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Background Primary outcomes analysis of the Multicenter Study of MagLev Technology in Patients Undergoing MCS Therapy With HeartMate 3 (MOMENTUM 3) trial short-term cohort demonstrated a higher survival rate free of debilitating stroke and reoperation to replace/remove the device (primary end-point) in patients receiving the HeartMate 3 (HM3) compared with the HeartMate (HMII). In this study we sought to evaluate the individual and interactive effects of pre-specified patient subgroups (age, sex, race, therapeutic intent [bridge to transplant/bridge to candidacy/destination therapy] and severity of illness) on primary end-point outcomes in MOMENTUM 3 patients implanted with HM3 and HMII devices. Methods Cox proportional hazard models were used to analyze patients enrolled in the “as-treated cohort” ( n = 289) of the MOMENTUM 3 trial to: (1) determine interaction of various subgroups on primary end-point outcomes; and (2) identify independent variables associated with primary end-point success. Results Baseline characteristics were well balanced among HM3 ( n = 151) and HMII ( n = 138) cohorts. No significant interaction between the sub-groups on primary end-point outcomes was observed. Cox multivariable modeling identified age (≤65 years vs >65 years, hazard ratio 0.42 [95% confidence interval 0.22 to 0.78], p = 0.006]) and pump type (HM3 vs HMII, hazard ratio 0.53 [95% confidence interval 0.30 to 0.96], p = 0.034) to be independent predictors of primary outcomes success. After adjusting for age, no significant impact of sex, race, therapeutic intent and INTERMACS profiles on primary outcomes were observed. Conclusions This analysis of MOMENTUM 3 suggests that younger age (≤65 years) at implant and pump choice are associated with a greater likelihood of primary end-point success. These findings further suggest that characterization of therapeutic intent into discrete bridge-to-transplant and destination therapy categories offers no clear clinical advantage, and should ideally be abandoned.

Purpose Left ventricular assist device (LVAD) explant or decommission for LV recovery is rare (1-2%). Furthermore, details regarding appropriate patient selection, surgical technique and short- and long-term patient outcomes are limited (1,2). Four different surgical techniques have been described for cessation of LVAD support for LV recovery (3). The purpose of our study is to describe our experience for patients undergoing LVAD explantation or decommission. Methods We retrospectively reviewed the surgical technique and outcomes for our LVAD patients who were explanted and decommissioned between 2010 and 2020. Baseline demographics were examined. Specific surgical techniques utilized along with outcome analysis including infection, thromboembolic events, LVEF change, need for re-implantation and death were analyzed. Results Thirteen patients were identified who underwent either LVAD explant or decommission with a mean age of 43. All patients had underlying non-ischemic cardiomyopathy. Nearly half (53%) of the patients were selected due to a combination of LV recovery (mean LVEF 47% in this group) and an indication for device removal including pump thrombosis or infection (versus LV recovery alone). Surgical technique varied between full sternotomy with pump explant (69%) and thoracotomy with pump decommission (31%) depending on indication. Median follow up was 70 months. Results are displayed in table 1. In those with LV recovery alone, many experienced a drop in LVEF with clinical HF symptoms, but not resulting in re-implantation or mortality. All patients with infection and LV recovery experienced a drop in LVEF and recurrent HF, with a mortality rate of 50%. Conclusion LVAD explant or decomissioning can be performed via full sternotomy or thoracotomy depending on the indication. When performed for LV recovery and another reason, such as device infection, recurrent, severe HF can be fatal in this cohort. Careful monitoring of these patients is therefore required after such an operation.

Device indications have changed for placement of continuous-flow left ventricular assist devices (CF-LVADs). We performed a multicenter analysis evaluating temporal variations in outcomes after CF-LVAD implantation.We retrospectively defined 3 time intervals to reflect changes in CF-LVAD technology (period 1, 2004-2009; period 2, 2010-2012; and period 3, 2012-2014). A total of 1,064 patients (Heartmate II [HMII] = 835; Heartware [HVAD] = 229) underwent CF-LVAD implantation from May 2004 to October 2014. Device utilization was different between periods: period 1: HMII = 134 (100%); period 2: HMII = 480 (88%) and HW = 63 (12%); and period 3: HMII = 221 (57%) and HW = 166 (43%); P .001. Despite few baseline group differences, adjusted survivals were similar among the time periods (P = .96). Adjusted multivariable analysis revealed age (per 10-year increase) and Interagency Registry for Mechanically Assisted Circulatory Support category (1 vs all others) as the only independent predictors of mortality: P .001 and P = .008, respectively. Furthermore, it also showed the later periods to be at an increased risk of adverse events: 1) pump thrombosis (periods 2 and 3); and 2) gastrointestinal bleeding (period 3).Despite significant differences in device types, indications, and patient characteristics, post-implantation survivals were similar across time intervals. The most recent cohort seems to be at an increased risk of gastrointestinal bleeding and pump thrombosis.

