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Purpose While thought to increase short-term mortality, the effect of amiodarone use prior to heart transplant (HT) on long-term survival is not well established. We therefore sought to examine the effect of amiodarone use on long-term survival following HT after adjustment for known risk factors. Methods We included adult patients who underwent HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients according to pre-transplant amiodarone use. We constructed logistic regression models using recipient and donor characteristics to calculate propensity scores. We then used overlap propensity score weighting to construct Cox proportional hazards regression models (adjusted for IMPACT score and PHM ratio) for mortality outcomes. Adjusted logistic regression compared the odds of primary graft failure and drug-treated rejection. Results 25,394 adult HT recipients were included: median (inter-quartile range) age was 55 (46, 62) years, and 25.5% were female. Amiodarone users had a significantly higher prevalence of hypertension (46.7% v. 50.2%; p Conclusion While pre-transplant amiodarone was associated with higher short-term mortality, its use did not affect long-term survival. Whether the short-term outcomes are related to greater graft failure risk is unclear.

Purpose Post heart transplant (HT) outcome of patients with body mass index ≥ 35 kg/m2 (morbidly obese) remain suboptimal. However, outcome of morbidly obese patients listed for heart transplant (HT) is unknown. We sought to examine the characteristic and outcome of such patients who were listed for HT in the United States. Methods Adults listed for HT with BMI information on the Scientific Registry of Transplant Recipients database between 2000 and 2018 were included. Characteristics and outcomes of patients with BMI≥ 35 kg/m2 or = 18.5-34.99 kg/m2 were compared. The patients were followed until death, transplant or end of data availability. Waitlist mortality and successful HT were compared between groups using a Fine and Gray competing risk hazard regression model adjusted for known risk factors. Results 55,717 patients identified: 5022 (9.0%) had a BMI ≥ 35 kg/m2; 13,058 (23.4%) were female. The median (25th, 75th percentile) age was 55 (45, 61) years, and the median waitlist time was 101 (27, 299) days. Morbidly obese patients were significantly younger (51 vs. 55 years; p Conclusion Listing of patients with BMI≥ 35 kg/m2 is on rise. However, this cohort is at significantly higher risk for death and lower HT rates.

Purpose Both underweight and overweight recipients have poor outcomes after heart transplant (HT). However, the precise threshold of body mass index (BMI) as a predictor of heightened risk is unclear. We, therefore, examined the effect of BMI on short term survival as a continuous metric. Methods We identified adult patients listed for HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients with recorded BMI at the time of listing. We calculated survival at 30 days and one year after HT and constructed Cox proportional hazards regression models adjusted for known recipient and donor risks. Recipient BMI was modeled using a restricted cubic spline with knots at 18, 25, 30, and 35 kg/m2 with a value of 22 used as a referent. Results 37,068 adult HT recipients were included: median (25th, 75th percentile) BMI of 27 (23, 30) kg/m2, recipient age 55 (46, 62) years, 27,668 (74.6%) men, and 9,683 (26.1%) with diabetes. After risk-adjustment, Cox proportional hazards regression showed a 3% increase in both 30-day (HR 1.031, 95% CI 1.024-1.037; p Conclusion Increases in recipient BMI was associated with an incremental risk of 30-days and 1-year mortality following HT.

Purpose Post heart transplantion (HT) outcomes of patients with body mass index ≥ 40 kg/m2 (morbidly obese) remain suboptimal. However, outcomes of morbidly obese patients listed for heart transplant (HT) is unknown. We sought to examine the characteristic and outcome of such patients who were listed for HT in the United States. Methods Adults listed for HT with BMI information on the Scientific Registry of Transplant Recipients database between 2000 and 2018 were included. Characteristics and outcomes of patients with BMI≥ 40 kg/m2 or = 18.5-39.99 kg/m2 were compared. The patients were followed until death, transplant or end of data availability. Waitlist mortality and successful HT were compared between groups using a Fine and Gray competing risk hazard regression model adjusted for known risk factors. Results 55,717 patients identified: 656 (1.2%) had a BMI ≥ 35 kg/m2; 13,058 (23.4%) were female. The median (25th, 75th percentile) age was 55 (45, 61) years, and the median waitlist time was 101 (27, 299) days. Severely obese patients were significantly younger (46 vs. 55 years; p Conclusion Listing of patients with BMI≥ 40 kg/m2 is declining. This cohort is at significantly higher risk for death and lower HT rates.

