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Intra-aortic balloon pump (IABP) utilization has significantly outpaced other Status 2 eligibility criteria for heart transplant. The risk of waitlist mortality of IABP-supported patients relative to other Status 2 listed patients has not been described.We performed a retrospective analysis of all adult patients listed Status 2 for heart transplantation under the current U.S. allocation policy, using data from the United Network for Organ Sharing. Patients listed status 1 and status 3 for high-dose inotropes were included for reference. Mortality and waitlist decompensation were modeled as a function of time-varying status in cause-specific Cox survival models.We identified 3638 Status 2 listings, of whom 1676 (46%) were Status 2 due to IABP. Relative to patients supported with IABP, status 2 patients with ventricular tachycardia/fibrillation [VT/VF] (HR 4.0, p.001), right-or-biventricular assist device configurations (HR 2.3, p = .002), or temporary surgical left ventricular assist devices [LVAD] (HR 2.6, p = .003) had greater risk of waitlist mortality and decompensation. Other Status 2 subgroups had mortality comparable to IABP Status 2. Risk of waitlist mortality and decompensation for IABP Status 2 was similar to Status 3 patients listed for high-dose inotropes (HR 1.2, p = .27) and lower than Status 1 patients (HR 0.7, p = .002).Waitlist mortality varies significantly by Status 2 eligibility criteria and is highest among patients listed for VT/VF, right-or-biVAD configurations, or temporary surgical LVADs. IABP-supported patients were among those with the lowest Status 2 waitlist mortality risk and comparable to Status 3 inotrope-supported patients.

Donor heart scarcity remains the fundamental barrier to increased transplant access. We examined whether 2018 United Network for Organ Sharing (UNOS) policy changes have had an impact on donor heart acceptance rates.We performed an interrupted time series analysis in UNOS to evaluate for abrupt changes in donor heart-acceptance rates associated with the new policy. All adult donor offers were evaluated between 2015 and 2021 (n = 66,654 donors). Donor volumes and transplants increased during this period, but the donor acceptance rate declined significantly from 31% in quarter 3 of 2018 to 26% acceptance in quarter 3 of 2021 (slope change -0.4% per quarter; P0.001). We identified 2 trends associated with this decline: (1) a growing number of donors with high-risk features, and (2) decreased acceptance of donors with certain high-risk features in the new allocation system.Heart transplant volumes have increased in recent years as a result of increased donor volumes, but donor heart acceptance rates began decreasing under the current allocation system. Changes in the donor pool and acceptance patterns for certain donor-risk features may explain this shift and warrant further evaluation to maximize donor heart use.

The mechanisms of coronavirus disease-2019 (COVID-19)-related myocardial injury comprise both direct viral invasion and indirect (hypercoagulability and immune-mediated) cellular injuries. Some patients with COVID-19 cardiac involvement have poor clinical outcomes, with preliminary data suggesting long-term structural and functional changes. These include persistent myocardial fibrosis, edema, and intraventricular thrombi with embolic events, while functionally, the left ventricle is enlarged, with a reduced ejection fraction and new-onset arrhythmias reported in a number of patients. Myocarditis post-COVID-19 vaccination is rare but more common among young male patients. Larger studies, including prospective data from biobanks, will be useful in expanding these early findings and determining their validity.

Background: Biological considerations suggest that renin–angiotensin system inhibitors might influence the severity of COVID-19. We aimed to evaluate whether continuing versus discontinuing renin–angiotensin system inhibitors (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) affects outcomes in patients admitted to hospital with COVID-19. Methods: The REPLACE COVID trial was a prospective, randomised, open-label trial done at 20 large referral hospitals in seven countries worldwide. Eligible participants were aged 18 years and older who were admitted to hospital with COVID-19 and were receiving a renin–angiotensin system inhibitor before admission. Individuals with contraindications to continuation or discontinuation of renin–angiotensin system inhibitor therapy were excluded. Participants were randomly assigned (1:1) to continuation or discontinuation of their renin–angiotensin system inhibitor using permuted block randomisation, with allocation concealed using a secure web-based randomisation system. The primary outcome was a global rank score in which participants were ranked across four hierarchical tiers incorporating time to death, duration of mechanical ventilation, time on renal replacement or vasopressor therapy, and multiorgan dysfunction during the hospitalisation. Primary analyses were done in the intention-to-treat population. The REPLACE COVID trial is registered with ClinicalTrials.gov, NCT04338009. Findings: Between March 31 and Aug 20, 2020, 152 participants were enrolled and randomly assigned to either continue or discontinue renin–angiotensin system inhibitor therapy (continuation group n=75; discontinuation group n=77). Mean age of participants was 62 years (SD 12), 68 (45%) were female, mean body-mass index was 33 kg/m2 (SD 8), and 79 (52%) had diabetes. Compared with discontinuation of renin–angiotensin system inhibitors, continuation had no effect on the global rank score (median rank 73 [IQR 40–110] for continuation vs 81 [38–117] for discontinuation; β-coefficient 8 [95% CI −13 to 29]). There were 16 (21%) of 75 participants in the continuation arm versus 14 (18%) of 77 in the discontinuation arm who required intensive care unit admission or invasive mechanical ventilation, and 11 (15%) of 75 participants in the continuation group versus ten (13%) of 77 in the discontinuation group died. 29 (39%) participants in the continuation group and 28 (36%) participants in the discontinuation group had at least one adverse event (χ2 test of adverse events between treatment groups p=0·77). There was no difference in blood pressure, serum potassium, or creatinine during follow-up across the two groups. Interpretation: Consistent with international society recommendations, renin–angiotensin system inhibitors can be safely continued in patients admitted to hospital with COVID-19. Funding: REPLACE COVID Investigators, REPLACE COVID Trial Social Fundraising Campaign, and FastGrants. Fil: Cohen, Jordana B.. State University of Pennsylvania; Estados Unidos Fil: Hanff, Thomas C.. State University of Pennsylvania; Estados Unidos Fil: William, Preethi. University of Arizona; Estados Unidos Fil: Sweitzer, Nancy. University of Arizona; Estados Unidos Fil: Rosado Santander, Nelson R.. Hospital Nacional Carlos Alberto Seguin Escobedo; Perú Fil: Medina, Carola. Hospital Nacional Edgardo Rebagliati Martins; Perú Fil: Rodriguez-Mori, Juan E. Hospital Nacional Alberto Sabogal Sologuren; Perú Fil: Renna, Nicolas Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina. Universidad Nacional de Cuyo; Argentina Fil: Chang, Tara I.. University of Stanford; Estados Unidos Fil: Corrales Medina, Vicente. Ottawa Hospital Research Institute; Canadá Fil: Andrade Villanueva, Jaime F.. Hospital Civil de Guadalajara; México Fil: Barbagelata, Alejandro. Pontificia Universidad Católica Argentina "Santa María de los Buenos Aires"; Argentina. University of Duke; Estados Unidos Fil: Cristodulo Cortez, Roberto. No especifíca; Fil: Díaz-Cucho, Omar A. Hospital Alberto Leopoldo Barton Thompson; Perú Fil: Spaak, Jonas. Danderyd University Hospital; Suecia Fil: Alfonso, Carlos E.. University of Miami; Estados Unidos Fil: Valdivia Vega, Renzo. Hospital Nacional Edgardo Rebagliati Martins; Perú Fil: Villavicencio Carranza, Mirko. Hospital Nacional Edgardo Rebagliati Martins; Perú Fil: Ayala García, Ricardo J.. Hospital Nacional Edgardo Rebagliati Martins; Perú Fil: Castro Callirgos, Carlos A.. Hospital Nacional Edgardo Rebagliati Martins; Perú Fil: González Hernández, Luz A.. Hospital Civil de Guadalajara; México Fil: Bernales Salas, Eduardo F.. Hospital Nacional Carlos Alberto Seguin Escobedo; Perú Fil: Coacalla Guerra, Johanna C.. Hospital Nacional Carlos Alberto Seguin Escobedo; Perú Fil: Salinas Herrera, Cynthia D.. Hospital Nacional Carlos Alberto Seguin Escobedo; Perú Fil: Nicolosi, Liliana. Hospital Espanol; Argentina Fil: Basconcel, Mauro. Hospital Espanol; Argentina Fil: Byrd, James B.. University of Michigan; Estados Unidos Fil: Sharkoski, Tiffany. University of Pennsylvania; Estados Unidos Fil: Bendezú Huasasquiche, Luis E.. Hospital Alberto Leopoldo Barton Thompson; Perú Fil: Chittams, Jesse. University of Pennsylvania; Estados Unidos Fil: Edmonston, Daniel L.. University of Duke; Estados Unidos Fil: Vasquez, Charles R.. University of Pennsylvania; Estados Unidos Fil: Chirinos, Julio A.. University of Pennsylvania; Estados Unidos

Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Because preimplant hypoalbuminemia is a known risk factor for adverse outcomes, we hypothesized that change in albumin may be a prognostic indicator in patients with continuous-flow left ventricular assist devices (cfLVADs). This is a retrospective single-center study of patients who underwent cfLVAD implantation (HeartMate II and HeartWare HVAD) at an academic center from 2008 to 2014. After excluding those who died, were transplanted, or hospitalized during the first 3 months post-implant, albumin values were obtained and stratified by an increase or a decrease from pre-implant to 3 months post-implant on 171 (81% male, mean age 57 ± 16 years) patients (139 for the survival analysis and 90 for the hospitalization analysis). Decrease in albumin from pre-implant to 3 months after implant correlated with increased mortality (hazard ratio 2.93, confidence interval 1.57 to 5.44, p 0.01) and reduced time to next hospitalization (hazard ratio 1.70, confidence interval 1.03 to 2.81, p = 0.04). The Kaplan-Meier survival curve estimated a 49.43% 2-year survival rate in those whose albumin decreased versus 83.62% in those whose albumin increased over 3 months (p 0.01). Improved outcomes were seen in patients whose albumin normalized versus patients whose albumin remained normal over 3 months. In conclusion, our study is the first to demonstrate the importance of change in albumin from pre- to postimplant on the prognosis of cfLVAD patients. Future studies are needed to determine whether therapeutic intervention to improve albumin post-implant will prevent hospitalizations and improve outcomes.

Purpose Despite significant improvements in survival with continuous flow left ventricular assist devices (LVADs), outflow graft obstruction remains a rare, but serious complication. We report the clinical course and management of patients supported with LVADs who were diagnosed with outflow graft obstruction at a large academic center. Methods We performed a retrospective review of patients receiving LVAD support from January 2012 through September 2020. Patients who developed outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. Results Of 324 patients supported by LVAD at our institution between January 2012 and February 2020, 10 patients (3.2%) were diagnosed with outflow graft obstruction. The most common presentation was low flow alarms, which was present in 8/10 patients. The other two patients had lightheadedness and/or dyspnea. Patients had minimal LDH elevation with 7/10 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/10 of the patients. Three patients were treated with endovascular stent placement, while one received heart transplant, one had an increase in INR goal, and one had an LVAD outflow revision; all of whom are still living. Three patients were treated with supportive care with two expiring away shortly after. The last patient was treated with tPA and also expired. Conclusion Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation and the fact that CTA is not a part of routine standard of care.

Purpose Patients supported by VA-ECMO are prioritized for heart transplantation under the new United States donor allocation system, which is intended to decrease their waitlist mortality. The use of VA-ECMO as a bridge to transplant (BTT) has increased under the new system, which may lead to shifts in the characteristics of the VA-ECMO BTT population. We hypothesize that 1) the rate of waitlist death or delisting for VA-ECMO BTT is lower under the new allocation system and 2) this improvement is mediated by a shorter waitlist duration. Methods Using the United Network for Organ Sharing database, we analyzed all adult patients listed for heart transplant between 1/1/2014 and 6/12/2020 who were on VA-ECMO at listing. Waitlist entry after October 18, 2018 defined the new allocation system. We used Fine-Gray competing risk models to analyze the subdistribution relative hazard (sdRH) of death or delisting while accounting for the competing risk of successful transplant, with adjustment for baseline characteristics. Risk of death may increase with additional waitlist duration, so we compared separate models conditional on survival (without transplant) to days 7 and 14. Results VA-ECMO was present at listing in 238 patients in the old system and 163 in the new system, with comparable baseline characteristics. Under the old system, waitlist death or delisting occurred in 125 patients (53%), with 108 (45%) transplanted and median time to transplant 51 days (IQR 11 to 228). In the new system, death or delisting occurred in 29 patients (18%), with 125 (77%) transplants and median time to transplant 4 days (IQR 2 to 7). The adjusted risk of death or delisting decreased by 73% in the new system (sdRH 0.27, 95%CI 0.17-0.42, P Conclusion For patients bridged to heart transplant with VA-ECMO, the risk of waitlist death or delisting is significantly lower in the new allocation system. This improvement is mediated by a shorter time to transplant.

Sudden cardiac death (SCD) is a common cause of death in the general population, occurring in 300,000 to 350,000 people in the United States alone. Currently, there are no data supporting implantable cardioverter-defibrillator therapy in patients who underwent orthotopic heart transplant (OHT) with low left ventricular ejection fraction (LVEF). In this retrospective study, we included all patients who underwent primary OHT at our institution from 2007 to 2013. We compared the cause of death in patients who underwent OHT and evaluated the correlation of the cause of death and the patients' LVEF. Our objectives were to determine whether patients who underwent OHT with LVEF35% are at increased risk for SCD compared with those who underwent OHT with normal LVEF. To summarize our results, a total of 345 patients were included in our study (mean age 50 ± 14 years, 68% men). The mean follow-up was 1,260 ± 698 days. Forty patients (11.5%) died6 months after OHT. Surviving patients had higher LVEF compared with deceased patients (64 ± 7% and 50 ± 24%, respectively, p ≤0.001). In all, 10 (25%) of the deceased patients died suddenly, 9 (23%) from sepsis, and 8 (20%) from malignancy. Of the 11 deceased patients with LVEF ≤35%, 2 patients (18%) died suddenly compared with 9 SCDs among the 29 deceased patients (31%) with LVEF35% (p = 0.54). In conclusion, patients who underwent OHT who died were more likely to have LVEF35%, and a quarter of the deceased patients who underwent OHT died suddenly. A reduced LVEF was not associated with an increased risk of SCD.

Purpose Obstructive sleep apnea (OSA) is associated with increased all-cause and cardiovascular mortality in the general population and may be associated with decreased exercise capacity on cardiopulmonary exercise testing (CPET). While comorbid OSA is often considered when evaluating patients for heart transplantation, post-transplant outcomes are poorly studied. Methods We conducted a retrospective analysis of 307 heart transplant recipients at a large academic institution with CPET ≤2 years after transplant. Patients with and without comorbid OSA were compared with respect to baseline characteristics and post-transplant exercise performance. Survival was compared with Cox proportional hazards modeling with time-varying exposure to account for patients who developed OSA during follow-up. Analyses were repeated after restricting the case definition to only ≥moderate OSA (apnea hypopnea index ≥15 or physician's qualitative report of sleep study result). Results Of 307 heart transplant recipients, 32 had OSA at baseline with 23 cases ≥moderate. Patients with OSA had higher body mass index (30.5 vs 27.0 kg/m2, p Conclusion Heart transplant recipients with and without OSA have similar peak VO2 and post-transplant survival. Exercise time may be shorter in patients with ≥moderate OSA compared to patients with no or only mild disease. Whether compliance with nocturnal positive airway pressure mitigates these comparable outcomes remains to be explored.

Purpose Intravenous iron repletion in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency has been shown to safely improve functional capacity and quality of life. Despite common use of intravenous (IV) iron repletion in patients with left ventricular assist devices (LVADs) and iron deficiency, there is insufficient evidence regarding outcomes in this patient population. In this study, we quantified safety and efficacy endpoints in patients with LVADs and iron deficiency who were treated as inpatients with IV iron sucrose. Methods We performed a retrospective analysis of patients on LVAD support with iron deficiency who received inpatient IV iron sucrose. Patient data was collected from a single, large academic medical center between 3/2017 and 7/2019. The primary endpoint was change in hemoglobin from baseline to 12 weeks post-infusion. Secondary endpoints were a change in mean corpuscular volume (MCV), ferritin, transferrin saturation, or New York Heart Association (NYHA) class from baseline to 12 weeks post-infusion. Safety endpoints included anaphylaxis, arrhythmias, or infections post-infusion and during admission. Iron deficiency was pre-defined as ferritin Results A total of 54 patients (median age 59, IQR 50-68, 80% male) on LVAD support with iron deficiency received inpatient iron sucrose infusions between 3/2017 and 7/2019. Mean difference in hemoglobin at 12 weeks post-infusion was +2.2 g/dL (9.3 to 11.5 g/dL; p Conclusion Use of IV iron therapy in patients with continuous-flow LVAD is well-tolerated and associated with longitudinal improvements in hemoglobin and functional capacity. This adds to limited data regarding IV iron use in patients supported by LVAD.

Purpose VA-ECMO technology has rapidly progressed over the last twenty years, leading to expanded indications and usage. Historically, patients bridged to transplant (BTT) following VA-ECMO have had higher post-transplant mortality than those bridged on other platforms. Whether the association between VA-ECMO and post-transplant mortality has improved over time with background technological improvements is unknown and potentially confounded by differences in comorbidities of VA-ECMO BTT patients across time. Methods We analyzed all 27,495 adult patients in the United Network for Organ Sharing database who underwent heart transplantation between 6/30/2004 and 12/30/2018, excluding re-transplantation or multiple organ transplantation. We quantified the associated hazard ratio of mortality in the first year in VA-ECMO BTT patients vs. all other transplanted patients. Multivariable Cox proportional hazard models controlling for recipient, donor, and transplant risk factors and models matched on the propensity for VA-ECMO BTT were compared. Hazard ratios were compared across time in 2-year intervals given the historically low annual rate of VA-ECMO BTT. Results VA-ECMO was used as BTT in 176 patients and increased in the percent of cases over time (0.5% in 2004, 1.39% in 2018). Age, gender, and ethnicity were similar in VA-ECMO BTT patients over time. Overall, VA-ECMO BTT was independently associated with increased post-transplant mortality (HR 3.3; 95% CI 2.2, 5.0). While mortality in all transplanted patients decreased after 2010 (HR 0.8; CI 0.72, 0.87), there was no significant interaction between time and the association between VA-ECMO BTT and post-transplant mortality (p=0.49). Similar results were observed with propensity-matched models. Conclusion Though VA-ECMO technology has advanced and overall mortality after heart transplantation has improved in the last decade, improvement in VA-ECMO BTT post-transplant survival has not been observed.

Purpose Patients bridged to heart transplantation (BTT) with VA-ECMO have increased mortality in the first post-transplant year. This has been observed even after robust adjustment for recipient and donor comorbidities, suggesting either residual unmeasured risk or possible exacerbation of risk in the VA-ECMO BTT patient. Human leukocyte antibody (HLA) sensitization is observed more frequently with mechanical circulatory support. We hypothesize an increased risk of mortality in VA-ECMO BTT as a function of HLA sensitization. Methods We analyzed all 27,495 adult patients in the United Network for Organ Sharing database who underwent heart transplantation between 6/30/2004 and 12/30/2018, excluding re-transplantation or multiple organ transplantation. HLA sensitization was assessed by panel reactive antibody (direct or calculated). Odds of early graft failure (within 48 hours) or acute rejection (during the index hospitalization), hazard of all-cause mortality, and cause-specific relative hazard (csRH) of graft failure were modeled with pre-transplant VA-ECMO with and without PRA. Models were adjusted for recipient, donor, and operative risk factors including center and transplant year. Results VA-ECMO was used as BTT in 176 patients (0.64%), who were younger than those without VA-ECMO (mean age 44 vs 53, p 20% (18% vs 12%, p=0.034). After risk adjustment, VA-ECMO patients had more early graft failure (OR 5.6; 95% 2.2, 14.5), shorter time to graft failure (csRH 3.6; 2.1,6.2), and shorter time to mortality (HR 3.5; 2.6, 4.7), but no difference in acute rejection. PRA was independently associated with early graft failure (OR 1.09 per 10%; 1.01, 1.18), acute rejection (1.07; 1.04, 1.09), time to graft failure (1.05; 1.0, 1.09), and time to mortality (1.03; 1.01, 1.06), but did not modify the association between VA-ECMO and mortality (HR 1.1; 0.99, 1.3). Conclusion VA-ECMO as BTT is independently associated with higher odds of early graft failure, shorter time to graft failure, and shorter time to all-cause mortality. HLA sensitization is independently associated with the same outcomes and with acute rejection, but with a small effect size. HLA sensitization did not modify the association of VA-ECMO with outcomes.

Intravenous (IV) iron repletion has shown improvements in quality of life and functional class in patients with heart failure with reduced ejection fraction (HfrEF) and iron deficiency. As a result, patients with left ventricular assist devices (LVADs) routinely receive IV iron repletion. However

A single, 6 mg/kg intraperitoneal injection of reserpine increased floating time during forced swim testing 24h after administration in rats in five experiments. Although such behavioral depression traditionally is attributed to drug-induced depletion of brain monoamines, we examined the potential contribution of adenosine signaling, which is plausibly activated by reserpine treatment and contributes to behavioral depression in other paradigms. Whereas peripheral administration of the highly selective A1 receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine (0.5, 1.0, or 5.0mg/kg i.p.) 15 min before swim testing failed to improve performance in reserpine-treated rats, swim deficits were completely reversed by 7 mg/kg of the nonselective receptor antagonist caffeine. Performance deficits were also reversed by the nonselective A2 antagonist 3,7-dimethylxanthine (0, 0.5, 1.0mg/kg i.p.), and the highly selective A2A receptor antagonist (CSC: 8-(3 chlorostyral)caffeine) (0.01, 0.1, or 1.0mg/kg i.p.) in a dose-dependent manner. The highly selective A2B antagonist alloxazine had no beneficial effect on swim performance at any dose under study (0.1, 1.0, and 5.0mg/kg i.p.).

Introduction Chronotropic incompetence is very common after heart transplant. The extent to which it affects the functional capacity of heart transplant patients is unknown. We hypothesize that a higher heart rate responsiveness would be associated with improved peak oxygen uptake and may have long-term prognostic impact. Methods We performed a retrospective analysis of all patients who underwent heart transplantation and cardiopulmonary exercise testing (CPET) in the first post-transplant year at a single large academic center between the year 2000 and 2011. Peak VO2 and total exercise time were assessed by CPET. Heart rate responsiveness was defined as the difference between peak and resting heart rate during CPET. The association of heart rate responsiveness with peak VO2 and total exercise time was analyzed using multivariable linear regression, and survival analysis was performed via a cox proportional hazard model. Results CPET was performed at our institution in 271 patients during the first year post heart transplantation at a median of 2.3 months. Subjects were 82% male, age 55 (IQR 45-61) at time of CPET. After multivariate adjustment, each ten beat/min increase in heart rate responsiveness was associated with a 0.9 ml/kg/min increase in peak oxygen consumption (p Conclusions Chronotropic incompetence after heart transplant is associated with decreased functional capacity but is not a prognostic indicator of mortality after transplant.

Background Early graft dysfunction after orthotopic heart transplantation is associated with worse survival and functional outcomes. However, the prognostic implication of acute cellular rejection (ACR) early after transplant is less well defined. Here, we analyzed the association between early ACR and post-transplant exercise capacity. Methods We performed a retrospective analysis of all heart transplant patients who underwent cardiopulmonary exercise testing (CPET) within a year of transplant at a single large academic center between 2000 and 2011. Early ACR was defined as cellular grade 2R or 3R histopathology seen on biopsy within 3 months of transplant. Exercise capacity was assessed during CPET by 1) peak VO2 and 2) total exercise time. CPET performed prior to diagnosis of rejection were excluded. The association between early ACR or grade of ACR and exercise parameters was analyzed using linear regression. Results A total of 230 patients (median age 55 [IQR 45-61], 79.6% male) who received a heart transplantation at our institution between 2000 and 2011 underwent CPET during the 1st year. Of these, 12% (n=40) developed early grade 2R rejection and 5% (n=12) developed early grade 3R rejection. No antibody mediated rejection (including hyperacute) was seen in this timeframe among patients who later underwent CPET. Neither peak VO2 (p=0.95) nor total exercise time (p=0.54) were predicted by early ACR of any grade. Conclusions Early cellular rejection does not predict worse exercise capacity in the first year after heart transplant. This inference is limited to patients who are able to undergo CPET.

Purpose Right ventricular (RV) dysfunction is often unmasked or exacerbated during implantation of a left ventricular assist device (LVAD). Prior to LVAD implantation, the effect of anesthesia induction on RV performance is unknown. We assessed for early hemodynamic changes in the RV after induction, prior to initiation of cardiopulmonary bypass (CPB), in the presence or absence of preoperative temporary mechanical circulatory support (tMCS). Methods We prospectively collected hemodynamic measurements in patients undergoing LVAD implantation at a large academic institution between 9/2017 and 9/2018. Preoperative RV hemodynamics were compared to RV hemodynamics post-induction and intubation but prior to CPB, including central venous pressure (CVP), mean pulmonary artery pressure (mPAP), and pulmonary artery pulsatility index (PAPi). Serial hemodynamics and vasoactive inotropic score (VIS) were analyzed over time using random effects models, adjusting for induction agents and use of pre-operative tMCS. Results There were 41 patients included in this analysis, with 4 intubated prior to induction. There was a significant increase in CVP (3.6 mmHg, p intra-aortic balloon pumps were 14 of 17 tMCS cases and had similar reduction in PAPi at all time points (-2.5, p Conclusion RV hemodynamics acutely worsen after anesthesia induction prior to bypass initiation in LVAD recipients. Patients with preoperative tMCS have worse RV hemodynamics at each timepoint but less significant decline over time.