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All transplant recipients receive tacrolimus, mycophenolate and glucocorticoids and these drugs have many side-effects and drug-drug interactions. Common complications include surgical complications, infections, rejection and acute kidney injury. Infections as CMV and PJP can be prevented with prophylactic treatment. Given the complexity of organ transplant recipients a multi-disciplinary team of intensivists, surgeons, pharmacists and transplant specialists is essential. After heart transplantation a temporary pacemaker is required until the conduction system recovers. Stiffening of the heart and increased cardiac markers indicate rejection. An endomyocardial biopsy is performed via the right jugular vein, necessitating its preservation. For lung transplant patients, early intervention for aspiration is warranted to prevent chronic rejection. Risk of any infection is high, requiring active surveillance and intensive treatment, mainly of fungal infections. The liver is immunotolerant requiring lower immunosuppression. Transplantation surgery is often accompanied by massive blood loss and coagulopathy. Other complications include portal vein or hepatic artery thrombosis and biliary leakage or stenosis. Kidney transplant recipients have a high risk of cardiovascular disease and posttransplant anemia should be treated liberally. After postmortal transplantation, delayed graft function is common and dialysis is continued. Ureteral anastomosis complications can be diagnosed with ultrasound.

Increasing evidence suggests a role for epicardial fat in the development of coronary artery disease in the general population. Heart transplantation patients are at increased risk of developing a specific form of coronary artery disease, cardiac allograft vasculopathy (CAV), which has far-reaching consequences in terms of morbidity and mortality. Until now, the role of epicardial fat volume (EFV) in the development of CAV remains unknown. Hence, we investigated the relationship between EFV and CAV as well as the influence of donor/recipient sex on EFV.Adult heart transplant patients who underwent coronary computed tomography angiography (CCTA) for CAV screening who were four or more years post-HT were included. Using the CT examinations, we quantified the EFV and the degree of CAV. Ordinal and linear regression models were used to assess the association of EFV with CAV.In total, 149 (median age 44.5 years, 36% women) patients were included. The median time between HT and the CT scan was 11.0 (7.3-16.1) years. CAV grade 0, 1, 2 and 3 were seen in 85 (57%), 32 (22%), 14 (9%), and 18 (12%) patients, respectively. The median EFV was 208.4 (128.9-276.0) mL. Larger EFV were related to higher degrees of CAV (median of 164.7 to 290.6 mL for CAV grade 0 and 3, respectively, OR 5.23 (2.47-11.06), p0.001). Male recipients had significantly more EFV than female recipients irrespective of the donor sex (232.7 mL vs. 147.2 mL respectively, p0.001). Determinants for EFV were recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus.EFV was associated with higher degrees of CAV. The recipient sex influenced the EFV more than the donor sex.• Patients after heart transplantation have a high amount of epicardial fat while larger amounts of epicardial fat are related to higher grades of cardiac allograft vasculopathy. • Determinants of higher epicardial fat volume included recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus. • Longitudinal studies are needed to further disentangle the role of epicardial fat in the development and progression of cardiac allograft vasculopathy. Demonstration of four patients (from CAV grade 0 to CAV grade 3) in whom epicardial fat volume was determined. In red, the voxels identified as epicardial fat.

BackgroundStudies on herpes zoster (HZ) incidence in solid organ transplant (SOT) recipients report widely varying numbers. We investigated HZ incidence, severity, and risk factors in recipients of four different SOTs, with a follow-up time of 6–14 years.MethodsRecords of 1,033 transplant recipients after first heart (HTx: n = 211), lung (LuTx: n = 121), liver (LiTx: n = 258) and kidney (KTx: n = 443) transplantation between 2000 and 2014 were analyzed for VZV-PCR, clinical signs of HZ, and complications.ResultsHZ was diagnosed in 108 of 1,033 patients (10.5%): 36 HTx, 17 LuTx, 15 LiTx, and 40 KTx recipients. Overall HZ incidence rate after HTx (30.7 cases/1,000 person–years (PY)), LuTx (38.8 cases/1,000 PY), LiTx (22.7 cases/1,000 PY) and KTx (14.5 cases/1,000 PY) was significantly higher than in the general 50–70 year population. Multivariable analysis demonstrated age ≥50 years at transplantation (p = 0.038, RR 1.536), type of organ transplant (overall p = 0.002; LuTx p = 0.393; RR 1.314; LiTx p = 0.011, RR 0.444; KTx p = 0.034, RR 0.575), CMV prophylaxis (p = 0.043, RR 0.631) and type of anti-rejection therapy (overall p = 0.020; methylprednisolone p = 0.008, RR 0.475; r-ATG p = 0.64, RR1.194) as significant risk factors. Complications occurred in 33 of 108 (31%) patients (39% of HTx, 47% of LuTx, 20% of LiTx, 20% of KTx): post-herpetic neuralgia, disseminated disease, and cranial nerve involvement.ConclusionHZ incidence and severity in SOT recipients are most pronounced after heart and lung transplantation, in older patients, and when CMV prophylaxis is lacking.

Aims: Recent reports demonstrated that patients with heart failure (HF) might have an increased risk to develop malignancies. This is also seen in patients with chronic kidney disease (CKD). Immunosuppression in heart transplantation (HT) recipients additionally increases the risk of malignancies. The aim of this study was to determine the relation between HF duration and CKD pre-HT and the risk of malignancy development post-HT. Methods and results: We included all adult HT recipients transplanted between January 2000 and November 2017 in our centre. Patients were excluded if they died or were retransplanted within 3 months post-HT. Clinical characteristics were retrospectively collected. Sixty out of 250 patients (24%) developed a malignancy after a median of 66 months [interquartile range 33–108] post-HT. In multivariable Cox regression analysis, HF duration was not a risk factor for all malignancies or solid organ malignancies post-HT [hazard ratio (HR) 1.033 (0.974–1.096), P = 0.281 and HR 1.036 (0.958–1.120), P = 0.376, respectively]. Age [HR 1.051 (1.016–1.086), P = 0.004] and CKD pre-HT [HR 2.173 (1.236–3.822), P = 0.007] were independent risk factors for all malignancies. CKD pre-HT [HR 2.542 (1.142–5.661), P = 0.022] increased the risk for solid organ malignancies. Exclusion of patients with durable mechanical circulatory support in the analysis did not alter the significance of these risk factors. Conclusions: Duration of HF pre-HT was not associated with malignancy risk post-HT. CKD was an independent risk factor for malignancies post-HT. More studies are needed to investigate this association.

Data on the risk of aortic root thrombosis in patients with aortic valve replacement (AVR) and left ventricular assist device (LVAD) surgery are scarce. Two out of nine patients receiving AVR concomitant with LVAD surgery and two out of two patients receiving AVR on LVAD support, at our centre, developed an aortic root thrombus, all diagnosed with computed tomography (CT) angiography. These results demonstrate that patients with concomitant AVR and LVAD surgery, or AVR on LVAD support, have an increased risk of aortic root thrombosis. Therefore, early anti‐thrombotic therapy and vigilant diagnostic follow‐up, using CT scans, are warranted to prevent thromboembolic events.

Purpose The difference in renal function between bridge-to-transplantation (BTT) and medically managed patients undergoing heart transplantation (HTx) is unknown. This study aimed to depict the difference in renal function between BTT and medically managed patients pre- and post-HTx. Methods A retrospective single-center cohort study was conducted including all HTx patients that were transplanted since the introduction of left ventricular assist device (LVAD) therapy in our center in 2006. Patients were dichotomized according to BTT and medical management strategy. Results In total, 164 patients were included, of whom 135 were medically managed (mean age 49.3±10.4), and 29 BTT patients (mean age 48.5±11.8). Median time on LVAD support pre-HTx was 551 days, interquartile range [230-863]. At 12 months prior to HTx, the BTT patients had higher mean eGFR compared to the medically managed patients (87 ml/min/1.73m2 vs 63 ml/min/1.73m2, p Outcomes, including mortality and primary graft dysfunction, following HTx were not significantly different Conclusion In conclusion, patients who are bridged with LVAD therapy had a higher mean renal function at the time of HTx. Additionally, patients who received BTT therapy preserved longer an improved renal function at 1-year pre- and post-HTx.

