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Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair.We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared.PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04).Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.

Invasive hemodynamic variables obtained from right heart catheterization have been used for risk-stratifying patients with advanced heart failure (HF). However, there is a paucity of data on the prognostic value of invasive hemodynamic variables in patients with left ventricular assist devices (LVAD). We hypothesized that cardiac power output (CPO), cardiac power efficiency (CPE), and left ventricular stroke work index (LVSWI) can serve as prognostic markers in patients with LVADs.Baseline hemodynamic data from patients who had LVAD ramp studies at our institution from 4/2014 to 7/2018 were prospectively collected, from which advanced hemodynamic variables (CPO, CPE, and LVSWI) were retrospectively analyzed. Univariate and multivariable analyses were performed for hemocompatibility-related adverse events (HRAE), HF admissions, and mortality.Ninety-one participants (age 61 ± 11 years, 34% women, 40% Black or African American, and 38% ischemic cardiomyopathy) were analyzed. Low CPE was significantly associated with mortality (HR 2.42, 95% CI 1.02-5.74, p = 0.045) in univariate analysis and Kaplan-Meier analysis (p = 0.04). Low LVSWI was significantly associated with mortality (HR 2.13, 95% CI 1.09-4.17, p = 0.03) in univariate analysis and Kaplan-Meier analysis (p = 0.02). CPO was not associated with mortality. CPO, CPE, and LVSWI were not associated with HRAE or HF admissions.Advanced hemodynamic variables can serve as prognostic indicators for patients with LVADs. Low CPE and LVSWI are prognostic for higher mortality, but no variables were associated with HF admissions or HRAEs.

Background While the pledget suture technique has been the standard for surgical aortic. valve replacement (AVR), discussion continues regarding the possibility of the nonpledget suture technique to produce superior structural and hemodynamic parameters. This study aims to assess the effectiveness of the figure-of-eight suture technique in AVR, as determined by the incidence of prosthesis-patient mismatch (PPM). Methods We reviewed records of patients (N = 629) who underwent a surgical AVR procedure between January 2011 and July 2018 at a single institution. Indexed effective orifice area values and PPM incidence were calculated from implanted valve size and patient body surface area. Incidence of none, moderate, and severe PPM was compared across AVR suture techniques. Results A total of 570 pledget and 59 figure-of-eight patients were compared for incidence of PPM. Patients who received AVR with the pledget suture technique had significantly lower echocardiographic measurements of baseline ejection fraction than patients who had received AVR with the figure-of-eight suture technique (p = 0.003). Patients who received the figure-of eight suture had a 14% decrease in moderate PPM compared to patients who received the pledget suture (p = 0.022). Patients who received the figure-of-eight suture also had a significantly higher rate of no PPM (p = 0.044). Conclusions The use of the figure-of-eight suture technique in AVR can reduce the incidence of moderate PPM. While the pledget suture is the standard technique in AVR, the figure-of-eight suture technique may offer better structural and hemodynamic outcomes, especially for patients with a smaller aortic annulus.

A female presented 2 weeks after birth with an unbalanced atrioventricular canal, double outlet right ventricle, mild pulmonary stenosis, and patent ductus arteriosus that eventually caused pulmonary over circulation. After pulmonary artery banding, she experienced myocardial ischemia, suggesting interference with coronary blood flow by the band that had been placed on the main pulmonary trunk. The band was removed and revised to bilateral branch pulmonary artery banding, and cardiac function improved. An anomalous left coronary artery from the underside of the right pulmonary artery was identified. Eight weeks later, the patient underwent coronary transfer and reimplantation of the left coronary artery into the aorta followed by main pulmonary artery banding. She subsequently underwent bidirectional Glenn.

Patients with concomitant anemia and congestive heart failure have poor outcomes. The prevalence and clinical risk of anemia in patients receiving durable left ventricular assist devices (LVAD) remain unknown.We retrospectively analyzed patients who underwent LVAD implantation between 2014 and 2018. The association between hemoglobin level at the time of index discharge and the one-year composite endpoint of heart failure readmissions or hemocompatibility-related adverse events was investigated.A total of 168 patients (57 [48, 66] years old, 123 males) were included and stratified into a classification of anemia (hemoglobin9.7 g/dl, N = 99) or non-anemia (N = 69). The anemia group had a higher one-year incidence of the composite endpoint (56% vs 36%, p = .013) with an adjusted hazard ratio of 1.83 (95% confidence interval 1.08-2.82). Patients with anemia also experienced suboptimal bi-ventricular unloading.Anemia was prevalent in LVAD patients and associated with a greater risk of heart failure and hemocompatibility-related adverse events. The optimal threshold for therapeutic intervention in response to post-LVAD anemia needs further investigation.

Background: Both hypo- and hyperkalemia are associated with adverse events in heart failure patients. Their effects on patients with left ventricular assist devices (LVADs) remains unknown. Methods and Results: The cohort included consecutive patients undergoing LVAD implantation between 2014 and 2018. In all, 170 patients (median age 56 years; 117 males) were stratified according to serum potassium levels 1 month after implantation into 3 groups: hypokalemia (5.0 mEq/L; n=9). Compared with the normokalemia group, the adjusted hazard ratios for 1-year mortality were 0.91 (95% confidence interval [CI] 0.21–3.92) for hypokalemia and 4.14 (95% CI 1.47–11.65) for hyperkalemia. In the hyperkalemia group, the prevalence of renin-angiotensin-aldosterone system inhibitors decreased and serum potassium levels normalized following the first month. Conclusions: Hyperkalemia was associated with increased mortality during LVAD support. Management of serum potassium needs further investigation.

Background: Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess post-operative and long-term outcomes of patients receiving either pericardial or synthetic repairs. Methods: We conducted a single center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N=38) with either autologous pericardium (n=30) or CorMatrix (n=8) between April 2009 and July 2016. Short and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, post-operatively, and at outpatient follow-up. Results: At five years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (P = 0.01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between pre- and post-operative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) post-operatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, 8 (100%) had moderate to severe AR which improved to 3 (38%) post-operatively and increased to 7 (88%) at time of follow-up. Conclusion: In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.

The negative impact of baseline hypoalbuminemia on clinical outcome following left ventricular assist device (LVAD) implantation is well known. However, the implications of perioperative change in serum albumin levels on post-LVAD outcomes remain uninvestigated.Among consecutive patients with baseline serum albumin3.5 g/dl who received durable LVAD implantation between April 2014 and August 2017 and were followed for 1 year, the impact of perioperative change in serum albumin level from baseline to 3 months post-LVAD on the incidence of adverse events was investigated.Sixty-eight patients (median 60 years and 69% male) were included. Serum albumin change was an independent predictor of the occurrence of adverse events with an adjusted hazard ratio of 0.32 (95% confidence interval, 0.13-0.78) and a cutoff change of 0.7 g/dl. Those with albumin increase0.7 g/dl had higher 1-year freedom from adverse events (45% vs. 14%, p = .008), dominantly due to lower incidence of death or sepsis compared with those without (p .05 for both).Among those with baseline hypoalbuminemia, a considerable perioperative increase in serum albumin levels following LVAD implantation was associated with lower mortality and morbidity. The implication of aggressive nutrition intervention on LVAD patients is the next concern.

