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Purpose Cannula position in HeartMate II and HVAD left ventricular assist devices (LVADs) is associated with clinical outcome. We aimed to investigate the clinical implication of the device positioning in HeartMate 3 LVADs. Methods Consecutive patients who underwent HeartMate 3 LVAD implantation were followed for one year from index discharge. At index discharge, chest X-ray parameters were measured: (1) cannula coronal angle, (2) height of pump bottom, (3) cannula sagittal angle, and (4) cannula lumen area. Results Sixty-four HeartMate 3 LVAD patients (58 years old, 64% male) were enrolled. In the multivariate Cox regression model, cannula coronal angle was a significant predictor of heart failure readmission (hazard ratio 1.27 [1.01-1.60], p = 0.045). Patients with a cannula coronal angle ≤28 degrees had lower central venous pressure (p = 0.030), lower pulmonary capillary wedge pressure (p = 0.027), and smaller left ventricular size (p = 0.019) compared to those with the angle >28 degrees. Right ventricular size and parameters of right ventricular function were also better in the narrow angle group, as was survival free of heart failure readmission (90% vs. 50%, p = 0.008; Figure). Conclusion Narrow cannula coronal angle in patients with HeartMate 3 LVADs was associated with improved cardiac unloading and higher survival free of heart failure readmission. Further studies to clarify the methodology and implication of optimal device positioning are warranted.

Purpose De novo diabetes mellitus (DM) is a common complication of solid organ transplantation. However, studies about post-transplant DM (PTDM) following heart transplantation (HT) are scarce. This study aims to compare baseline characteristics and clinical outcomes between patients who developed PTDM and those who did not as well as investigate the incidence and prevalence of PTDM following HT. Methods 148 consecutive patients undergoing HT between 4/2014 and 12/2018 were enrolled to this retrospective study. PTDM diagnosis was made based on a HbA1c ≥6.5%, fasting blood glucose ≥ 126mg/dL or use of insulin or oral hypoglycemic agents. Results Of the 148 patients, 57 (39%) had no DM, 37 (25%) had DM prior to HT, and 54 (36%) developed PTDM. Among the patients without DM at the time of HT, cumulative incidence of PTDM was 37% at discharge, 46% at 6 months, and 48% at 1 year post-HT. The prevalence of PTDM at 6 months post-HT was 44% and decreased to 36%, 26%, and 17% at 1, 2, and 3 years, respectively (Figure 1A). PTDM patients had a significantly higher pre-HT HbA1c compared to those without DM (5.8 (5.6, 6.0) vs 5.5 (5.3, 5.9)%; p=0.017). There was no difference in the dose of immunosuppressive medications between the groups. PTDM patients had a higher rate of infection requiring hospitalization compared to patients with no DM post-HT (80% vs 61%; p=0.036). Infection free survival was significantly lower in the PTDM group at 2 years (16% vs 35%; p=0.046) (Figure 1B). Overall survival (96% vs 96% at 2 years; p=0.986), rejection-free survival (46% vs 51% at 2 years; p=0.410), rate of cardiac allograft vasculopathy (33% vs 22%; p=0.267), kidney function and number of hospitalizations were similar between the PTDM and no DM groups. Conclusion The incidence of PTDM after HT was high but prevalence decreased after 6 months. Patients with PTDM had increased pre-HT HbA1c and higher post-HT rates of infection compared to patients without DM. Further studies are needed to determine the clinical impact of PTDM.

Purpose Aortic valve opening in patients supported by left ventricular assist devices (LVAD) preserves native valve geometry and structure and reduces rates of aortic insufficiency and need for aortic valve interventions. With LVAD speed optimization studies (Ramp studies) hemodynamic optimization can sometimes come at the expense of aortic valve opening. Here we explore the impact of aortic valve opening after optimization on morbidity and mortality. Methods LVAD Patients from a single institution underwent simultaneous echocardiographic (TTE) and hemodynamic LVAD ramp study. Patients were deemed optimized when their hemodynamic profile reached a target right atrial (RA) pressure 2.2L/min/m2. The impact of presence or absence of aortic valve opening on readmission-free survival, hemocompatibility related adverse events (HRAE)-free survival and overall survival at 3 years was determined. Results 113 LVAD patients were included in the analysis (62=HMII, 34=HVAD, 17 =HM3). Mean CI was 2.73L/min/m2, RAP 9.4mmHg and PCWP 13.7mmHg after optimization. 52 patients had absence of aortic valve opening at their set speed. There was no difference in overall survival (p = 0.89), HF admissions (p = 0.81) and HRAE (p = 0.85) at 3 years in those with and without aortic valve opening (Figure A-C). Conclusion Absence of aortic valve opening after LVAD speed optimization did not demonstrate more adverse events or LVAD-related morbidity and mortality compared to those who had aortic valve opening. Speed optimization should focus on hemodynamic optimization with less emphasis on aortic valve opening.

