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Angiodysplasias (AGD) are common sites of bleeding in the gastrointestinal (GI) tract after Continuous Flow Left Ventricular Assist Device (CF-LVAD) implantation. We sought to investigate whether AGDs are formed as a result of LVAD physiology or preexist as a consequence of heart failure. Thirty-six subjects with HF reduced EF (HFrEF) underwent video capsule endoscopy (VCE) to assess for the presence of AGD. Fifty-three subjects without HF who underwent VCE for a nonbleeding indication formed a control group. The prevalence of AGD was significantly higher in the HFrEF compared to the non-HF controls (50% vs 13%, p = 0.0002). This association persisted after controlling for age and comorbidities. Within the HFrEF cohort, higher Ang2, NT-proBNP and BUN were associated with the presence of AGD. AGD in the GI tract are associated with HFrEF. This is the first description of a new pathology associated with HFrEF and adds to our understanding of CF LVAD associated GI bleeding.

The trends and outcomes of multiorgan heart-transplantation (HT) using hepatitis C virus (HCV) donors in the contemporary era are sparsely known. Using UNOS registry, 1322 adult multiorgan-HTs (n = 986 heart-kidney, n = 155 heart-lung, n = 181 heart-liver) between August-2015 and August-2020 were identified, of which 109 were performed using HCV-donors (n = 77 HCV nucleic-acid-amplification testing [NAT] positive irrespective of antibody status [HCV-viremic]; and n = 32 HCV Ab+/NAT-[HCV antibody + nonviremic]). The percentage of HCV-donors used for multiorgan-HT increased from 0% in 2015 to 14% in 2020 (p < 0.001), but there was wide variation across UNOS regions and center volumes. Recipients of multiorgan heart-kidney transplants from HCV-donors (n = 90) and HCV-naive (HCV Ab-/NAT-) donors (n = 896) had similar 1-year survival using unadjusted and adjusted Cox-proportional hazards-regression models including in propensity-score matched cohorts. Post-HT rates of cardiac-allograft-vasculopathy (5.4% vs 5.8%) and chronic-dialysis (7.3% vs 4.9%) at 1-year were also similar. Use of HCV-donors (HCV-viremic, HCV Ab+ nonviremic) for multiorgan-HT has increased significantly. Encouraging 1-year outcomes in heart-kidney recipients from HCV-donors should support further expansion of heart-kidney transplantation using HCV-donors.

BackgroundThe safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain.MethodsUtilizing Get With The Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC.ResultsA total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC. Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p

Peripheral venous pressure (PVP) monitoring is a noninvasive method to assess volume status. We investigated the correlation between PVP and central venous pressure (CVP) in heart failure (HF), heart transplant (HTx), and left ventricular assist device (LVAD) patients undergoing right heart catheterization (RHC). A prospective, cross-sectional study examining PVP in 100 patients from October 2018 to January 2020 was conducted. The analysis included patients undergoing RHC admitted for HF, post-HTx monitoring, or LVAD hemodynamic testing. Sixty percent of patients had HF, 30% were HTx patients, and 10% were LVAD patients. The mean PVP was 9.4 ± 5.3 mm Hg, and the mean CVP was 9.2 ± 5.8 mm Hg. The PVP and CVP were found to be highly correlated (r = 0.93, p0.00001). High correlation was also noted when broken down by HF (r = 0.93, p0.00001), HTx (r = 0.93, p0.00001), and LVAD groups (r = 0.94, p0.00005). In conclusion, there is a high degree of correlation between PVP and CVP in HF, HTx, and LVAD patients. PVP measurements can be used as a rapid, reliable, noninvasive estimate of volume status in these patient populations.

Alteplase, a tissue-type plasminogen activator, is recommended for ischemic stroke patients presenting within 4.5 h. Due to bleeding risks, current guidelines advise delaying antiplatelet therapy for 24 h after alteplase. However, specific scenarios may require antiplatelet therapy to be given within the 24 h window. This study aimed to examine the safety of early antiplatelet therapy administration within the first 24 h after alteplase.This study is a retrospective, observational study of adult patients with acute ischemic stroke who received alteplase across a multi-hospital system. Patients were grouped based on early antiplatelet therapy (within 24 h window) or as recommended per guidelines. The occurrence of bleeding events, including symptomatic intracranial hemorrhage and/or gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes (modified Rankin score 3-6), and hospital length of stay, were compared between groups.Patients were predominantly African American (72%) and female (53%) with a median age of 62 years. Median baseline NIHSS scores were higher in the early group (5 vs. 7; p = 0.04), and patients in the early group were more likely to undergo endovascular therapy (26% vs. 8%, p 0.0001). In patients treated with alteplase only and who did not undergo endovascular therapy, there was no difference in symptomatic intracranial hemorrhage (1.4% vs. 0%, p = 0.1), gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes, or length of stay.In our retrospective analysis, early administration of antiplatelet therapy (24 h post-alteplase) did not increase the risk of symptomatic intracranial hemorrhage, gastrointestinal bleeding, or unfavorable outcomes in patients who received alteplase alone for management of acute ischemic stroke. Prospective studies are needed to validate these findings.

BACKGROUND Hepatitis C virus (HCV) donors should be categorized as HCV-viremic (antibody [Ab] negative or positive/Nucleic Acid testing [NAT] positive) or HCV Ab+ nonviremic (Ab+/NAT–). Whereas recipients of hearts from HCV-viremic donors will develop viremia but can be cured of HCV shortly after transplant with direct-acting antivirals (DAAs), recipients of hearts from HCV Ab+ nonviremic donors are highly unlikely to become viremic or require DAAs. Given this important difference in risk, we assessed the utilization trends and post-heart-transplantation outcomes of HCV-naive (Ab–/NAT–), HCV-viremic, and HCV Ab+ nonviremic donor hearts. METHODS A total of 26,572 adult donors (≥18 years) with information on HCV Ab and NAT status were identified in the United Network for Organ Sharing registry between August 2015 and June 2018 for utilization rates. Adult heart transplant recipients of these donors were compared for primary graft failure (PGF) at 90 days and 1-year recipient survival. RESULTS A total of 96 HCV Ab+ nonviremic and 135 HCV-viremic adult donor hearts were transplanted during the study period. The utilization rates of both HCV Ab+ nonviremic (1.4%–23.4%) and HCV-viremic (0.7%–25.4%) donor hearts increased significantly approaching HCV-naive rates (29.04%). There was no significant difference in rates of PGF and 1-year survival between recipients in the 3 donor HCV groups. We also used (1:3) propensity score matching and found similar 1-year survival in different donor HCV groups (HCV-naive vs HCV Ab+ nonviremic, p = 0.59, and HCV-naive vs HCV-viremic, p = 0.98). CONCLUSIONS Recipients of HCV-viremic and HCV Ab+ nonviremic donor hearts had equivalent risk of PGF and 1-year mortality compared with recipients of HCV-naive donor hearts. Although only HCV-viremic organs require DAAs and the risk of coronary artery vasculopathy after treated HCV infection has not been defined, the utilization rates of both HCV Ab+ nonviremic and HCV-viremic adult donor hearts have increased at an equal pace now approaching HCV-naive rates.