Temporary circulatory support (TCS) is used to stabilize patients in critical cardiogenic shock and bridge patients to a durable ventricular assist device (VAD). Whether TCS confers increased risk at the time of VAD implant is unknown.Prospectively collected data from five institutions was retrospectively reviewed. All profile 1 through profile 3 patients implanted with a continuous-flow VAD (n = 804) were categorized into three groups: TCS (n = 68); non-TCS profile 1 (n = 70); and non-TCS profile 2-3 (n = 666).End-organ function and hemodynamics were worse before TCS than in non-TCS profile 1 patients: creatinine (1.7 ± 0.1 mg/dL versus 1.3 ± 0.06 mg/dL, p = 0.003); and right atrial pressure (16 ± 0.8 mm Hg versus 13 ± 1.1 mm Hg, p = 0.048). The TCS restored cardiac output before durable VAD (4.9 ± 0.2 L/min), and was comparable to profile 2-3 patients (4.3 ± 0.05 L/min) and better than profile 1 patients (4.0 ± 0.2 L/min, p = 0.002). Markers of hepatic function such as bilirubin were impaired before VAD in TCS and profile 1 patients (2.0 ± 0.2 mg/dL) compared with profile 2 and 3 patients (1.1 ± 0.03, p0.001). The incidence of postoperative right ventricular failure necessitating a right VAD was 21% for TCS patients and non-TCS profile 1 patients compared with 2% for profile 2-3 patients (p0.001). Profile 1 and TCS patients had similar 1-year survival (70% and 77%, p = 0.57), but inferior survival as compared with profile 2 and 3 patients (82%, p0.001). On multivariable analysis, TCS increased the hazard of death twofold.Temporary circulatory support restores hemodynamics and reverses end-organ dysfunction. Nevertheless, these patients have high residual risk with postoperative morbidity and mortality that parallels profile 1 patients without TCS. Caution is suggested in downgrading risk for TCS patients with improved hemodynamic stability.

Introduction Cardiac transplant centers are now successfully utilizing hepatitis C virus (HCV) donor hearts to increase the availability of organs now that a curative treatment is available with direct acting antivirals (DAA). We present the first described case of DAA treatment failure in a patient who received an HCV donor, nucleic acid testing (NAT) positive heart. Case Report A 65-year-old male with a mixed cardiomyopathy underwent orthotopic heart transplant with an HCV+/NAT+ heart. He seroconverted within seven days of transplant, noted by a peak HCV viral load of 7.65 log IU/mL and genotype of 1a without resistance markers. Planned initial treatment with glecaprevir/pibrentasvir (G/P) was denied by insurance. After approval for and treatment with ledipasvir/sofosbuvir (L/S) for 8 weeks, the patient's viral load was initially undetectable. However, he developed recurrent viremia 6 months after treatment completion with an HCV load of 7.40 log IU/mL with NS5A resistance due to a Y93H mutation. He was subsequently initiated on sofosbuvir/velpatasvir/voxilaprevir (S/V/V) with persistent undetectable viral loads to date at 4 months. Summary This is the first documented case of DAA treatment failure in a recipient of HCV+/NAT+ transplanted heart treated with L/S. This treatment failure was likely secondary to insufficient treatment duration. The ION-3 study demonstrated noninferiority for an 8 week treatment duration compared to 12 weeks of L/S, but at the cost of a higher relapse rate in the 8 week arm (5% vs 1%) associated with viral load of >6.78 log IU/mL. The Y93H mutation is more likely to reduce treatment efficacy in L/S as noted by a pooled resistance analysis compared to G/P, which has a failure rate of