Background: The seasonal variation of incidence and severity of heart failure is well known. However, the impact of seasonal variation on clinical outcomes following left ventricular assist device (LVAD) implantation remains unknown. Methods: We retrospectively reviewed consecutive patients who received LVAD implantation between January 2014 and December 2016 along with their first year of post-implant outcomes. Clinical outcomes were compared between those with winter LVAD implantation (between October and March) and those with non-winter LVAD implantation. Results: 168 patients with a median age of 57 years and 130 males were included. There was no seasonal difference in the number of LVAD implantations. One-year survival free from major adverse events was significantly lower in the winter implant group ( n = 88) compared to the non-winter group ( n = 80) (44% vs 61%) with an adjusted hazard ratio of 1.81 (95% confidence interval 1.11–2.90, p = 0.014), largely due to a higher rate of heart failure readmission in the winter implant patients (incidence rate ratio 2.29, 95% confidence interval 0.89–5.84). Conclusion: Patients who underwent LVAD implantation during the winter season had a higher heart failure readmission rate. A detailed mechanism and therapeutic strategy given our findings warrant further investigation.

Background Active smoking is associated with worse clinical outcomes following left ventricular assist device (LVAD) implantation. However, the effect of sex differences in conjunction with smoking status remains uninvestigated. Methods Consecutive patients who underwent LVAD implantation between January 2013 and September 2018 were included. Clinical outcomes were retrospectively compared between the current smokers and never smokers among male cohorts and female cohorts separately. Results About 130 patients, with a median age of 56 years, were included. Among the male cohort (N = 85), the current smokers (N = 25/85) had a higher total readmission rate than the never smokers (N = 60/85) with an adjusted incidence rate ratio of 2.38 (95% confidence interval, 1.16-3.85, P = .014), dominantly due to higher rates of gastrointestinal bleeding, stroke, and hemolysis. Among the female cohorts (N = 45), never smokers (N = 36/45) had a statistically comparable total readmission rate (2.80 vs 2.50 events per year; P = .37) compared with current smokers (N = 9/45). Conclusion Among male patients with LVAD, active smoking was associated with higher rates of adverse events. Female patients with LVAD had a high rate of adverse events irrespective of smoking status. Gender-specific therapeutic approaches might be required to prevent LVAD-related comorbidities.

The use of opioids during left ventricular assist device (LVAD) support is increasing, but the implication remains unknown. We investigated the association between the use of opioid and morbidities during LVAD supports. We retrospectively reviewed the clinical data of patients who received LVAD between 2014 and 2017, which were stratified by the use of opioid at post-LVAD 3 months. Among 136 patients, 77 (57%) were in the opioid group. Hemoglobin and albumin were lower, and C-reactive protein was higher at baseline and 3 months later in the opioid group (P < 0.05 for all). The opioid group displayed worse hemodynamics, with higher pulmonary capillary wedge pressure and central venous pressure (P < 0.05 for both). Furthermore, the opioid group had higher incidences of gastrointestinal bleeding (31% versus 17%, P = 0.043) and sepsis (30% versus 13%, P = 0.036) during the 1 year observational period, whereas survivals were not stratified by the use of opioid (83% versus 90%, P = 0.27). Opioid use was associated with morbidities accompanied by poor hemodynamics during LVAD supports. The detailed causality of opioid use on morbidities remains a future concern.

The allocation system for heart donors in the United States changed on October 18, 2018. The typical distance from donor hospitals to recipient hospitals has increased as has the ischemic time. We investigated patient outcomes with the new allocation system and the differential effects of ischemic time under both the old and new allocation schemas.The United Network for Organ Sharing Registry (UNOS) was queried for data regarding heart transplants occurring from October 1, 1987 to March 1, 2021. In total, 62,301 adult heart transplants were examined. Survival outcomes at 30 days and 1 year and ischemic times were compared via adjusted logistic and Cox models (overall survival and time until post-transplant rejection).Mean ischemic time was slightly increased in the new system (3.43 h vs. 3.03 h, p .001). Survival differences between old versus new systems were not observed in adjusted models (p = .818). However, there was evidence to suggest longer ischemic times are more detrimental to long-term survival under the new system (hazard ratio [HR] = 1.15 per hour increase; p = .001) versus the old system (HR = 1.08 per hour increase; p .001), although this relationship did not reach statistical significance (p = .150).Although travel distances have significantly increased under the new allocation system, survival outcomes remain largely unchanged. Ischemic time is an influential factor in recipient survival that should be limited during organ transport. Further studies on the impact of travel distances and ischemic time under the new allocation system are needed.

Until recently, combined heart-liver-kidney transplantation was considered too complex or too high-risk an option for patients with end-stage heart failure who present with advanced liver and kidney failure as well.The objective of this paper is to present our institution's best practices for successfully executing this highly challenging operation. At our institution, referral patterns are most often initiated through the cardiac team.Determinants of successful outcomes include diligent multidisciplinary patient selection, detailed perioperative planning, and choreographed care transition and coordination among all transplant teams. The surgery proceeds in three distinct phases with three different teams, linked seamlessly in planned handoffs. The selection and perioperative care are executed with determined collaboration of all of the invested care teams.Combined heart-liver-kidney transplantation can be successfully done by careful selection, coordination, and execution.

Unplanned readmissions frequently occur following the implantation of a durable left ventricular assist device (LVAD) due to complications such as gastrointestinal bleeding and driveline infection. There is a paucity of literature describing the incidence of unplanned readmission in patients with a HeartMate 3 (HM3) Left Ventricular Assist System. In this report, we present the successful outcome of a patient with an HM3 LVAD who has experienced no unplanned readmissions in the 4-year post-implant phase. To our knowledge, this is the longest readmission-free case after HM3 implantation. A successful patient outcome was enabled by the use of the modular HM3 device, the postoperative prescription of beta-blockers and omega-3, the presence of strong social support, and open communication between the patient's caregivers and the LVAD team. Reducing the instance of unplanned readmission confers clinical benefits to the patient, as well as reducing the cost burden on the patient and the healthcare system.

We report a case of successful heart and liver transplantation requiring intraoperative extracorporeal membrane oxygenation (ECMO) for primary cardiac allograft dysfunction in a patient with Fontan failure. A successful outcome for both the heart and the liver can be achieved with the timely management of ECMO support. In describing our experiences treating a Fontan patient requiring multiorgan transplantation, we have shown that challenging cases such as this one can have successful outcomes if multidisciplinary collaborations and proper treatment strategies are utilized at the optimal timing, along with family support and patient cooperation.

Bulky processing tasks are expected to burden the limited resources of energy harvesters by draining the stored energy, and thereby, reaching rapidly to energy causality constraint. In such scenario, energy harvesters flip into sleep mode, and thereby, the execution time of the next task will be delayed until the energy harvesters revert back into active mode. To tackle this problem, this paper proposes a novel energy harvesting network (EHN) that deploys wireless distributed computing (WDC) network within the decision making process (DMP). The DMP is formulated as constrained partially observable Markov decision process in order to enable the energy harvesters to act under uncertainty. Furthermore, various challenges of WDC networks, e.g., nominating the collaborating nodes and task allocation, have been addressed herein. Unlike conventional research works on WDC networks, a system model is proposed for WDC network based on divisible load theory instead of graph theory. In addition, an adaptive task allocation algorithm is proposed to distribute the task efficiently among the collaborating nodes. Finally, the novel EHN system is analyzed and compared against the conventional research works on WDC, offloading computing, and local computing-EHN, where the proposed system is found to outperform in terms of energy and delay.

