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

Cardiovascular magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) has recently been examined in patients after orthotopic heart transplantation (OHT); however, the data is limited to relatively small cohorts [(1–3)][1]. The objective of this study was to examine natural

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

The purpose of this study was to examine prognostic value of T1- and T2-mapping techniques in heart transplant patients.Myocardial characterization using T2 mapping (evaluation of edema/inflammation) and pre- and post-gadolinium contrast T1 mapping (calculation of extracellular volume fraction [ECV] for assessment of interstitial expansion/fibrosis) are emerging modalities that have been investigated in various cardiomyopathies.A total of 99 heart transplant patients underwent the magnetic resonance imaging (MRI) scans including T1- (n = 90) and T2-mapping (n = 79) techniques. Relevant clinical characteristics, MRI parameters including late gadolinium enhancement (LGE), and invasive hemodynamics were collected. Median clinical follow-up duration after the baseline scan was 2.4 to 3.5 years. Clinical outcomes include cardiac events (cardiac death, myocardial infarction, coronary revascularization, and heart failure hospitalization), noncardiac death and noncardiac hospitalization.Overall, the global native T1, postcontrast T1, ECV, and T2 were 1,030 ± 56 ms, 458 ± 84 ms, 27 ± 4% and 50 ± 4 ms, respectively. Top-tercile-range ECV (ECV29%) independently predicted adverse clinical outcomes compared with bottom-tercile-range ECV (ECV 25%) (hazard ratio [HR]: 2.87; 95% confidence interval [CI]: 1.07 to 7.68; p = 0.04) in a multivariable model with left ventricular end-systolic volume and LGE. Higher T2 (T2 ≥50.2 ms) independently predicted adverse clinical outcomes (HR: 3.01; 95% CI: 1.39 to 6.54; p = 0.005) after adjustment for left ventricular ejection fraction, left ventricular end-systolic volume, and LGE. Additionally, higher T2 (T2 ≥50.2 ms) also independently predicted cardiac events (HR: 4.92; CI: 1.60 to 15.14; p = 0.005) in a multivariable model with left ventricular ejection fraction.MRI-derived myocardial ECV and T2 mapping in heart transplant patients were independently associated with cardiac and noncardiac outcomes. Our findings highlight the need for larger prospective studies.

Magnetic resonance tissue phase mapping (TPM) measures three-directional myocardial velocities of the left and right ventricle (LV, RV). This noninvasive technique may supplement endomyocardial biopsy (EMB) in monitoring grafts post-heart transplantation (HTx).To assess biventricular myocardial velocity alterations in grafts and investigate the relationship between velocities and acute cellular rejection (ACR) episodes.Prospective.Twenty-seven patients within 1 year post-HTx (49 ± 13 years, 19 M) and 18 age-matched controls (49 ± 15 years, 12 M).1.5T, 2D balanced steady-state free precession, and TPM.Ventricular function: end-diastolic and end-systolic volumes, stroke volumes, ejection fraction (EF), and myocardial mass. TPM velocities: peak-systolic and peak-diastolic velocities, cardiac twist, and interventricular dyssynchrony. ACR rejection episodes: International Society for Heart and Lung Transplantation grading of EMB specimens.The Lilliefors test for normality, unpaired t-tests, and Wilcoxon rank-sum tests for normally and nonnormally distributed data, respectively, were used, as well as multivariate regression for confounding variables and Pearson's correlation for associations between TPM velocities and global function.Compared to controls, HTx patients demonstrated reduced biventricular systolic longitudinal velocities (LV: 5.2 ± 2.1 vs. 4.0 ± 1.5 cm/s, P 0.05; RV: 4.2 ± 1.3 vs. 3.1 ± 1.2 cm/s, P 0.01). Correlation analysis revealed significant positive relationships for biventricular EF with radial peak velocities of the same ventricle in both systole and diastole (LV systole: r = 0.48, P 0.01; LV diastole: r = 0.28, P 0.05; RV systole: r = 0.35, P 0.01; RV diastole: r = 0.36, P 0.01). Segmentally, longitudinal velocities were impaired in 7/16 LV segments and 5/10 RV segments in systole and 7/10 RV segments in diastole. TPM analysis in studies with4 preceding ACR episodes showed globally reduced RV and LV systolic radial velocity, and segmentally reduced radial and longitudinal systolic velocities.Biventricular global and segmental velocities were reduced in HTx patients. Patients with4 rejection episodes showed reduced myocardial velocities. The TPM sequence may add functional information for monitoring graft dysfunction.2 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:920-929.