Purpose In October 2018, the United Network for Organ Sharing (UNOS) implemented extensive changes to the adult heart allocation policy. These changes were developed to better stratify medically urgent patients and provide more equitable geographic distribution of donor hearts. Instead of preferential distribution within a local donor service area, hearts are first considered by centers within 500 nautical miles of a donor hospital. We evaluated the impact of the new system on the mode and associated expense of procurement travel. Methods We retrospectively analyzed data from 5 centers across 5 states and 4 UNOS regions (regions 2, 5, 10, 11). Pre-allocation change (pre-change) was considered 10/1/2016-10/17/2018 and post-allocation change (post-change) was considered 10/18/18-8/31/2019. The share of procurements requiring a flight vs local transportation from all centers was compared. Cost of transportation for procurement and distance from donor hospital to transplant center was available from 4 centers. Results Total of 693 transplants were performed during the study period: 477 pre-change and 216 post-change. Pre-change, there were 274 flights for procurement compared to 182 flights post-change (57 vs 84%, p Conclusion Following the 2018 UNOS change to the heart allocation system, the proportion of flights and distance traveled for organ procurements significantly increased across 5 moderate-high volume centers, nearly doubling the average travel cost for procurement. These findings may guide transplant centers, payers, and policy makers regarding necessary procurement resources. Further study is needed to determine how these changes may affect lower volume centers with fewer resources.

Purpose Hepatitis C (HCV) organs have been increasingly utilized in solid organ transplantation since the advent of curative direct acting anti-viral (DAA) therapy. Despite the adoption of this strategy, many unanswered questions remain regarding the management of immunosuppression. In two small case series of liver transplant recipients, tacrolimus concentrations have been shown to decrease with clearance of HCV viremia. We seek to describe our experience and clinical implications in our cardiac transplant population. Methods We adopted the strategy of HCV cardiac transplantation followed by curative treatment in February of 2018. We analyzed the change in tacrolimus levels after DAA therapy in those who developed viremic HCV after receiving an HCV organ. Immunosuppression regimens were not altered for these patients from standard of care, which includes no induction therapy, corticosteroid taper by 6 months, and tacrolimus and mycophenolate mofetil as tolerated. Drug levels of tacrolimus were collected, as were clinical outcomes inclusive of infection, rejection and death. Results Twenty of twenty six NAT+/HCV+ patients experienced a decrease in tacrolimus levels with treatment, from a mean of 11.6 to a mean of 6.5 after HCV treatment. This decrease occurred towards the end of treatment and did not correspond with changes in tacrolimus dosing or other immunosuppressive agents. When compared to the non-HCV transplant population (n=37), no change in outcomes were observed. Conclusion Treatment of HCV after transplantation may be correlated with increased metabolism, resulting in more rapid clearance of tacrolimus. Careful monitoring of drug levels and graft function is recommended as HCV organs are increasingly utilized. Further investigation into the clinical implications of these metabolic changes is warranted.

Objectives Secondary mitral regurgitation (MR), not amenable to percutaneous or surgical repair, is common in advanced heart failure patients considered for LVAD implantation. Single center analyses have suggested variable frequency of persistent MR after LVAD implantation and consequent pulmonary hypertension, worse right heart function and more readmissions. The contemporary impact of newer devices such as the HeartMate 3 (HM3) on amelioration of MR post-LVAD implant remains uncertain. In this analysis of the MOMENTUM 3 pivotal trial and its Continued Access Protocol (CAP) study, we propose to assess the burden of significant residual MR and to evaluate the impact on clinical outcomes. Methods Patients implanted with the HeartMate II (HMII) or HM3 pump in the MOMENTUM 3 pivotal trial were evaluated over 24 months to assess their relative impact on residual MR. An extended analysis of the first 500 implanted patients in CAP (HM3 only) will also be performed to validate observations from within the pivotal trial. Data on the presence and severity of MR using echocardiography were collected at baseline (pre-implant) and throughout the 24-month follow-up. Endpoints In the pivotal trial (n=1020), 44% of patients had significant (moderate to severe) MR at baseline and 8.8% (90/1020) had undergone a prior or concomitant mitral valve procedure. In patients with no surgical mitral valve correction, overall rates of significant residual MR (irrespective of baseline MR) at each follow-up visit are shown in Figure 1. Of those patients with significant MR at baseline, 28% had persistent significant residual MR during study follow-up. In this group, HM3 patients experienced a lower frequency of significant residual MR (24%) than HMII patients (33%, p=0.05). Survival, right heart failure, and freedom from all-cause readmissions were not significantly different between patients with and without significant residual MR. Endpoints will also be validated in the CAP cohort and in patients with concomitant mitral valve correction. (Funded by Abbott).