Background Smoking would have a negative impact on clinical outcomes following left ventricular assist device (LVAD) implantation. However, its impact on male and female cohorts separately remains uninvestigated. Purpose We aimed to investigate the association between smoking and post-LVAD outcomes among male and female cohorts separately. Methods Data of consecutive patients who received LVAD implantation at our institute between Jan 2013 and Sep 2018 were retrospectively reviewed. Clinical outcomes were compared between the never smokers and the current smokers among male and female cohorts separately. Those with former smoking were excluded. Results Of all, 85 male patients (median 56 years old) and 45 female patients (median 56 years old) were included. Among the male cohort, total readmission rate was higher in the current smokers than never smokers (incidence rate ratio 1.51, p=0.09). Rates of gastrointestinal bleeding, stroke, and hemolysis trended to be higher in current smokers (Figure 1A). Among the female cohort, these rates were not different irrespective of the smoking status (Figure 1B). Survival was not different irrespective of smoking status among both male and female cohorts. Conclusion The impact of smoking on post-LVAD outcomes seems to be different between males and females. Different therapeutic strategy might be required for the LVAD candidates with active smoking between male and female cohort. Figure 1 Funding Acknowledgement Type of funding source: None

Worsening systemic congestion is often the central trigger of hospitalization in patients with heart failure. However, accurate assessment of congestion is challenging. The prognostic impact of systemic congestion following durable continuous-flow left ventricular assist device (LVAD) implantation remains unknown. Consecutive patients who received durable continuous-flow LVAD implantation between January 2014 and June 2017 and were followed for 1 year were included. The association of preoperative plasma volume status, which was calculated using patients' body weight and hematocrit and expressed as a deviation from ideal plasma volume, with 1-year mortality following LVAD implantation was investigated. In total, 186 patients (median 57 years and 138 males) were included. Baseline plasma volume status was -30.1% (-37.1%, -19.4%) on median. Eighty-eight patients (47%) had higher plasma volume status (>-29.8%), and their 1-year survival was significantly lower than those without (67% vs. 87%, P = .001). High plasma volume status was an independent predictor of 1-year death with an adjusted hazard ratio of 4.52 (95% confidence interval 1.52-13.5). Baseline systemic congestion, as defined by the high plasma volume status, was associated with higher mortality following durable continuous-flow LVAD implantation. The implication of improving preoperative plasma volume remains an area of needed investigation.

Background: Tobacco smoking is a significant source of morbidity in patients with a durable left ventricular assist device. While various cessation strategies have been investigated, the ability of ventricular assist device centers to implement a successful tobacco cessation program remains uncertain. We explored various cessation strategies employed by ventricular assist device centers and assessed perspectives of their effectiveness, as well as institutional investment in these programs. Methods: A 37-question online self-report survey was created using Survey Monkey® and distributed worldwide. We investigated (1) programmatic strategies utilized for smoking cessation, (2) the respondent’s perspective on the effectiveness of these strategies, (3) the structure with which these therapies are administered, and (4) overall organizational support for these treatments. Results: A total of 47 centers worldwide completed the survey. The most common methods of tobacco cessation were pharmacologic and nicotine replacement therapy (78% and 66%). However, only about half (47% and 50%, respectively) of the centers indicated that these strategies were effective. When asked whether a respondent’s center perceives that tobacco smoking should be a deciding factor in destination therapy evaluations, nearly a third (15, 32%) responded in the affirmative. Conclusion: While significant overlap exists among centers regarding treatments used for smoking cessation with left ventricular assist device patients, the most common treatments are not thought to be effective. While the current recommendations require tobacco smoking cessation in only bridge-to-transplant patients and not destination therapy patients, a number of centers disagree with the national guidelines and believe smoking should be prohibited in both populations.

Purpose Hemocompatibility-related clinical adverse events (HRAE) are thought to be driven by the pump-patient interaction. We hypothesized that the hemodynamic variables cardiac power output (CPO) and cardiac power efficiency (CPE), which reflect underlying ventricular contribution, have prognostic value in patients with left ventricular assist devices (LVADs). Methods Prospectively collected hemodynamic data from patients with LVADs who had undergone invasive hemodynamic ramp study at our institution between 4/2014-7/2018 were analyzed. CPO [(mean arterial pressure x cardiac output)/451], cardiac power index (CPI) (CPO/body surface area), and CPE (CPI/ pulmonary capillary wedge pressure) were calculated. Patients were divided into groups of high and low CPO and CPE using ROC-derived cutoff values of 0.847W and 0.0552 WmmHg/m2 respectively. Hemocompatibility scores (HCS) were also calculated for each patient based on their HRAE. Univariate and multivariate logistic regression analyses were performed to determine the association between CPO and CPE with primary endpoints of HRAE, HCS, heart failure readmissions, and mortality. Results 91 patients (average age 61 ± 11 years, 34% women, 40% Black, 38% ischemic cardiomyopathy) were included in the analysis. Low CPO was significantly associated with higher rates of HRAE, HR 2.02 (95% CI 1.12-3.66, p=0.02, Figure 1A). CPO was not significantly associated with mortality or heart failure readmission, HR 1.84 (95% CI 0.68-3.32, p=0.31) and HR 1.84 (95% CI 0.92-3.68, p=0.083), respectively. Low CPE was significantly associated with higher rates of HRAE, heart failure readmission (Figure 1B), and mortality (Figure 1C) when adjusted for LVAD type: HR 1.97 (95% CI 1.02-3.81, p=0.043), HR 3.11 (95% CI 1.28-7.58, p=0.012), and HR 3.41 (95% CI 1.18-9.88, p=0.024), respectively. Conclusion CPO and CPE demonstrate prognostic value in patients with LVADs, showing significant associations with HRAE, heart failure readmissions, and mortality.

Purpose We hypothesized that the change in hemodynamic values after milrinone infusion would predict clinical outcomes. Methods We reviewed 177 patients undergoing right heart catheterization and milrinone loading at our center between January 2013 and December 2018. Percent increase in aortic pulsatility index (piAPI) was calculated as 100 * (aortic pulsatility index after milrinone infusion - aortic pulsatility index prior to milrinone infusion)/aortic pulsatility index prior to milrinone infusion, and percent increase in pulmonary artery pulsatility index (piPAPI) was calculated as 100 * (pulmonary artery pulsatility index after milrinone infusion - pulmonary artery pulsatility index prior to milrinone infusion)/pulmonary artery pulsatility index prior to milrinone infusion. Cutpoints were determined by ROC analysis, and patients were stratified as follows: (1) High piAPI, High piPAPI; (2) High piAPI, Low piPAPI; (3) Low piAPI, High piPAPI; and (4) Low piAPI, Low piPAPI. Univariate and multivariate logistic and cox regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Cutpoints of 70% and 103% were determined for piAPI and piPAPI, respectively. Low piAPI, Low piPAPI was associated with escalation of therapy or death at 30-days (OR 2.42, 95% CI 1.16 - 5.3, p = 0.022; OR). In multivariate analysis, Low piAPI, Low piPAPI and High piAPI, Low piPAPI were predictors of the one-year endpoint (OR 8.95, 95% CI 2.43 - 43.1, p = 0.002; OR 6.87, 95% CI 1.79 - 34.16, p = 0.008; respectively). Grouping patients according to whether they possessed Low piAPI, Low piPAPI showed a greater hazard for the endpoint at 30-days and one-year (HR 2.27, 95% CI 1.24 - 4.15, p = 0.0076; HR 1.58, 95% CI 1.01 - 2.28, p = 0.014; respectively). Conclusion Low piAPI, Low piAPI status may indicate lower myocardial reserve and predict poorer outcomes.