Introduction The management of patients with heart failure who contract COVID-19 and those who develop heart failure as a consequence of the disease is challenging. The use of advanced therapies in the form of durable left ventricular assist device or heart transplant in this patient population remains a data free zone. We present, to our knowledge, the first case of durable LVAD implantation in a recovered COVID-19 patient. Case Report A 63-year old, previously healthy, male was admitted to OSH with COVID-19 pneumonia and acute respiratory distress syndrome requiring prolonged mechanical ventilation. This hospitalization was complicated by anterior STEMI, cardiomyopathy with severe LV dysfunction and cardiogenic shock. Due to widespread COVID-19 pandemic, invasive evaluation was deferred and the patient was medically managed. He was then transferred to our institution after re-admission for recurrent cardiogenic shock. Echocardiogram revealed dilated LV cavity (6.3 cm), LVEF 10% and large apical aneurysm. Chest CT showed sequelae of prior COVID-19 with changes suggestive of fibrosis. CMR which showed LV dilatation, severe LV systolic dysfunction, LVEF 7% and large apical aneurysm with evidence of thrombus. A large transmural infarct in the LAD territory without viability was confirmed. Cardiogenic shock was managed with Dobutamine and attempts to wean inotrope resulted in worsening hemodynamic and clinical profile. Axillary IABP was placed to facilitate physical and respiratory rehabilitation. The patient underwent placement of HeartMate™ 3 device as DT and LV aneurysm repair. Post-operative course was uneventful and he was ultimately discharged to acute rehabilitation in stable condition. Summary As the global case rate continues to climb and the threat of an exponential surge of long-term cardiac complications looms in the not so distant future, the use of durable MCS in recovered COVID-19 patients may evolve. This case highlights LVAD as a feasible option in end-stage HF and emphasizes the importance of a multidisciplinary approach in assessing candidacy for advanced HF therapies in post-COVID-19 patients. Continued international collaboration and further study regarding use of MCS will be paramount in optimizing care and outcomes in this growing patient population.

Introduction Comorbidities including pulmonary disease are common in patients undergoing LVAD implantation. The impact of pre-implant pulmonary function on post-implant LVAD outcomes has not been comprehensively explored. In this study, we examined the association between pre-implant pulmonary function on post-implant outcomes. Methods A retrospective review of 415 primary LVAD implants at our center between 2008 and 2019 identified 251 patients with pre-implant pulmonary function tests (PFT), of which 248 had pre-implant chest CT scans. PFT results were classified as obstructive or restrictive and were sub-stratified by severity. Chest CT scan findings were assessed for presence of fibrosis or emphysema. Our primary outcome was 1-year mortality. Secondary outcomes included reintubation, days on mechanical ventilation, post-operative pneumonia, ICU length of stay (LOS), hospital LOS and 30-day mortality. Continuous variables were evaluated using two-sample Student's t-test or Wilcoxon test. Categorical variables were evaluated using χ2 test or Fisher's exact test. The group comparison in outcomes were assessed using logistics regression and linear regression. Results PFTs and chest CT scans were completed at a median of 42 days (IQR 18-127 days) and 26 days (IQR 10-63 days), respectively, prior to LVAD implantation. 84 patients (35%) had obstructive lung disease (52% moderately severe or severe) and 132 patients (55%) had restrictive lung disease (23% moderately severe or severe). Lung diffusing capacity for carbon monoxide (DLCO) was normal in 23% of patients and reduced in others by mild (29%), moderate (41%) or severe (7%) degrees. Presence or severity of either obstructive or restrictive lung disease on PFTs were not associated with primary or secondary outcomes. Severe reduction in DLCO and presence of fibrosis on chest CT scan were both strongly predictive of mortality at 30 days (OR 10.0, CI 1.52-65.63, p Conclusions Pulmonary disease is common in patients undergoing LVAD implantation. The presence and severity of obstructive or restrictive lung disease on pre-implant PFTs were not predictive of post LVAD outcomes. However, a severe reduction of DLCO and pulmonary fibrosis on pre-implant chest CT scan were associated with 30-day and 1-year mortality.

Introduction Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD), however predicting RVF remains challenging. Hypothesis We hypothesized that an analysis of late gadolinium enhancement (LGE) patterns on pre-operative cardiac MRI (cMRI) could identify patients at risk for RVF after LVAD. Methods We analyzed reports for cMRIs performed on patients within one year prior to LVAD at our institution and abstracted LGE patterns using the 17-segment model. Patients were then grouped into clusters by similarities in LGE patterns using an unsupervised machine learning (ML) algorithm of hierarchical agglomerative clustering. Statistical comparison of the resulting clusters was then performed. Results Patients (N=31) were grouped into 3 clusters (Figure) with varying patterns of LGE. Cluster 1 patients (n=16) had no LGE or atypical LGE patterns and were significantly younger (age 42 ± 18) than other clusters (p=0.029). Cluster 2 patients (n=11) had extensive transmural LGE patterns and were more likely to have hypertension (p=0.006) and dyslipidemia (p=0.002) than other groups. Cluster 3 patients (n=4) had some degree of subendocardial LGE but no extensive transmural LGE patterns. No patients in cluster 2 developed RVF after LVAD, while 4 patients (25%) in cluster 1 and 2 patients in cluster 3 (50%) had RVF after LVAD, though the difference between groups did not reach statistical significance due to small number of patients in the cohort overall (p=0.058). Importantly, traditional factors associated with RVF including hemodynamics and echocardiographic/MRI parameters of LV and RV function were not significantly different between clusters. Further, LGE enhancement of the RV myocardium or RV insertion points were not associated with RVF after LVAD. Conclusions Unsupervised ML of LGE patterns on cMRI can identify clusters of patients at risk for RVF. LGE patterns on cMRI may identify patients with non-ischemic (cluster 1) and mixed (cluster 3) etiologies of their heart failure who are at higher risk for developing RVF due to global biventricular myocardial involvement than patients with a truly ischemic etiology of their heart failure (cluster 2). Future research in a larger cohort is needed to confirm this hypothesis. Figure: Dendrogram produced from agglomerative hierarchal clustering of LGE analysis of cardiac MRIs using standardized myocardial segmentation

Background Pulmonary hypertension (PH) is a common in patients with chronic heart failure (HF). For patients who progress to end stage HF and require orthotropic heart transplant (OHT), irreversible PH is a relative contraindication as it may lead to post-operative right HF. The International Society of Heart and Lung Transplant (ISHLT) recommends that transplantation be pursued in patients with a pulmonary vascular resistance (PVR) Methods This was an analysis of OHT recipients captured in the United Network for Organ Sharing (UNOS) transplant registry. We included OHT recipients with a PVR ≤ 3 Woods Units for analysis. The cohort was further categorized by PASP (PASP > 50 mmHg and PASP ≤ 50 mmHg). Primary outcome was survival. We classified survival as short term (0-5 years), Intermediate (6-10 years) and long-term (>15 years). Secondary outcome was graft failure. Baseline characteristics were compared between the two groups using the chi-squared analysis. Unadjusted associations between PASP and patient survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. Results Our study included 62,793 OHT recipients (7,187 PASP>50 mmHg, 55,606 PASP ≤50 mmHg) from 1999-2019. The PASP >50 mmHg group had a mean PASP of 60 ±8 mmHg, were older (50.9 vs 44.9 years, p= Conclusions In this large multicenter study of OHT recipients, patients with PASP>50 mmHg have similar outcomes to patients with lower PASP. OHT should be considered an option for patients with this hemodynamic derangement. Studies into factors that affect long-term outcomes is warranted.

Background Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation is an important source of morbidity and mortality but is difficult to predict. Right atrial (RA) strain by echocardiography is a novel hemodynamic parameter likely indicative of atrial functional capacity and RV diastolic function. Previous studies have suggested that pre-LVAD RV strain may be a predictor of RVF, but no studies have systematically evaluated the association of RA strain with outcomes after LVAD. We hypothesized that pre-LVAD RA strain may improve the ability to predict RVF after LVAD. Methods We evaluated 31 adults who received continuous flow LVAD between 2008-2018. Peak RA and RV strain values were measured by two-dimensional speckle-tracking echocardiography. RA strain was measured during three phases: reservoir phase (end-diastole to onset of ventricular filling), conduit phase (onset of ventricular filling to onset of atrial contraction), and contractile phase (onset of atrial contraction to end-diastole). RVF was defined as need for inotropic support longer than 14 days, inhaled nitric oxide for longer than 48 hours, or unplanned RVAD. Pearson correlation was used to compare RA and RV strain parameters. Logistic regression was performed for the outcome of RVF. Cox-proportional hazards modelling was performed for the outcome of survival free from transplant or device explant/exchange and hazard ratios were calculated per standard deviation change in regressors. Results Four patients (13%) developed RVF. Median time from echo to LVAD was 31 days. Correlation between RV free wall longitudinal strain (FWLS) and RA reservoir (R=-0.45, p=0.01), conduit (R=-0.30, p=0.10), and contractile strain (R=-0.27, p=0.15) was modest at best. None of the RA strain parameters were associated with RVF. Lower RA reservoir strain (HR 2.26, p=0.003) and RA conduit strain (HR 3.63, p=0.004) were associated with decreased survival free from transplant or device explant/exchange, while RA contractile strain was not. Conclusions In this small cohort, RA strain parameters were not associated with early RVF following LVAD implant. However, RA reservoir strain and RA conduit strain were strongly associated with post LVAD long term survival. RA strain parameters may represent a form of RV diastolic dysfunction that impacts long term outcomes more so than early post operative events. The utility of RA strain parameters for predicting outcomes following LVAD implant deserves further investigation and validation in a larger cohort.

Introduction Right heart function impacts outcomes in left ventricular assist devices (LVADs) but a comprehensive exploration of changes in right heart function over time and its effects on outcomes has not been fully elucidated. We sought to characterize changes in right heart function according to hemodynamic, imaging, and laboratory data at multiple time points and evaluate how pre-implant function compares to postoperative function in predicting heart failure (HF) outcomes. We hypothesized that postoperative (pre-discharge) right ventricular (RV) systolic function would be more predictive of HF readmissions compared to preoperative RV function. Methods In this single-center study, we included consecutive patients (n=298) who received primary LVADs between May 2008 and December 2018. Invasive hemodynamics, echocardiography (ECHO), and laboratory data were collected preoperatively, postoperatively, and at 3, 6, and 12 months following LVAD implantation. Post-implant readmission data were also collected up to 12 months post hospital discharge. Results Compared to pre-implant values, significant and persistent improvements in right atrial pressure (RAP), pulmonary artery (PA) pressures, pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistance (PVR), and RAP/PCWP occurred at 3, 6, and 12 months post-implant respectively (figure 1a). On the other hand, PA pulsatility index (PAPi) fluctuated over time and RV stroke work index (RVSWI) decreased over time (figure 1a). In addition, the proportion of patients with moderate-severe/severe RV dilation, tricuspid regurgitation (TR), and RV systolic function reduction eventually decreased on average by 12 months post-implant (figure 1b). Significant improvements in BNP and bilirubin levels occurred (figure 1c). Finally, we found that postoperative (pre-discharge) RV systolic function by ECHO was significantly predictive of readmissions due to HF (p=.03) whereas preoperative RV systolic function was not (p=0.81). Conclusions Right heart function metrics generally improve and persist at various time points post-implant compared to preoperative values. However, normalization of right heart function is rarely achieved, highlighting the need to redefine “normal” in LVAD patients. Additionally, the superior predictive value of postoperative RV function on HF readmissions underscores the importance of re-assessing right heart function post-implant for improved risk stratification.

Background Transposition of the great arteries (TGA) is a common congenital anomaly in which the aorta arises from the morphological systemic right ventricle (SRV), and the pulmonary artery arises from the morphologic left ventricle. With surgical and medical advancements, TGA patients are living longer and as a result failure of the SRV is a common cause of morbidity and mortality. Orthotopic heart transplantation (OHT) has been shown to be a successful strategy for TGA patients that progress to end stage heart failure. Candidacy for OHT is often jeopardized due to allosensitization, pulmonary hypertension, or hemodynamic instability. Little is known about long term outcomes of Left Ventricular Assist Devices (LVAD) in patients with TGA. In this study we present long term outcomes of TGA patients with LVADs. Methods This was a single center retrospective analysis of 309 consecutive patients who underwent LVAD placement from May 2008 to February 2020. Our primary outcome of interest was Post LVAD survival. Secondary outcomes of interest were hospitalizations for gastrointestinal (GI) bleeds, driveline infections (DLI), pump thromboses, acute heart failure, and right ventricular (RV) failure were outcomes of interest. The Cox proportional hazard model was used to estimate the association of TGA and AE-related hospital admissions. The cumulative incidence competing risk method was used for survival analysis. Results From May 2008 - February 2020, 10 patients with TGA underwent LVAD placement. Mean follow up was 1.3 years. TGA patients were younger, Caucasian and more likely to be male. TGA patients had similar likelihood of LVAD mortality (HR 1.35, CI 0.70-2.61, p= 0.37), RV failure (1.8, CI 0.35-10.16, p= 0.46), GI bleeding (OR 1.76, CI .33-9.47, p= 0.51), Heart failure hospitalizations (OR 1.12, CI 0.13-9.84, p= 0.55), DLI (OR 0.63, CI 0.07-5.40, p=0.64) and VAD thrombosis (OR 1.23, CI 0.28-6.68, p=0.69) as non TGA patients. Conclusions In this analysis of TGA patients with end stage heart failure, we report that TGA patients have similar outcomes to non-TGA patients post LVAD. LVAD should be considered a durable option for TGA patients who progress to end stage HF. Further studies with a larger population is warranted to further assess LVAD associated adverse events in this patient population.

Purpose Acute kidney injury (AKI) and chronic kidney disease (CKD) cause morbidity and mortality following heart transplantation (HT). Left ventricular assist devices (LVAD) are often used as a bridge to HT. We sought to determine the incidence and risk factors for developing AKI and CKD following HT in LVAD patients. Methods We examined the ISHLT Transplant Registry for heart alone transplant patients between 2000-15. We compared patients bridged with durable continuous-flow LVAD to those without LVAD bridging. Primary outcomes were AKI (defined as post-HT dialysis prior to discharge) and CKD (defined as creatinine >2.5 mg/dL, chronic dialysis, or renal transplant) within 3 years. Chi-squared and Gray's tests compared incidence rates while accounting for competing risk of death. Multivariable logistic and Cox regression analyses were used. Results There were 21,432 total patients, with 5,038 having LVAD support. LVAD patients had a higher incidence of AKI and CKD at 1 year, but a similar incidence of CKD at 3 years (Table). Multivariable regression analysis showed that non-LVAD patients had OR 0.74 (95% CI 0.63-0.86; p=0.0001) for AKI at discharge and HR 0.90 (95% CI 0.80-1.01; p=0.0635) for CKD at 3 years. Among LVAD patients, certain characteristics were significantly associated with development of AKI and CKD (Fig). Conclusion LVAD patients had higher incidence of AKI at hospital discharge and CKD at 1 year after HT compared to patients without LVAD bridging, but development of CKD was similar by 3 years. Baseline renal function, BMI, ischemic time, and diabetes can identify LVAD patients at risk for post-HT AKI or CKD.

Intracardiac and pulmonary artery (PA) pressures are currently assessed by cardiac catheterization (CC). Tissue phase mapping (TPM) is a cardiac magnetic resonance (CMR) 2D phase contrast technique for 3-directional myocardial velocity calculation. This study aims to verify correlations between LV/

T2-mapping (T2M) by cardiac magnetic resonance (CMR) is a validated diagnostic biomarker in cardiac conditions. In heart transplantation (HTx), T2M has been studied as an adjunct to biopsy in diagnosing cellular rejection. However, no studies explored the prognostic value of T2M. Seventy-nine

The purpose of this study was to evaluate the sensitivity of multiparametric cardiac magnetic resonance imaging (CMR) for the detection of acute cardiac allograft rejection (ACAR).ACAR is currently diagnosed by endomyocardial biopsy, but CMR may be a noninvasive alternative because of its capacity for regional myocardial structure and function characterization.Fifty-eight transplant recipients (mean age 47.0 ± 14.7 years) and 14 control subjects (mean age 47.7 ± 16.7 years) were prospectively recruited from August 2014 to May 2017 and underwent 97 CMR studies (83 transplant recipients, 14 control subjects) for assessment of global left ventricular function and myocardial T2, T1, and extracellular volume fraction (ECV). CMR studies were divided into 4 groups on the basis of biopsy grade: control subjects (n = 14), patients with no ACAR (no history of ACAR; n = 36), patients with past ACAR (history of ACAR; n = 24), and ACAR+ patients (active grade ≥1R ACAR; n = 23).Myocardial T2 was significantly higher in patients with past ACAR compared with those with no ACAR (51.0 ± 3.8 ms vs. 49.2 ± 4.0 ms; p = 0.02) and in patients with no ACAR compared with control subjects (49.2 ± 4.0 ms vs. 45.2 ± 2.3 ms; p 0.01). ACAR+ patients demonstrated increased T2 compared with the no ACAR group (52.4 ± 4.7 ms vs. 49.2 ± 4.0 ms, p 0.01) but not compared with the past ACAR group. In contrast, ECV was significantly elevated in ACAR+ patients compared with transplant recipients without ACAR regardless of history of ACAR (no ACAR: 31.5 ± 3.9% vs. 26.8 ± 3.3% [p 0.01]; past ACAR: 31.5 ± 3.9% vs. 26.8 ± 4.0% [p 0.01]). Receiver operating characteristic curve analysis revealed that a combined model of age at CMR, global T2, and global ECV was predictive of ACAR (area under the curve = 0.84).The combination of CMR-derived myocardial T2 and ECV has potential as a noninvasive tissue biomarker for ACAR. Larger studies during acute ACAR are needed for continued development of multiparametric CMR for transplant recipient surveillance.

We present a 43-year-old woman with a nonischemic cardiomyopathy implanted with a ventricular assist device (VAD) as bridge to transplant due to severe, “fixed” pulmonary hypertension (PH). Within three months of VAD implant, her “fixed” PH had resolved entirely. Nearly two years later, still supported with a VAD because of severe HLA allosensitization, she developed dyspnea and “moderate” aortic insufficiency (AI) by standard criteria. Invasive hemodynamics revealed recurrence of severe PH in the setting of elevated left-sided filling pressures. We concluded the AI was indeed severe and the cause of her symptoms and recurrent PH. Despite her noncalcified aortic valve and small body habitus, after a thorough assessment, including meticulous annular measurements and appropriate valve sizing, she underwent a transcatheter aortic valve replacement (TAVR) with complete resolution of both her AI and recurrent, severe PH. This case highlights, in a single patient, reversal of “fixed” PH with adequate left ventricular unloading, that “moderate” AI by standard criteria is often “severe” and must be considered in a VAD patient with recurrent PH, and the need for meticulous pre-procedural planning for TAVR in patients with VADs, including accurate measurements of the aortic annulus to ensure adequate oversizing of the valve.

Introduction Serum sodium is an important prognostic marker in heart failure patients, with lower values associated with increased risk of mortality. However, prognostic value of serum sodium has not been assessed in left ventricular assist device (LVAD) patients. Hypothesis We hypothesized lower serum sodium is associated with increased risk of mortality in LVAD patients. Methods We retrospectively identified 253 consecutive patients that had LVAD implantation at a single center between 2008-2016. To minimize confounding by peri-operative factors, we evaluated serum sodium at 3 months after implantation and time to all-cause mortality with a univariate Cox proportional hazards analysis. A secondary outcome was time to hospital readmission. Groups were defined as having lower and higher sodium levels relative to the median value. Censoring occurred at death, transplant, or pump exchange. A multivariate Cox proportional hazards analysis included estimated GFR and bicarbonate levels to account for effects of renal dysfunction and acid-base disturbance on sodium levels. Results There were 195 eligible LVAD patients with a sodium value at 3 months. Average age was 53 ± 14 yrs, 77% were male, 26% black. Half (50%) received a Heartmate II device and 50% received a Heartware HVAD. Median serum sodium was 137 mmol/L. Median follow-up was 346 days with 26 deaths (13%). In a univariate analysis, increasing serum sodium at 3 months was associated with a lower risk of all-cause mortality (HR 0.826, p=0.006). Pre-operative sodium levels were not associated with mortality (HR 1.004, p=0.941). Serum sodium at 3 months remained predictive of mortality in a multivariate model with estimated GFR and HCO3 (Table). When stratified by the median, the lower sodium group had a significantly shorter time to all-cause mortality (Figure). Sodium levels at 3 months were not associated with time to readmission. Conclusions Hyponatremia in LVAD patients (sodium

PURPOSE: To use structure-function cardiac MRI in the evaluation of relationships between donor and heart transplantation (HTx) recipient characteristics and changes in cardiac tissue structure and function. HTx candidates and donor hearts are evaluated for donor-recipient matches to improve survival, but the impact of donor and recipient characteristics on changes in myocardial tissue and function in the transplanted heart is not fully understood. MATERIALS AND METHODS: Cardiac MRI at 1.5 T was performed from August 2014 to June 2017 in 58 HTx recipients (mean age, 51.1 years ± 12.6 [standard deviation], 26 female patients) and included T2 mapping (to evaluate edematous and/or inflammatory changes), precontrast and postcontrast T1 mapping (allowing the calculation of extracellular volume fraction [ECV] to estimate interstitial expansion), and tissue phase mapping (allowing the calculation of myocardial velocities and twist). Donor and recipient demographics (age, sex, height, weight, and body mass index [BMI]) and comorbidities (hypertension, diabetes, and smoking history) were evaluated for relationships with cardiac MRI measures. RESULTS: Sex-influenced cardiac MRI measures of myocardial tissue and function are as follows: Female HTx recipients demonstrated increased precontrast T1 (P = .002) and reduced systolic peak long-axis velocities (P = .015). Increased age of the donor heart was associated with elevated T2 (r = 0.32; P < .05) and ECV (r = 0.47; P < .01), indicating increased edema and interstitial expansion, as well as impaired diastolic peak long-axis velocities (r = 0.41; P < .01). Recipient-donor differences in age, weight, and BMI were significantly associated with elevated ECV (r = 0.36–0.48; P < .05). Hypertension in donors resulted in increased ECV (31.0% ± 4.2 vs 26.0% ± 3.3; P = .001). CONCLUSION: Donor and HTx recipient characteristics were significantly associated with cardiac MRI–derived measures of myocardial tissue structure and function. © RSNA, 2019

Introduction Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is a well-studied predictor of adverse clinical outcomes in many cardiac conditions. While the presence of LGE in heart transplant (HTx) patients has been previously demonstrated, these studies were limited by sample size and short follow-up. Therefore, we sought to examine the presence and extent of myocardial LGE at two time points and its association with long-term outcomes following HTx. Hypothesis Myocardial LGE persists over time and portends worse prognosis in HTx patients. Methods This was a single-center, prospective, longitudinal study of HTx patients who underwent CMR imaging at baseline (median of 5.1 years post-HTx; IQR 2.1, 8.0) and follow-up imaging (median of 12 month from baseline scan; IQR 6,22). Quantification of LGE was performed using Circle Cardiovascular Imaging. The primary endpoint was pre-defined as a composite of death, nonfatal myocardial infarction, coronary revascularization and hospitalization. Survival by LGE status (absence/presence) was assessed using Kaplan-Meier-curve. Differences in event-free survival curves between patients with and without LGE were compared using log-rank test. Univariate and multivariate Cox regression analysis was performed to examine the association of myocardial LGE on clinical outcomes adjusted for demographic and clinical characteristics. Results Of the 92 patients enrolled, mean age was 50±16 years, 72% were male, and 80 % had a history of cellular rejection. Median follow-up after the baseline scans was 2.4 years (IQR 1.5, 3.5). LGE was present in 35% (n=32) of patients at baseline and follow-up. Among patients with LGE, the extent of LGE in the baseline and follow-up was 3% (median; IQR 2.3, 6.8) and 3% (median; IQR 2.3, 6.0) of the LV myocardium respectively. All patients with LGE had a non-coronary pattern. No incident or resolution of LGE was observed. Patients with a higher prevalence of baseline LGE were at increased risk of major clinical events (52% vs 25%; p=0.012). Furthermore, the presence of baseline LGE independently predicted adverse clinical events even after adjustment for clinical characteristics in a multivariate model (HR 2.25; 95% CI 1.10, 4.60, p=0.027, FIGURE). Conclusions Presence and extent of myocardial LGE was stable over a median follow-up of 24 months and was independently associated with adverse prognosis in HTx patients.

In the article published in Revista Espanola de Cardiologia, Barge-Caballero et al report on the results of a single-center retrospective observational study to explore the prognostic significance of the mean resting heart rate (HR) at 1 year after heart transplantation and its temporal trend. The authors concluded that elevated resting HR after heart transplantation is a poor prognostic marker, being associated with increased mortality. This topic is of keen interest to the field of heart transplantation particularly as it questions whether HR slowing medications may be of value for patients with sinus tachycardia. The ‘‘resting HR’’ in the intact heart is predominately determined by vagal influence and hence it is slower than the intrinsic HR. The ‘‘intrinsic HR’’ refers to the HR following complete pharmacologic blockade of the cardiac autonomic system; it has been shown to be related to age, physical fitness and probably to the overall state of health of the myocardium. Over the past few decades, several epidemiological studies have shown an association between elevated resting HR in the intact heart and all-cause and cardiovascular mortality in the general population, as well as in groups with various cardiovascular diseases. Also, inference from clinical trials has suggested that the mortality benefit from beta-blocker use in patients with acute myocardial infarction or heart failure is at least in part related to the drug-mediated reduction in the resting HR. More recently, novel pharmacologic intervention with the drug ivabradine has targeted elevated resting HR as a modifiable cardiovascular risk factor with promising results. In heart transplantation, transection of the autonomic fibers during transplant surgery has 2 major outcomes: delayed and blunted HR response to exercise due to sympathetic denervation, and elevated resting HR due to vagal denervation. The ‘‘normal’’ range of resting HR in heart transplant recipients is not clearly defined but generally a value between 90 and 110 beats per minute (bpm) is considered acceptable. The relevant unanswered questions in heart transplantation include: a) is the elevated resting HR an

Background: Current diagnostic criteria for cardiogenic shock (CS) require the use of a pulmonary artery catheter (PAC), which is time-consuming and may cause complications. A set of simple yet accurate noninvasive diagnostic criteria would be of significant utility. Methods: Candidate components for the Noninvasive Parameters for Assessment of Cardiogenic Shock (N-PACS) criteria were required to be objective, readily available, and noninvasive. Variables encompassing hypotension, hypoperfusion, predisposing conditions, and elevated intracardiac filling pressures were optimized versus a PAC-based standard in a retrospective developmental cohort of 122 patients with acute myocardial infarction (AMI). The finalized criteria were validated in a prospective cohort of coronary care unit patients in whom a PAC was placed for clinical indications. Results: According to invasive criteria, CS was present in 32 of 217 consecutive patients undergoing PAC. Compared to the PAC-based standard, the N-PACS criteria had a sensitivity of 96.9% (95% confidence interval (CI) 82.0–99.8), specificity of 90.8% (95% CI 85.5–94.4), positive predictive value of 64.6% (95% CI 49.4–77.4), negative predictive value of 99.4% (95% CI 96.2–100), positive likelihood ratio of 10.5 (95% CI 6.7–16.7), negative likelihood ratio of 0.03 (95% CI 0.00–0.24), and diagnostic odds ratio of 306.4. Results were similar among patients with and without AMI. Conclusion: A simple, echocardiography-based set of noninvasive diagnostic criteria can be used to accurately diagnose CS.

BACKGROUND: Original descriptions of the takotsubo syndrome (TS) included a characteristic left ventricular (LV) contraction pattern, “apical ballooning.” Recently, several reports have associated contraction patterns not strictly conforming to the original description with TS. The specifics of the contraction pattern seem to set TS apart from the much larger population of patients with acute coronary syndrome (ACS) but no obstructive coronary artery disease (OCAD). This study was undertaken to compare patients with midventricular and apical dysfunction with those with other LV contraction patterns. HYPOTHESIS: If TS can present with a variety of patterns of LV dysfunction, then both those with and those without the pattern should have the clinical components previously assigned to the syndrome. METHODS: We studied LV contraction patterns in consecutive ACS patients referred for consideration of emergent or urgent percutaneous coronary intervention. RESULTS: Of the 893 patients evaluated in 2008, we excluded 862 on the basis of OCAD, preexisting LV dysfunction, or an obvious alternative cause of symptoms. The remaining 31 (3.5%) also had no OCAD but manifested an LV contraction abnormality. We compared the 15 patients (1.7%) whose ventriculograms met criteria for TS with the 16 patients (1.8%) whose did not. The most common alternative pattern was global hypokinesis, followed by a variety of segmental contraction abnormalities. Patients with the TS pattern were older and had evidence of greater myocardial injury. More than 85% were women. CONCLUSIONS: The TS pattern identifies a distinct subset of ACS patients with a remarkable predominance of postmenopausal women and is therefore fundamental to the definition of this entity. This distinctive facet of the syndrome is likely to be an important clue to its pathogenesis. We did not encounter patients with other patterns of LV dysfunction that could be thought to represent stress‐induced cardiomyopathy. Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Mitral regurgitation (MR) is important for patients (pts) with prosthetic mitral valves (PMV). Routine cine CMR can assess MR based on regurgitation associated intervoxel dephasing. Diagnostic performance of cine CMR for prosthesis associated MR is unknown. Databases at 9 sites were queried for PMV