Purpose LVAD speed optimization via invasive ramp studies have been shown to reduce LVAD related morbidity. Many LVAD implanting centers use non-invasive echocardiographic (TTE) ramp studies for optimization and use mitral (MR) and aortic insufficiency (AI) severity as surrogates for unloading and optimization. We examined the prognostic value of residual MR and AI after invasive hemodynamic optimization. Methods Patients underwent simultaneous TTE and hemodynamic LVAD ramp study with hemodynamic and TTE measurements at each incremental speed increase. The device was set at a speed that demonstrated an optimized hemodynamic profile with target CVP 2.2L/min/m2. MR and AR severity at the optimized speed was quantified by TTE and the impact of residual regurgitant lesions on heart failure (HF) readmission-free survival and hemocompatibility related adverse events (HRAE) free survival and overall survival at 3 years was determined. Results After hemodynamic optmization, mean PCWP was 13.7mmHg, CI was 2.73L/min/m2 and RAP was 9.4mmHg for the entire cohort. 24 patients had residual mild/moderate or greater AI and 27 patients had mild or greater MR after optimization. Freedom from HRAE was higher in those without residual AI (45% vs 24%, p =0.05) at 3 years with no difference in overall survival or HF admission (Figure Top). Patients without residual MR had higher 3 year survival compared to those with residual MR (75% vs 51%, p =0.03). There was a trend toward higher HRAE and HF readmission rates in those with residual MR (Figure Bottom). Conclusion Residual AI and MR after LVAD hemodynamic speed optimization has negative consequences with regard to HRAE and HF readmission-free survival and overall mortality at 3 years. Additional speed optimization may be needed in this cohort to mitigate morbidity and mortality.

Purpose Donor-derived cell-free DNA (dd-cfDNA) has recently been introduced as a novel marker of acute cellular and antibody mediated rejection. We hypothesized that levels of dd-cfDNA would correlate with markers of chronic inflammation and angiogenesis in a stable post-transplant population. Methods 65 heart transplant recipients who were 8.5±5.4 years post transplant were enrolled at routine clinic visits. Exclusion criteria for the study were episodes of rejection within 6 months or recent infection. Peripheral blood protein expression of interluekin-6 (IL-6), interluekin-18 (IL-18), tumor necrosis factor-alpha (TNF-α), soluble Fas-ligand (sFASL), angiopoetin-2, vascular endothelial growth factor (VEGF) A, C and D and transforming growth factor alpha (TGF-α) was assessed using a multiplex immunoassay system (Bioplex®). Dd-cfDNA was measured using a targeted amplification, next generation-sequencing assay (AlloSure®; CareDx, Inc.). Results Patients were stratified for levels of dd-cfDNA % as low and high defined as above (≥0.14%) or below the mean ( Conclusion Inflammatory and angiogenesis cytokines are not associated with levels of dd-cfDNA in a stable post transplant population. Further studies of should investigate if temporal changes can predict adverse outcomes.

Purpose There is mounting evidence on the use of donor-derived cell-free DNA (dd-cfDNA) as a non-invasive tool to detect acute antibody and cellular mediated rejection. However the role of dd-cfDNA in detecting and monitoring cardiac allograft vasculopathy (CAV) in the absence of acute rejection remains unknown. We hypothesized that dd-cfDNA levels would correlate with the presence of CAV. Methods 65 clinically stable heart transplant recipients ≥ 2 years post-transplant, with no rejection episodes in the preceding 6 months were enrolled. CAV was assessed by routine coronary angiogram and intravascular ultrasound. Patients were stratified by time since transplant (2-5, 5-10 and ≥ 10 years post transplant) and high versus low levels of dd-cfDNA defined as above and below the median. Significant CAV was defined as Stanford III-IV or angiographic disease. A targeted amplification, next generation-sequencing assay (AlloSure®; CareDx, Inc.) was used to detect dd-cfDNA. Results Of 58 patients with known CAV status, 30 had high levels of ddcf-DNA (≥0.14%) and 28 had low levels ( Conclusion dd-cfDNA levels were associated with CAV in a cohort of stable transplant recipients >2 years post HT and thus might help to identify those in need for invasive assessment. Further studies should investigate if there is an association between dd-cfDNA levels and CAV severity and whether dd-cfDNA levels can predict CAV progression.

Purpose Hypogammaglobulinemia (HGG) can be identified in patients following solid organ transplantation and is thought to be predominantly due to immunosuppression. There is limited data describing the extent, degree and clinical outcomes associated with HGG following heart transplantation. The aim of this study is to investigate the prevalence and clinical significance of HGG in heart transplant recipients. Methods We retrospectively reviewed data of patients who had underwent heart transplantation at our institution between 4/2014 and 12/2018. We excluded patients with multi-organ transplantation. We defined serum IgG Results We enrolled 132 patients who had at least one serum IgG value following heart transplantation during the study period. Mean age was 53±14 years old and 94 (71%) patients were male. During 761 (463, 1266) days of follow-up, patients had a median of 4 (3, 6) IgG measurements. Prevalence of severe HGG was highest (27%) 3-6 months post-heart transplant and then decreased to 5% at 1-2 years (Figure A). Survival freedom of infection was 51%, 35% and 17% at 2 years in the normal, mild HGG and severe HGG groups, respectively (P=0.03, Figure B). Overall survival and rejection-free survival were comparable between the groups. Conclusion There is a high prevalence of HGG in the early post-heart transplant period that decreases over time. HGG is significantly associated with infectious complications. Further studies are needed to investigate the prophylactic treatment of HGG with IVIG in heart transplant recipients.

Purpose Hemocompatibility-related adverse events (HRAEs) are major causes of readmission in LVAD patients. Decoupling between diastolic pulmonary artery pressure (dPAP) and pulmonary capillary wedge pressure (PCWP) is an index of pulmonary vascular damage. This study assessed the implication of decoupling on HRAEs in LVAD patients. Methods In this prospective study LVAD patients underwent invasive hemodynamic tests and were followed for 1 year. Decoupling was defined as a difference >5 mmHg between dPAP and PCWP. One-year freedom from any HRAEs and the net burden of HRAEs, which was calculated by using a hemocompatibility score (using 4 escalating tiers of hierarchal severity to derive a total score for events), were compared between those with and without decoupling. Results Among 92 LVAD patients (median age 61 years, 57% male), 44 patients (48%) had decoupling. One-year freedom from any HRAEs was 49% in the decoupling group compared with 79% in the decoupling-free group (p = 0.005; Figure 1A). The average hemocompatibility score in the decoupling group was significantly higher compared with the control group (2.14 vs. 0.67; p = 0.004; Figure 1B), due to reduced Tier I (1-2 gastrointestinal bleedings or medically managed pump thrombosis; p = 0.027) and Tier IIIB scores (HRAEs-related death; p = 0.041). Conclusion The presence of decoupling between dPAP and PCWP was associated with HRAEs in LVAD patients. Studies evaluating if a reduction in decoupling will also reduce HRAE's is warranted.

Purpose Tricuspid regurgitation (TR) is a significant complication after heart transplantation (HTx). Tricuspid valve annuloplasty (TVA) may be performed empirically at the time of transplant to prevent the development of TR and right ventricular failure. This study aims to investigate the long-term impact of TVA on incidence of TR and survival. Methods All patients transplanted between 1/2010 - 8/2018 were enrolled. At our institution, we routinely perform DeVega TVA during HTx. All echocardiograms post-HTx were evaluated. TR was classified into 5 groups: none, trace, mild, moderate and severe. The incidence of significant TR (moderate or severe) over time and the effect of TR on survival were evaluated. Echocardiograms were evaluated starting 3 months post-HTx. Results 248 patients underwent HTx in this period, and 243 who underwent concomitant TVA were included in this analysis (mean age 54 years, 76% male). During 3.0 ± 2.1 years follow-up, 22 (9.1%) of patients developed significant TR. In the TVA group, survival free of significant TR was 96.9% at 6-months, 94.3% at 1 year, 91.6% at 2 years, 90.8% at 3 years, 90.8% at 4 years, and 88.8% at 5 years (Figure 1A). 5-year survival among those who experienced significant TR was numerically lower, but not significantly different (70.7% vs 81.5%, p=0.24) (Figure 1B). Only 8 (3.3%) patients required permanent pacemaker implantation over a median of 51 days (IQR 14-522) following HTx. Conclusion Significant TR after HTx is common and progressively worsens despite concomitant TVA. The association of significant TR with long-term survival and the benefit of TVA require further evaluation.

Purpose Although tricuspid regurgitation (TR) following left ventricular assist device (LVAD) implantation is known to be related to unfavorable outcomes, the longitudinal trend of TR during LVAD course remains unknown. The aim of this study is to clarify the longitudinal trend of TR prior to and following LVAD implantation. Methods We retrospectively reviewed patients who received LVAD implantation between 4/2014-8/2018. We evaluated the grade of TR by echocardiography prior to and following LVAD implantation. TR grade was determined based on the color flow jet area. Moderate or severe TR was defined as significant. We compared clinical outcomes of patients with concomitant tricuspid valve (TV) procedure (TVP+) and those without (TVP-). Results Among 199 consecutive patients, 194 patients had at least 2 echocardiographic TR grade assessments. All patients had a test prior to LVAD implantation, and had an average of 6±4 tests after LVAD implantation during a median of 389 (range 8-1540) days of follow-up. Mean age was 57±13 years and 132 patients (68%) were male. 107 (55%) patients were included in TVP+. Prior to LVAD implantation the prevalence of significant TR was higher in TVP+ (51% in TVP+ vs 20% in TVP-, P All-cause mortality and heart failure (HF) readmission-free survival were similar between the groups. In contrast, patients with significant TR in the early period (within 6 months) had lower HF readmission-free survival (at 1 year, 60% in significant TR vs 74% in non-significant TR, P=0.015, Figure 1B). Conclusion Long-term trend of TR and clinical outcomes throughout LVAD course were similar between TVP+ and TVP-. Patients with significant TR had decreased HF-free survival.

Purpose Pulmonary artery pulsatility index (PAPi) before left ventricular assist device (LVAD) implantation is associated with postoperative right ventricular failure . This study aimed to investigate the implication of post LVAD PAPi on clinical outcomes. Methods Following LVAD implantation, invasive hemodynamic tests were performed. PAPi was calculated as (systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/mean right atrial pressure . One-year mortality, gastrointestinal bleeding (GIB), heart failure (HF), pump thrombosis (PT), and stroke event rates were compared between low PAPi group and high PAPi group based on the established ROC cut-off value. Results 97 LVAD patients received hemodynamic tests at 598 ± 668 days following LVAD implantation. The mean age was 60 years old and 60 (62%) were male. Mean PAPi was 2.9 ± 2.6. We divided the subjects into a low PAPi group (PAPi ventricular tachyarrhythmia prior to LVAD implantation (p 0.05 for all). Conclusion Lower PAPi post LVAD implantation is associated with reduced survival free from HF hospitalization. PAPi may serve as a marker of right ventricular failure in this population.

Purpose Omega-3, an unsaturated fatty acid, reduces the risk of gastrointestinal bleeding (GIB) in patients with left ventricular assist devices (LVADs). However, its biological mechanism remains uncertain. This study aims to evaluate the impact of omega-3 on angiogenesis. Methods We measured inflammatory and angiogenesis biomarkers in plasma from LVAD patients by using Bio-plex ProTM Biomarker Assay kit and compared their levels between those with and without omega-3 therapy. GIB rates were also compared between the two groups by using binomial negative regression analysis. Results Among 38 patients (mean age 56.4 years, 66% male), 16 (42%) received 4 g/day omega-3 therapy. There was no significant difference in baseline characteristics between the two groups (p >0.05 for all). The GIB rate was significantly lower in the omega-3 group (0.100 event/year vs. 0.381 event/year, p Conclusion LVAD patients treated with omega-3 have significantly lower GIB rates and significantly lower angiopoietin-2 levels. The reduction in GIB rate with omega-3 may be due to the suppression of abnormal angiogenesis.

