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A new, simple method for the synthesis of N,N-diethyl-m-methylbenzamide (DEET) from m-toluic acid and diethylamine using 1,1'-carbonyl-di-(1,2,4-triazole) (CDT) as a coupling agent has been performed. The basic principles of activated carbonyls have been explored with the ability to prepare new amides easily. All reaction by-products are water-soluble as well as removed by filtration, the reaction could be purified easily in an aqueous solution by liquid-liquid extraction, and the product DEET was high purity. This experimental efficiency is about 94-95%, purity (HPLC): 97-98%.

Aircraft trajectory prediction is a challenging problem in air traffic control, especially for conflict detection. Traditional trajectory predictors require a variety of inputs such as flight-plans, aircraft performance models, meteorological forecasts, etc. Many of these data are subjected to environmental uncertainties. Further, limited information about such inputs, especially the lack of aircraft tactical intent, makes trajectory prediction a challenging task. In this work, we propose a deep learning model that performs trajectory prediction by modeling and incorporating aircraft tactical intent. The proposed model adopts the encoder-decoder architecture and makes use of the convolutional layer as well as Gated Recurrent Units (GRUs). The proposed model does not require explicit information about aircraft performance and wind data. Results demonstrate that the provision of enriched aircraft intent, together with appropriate model design, could improve the prediction error up to 30% at a prediction horizon of 10 minutes (from 4.9 nautical miles to 3.4 nautical miles). The model also guarantees the mean error growth rate with increasing look-ahead time to be lower than 0.2 nautical miles per minute. In addition, the model offers a very low variance in the prediction, which satisfies the variance-standard specified by EUROCONTROL (EU Organization for Safety and Navigation of Air Traffic) for trajectory predictors. The proposed model also outperforms the state-of-the-art trajectory prediction model, where the Root Mean Square Error (RMSE) is reduced from 0.0203 to 0.0018 for latitude prediction, and from 0.0482 to 0.0021 for longitude prediction in a single prediction step of 15 seconds look-ahead. We showed that the pre-trained model on ADS-B data maintains its high performance, in terms of cross-track and along-track errors, when being validated in the Bluesky Air Traffic Simulator. The proposed model would significantly improve the performance of conflict detection systems where such trajectory prediction models are needed. Civil Aviation Authority of Singapore (CAAS) National Research Foundation (NRF) Published version This work was supported in part by the National Research Foundation, Singapore; and in part by the Civil Aviation Authority of Singapore under the Aviation Transformation Program.

κ-Oligocarrgeenan (OC) is well known as an effective and green plant growth promoter and elicitor. However, its effect on coffee plant has not been investigated so far. This study aimed to examine the impacts of OC on biophysical activity, vegetative growth and productivity of coffee plant (Coffea robusta). OC with average molecular weight (AMW) of 4.0 kDa was prepared by depolymerization of carrageenan using ascorbic acid. Field experiments were conducted by foliar spray four times per year at various OC concentrations (50, 100, 150, 200, and 250 ppm) for three years (2017-2019). The results showed that OC promoted growth of coffee plant in all tested concentrations, and an optimized concentration was found at 150 ppm which showed a significant increase compared to the control plant in total chlorophyll (24.79%), carotenoid (31.65%), uptakes of N (15.66%), P (15.81%), and K (22.25%) minerals in leaves, crop yield (19.80%) and bean size (13.10%). Therefore, OC is potentially promising to apply as a promoter to enhance yield of crops for sustainable coffee plantation.

Background: Restoring health-related quality of life (HRQOL) is a therapeutic goal for older patients with advanced heart failure. We aimed to describe change in HRQOL in older patients (60–80 years) awaiting heart transplantation (HT) with or without pretransplant mechanical circulatory support (MCS) or scheduled for long-term MCS, if ineligible for HT, from before to 6 months after these surgeries and identify factors associated with change. Methods: Patients from 13 US sites completed the EuroQol 5-dimension 3L questionnaire and Kansas City Cardiomyopathy Questionnaire-12 at baseline and 3 and 6 months after HT or long-term MCS. Analyses included univariate comparisons and multivariable linear regression. Results: Among 305 participants (cohort mean age=66.2±4.7 years, 78% male, 84% White, 55% New York Heart Association class IV), 161 underwent HT (n=68 with and n=93 without pretransplant MCS), and 144 received long-term MCS. From baseline to 3 months, EuroQol 5-dimension visual analog scale scores improved in HT patients without pretransplant MCS (54.5±24.3 versus 75.9±16.0, P P P P P =0.002). No further HRQOL improvement was found from 3 to 6 months. Factors most significantly associated with change in HRQOL, baseline 3 months, were right heart failure and 3-month New York Heart Association class, and 3 to 6 months, were 6-month New York Heart Association class and major bleeding. Conclusions: In older heart failure patients, HRQOL improved from before to early after HT and long-term MCS. At 6 postoperative months, HRQOL of long-term MCS patients was lower than one or both HT groups. Understanding change in HRQOL from before to early after these surgeries may enhance decision-making and guide patient care. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02568930.

BACKGROUND Limb ischemia is a major complication of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Use of ankle-brachial index (ABI) to monitor limb perfusion in VA-ECMO has not been described. We report our experience monitoring femoral VA-ECMO patients with serial ABI and the relationships between ABI and near infrared spectroscopy (NIRS). METHODS This is a retrospective single-center review of consecutive adult patients placed on femoral VA-ECMO between January 2019 and October 2019. Data were collected on patients with paired ABI and NIRS values. Relationships between NIRS and ABI of the cannulated (E-NIRS and E-ABI) and non-cannulated legs (N-NIRS and N-ABI) along with the difference between legs (d-NIRS and d-ABI) were determined using Pearson correlation. RESULTS Overall, 22 patients (mean age 56.5 ± 14.0 years, 72.7% male) were assessed with 295 E-ABI and E-NIRS measurements, and 273 N-ABI and N-NIRS measurements. Mean duration of ECMO support was 129.8 ± 78.3 h. ECMO-mortality was 13.6% and in-hospital mortality was 45.5%. N-ABI and N-NIRS were significantly higher than their ECMO counterparts (ABI mean difference 0.16, 95% confidence interval [CI]: 0.13-0.19, p

Amyloid cardiomyopathy (ACM) is a progressive and life-threatening disease caused by abnormal protein deposits within cardiac tissue. The most common forms of ACM are caused by immunoglobulin derived light chains (AL) and transthyretin (TTR). Orthotopic heart transplantation (OHT) remains the definitive treatment for patients with end stage heart failure. In this study, we perform a contemporary multicenter analysis evaluating post OHT survival in patients with ACM.We conducted a multicenter analysis of 40,044 adult OHT recipients captured in the United Network for Organ Sharing (UNOS) registry from 1987-2018. Patients were characterized as ACM or non-ACM. Baseline characteristics were obtained, and summary characteristics were calculated. Outcomes of interest included post-transplant survival, infection, treated rejection, and the ability to return to work. Racial differences in OHT survival were also analyzed. Unadjusted associations between ACM and non-ACM survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models.Three hundred ninety-eight patients with a diagnosis of ACM were identified of which 313 underwent heart only OHT. ACM patients were older (61 vs 53; P.0001) and had a higher proportion of African Americans (30.7% vs 17.6%; P.0001). Median survival for ACM was 10.2 years vs 12.5 years in non-ACM (P = .01). After adjusting for confounding, ACM patients had a higher likelihood of death post-OHT (HR 1.39 CI: 1.14, 1.70; P = .001). African American ACM patients had a higher likelihood of survival compared to White ACM patients (HR 0.51 CI 0.31-0.85; P = .01). No difference was observed in episodes of treated rejection (OR 0.63 CI 0.23, 1.78; P = .39), hospitalizations for infections (OR 1.24 CI: 0.85, 1.81; P = .26), or likelihood of returning to work for income (OR 1.23 CI: 0.84, 1.80; P = .30).In this analysis of OHT in ACM, ACM was associated with a higher likelihood of post-OHT mortality. Racial differences in post-OHT were observed with African American patients with ACM having higher likelihood of survival compared to White patients with ACM. No differences were observed in episodes of treated rejection, hospitalization for infection, or likelihood to return to work for income.

Climate smart agriculture (CSA) has gained considerable attention in Vietnam due to its potential to increase food security and farming system resilience while decreasing greenhouse gas emissions. In recent years, several CSA practices have been introduced in rice production, the most important sub-sector of Vietnam’s agriculture. However, few studies have been done in Vietnam to produce comprehensive assessments of CSA performance in the rice sector. This research proposes a comprehensive approach to assess CSA practices through a new set of evaluation indicators. A case study in An Giang province of the Vietnamese Mekong River Delta was implemented to evaluate the performance of five CSA models versus that of the triple rice crop system (i.e., benchmarking model). Results show that rice-shrimp and rice-lotus rotations are most profitable, low-risk, and applicable at a larger scale. Given that the current study analyzed and calculated only a small number of indicators and types of CSA practices, further research is necessary to test all indicators and diversified types of CSA models.

Intracranial hemorrhage (ICH) is a devastating complication for patients with ventricular assist devices (VADs). The safety of emergent anticoagulation reversal with four-factor prothrombin complex concentrate (PCC) and optimal timing of anticoagulation resumption are not clear. In addition, lactate dehydrogenase (LDH) is used as a biomarker for thromboembolic risk, but its utility in guiding anticoagulation management after reversal with PCC has not be described. We retrospectively reviewed a consecutive series of patients with VADs presenting with ICH between 2014 and 2020 who received four-factor PCC for rapid anticoagulation reversal. We collected the timing of PCC administration, timing of resumption of anticoagulation, survival, occurrence of thromboembolic events, and LDH levels throughout hospitalization. We identified 16 ICH events in 14 patients with VADs treated with rapid anticoagulation reversal using four-factor PCC (11 intraparenchymal, 4 subdural, 1 subarachnoid hemorrhage). PCC was administered at a mean of 3.3 ± 0.3 h after imaging diagnosis of ICH. Overall mortality was 63%. Survivors had higher presenting Glasgow Coma Scale (median 15, interquartile range [IQR] 15–15 versus 14, IQR 8–14.7, P = 0.041). In all six instances where the patient survived, anticoagulation was resumed on average 9.16 ± 1.62 days after reversal. There were no thromboembolic events prior to resumption of anticoagulation. Three events occurred after anticoagulation resumption and within 3 months of reversal: VAD thrombosis in a patient with thrombosis at the time of reversal, ischemic stroke, and readmission for elevated LDH in the setting of subtherapeutic international normalized ratio. Our limited series found no thromboembolic complications immediately following anticoagulation reversal with PCC prior to resumption of anticoagulation. LDH trends may be useful to monitor thromboembolic risk after reversal.

Alginate lyase is an enzyme that degrades alginate to create bioactive oligoalginate for application in medicine, industry, agriculture... In this study, cultural conditions of marine bacteria, Bacillus velezensis AlgSm1 have been investigated for producing alginate lyase with high content and activity. The nutritional components such as carbon source, nitrogen source, initial pH value, and cultural time were investigated. The results showed that the cultural conditions of B. velezensis AlgSm1 to biosynthesize alginate lyase with high activity were 5 mg/ml alginate, 0.8 mg/ml yeast extract; pH 5.5 and 18-hours fermentation at 28-30°C.

Shorter length of stay (LOS) is a welcome consequence of optimized perioperative care. However, accelerated hospital discharge may have unintended consequences. Before implementing an institutional enhanced recovery after surgery protocol, we evaluated the safety of shorter LOS and compared outcomes of patients with shorter LOS (LOS ≤ 3 days) to those with longer LOS (LOS 3 days).We identified all patients undergoing elective cardiac surgery with cardiopulmonary bypass between July 2004 and June 2017. Transcatheter approaches, ventricular assist devices, transplants, and traumas were excluded. Patients were divided into two cohorts, one with shorter hospitalizations (LOS ≤ 3 days) and one with longer hospitalizations (LOS 3 days). Propensity score matching (PSM) was performed and differences between the two groups were compared.A total of 5,987 patients (63.0 ± 13.8 years old, 34% female) were identified and 131 (2.2%) patients were LOS ≤ 3 days; median STS Risk score was 1.2 (0.6-2.4). PSM resulted in a total of 478 patients (357 LOS 3 and 121 LOS ≤ 3 days); median STS Risk score was 0.4 (0.3-0.9). LOS ≤ 3 days had lower rates of postoperative atrial fibrillation (2% vs. 19%; p .001) and major in-hospital complications (0% vs. 9%; p = .001); however, 30-day readmissions (8% LOS ≤ 3 vs. 6% LOS 3 days; p = .66) and mortality rates (0% vs. 0%) were comparable between the two groups.LOS ≤ 3 days was associated with less postoperative atrial fibrillation and fewer major in-hospital complications. LOS ≤ 3 days was not associated with rehospitalization or mortality. Shorter LOS after elective cardiac surgery appears to be a safe practice with favorable outcomes, especially in low operative risk patients.

Acute limb ischemia (ALI) and cannulation site bleeding are frequent complications of venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and are associated with worse outcomes. The goals of this study were to assess our rates of ECMO-related ALI and bleeding and to evaluate the efficacy of strategies to prevent them, such as distal perfusion cannula (DPC) and ultrasound-guided cannulation.This is a single-center retrospective cohort study of adult patients placed on peripheral VA-ECMO at a tertiary medical center between 2014 and 2018. ALI was defined as new ischemia of the extremity ipsilateral to arterial cannulation. Significant cannulation site bleeding was defined as excessive bleeding requiring intervention (eg, transfusion or reoperation). Univariate analyses were used to identify factors associated with ALI, bleeding, and in-hospital mortality.During the study period, 105 patients were placed on peripheral VA-ECMO (61.3% female; mean age, 54.9 ± 14.8 years). Nearly half (46.6%) had ECMO implantation in an extracorporeal cardiopulmonary resuscitation setting and 37 (44.0%) had a DPC. Average duration of support was 5.6 ± 5.0 days. Overall in-hospital mortality and death on ECMO support were 65.1% and 50%, respectively. ALI occurred in 21 (20%) and cannulation-related bleeding occurred in 24 (22.9%) patients who were treated with a total of 27 procedures, including thromboembolectomy (22.2%), vascular repair (18.5%), and fasciotomy (25.9%). On univariate analysis, cannulation in the operating room (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.08-0.77; P = .02) was associated with decreased risk of ALI, whereas cannulation in the operating room (OR, 2.65; 95% CI, 1.09-6.45; P = .03) and cutdown approach (OR, 4.96; 95% CI, 2.32-10.61; P .0001) were associated with increased risk of bleeding. Ultrasound-guided placement was associated with decreased risk of bleeding (OR, 0.81; 95% CI, 0.04-0.84; P = .03). DPC was not associated with either ALI (P = .47) or bleeding (P = .06). ALI (OR, 2.68; 95% CI 1.03-6.98; P = .04), age (OR, 1.94; 95% CI, 1.03-3.69; P = .04), and worse baseline heart failure (OR, 2.01; 95% CI, 1.02-3.97; P = .04) were associated with greater risk of in-hospital mortality. Ultrasound-guided cannulation (OR, 0.41; 95% CI, 0.20-0.87; P = .02) was associated with decreased risk of in-hospital mortality.ALI and significant bleeding are common occurrences after peripheral VA-ECMO cannulation. Whereas DPC placement did not significantly decrease risk of ALI, ultrasound-guided cannulation decreased the risk of bleeding. Cannulation in the operating room is associated with decreased risk of ALI at the expense of increased risk of bleeding. ALI, older age (≥65 years), and worse heart failure increased risk of in-hospital mortality.

Aims Chronic total occlusion (CTO) has been linked to worse survival. While controversial and limited to observational data, successful CTO percutaneous coronary intervention (PCI) has been associated with improved left ventricular (LV) function and mortality. However, the role of CTO PCI prior to transcatheter aortic valve replacement (TAVR) is not clear. We sought to explore the prognostic impact of a pre-TAVR CTO on post-TAVR outcomes. Methods and results We retrospectively reviewed 783 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 12.6% (n = 99) patients had a CTO. At one-year post-TAVR, there was no significant association between the presence of a CTO and death (14.2% vs 13.1%, p = 0.75), functional status, quality of life, or adverse events. There was also no difference in long-term survival (4.1 years vs 4.1 years, p = 0.55). LV ejection fraction was lower in the CTO group at baseline and one year (p Conclusions The presence of a CTO did not have any prognostic impact on mortality, change in LV function, or improvement in functional status and angina scores following TAVR in our cohort of elderly, high-risk patients. CTO before TAVR was associated with decreased ejection fraction at baseline and at one year.

Tricuspid valve (TV) degeneration after surgical repair with an annuloplasty ring is problematic as redo operation carries high mortality. This can be addressed with transcatheter therapies to implant a valve within in prior ring (tricuspid valve-in-ring). When an incomplete ring is present, paravalvular leak is commonly encountered after tricuspid valve-in-ring (TViR) implant; however, this can be addressed with paravalvular leak closure devices. Multimodality imaging including cardiac computed tomography and three-dimensional (3D) transesophageal echocardiography (TEE) are important for successful TViR implant. We report a case of tricuspid regurgitation after tricuspid repair with an incomplete annuloplasty ring and subsequent paravalvular leak closure.

Background There is a paucity of research describing health‐related quality of life (HRQOL) in older adults considered for advanced heart failure surgical therapies. Using data from our SUSTAIN‐IT (Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support) study, we aimed to compare HRQOL among 3 groups of older (60–80 years) patients with heart failure before heart transplantation (HT) or long‐term mechanical circulatory support (MCS) and identify factors associated with HRQOL: (1) HT candidates with MCS, (2) HT candidates without MCS, or (3) candidates ineligible for HT and scheduled for long‐term MCS. Methods and Results Patients from 13 US sites completed assessments, including self‐reported measures of HRQOL (EuroQol‐5 Dimension Questionnaire, Kansas City Cardiomyopathy Questionnaire–12), depressive symptoms (Personal Health Questionnaire–8), anxiety (State‐Trait Anxiety Inventory–state form), cognitive status (Montreal Cognitive Assessment), and performance‐based measures (6‐minute walk test and 5‐m gait speed). Analyses included ANOVA, χ 2 tests, Fisher’s exact tests, and linear regression. The sample included 393 patients; the majority of patients were White men and married. Long‐term MCS candidates (n=154) were significantly older and had more comorbidities and a higher New York Heart Association class than HT candidates with MCS (n=118) and HT candidates without MCS (n=121). Long‐term MCS candidates had worse HRQOL than HT candidates with and without MCS (EQ‐5D visual analog scale scores, 46±23 versus 68±18 versus 54±23 [ P P Conclusions Our findings demonstrate important differences in overall and domain‐specific HRQOL of older patients with heart failure before HT or long‐term MCS. Understanding HRQOL differences may guide decisions toward more appropriate and personalized advanced heart failure therapies.

Infection is a leading cause of morbidity and mortality in patients with ventricular assist devices (VAD). The impact of colonization with multidrug-resistant organisms (MDRO) on outcomes in this cohort is unknown. Patients on VAD support from July 2008 to September 2018 at a single site were evaluated for MDRO colonization after implantation. MDROs included methicillin-resistant Staphylococcus aureus , vancomycin-resistant Enterococcus species, and extended-spectrum beta-lactamase producing gram-negative bacteria. 378 patients with 433 VADs were included. 42.6% (n = 161) of patients were colonized with an MDRO throughout the duration of VAD support. Eighty-two VAD infections occurred, 74.4% (n = 61) of whom were MDRO colonized before infection. MDRO colonization was associated with an increased risk of a subsequent VAD infection (hazard ratio 3.704, p0.001). MDRO colonization is common after VAD implantation and is associated with future VAD infections. Further study is needed to determine best management strategies for VAD recipients with MDRO colonization given this increased risk.

To determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options.Between April 2004 and June 2018, 3289 patients underwent coronary artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching.One hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P lt; .01), rheumatic valve disease (16% vs 3%; P lt; .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P lt; .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR.Aortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.

The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.

In the last decade, machine learning is increasingly attracting researchers in several scientific areas and, in particular, in the additive manufacturing field. Meanwhile, this technique remains as a black box technique for many researchers. Indeed, it allows obtaining novel insights to overcome the limitation of classical methods, such as the finite element method, and to take into account multi-physical complex phenomena occurring during the manufacturing process. This work presents a comprehensive study for implementing a machine learning technique (artificial neural network) to predict the thermal field evolution during the direct energy deposition of 316L stainless steel and tungsten carbides. The framework consists of a finite element thermal model and a neural network. The influence of the number of hidden layers and the number of nodes in each layer was also investigated. The results showed that an architecture based on 3 or 4 hidden layers and the rectified linear unit as the activation function lead to obtaining a high fidelity prediction with an accuracy exceeding 99%. The impact of the chosen architecture on the model accuracy and CPU usage was also highlighted. The proposed framework can be used to predict the thermal field when simulating multi-layer deposition.

In this study, a data-driven deep learning model for fast and accurate prediction of temperature evolution and melting pool size of metallic additive manufacturing processes are developed. The study focuses on bulk experiments of the M4 high-speed steel material powder manufactured by Direct Energy Deposition. Under non-optimized process parameters, many deposited layers (above 30) generate large changes of microstructure through the sample depth caused by the high sensitivity of the cladding material on the thermal history. A 2D finite element analysis (FEA) of the bulk sample, validated in a previous study by experimental measurements, is able to achieve numerical data defining the temperature field evolution under different process settings. A Feed-forward neural networks (FFNN) approach is trained to reproduce the temperature fields generated from FEA. Hence, the trained FFNN is used to predict the history of the temperature fields for new process parameter sets not included in the initial dataset. Besides the input energy, nodal coordinates, and time, five additional features relating layer number, laser location, and distance from the laser to sampling point are considered to enhance prediction accuracy. The results indicate that the temperature evolution is predicted well by the FFNN with an accuracy of 99% within 12 seconds.

Accidental hypothermia with a core temperature below 28°C is associated with an increased risk of hemodynamic instability. It is difficult to predict which patients will survive with a favorable neurologic outcome; therefore, decision-making regarding extracorporeal support is not straightforward. We report a case of rewarming using veno-venous dual-lumen cannula as an alternative to veno-arterial support with full recovery and normal neurologic examination. In centers where extracorporeal membrane oxygenation is available, rewarming using veno-venous dual-lumen extracorporeal support may be a useful strategy to mitigate the risks associated with veno-arterial extracorporeal support.

The ground movement is one of the most critical airside operations. It includes two sub-problems: routing and scheduling and serves the purpose of guiding aircraft on the surface of an airport to meet the departure schedule while minimizing overall travel time. To achieve that purpose, ground movement controllers manage the taxi-route assignments and taxi-time estimation for each aircraft in arrival or departure queue. A high-accuracy taxi-time calculation is required to increase the efficiency of airport operations. In this study, we propose a data-driven approach to construct features set and build predictive models for taxi-time prediction for departure flights. The proposed approach can suggest the taxi-route and predict the corresponding taxi-time by analyzing ground movement data. The controller’s operational preferences are extracted and learned by machine learning algorithms for predicting taxi-route and taxi-time of given aircraft. In this approach, we take advantage of taxiing trajectories to learn the controller’s decision, which reflects how the controller had decided the routing for a given situation. Two machine learning models, random forest regression, and linear regression are implemented and show similar performances in estimating the taxi-time. However, since the random forest is an ensemble method that has advantages in handling outliers, performing feature selection, and assessing feature importance, it can provide more stable results and interpretability, for real operations. The predictive model for taxi-time can predict the taxi-out time with high accuracy with given assigned taxi-route. The model can cover the controller’s decision up to 70% in the top-1 and 89% in top-2 recommends. The mean absolute error is less than 2.07 min for all departure flights, and root mean square error is approximately 2.5 min. Moreover, the ± 3-minute error window can cover around 76% of departures, while more than 95% of departures are within the ± 5-minute error window.

Introduction: Improvement in social functioning is an important goal for advanced heart failure (HF) patients (pts) who receive left ventricular assist devices (LVADs). Self-reported social functioning and its association with clinical change is understudied. Methods: Adult HF pts who received LVADs at nine U.S. sites completed two measures of social functioning prior to, and 3-6 months after, surgery. Patient-Reported Outcomes Measurement Information System (PROMIS) measures were: Ability to Participate in Social Roles and Activities (Ability) and Satisfaction with Social Roles and Activities (Satisfaction). PROMIS uses T-scores standardized to a U.S. general population (mean=50; standard deviation, SD=10); higher scores represent better outcomes. New York Heart Association (NYHA) Functional Classification was assigned at both times by treating clinicians; change was subsequently categorized as Better, Same or Worse NYHA. Linear mixed effects models and least-squares means were estimated for Ability and Satisfaction. Results: Pts ( n =107) were primarily male (78%) and non-Hispanic White (68%); mean age (SD)=54 (12.5) years; 74% were NYHA Class IV prior to surgery and only 18% were NYHA IV at follow-up. NYHA was better for the majority ( n =75, 70%); 24% ( n =26) were the same, and 6% ( n =6) were worse. Mean Ability and Satisfaction were lower than the general population mean of 50 at both time points (Figure). Ability improved for the NYHA Better ( p p =0.030) groups, and nominally decreased for the Worse group ( p =0.800). Satisfaction improved for the Better ( p p >0.300). Conclusions: Self-reported social functioning measures were responsive to clinician-rated clinical change. Understanding these relationships may guide clinicians in providing targeted health-related quality of life therapies to improve social functioning.

Introduction: Caregivers (CGs) of heart failure (HF) patients (PTs) who undergo heart transplantation (HT) or Destination Therapy Mechanical Circulatory Support (DT MCS) provide support to PTs before and after surgery, which may affect their own health-related quality of life (HRQOL). In SUSTAIN-IT, we previously reported that CG HRQOL was good at baseline (i.e., before HT and DT MCS surgery) and was impacted by CG comorbidities and CG anxiety. This report explores change in CG overall HRQOL, depression, and anxiety from baseline to 12 months after HT or DT MCS surgery. Methods: From 10/1/15-12/31/18, 13 U.S. centers enrolled 301 CGs of HF PTs: 193 awaiting HT (92 HT with MCS as a bridge to transplant [HT BTT] and 101 HT without MCS [HT non-BTT]), and 108 awaiting DT MCS. At baseline, 3, 6, and 12 months post HT or DT MCS surgery, CGs completed the following instruments: EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state), PHQ-8 (range=0-24; score ≥10=depressive symptoms requiring evaluation), and STAI-State (range=20-80, higher score=more anxiety). Analyses included unadjusted and baseline-adjusted linear regression models. Results: CGs were age 61.0±10.3 years; the majority were Caucasian (86%), female (86%), spouses (85%) of enrolled HF PTs. At baseline, CG EQ-5D-3L VAS and PHQ-8 average scores were 83.8 ± 13.99 (high) and 2.6 ± 2.85 (low), respectively, for the entire cohort. No significant interval changes in CG HRQOL and depressive symptoms were found within or between groups. DT MCS and HT non-BTT CG anxiety significantly decreased over time (baseline to 12 months) (Figure). Levels of CG anxiety were similar among all groups at 12 months after HT or DT MCS surgery. Conclusions: The demonstrated reduction in anxiety among CGs in the post-operative period provides clinicians with important information to share with CGs when PTs are considering surgical treatment options for HF.

Purpose: Caregivers (CGs) for patients with advanced heart failure (HF) assist in HF-specific disease management. In the SUSTAIN-IT study, we reported CG perception of difficulty and time needed to perform tasks for patients awaiting surgery in 3 groups: HF patients awaiting heart transplant (HT) without mechanical support (HT-non-MCS), HF patients awaiting HT bridged with mechanical support (HT-MCS), and HF patient awaiting left ventricular device implantation as destination therapy (DT-MCS). In this report, we compare CG perceived burden from baseline to 1 year after surgery. Methods: We enrolled 301 CGs of HF patients between 10/1/15-12/31/18 from 12 U.S. hospitals: 193 awaiting HT (92 with and 101 without MCS), and 108 scheduled for DT-MCS. Prior to surgery and 3, 6, and 12 months after surgery, CGs completed the Oberst Caregiver Burden Scale (OCBS) which has 15 items with 2 subscales: (1) time and (2) difficulty: range=1-5, higher score=more time required for tasks and more task difficulty. Analyses included t-tests, chi-square tests, and baseline-adjusted linear regression models. Results: CGs were age 61.0±10.3 years, the majority were spouses (85%), female (86%), and white (86%). Average time spent on caregiving was moderate and decreased significantly from baseline to 12 months after surgery for all groups (Figure). DT-MCS CGs spent significantly more time than HT CGs on tasks 12 months after surgery. There were no significant differences in perceived difficulty (which was low) in performing CG tasks in all groups from baseline to 12 months. DT-MCS CGs did perceive tasks to be more difficult than HT CGs at 12 months. Conclusion: CGs of advanced HF patients adapted well to assisting with care, without increased burden, 1 year after HT and DT-MCS surgery. CGs of DT-MCS patients required more time and reported CG tasks to be more difficult than HT CGs. Understanding differences in CG burden will aid in pre surgical risk discussions and post-surgical follow-up.

Introduction: Adverse events (AEs) associated with left ventricular assist devices (LVADs) cause significant morbidity and mortality. Little is known about patient-specific factors that contribute to rates of AEs. The purpose of this study was to assess the association of cigarette smoking history and AEs following LVAD implantation. Methods: This study was a single-center, observational examination of 355 consecutive patients who underwent continuous-flow LVAD implantation from May 1, 2008 to July 1, 2018. Based on self-report, 348 patients with available data were categorized as never, former, or current smokers. Pre-LVAD implantation baseline characteristics were obtained, and summary characteristics were calculated. Hospitalizations for gastrointestinal bleeds, driveline infections, strokes, pump thromboses, and acute heart failure were evaluated. The Cox proportional hazard model was used to estimate the association of smoking and AE-related hospital admissions. The cumulative incidence competing risk method was used for survival analysis. Results: Current (8.22%, p 0.006) and former (4.75%, p 0.026) smokers had a greater proportion of admissions for pump thrombosis compared to never smokers (2.22%). Former smoking was associated with admission for driveline infection (HR 2.43, CI 1.08–5.46, p 0.03) on multivariate analysis. There were no significant associations between smoking and the other AEs of interest. There was no difference in survival among the three groups. Conclusions: Smokers had a higher proportion of admissions for pump thrombosis compared to never smokers, and former smoking was associated with admission for driveline infections in patients with LVADs.

Background The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic "non-full sternotomy approaches" using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, there remains a lack of consensus regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. Methods A worldwide group of LT-VAD experts was convened to openly discuss these key topics. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. Results This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts´ opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This paper also emphasizes the critical need for multidisciplinary teams and specified training. Conclusions This expert consensus paper provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

Prior to the widespread adoption of the arterial switch operation, patients with transposition of the great arteries (TGA) commonly underwent atrial switch operation (Mustard or Senning). It is not uncommon for these patients to progress to end stage heart failure and increasingly ventricular assist devices (VADs) are used to support these patients as a bridge to transplantation, though there is limited experience with this worldwide. A retrospective review of our institution's VAD database was undertaken and revealed seven adult patients with a history of TGA and subsequent systemic ventricular failure were implanted with a VAD: four of whom received the VAD as a bridge to transplantation (BTT) at the time of implantation, two who were initially designated as destination therapy secondary to severe pulmonary hypertension, and one who was designated as destination therapy secondary to a high risk of life-threatening non-compliance. Seven patient cases who received a VAD for severe systemic ventricular failure were included in this study. The mean age of the patients was 40 years and the majority of patients were male (6/7, 85%). Five of the patients (71.4%) had previously undergone an atrial switch operation and all of these were Mustard procedures. Two of the seven patients (28.5%) had congenitally corrected transposition of the great arteries (CC-TGA). Two of the seven patients (28.5%) had supra-systemic pulmonary pressures before VAD implantation and were designated as destination therapy (DT). One of these patients was later designated as BTT as an improvement in his pulmonary vascular resistance was observed, and subsequently underwent heart transplantation. Because of anatomic considerations, four of the patients (57%) underwent redo-sternotomy with outflow cannula anastomosis to the ascending aorta, one patient underwent VAD implantation via a left subcostal incision with anastomosis of the outflow graft to the descending thoracic aorta, and two patients (28.5%) underwent VAD implantation via a left thoracotomy and anastomosis of the outflow cannula to the descending thoracic aorta. Six of the seven patients had a HeartWare HVAD VAD implanted; one received a Thoratec Heartmate II VAD. Two patients underwent VAD explant and orthotopic heart transplant, 222 days and 444 days after VAD implant, respectively. One patient died on postoperative day 17 after complications from recurrent VAD thrombosis despite multiple pump exchanges. Four patients remain on VAD support, three of these patients are awaiting transplantation at last follow-up (mean days on support, 513 days). Bridge to transplantation with a durable VAD is technically feasible and relatively safe in patients with TGA. Multiple redo-sternotomies can be avoided with a left posterior thoracotomy approach and outflow graft anastomosis to the descending thoracic aorta after careful anatomic considerations.

BACKGROUND Severe right ventricular failure necessitating a right ventricular assist device (RVAD) complicates 6% to 11% of left ventricular assist device (LVAD) implants. Patient outcomes for those receiving durable continuous-flow VADs in a biventricular configuration (i.e., BiVAD) have been reported in limited case series. METHODS Data from United States centers with ≥ 6 BiVAD implants were collected. Characteristics and outcomes of patients receiving contemporaneous (i.e., same surgery) vs staged implantation of the HVAD as a BiVAD were compared. RESULTS From 2011 to 2017, 46 patients received durable BiVADs and had the following characteristics: median age, 46 years (interquartile range [IQR], 19–67 years), non-ischemic cardiomyopathy (80%), bridge to transplant (83%), Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 or 2 (92%), use of temporary circulatory support (37%), right atrial pressure 19 mm Hg (IQR, 14–23 mm Hg), and cardiac index of 1.6 liters/min/m 2 (IQR, 1.2–2.1 liters/min/m2 ). Operative mortality was 33%. Equal numbers of patients received a right atrial or right ventricular implant. Contemporaneous BiVAD implantation occurred in 31 patients (67%), and compared with 15 patients (33%) with staged implants, these patients had a shorter intensive care unit length of stay of 12 days (IQR, 7–23 days) vs 42 days (IQR, 28–48 days, p = 0.035) and were more likely to be discharged from the hospital on BiVAD support (61% vs 27%, p = 0.04). RVAD thrombosis developed in 17 patients (37%). Patients with contemporaneous BiVAD implants had a 1-year survival of 74% compared with 40% in staged BiVAD patients (p = 0.11). CONCLUSIONS Patients receiving durable BiVADs represent a critically ill patient population with severe biventricular failure who have high operative mortality and RVAD thrombosis rates. The 1-year survival for patients receiving contemporaneous BiVADs in experienced centers mirrors other contemporary durable biventricular support strategies.

Patients with isolated right ventricular (RV) failure have poor outcomes and minimal treatment options. We report a case where a durable RV assist device (RVAD) was implanted for end-stage RV failure from combined pre- and postcapillary pulmonary hypertension (PH) due in part to chronic thromboembolic PH using a temporary percutaneous RVAD as a bridging strategy. While the patient ultimately died from non-cardiovascular causes, there was significant improvement in markers of cardiogenic shock and hemodynamic RV function parameters without adverse effects from increased pulmonary artery pressures. More research is needed to identify an appropriate long-term mechanical support strategy for this patient population.

Purpose For patients with end stage heart failure, orthotopic heart transplant (OHT) remains the definitive management. Advances in immunosuppression have led to improved long-term survival. Malignancy is an important cause of long-term morbidity and mortality with a reported rate of occurrence between 20-40% within 10 years of transplant. To date, significant evidence into mechanisms and risk profiles for post OHT malignancy is lacking. The purpose of this study is to identify patient and donor related factors associated with post OHT malignancy. Methods We performed a retrospective analysis of 51,218 OHT recipients captured in the United Network for Organ Sharing (UNOS) registry. Included in this analysis were adults 18 years and older who received a heart transplant between 1987 and 2019. The patients were categorized by the presence of post OHT malignancy (“yes”, “no”). Baseline characteristics were compared using chi-squared analysis for categorical variables and Mann-Whitney test for continuous variables. Logistic regressions were applied to evaluate the association between post OHT malignancy and the risk factors. Results Within the study period (1987-2019), 13,060 OHT recipients (25.5%) developed a malignancy. Denovo solid tumors comprised 82% of all malignancy types. OHT recipients with malignancy were older (56 vs 50.9 years, p= Conclusion In this study, we reported the prevalence of post OHT malignancy as well as recipient and donor factors associated with post OHT malignancy. Further analysis based on malignancy subtype should be performed to aid in risk stratification and surveillance.

Purpose To evaluate the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) generic measures of social and physical function in patients with a left ventricular assist device (LVAD). Methods Adult heart failure (HF) patients at 12 U.S. sites in 2016-2020 enrolled in The Mechanical Circulatory Support: Measures of Adjustment and Quality Of Life Study (n=361). Post-LVAD implant, they completed PROMIS Ability to Participate in Social Roles and Activities, Satisfaction with Social Roles and Activities, and Physical Function; and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) Social and Physical Limitation measures. PROMIS is standardized to a general population (mean=50; SD=10). KCCQ-12 range is 0-100. Higher scores represent better outcomes. Construct validity was evaluated by Pearson correlations between PROMIS and KCCQ-12 scores. Known-groups validity was evaluated by analysis of variance to distinguish PROMIS means across NYHA and self-reported financial difficulties. Results Mean age was 58 years; 80% were male, 70% were Non-Hispanic White, 79% had financial difficulties due to condition/treatment, and 61% were NYHA I-II. Similar numbers enrolled at 3, 6, 12-26, and > 26 months post-implant. Mean scores for PROMIS and KCCQ-12 measures decreased (worsened) as NYHA worsened (p Conclusion PROMIS measures of social and physical function were associated with well-accepted measures commonly assessed in HF and post-LVAD. Unlike condition-specific measures, PROMIS scores can be compared to the general population or other clinical conditions, thus providing a useful way to interpret social and physical function after LVAD implant.

Purpose The purpose of this study is to compare short term results of patients undergoing a third generation (HVAD™or HeartMate™ 3) Left Ventricular Assist Device (LVAD) implantation through either minimally-invasive, thoracotomy approach or standard median sternotomy. Methods We prospectively collected data on all patients at our institution that received an LVAD from September 2008 to February 2020. Surgical approach was decided by the implanting surgeon. We used 1:1 propensity score (PS) matching to compare the sternotomy versus thoracotomy groups. A logistic regression model based on 19 explanatory variables was used to estimate the propensity score. Overall survival post-implantation was summarized using Kaplan-Meier curves and compared using the log-rank test. Results A total of 272 patients were included, of whom 194 had sternotomy and 78 had either left thoracotomy and hemi-sternotomy or bilateral thoracotomies. Using PS matching, 128 (64/64) patients were selected. Demographics and operative characteristics were well balanced between groups. Overall, there was a trend towards better survival in thoracotomy group (33.1% vs 66.4%, p=0.06) at 5 years, but higher stroke rate (11% in sternotomy group vs 21% in thoracotomy group, p = 0.035). Following PS-matching, however, there was no difference in early or late mortality (Graph 1) but there was a higher rate of pump exchange in the thoracotomy group (2% vs 9%, p = 0.052). There was no difference in perioperative stroke rates (sternotomy 6% vs thoracotomy 9%), extubation time (2.5 days vs 2.5 days), right ventricular failure (13% vs 14%), renal failure (8% vs 5%) or hospital readmissions (81% vs 88%). Conclusion Minimally invasive LVAD implantation is feasible and safe in the current LVAD era. In a PS matched analysis, patients in the minimally invasive group displayed lower overall mortality, but without reaching statistical significance. Adverse events were similar in both groups.

The HeartWare Ventricular Assist System (HVAD) provides significant improvements in survival and quality of life, and here, we seek to evaluate temporal differences in the adverse event (AE) rates. Patients (n = 382) in the ADVANCE bridge-to-transplant and continued access protocol trial were assessed for bleeding, cardiac arrhythmia, infection, ischemic and hemorrhagic stroke, and right heart failure during predetermined time periods (≤30,30-180,180-365,365-730,730-1,095 days) after HVAD implant. The Kaplan-Meier survival at 30 days, 6 months, 1, 2, and 3 years was 98%, 90%, 84%, 71%, and 63%, respectively. There were significantly fewer total AEs in days30-180 (events per patient year [EPPY] = 5.34) compared with the first 30 days post HVAD implantation (EPPY = 30.36; p0.0001). The total AE rate in days180-365 (EPPY = 4.09) was also significantly lower than the event rate in days30-180 (EPPY = 5.34; p0.0001). Incidence of cardiac arrhythmias, infections, strokes, and right heart failure were highest immediately post implant and lower rates occurred after 6 months. After 1 year, all AEs exhibited stable rates that were comparable up to 3 years of support (all p0.05). This changing risk over time has clinically meaningful implications toward improving patient management.

Background Current practices for the reversal of warfarin before cardiac surgery include the use of vitamin K and fresh frozen plasma (FFP) to reduce the risk of bleeding. Although the 2010 International Society of Heart and Lung Transplantation guidelines acknowledge the use of prothrombin complex concentrate (PCC), there is no clear consensus on its efficacy. The objective of this study was to assess the efficacy of four-factor (4-F) PCC administration in patients requiring warfarin reversal before heart transplantation by determining blood product utilization perioperatively. Methods Twenty-one patients who received 4-F PCC for warfarin reversal before heart transplantation were compared to a similar cohort of 39 patients who did not receive 4-F PCC, from January 2011 to July 2015. Blood product utilization was collected retrospectively for the 24-hour preoperative, intraoperative, and 48-hour postoperative periods. Results Patients receiving 4-F PCC required fewer blood products in all three time periods. In the 24-hour preoperative period, 22 (56%) patients in the control group and 2 (10%) patients in the 4-F PCC groups received blood products (p

Purpose Heart transplantation candidates are often bridged to transplantation with medical therapy (MT) or mechanical circulatory support (MCS). Recent changes were made in the UNOS adult heart allocation system, partly based on bridging strategy, and potential effects remain uncertain. We compared outcomes of patients bridged to OHT with durable VAD (dVAD), intra-aortic balloon pump (IABP), and MT prior to the new allocation system. Methods A retrospective review was performed on 513 consecutive patients listed for OHT between April 2004 and December 2018. Patients were excluded if bridged with extracorporeal ventricular assist devices or multiple concomitant MCS devices. Pre-, intra-, and post-operative characteristics were compared between the BTT strategies. Continuous variables are expressed as mean ± standard deviation or median (Q1-Q3) while categorical variables are expressed as number (%). Results A total of 501 patients were included (age 54.5(42.5-62.0) years, 104(30%) female). Of these, 348(69.5%) were transplanted (dVAD 175(50.3%), IABP 69(19.8%), and 104(29.9%) MT). Overall, 30-day mortality was 4% and 2-year mortality was 11%. dVAD had longer CPB minutes (dVAD 155.9±42.9, IABP 145.3±65.7, MT 139.7±52.6, p=0.031), but donor ischemic minutes were similar (dVAD 179.9±44.4, IABP 188.2±49.1, MT 179.9±53.7, p=0.44). IABP patients had longer overall LOS (IABP 55.0(31.0-90.0) days, dVAD 16.0(11.0-26.0) days, MT 40.0(20.5-75.0) days, p Conclusion In this study, OHT outcomes were similar between the three bridging strategies, but overall LOS was higher in the IABP group. Further study is needed to determine the long-term effects of the new UNOS allocation system in regards to waiting-time, death on waiting list, transplant survival and cost-effectiveness of these bridging strategies.

Purpose Factors related to health-related quality of life (HRQOL) of older patients (pts) with advanced heart failure (HF) scheduled for left ventricular assist device (LVAD) implantation as destination therapy (DT) or while a candidate for heart transplantation (HT) with or without an LVAD, may guide therapeutic strategies. We sought to identify pt and caregiver (cg) factors related to HRQOL of pts (60-80 years) awaiting these surgeries. Methods From 10/1/15-12/31/18, we enrolled 302 pts with cgs (n=302) from 13 U.S. sites: 193 pts awaiting HT (92 with and 101 without LVAD) and 109 DT LVAD pts. Pts completed the EQ-5D-3L Visual Analog Scale (VAS): 0-100 (worst-best) health; KCCQ-12 summary score (SS), 0-100=low-high; PHQ-8 (0-24; score > 10=significant depressive symptoms) and STAI-state (20-80; higher score=more anxiety). Cgs completed the EQ-5D, STAI, PHQ-8 and Oberst Caregiving Burden Scale (OCBS): 2 subscales (time and difficulty, 1-5; higher score=more time and more task difficulty). Analyses included multivariable logistic regression models; the binary outcomes were whether individual EQ-5D VAS and KCCQ-12 SSs were higher than the cohort median of 60 and 46, respectively. Results Pts were 66.1±4.5 years, 82% male, and 86% white. Pts reported relatively low generic HRQOL (VAS mean=55.3±23.5) and low HF-specific HRQOL (SS mean=47.5±22.5), both with significant group differences. HT pts with LVADs were more likely to have higher EQ-5D VAS scores; DT pts had the lowest VAS scores (p > 10 was related to lower VAS scores (p > 10 was related to lower KCCQ-12 SSs (p Conclusion Implant strategy, pt depression, and cg time spent on care were significantly related to older advanced HF pt HRQOL. Findings may inform interventions for HF pts awaiting surgery.

Purpose Heart transplantation (HT) and mechanical circulatory support (MCS) has improved heart failure (HF) patient (PT) outcomes; it has also led to increased caregiver (CG) responsibility pre and post-surgery. We assessed whether PT and CG factors were related to baseline CG perceived burden in 3 groups of CGs of HF PTs (60-80 years): (1) PT supported with MCS as a bridge to HT (HT BTT), (2) PT awaiting HT without MCS (HT non BTT), and (3) PT prior to MCS for destination therapy (DT MCS). Methods Between 10/1/15-12/31/18, we enrolled 302 CGs from 13 U.S. sites: 92 HT BTT, 101 HT non BTT, and 109 DT MCS. CG burden was measured with the Oberst Caregiving Burden Scale (OCBS: [1] time: higher score=more time spent on task and [2] difficulty: higher score=more difficulty of task). CGs also completed the EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state and 5 dimensions); STAI-State (higher score=more anxiety); PHQ-8 (score ≥10=significant depressive symptoms), and demographic/health history/impact of caregiving on own health questions. PTs completed the KCCQ-12, MoCA (measure of cognitive dysfunction) and all above measures except the OCBS. Analyses included multivariable logistic regression models in which the binary outcomes were whether individual OCBS difficulty and time scores were higher than the cohort median values of 1.20 and 2.26, respectively. Results CGs were 61.1±9.7 years, 85% spouses, 85% female, and 85% white. Overall CG difficulty was low and CG time spent was moderate. CGs who reported more difficulty on tasks perceived more impact on their own health and had more anxiety, with no differences by PT implant strategy (table). CGs with Conclusion Only CG factors, and not PT factors, were related to CG perceived burden. Understanding factors that affect CG burden may aid in preoperative advanced therapies discussions.

Objective Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. Methods Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. Results General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours; P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes; P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days; P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%; P < 0.001). There was no difference in 30-day mortality (0% vs 3%; P = 0.15). Conclusions Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.

With the continuous innovation in mechanical circulatory support as an option for the management of patients in cardiogenic shock from myocardial infarction, it is important to understand the current evidence and recommendations for the use of these devices for patients who require or underwent coronary artery bypass surgery.The use of mechanical circulatory support (MCS) in patients with cardiogenic shock who require or underwent coronary artery bypass surgery has not been well studied. Observational studies have shown that the use of intra-aortic balloon pump or percutaneous ventricular assist devices prior to revascularization lead to better survival. Extracorporeal membrane oxygenation (ECMO) still carries significant risk of mortality and complications; the use of additional MCS devices for left ventricular unloading during ECMO improves outcomes.MCS will continue to play an important role in coronary artery surgery patients. Multidisciplinary Cardiac Shock Team can assist in proper patient selection and device choice, whereas prospective clinical trials are required to provide evidence-based guidance towards the management of these patients.

Background Aortic valve insufficiency can have significant hemodynamic consequences for patients with left ventricular assist devices. A circulation loop can limit systemic blood flow and increase left ventricular filling pressure. Case presentation A 64-year-old male with non-ischemic dilated cardiomyopathy underwent Heartware™ HVAD left ventricular assist device implantation with successful concomitant aortic valve replacement with an Edwards Intuity rapid deployment prosthetic valve. Conclusions The use of this rapid deployment valve may have benefits over other techniques including shorter cross clamp times during surgery, intermediate-long term durability, and preservation of aortic valve opening to allow for potential ventricular recovery. The Intuity rapid deployment valve should thus be considered a viable and suitable option for aortic insufficiency intervention during LVAD implantation.

Less invasive techniques for left ventricular assist device implantation have been increasingly prevalent over past years and have been associated with improved clinical outcomes. The procedural economic impact of these techniques remains unknown. We sought to study and report economic outcomes associated with the thoracotomy implantation approach.The LATERAL clinical trial evaluated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare centrifugal-flow ventricular assist device system (HVAD). We collected UB-04 forms in parallel to the trial, allowing analysis of index hospitalization costs. All charges were converted to costs using hospital-specific cost-to-charge ratios and were subsequently compared with Medicare cost data for the same period (2015-2016). Because thoracotomy implants were off-label for all left ventricular assist devices during that period, the Medicare cohort was assumed to consist predominately of traditional sternotomy patients.Thoracotomy patients demonstrated decreased costs compared with sternotomy patients during the index hospitalization. Mean total index hospitalization costs for thoracotomy were $204,107 per patient, corresponding to 21.6% reduction (P.001) and $56,385 savings per procedure compared with sternotomy. Across almost all cost categories, thoracotomy implants were less costly.In LATERAL, a clinical trial evaluating the safety and efficacy of the thoracotomy approach for HVAD, costs were lower than those reported in Medicare patient claims occurring over the same period. Because Medicare data can be presumed to consist of predominately sternotomy procedures, thoracotomy appears less expensive than traditional sternotomy.

Objectives During degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late echocardiographic and clinical outcomes, and influence of surgical experience in decision making. Methods From April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed. Results Mild mitral regurgitation was present in 73 patients (6%). Propensity score–matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P = .033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P = .016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P = .10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P = .027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P = .002). Conclusions Residual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair.