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Patients with existing Left Ventricular Assist Device (LVAD) who undergo non-cardiac surgery have a 9% risk of surgical site infection and up to a 44% chance of peri- and post-operative bleeding. This, along with the hemodynamic compromise of advanced heart failure, often makes LVAD patients prohibitively high risk for non-emergent surgeries. We present a successful case of an LVAD implanted into a patient with prior colostomy, who then later underwent a technically difficult colostomy reversal and parastomal hernia repair, without any of the aforementioned complications. A 44-year-old male with a history of non-ischemic cardiomyopathy (LVEF 20%) subsequently suffered perforated diverticulitis which was treated with a sigmoid colon resection with end colostomy. Later that year, he required LVAD (HeartMate 3™ Abbott) placement for cardiogenic shock requiring chronic inotropic support. Prior to his LVAD placement, colostomy reversal was considered to reduce the risk of post-operative LVAD driveline infection. Ultimately, colostomy reversal was deferred due to concern that a colorectal anastomosis may leak due to poor perfusion. However, he then developed a parastomal hernia with loss of domain which hindered colostomy care. Because he was weaned off inotropes and had clinically improved after his LVAD placement, it was felt he would be hemodynamically stable to tolerate colostomy reversal and subsequent parastomal hernia repair. His anticoagulation with warfarin was held for bridging enoxaparin one week before surgery. The colostomy site fascial defect was closed primarily and a sublay of synthetic mesh was placed. The surgical dissection at the old colostomy site was done to ensure there was adequate distance between the surgical field and LVAD driveline. The presence of the LVAD driveline along the right abdominal wall limited the ability to perform a right sided component separation but it was done on the left side to gain intra-abdominal domain. He remained stable during and after the procedure. Warfarin was re-started post-operative day one. This demonstrates feasibility to receive an LVAD with an existing colostomy, despite risk of infection. It also highlights that patients with an LVAD can undergo colostomy reversal and parastomal hernia repair, despite risk of poor anastomosis healing, bleeding, subcutaneous infection, and LVAD driveline infection. [ABSTRACT FROM AUTHOR]

A subset of patients with Takotsubo Cardiomyopathy (TCM) develops hemodynamic instability requiring temporary mechanical circulatory support (tMCS). We examined the National Inpatient Sample (NIS), a large national registry of hospitalized patients in the United States, to identify temporal trends in the utilization of tMCS in TCM patients along with clinical outcomes and cost. All adult hospitalizations of TCM from the National Inpatient Sample Database between 2007 to 2015 using ICD-9-CM codes were identified. We compared baseline characteristics, co-morbidities, mortality, length of stay and hospitalization costs among TCM patients with and without the need for tMCS. Propensity score matching to mitigate the differences was used. SAS 9.4 software was used for statistical analysis. Of 44,842 TCM hospitalizations, 1,120 (2.5%) received tMCS. Table 1 summarizes the baseline characteristics of this study population. Intra-aortic balloon pump (IABP) (1049/1120, 94%) was the most commonly utilized followed by extracorporeal oxygenation (66/1120, 5.8%) and paracorporeal ventricular assist device (20/1120, 0.2%) without any temporal trend in utilization pattern during the study period. After propensity matching, patients requiring tMCS for TCM as primary diagnosis were significantly younger (64.1±12.2 vs 66.3 ±12.9, P<0.0001) and more likely to be male. In-hospital mortality (9.3 % vs. 8.4 %; P = 0.73) was indifferent between the groups. However, the cost incurred during hospitalization and length of stay were higher in patients who underwent tMCS. The use of tMCS in patients with TCM and hemodynamic instability resulted in significantly higher cost, and length of hospital stay without positive impact on survival. This may be secondary to higher utilization of IABP contributing to worsening dynamic left ventricular outflow obstruction, systemic studies are needed. [ABSTRACT FROM AUTHOR]