Purpose We evaluated the utility of combined assessment of left and right ventricular function for prediction of clinical outcomes in hospitalized heart failure patients. Methods The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial individual-level data were used. Aortic pulsatility index (API), (systolic - diastolic blood pressure)/pulmonary capillary wedge pressure, and pulmonary artery pulsatility index (PAPI), (systolic pulmonary arterial pressure - diastolic pulmonary arterial pressure)/right atrial pressure, were computed from the final hemodynamic measurements. Participants were grouped as: Low API/Low PAPI, Low API/High PAPI, High API/Low PAPI, and High API/High PAPI based on cut-points of 2.9 and 2.6 for API and PAPI, respectively, which were previously determined by our group using receiver operator characteristic analysis. The primary outcome was need for left ventricular assist device or heart transplant, or death at six-months post-hospital discharge. Secondary outcomes included any rehospitalization and cardiac rehospitalization. Results Of 433 participants enrolled in the ESCAPE trial, 142 had complete final hemodynamic data with which to calculate API and PAPI. Low API/Low PAPI was associated with the primary outcome when compared to the 3 other groups, HR 3.58 (95%CI 1.95-6.57), p Conclusion Combined measurements of left and right ventricular function using API and PAPI is associated with significant clinical outcomes in patients hospitalized with acute decompensated heart failure, and may be useful for prognostic risk stratification.

Purpose Several studies report the negative consequences of tobacco smoking on ventricular assist device (VAD) patient outcomes, but it is not a contraindication for VAD implantation in destination therapy (DT) patients. This international survey seeks to assess the importance of smoking cessation in DT VAD recipients, as well as center support and strategies in place to achieve cessation Methods A survey was created using Survey Monkey® and sent to VAD centers worldwide. The survey consisted of 37 multiple-choice and open response questions. Results Of the 47 respondents, 18 (38%) centers implanted 50 per year. Twenty-four (83%) larger-volume centers implant all patients indicated for DT regardless of smoking status, while five (17%) do not implant current smokers. Conversely, 14 (78%) smaller-volume centers implant all patients, while three (17%) do not implant current smokers, and one does not implant previous smokers. Twenty (69%) larger centers offered cessation programs prior to implant, as did 14 (78%) smaller centers. Twenty-three (79%) respondents from larger centers and 11 (61%) from smaller centers believed bridge-to-transplant (BTT) patients were more likely to achieve cessation than DT patients. Sixteen (55%) respondents from larger centers and 11 (61%) from smaller centers thought their center provides adequate support for cessation programs. Smaller centers were more likely to believe that tobacco smoking should be a deciding factor in DT evaluations (50% vs 21%, p = 0.055). Conclusion The importance of smoking cessation in DT VAD patients and the adequacy of center support varies by program. A considerable number of centers believed that tobacco smoking should be a deciding factor in DT evaluations. Open discussion regarding the role of tobacco cessation prior to LVAD implant should be encouraged. External confounder and sampling bias may affect these results, so further studies should be conducted for validation.

Purpose To assess the prognostic role of simultaneous biventricular function using hemodynamic parameters in advanced heart failure patients. Methods We retrospectively analyzed 184 patients undergoing a milrinone drug study at time of right heart catheterization (RHC) at our institution from January 2013 to January 2019. Aortic pulsatility index (API) was calculated as (systolic blood pressure - diastolic blood pressure)/pulmonary capillary wedge pressure, and pulmonary artery pulsatility index (PAPI) was calculated as (systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure. Using our team's previous identification of cutpoint values for API and PAPI, 1.45 and 2.3, respectively, we stratified patients into the following groups: (1) High API, High PAPI; (2) High API, Low PAPI; (3) Low API, High PAPI; and (4) Low API, Low PAPI. Univariate and multivariate logistic regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Low API, Low PAPI was associated with escalation of therapy or death at 30-days (OR 3.2, 95% CI 1.23 - 9.49, p = 0.024). Low API, Low PAPI and Low API, High PAPI were also associated with the one-year endpoint of freedom from escalation of therapy or death (OR 3.63, 95% CI 1.55 - 8.75, p = 0.003; OR 4.13, 95% CI 1.5 - 12.45, p = 0.008; respectively). In multivariate analysis, both of these risk statuses remained significant predictors of the one-year endpoint when adjusting for Fick cardiac index (OR 3.72, 95% CI 1.5 - 9.48, p = 0.005; OR 4.18, 95% CI 1.49 - 12.82, p = 0.009; respectively). Conclusion The combined use of API and PAPI possesses utility for risk stratification regarding both short- and long-term freedom from escalation of therapy or death.

Purpose The non-invasive AlloMap gene expression profiling test has been demonstrated to possess high negative predictive value for detecting cardiac allograft rejection and dysfunction after heart transplant. We assessed longitudinal trends in AlloMap score post-transplant. Methods We retrospectively analyzed AlloMap scores, organized by season and year post-transplant, for patients undergoing heart transplantation at our center. Patients with multiple tests in one season had their scores averaged. Relative AlloMap score was calculated for each patient as (AlloMap score)/(average AlloMap score across all tests). The association between season and AlloMap score was also investigated. Seasons were defined as the following: (1) Winter: January - March, (2) Spring: April - June, (3) Summer: July - September, (4) Fall: October - December. Results A total of 658 tests were included in our study. AlloMap scores were significantly greater in tests done more than one-year post-transplant compared to those completed in the first year (median: 32 (29, 34) vs 28 (24.5, 32), p Conclusion We observed longitudinal trends of rising absolute and relative AlloMap scores after one-year post-transplant. Clinically, the variability score may be more meaningful than the raw score in the long-term due to more specific comparison of patient level variation from baseline. Further analyses with multicenter data are warranted.

Despite the well-established correlation between the tobacco use and cardiovascular disease, little is known about postoperative outcomes following the left ventricular assist device (LVAD) implantation. We aimed to elucidate the effect of tobacco smoking on post-LVAD implant outcomes. Patients who received LVADs from 2013 to 2018 were retrospectively characterized as current, former, or never smokers at the time of implant. We examined 1-year survival, total hospital readmissions, and specific hospital readmissions for LVAD-related adverse events based on patient's smoking status. Of the enrolled patients (n = 292), 55% were former smokers, 33% were never smokers, and 11% were current smokers. The majority of patients were African-American (48%) with a median age of 58 years. Never smokers were younger and less likely to be Caucasian compared to former or current smokers (P .05, for both). The category of former smokers had statistically comparable total readmission rates with never smokers (2.49 vs. 2.13 event/year), whereas current smokers had significantly higher rates compared to never smokers (2.81 events/year, P .05), with odds ratio 2.12 (95% CI = 1.35-3.32) adjusted for age and Caucasian race for 5 times of total readmissions per year. The rates of driveline infection, stroke, and hemolysis were statistically comparable between the never smokers and former smokers, while current smokers had significantly higher rates compared to never smokers (P .05 for all).