Background Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Methods A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. Results Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p Conclusions Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.

Background Continuous-flow left ventricular assist devices have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy. Methods Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up. Results Demographic characteristics for pre-HTMCS (n = 71) and HTMCS (n = 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p = not significant), percentage of men (77.5% versus 71.7%, p = not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p = not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p = 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p = 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p = 0.019), gastrointestinal bleeding (0.87 versus 0.51, p = 0.11), and driveline infection (0.24 versus 0.10, p = 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p = 0.14). Conclusions Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.

Human immunodeficiency virus-positive (HIV+) patients are not routinely offered heart transplantation (HT) due to lack of adequate outcomes data. Between January 2004 and March 2017, we identified 41 adult (≥18 years) HT recipients with known HIV+ serostatus at the time of transplant in UNOS and evaluated post-HT outcomes. Overall, Kaplan-Meier (KM) estimates of survival at 1 and 5 years were 85.9% and 77.3%, respectively, with no significant difference in bridge-to-transplant ventricular-assist device (BTT-VAD, n = 22) and no-BTT-VAD (n = 19). KM estimates of cardiac allograft vasculopathy (CAV) and malignancy at 5 years were 32% and 19%, respectively. Using propensity scores, 41 HIV+ HT recipients were matched to 41 HIV- HT recipients for idiopathic dilated-cardiomyopathy; and there was no significant difference in post-HT survival up to 5 years. Furthermore, only 24 centers in the United States had performed HIV+ HT during the study period, indicating that >80% of HT centers in the United States had not performed any HIV+ HT. In a cohort representative of the current status of HIV+ HTs in the United States, we found that the posttransplant survival was excellent and rates of CAV and malignancy were comparable to the overall HT population. These results should encourage greater number of centers to offer HT to suitable HIV+ candidates and help reduce unequal access to HT for HIV+ patients.

Advanced imaging modalities provide essential anatomic and spatial information in patients with complex heart disease. Two-dimensional imaging can be limited in the extent to which true 3-dimensional (3D) relationships are represented. The application of 3D printing technology has increased the creation of physical models that overcomes the limitations of a 2D screen. Many groups have reported the use of 3D printing for preprocedural planning in patients with different causes of heart failure. This paper reviews the innovative applications of this technique to provide patient-specific models to improve patient care.

Background We performed this study to identify demographic, clinical, and angiographic characteristics of adult patients with angiographically confirmed vertebral artery occlusive disease (VAOD) and associated risk factors. Methods The demographic and clinical characteristics, and angiographic features were ascertained using predefined criteria. Controls were selected from the National Health and Nutrition Examination Surveys matched according to age, sex, and ethnicity. A stepwise logistic regression for odds ratio (OR) was performed to identify the effects of risk factors on occurrence of VAOD. Results Of 56 patients with VAOD (mean age ± standard deviation [SD]; 65.4 ± 11.7years, 44.6% women), 37.5% were classified as suffering from moderate stenosis (50%-69%), 16.1% from severe stenosis (70%-99%), and 46.4% from occlusion of at least 1 vertebral artery. There was a significantly higher severity of stenosis (percentage with SD; 88.1 ± 16.5 versus 75.4 ± 20.8, P = .02) and frequency of bilateral vertebral artery disease in patients with ischemic symptoms (40.9% versus 8.8%, P = .004). In the multivariate analysis, hypertension (OR 3.0; 95% confidence interval [CI], 1.4-6.5), diabetes mellitus (OR 2.5; 95% CI, 1.4-4.6), coronary artery disease (OR 3.2; 95% CI, 1.7-6.0), and active cigarette smoking (OR 3.1; 95% CI, 1.5-6.3) were significantly associated with vertebral artery disease. Conclusions Severity of stenosis and bilateral involvement were associated with symptomatic VAOD. Hypertension, diabetes mellitus, coronary artery disease, and active cigarette smoking were associated with occurrence of VAOD.

BACKGROUND Hepatitis C (HCV) donors are rarely used for cardiac transplantation due to historically poor outcomes. In 2015, nucleic acid testing (NAT) for viral load was added to the routine work-up of organ donors, allowing for the distinction between subjects who remain viremic (HCV Ab + /NAT + ) and those who have cleared HCV and are no longer viremic (HCV Ab + /NAT – ). The American Society of Transplantation recently recommended that HCV Ab + /NAT – donors be considered non-infectious and safe for transplantation. We present our initial experience with such donors. METHODS All patients were counseled regarding donor HCV antibody (Ab) and NAT. Transplant recipients were tested post-transplant at 1 week and at 1, 3, and 6 months for HCV seropositivity and viremia. We also analyzed the UNOS database to determine the potential impact of widespread acceptance of HCV Ab + /NAT – organs. RESULTS Fourteen HCV Ab ‒ subjects received hearts from HCV Ab + /NAT – donors in 2017. Over a median follow-up of 256 (192 to 377) days, 3 patients developed a reactive HCV Ab, yet none had a detectable HCV viral load during prospective monitoring at any time. Analysis of the UNOS database for the calendar year 2016 revealed that only 7 (3%) of 220 HCV Ab + /NAT – donors were accepted for heart transplantation. CONCLUSIONS We have demonstrated the feasibility of utilizing HCV Ab + /NAT – donors for cardiac transplantation without recipient infection. A small percentage of recipients developed HCV Ab without evidence of viremia, possibly consistent with a biological false reactive test, as has been seen in other settings. Large-scale validation of our data may have a significant impact on transplantation rates.

Objective The total number of citations of a research article can be used to determine its impact on the scientific community. We aimed to identify the top-100 articles published on ischemic stroke and evaluate their characteristics. Methods Based on the database of Journal Citation Reports, 934 journals were selected that published original ischemic stroke articles. We used Web of Science citation search tool to identify top-100 citation classics, i.e., articles with more than 400 citations, in the field of ischemic stroke. All original articles were evaluated for publication year, journal category, journal and its impact factor, number of total and annual citations, research topic, publishing country, and institutional affiliation. Results The top-100 citation classics in ischemic stroke were published from 1970 to 2015, with the decade of 1990–1999 contributing 47 articles of historical significance. Median of total citations and annual citations in our analysis were 625.0 (interquartile range [IQR] 851.3–494.5) and 35.7 (IQR 79.9–25.9), respectively. The majority of the articles originated from the United States (n = 57), focused over the medical management (n = 26), and were published in the New England Journal of Medicine or Stroke (n = 25 each) journals. The median impact factor for the journals that published top-100 ischemic stroke citation classics was 9.11 (IQR 21.49–6.11). Conclusions Our list of top-100 citation classics specific to ischemic stroke provide a detailed insight into academic achievements, historical perspective and serves as a guide for the scientific progress in stroke.

Patients with restrictive (RCM) and hypertrophic (HCM) cardiomyopathies are felt to be a difficult population to treat with left ventricular assist device (LVAD) therapy. Scarce data exist on outcomes of continuous-flow (CF) LVAD support in these challenging patient cohorts.The Interagency Registry for Mechanically Assisted Circulatory Support Registry was queried for all patients with RCM (n = 94) and HCM (n = 104) who underwent CF LVAD implantation between March 2008 and March 2014. Survival, adverse event rates, baseline demographics, echocardiography parameters, and competing outcomes were compared with patients with dilated cardiomyopathy (DCM) (n = 8749).Left ventricular size was smaller and baseline EF was higher in RCM and HCM compared with DCM patients. Nonetheless, these parameters were not completely normal in the RCM and HCM groups, suggesting that most of these patients exhibited features of a DCM and represented a mixed phenotype. In these specific patient populations, survival up to 4 years was not different among the 3 groups (log rank 0.25) and competing outcomes at 1 year were similar. In the subgroup of patients with very small ventricles (ie,5.0 cm), survival was far inferior. Finally, overall rates of right ventricular assist device requirement, hemolysis, pump dysfunction, and cardiac arrhythmias were similar among the 3 groups.Relatively few patients with HCM and RCM undergo CF LVAD implantation, and most that do display some features of a DCM. Overall survival and adverse event profiles of these patients were similar to traditional DCM patients; however, in those with very small ventricles, survival was inferior.

Purpose Speed optimization in left ventricular assist device (LVAD) recipients remains a key feature in patient management. Noninvasive evaluation with echocardiography is routinely performed, however, around 38% of LVAD patients considered stable had non-optimal hemodynamics at baseline speed. Pulmonary congestion can be seen on lung ultrasound (LUS) in the form of B-lines. In heart failure (HF) patients, the number of B-lines has proven to be an excellent prognostic marker and a strategy of treatment guided by LUS appears to decrease the number of HF admissions. LUS, a noninvasive point of care test, seems an attractive tool to complement echocardiographic assessment in LVAD recipients; however, this has never been studied. Methods This is a single center, observational, prospective study. Heart Mate 3 (HM3) patients 18 years or older were invited to participate during an outpatient clinic visit or during a right heart catheterization. Patients with known severe pulmonary diseases were excluded. We examined eight thoracic sites (4 in each hemithorax) and the number of B-lines was reported in real time as the sum of the B-lines visualized in each site. Results This is the report of the first 10 patients included. Mean age was 49 ± 11 years. 80% of patients were male, 80% had a nonischemic cardiomyopathy, and 20% had a history of COPD. The median BMI was 36 kg/m^2 (25-37). 100% of the thoracic sites examined were interpretable and the median number of B-lines was 2.5 (1-7). 2 patients also had a pleural effusion. In contrast, patients had very few signs of congestion on physical examination (Figure). Conclusion LUS in HM3 patients is feasible and no interference with the LVAD has been encountered in an 8-site protocol. Whether LUS can help LVAD optimization and improve outcomes in this challenging population remains to be determined.

Background Left ventricular systolic dysfunction (LVSD) accounts for almost 25% of nonacceptance of potential donor hearts. Previous smaller, single-center studies showed that LVSD following brain death may be transient, and such hearts can be successfully resuscitated with resolution of LVSD, then transplanted. Objectives This study evaluated outcomes of donor hearts with LVSD on initial transthoracic echocardiogram (TTE) that resolved during donor management. Methods We reviewed echocardiograms of all cardiac donors in the United Network of Organ Sharing database that were transplanted from January 1, 2007, to September 30, 2015, and identified 472 donor hearts with LVSD (left ventricular ejection fraction [LVEF] ≤40%) on initial TTE that resolved (LVEF ≥50%) during donor management on a subsequent TTE. These patients comprised the improved donor LVEF group. These were compared with donor hearts with normal LVEF (LVEF ≥55%) on the initial TTE for recipient mortality, cardiac allograft vasculopathy (CAV), and primary graft failure (PGF). Results There was no significant difference in recipient mortality at 30 days, 1 year, 3 years, and 5 years of follow-up, nor any difference in rates of PGF at 90 days and CAV at 5 years between recipients of donor hearts with improved LVEF and recipients of donor hearts with initially normal LVEF. Post-transplant length of stay was also similar between the 2 groups. Using propensity scores, 461 transplants in the improved-donor LVEF group were matched to 461 transplants in the normal-donor LVEF group. There was no significant difference in PGF at 90 days or recipient mortality after up to 5 years of follow-up. Conclusions In the largest analysis of donor hearts with transient LVSD, we found that such hearts can be successfully resuscitated and transplanted without increasing recipient mortality, CAV, or PGF. These results underscore the importance of appropriate donor management and should help to increase utilization of donor hearts with transient LVSD.

Purpose Increased mean platelet volume (MPV) has been associated with elevated risk of stroke and myocardial infarction in the general population and stroke/pump thrombosis in Heartmate II recipients. It has been proposed that contact with foreign surfaces and centrifugation promote prothrombotic states with platelet activation and increased MPV. An association between MPV and outcomes of patients treated with percutaneous short-term circulatory devices has not been investigated. Methods This was a retrospective study of 67 patients who received percutaneously inserted ventricular assist device (pVAD) support for high risk percutaneous coronary interventions. Mean platelet volume (MPV) was measured by impedance technology with Sysmex XN-10 hematological analyzer and expressed in femtoliters (fL). Average MPV (aMPV) and percentage change from admission (∆MPV%) were calculated. Results All patients experienced rise in MPV during the hospital stay (10.7+/-0.9 pre-pVAD, 10.8+/-0.8 in 24hrs post pVAD, and 11.1+/-1 fL at 7d, p Conclusion This pilot study indicates that rise in MPV is associated with increased mortality in PCI patients treated with pVAD. Simple and widely available MPV measurements may be useful in identifying high risk patients and estimating prognosis, which may aid in proper resource allocation. More studies on this subject are necessary.

Purpose Continuous flow left ventricular assist device (CF LVAD) supported patients with blood group O may wait longer for heart transplantation (HT), but it remains uncertain if during this waiting period such patients have greater morbidity and mortality from major adverse events (AEs). Methods We conducted a UNOS database analysis of all patients that were waitlisted for HT after CF LVAD implantation from January 2006 to March 2019. Major demographics, waitlist times, waitlist mortality and occurrence of major AEs were retrieved. Patients were categorized as blood group O and non-blood group O. Post-transplant survival was also retrieved. Waitlist and post HT survival were assessed by Kaplan Meier analysis and Cox proportional hazard ratios were calculated. AEs during device support were compared by logistic regression. Results Overall, 8,578 patients with CF LVADs were placed on the UNOS waitlist during the study period. As expected, Blood group O (n=4,115) had longer waitlist times (412 days, IQR: 102-576; non-O 250 days, IQR 39-323 days, p Conclusion Despite more major AEs during CF LVAD support, patients with blood group O experience similar wait list and post HT survival.

Purpose Right ventricular failure (RVF) remains a significant source of post-LVAD implantation morbidity despite advances in these mechanical circulatory support devices. The vasoactive inotropic score (VIS) is an emerging novel way to estimate total inotropic and vasotropic support, and we believe the post-operative VIS score could correlate with severe RVF post-LVAD implantation. Methods We performed a single-center retrospective study of 240 patients who received a continuous-flow durable LVAD between Jan 1st, 2006 through Dec 31st, 2017. Patients who were less than 18 years old, who underwent LVAD exchange, and who received a planned BiVAD were excluded. The VIS score was calculated as: dobutamine (mcg/kg/min) + 10 x milrinone (mcg/kg/min) + dopamine (mcg/kg/min) + 100 x epinephrine (mcg/kg/min) +100 x norepinephrine (mcg/kg/min) + 10,000 x vasopressin (mcg/kg/min). The VIS score at 6, 24, and 48 hours postoperatively were calculated and then the maximum VIS score within 48 hours for each patient used to stratify the cohort into quartiles. Severe RVF was defined as meeting clinical RVF and having inotropes >14 days after implant, RVAD placement during implant admission, or death from RVF during implant admission. Results In our 240-patient cohort, the VIS quartiles groups were 0-10, 11-15, 16-22, and 23-87. Patients in quartile 4 were older, had a higher CVP and INTERMACS level (Table 1). In our univariate analysis, quartile 4 was associated with severe RVF (OR 3.62, CI [1.37-9.56], p = 0.009). The multivariable model (which included age, INTERMACS level, total bilirubin over 2.5 mg/dL, RV dysfunction on echocardiogram, and gender) found that maximum VIS score within 48 hours for quartile 4 independently correlated with severe RVF (OR 3.04, CI [1.5 - 8.83], p = 0.04). The ROC-curve for this model had an AUC of 0.68. Conclusion Our results demonstrate that the highest VIS score within the first 48 hours after LVAD implantation correlates with severe RVF.

Purpose Recent data from single centers and registry analysis have demonstrated comparable one year survival after cardiac transplantation with HCV non-viremic donors. On the other hand, long-term outcomes remain unknown which is particularly relevant given the concern for accelerated CAV from HCV donors in the pre-DAART era. Therefore, in the current analysis we report our one year rates of CAV in recipients of HCV non-viremic organs. Methods A retrospective chart review was conducted of all transplants at Montefiore Medical Center between January 2017 and April 2019. Recipients were divided into 2 cohorts based on donor HCV status: non-HCV or HCV non-viremic (Ab+/NAT-). Donor and recipient characteristics as well as presence of CAV at one year assessment were collected. CAV was defined as intimal thickness >0.5mm by IVUS or OCT of the LAD when available or in cases without IVUS/OCT as Grade 1 or greater per the 2010 ISHLT CAV recommendations. Patients who received a HCV viremic organ, died before one year or did not have one year CAV assessment were excluded. Results During the study period, 97 transplants were performed. Breakdown by HCV status was: 70 non-HCV, 21 non-viremic, and 6 viremic transplants. 48 subjects in the non-HCV and 14 in HCV non-viremic categories reached one year and underwent CAV assessment. Characteristics associated with the development of CAV including recipient age, donor age, pre-transplant PRA, and rejection in the first year were not statistically different between groups. Rates of CAV were not different between recipients of non-HCV and HCV viremic organs at one year: 27% vs 14% (p=.32). At the time of presentation we anticipate data on presence of CAV on all 97 patients. Conclusion In this preliminary analysis, rates of CAV in recipients of HCV non-viremic organs were comparable to non-HCV donors. This finding provides further reassurance for the use of such donors in standard risk recipients.

Purpose Although various temporary mechanical circulatory support devices are utilized during acute myocardial infarction cardiogenic shock (AMI CS), comparisons of interdevice outcomes remain uncertain. We sought to determine patient characteristics and outcomes between venoarterial extracorporeal membrane oxygenation (VA ECMO) and Impella supported patients during AMI CS. Methods A single center retrospective study was conducted in consecutive patients with AMI CS from 02/12 to 09/19. Patients were grouped and analyzed by their initially assigned device as either VA ECMO or Impella. Device crossover was censored. Severity of illness was compared by sequential organ failure assessment (SOFA) and Vasoactive Inotropic Score (VIS). Thirty day survival and a composite of adverse neurologic (ischemic stroke and intracranial hemorrhage), thromboembolic and major bleeding events were compared between devices by Kaplan Meier analysis. Results One hundred and twelve patients with AMI CS underwent VA ECMO (n=57) or Impella (n=55) placement. Patients with VA ECMO had higher SOFA (15.0 IQR: 11.5-18.0 vs. 8.0 IQR: 5.0-13.0, p Conclusion Despite a higher severity of illness, AMI CS patients experienced similarly limited survival with VA ECMO or Impella. More adverse events occurred during VA ECMO support. Larger studies are warranted for optimal device selection during AMI CS.

Purpose Increased hemoglobin A1C was reported to be a predictor of angiographically detected CAV. Our study examined the impact of glycemic control on myocardial blood flow (MBF) measured by 13N-ammonia positron emission tomography (PET) in transplant recipients. Methods We reviewed the records of patients who had heart transplant in the past 5 years at our center, and who had regadenoson-stress 13N-ammonia PET imaging. Three PET flow parameters were measured: stress MBF, myocardial flow reserve (MFR), and coronary vascular resistance (CVR = systolic blood pressure / stress MBF). Age, time from heart transplant to PET imaging, cold ischemia time during transplant, history of ≥ 2R cellular rejection, cholesterol level and A1C within 3 months of PET were recorded as potential risk factors. Correlations between PET and potential risk factors were analyzed (Pearson and Spearman's rank). Mann-Whitney test was used to compare PET flow between patients with A1C Results 57 patients (median age 57.6 years, 73% men) were identified. Median time from transplant to PET imaging was 25 months. Median stress MBF was 2.8 (2.3-3.2) ml/min/g, CVR was 46.7 (39.1-54.0) mmHg/ml/min/g, and MFR was 3.0 (2.6-3.6). A1C (median 6.4%) correlated significantly with stress MBF: r -0.395 (P 0.006), and with CVR: r 0.392 (P 0.006). Time from transplant to PET imaging showed weaker correlation with stress MBF: r -0.284 (p 0.032) and CVR: r 0.279 (p 0.035). Patients with A1C Conclusion Time from heart transplant and A1C level significantly correlated with MBF by 13N-ammonia PET. Patients with high HbA1C level had significantly lower MBF, suggesting that glycemic control may have an important role in prevention of CAV.

Purpose Early acute cellular rejection (ACR) after orthotopic heart transplantation (OHT) is associated with adverse long-term outcomes. Data on whether the Mycophenolate mofetil (MMF) dose has any impact on rates of early ACR is lacking. The target MMF dose studied in clinical trials for immunosuppression with OHT has ranged from 2 to 3gm/day. In January of 2016 due to an increase in infectious complications, we modified our institutional policy whereby the target MMF dose was lowered from 3 gm/day to 2gm/day. In this analysis, we examined rates of early rejection stratified by target MMF dose. Methods We performed a retrospective analysis of consecutive OHT recipients at a single center from January 2015 to July 2019. Patients were divided into two groups based on the target MMF dose (3gm vs. 2 gm/day). The rates of ACR warranting a change in immunosuppressive regimen within 4 weeks of OHT (1R/1B or ≥ 2R) were compared between the two groups. Data on other factors that could impact early ACR such as age, gender, race, induction immunosuppression, and PRA was also collected. Univariate and multivariate-adjusted statistical analyses were performed. Results Of 169 OHT, mean age 53 years and 26% females, 67 patients were in the MMF 3gm/day group (Group 1) and 102 were in the 2 gm/day group (Group 2). Baseline characteristics were similar in both groups. The average daily dose of MMF for the first week after OHT was 2245 ± 724 mg in Group 1 and 1866 ± 525 mg in Group 2 (p Conclusion In this single-center study of OHT recipients comparing daily target MMF dose of 3gm with 2gm in the early post OHT period, there was a trend towards early ACR in the 2gm/day MMF dose group. This suggests that a higher MMF dose of 3gm/day, if tolerated, may help lower rates of early ACR. Further investigation in a larger sample is warranted to validate this finding.

Purpose Traditionally, heart transplant (HT) patients with cardiac allograft vasculopathy (CAV) are treated with a combination of calcineurin inhibitor (CNI) and sirolimus (SRL). Recent data suggest outcomes in patients with CAV may be improved by treatment with SRL and mycophenolate mofetil (MMF), without CNI. However, this CNI free regimen for HT patients with renal dysfunction resulted in more rejection. Here we evaluated the relationship between risk of rejection and SRL use in CAV. Methods This is a single center, retrospective study of HT patients with CAV, transplanted between 6/2003 - 10/2018. From 357 HT patients, 39 with CAV treated with SRL were identified. Rejection included ISHLT grading ≥ 1R/1B requiring therapy. Incidence of post SRL conversion rejection was analyzed for 2 groups: SRL/CNI and SRL/MMF. Results Of 39 patients identified, 11 received SRL/MMF and 28 received SRL/CNI. Six of 11 patients in the SRL/MMF group developed cellular rejection after transition to SRL, compared to 3 of 28 in the SRL/CNI group (55% vs 11%, p = 0.004; Fig. 1). Four of 6 patients on SRL/MMF who developed post SRL transition rejection, had a history of previous rejection. However, those who did not experience late rejection also had no history of early rejections (66% vs 0%, p=0.045). The average level of SRL was 10.5 ng/ml +/- 1.1 in the group with post SRL rejection and 7.6 ng/mL +/- 1.9 in the group without (p = 0.01). The average dose of MMF was 1834 +/- 376 mg daily in the group with post SRL rejection and 2000 +/- 0 mg daily in the group without (p = 0.78). Conclusion In HT patients with CAV treated with CNI free regimen, despite therapeutic levels of SRL, there is a significant increase in the risk of cellular rejection not seen in those on SRL/CNI. In those on SRL/MMF therapy who experienced post SRL rejection, there was a higher incidence of pre-conversion rejection. Reduced dose CNI/SRL immunosuppression regimens need to be considered in CAV patients, especially those with a history of previous rejection.

Purpose Despite the recent advances in Left Ventricular Assist Device (LVAD) therapy, stroke remains a frequent and catastrophic complication. Hypertension (HTN) after LVAD implant has been associated with an increased risk of stroke, but the association between HTN before LVAD implant and stroke has never been studied. We hypothesized that LVAD patients with elevated blood pressure (BP) during outpatient visits before the LVAD implant may have an increased risk of stroke. Methods We retrospectively identified 175 patients on HeartMate II or HeartMate 3 LVAD support (age 54.3±13.1 y, 77% male, 35% ischemic etiology, 32% HeartMate 3) who had at least one outpatient BP measurement with a regular BP cuff in the 2 years preceding the LVAD implant. Average pre-implant BP was calculated based on outpatient visits. Stroke was defined based on clinical and radiographic evidence. Patients who had any event (death, stroke, device exchange, pump thrombosis, heart transplant) in the first 30 days post-implant were excluded. Results 17 patients (9.7%) had a stroke. Average pre-implant SBP was significantly higher in the patients who had a stroke after LVAD implant (105±13 vs 116±13 mmHg, p Conclusion High SBP in the years before LVAD implant is associated with an increased risk of post-implant stroke. Further studies are necessary to establish if high SBP before the implant may represent an early sign of vascular dysfunction that eventually leads to stroke.

Purpose Driveline infection (DLI) is a significant source of morbidity and mortality during left ventricular assist device (LVAD) support yet limited data are available to describe preventive practices and their potential effectiveness. Methods We surveyed LVAD centers within the United States to assess local practices for driveline stabilization and preventive approaches towards DLIs. An online, anonymous, question-based survey was created and sent to expert providers at implanting centers. Respondents were participants in FLIGHT and IDEAL heart failure (HF) working groups and only a single respondent completed the survey for each center. As an exploratory analysis, we compared specific DLI preventive practices between centers with low (≤10%) and high (>10%) reported rates of DLI. Results Representatives from 55 centers responded to the survey. Respondents comprised of 37 HF cardiologists, 14 cardiothoracic surgeons, 2 LVAD advanced practitioners and 2 LVAD RNs. The response rate was 95%. Centers were geographically well distributed throughout the United States and 80% reported implanting over 20 LVADs per year. Forty-five (81%) centers reported usage of an anchor stitch, 48 (87%) used an external device to stabilize the driveline, while 7 (13%) utilized a wound vacuum after device placement. Eighteen centers (33%) reported a low DLI rate in comparison to 37 (66%) reporting a high rate. Centers with low DLI rates trended to utilize an anchor stitch (94% vs. 76%, p=0.09) and wound vacuum (22% vs. 8%, p=0.14) more often than those with high DLI rates (figure 1). Conclusion Variation exists in preventive practices and DLI rates across centers. Although no significant differences were noted for assessed practices between centers with high and low DLI rates, further studies are warranted to determine the effectiveness of an anchor stitch and wound vacuum placement for preventing DLIs.

As the population of adults with congenital heart disease continues to grow, so does the number of these patients with heart failure. Ventricular assist devices are underutilized in adults with congenital heart disease due to their complex anatomic arrangements and physiology. Advanced imaging techniques that may increase the utilization of mechanical circulatory support in this population must be explored. Three-dimensional printing offers individualized structural models that would enable pre-surgical planning of cannula and device placement in adults with congenital cardiac disease and heart failure who are candidates for such therapies. We present a review of relevant cardiac anomalies, cases in which such models could be utilized, and some background on the cost and procedure associated with this process.

Purpose Despite recent advances in the understanding of antibody-mediated rejection (AMR), our immunologic and histologic characterization remains imperfect. At present, robust markers of AMR severity are lacking. We examined the association between a readily available index - sum total mean fluorescence intensity (MFI) of all de-novo donor-specific antibodies (DSA) - and clinical outcomes. Methods A retrospective chart review of 146 consecutive heart transplant recipients from 2015-2018 was performed. AMR was defined as histologic (activated endothelial cells and intravascular macrophages) or immunopathologic (C4d) evidence on biopsy. DSA and MFI were determined via Luminex. Sum total MFI was calculated as the sum of the MFI of all class I and class II de-novo DSA at the time of initial presentation with AMR. Clinical outcomes through September 15, 2019 were retrieved for the endpoints of death or persistently depressed (>90 days) left ventricular ejection fraction (LVEF) Results Within the population of 146 patients, 46 patients developed de-novo DSAs. Of these, 15 met criteria for AMR and 31 did not. AMR patients had a significantly higher sum total MFI than those without clinical AMR. [38,296 ± 26,667 vs. 7,714 ± 6564; p Of AMR patients, all had at least one Class 2 DSA (13 out of 15 had DQ) while 4 of the patients did not have any Class 1 DSA. All patients were treated according to our institutional protocol with plasmapheresis/IVIG and bortezomib and/or rituximab. Over a mean follow up of 466 days ±356, 5 patients died, while an additional 3 patients had persistently reduced LVEF. Patients were dichotomized according to sum total MFI >30,000; 80% above this value had an adverse event vs. 33% below (p=0.05) Figure 1. The 2011 ISHLT pathologic grading system for AMR had no correlation to outcomes. Conclusion Sum total MFI, a simple and intuitive index, is a prognostic marker of clinical outcomes at the time of AMR. This index may help stratify patients for more aggressive treatment at the time of diagnosis.

Purpose Antiplatelet therapy with aspirin (ASA) is mandated with Left Ventricular Assist Devices (LVADs) on the presumption that this therapy modulates Hemocompatibility-related adverse events (HRAEs). The effect of aspirin (ASA) dosing, particularly during support with the HeartMate 3 (HM3) LVAD is unknown. Methods We conducted an exploratory analysis of HM3 supported patients in the MOMENTUM 3 clinical trial. HM3 patients were categorized into 2 groups based on daily ASA dose as Usual-dose (325 mg) or Low-dose (81 mg) with anticoagulation targeted to an INR 2.0-3.0. Exclusion criteria included patients not receiving either ASA 81mg or 325mg dose, those with HRAEs ≤7 days after LVAD implantation, or those receiving >1 antiplatelet agent. The composite primary endpoint was freedom from HRAEs, including non-surgical bleeding, pump thrombosis, stroke and peripheral arterial thromboembolic events at 2 years. Results Overall, 321 HM3 patients (Usual-dose n=141; Low-dose n=180) were included. Patients in the Usual-dose group were younger (57±13 vs. 60±12 years, p=0.035) and less often implanted as destination therapy (55% vs. 67%, p=0.029) than those receiving Low-dose. INR at the time of HRAEs was clinically similar between Usual- and Low-dose groups (2.20 [1.66, 3.20] vs. 2.0 [1.50, 2.60], p=0.054 respectively). At 2 years, a similar proportion of patients in the Usual- and Low-dose (43.5% vs 45.3%, p=0.94, Figure 1) groups survived free from HRAEs. There were no differences in survival free from component hemorrhagic (Usual-dose: 54.4% vs Low-dose: 51.7%, p=0.42) and thrombotic (Usual-dose: 76.8% vs Low-dose: 75.7%, p=0.92) events. Conclusion At 2-years after HM 3 LVAD implant, no difference in HRAEs between Usual- and Low-dose ASA was shown in the MOMENTUM 3 clinical trial. These findings suggest similar efficacy and safety of these two distinct aspirin dose ranges and call into question any meaningful therapeutic effect of this agent in HM 3 treated patients.

Purpose The development of post-transplant diabetes mellitus (PTDM) is associated with an increased risk of acute rejection after kidney and liver transplantation, however, the outcomes after orthotopic heart transplant (OHT) have yet to be systematically studied. We sought to investigate whether there is any relationship between the development of PTDM and acute rejection after cardiac transplant. Methods This was a single center retrospective review of 100 consecutive OHT patients between May 2015 and May 2018. A total of 39 patients with a documented history of diabetes mellitus were excluded from the study. Patients were divided into 2 groups: those who developed PTDM and those who did not. PTDM was defined by a hemoglobin A1C (HBA1c) ≥ 6.5 and/or a fasting blood glucose (FBG) ≥ 126 at 6 months post-transplant. Rates of rejection (ISHLT grading ≥ 1R/1B - 3R/3B) were compared between the 2 groups. Results Of the 61 patients (mean age 54.5 ± 11.9), 12 (19.6%) developed persistent PTDM at 6 months. Nine of the 12 patients who developed PTDM at 6 months had rejection compared to 9 of 49 patients who did not develop PTDM (75 % vs 18.37 %; p= Conclusion PTDM is associated with an increased risk of acute cellular rejection within 6 months post-OHT. Larger studies are warranted to examine whether any causal relationship exists between the development of PTDM and acute rejection in heart transplant recipients.

Purpose Previous studies have demonstrated a correlation between increasing center volume and improved post heart transplant (HTx) survival. We performed a contemporary analysis to evaluate this relationship. Methods The UNOS database was analyzed to include adult (≥18 years) HTx recipients from years 2006 to 2016. Each center had to perform >65 transplants to be included. Centers were categorized based on annual transplant volume: 6-15, 16-25, 26- 39 and ≥40. Primary endpoint was one-year mortality or retransplantation. Survival analysis was performed using Kaplan-Meier method. Adjusted analysis were performed using Cox-regression modeling. Results Among 17,853 HTx recipients, distribution of patients was 32.1%, 30.8%, 14.5% and 22.6% in the order of increasing center Htx volume, respectively. Median recipient age was 56 years (IQR 47-63) and 75.5% were male. Primary endpoint of one-year mortality or retransplantation was similar across the centers irrespective of transplant volume (6-15/yr: 10.4%, 16-25/yr: 9.5%, 26-39/yr: 11.1%, ≥40/yr: 9.7%; χ2 p=0.10 and Log-rank p=0.11) as noted in figure 1. When adjusted for recipient and donor risk factors, the Cox-regression analysis showed that centers with ≥40 Htx/yr had a lower rate of one-year mortality/retransplantation (HR 0.86; 95% CI 0.75-0.98; p=0.029) compared to patients at centers with volume 6-15/yr. The two remaining categories 16-25/yr (HR 0.94; p=0.31) and 26-39/yr (HR 1.06; p=0.43) showed no difference in primary endpoint when compared to the lowest volume category (6-15 /yr). Conclusion There was no difference in baseline rate of mortality or retransplantation at 1-year among Htx centers irrespective of volume. Among all categories, only centers with ≥40 Htx/yr had an improved risk adjusted primary endpoint compared to the centers with lowest volume. The correlation between increasing center volume and improved survival appears to have weakened in this updated analysis among US transplant centers.

Purpose Gastrointestinal bleeding (GIB) in LVAD patients is most commonly caused by gastrointestinal angiodysplasia (GIAD). Non-pulsatile blood flow in LVAD patients can cause splanchnic submucosal hypoperfusion and hypoxia leading to activation of a HIF1-α /Angiopoietins (Ang) signaling cascade, that can trigger pathological angiogenesis. We have recently shown that the use of digoxin, a potent inhibitor of HIF1-α, is associated with a significant reduction in GIAD related GIB in HeartMate (HM) II and HeartWare HVAD patients. However, HM3 support is associated with less GIB then previous generation pumps. We now hypothesize that dysregulation of Ang-1 and Ang-2 levels in patients with HM3 can be restored by digoxin treatment and may contribute to decreased incidence of GIB. Methods We have collected blood samples from 7 patients supported with HM3 before and after two weeks of digoxin therapy (0.125 mg daily). Ang-1 and Ang-2 levels were measured in patients' serum by ELISA. In single-center retrospective study, charts of all patients implanted with HM3 between June 2015 and October 2019 were reviewed with emphasis on the occurrence of GIB and digoxin therapy. Pearson's chi-squared test was used to assess the frequency of overall GIB and their association with digoxin therapy. Results Digoxin treatment in HM3 patients increased Ang-1 (11.5 to 30.7 ng/ml, p=0.02), and decreased Ang-2 levels (14.9 to 9.4 ng/ml, p=0.04), reversing angiogenic switch. Seven of 72 patients (10%) supported by HM3 during median observation time (236, IQR76-620) days experienced a GIB. We identified 38 patients treated and 34 not treated with digoxin (age 52.38 vs. 52.65, p=0.97). The frequency of GIB was significantly lower in the patients receiving compared to the ones not receiving digoxin (3% vs. 17% p=0.03; Fig.1), respectively. Conclusion Digoxin, an inhibitor of HIF1-α signaling cascade, may contribute to a lower risk of GIB in HM3 patients by restoring angiogenic equilibrium.

Purpose Despite the recent advances in Left Ventricular Assist Device (LVAD) therapy, gastrointestinal bleeding (GIB) remains a frequent and severe complication. A growing body of evidence suggests that the combination of hypoperfusion and hypoxia in the microcirculation may activate the angiogenesis cascade and promote the formation of arteriovenous malformations. We hypothesized that LVAD patients with concomitant significant restrictive or obstructive lung diseases may have an increased risk of GIB due to their chronic hypoxemic state. Methods We retrospectively identified 99 patients on HeartMate II LVAD support (age 54±13 y, 77% male, 36% ischemic etiology) who had a pulmonary function test (PFT) performed. Significant lung disease was defined as a moderate or severe obstructive/restrictive pattern detected during PFT and the concomitant use of inhaler therapy. GIB was defined as clinical evidence of GI bleeding and a decrease in hemoglobin of at least 1 g/dL. Results 11 patients (11%) had significant lung disease and 27 patients (27%) experienced a GIB. The risk of GIB was increased in patients with significant lung diseases (Hazard Ratio 2.59, 95% confidence interval 1.038 to 6.452). Freedom from GIB was significantly higher in patients without significant lung disease in Kaplan-Meier analysis (Figure). Conclusion Significant obstructive or restrictive lung diseases were associated with an increase in the risk of GIB. Further studies on the association of tissue hypoxia and activation of the angiogenesis cascade/bleeding diathesis in LVAD patients are warranted.

Purpose To address the high incidence of driveline malfunction in the HeartMate II® (HM2), a shield less, polyurethane -insulated, and modular cable driveline was introduced into the HeartMate 3® (HM3). Because these modifications resulted in changes to the physical properties of the driveline, we sought to evaluate the impact of these putative improvements on the incidence of driveline infection (DLI). Methods Retrospective chart review of all HM2 and HM3 between 2015 and 2019. DLI was defined according to the INTERMACS 2016 definition. Patients with DLI were reviewed for clinical course including diagnosis, treatment, and outcomes. Data were analyzed using Kaplan-Meier methodology. Results Over the study period, 93 HM2 and 68 HM3 were implanted. DLI was diagnosed in 16% of HM2 patients vs. 21.7% of HM3 patients (p=0.14, figure 1). Average time to DLI was 428.2 days in HM2 vs 370.3 days in HM3. EPPY was 0.14 for HM2 vs. 0.23 for HM3. HM3 DLI tended to be more severe as evidenced by need for surgical intervention 80% vs. 40% (p Conclusion In this single center experience, HeartMate 3® patients develop infections with shorter support times and required more aggressive interventions. Anecdotally, our team has noted a delayed or lack of integration of skin to polyurethane after implantation. In response, we have implemented the following: dual adjustable anchor, cadexomer iodine for excessive drainage, showering without dressings, suture removal prior to patient discharge, and incorporating picture instructions in driveline dressing kits to facilitate adherence to sterile technique. At the time of presentation of this abstract, we anticipate sharing our outcomes with these new techniques.

Cardiac sarcoidosis is notoriously difficult to diagnose and treatment protocols for the disease are not well-defined. The use of cardiac positron emission tomography (PET) imaging has been suggested in guiding immunosuppression. We sought to review the utilization of cardiac PET guided

Intravenous (IV) boluses of nondihydropyridine calcium channel blockers (CCBs) or beta-blockers (B-blockers) are often used for acute rate control in patients with atrial fibrillation (AF) with rapid ventricular response (RVR). However, due to their negative chronotropic and inotropic properties

Background Atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) has been associated with poor clinical outcomes. Catheter ablation has been shown to be an effective way to limit recurrence of AF and reduce stroke and mortality in patients with normal ventricular function and heart failure with reduced ejection fraction (HFrEF). Efficacy of catheter ablation in patients with HFpEF is less clear. We sought to evaluate clinical outcomes in the HFpEF population with ablation plus medical therapy as compared to medical therapy alone. Methods We conducted a single-center retrospective cohort review of 180 patients from 2007 to 2017. Inclusion criteria were patients who had a hospitalization with HFpEF and AF as hospital problems, EF≥50% and age ≥40. The ablation group includes all AF patients who underwent ablation and met inclusion criteria. The medical therapy cohort also met all the inclusion criteria and excluded patients with any ablations. Medical therapy included rate control, rhythm control or both. The primary outcome was AF at 1 year. Secondary outcomes were hospital admissions, stroke, and all-cause mortality. Results Out of 180 patients who met the inclusion criteria, 85 underwent catheter ablation and 95 were managed medically. More men underwent ablation vs. medical therapy (62.5% vs. 25.3%, p Conclusion In patients with HFpEF and AF, catheter ablation along with medical therapy is an effective method of rhythm control and resulted in fewer strokes than medical management alone.

Purpose We have previously reported a high prevalence of gastrointestinal angiodysplasia (GIAD) in advanced HF patients undergoing LVAD evaluation. We now hypothesize that GIAD develop in relation to advancing heart failure and are associated with angiogenic dysregulation. Methods After informed consent, patients being evaluated for LVAD underwent video capsule endoscopy (VCE) for assessment of GIAD. Two control groups were formed: (1) NYHA Class 1 HF patients with LVEF angiogenesis was measured in both HF groups and a subset of paired pre and post LVAD patients. Results Median age and percent female of the advanced HF (n=17), NYHA 1 (n=4), non-HF controls (n=36) were as follows: (61, 61, 56; p = .789) and (18%, 0%, and 56%; p =0.020). Prevalence of GIAD was much higher in the advanced HF group as compared to the NYHA 1 and non-HF controls: 71% vs 25% vs 33% (p=0.009). Median Ang2 levels were numerically higher in the advanced HF as compared to the NYHA 1 group (5.4 vs 3.3ng/mL; p=0.138) although this did not reach statistical significance in this small sample. In 9 subjects with paired measurements, Ang2 increased from a mean of 6.7±3.5 to 11.3±7.6ng/mL (p=0.047) after LVAD implantation. Conclusion GIADs are already present in the majority of patients undergoing LVAD implantation and appear to be part of the pathophysiology of advanced heart failure. Angiogenic dysregulation predates LVAD implantation but is augmented in the setting of continuous flow LVAD support. Enrollment in this study is ongoing and at the time of abstract presentation, we anticipate a larger sample size.