% CI= -1.2-1.9, p=0.68). The risk of developing severe PGD was also not correlated with amiodarone level (r = -0.05, 95% CI=-1.4-1.4, p=0.94). Conclusion No predictive association could be made between the one-time preoperative amiodarone serum level and the risk of developing PGD. [ABSTRACT FROM AUTHOR]

Purpose Pre-existing mitral valve pathology is common in patients undergoing continuous-flow left ventricular assist device (LVAD) implantation. Best management of pre-existingmitral valve disease remains controversial. Methods Between March 2004 and December 2017, a total of 594 patients received a continuous-flow left ventricular assist device. Of these, a total of 93 patients (16%) underwent a concurrent mitral valve repair, either with an Alfieri stitch via the left ventricular (LV) apex coring site (n =30, 32%) or with an annuloplasty ring via a left atriotomy (n = 63, 68%). Outcomes were compared between patients who received an Alfieri stitch and those who received an annuloplasty ring repair. Results All patients had moderate or greater mitral regurgitation at the time of LVAD implantation. Median age was 54 years (interquartile range [IQR], 43-74) in the annuloplasty cohort, and 56 years (interquartile range [IQR], 44-79) in the Alfieri stitch group. A proportionately greater number of women underwent Alfieri stitch repair (n = 6, 20%) compared to ring annuloplasty (n = 5, 8%; p = 0.01). Additionally, a greater number of patients in the Alfieri group underwent a concomitant valve intervention such as a Park stitch or tricuspid repair (n = 15, or 50%) compared to those patients undergoing a ring annuloplasty (n = 28, 44%; p = 0.04). Cardiopulmonary bypass times were shorter on average in the Alfieri patients, independent of concomitant valve procedure (111 minutes versus 134 minutes, p =.02). Thirty-day survival in the Alfieri group (n = 27, 90%) was similar to that of the ring annuloplasty group (n = 57, 91%); p > 0.05. However, in the 84 patients for whom data was available, 1-year survival was higher in the Alfieri group compared to the ring annuloplasty group (26.3% versus 18.6%, p = 0.032). Conclusion Concomitant mitral valve intervention is fairly common in patients undergoing continuous-flow LVAD placement. Our findings suggest that short-term outcomes are not impacted by type of mitral valve repair technique, but mitral valve repair via the LV apex coring site may be a favorable approach. [ABSTRACT FROM AUTHOR]

Purpose The indications, efficacy, and safety profile of temporary, percutaneous dual lumen cannula-based right ventricular assist devices (RVAD) [TandemLife ProtekDuo] after left ventricular assist device (LVAD) placement have not been well characterized. We describe our experience with the largest series of patients reported to date. Methods We conducted a retrospective review of 24 patients who received ProtekDuo RVAD support from January 2016 through July 2018. Outcomes of interest included indications for support, procedural success, complications, and clinical outcomes. Results Patients were 79% male (n=19) with a median age of 66 (IQR 58-72). ProtekDuo RVAD support was initiated a median of 1 day (IQR 0-2) after LVAD implantation. Indications for RVAD placement included pure RV failure (n=14, 58%), vasoplegia (n=2, 8%), or mixed syndrome (n=8, 33%). Procedural success was 100% without any complications. Initial median flow was 4.1 L/min (IQR 3.8-4.5) with a median indexed flow of 2.0 L/min/m2 (IQR 1.8-2.3). During a median support of 11 days (IQR 7-14), major complications included cannula thrombosis (n=1), cannula migration into the RV requiring repositioning (n=2), and hemolysis, as defined by progressively rising LDH and plasma free hemoglobin levels (n=4). A total of 18 patients (75%) were weaned from the ProtekDuo RVAD with cannulas removed at the bedside in all patients. Three patients died while on ProtekDuo support and three were converted to central RVAD support. Overall survival to discharge was 78% (n=18/23) with one patient remaining in-hospital. Survival post-discharge was 100% at the time of most recent follow-up, with a median duration of 211 days (IQR 98-523). Conclusion The ProtekDuo RVAD affords a safe and reliable bridge to right ventricular recovery as a less invasive percutaneous option after LVAD placement. [ABSTRACT FROM AUTHOR]

Purpose Stroke is a major complication with potentially devastating consequences for patients receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Arterial cannulation sites for VA-ECMO include ascending aorta, axillary artery, and femoral artery. However, rates of stroke according to cannulation site are currently unknown. The purpose of this study was to investigate the association between occurrence and patterns of stroke with ECMO arterial cannulation sites. Methods We retrospectively reviewed 498 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Patients were categorized by cannulation strategy. The rates, subtype and location of strokes as assessed by CT scans of the head during and after VA-ECMO support were analyzed. Results Median age was 60 years (IQR 49-68); 69% were male. 87 patients were cannulated via the ascending aorta (18%), 37 via the axillary artery (7%), and 374 (75%) via the femoral artery. In total, 27 patients (5.4%) developed 32 stroke events at a median of 4.3 (2.8-6.0) days after ECMO cannulation. Ischemic stroke was the most common subtype (63%), followed by hemorrhagic conversion (22%) and hemorrhagic stroke (15%). Location by CT was right hemispheric in 34%, left hemispheric in 34%, bilateral in 19%, and vertebrobasilar in 13%. The incidence of stroke was similar across cannulation strategies: aorta (n=5, 5.8%), axillary artery (n=2, 5.4%), and femoral artery (n=20, 5.3%), (p=0.94). Stroke subtype and location based on cannulation site are summarized in Table 1. Conclusion Stroke occurred in approximately 5% of all patients with cardiogenic shock receiving VA-ECMO, with ischemic stroke being the most common subtype. Incidence of stroke does not appear to differ among patients cannulated via the ascending aorta, axillary artery, or femoral artery, although clinical patterns may vary based on the cannulation strategy. [ABSTRACT FROM AUTHOR]

Purpose Neurological complications (NC) are potentially devastating for cardiogenic shock patients receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The purpose of this study was to investigate the overall incidence and pattern of NC and their impact on outcome. Methods We retrospectively reviewed 498 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Information on NC type, including stroke, altered mental status, seizure, encephalopathy, and transient ischemic attack and other neurological events was collected. Survival to discharge was compared between patients with and without neurological complications. Results Median age of the entire cohort was 60 years (IQR 49-68), and 69% were male. Etiology of cardiogenic shock included post-cardiotomy shock (n=154, 33%), acute myocardial infarction (n=124, 27%), post-transplant graft failure (n=60, 13%), acute decompensated heart failure (n=65, 14%), and others (n=57, 12%). Eighty-seven patients were cannulated via the ascending aorta (18%), 37 via the axillary artery (7%), and 374 (75%) via the femoral artery. In total, 125 patients (25%) were diagnosed with NC: altered mental status was most common n=62 (12%), stroke n=29 (6%), encephalopathy n=16 (3%), seizure n=15 (3%), transient ischemic attack/others n=16 (3%). NC diagnosis was significantly associated with higher in-hospital mortality rates (74%, n=93) vs. non-NC diagnosis (61%, n=229), (p=0.008). Among NC subtypes, encephalopathy had the highest in-hospital mortality rate (94%, n=15), followed by stroke (72%, n=21) and AMS (71%, n=44). Conclusion Neurological disorders are common in cardiogenic shock patients who receive VA-ECMO and significantly impact in-hospital mortality rates. [ABSTRACT FROM AUTHOR]

Purpose In postcardiotomy shock patients with prosthetic valves, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may induce prosthetic valve thrombosis due to blood stasis in cardiac chambers. Incidence and outcomes of prosthetic valve thrombosis during VA ECMO has not been previously described. Methods Between January 2007 and June 2018, a total of 171 patients underwent VA ECMO therapy after major cardiovascular surgery at our center. Of these patients, 89 had a prosthetic valve in place, and we conducted a retrospective review of this cohort. Results Of the 89 patients with prosthetic valves placed on VA ECMO, 37 (41.5%) had central VA ECMO cannulation, and the remaining 52 patients (58.5%) underwent peripheral VA ECMO cannulation. Median age was 66 years (interquartile range [IQR], 55-74) and 53 (59.6%) were men. Average duration of ECMO support was 5.1 days (IQR 3.0, 8.5). The majority of patients (76.4%, n = 68) were on therapeutic anticoagulation within 24 hours post-cardiotomy, and inotropes were used in all patients. A total of 8 patients (9%) developed prosthetic valve thrombosis: 5 involved the aortic valve (including one mechanical aortic valve prosthesis), 2 involved bioprosthetic mitral valves, and 1 involved a bioprosthetic pulmonary valve (Table). Overall cohort survival to discharge was 41.2% (n = 35), but was reduced to 9% (n = 1) amongst those patients that developed valve thrombosis. Conclusion Prosthetic valve thrombosis is relatively common complication while patients with prosthetic valves are placed on VA-ECMO, and it is almost uniformly fatal when it does develop. [ABSTRACT FROM AUTHOR]