Purpose Patients with the HeartWare HVAD require careful medical management in order to maintain an INR within therapeutic range (2-3) and prevent thrombotic events. We compared the incidence of epistaxis in patients with the HVAD and HeartMate 3 using propensity score matching (PSM). Methods Ninety-eight patients implanted with a left ventricular assist device (LVAD) from 2015-2020 were included in this study. Patients were matched on the basis of baseline characteristics, including age, gender, body mass index (BMI), indication, etiology, concomitant procedures, and the right ventricular assist device (RVAD) usage. Results To our knowledge, this is the first study to perform a PSM comparison of epistaxis events in patients with the HVAD and HeartMate 3. After matching, there were no significant differences in any of the baseline characteristics between groups (P >0.05 for all). Patients with the HVAD were more likely to suffer from epistaxis than HeartMate 3 patients (43% vs 18%, P = 0.027), an absolute risk increase of 25% (95% CI 5.7-44.3%) and a number needed to harm of 4 patients (95% CI 2.3-17.6). In both the univariate and multivariate analyses, HVAD usage was significantly associated with epistaxis (P 0.05 for all). Conclusion Patients with the HVAD may be at a greater risk for developing epistaxis than those with the HeartMate 3. However, other outcomes such as length of stay and survival are comparable. Prospective, multi-center studies should be done to accurately assess the impact of device type on clinical outcomes following LVAD implantation.

Purpose Graft rejection remains a significant complication following cardiac transplantation. As infection results in elevated immune system activity, we hypothesized that acute rejection events would be more common following infectious exposures and during the winter respiratory virus season. Methods Patients were included who underwent cardiac transplantation at our center in the Midwest, between January 1st, 2014 and December 31st, 2017. The composite endpoint consisted of antibody mediated rejection (AMR), donor specific antibodies (DSA), heart failure readmissions, and death within two years. Infectious events collected during readmissions included a primary infectious diagnosis, positive respiratory virus panel, and other diagnosed or treated infections excluding BK, CMV, and EBV. Results We analyzed 115 patients meeting inclusion criteria. The primary composite endpoint was met by 69 patients (60%). Pre-transplant PRA Class 1 was associated with the composite endpoint (HR 1.03, 95% CI 1.003-1.05, p 0.05). However, patients transplanted during winter - defined as January to March - had worse survival when compared to a composite of other seasons (2-year survival: 75% vs 88.7%, p=0.014) (Figure 1). Freedom from the composite endpoint was not associated with whether a patient had an infectious event (p>0.05). Conclusion Our study did not show any association between infectious exposure and rejection following cardiac transplantation. However, this analysis was likely underpowered to determine this association and national studies are needed.

Purpose We hypothesized that simultaneous assessment of biventricular function could predict clinical outcomes. Methods We reviewed 180 patients undergoing a milrinone drug study and right heart catheterization at our center from January 2013 to January 2019. Left ventricular stroke work index (LVSWI) was calculated as 0.0136 * ((cardiac index/heart rate) * 1000) * (mean arterial pressure - pulmonary capillary wedge pressure), and right ventricular stroke work index (RVSWI) was calculated as 0.0136 * ((cardiac index/heart rate) * 1000) * (mean pulmonary arterial pressure - right atrial pressure). Cutpoints were determined by ROC analysis. Patients were stratified as: (1) High LVSWI, High RVSWI; (2) High LVSWI, Low RVSWI; (3) Low LVSWI, High RVSWI; and (4) Low LVSWI, Low RVSWI. Univariate and multivariate logistic regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Cutpoints of 18.3 and 10 were determined for LVSWI and RVSWI, respectively. Low LVSWI, High RVSWI was associated with escalation of therapy or death at 30 days (OR 4, 95% CI 1.05 - 15.59, p = 0.041). All of the following statuses were associated with a negative outcome at one year: Low LVSWI, High RVSWI (OR 14, 95% CI 2.44 - 265.8, p = 0.015), Low LVSWI, Low RVSWI (OR 4.85, 95% CI 2.25 - 10.85, p Conclusion Simultaneous assessment of biventricular function using LVSWI and RVSWI is associated with clinical outcomes and may be useful for risk stratification.

Purpose Decision aids have become a powerful tool in left-ventricular assist device (LVAD) therapy for patients with advanced heart failure. Despite the vast availability of decision aids, a paucity of research exists regarding the nature of the information that patients receive about living with the LVAD. This study describes the extent of the knowledge that patients should possess before making decisions to receive an implantable LVAD. Methods We employed a qualitative description method using the data generated by two open-ended questions on shared decision-making and lifestyle from an online survey (n=125). Of the 125 LVAD patients, 116 provided with at least one response for the two-item question appended in the parent study. Content analysis included the assessment of word repetitions, metaphors, and other thematic phenomena. Most participants were male (66.4%), caucasian (75%), married (70.7%), bridge-to-transplant (70.7%), and HeartMate II (86.2%) patients. Results Four overarching themes emerged from the analyses: ‘choosing life or death,’ ‘forfeiting a normal lifestyle,’ ‘feeling insignificant,’ and ‘knowing what to expect.’ Notable sub-themes that emerged included the following: ‘powerlessness,’ ‘gratitude for life,’ ‘unknown complications,’ ‘physical restraints,’ ‘caregiver dependence,’ ‘manipulation,’ ‘false expectations,’ ‘self-guided care,’ ‘decision aids,’ ‘well-informed,’ ‘support system.' Conclusion We report a qualitative study featuring the largest sample size of its kind to date. Overall, patients were grateful for the life-saving nature of the LVAD, yet complications, along with poor support from the LVAD team, led some to feel unprepared for what was to come. Our study reinforces the need for decision aids and open communication regarding the lifestyle changes associated with LVAD therapy prior to implantation. The assistance of the care team is critical to ensuring patients make informed decisions and feel well-supported on these devices.

Purpose Due to their religious beliefs, Jehovah's Witnesses (JWs) do not accept blood products; consequently, these patients with end-stage heart failure frequently seek a center willing to perform bloodless left ventricular assist device (LVAD) implantation. We assessed the challenges JWs confront in obtaining access to care, based on our center's experience orchestrating bloodless LVAD implantation. Methods We retrospectively reviewed the medical records of 36 patients - 18 JWs and 18 non-JWs - undergoing LVAD implantation at our center. Results Our findings revealed that JWs travelled a significantly greater distance to receive treatment than non-JWs (median: 293 (107.75, 667.5) vs 32.5 miles (15.3, 74.5), P = 0.006). Pre-operative characteristics, including INTERMACS profiles and re-operative status at implant, were comparable between the two groups (P > 0.05 for all). However, all JWs underwent concomitant surgeries at the time of bloodless LVAD implantation, as compared to 67% of non-JWs (P = 0.019). Length of stay, discharge location, and peri-operative outcomes were not significantly different (P > 0.05). We found that JWs currently face barriers in the availability, appropriateness, preference, and timeliness of access to care (Figure 2). In particular, being refused implantation at centers nearer to their residence causes JWs to travel excessive distances in hopes of treatment; however, long-distance travel may prolong the time until treatment and may not be an option for patients with financial or logistical challenges. Conclusion Our center's experience has shown that JWs face unnecessary barriers in access to care, but they can be successfully operated on with the use of optimization protocols and open communication between the patient and care team. Further research is needed to elucidate the challenges JWs face in accessing care and identify potential solutions which balance ethical considerations with patient autonomy.

Purpose We hypothesized that changes in biventricular function would approximate myocardial reserve and predict outcomes. Methods We reviewed 178 patients undergoing right heart catheterization and milrinone loading at our center between January 2013 and January 2019. Percent increase in left ventricular stroke work index (piLVSWI) was calculated as 100 * (left ventricular stroke work index after infusion - left ventricular stroke work index before infusion)/left ventricular stroke work index before infusion, and percent increase in right ventricular stroke work index (piRVSWI) was calculated as 100 * (right ventricular stroke work index after infusion - right ventricular stroke work index before infusion)/right ventricular stroke work index before infusion. Cutpoints were determined by ROC analysis, and patients were stratified as follows: (1) High piLVSWI, High piRVSWI; (2) High piLVSWI, Low piRVSWI; (3) Low piLVSWI, High piRVSWI; and (4) Low piLVSWI, Low piRVSWI. Cox regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Cutpoints of 18.9% and 17.5% were determined for piLVSWI and piRVSWI, respectively. Low piLVSWI, High piRVSWI was associated with escalation of therapy or death at 30-days (HR 3.78, 95% CI 1.41 - 10.17, p = 0.0084). Multivariate analysis identified Low piLVSWI, High piRVSWI as a predictor of escalation of therapy or death at one-year (HR 1.96, 95% CI 1.02 - 3.78, p = 0.043). Grouping patients according to whether they possessed Low piLVSWI, High piRVSWI revealed a greater hazard for the endpoint at 30-days and one-year (HR 2.98, 95% CI 1.41 - 6.28, p = 0.004; HR 1.79, 95% CI 1.0002 - 3.2, p Conclusion Change in biventricular function after milrinone infusion, particularly Low piLVSWI, High piRVSWI, may prognosticate worse clinical outcomes at 30-days and one-year.

Purpose Cardiopulmonary stress testing (CPX) has been used as a reliable marker for poor outcomes among patients with chronic heart failure. The utility of pre-transplant CPX to predict post heart transplant (HT) outcomes has not been evaluated. Methods We conducted an observational, retrospective, cohort study of all HT recipients who underwent a pre-HT CPX at a single center from 2013 to 2019. Measures of cardiovascular performance were evaluated including METs achieved, peak VO2, %-predicted peak VO2, VE/VCO2 slope, RER, and VO2/heart rate (HR). These were correlated to post-HT clinical outcomes including hospital length of stay (LOS), ICU LOS, need for mechanical circulatory support (MCS) (e.g. intra-aortic balloon pump or VA-ECMO), and death. Results 52 HT recipients were included (mean age 57 years, 67% male). All subjects underwent a CPX and subsequently received a HT within 139 ± 122 days. Subjects exhibited poor cardiovascular performance with 57% achieving a VE/VCO2 greater than 35 (average 37± 8), only 35% able to demonstrate greater than 6 METs, 58% with %-predicted peak VO2 less than 50, and 60% with VO2/HR of less than 11. Subjects with VE/VCO2 greater than 35 were older (60 years vs 49 years, p = 0.013) and had lower BSA (1.9 m2 vs 2.1 m2, p = 0.04). Ability to achieve greater than 6 METs was associated with less than 5-day ICU LOS (25% vs 10%, p=0.03) and a reduced need for MCS (2% vs 33%, p Conclusion Ability to achieve greater than 6 METs and a VE/VCO2 less than 35 were associated with positive post-HT clinical outcomes of reduced ICU LOS, reduced need for MCS, and reduced total hospital LOS. Pre-operative CPX measures may provide clinical utility in identifying subjects at risk for adverse post-HT outcomes.

Purpose Hemocompatibility-related adverse events (HRAE) are thought to be largely driven by the pump-patient interaction. We hypothesized that patients with left ventricular assist devices (LVADs) with low left ventricular stroke work index (LVSWI), and thus less native contribution to total flow, would have more adverse clinical outcomes. Methods Hemodynamic data was prospectively collected from LVAD patients who had undergone a right heart catheterization with ramp study at our institution between April 2014 and July 2018. LVSWI was calculated as 0.0136 * ((cardiac index/heart rate) * 1000) * (mean arterial pressure - pulmonary capillary wedge pressure). We used a previously identified cutoff point of 31.73 for LVSWI to separate patients into low and high LVSWI groups. Univariate and multivariate logistic regression analyses were performed to determine the association between LVSWI and HRAE, heart failure (HF) readmission, and mortality. Results A total of 93 patients were included in this analysis - average age 61 +/- 11 years, 34% women, 40% Black, and 38% ischemic cardiomyopathy. Low LVSWI was not significantly associated with HRAE (HR 1.65, 95% CI 0.93-2.91, p = 0.081) in univariate analysis, but was statistically significant (HR 1.81, 95% CI 1.02-3.22, p = 0.042) when adjusted for LVAD type (HeartWare HVAD, Heartmate II, and Heartmate 3). Low LVSWI was significantly associated with HF readmission (HR 3.02, 95% CI 1.46-6.24, p = 0.0029) and mortality (HR 2.97, 95% CI 1.29-6.85, p = 0.011), even when adjusted for LVAD type (HR 3.15, 95% CI 1.52-6.54, p = 0.0021 and HR 3.13, 95% CI 1.36-7.21, p = 0.0074, respectively). Conclusion Low LVSWI in LVAD patients is associated with poor prognosis and worse clinical outcomes such as increased HF readmission and mortality.

Purpose Studies have shown seasonal variation in the incidence of epistaxis. However, this trend has not been evaluated in patients with left ventricular assist device (LVADs), who are at an increased risk for this frequent adverse event. We assessed the seasonality of epistaxis recurrence and its impact on mortality in LVAD patients. Methods We retrospectively reviewed 103 patients undergoing LVAD implantation from 2015-2020. Univariate and multivariate binary logistic regression analyses were used to evaluate predictors for mortality. Results 33 (32%) patients developed epistaxis; of these patients, 25 (75%) had recurrent events. The median time to event was 27 (10, 225) days post-implantation, and 67% of events occurred within 3 months. Fall and winter were the seasons with the most events (36% and 33%, respectively), while spring and summer had comparatively fewer events (18% and 12%, respectively). Patients with epistaxis in winter were most likely to have a recurrence (91%), followed by spring, summer, and fall (83%, 75%, and 58%, respectively). Winter implantation (OR 9.5; 95% CI 1.7-78.14) and age ≥ 58 years (OR 14.88; 95% CI 2.15-303.8) were significantly associated with mortality in LVAD patients with epistaxis (P Conclusion We found that the fall and winter seasons had an increased number of epistaxis events, which is consistent with the results of studies conducted in non-LVAD patient populations. Older patients with epistaxis are at an increased risk for mortality. Furthermore, the effect of winter implantation on mortality in epistaxis patients warrants further investigation. Larger, prospective studies should be done to validate these findings.