Purpose In the era of increased left ventricular support device (LVAD) implantation, limited data is available on outcomes in the obese population, with most available data describing elevated BMI with a cutoff of >30 kg/m2. Forest et al examined the ISHLT Mechanically Assisted Circulatory Support (IMACS) registry and found no impact in 2-year mortality in those with higher BMIs, but an increase in all adverse events describing BMI > 40 kg/m2 group. We seek to provide our experience with this population. Methods We retrospectively reviewed outcomes in over 580 LVAD implantations performed at St. Vincent, Indianapolis IN between 2008-19. Baseline demographics of BMI subgroups (BMI 40 kg/m2) and outcomes were collected. Endpoints including survival, stroke, infection, gastrointestinal (GI) bleeding and right heart failure (RHF) were analyzed by BMI strata, with a specific focus on BMI > 40 kg/m2. RHF was defined with Interagency for Mechanically Assisted Circulatory Support (INTERMACS) definitions. Results Over 8% of LVAD patients had a BMI > 40 kg/m2 in our population. No differences were found in survival, stroke, infection, GI bleeding or hemolysis. Figure 1 displays time to right heart failure in BMI subgroups (1= BMI 40 kg/m2). As seen in figure 1, those with a BMI of > 40 kg/m2 were at significantly increased risk of RHF. Conclusion An increased incidence of RHF after LVAD without a concurrent increase in mortality is seen in our patients with a BMI > 40 kg/m2. Strategies for peri-operative and long-term management should take this finding into consideration. Further investigation on a larger, multi-center scale is warranted.

Purpose The psychosocial evaluation is of paramount importance when evaluating a patient's ability to be successful with left ventricular assist device (LVAD) therapy. Current guidelines recommend a “detailed psychosocial evaluation” but do not give any recommendations regarding the use of a specific clinical tool. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) has been shown to predict both the psychosocial and medical outcomes in patients post-transplant; however, studies examining its utility in LVAD patients are limited. Methods We performed a single center, retrospective analysis, of 82 consecutive patients who underwent LVAD implantation from May 2017 to September 2018. Patients were classified into two groups based on a validated SIPAT cutoff score of Results Of the 82 patients, 46 (56%) had a score Conclusion Unlike cardiac transplant, the SIPAT score was not predictive of medical outcomes in patients undergoing LVAD therapy. A patient's underlying biologic effects may influence outcomes more than their psychosocial aspects. Prospective studies should be considered to further explore the validity of the SIPAT score in patients undergoing LVAD implantation.

Objectives The purpose of this study was to determine the risk factors for ischemic in hemorrhage cerebrovascular events in patients supported by the HeartWare ventricular assist device (HVAD). Background Patients supported with left ventricular assist devices are at risk for both ischemic and hemorrhagic cerebrovascular events. Methods Patients undergoing implantation with a HVAD as part of the bridge-to-transplant trial and subsequent continued access protocol were included. Neurological events (ischemic cerebrovascular accidents [ICVAs] and hemorrhagic cerebrovascular accidents [HCVAs]) were assessed, and the risk factors for these events were evaluated in a multivariable model. Results A total of 382 patients were included: 140 bridge-to-transplant patients from the ADVANCE (Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure) clinical trial and 242 patients from the continued access protocol. Patients had a mean age of 53.2 years; 71.2% were male, and 68.1% were white. Thirty-eight percent had ischemic heart disease, and the mean duration of support was 422.7 days. The overall prevalence of ICVA was 6.8% (26 of 382); for HCVA, it was 8.4% (32 of 382). Pump design modifications and a protocol-driven change in the antiplatelet therapy reduced the prevalence of ICVA from 6.3% (17 of 272) to 2.7% (3 of 110; p = 0.21) but had a negligible effect on the prevalence of HVCA (8.8% [24 of 272] vs. 6.4% [7 of 110]; p = 0.69). Multivariable predictors of ICVA were aspirin ≤81 mg and atrial fibrillation; predictors of HCVA were mean arterial pressure >90 mm Hg, aspirin ≤81 mg, and an international normalized ratio >3.0. Eight of the 30 participating sites had established improved blood pressure management (IBPM) protocols. Although the prevalence of ICVA for those with and without IBPM protocols was similar (5.3% [6 of 114] vs. 5.2% [14 of 268]; p = 0.99), those with IBPM protocols had a significantly lower prevalence of HCVA (1.8% [2 of 114] vs. 10.8% [29 of 268]; p = 0.0078). Conclusions Anticoagulation, antiplatelet therapy, and blood pressure management affected the prevalence of cerebrovascular events after implantation of the HVAD. Attention to these clinical parameters can have a substantial impact on the occurrence of serious neurological events. (Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure [ADVANCE]; NCT00751972)