Purpose Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects heart transplant (HT) patients. Routine surveillance for CAV is warranted. We evaluated the feasibility, utility and safety of cardiac CT to screen for CAV in HT patients. Methods From Feb 2018 to Jul 2019 all HT patients >four years post-HT were converted from using stress myocardial perfusion imaging for the annual CAV surveillance to cardiac CT (calcium score scan and CT angiography (CTA)). All first scans were included. Scans were scored for image quality (non-diagnostic, moderate, good, excellent), Agatston calcium score and coronary stenosis (0%, Results In total, 141 CT scans were included. CTA was performed in 140 out of 141 patients who were planned for cardiac CT (55 (43-64) years, 66% men, and 11 (8-16) years post-HT). One patient only had a calcium score due to no IV access. Mean heart rate during CTA was 75±11 beats per minute with beta-blockers given in 90 patients. Image quality was good/excellent in 124 (89%) scans. Median radiation dose was 2.1 (1.6-2.9) mSv. Median Agatston calcium score was 4 (0-73), 56 (40%) patients had no detectable calcium. CTA showed new obstructive coronary disease (≥50% stenosis) in 25 (18%) patients (Figure 1). CTA reclassified CAV score in 49 (35%) patients (p Conclusion Cardiac CT can be performed successfully in HT patients with good/excellent image quality and low radiation dose. CTA successfully detects significant CAV which leads to substantial reclassification of CAV grades.

Purpose Cardiac allograft vasculopathy (CAV) is a poorly understood, accelerated form of coronary artery disease in patients that underwent heart transplantation (HT), and substantially contributes to post-transplantation morbidity and mortality. Increasing evidence shows an active role for epicardial fat (EF) in the development of coronary artery disease, as a result of its inflammatory properties. Yet, whether the amount of EF is also related to CAV remains unknown. Hence, we investigated the association of epicardial fat volume (EFV) with CAV. Methods For this pilot study, we included post HT-patients whom underwent cardiac computed tomography (CCT) for CAV screening between February 2018 and January 2019. CCT included a non-enhanced CT (NECT) and CT angiography (CCTA). Using the NECT, we quantified the EFV using an automated algorithm (Fig 1.). CAV was graded on CCTA similar to the guidelines of the International Society for Heart and Lung Transplantation. The association of EFV with the presence and grade of CAV was investigated using binary- and ordinal logistical regression models, adjusted for recipient age and gender, time since HT and number of rejections pre-CCT. Results We included 74 patients, with a median age of 45 years [IQR 27-51] at HT of whom 29 were women. Median time since HT was 10.0 years [IQR 8.0-15.3]. CAV was prevalent in 28 (38%) patients, of whom 17 (61%) had CAV 1, 5 (18%) had CAV 2 and 6 (21%) had CAV 3. Median EFV was 198.5 [IQR 123.4-262.1] mm3. The median EFV was larger with higher CAV grades: 162.2 (CAV 0), 211.5 (CAV 1), 230.0 (CAV 2) and 278.3 (CAV 3) mm3 (p=0.031). Albeit not statistically significant, we found an association of EFV with the presence of CAV (odds ratio (OR) per 1-standard deviation increase in log-transformed EFV: 1.48 (95%CI: 0.80-2.72), p=0.21) and with CAV grade (OR 1.52 (95%CI: 0.85-2.71), p=0.15). Conclusion Our preliminary results show a promising trend towards an association of the amount of epicardial fat and the presence of CAV, which should be confirmed in larger studies.

Purpose Post-transplant diabetes mellitus (PTDM) is a frequent complication post-heart transplantation (HT). Moreover, PTDM has been associated with cardiovascular adverse events long-term post-HT. The golden standard to diagnose PTDM is an oral glucose tolerance test (OGTT). Studies investigating the incidence of PTDM long-term post-HT are missing. The aim was to investigate the prevalence of unknown PTDM long-term post-HT. Methods Data were prospectively collected from all adult HT patients who had an OGTT between August 2018 and October 2020. Patients with known DM, an active infection or active treatment of a malignancy were excluded as well as patients who did not want to undergo an OGTT. Either the patient came sober to the outpatient clinic for a regular appointment or visited the general practitioner when the distance to the hospital was too far. A fasting glucose was determined after which the patient was administered 75 grams of glucose in a 200 mL solution as advised by the American Diabetes Association. After two hours, glucose was measured again. Furthermore, glycated hemoglobin (HbA1c) was determined. Definitions of PTDM, pre-diabetes and no diabetes are mentioned in Table 1. Diabetes range tests were repeated after six weeks with another OGTT to confirm PTDM. Results Out of 251 patients, 148 patients were tested excluding 71 patients with known DM and 32 patients not able or willing to undergo an OGTT. Median age at OGTT was 54.5 [IQR 42.4-64.8] years and 60 (41%) were female. Main reason for HT was non-ischemic cardiomyopathy (n=118, 80%). Median time from HT until OGTT was 8.6 [IQR 4.8-14.4] years. Steroids were used in 90 (61%) patients and 134 (91%) patients used tacrolimus at the time of OGTT. In total, OGTT demonstrated new PTDM in 21 (14%) patients, pre-diabetes in 41 (28%) patients and no diabetes in 86 (58%) patients. Conclusion PTDM as well as pre-diabetes are frequently seen long-term post-HT. As such, systematic screening by OGTT is warranted for timely intervention as this may improve the long-term outcome.

The levelized cost of electricity (LCOE) of photovoltaic (PV) systems is determined by, among other factors, the PV module reliability. Better prediction of degradation mechanisms and prevention of module field failure can consequently decrease investment risks as well as increase the electricity yield. An improved knowledge level can for these reasons significantly decrease the total costs of PV electricity. In order to better understand and minimize the degradation of PV modules, the occurring degradation mechanisms and conditions should be identified. This should preferably happen under combined stresses, since modules in the field are also simultaneously exposed to multiple stress factors. Therefore, two 'Combined Stress test with in situ measurement' setups have been designed and constructed. These setups allow the simultaneous use of humidity, temperature, illumination, and electrical biases as independently controlled stress factors on solar cells and minimodules. The setups also allow real-time monitoring of the electrical properties of these samples. This protocol presents these setups and describes the experimental possibilities. Moreover, results obtained with these setups are also presented: various examples about the influence of both deposition and degradation conditions on the stability of thin film Cu(In,Ga)Se2 (CIGS) as well as Cu2ZnSnSe4 (CZTS) solar cells are described. Results on the temperature dependency of CIGS solar cells are also presented.

The levelized cost of electricity (LCOE) of photovoltaic (PV) systems is determined by, among other factors, the PV module reliability. Better prediction of degradation mechanisms and prevention of module field failure can consequently decrease investment risks as well as increase the electricity yield. An improved knowledge level can for these reasons significantly decrease the total costs of PV electricity. In order to better understand and minimize the degradation of PV modules, the occurring degradation mechanisms and conditions should be identified. This should preferably happen under combined stresses, since modules in the field are also simultaneously exposed to multiple stress factors. Therefore, two 'Combined Stress test with in situ measurement' setups have been designed and constructed. These setups allow the simultaneous use of humidity, temperature, illumination, and electrical biases as independently controlled stress factors on solar cells and minimodules. The setups also allow real-time monitoring of the electrical properties of these samples. This protocol presents these setups and describes the experimental possibilities. Moreover, results obtained with these setups are also presented: various examples about the influence of both deposition and degradation conditions on the stability of thin film Cu(In,Ga)Se2 (CIGS) as well as Cu2ZnSnSe4 (CZTS) solar cells are described. Results on the temperature dependency of CIGS solar cells are also presented.

Despite all the research carried out to date, LID is not yet fully understood as it has many origins that affect differently several types of crystalline solar cells. Latest available high-tech equipment allows to test modules under a wide range of elevated temperatures while simultaneously light-soaking them with Class AAA light and doing in-situ measurements, for a prolonged time of weeks or months. Employing this setup, the timelines of LID degradation and regeneration under different temperatures and light intensities can be assessed in detail. The present abstract performs this analysis on mono-crystalline silicon (mono-Si) p-type PERC PV modules at elevated temperatures and quantifies the losses due to degradation, which becomes 0.8 to 1.0 % in maximum 12 hours at 92°C under 1000 W/m2, followed by a regeneration of 1 % which can take between 24 and 60 hours. The complete work based on this abstract extends the research to micro-crystalline Silicon (mc-Si) PERC PV modules as well as perform the analysis at different temperatures and light intensities, while relating the output to outdoor long-term exposure data for different locations.

Dobutamine stress myocardial perfusion imaging (MPI) is a useful alternative for the evaluation of coronary artery disease (CAD) in elderly patients who are unable to perform an exercise stress test. However, data on the long-term prognostic value of stress MPI in elderly patients are lacking. Therefore, this study evaluated the long-term prognostic value of dobutamine stress MPI in elderly patients unable to perform an exercise test. The study population consisted of 247 elderly patients (mean age 71 ± 5 years) who underwent dobutamine stress single-photon emission computed tomography (SPECT) MPI. An abnormal SPECT study was defined as the presence of fixed and/or reversible perfusion defects. A summed stress score (SSS) was obtained to estimate the extent and severity of perfusion defects. End points during follow-up were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI). During a median follow-up of 14 years (range 12-16), 168 (68%) patients died (all-cause mortality), of which 56 (23%) were due to cardiac causes. Nonfatal MI occurred in 19 (8%) patients. Kaplan-Meier survival curves showed that MPI provided optimal risk stratification in patients with normal and abnormal MPI. Multivariable analysis identified an abnormal MPI as a strong significant predictor of all-cause mortality and cardiac events. A multivariable analysis also revealed that a reversible defect and SSS were strong long-term predictors of cardiac mortality and hard cardiac events. Dobutamine stress 99mTc-tetrofosmin SPECT provides incremental prognostic information for the prediction of long-term cardiovascular outcomes in elderly patients, unable to perform exercise testing. Dobutamine stress MPI is useful in risk classifying elderly patients.

Industrial production of bifacial photovoltaic modules is becoming more and more cost-effective in recent years. For this reason, the development of an agreed international standard test that provides the guidelines to measure the current-voltage characteristics of bifacial modules, especially under standard test conditions, is of utmost importance [1]. In order to contribute to the international norm, the goal of this research is to compare the two main bifacial indoor testing methods under several irradiance and temperature conditions, combining a flash simulator and a steady-state simulator. Among other insights, the results successfully quantify the offset in maximum power measurements between methods.

Purpose Extreme shortage in donors in the Netherlands has led to increasingly aging donors in heart transplantations (HT). The aim of the study was to evaluate the relationship between donor age and the need for a permanent pacemaker (PPM) implantation after HT. Methods All HTs in our centre between 1984 and august 2018 were retrospectively analysed. Retransplantation within 30 days (n=2) and patients who died within 30 days after HT (n=53) were excluded from the study. In this study 664 HTs were included. Based on the donor age, the HTs were divided into three groups: Group I ( 50 years, n=96). Primary outcome was the implantation of a PPM post-HT, either early (≤ 90 days) or late (> 90 days). Results The biatrial technique was performed in 659 HTs and only 5 using the bicaval technique. Before 2000 (the moment of immunosuppressive regime switch from cyclosporine- to tacrolimus-based therapy), the median donor age was 26 [IQR 20-35] and after 2000 42 [IQR 25-51] (P 90 days (median 7.6 years [IQR 3.4-13.4]) post-HT. The early PPM rate was 1.5% before 2000 vs 11% late PPM rate, while after 2000 the rates were 10.6% and 5.9% respectively. Indications for PPM implantation were sinus node dysfunction in 52.1% and atrioventricular block in 47.9%. Total PPM rates were 10% (Group I), 18% (Group II) and 25% (Group III) (P Conclusion The need for an early PPM is statistically higher in HTs with a donor age > 50 years. However, the long-term survival was non-inferior in patients with a PPM.

Purpose The risk of developing thromboembolic events is elevated in the first 3 months after an aortic valve replacement (AoVR). Therefore, the current guidelines recommends very early (at day 1) introduction of low dose aspirin or therapeutic warfarin therapy after AoV replacement. Following Left Ventricular Assist Device (LVAD) implantation, AoVR with a bioprothesis is advised in patients with a moderate to severe aortic regurgitation (AR). Aim of this study was to evaluate the clinical outcome of bioprothesis post-LVAD, especially in relation to thromboembolic events. Methods We revised all LVAD implantations in our center (64 HeartMate II and 40 HeartMate 3 LVAD patients) starting from 2006 for AoVR and thromboembolic events diagnosed on CT-angiography (CT-a). Results Nine patients (8.7%; median age 53 years, 89% male) had concomitant AoVR at the time of LVAD implantation, one patient (1.0%; 56 years of age, male) had AoVR 520 days post-LVAD, one patient (1.0%; 59 years of age, female) had a Transcatheter Aortic Valve Implantation (TAVI) after 337 days post-LVAD. An overview of the clinical data is shown in the Table. Median follow-up time on LVAD support was 750 days [range: 86-2065]. Median time to therapeutic heparin/warfarin therapy was 4 days [range: 1-7] and median time to start of aspirin was 11.5 days [range: 5-39] after implantation. Three patients developed an aortic root thrombus within the first month after implantation, all primarily diagnosed with CT-a, and subsequently confirmed by transthoracic echocardiography. Furthermore, two patients suffered from a stroke, one ischemic and one hemorrhagic. Conclusion In our cohort, consisting of eleven patients with LVAD and AoVR, almost one third had LVOT/AoV thrombosis at CT-a, one of them developed an ischemic stroke. We hypothesize that concomitant AoVR at the time of LVAD implantation in selected patients may be associated with less risk for thrombus formation on LVOT/AoV as compared to a later intervention on the aortic valve.

Dobutamine stress myocardial perfusion imaging (MPI) is a useful alternative for the evaluation of coronary artery disease (CAD) in elderly patients who are unable to perform an exercise stress test. However, data on the long-term prognostic value of stress MPI in elderly patients are lacking. Therefore, this study evaluated the long-term prognostic value of dobutamine stress MPI in elderly patients unable to perform an exercise test.The study population consisted of 247 elderly patients (mean age 71 ± 5 years) who underwent dobutamine stress single-photon emission computed tomography (SPECT) MPI. An abnormal SPECT study was defined as the presence of fixed and/or reversible perfusion defects. A summed stress score (SSS) was obtained to estimate the extent and severity of perfusion defects. End points during follow-up were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI).During a median follow-up of 14 years (range 12-16), 168 (68%) patients died (all-cause mortality), of which 56 (23%) were due to cardiac causes. Nonfatal MI occurred in 19 (8%) patients. Kaplan-Meier survival curves showed that MPI provided optimal risk stratification in patients with normal and abnormal MPI. Multivariable analysis identified an abnormal MPI as a strong significant predictor of all-cause mortality and cardiac events. A multivariable analysis also revealed that a reversible defect and SSS were strong long-term predictors of cardiac mortality and hard cardiac events.Dobutamine stress