Purpose Elevated mean arterial pressure (MAP) is associated with stroke in patients with HeartMate II and Heartware HVAD left ventricular assist devices (LVADs). We assessed the relationship between mean arterial pressure (MAP) and hemocompatibility-related clinical adverse events (HRAE) in patients with LVADs. Methods Prospectively collected hemodynamic data from LVAD patients who had undergone invasive hemodynamic ramp study at our institution between 4/2014-7/2018 were analyzed. ROC analysis was performed to determine optimal cutoff value for MAP, and patients were divided into two groups: high MAP (≥90mmHg) and low MAP ( Results 91 patients (average age 61 ± 11 years, 34% women, 40% Black, 38% ischemic cardiomyopathy) were included in the analysis. Of all patients, 29% had HeartWare HVADs, 57% HeartMate II, and 14% HeartMate 3 LVADs. MAP was not significantly associated with HRAE, HR 1.53 (95% CI 0.88-2.64, p=0.13), even when adjusted for LVAD type, HR 1.65 (95% CI 0.95-2.87, p=0.076). Similarly, MAP was not significantly associated with HCS. Low MAP was, however, significantly associated with higher mortality, HR 2.47 (95% CI 1.13-5.39, p=0.024, Figure 1A), and higher rates of heart failure readmission, HR 2.05 (95% CI 1.06-3.99, p=0.034) (figure 1B). Conclusion MAP was not significantly associated with HRAE in this population of LVAD patients. However, low MAP was significantly associated with mortality and heart failure readmission.

Background Fewer than 25 simultaneous heart-liver-kidney transplants (SHLKTxs) have been performed in the U.S. This highly complex operation was performed nine times by only four centers from 2018 to 2019. However, one institution, the University of Chicago Medical Center (UCMC), is responsible for two-thirds of all SHLKTxs performed in that period. There is a paucity of literature regarding the logistics and infrastructure of performing SHKLTxs. The development of a standardized, effective protocol would improve outcomes in the high-risk patients who undergo this operation. We assessed the unique strategies that this center employs to successfully perform a high volume of SHLKTxs to understand possible programmatic procedures. Methods We reviewed the logistical methods and infrastructure of the UCMC concerning the process of SHLKTx, spanning the stages from patient selection to operating room (OR) management. Additionally, we attempted to identify areas of future improvement. Results The UCMC employs strict patient selection criteria, as potential candidates must meet the listing criteria for each organ independently. The severity of illness, however, must also indicate the potential for a successful outcome, and the age limit for candidates is typically 60 years. Donor selection and organ allocation are critical to ensure that all organs are received from the same donor, which can require negotiation when the procurement is not in a local area. The technically challenging surgery requires the transplant teams to move quickly in order to minimize ischemic time for the heart and prevent reperfusion injury in the liver, while the kidney is perfused. Due to the risk of these events, the transplant team recommends the use of mechanical support, such as extra-corporeal membrane oxygenation (ECMO). The key element of the UCMC's success was found to be the team's ability to procure and achieve success with organs that many other centers would turn down. The team is willing to accept undersized hearts, travel further distances, use DCD organs, and transplant Hepatitis C seropositive non-viremic (HCV Ab+/NAT-) livers to an HCV seronegative recipient in pursuit of an expeditious and successful SHLKTx. The combined efforts of a skilled, multidisciplinary team are also essential. The various teams see the patients together in a structured rounding schedule, and the operation itself consists of three distinct phases with choreographed and planned handoffs. Areas identified for future improvement included standardizing the approach used in the OR, particularly team transfer and timing. Conclusion The UCMC owes its established track record of successful SHLKTxs to the internal infrastructure of its program. In particular, its willingness to accept organs that other centers refuse allows it to perform a high volume of expeditious and successful SHLKTxs. Future steps include protocolizing OR management along with identifying parameters that allow for a structured system of team transfer.

Background Triple-organ transplants are rare, challenging operations necessitated by multi-organ failure. The difficulty of matching patients with a prospective donor, as well as the high level of complexity and coordination involved, prevents most transplant centers from performing these procedures, leaving patients who are in need of a triple-organ transplant searching for willing centers or opting for palliative care. We assessed the trends in frequency of various triple-organ transplants involving the heart over the last three decades by exploring the UNOS database. Methods Collected data was obtained from the UNOS Transplant Database and U S Department of Health & Human Services OPTN National Data web app. Triple-organ transplants performed from January 1988 to February 2020 were included in the analysis, while excluding transplants not involving the heart. Results To date, a total of 54 triple-organ transplants involving the heart have been performed. Although the overall number of transplants per year has remained relatively constant over time, it increased from one to three in 2017 and then to five and seven in 2018 and 2019, respectively (Figure 1). In particular, the growth in the frequency of heart-liver-kidney transplants is responsible for 75% of the rise in transplants performed from 2017 to 2019. However, whether these increases will persist as a long-term trend remains to be determined. Notably, the University of Chicago Medical Center (UCMC) has performed 10 of the 23 heart-liver-kidney transplants to date, transplanting 6 in the past two years. Thus, this particular center is responsible for two-thirds of all heart-liver-kidney transplants and half of all triple-organ transplants involving the heart performed between 2018 and 2019 (Figure 2). Conclusion Not only has the total number of triple-organ transplants involving the heart steadily increased in the last three decades, but also the frequency of transplants per year has increased from 2017 to 2019. In the same time period, the UCMC has been responsible for 50% of the increase in transplants performed. Further studies should be done to evaluate strategies for coordination and care of triple-organ transplants involving the heart. Additionally, complexity of procedure and donor organ shortages remain issues of concern.

Background The seasonal variation of incidence and severity of heart failure is well known. However, the impact of seasonal variation on clinical outcomes following left ventricular assist device (LVAD) implantation remains unknown. Methods We retrospectively reviewed consecutive patients who received LVAD implantation between January 2014 and December 2016 along with their first year of post-implant outcomes. Clinical outcomes were compared between those with winter LVAD implantation (between October and March) and those with non-winter LVAD implantation. Results 168 patients with a median age of 57 years and 130 males were included. There was no seasonal difference in the number of LVAD implantations. One-year survival free from adverse events was significantly lower in the winter implant group (N = 88) compared to the non-winter group (N = 80) (44% vs. 61%; Figure 1A) with an adjusted hazard ratio of 1.81 (95% confidence interval 1.11-2.90, p = 0.014), largely due to a higher rate of heart failure readmission in the winter implant patients (incidence rate ratio 2.29, 95% confidence interval 0.89-5.84; Figure 1B). Conclusion Patients who underwent LVAD implantation during the winter season had a higher heart failure readmission rate. A detailed mechanism and therapeutic strategy given our findings warrant further investigation.

Purpose It is well-documented that tobacco smoking has significant cardiovascular ramifications. However, the effects of tobacco smoking upon Ventricular Assist Device (VAD) implant outcomes are understudied. We aimed to ascertain the effort that institutions devote to smoking cessation programs for VAD patients and the success of these programs. Methods Using Survey Monkey®, a 13-question survey was created and distributed to 26 VAD institutions. Examples of multiple-choice questions included: 1) the volume of VAD patients at the respondent's center, 2) the patient population with active or past use of tobacco, 3) the presence and breadth of smoking cessation programs, and 4) the respondents’ views on program success. Results Respondents (n=15, 58%) stated that more male patients (n=12,75%) were smokers at the time of implantation. The most prevalent ages of tobacco smoking among patients were nearly evenly distributed between the ages of 35-70, but one institution reported the most common age as below 35 years. While pre-implant smoking cessation was not required at most programs (n=13, 87%), nearly all (n=14, 93%) offered cessation therapy after implant, with half of the respondents viewing the programs as effective. There was no apparent correlation between feelings of effectiveness and the category of tobacco smoking cessation therapy (Figure 1). Several respondents indicated that tobacco smoking cessation programs are not effective in Destination Therapy patients, while Bridge-to-Candidacy offers an incentive for compliance. Conclusion Although tobacco smoking is not a contraindication for device implantation, our data suggests programs are dedicated to utilizing smoking cessation strategies for patients. However, no definitive strategy was identified in successful tobacco smoking cessation programs in our study, pointing to the need for research. Additionally, studies of standards, protocols, and team involvement are areas that could provide data to improve the outcomes of tobacco smoking cessation among VAD patients.

Purpose Standard therapy with aspirin is recommended for patients after HVAD™ implantation. Bleeding in HVAD™ patients may lead to aspirin dose reductions or discontinuation to prevent future events. Previous studies in mixed cohorts of VAD patients have evaluated modified antiplatelet regimens with varied results regarding thrombotic outcomes. This study aims to report the impact of dose-reduced aspirin on thrombotic outcomes in HVAD™ patients. Methods This was a single-center retrospective evaluation of adult HVAD™ patients implanted from 7/1/2014 to 12/5/2018, maintained on therapeutic anticoagulation with warfarin. Outcomes were compared between two aspirin dosing groups: per-protocol aspirin (162 mg and 325 mg), and dose-reduced aspirin (0 mg and 81 mg). The primary endpoint was the composite incidence of ischemic stroke or pump thrombosis during the first year after implant. Secondary endpoints included ischemic stroke, pump thrombosis, gastrointestinal bleeding and hemorrhagic stroke. Results Seventy-six patients were analyzed (Table 1). No difference was observed between the two groups with respect to the composite primary endpoint of ischemic stroke or pump thrombosis (Figure 1). No statistically significant differences were observed in any of the secondary endpoints. Conclusion Numerically more events were observed in the dose-reduced aspirin group. In this cohort, dose reduction did not afford any benefit with regards to hemocompatability-related adverse events, indicating HVAD™ patients should be maintained on per-protocol aspirin dosing. More studies may add to the impactful nature of the results found in this investigation.

One of the main security criteria that mostly influence the strength of a conventional cipher system is the Nonlinearity criterion. A classical cipher system is considered strong if it is characterized by high nonlinearity. That is, the underlying Boolean function employed within the system is required to be far from being linear. The measure of a Boolean function's nonlinearity can be done with the help of the Walsh transform as a tool. This paper presents an analysis of the nonlinearity criterion from the Haar transform domain perspective. The paper proceeds by utilizing the connection between the Haar and the Walsh transforms. The work provides two main contributions in the form of the definition of nonlinearity given the Haar spectrum of an arbitrary Boolean function and a Haar-Walsh hybrid algorithm for measuring the nonlinearity given the Haar spectrum. The derived algorithm is then simulated along with the Walsh benchmark and the results are presented in a comparison study. The paper then follows up by presenting a discussion on the computational advantages of employing the Haar-Walsh hybrid method in terms of time and space complexities. It is shown that, the Haar-Walsh hybrid method performs better when the transformed function is characterized by high number of input variables (n > 11). The paper concludes with a summary of the presented work and suggestions for future work.

Design of strong symmetric cipher systems requires that the underlying cryptographic Boolean function meet specific security requirements. Some of the required security criteria can be measured with the help of the Autocorrelation function as a tool, while other criteria can be measured using the Walsh transform as a tool. The connection between the Walsh transform and the Autocorrelation function is given by the well known Wiener-Khintchine theorem. In this paper, we present an analysis of the Autocorrelation function from the Haar spectral domain. We start by presenting a brief review on Boolean functions and the Autocorrelation function. Then we exploit the analogy between the Haar and Walsh in deriving the Haar general representation of the Autocorrelation function. The derivations are carried out in two ways namely, in terms of individual spectral coefficients, and based on zones within the spectrum. The main contribution of the paper is the establishment of the link between the Haar transform and the Wiener-Khintchine theorem. This is done by deducing the connection between the Haar transform, the Autocorrelation, and the Walsh power spectrum for an arbitrary Boolean function. In the process we show that, the same characteristics of the Wiener-Khintchine theorem holds locally within the Haar spectral zones, instead of globally as with the Walsh domain. The Haar general representations of Autocorrelation function are given for arbitrary Boolean functions in general and Bent Boolean functions in particular. Finally, we present a conclusion of the work with a summary of findings and future work.

The concept of wireless distributed computing (WDC), proposed recently, is used to distribute and allocate computational tasks wirelessly. Despite various benefits of WDC, such as distributing the workload efficiently among cooperating nodes, WDC concept is facing enormous challenges. Proposing an efficient task allocation algorithm is one of the key challenges in WDC network. The work reported here proposes a novel task allocation algorithm called as adaptive load balancing (ALB). The ALB algorithm nominates the cooperating nodes in WDC network adaptively based on the channel conditions among the cooperating nodes. Then, it balances the workload amongst the cooperating nodes based on the available energy in each node. Herein, the validity of the proposed novel ALB algorithm is proved first. Then, ALB algorithm is applied to an application in cognitive radio network (CRN). Furthermore, the channel impact on the distributed tasks by ALB algorithm, in WDC-CRN, is investigated and benchmarked. Accordingly, the probability of detection results in case of applying the novel ALB algorithm is found to be enhanced.

In this paper, we present simulation results for Reed–Muller (RM) turbo codes over AWGN and Rayleigh fading channels. We also compare the simulation results of turbo product codes and block turbo codes with RM component codes over an AWGN channel. We show that minimum distance is not important as far as the BER performance of long codes is concerned. The weight distribution of RM codes of different lengths and turbo product codes with first-order RM component codes are obtained and analyzed for their good performance. We show that the weight distribution asymptotically approaches that of random coding as the code length increases.

This paper presents some results on multiple error detection and correction based on the Redundant Residue Number System (RRNS). RRNS is often used in parallel processing environments because of its ability to increase the robustness of information passing between the processors. The proposed multiple error correction scheme utilizes the Chinese Remainder Theorem(CRT) together with a novel algorithm that significantly simplifies the error correcting process for integers. An extension of the scheme further reduces the computational complexity without compromising its error correcting capability. Proofs and examples are provided for the coding technique.