Purpose Mobile ECMO program supports patients with refractory acute respiratory failure deemed at high risk for transfer to an ECMO center. Transesophageal or transthoracic echocardiography and/or radiographic imaging is routinely done to confirm cannula position before departure to the receiving center. We herein report the feasibility and outcomes of the first case-series with transportation of VV-ECMO patients without confirmatory imaging. Methods Adult patients who underwent mobile VV-ECMO implantation. Results 71 adult VV-ECMO recipients were included, all with dual cannula implant schema: 14 (19.7%) transferred without confirmation; median (inter-quartile range) age was 51 (18, 80) years, BMI was 33.05 (21.7, 62.8) and 43.7% were female. Baseline characteristics of patients were similar in groups with and without cannula confirmation (Table). No complications occurred during cannulation or transportation. Two cannula malpositions were identified: 1) imaging group - venous inflow was noted to course from right femoral vein to the left without flow issues and was changed at the sending center; 2) non-imaging group a “kink” in IVC cannula was noted after arrival without flow issues. Conclusion With the use of point of care ultrasound, line placement safety is drastically improved, and transportation of patients with ARDS on VV ECMO with a stable flow is feasible without cannula position confirmation. This approach can decrease resource utilization, healthcare cost and minimize out-of facility time for the implant team.

Purpose Severe obesity, defined as body mass index (BMI) ≥ 40 kg/m2, is a contraindication for a heart transplant (HT). However, practice varies across transplant centers. This study examined the post-transplant survival of these patients who underwent HT in the United States. Methods We included adult patients who underwent HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients with available BMI information. We compared 30-day, 1-, 5- and 10-year survival of those with a BMI≥ 40 kg/m2 with BMI = 18.5-39.99 kg/m2 using the Kaplan-Meier method. Cox proportional hazards regression models then determined the influence of BMI category on survival adjusting for known recipient and donor risk factors, including Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score and predicted heart mass ratio. Results 36,115 adult HT recipients were included: 275 (0.8%) severely obese. The median (inter-quartile range) age was 55 (46, 62) years, and 25.4% were female. Severely obese patients had more hypertension (p=0.0019), diabetes (p Conclusion Survival following HT was significantly lower in recipients with severe obesity. Severe obesity should be addressed before HT is considered.

Purpose Extracorporeal membrane oxygenation (ECMO) treats acute reversible severe heart/lung failure in adults at high mortality risk. While often initiated in-hospital, ECMO's portability allows for experienced centers to implant it off site. We examined the impact mobile ECMO on survival in patients with severe cardiopulmonary failure. Methods This is a retrospective review of patients with in-hospital or mobile ECMO from January 2013 to October 2019. Participants were included if they were ≥ 18 years old and received ECMO performed at Hartford Hospital or through the mobile, “ECMO on the Go” unit. The Survival After Veno-Arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores were calculated. The primary endpoints were 48-hour and hospital discharge survival. Results We included 201 patients with a median (25th, 75th percentile) age 54.0 (39.5, 64.0) years and median ECMO time of 5.0 (3.0, 8.0) days. VA (median SAVE score -6.5 [-9.0, -3.0]) and VV ECMO (median RESP score 2.0 [-1.0, 5.0]) were initiated in 51.7% and 48.3% of patients, respectively. Mobile ECMO was initiated in 61 (30.3%) patients. 48-hour survival was higher in the mobile (65.6%) vs hospital ECMO patients (55.7%, p=0.192). Survival to hospital discharge was also higher with mobile (59.0%) vs hospital ECMO patients (41.4%, p=0.097). Baseline SAVE and RESP scores were higher in patients surviving to 48-hr and hospital discharge (p Conclusion We showed that mobile ECMO is effective for treatment of severe cardiopulmonary failure refractory to standard modalities. Mobile ECMO trended towards improved survival compared with in-hospital initiation. SAVE and RESP scores may be predictive of survival using mobile ECMO applications.