Coronavirus disease-2019 (COVID) in patients with advanced heart failure presents unprecedented challenges in management of cardiogenic shock. Recommendations for perioperative triaging of cardiac surgery have been proposed but none regarding LVAD implantation. To our knowledge, we are the first to report on LVAD implantation in a patient with COVID and cardiogenic shock A 37-year-old-male with Stage D, NYHA class IV heart failure on chronic milrinone was admitted for cardiogenic shock. Despite uptitration of milrinone and addition of dobutamine,the patient remained in cardiogenic shock. Our Selection Committee discussed and approved him for an LVAD. Institutional protocol required COVID screening prior to surgery and returned positive. Given the absence of clinical signs of COVID infection contrasted with the severity of shock, the decision was made to proceed with implantation. Temporary mechanical support was considered but not thought to mitigate risks of thrombosis rather adding procedural risk with ECMO cannulation and left ventricular unloading. He successfully underwent LVAD implantation as INTERMACS 1. He required high doses of heparin to achieve ACT for cardiopulmonary bypass. On day 2, he developed left-sided weakness with imaging revealing multifocal acute cerebral infarcts. Despite normal LVAD function, the embolic infarcts to multiple organs led to further deterioration and death LVAD implantation in COVID patients appears inevitable. Centers must risk stratify this cohort to reduce susceptibility to thrombosis and improve outcomes. We propose an algorithm that triages patients for elective and urgent LVAD implantation based on specific coagulation and inflammatory markers (figure 1) and have successfully implanted an LVAD in a COVID patient using this. We acknowledge this method has not been validated in a large cohort and are unable to recommend anticoagulation protocols. Further research is necessary to address safety of LVAD implantation in COVID patients [ABSTRACT FROM AUTHOR]

In many heart transplant (HTx) programs, patients greater than 65 years of age who have had a previous left ventricular assist device (LVAD) are not candidates for HTX. They are kept at destination therapy. It is believed that these patients will have complications if transplanted. It has not been well established as to the outcome of these older LVAD patients undergoing HTx. Between 2010 and 2021, we assessed 35 patients who underwent a previous LVAD placement and subsequently underwent HTx at ≥65 years of age (range 65 to 70). A control group was comprised of patients (≥65 years) who underwent HTx without LVAD support. Post-transplant outcomes included 30-day and 1-year survival as well as 1-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), cardiac allograft vasculopathy (CAV: stenosis ≥30%), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). LVAD patients who underwent HTx at the age ≥65 years appear to have comparable outcomes compared to patients who underwent HTx without LVAD support ≥65 years. 1-year survival, freedom from NF-MACE, CAV, ACR, AMR were not significantly different. Older patients (≥65years) supported on an LVAD do not have compromised post-HTx outomes. These patients do not necessarily need to be committed to destination therapy. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygen (ECMO) is increasingly used as a bridge to lung transplantation. Although other mechanical circulatory support devices have been associated with a transfusion-independent increase in calculated panel reactive antibodies (CPRA), it is unknown whether ECMO is a sensitizing exposure. In this single center retrospective cohort study of lung transplant candidates between 5/1/2015-6/30/2021, antibodies against human leukocyte antigens (HLA-Ab) were evaluated at the time of ECMO initiation and weekly thereafter. Multivariate logistic regression was used to evaluate associations between CPRA increase and ECMO exposure adjusting for a history of any packed red blood cell (PRBC) transfusion and female gender. Sixty-two candidates were placed on ECMO as a bridge to transplant. Of these, 39 (62.9%) either had available HLA-Ab screens from pre- and post-ECMO initiation or multiple HLA-Ab screens post-ECMO. Of the 250 non-ECMO exposed recipients, 224 (89.6%) had multiple pre-transplant screens and served as the comparison cohort. Nine (23.1%) ECMO bridged recipients had an increase in CPRA, compared to 16 (7.1%) of non-ECMO exposed recipients (Fisher's exact p=0.005). Among those with increased CPRA, the median increase was 6% in ECMO bridge patients and 9% in non-ECMO exposed patients. After adjusting for covariates, however, ECMO bridge was not an independent risk factor for increased CPRA (OR=1.85, 95% CI 0.58-5.95, p=0.30). A history of PRBC transfusion trended toward an association with increased CPRA (OR=2.93, 95% CI 0.98-8.78, p=0.06). Pre-lung transplant ECMO was not independently associated with an increase in CPRA when adjusting for PRBC transfusion, although the study was underpowered for small or moderate effect sizes. Where clinically appropriate, PRBC transfusions should be limited in these patients. [ABSTRACT FROM AUTHOR]

Patients with severe heart failure who have undergone placement of a mechanical circulatory support (MCS) device do develop renal dysfunction. This renal dysfunction is not severe enough to necessitate the use of combined heart transplantation (HTx) and kidney transplantation. However, it has not been firmly established whether kidney dysfunction does add to increased morbidity or mortality after HTx in these device patients. Between 2012 and 2019, we assessed 79 patients who have undergone MCS, either with total artificial heart (n=22) or left ventricular assist device (n=53). Baseline creatinine/glomerular filtration rate (GFR) was measured and patients were divided into GFR categories which include 30-39 mL/min, 40-49 mL/min, 50-59 mL/min, and greater than or equal to 60 mL/min. All patients underwent HTx alone. The need for temporary dialysis was recorded, as well as peak creatinine in the first 3 months after HTx and serum creatinine at 1 year compared to baseline. Further outcomes include subsequent 1-year survival, freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30%), and freedom from non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). There was no significant difference in 1-year survival, CAV, and NF-MACE or the need for temporary dialysis amongst all groups. Furthermore, no patient in any group needed chronic dialysis. In the GFR 40-49 group compared to the other groups, there was a trend for higher creatinine at 1 year but the baseline was high. Baseline lower GFRs between 30-39 and 40-49 mL/min in MCS patients do not appear to be a predictor of poorer outcomes after HTx in patients. These patients do not appear to require combined heart and kidney transplantation. [ABSTRACT FROM AUTHOR]

Candidates for heart transplantation may be placed on durable left ventricular assist devices as bridge to transplantation. These patients are known to develop circulating antibodies mainly due to blood transfusion. It has been reported that up to 30-40% of these patients develop circulating antibodies which may limit the donor pool. It has not been established whether temporary mechanical circulatory support (tMCS) devices result in similar sensitization. Between 2016 and 2021, we assessed 16 patients waiting for heart transplantation who required temporary left ventricular support. tMCS included Impella (n=11) and IABP (n=5). Only patients who had no circulating antibodies at the time of tMCS were entered into this study. Blood samples were drawn beginning at 2 weeks following placement of the temporary device. Freedom from development of circulating antibodies was determined at 2-4 weeks following placement of tMCS. Only 1 of these 16 patients (6%) developed circulating antibodies just prior to heart transplantation while on tMCS. The mean time on tMCS devices prior to transplant was 22 days, and 10 of these 16 patients (63%) received packed red blood cells either during or after tMCS placement but prior to transplant. Patients placed on tMCS have a low likelihood of developing circulating antibodies despite receiving blood transfusions. tMCS does not appear to activate sensitization pathways. [ABSTRACT FROM AUTHOR]

Patients more than 50 years of age routinely undergo screening colonoscopies. These patients can develop severe end-stage heart disease and may require heart transplantation. Many of these patients present in cardiogenic shock and it is unclear whether the use of colonoscopy is safe and efficacious in the screening of these patients for candidacy for heart transplantation. In our single-center program, we preform colonoscopies routinely on older patients at risk for colon cancer (family history, previous polyps or adenomas, stools heme positive) awaiting heart transplantation. We now report our experience of performing colonoscopes in these patients who are in cardiogenic shock, defined as patients who are on intravenous inotropic or left ventricular assist device (LVAD) support to maintain acceptable cardiac hemodynamics. Between 2014 and 2019, we evaluated 300 heart transplant candidates who developed cardiogenic shock, defined as the need for IV inotropes or LVAD support. 30 of these patients underwent colonoscopy while on IV inotropes (n=27) and LVAD (n=3). All patients had compensated hemodynamics and anticoagulation was held prior to the procedure. Of the 30 patients with inotropic/LVAD support who underwent colonoscopy, the average age was 61.5 years and 87% were male. The specific inotrope(s) administered are listed in the table. The following findings at colonoscopy were found: 0 adenomas and 13 benign malignancies. There was no metastatic disease demonstrated. There were no complications arising from this colonoscopy except for bleeding due to biopsies that required hemoclips but no blood transfusions. Inotropic/LVAD support was continued through these procedures. Colonoscopies for evaluation of heart transplant candidates who are in cardiogenic shock are acceptable, but caution should be taken in terms of risk for bleeding. Colonoscopies in cardiogenic shock should be limited to patients who are at risk for colon cancer. [ABSTRACT FROM AUTHOR]