Purpose Continuous-flow left ventricular assist devices (LVAD) dramatically improve the hemodynamics of patients with advanced heart failure. However, longitudinal trends of hemodynamics in LVAD patients remain unknown. The aim of this study is to clarify the trends of hemodynamic parameters following LVAD implantation. Methods We retrospectively reviewed patients who received LVAD implantation between 4/2014-8/2018. We collected hemodynamic parameters obtained from right heart catheterization (RHC) prior to and following LVAD implantation. Results Among 199 consecutive patients, we enrolled 145 patients who had at least two RHCs. Each patient had a test before LVAD implantation, and an average of 2.2±1.4 RHCs after LVAD implantation during median 493 (15-1540) days of follow-up. Mean age was 57±13 years old and 101 patients (70%) were male. Following LVAD implantation, mean pulmonary arterial pressure (PAP) and pulmonary capillary wedge pressure (PCWP) decreased significantly and remained lower throughout LVAD course. Cardiac Index (CI) increased significantly and remained higher throughout LVAD course (Figure 1A). Right atrial pressure (RAP) improved initially and then returned to pre-implant values. Pulmonary artery pulsatility index (PAPi) did not improve early after implantation (3.0±2.7 to 2.7±2.1, P=1.00), and then progressively decreased over longer follow-up periods (2.3±3.6 at 1-2 years and 1.5±0.5 at 2-3 years) (Figure 1B). Conclusion Despite improvement in left-side filling pressure following LVAD implantation, PAPi worsened over time suggesting progressive right ventricular dysfunction.

Purpose Decoupling between diastolic pulmonary artery pressure (dPAP) and pulmonary capillary wedge pressure (PCWP) is an index of pulmonary vascular damage and is associated with recurrence of heart failure during LVAD support. This study aimed to investigate the impact of decoupling on right heart function. Methods In this prospective study, LVAD patients underwent invasive hemodynamic testing. Decoupling was defined as >5 mmHg of difference between dPAP and PCWP. We compared right heart function between those with and without decoupling, as assessed by transthoracic echocardiography at the time of catheterization and one year later. Results 69 patients (mean age 61 years, 49% male) were enrolled. 33 patients (48%) had decoupling. At baseline, all investigated right heart parameters were worse in the decoupling group (p Conclusion Presence of decoupling has a negative impact on right heart function during LVAD support. Therapeutic strategies to address decoupling may reduce right heart failure post-LVAD.

Purpose Flow waveform visualization is a unique feature of the HVAD left ventricular assist device (LVAD) that provides graphical real-time information linking device performance with patient hemodynamics. A previous study demonstrated a good correlation between the slope of the ventricular filling phase (VFPS) and the pulmonary capillary wedge pressure (PCWP). We aimed to validate the utility of VFPS to estimate PCWP and predict clinical outcomes. Methods In this prospective blinded study, screenshots from the HVAD monitor and simultaneous invasive hemodynamic measurements were obtained. Each screenshot was digitized (IGOR Pro, WaveMetrics Inc., Oswego, OR) and the VFPS was calculated for each screenshot (Figure 1A) by two independent readers who were blinded to the hemodynamic results. VFPS and the estimated PCWP [using the previously derived equation: PCWP = 7.05 +1.38 × (VFPS)] were correlated to the measured PCWP. Association between VFPS and heart failure (HF) readmission rates was evaluated. Results 107 sets of simultaneous measurements (VFPS and PCWP) were performed (mean age 55 years, 47% male). Prospectively collected VFPS had a very strong and significant correlation with PCWP (p 2 = 0.69). The previously proposed cutoff of VFPS ≥5.8 L/min/sec predicted PCWP ≥18 mmHg with 91.5% sensitivity and 95.2% specificity. The previously derived equation had significant correlation with measured PCWP (p 2 = 0.68; Figure 1B) and acceptable agreement with the measured PCWP (Figure 1C). Patients with VFPS ≥5.8 L/min/sec had significant higher HF readmission rates than those with VFPS Conclusion VFPS of the HVAD flow waveform is a novel noninvasive parameter that can estimate PCWP and predict HF readmissions. VFPS may aid in clinical management of HVAD patients and serve as a step in the development of a smart LVAD pump.

Purpose Left ventricular assist device (LVAD) outcomes differ between Japan and US. While GI bleeding is common in US and rare in Japan, stroke and driveline infections are more common in Japan than US. The aim of this study was to explore whether inflammatory and angiogenesis biomarkers can explain these differences. Methods Plasma levels of inflammatory and angiogenetic biomarkers were measured with Bio-plex ProTM Biomarker Assay kits. Levels were compared between US and Japanese LVAD patients. Adverse event rates were also compared between the two countries using binomial negative regression analysis . Results 61 patients were enrolled. The US cohort (N=38) was older (56.4 vs. 42.4 years; p angiopoietin-2 levels (823 vs. 172 pg/mL, p Conclusion Different rate of comorbidities between US and Japan are associated with the different expression of inflammatory and angiogenesis biomarkers. Longitudinal studies focusing on these biomarker levels are warranted.

Purpose Hemocompatibility Related Adverse Events (HRAE) remain a significant cause of morbidity and mortality in LVAD patients. The association between device specific factors and HRAE has been studied, however less is known about patient specific factors. The aim of this study was to investigate the influence of the etiology of heart failure on HRAE. Methods Retrospective single center chart review of all patients who underwent LVAD implantation from 3/2014 to 8/2018 was performed. The etiology of heart failure was classified as Ischemic Cardiomyopathy (ICM) or Non Ischemic Cardiomyopathy (NICM). An age matched cohort was analyzed using propensity score matching. Results 50 patients with ICM (age 61 yrs ± 11, 73% male) were compared to 49 patients with NICM (age 60 yrs ± 10, 76% male). There was no significant difference in heart failure free survival at 2 years(ICM= 50.2% vs NICM 58.3%,p=0.39) or all-cause mortality(ICM=25.8% vs NICM 27.7%,p=0.69) between the two groups. There was a statistically significant increase in HRAE -free survival in patients with NICM(61.9%) compared to ICM (25.5%) at 2 years(p=0.006) (Figure 1) Conclusion ICM is a risk factor for increased HRAE compared to NICM. Further studies are needed to ascertain whether these patients may benefit with different management strategies to avoid HRAE.

Purpose Right heart catheterization (RHC) is the gold standard in hemodynamic assessment. The specific hemodynamic waveforms may provide additional information about heart function. This study aims to investigate changes in RHC waveforms following LVAD implantation. Methods Patients with sinus rhythm underwent invasive RHC before LVAD implantation and at 6 months post-operatively. We compared waveform parameters of right atrium (RA) and right ventricle (RV) between these two time points. Results 42 patients (mean age 56 years, 62% male) had RHC before and after LVAD implantation (Figure 1A-E). Following LVAD implantation, mean RA pressure remained unchanged (p = 0.70). The a-wave height decreased, while the magnitude of the y-descent increased (p Conclusion RHC waveforms change following LVAD implantation and may indicate worsening of right heart function.

Purpose Right atrial waveform provides diagnostic and clinical information in heart failure patients. Notably, the y-descent (Figure 1A) may provide information about right ventricular systolic and diastolic function . We aimed to investigate the clinical implication of right atrial waveform in LVAD patients. Methods Patients underwent right heart catheterization (RHC) at 6 months following LVAD implantation and were followed for 1 year afterwards. Impact of a deep y-descent (>3 mmHg) on echocardiographic RA and RV function and clinical outcomes were investigated. Results 56 LVAD patients (mean age 56.2 years, 77% male) underwent RHC. Patients with post-LVAD deep y-descent (N = 22 [39%]) had increased right ventricular size and worse right ventricular function (Table 1A). The patients with deep y-descent had higher rates of GI bleeding (1.10 vs. 0.32 event/year), stroke (0.28 vs. 0.0 event/year), and heart failure readmissions (0.57 vs. 0.12 events/year) compared to those without (p Conclusion Deep y-descent of the right atrial waveform during LVAD support is associated with impaired right ventricular function and worse clinical outcomes.

Purpose Both pulmonary effective arterial elastance (EaPV) and pulmonary artery capacitance (PAC) are indices of right ventricular afterload and the pulmonary circulation. The aim of this study was to assess the clinical implications of these parameters following left ventricular assist device (LVAD). Methods Patients who underwent hemodynamic testing following LVAD implantation between 4/2014-8/2018 were enrolled. EaPV was calculated as systolic pulmonary artery pressure/stroke volume. PAC was calculated as stroke volume/pulmonary artery pulse pressure. Mortality and hemocompatibility-related adverse events (HRAEs) (including non-surgical bleeding, neurological events and thromboembolic events) during a one-year observational period were evaluated based on the established ROC cut-off value of these variables and compared between the two groups. Results 97 patients (mean 60 years old, 62% male) underwent hemodynamic testing at 598 ± 668 days following LVAD implantation. Low EaPV was defined as 3.15 ml/mmHg. Patients in the low EaPV group had higher one year survival free of HRAEs (86.4% vs 52.0%, p Conclusion Low EaPV and high PAC are associated with improved HRAEs free survival demonstrating the impact of right ventricular afterload and pulmonary arterial remodeling on outcomes of LVAD patients.

Purpose Hemocompatibility-related clinical adverse events (HRAEs) are major causes of readmission and reduce quality of life in LVAD patients. The impact of aortic insufficiency (AI) on HRAEs remains uncertain. This study assessed the impact of AI, which was graded by using novel Doppler echocardiographic parameters obtained at the LVAD outflow cannula , on HRAEs. Methods LVAD patients with varying degrees of AI underwent Doppler echocardiography of the LVAD outflow cannula. AI regurgitation fraction (RF) was calculated from the systolic/diastolic velocity ratio and the rate of diastolic flow acceleration of the LVAD outflow cannula (Figure 1A). RF >30% defined as significant AI. Freedom from any HRAEs and the net burden of HRAEs, which was calculated by using a hemocompatibility score (with 4 escalating tiers of hierarchal severity), were compared between those with/without significant AI during a 1-year observational period. Results Among 105 patients (median age 56 years, 76% male), 36 patients (34%) had significant AI. Baseline characteristics were comparable between two groups (p >0.05 for all). One-year survival free from HRAEs was 44% in the significant AI group compared with 67% in the non-significant AI group (p = 0.018; Figure 1B). The average hemocompatibility score in the significant AI group was higher compared with the non-significant AI group (1.72 vs. 0.64; p = 0.009; Figure 1C), due to higher tier I (gastrointestinal bleedings or medically managed pump thrombosis ; p = 0.034) and tier IIIB scores (HRAE-related death; p = 0.011). Conclusion Significant AI, which was assessed by using novel Doppler echocardiographic parameters, was associated with an increased rate of HRAEs in LVAD patients.

Purpose Mortality from acute decompensated heart failure (DHF) remains high despite contemporary therapeutic interventions. Cardiogenic shock indices may be useful in risk-stratifying patients at highest risk for death, need for heart transplantation or durable mechanical support. The aim of this study was to compare a novel hemodynamic parameter, systolic blood pressure/pulmonary capillary wedge pressure (SBP/PCWP), to cardiac power output (CPO) in patients presenting with DHF. Methods In this retrospective analysis, CPO (Watts; mean arterial pressure x cardiac output/451) and SBP/PCWP were calculated in those with chronic heart failure presenting with DHF, who received right heart catheterization at index admission. Hemodynamic parameter cutpoints were derived from a receiver operator curve analysis; a combined endpoint of one-year freedom from death, need for heart transplant or LVAD was compared for presence or absence of one or both hemodynamic parameters. Results Among 128 patients (median age 60 years, 75% male), mortality at one-year was 36.7% (n=48). 38 (29.7%) were discharged with medical therapy, 14 (10.9%) underwent heart transplantation, 29 (22.7%) underwent LVAD implant. CPO Conclusion SBP/PCWP ratio is a novel hemodynamic parameter that is comparable to CPO in predicting mortality and need for advanced heart failure therapies. In combination with CPO, this marker identifies patients who may require rapid escalation of care.