The use of left ventricular assist devices (LVADs) is increasing exponentially, but is accompanied by a rise in unanticipated adverse events. We describe an endovascular repair of a symptomatic mid-segment LVAD outflow cannula kink. A 31-year-old man with Becker muscular dystrophy underwent HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD implantation as bridge to transplant. The inflow catheter was placed at the apex of the left ventricle and the outflow cannula in the ascending aorta, as per the standard technique. The patient had an unremarkable post-operative recovery and was discharged home with New York Heart Association (NYHA) Functional Class II symptoms. Four months post-implant the patient reported lightheadedness when moving from the supine to seated position. He was not orthostatic and LVAD interrogation demonstrated power surges from 6.5 to 13, but lactate dehydrogenase (LDH) was 276 units/liter. Computed tomographic angiography showed no evidence of thrombus; however, a 751 kink in the outflow graft was noted 12 cm distal to a normal LVAD outflow bend-relief and 9 cm proximal to the cannula insertion in the ascending aorta

Purpose Left ventricular (LV) assist device (AD) placement for end-stage LV failure (F) is contraindicated with co-existing right ventricular (RV) F. We propose a strategic pre-op management (“HF tune up”) prior to LVAD allowing safe LVAD implant despite RVF. Methods and Materials This single center study identified 47 patients (pts) who underwent Heart Mate II implant from 2009 to 2011. Pre-op hemodynamics were analyzed at three time points: presentation (T0), 1 day pre-op (T1) and 3 days post-op (T2). Pre-op RVF was defined visually by 2D-echocardiography &/or by RV Stroke Work Index (RVSWI 14 days &/or RVAD placement. All pts underwent escalating pre-op “HF tune up” (diuresis, vasodilators, inotropes). Results Mean INTERMACS score for all HF pts who underwent HMII LVAD insertion was 1.7 ±0.6. Mean age was 61±16 yrs. 62% (n=29) of pts had preexisting RVF by echocardiography (51% moderate, 11% severe) with markedly elevated CVP at T0 compared to non-RVF. Of those, 24% (n=7) pts had RVF by RVSWI criteria. HF tune up significantly improved CVP and PCWP (T1) without change in RVSWI (T0: 0.6 ±0.5 vs T1: 0.3±0.3; p=ns). Despite marked pre-op RVF, post-op RVF rate were markedly low with 2% (n=1) suggesting that under ideal hemodynamics (Fontan physiology) the LVAD can support both, LV & RV. 1-year morbidity and mortality was excellent and not different between RVF vs non-RVF. Conclusions Effective pre-op HF tune up targeting CVP ≤ 8, PCWP ≤18, and PVR≤1.2 in end-stage HF pts with refractory pre-op RVF can greatly reduce post-op RVF. In this setting, LVAD placement appears to be safe and supports both ventricles via a “Fontan” circuit. LVAD and Hemodynamics at different time points Variables No RVF(n=18) RVF(n=29) CVP (mmHg) T0 13.8 ± 4.5 17.7 ± 4.1 0.004 T1 8.6 ± 3.9 9.1 ± 2.1 NS NS T2 12.4±4.9 11.5±4.2 NS PCWP(mmHg) T0 23.2±4.3 22.9±5.0 NS T1 17.6±5.6 15.43±3.7 NS NS NS T2 19.3±5.6 14±5.6 0.02 PVR (WU) T1 3.1±2.0 2.53±1.7 NS NS T2 1.95±4.2 1.14±1.8 NS