The aim of this study was to evaluate the prevalence of early pump power elevation events in patients with the HeartMate II (HMII) and its impact on subsequent development of stroke and pump thrombosis.We analyzed45,000 measurements of pump power and pump speed measured during the initial hospitalization period and12,000 follow-up measurements obtained from 138 consecutive patients implanted with a HMII between January 2009 and December 2012. An early power elevation (PEL) event was defined as power ≥10 W within the first 14 post-operative days. Patients were divided into two groups: those with an early PEL event and those without (NP).Median follow-up duration was 316 (range 2 to 1,264) days. Twenty-seven (20%) patients had early PEL events that lasted for a total duration of 4 (range 1 to 77) hours per patient. Pump speed averaged 9,400 rpm in both groups. Although patients in the PEL group had higher median power (7.1 [6.0 to 9.9] W vs 6.7 [5.7 to 7.8] W, p0.001) in the immediate post-operative period, there was no difference between the two groups noted at first follow-up (6.6 [5.9 to 8.7] W vs 6.7 [5.5 to 7.7] W, p = 0.940). No differences in the prevalence of hemorrhagic stroke (4% vs 3%, p = 0.56), ischemic stroke (0% vs 4%, p = 0.41), hemolysis (7% vs 5%, p = 0.32), pump thrombosis (7% vs 4%, p = 0.21) or survival (76% at 1 year in both groups) were found between the two groups.In this single-center experience, PEL events that occurred early all resolved by discharge. No relationship was found between early PEL events and subsequent development of pump thrombosis, hemorrhagic stroke or ischemic stroke.

Background Preexisting valve pathology is common in patients with end-stage heart failure undergoing left ventricular assist device (LVAD) placement. The indications and subsequent benefits of performing valvular procedures in these patients are unclear. The objective of this study was to determine the impact of performing concurrent surgical valve procedures in a large cohort of patients receiving LVADs. Methods One thousand one hundred six patients received the HeartMate II (HMII) LVAD in the bridge to transplant (n = 470) and destination therapy (n = 636) clinical trials. Of these, 374 patients (34%) had concurrent cardiac surgery procedures as follows: 242 patients (21%) with 281 concurrent valve procedures (VP) (aortic 80, mitral 45, and tricuspid 156), and 641 patients had only HMII LVAD. The focus of this study was to determine the clinical outcomes of patients undergoing HMII + VP compared with those who received HMII alone. Results Patients undergoing HMII + VP were significantly older, had higher blood urea nitrogen levels and central venous pressure, and decreased right ventricular stroke work index; intraoperatively, the median cardiopulmonary bypass times were also longer. The unadjusted 30-day mortality was significantly higher in patients undergoing HMII + VP (10.3% vs 4.8% for LVAD alone, P = .005). Subgroup analysis of individual VPs showed that higher mortality occurred in patients with HMII plus 2 or more VPs (13.5%, P = .04) followed by trends for increased mortality with HMII plus mitral alone (11.5%, P = NS), HMII plus aortic alone (10.9%, P = NS), and HMII plus tricuspid (8.9%, P = NS) procedures. Of these various groups, only patients undergoing HMII + isolated aortic VP ( P = .001) and HMII + multiple VPs ( P = .046) had significantly worse long-term survival compared with patients undergoing HMII alone. Right heart failure and right ventricular assist device use was increased in patients undergoing VPs, but there was no difference in the incidence of bleeding or stroke. Conclusions Patients frequently require concurrent VPs at the time of LVAD placement; these patients are sicker and have higher early mortality. Furthermore, right ventricular dysfunction is increased in these patients. Further studies to develop selection criteria for concurrent valve interventions are important to further improve clinical outcomes.

Purpose The HeartMate 3 (HM3) Left Ventricular Assist System is a fully magnetically levitated, centrifugal, continuous-flow pump. In the MOMENTUM 3 trial, the HM3 apical cuff could be attached with two different Methods Cut then Sew or Sew then Cut. This analysis describes the surgical techniques used in the trial and evaluates their impact on outcomes. Methods 189 patients in the Long Term (LT) cohort were implanted with the HM3 pump. Patients were divided into groups based on the technique used to attach the apical cuff at implant. Survival and adverse events at 2 years of follow-up were compared between the groups. The burden of hemocompatibility related adverse events (HRAE) was evaluated with a previously defined hemocompatibility score (Mehra. Eur Heart J. 2017). Continuous and categorical data were compared with the Wilcoxon rank sum and chi-square tests. The log-rank test was used to compare survival. This analysis will be updated to the 515 patients implanted with HM3 in the Full Cohort, which will be available in March 2019. Results 189 patients were implanted with HM3 by 68 surgeons at 52 centers. The median implant and bypass times were 261 and 83 minutes respectively. The majority of implants used the Cut then Sew apical attachment method (64%), true apical inflow cannula insertion (79%), silicone to skin driveline interface (90%), and right-sided driveline exit (54%). Cut then Sew was associated with longer median bypass times when compared to Sew then Cut (86 vs 77.5 minutes, p = 0.033). In the LT Cohort, there were no significant differences in 2-year survival between the groups (log-rank P=0.16). However, there was a trend for Cut then Sew to have a higher risk of stroke compared to Sew then Cut (Figure). Patients implanted with Cut then Sew vs Sew then Cut were also more likely to have a hemocompatibility score>1 (27% vs 15%, p=0.048). Conclusion We demonstrate that the Cut then Sew method used additional bypass time and may confer a higher stroke risk and HRAE net burden compared to Sew then Cut pump implantation technique.

Purpose Patients with end-stage heart failure eligible for orthotopic heart transplantation (OHT) exceeds the number of available donor organs. With the introduction of curative medications for hepatitis C (HCV), these hearts are now being utilized in an effort to expand organ availability. The safety and feasibility of these organs in OHT has been previously described; however, many of the donor hearts were HCV immune and non-viremic. We seek to describe our experience with patients receiving HCV viremic organs. Methods St. Vincent Hospital in Indianapolis, IN began utilizing HCV hearts for OHT in February 2018. We retrospectively reviewed baseline demographics, laboratory data and outcomes for those undergoing OHT from a viremic donor. Results Basic information and results are reported in Tables 1 and 2. To date, 5 recipients have completed HCV treatment, with the longest duration of follow up currently 8 months. The average seroconversion time of a viremic heart was 7 days. Compared to non-HCV donors during this same timeframe, there was no increase in infection, rejection or number of hospitalizations. Additionally, patients completing antiviral treatment have had a sustained virologic response, with another 2 currently undergoing treatment and the final 3 awaiting insurance approval to initiate treatment. Conclusion In our early experience, we have demonstrated the feasibility of utilizing viremic HCV donor hearts for organ transplantation , thereby increasing the pool of available donors for patients that may not have otherwise received an organ. Further analysis of discordant HCV transplantation's financial impact is currently ongoing.

Influenza remains a frequent cause of hospitalization and death during the winter season. Since early in March of 2018, influenza B has been more frequently reported than influenza A. While the incidence of myocarditis from influenza is rare (from 0-11%), the severity of illness can include

Pump thrombosis is a dreaded complication of long-term implantable ventricular assist devices. No guidance exists regarding the diagnosis and management of this entity despite its significant morbidity. After considerable thought and deliberation, a group of leading investigators in the field of mechanical support propose an algorithm for the diagnosis and management of this vexing entity based on clinical symptoms and serologic and imaging studies.

The concept of neutral money plays a central role in contemporary macroeconomic theory as an implication of the “classical dichotomy” and is also very much a live issue in recent monetary policy discussion revolving around the notion of a “neutral interest rate.” Modern scholars acknowledge that it was Friedrich A. Hayek who was the first economist to employ the term “neutral money” to clearly designate a state of affairs in which money does not exert an active influence on the determination of real variables and whose work in the early 1930’s gave the concept currency among English-speaking economists. The source of Hayek’s conception is usually presumed to be the work of Ludwig von Mises, his acknowledged mentor in monetary and business cycle theory. This paper argues that the basic elements of Hayek’s concept of neutral money were derived from the work of his teacher at the University of Vienna and his formative influence in general economic theory, Friedrich von Wieser and that Mises, following Carl Menger, unequivocally rejected the concept as useless for both theoretical analysis and as a benchmark for formulating a policy standard.

Background The management of traumatic aortic rupture has evolved from emergency surgery for all to incorporating nonoperative and endovascular approaches. In addition, the greater emphasis on restraint systems over the past decade might result in lower immediate mortality. Methods We reviewed our contemporary experience with reference to a previous report from the same institution to determine whether there has been improvement in outcome related to these factors. Results In 1990, a review of 104 patients admitted to our center over a 15-year period (1975-1990) noted an overall mortality of 65%. Forty-two patients died before they could reach the operating room, including 15 who were declared dead on arrival and 27 who died before reaching the operating room. All patients underwent angiography, followed by immediate operation. The mortality rate of those who reached the operating room was 34%, and paralysis-paraplegia occurred in 26% of survivors. A review of 53 patients admitted between January 1, 2000, and April 2005 documented an overall mortality of 26% and a paralysis rate of 4.5% in operative survivors. Only 3 patients died during initial evaluation, 2 who were in arrest on arrival. Eight patients were managed nonoperatively, and 13 were managed by means of deliberate delay before intervention to improve physiologic status. Finally, 19 patients were managed with endografts. Conclusion The improved outcome over the decade since the initial experience reflects both a reduced severity of injury attributable to restraint systems and a more flexible approach to the acute management, which can modify the effect of associated injuries.

Background Heart transplantation is an accepted treatment modality for end-stage heart failure. However, acute cellular rejection (ACR) continues to be a morbid complication. Recently a novel mechanism of inflammatory allograft injury has been characterized which involves overactivation of the nuclear enzyme poly (ADP-ribose) polymerase (PARP). In the present studies, we compared the efficacy of INO-1001, a novel, potent PARP inhibitor, in limiting ACR with and without adjuvant low-dose cyclosporine (CSA). Methods Heterotopic heart transplantation was performed utilizing Brown-Norway strains as donors and Lewis rats as recipients. Groups received daily intraperitoneal injections of: vehicle, low-dose CSA, low-dose INO-1001, high-dose INO-1001, and low-dose CSA combined with high-dose INO-1001. Additional animals were sacrificed on postoperative Day 5 for histologic assessments of allograft inflammation, including immunohistochemistry for nitrotyrosine and poly (ADP-ribose) (the product of PARP) staining. Results PARP inhibition significantly prolonged allograft survival relative to vehicle controls. The combination of low-dose CSA and INO-1001 resulted in a marked increase in allograft survival and significant reductions in allograft rejection scores. This was associated with decreased nitrotyrosine and PAR staining in transplanted cardiac allografts. Conclusions Pharmacologic inhibition of INO-1001 prolongs allograft survival in a dose-dependent fashion in a rodent model of heart transplantation. PARP inhibitors may permit reductions in the dose of CSA needed for adequate immunosuppression after heart transplantation.

In the years immediately prior to the financial crisis, the doctrine of an independent Fed had achieved broad and unquestioned acceptance, especially within the economics profession. Under cover of this doctrine the Fed deployed unconventional monetary policies to vastly expand its balance sheet as well as the range of its activities in financial markets. Recently, this unilateral and arbitrary expansion of the Fed’s powers combined with its failure to stimulate a robust recovery from the Great Recession has provoked increasing opposition even among some economists. In this changing intellectual climate, the time is ripe to implement a short-run program, under the existing regime of the fiat dollar, to terminate the Fed’s anomalous status as a quasi-independent agency and make it directly accountable to Congress like any other department or agency of the Executive Branch.

Background: Extracorporeal photopheresis is an immunomodulatory technique in which a patient's leukocytes are exposed to ultraviolet-A light after pretreatment with 8-methoxypsoralen (methoxsalen). There have been few reports describing the use of extracorporeal photopheresis in lung transplant recipients. Methods: We reviewed our experience using extracorporeal photopheresis in 8 lung transplant recipients since 1992. All 8 patients had progressively decreasing graft function and 7 were in bronchiolitis obliterans syndrome grade 3 before the initiation of photopheresis. One patient had undergone a second transplant operation for obliterative bronchiolitis. Two patients had a pretransplantation diagnosis of chronic obstructive pulmonary disease, 1 α 1 -antitrypsin deficiency, 1 cystic fibrosis, 1 bronchiectasis, 1 idiopathic pulmonary fibrosis, and 2 primary pulmonary hypertension. Before refractory rejection developed, all patients had been treated with 3-drug immunosuppression and anti-T-cell therapy. The median time from transplantation to the start of extracorporeal photopheresis was 16.5 months and the median number of treatments was 6. Results: The condition of 5 of 8 patients subjectively improved after extracorporeal photopheresis therapy. In these 5 patients photopheresis was associated with stabilization of the forced expiratory volume in 1 second. In 2 patients there was histologic reversal of rejection after photopheresis. With a median follow-up of 36 months, 7 patients are alive and well. Three patients required retransplantation at a median of 21 months after completion of the treatments. Four patients have remained in stable condition after photopheresis. There were no complications related to extracorporeal photopheresis. Conclusion: We believe that this treatment is a safe option for patients with refractory lung allograft rejection when increased immunosuppression is contraindicated or ineffective. (J Thorac Cardiovasc Surg 1999;117:1063-9) J Thorac Cardiovasc Surg 1999;117:1063-9

s S153 and cerebral bleeding rates, a newly developed titanium mesh covered inflow cannula introduced since September 2013. Initial clinical results suggested suppression of both stroke and cerebral bleeding rates within at least acute phase after LVAD implantation, when those complications with previous type (smooth surface) inflow cannulas were observed predominantly. Conclusion: The bridge to heart transplant mechanical circulatory support with EVAHEART LVAD achieved long-term survival without pump replacement as well as with relatively low rate of pump pocket infection, right heart failure, GI bleeding, and hemolysis. The suppression of stroke and cerebral bleeding rates with the newly developed inflow cannulas is expected.

The financial crisis and the events leading up to it have sparked a remarkable renewal of interest in Austrian Business Cycle Theory (ABCT). Interest in the theory was reinforced by the fact that a number of economists and financial commentators associated with the modern Austrian school had warned of an emerging housing bubble during the Greenspan era when the conventional wisdom was that the Federal Reserve System had matters well in hand. A number of mainstream macroeconomists, such as Paul Krugman and Brad DeLong, have noted and criticized this resurgence of interest in ABCT on the grounds that it cannot explain the positive correlation of consumption and investment that occurs over the course of the business cycle. In particular they allege that the theory predicts a slump in investment and capital goods’ industries and a corresponding boom in consumer spending and retail sales during the recession. They therefore conclude that ABCT is manifestly in conflict with the stylized facts of the business cycle and should not be seriously entertained. In this paper I respond to these claims in two parts. First I argue that this interpretation grossly misrepresents essential features of the theory and is based on a single secondary source published in the mid-1930s which incorrectly portrayed ABCT as a “monetary overinvestment theory.” I show that this interpretation is manifestly in conflict with the presentation of the theory in the publications of its leading proponents. I then present an alternative version of the theory that is based on the works of Ludwig von Mises, Friedrich A. Hayek and Murray N. Rothbard. I argue that this version does satisfactorily account for the overconsumption boom and subsequent retail slump that were such conspicuous elements of the boom-bust cycle that played out over the past decade.

Life-threatening, recurrent ventricular tachycardia developed in a 54-year-old heart transplant candidate with ischemic cardiomyopathy. The episodes of ventricular tachycardia were refractory to aggressive medical management and implantable cardiac defibrillator placement. A Heartmate left ventricular assist device was implanted, in combination with isolated right coronary artery bypass grafting, which abolished any further episode of ventricular tachycardia. The patient successfully underwent cardiac transplantation 79 days later.

Reducing 30 Day Hospital Readmissions for Patients with Left Ventricular Support Devices R.C. Starling ,1 T.J. Myers,2 R.R. Bostic,2 J.B. O’Connell,2 N.A. Mokadam,3 C.T. Salerno,4 R.L. Kormos.5 1Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH; 2Thoratec Corporation, Pleasanton, CA; 3Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA; 4Heart Transplant and Mechanical Assist Device Program, St. Vincent Heart Center of Indiana, Indianapolis, IN; 5Cardiothoracic Surgery, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA.