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Objective: Due to severely limited donor heart availability, durable mechanical circulatory support remains the only treatment option for many patients with end-stage heart failure. However, treatment complexity persists due to its univentricular support modality and continuous contact with blood. We investigated the function and safety of reBEAT (AdjuCor GmbH), a novel, minimal invasive mechanical circulatory support device that completely avoids blood contact and provides pulsatile, biventricular support., Methods: For each animal tested, an accurately sized cardiac implant was manufactured from computed tomography scan analyses. The implant consists of a cardiac sleeve with three inflatable cushions, 6 epicardial electrodes and driveline connecting to an electro-pneumatic, extracorporeal portable driver. Continuous epicardial electrocardiogram signal analysis allows for systolic and diastolic synchronization of biventricular mechanical support. In 7 pigs (weight, 50-80 kg), data were analyzed acutely (under beta-blockade, n = 5) and in a 30-day long-term survival model (n = 2). Acquisition of intracardiac pressures and aortic and pulmonary flow data were used to determine left ventricle and right ventricle stroke work and stroke volume, respectively., Results: Each implant was successfully positioned around the ventricles. Automatic algorithm electrocardiogram signal annotations resulted in precise, real-time mechanical support synchronization with each cardiac cycle. Consequently, progressive improvements in cardiac hemodynamic parameters in acute animals were achieved. Long-term survival demonstrated safe device integration, and clear and stable electrocardiogram signal detection over time., Conclusions: The present study demonstrates biventricular cardiac support with reBEAT. Various demonstrated features are essential for realistic translation into the clinical setting, including safe implantation, anatomical fit, safe device-tissue integration, and real-time electrocardiogram synchronized mechanical support, result in effective device function and long-term safety., (Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.)

Background: In recent years, rapid advances in cardiac surgery and changes in attitude towards patients with cognitive disability have led to these patients receiving cardiac transplantation., Method: This is a retrospective report describing the experience of four patients with Down Syndrome who received heart transplantation in a single institution., Results: Anthracycline-induced cardiomyopathy was the most common cause of heart failure in this group (3/4). Two patients were bridged to transplantation, one by using a combination of extra-corporeal membrane oxygenation and biventricular assist device and the other by using a durable implantable left ventricular assist device. All the four patients are alive with the longest surviving patient 17 years after transplantation. Against strong hypothetical predictions, we observed no propensity for the development of post-transplant infections or lymphoproliferative disorders., Conclusion: Down Syndrome should not be the sole contraindication to heart transplantation. The decision for transplantation should be on a case-by-case basis provided adequate social support is in place., (© 2022 Wiley Periodicals LLC.)

Purpose: There are marked gender differences in all etiologies of advanced heart failure. We sought to determine whether there is evidence of gender-specific decision making for transplant assessments, and how gender effects outcomes., Methods: Retrospective analysis of adult heart transplant assessments at a single UK center between April 2015 and March 2020., Results: Females were 32% of referrals (N = 137 females, 285 males), with marked differences between diagnoses - 11% ischemic and 43% of adult congenital. Females were younger, shorter, weighed less, and had lower pulmonary pressures. Females were much less likely to receive a ventricular assist device (13%). Blood type "O" females were relatively more likely compared to males to receive a transplant (45%). Comparing males and females who received a ventricular assist device, both had similar levels of high pulmonary pressures, indicating consistent decision-making based on hemodynamics to implant a device. Overall survival was better for females (in noncongenital patients), and this was due to female patients who were not accepted for transplant or a ventricular assist device being more often "too well for transplant," rather than in males when they were more often "unsuitable.", Conclusions: Marked gender differences exist at all stages of the heart transplant assessment pathway. Appropriate decision-making based on clinical grounds is shown with less transplants in male blood type "O"s and hemodynamic criteria for ventricular assist device implantation in both genders. Further studies are needed to determine if there is a wider community bias in advanced heart failure treatments for females., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Myocarditis can be refractory to medical therapy and require durable mechanical circulatory support (MCS). The characteristics and outcomes of these patients are not known. We identified all patients with clinically-diagnosed or pathology-proven myocarditis who underwent mechanical circulatory support in the International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support registry (2013-2016). The characteristics and outcomes of these patients were compared to those of patients with nonischemic cardiomyopathy (NICM). Out of 14,062 patients in the registry, 180 (1.2%) had myocarditis and 6,602 (46.9%) had NICM. Among patients with myocarditis, duration of heart failure was <1 month in 22%, 1-12 months in 22.6%, and >1 year in 55.4%. Compared with NICM, patients with myocarditis were younger (45 vs. 52 years, P < 0.001) and were more often implanted with Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (30% vs. 15%, P < 0.001). Biventricular mechanical support (biventricular ventricular assist device [BIVAD] or total artificial heart) was implanted more frequently in myocarditis (18% vs. 6.7%, P < 0.001). Overall postimplant survival was not different between myocarditis and NICM (left ventricular assist device: P = 0.27, BIVAD: P = 0.50). The proportion of myocarditis patients that have recovered by 12 months postimplant was significantly higher in myocarditis compared to that of NICM (5% vs. 1.7%, P = 0.0003). Adverse events (bleeding, infection, and neurologic dysfunction) were all lower in the myocarditis than NICM. In conclusion, although myocarditis patients who receive durable MCS are sicker preoperatively with higher needs for biventricular MCS, their overall MCS survival is noninferior to NICM. Patients who received MCS for myocarditis are more likely than NICM to have MCS explanted due to recovery, however, the absolute rates of recovery were low., Competing Interests: Disclosure: J.K.K. serves as the director of the data center for the STS INTERMACS database and received partial salary support from funds paid to the institution. J.C. has received honoraria from Medtronic and Abbot; serves as the vice chair of data studies for IMACS. S.S. has received honorarium from Medtronic as an advisor and proctor. D.G. has received personal fees from Abbot Inc as a Surgical Proctor, Educator, and Consultant. The other authors have no conflicts of interest to report., (Copyright © ASAIO 2021.)

Aims: Continuous-flow left ventricular assist devices (LVADs) as destination therapy (DT) are a recommended treatment by National Institute for Health and Care Excellence England for end-stage heart failure patients ineligible for cardiac transplantation. Despite the fact that DT is frequently used as an LVAD indication across other major European countries and the United States, with consistent improvements in quality-of-life and longevity, National Health Service (NHS) England does not currently fund DT, mainly due to concerns over cost-effectiveness. On the basis of the recently published ENDURANCE Supplemental Trial studying DT patients, we assessed for the first time the cost-effectiveness of DT LVADs compared with medical management (MM) in the NHS England., Methods and Results: We developed a Markov multiple-state economic model using NHS cost data. LVAD survival and adverse event rates were derived from the ENDURANCE Supplemental Trial. MM survival was based on Seattle Heart Failure Model estimates in the absence of contemporary clinical trials for this population. Incremental cost-effectiveness ratios (ICERs) were calculated over a lifetime horizon. A discount rate of 3.5% per year was applied to costs and benefits. Deterministic ICER was £46 207 per quality-adjusted life year (QALY). Costs and utilities were £204 022 and 3.27 QALYs for the LVAD arm vs. £77 790 and 0.54 QALYs for the MM arm. Sensitivity analyses confirmed robustness of the primary analysis., Conclusions: The implantation of the HeartWare™ HVAD™ System in patients ineligible for cardiac transplantation as DT is a cost-effective therapy in the NHS England healthcare system under the end-of-life willingness-to-pay threshold of £50 000/QALY, which applies for VAD patients., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: The paucity of available hearts for transplantation means that more patients remain on durable left ventricular support for longer periods of time. The Registry to Evaluate the HeartWare Left Ventricular Assist System was an investigator-initiated multicenter, prospective, single-arm database established to collect post-Conformité Européene mark clinical information on patients receiving the HeartWare ventricular assist device system as a bridge to transplantation. This registry represents the longest multicenter follow-up of primary left ventricular assist device outcomes., Methods: Data were collected on 254 commercial implants performed between February 2009 and March 2012 from 9 centers in Europe (7) and Australia (2). Patients were followed to device explant, heart transplantation, or death. The outcomes of patients through July/August 2018 were analyzed. Summary statistics were used to describe patient demographics, adverse events, length of support, and outcomes for this extended-term cohort., Results: A total of 122 patients were on support for >2 years, and 34 patients were on support for >5 years. Twenty nine patients are still alive on support (support ranging from 1213 to 3396 days), and 23 of those are on their original HeartWare ventricular assist device system. Kaplan-Meier survival through 7 years was 51%. Through 6 years, freedom from any stroke was 82%, while freedom from severely disabling stroke was 89%., Conclusions: Low rates of heart transplant now require longer periods of left ventricular assist device support in patients. This analysis demonstrates that long-term support using a HeartWare ventricular assist device system offers survival of 51% through 7 years.

Objectives: Left ventricular assist devices are funded in the UK exclusively as a bridge to transplant (BTT). However, patients who potentially could receive a transplant may develop reversible contraindications to transplant. Bridge to candidacy (BTC) has sometimes been controversial, given the uncertain clinical efficacy of BTC and the risk that reimbursement could be denied. We analysed the UK ventricular assist device database to understand how common BTC was and to assess patient survival rates and incidences of transplants., Methods: We identified BTC implants in patients with pulmonary hypertension, chronic kidney disease and obesity using the UK guidelines for heart transplants., Results: A total of 306 of 540 patients had complete data and 157 were identified as BTC (51%). Overall, there was no difference in survival rates between patients designated as BTC and those designated at BTT (71.9 vs 72.9% at 1 year, respectively; P = 0.82). However, the survival rate was lower at all time points in those with an estimated glomerular filtration rate (eGFR) <40 and in patients with a body mass index (BMI) >32 up to 1-year postimplant. There were no significant differences in the incidence of transplant between patients who were BTC and BTT or for any subgroup up to 5 years. However, we noted a diverging trend towards a lower cumulative incidence of transplant for patients with a BMI >32., Conclusions: BTC is common in the UK and appears clinically effective, given that the survival rates and the incidence of transplants were comparable with those for BTT. Patients with a high BMI have a worse survival rate through to 1 year and a trend for a lower incidence of a transplant. Patients with a low eGFR also have a worse survival rate, but a similar proportion received transplants., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: This study aimed to quantify the impact of donor variables on post-heart transplantation mortality and morbidity in recipients with and without a pretransplant left ventricular assist device (LVAD)., Methods: This is a prospective cohort study of the ISHLT Transplant Registry that includes all primary heart transplants in adult recipients (January 2005-June 2013, n = 15 532). All recipients were divided into patients with a durable continuous-flow LVAD (LVAD recipient, n = 3315) and without mechanical support (standard recipient, n = 12 217). Donors were classified as high risk (n = 3751) and low risk (n = 11 781). Transplants were categorized into low-risk donor/standard recipient (n = 9214), high-risk donor/standard recipient (n = 3003), low-risk donor/LVAD recipient (n = 2567) and high-risk donor/LVAD recipient (n = 748). Outcomes prior to discharge, survival at 5 years and freedom from complications were computed for each group., Results: LVAD recipients experienced more episodes of infection, stroke and acute rejection with both low- (P < 0.001, P < 0.001, P < 0.001) and high-risk donors (P < 0.001, P = 0.008, P = 0.028) prior to transplant discharge. Within standard recipients, a higher rate of primary graft failure (P = 0.035), infection (P = 0.001), dialysis (P = 0.012), acute rejection (P = 0.037) and less freedom from cardiac allograft vasculopathy (P < 0.001) and malignancy (P = 0.004) was observed with high-risk donors. Within LVAD recipients, no differences in complications prior to discharge or long-term morbidity were detected between low- and high-risk donors. When compared to standard recipient/low-risk donors, all the 3 remaining categories had an increased probability of death or graft failure within 90 days: LVAD recipient/low-risk donor [hazard ratio (HR) 1.26, confidence interval (CI) 1.05-1.51; P = 0.012], standard recipient/high-risk donor (HR 1.47, CI 1.27-1.71; P < 0.001) and LVAD recipient/high-risk donor (HR 1.72, CI 1.32-2.24; P < 0.001). Between 90 days and 5 years, only standard recipient/high-risk donor had an increased probability of death or graft failure (HR 1.140, CI 1.020-1.274; P = 0.021) when compared to standard recipient/low-risk donor., Conclusions: LVAD recipients, whether with high- or low-risk donors, have worse early (but not late) survival and more early complications than those of standard recipients. We found that adverse donor characteristics are less predictive for determining the outcome of LVAD-bridged recipients than standard recipients., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To study the survival and patient outcome in a population of UK patients supported by an implantable left ventricular assist device (LVAD) as a bridge to heart transplantation., Methods: Data on all adult patients (n=342) who received a HeartMate II or HVAD as a first long-term LVAD between January 2007 and 31 December 2013 were extracted from the UK Ventricular Assist Device (VAD) Database in November 2015. Outcomes analysed include survival on a LVAD, time to urgent listing, heart transplantation and complications including those needing a pump exchange., Results: 112 patients were supported with the Thoratec HeartMate II and 230 were supported with the HeartWare HVAD. Median duration of support was 534 days. During the study period, 81 patients required moving to the UK urgent waiting list for heart transplantation. Of the 342 patients, 85 (24.8%) received a heart transplant, this included 63 on the urgent list. Thirty-day survival was 88.9%, while overall patient survival at 3 years from LVAD implant was 49.6%. 156 patients (46%) died during LVAD support; the most common cause of death on a VAD was a cerebrovascular accident. There was no significant difference between the two devices used in any outcome., Conclusions: In a population of patients with advanced heart failure, who have a very poor prognosis, support with an implantable LVAD allowed a quarter to receive a heart transplant in a 3-year period. Overall survival of the cohort was about 50%. With improvement in technology and in post-LVAD management, it is likely that outcomes will improve further., Competing Interests: Competing interests: ST: Proctor and Investigator for Medtronic (HeartWare); RV: Proctor and Consultant for Abbott (Thoratec), SSh: Proctor and Consultant for Medtronic (HeartWare), AS: Consultant for Medtronic (HeartWare), SSc: Consultant for Abbott (Thoratec)., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

The study objective is to quantify the impact of donor and recipient variables on heart transplant survival in recipients with a significant proportion of implanted continuous-flow left ventricular assist devices (LVADs). This is a prospective cohort study of International Society for Heart and Lung Transplantation (ISHLT) Registry that includes all primary heart-alone transplants in adult recipients (January 2005 and June 2013, N = 15 532, 27% LVADs). Donor and recipient characteristics were assessed for association with death or graft failure within 90 days and between 90 days and 5 years after transplantation. On Cox proportional hazard model donor cause of death other than head trauma (hazard ratio [HR] 1.985, P < 0.0001), recipient congenital (HR 2.7555, P < 0.0001) and ischemic (HR 1.165, P = 0.0383) vs dilated etiology and female donor heart transplanted into male recipient (HR 1.207, P = 0.0354) were predictors of death or graft failure within 90 days. Between 90 days and 5 years, donor cigarette use (HR 1.232, P = 0.0001), recipient cigarette use (HR 1.193, P = 0.0003), diabetes (HR 1.159, P = 0.0050), arterial hypertension (HR 1.129, P = 0.0115), and ischemic vs dilative cardiomyopathy had an increased probability of death or graft failure., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Left ventricular assist devices (LVADs) have been used as an effective therapeutic option in patients with advanced heart failure, either as a bridge to transplantation, as destination therapy, or in some patients, as a bridge to recovery., Objectives: This study evaluated whether patients undergoing an LVAD bridge-to-recovery protocol can achieve cardiac and physical functional capacities equivalent to those of healthy controls., Methods: Fifty-eight male patients-18 implanted with a continuous-flow LVAD, 16 patients with LVAD explanted (recovered patients), and 24 heart transplant candidates (HTx)-and 97 healthy controls performed a maximal graded cardiopulmonary exercise test with continuous measurements of respiratory gas exchange and noninvasive (rebreathing) hemodynamic data. Cardiac function was represented by peak exercise cardiac power output (mean arterial blood pressure × cardiac output) and functional capacity by peak exercise O 2 consumption., Results: All patients demonstrated a significant exertional effort as demonstrated with the mean peak exercise respiratory exchange ratio >1.10. Peak exercise cardiac power output was significantly higher in healthy controls and explanted LVAD patients compared with other patients (healthy 5.35 ± 0.95 W; explanted 3.45 ± 0.72 W; LVAD implanted 2.37 ± 0.68 W; and HTx 1.31 ± 0.31 W; p < 0.05), as was peak O 2 consumption (healthy 36.4 ± 10.3 ml/kg/min; explanted 29.8 ± 5.9 ml/kg/min; implanted 20.5 ± 4.3 ml/kg/min; and HTx 12.0 ± 2.2 ml/kg/min; p < 0.05). In the LVAD explanted group, 38% of the patients achieved peak cardiac power output and 69% achieved peak O 2 consumption within the ranges of healthy controls., Conclusions: The authors have shown that a substantial number of patients who recovered sufficiently to allow explantation of their LVAD can even achieve cardiac and physical functional capacities nearly equivalent to those of healthy controls., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Third-generation ventricular assist devices (VADs) are associated with improved outcomes, though in recent clinical trials bridge-to-transplant (BTT) rates are ∼30% at 6 months, so that transplantation can be used as a 'bail out' for serious complications. In the UK, there was a significant reduction in heart transplantation rates over the last decade, so that transplantation from VADs is much less frequent. The objective of this study was to determine outcomes and their predictors in this situation of low BTT rates, and as patients were exposed to long-term support, the incidence and outcomes of VAD thrombosis., Methods: We analysed outcomes for 102 consecutive patients between 2009 and 2013 (mean age 47 ± 13; VentrAssist n = 6 and HeartWare n = 96). The median duration of support was 462 ± 426 days., Results: Survival rates on the device were 75 and 66% at 1 and 2 years, respectively. Older age and more acute INTERMACS groups were significantly related to reduced survival within the first 90 days (P = 0.030 and 0.010, respectively). Poor preoperative right ventricular (RV) function had a negative effect on survival after 1 year (P = 0.009), though not earlier. VAD thrombosis (n = 24 HeartWare and n = 1 VentrAssist) occurred at 0.18 events per patient-year for HeartWare and 0.07 for VentrAssist devices at a median time of onset at 404 ± 281 days. There was no significant effect of VAD thrombosis on survival. Only 14 of 102 patients were transplanted at a median of 334 ± 347 days, and only 3 were transplanted within the first 6 months., Conclusions: Third-generation left ventricular assist device implants with a low rate of transplantation have similar survival to destination therapy, and are susceptible to long-term complications of VAD thrombosis and right heart failure., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

The present study defined the short- and long-term effects of left ventricular assist device (LVAD) implantation and heart transplantation (HT) on physical activity and quality of life (QoL). Forty patients (LVAD, n = 14; HT, n = 12; and heart failure [HF], n = 14) and 14 matched healthy subjects were assessed for physical activity, energy expenditure, and QoL. The LVAD and HT groups were assessed postoperatively at 4 to 6 weeks (baseline) and 3, 6, and 12 months. At baseline, LVAD, HT, and HF patients demonstrated low physical activity, reaching only 15%, 28%, and 51% of that of healthy subjects (1,603 ± 302 vs 3,036 ± 439 vs 5,490 ± 1,058 vs 10,756 ± 568 steps/day, respectively, p <0.01). This was associated with reduced energy expenditure and increased sedentary time (p <0.01). Baseline QoL was not different among LVAD, HT, and HF groups (p = 0.44). LVAD implantation and HT significantly increased daily physical activity by 60% and 52%, respectively, from baseline to 3 months (p <0.05), but the level of activity remained unchanged at 3, 6, and 12 months. The QoL improved from baseline to 3 months in LVAD implantation and HT groups (p <0.01) but remained unchanged afterward. At any time point, HT demonstrated higher activity level than LVAD implantation (p <0.05), and this was associated with better QoL. In contrast, physical activity and QoL decreased at 12 months in patients with HF (p <0.05). In conclusion, patients in LVAD and HT patients demonstrate improved physical activity and QoL within the first 3 months after surgery, but physical activity and QoL remain unchanged afterward and well below that of healthy subjects. Strategies targeting low levels of physical activity should now be explored to improve recovery of these patients., (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

Heart transplantation has become a routine procedure. Surgical techniques have been standardized and triple-drug immunosuppression has proven to be the most effective posttransplantation medical treatment. A shortage of donor organs has remained the major factor inhibiting extensive application of heart transplantation. Improved techniques of organ protection may eventually contribute to an extension of the donor pool. However, it seems to be more important to develop alternative procedures further (artificial heart, xenotransplantation, extended use of conservative surgical or medical treatment). The patient population undergoing heart transplantation will undoubtedly include more older, severely ill, polymorbid patients who are not suitable for alternative procedures. Pediatric heart transplantation may increase in the coming years and mechanical circulatory support will surely gain in importance for both adult and pediatric patients awaiting heart transplantation.

Purpose Temporary mechanical Right Ventricle(RV) support around planned LVAD implantation has always carried a substantial risk of mortality and morbidity. Historically insertion and removal of RVAD have been highly invasive. We use a less invasive variation of RV support concomitant with LVAD implantation. Methods Retrospective review of patient records who underwent temporary RVAD insertion along with LVAD insertion. The inflow cannula is an 8mm vascular graft on to the main pulmonary artery which is brought out through the second intercostal space and tunneled again under the skin for 10cm before the cannula exits. The drainage cannula could be in the neck or groin. A 25 Fr. cannula is inserted into the Right Internal Jugular Vein or the stump of the Saphenous Vein. When the RV has recovered, under the local anaesthesia the vascular graft is tied and the venous cannula is removed respectively. Results Over the past 3 years, 71 patients have undergone LVAD insertion (HVAD, Heartware II) at our institute; out of whom 14 (19.7%) required temporary RVAD support. The majority of these patients were male (78.5%) with a mean age of 49.7±12.2 years. 42.8 % of the patients had ischaemic cardiomyopathy, 35.7% had dilated cardiomyopathy and 21.4% had viral myocarditis. Most of the patients had deranged RV parameters preoperatively. Temporary RVAD support was instituted if the patient could not be weaned off Cardiopulmonary Bypass or had poor LVAD flows despite optimal inotropic support. The neck venous cannulation allowed for early patient mobilisation while still on the RVAD. The average duration of RVAD support was around 8.7±4.4 days. It is our standard practice to extubate patients while on RVAD, aggressively remove fluid either with Continuous Veno-Venous Haemofilteration or diuresis and inotropic support with a combination of Milrinone, Adrenaline and Levosimendan. We were able to successfully wean off, all our 14 patients from RVAD. Our long term follow-up reveals that 11 out of 14 patients (78.5%) are still alive and healthy. Two of these patients have already had their heart transplanted and the rest are enlisted for heart transplantation. We unfortunately lost 3 of the 14 patients - one each to VAD thrombosis, VAD related infection and multiorgan failure Conclusion Experience with this technique is highly encouraging and we plan to undertake a prospective study to validate this. [ABSTRACT FROM AUTHOR]

Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) post atrial switch for transposition of the great arteries (TGA) and congenitally corrected TGA (ccTGA) has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. The hemodynamic impact of severe tricuspid regurgitation (TR), potential role of systemic tricuspid valve replacement (TVR) and long-term outcomes are still unknown. The purpose of this study is to describe our experience of VAD in SRVF and our move towards concomitant TVR. Single-centre retrospective study of consecutive adult patients receiving HeartWare-VAD for SRVF between 2010 and 2020. From 2017, concomitant TVR was performed routinely. Demographic, clinical variables and echocardiographic and haemodynamic measurements pre and post VAD implantation were recorded. Complications on support, heart transplantation and survival rates were described. 24 patients underwent VAD implantation. Moderate or severe systemic TR was present in 83% of patients, and subpulmonic left ventricular (LV) impairment in 79%. One and two-year survival rates were 75% and 60% respectively. VAD implantation was technically feasible and successful in all but one. Post VAD, TPG fell from 16 (15-20) to 10 (7-13) mmHg; p=0.002. Patients with TVR (n=12) also demonstrated reduction in pulmonary and atrial pressures (figure). Subpulmonic LV end-diastolic dimension (50 vs 42mm; p=0.05) and systolic function improved in this group. On the other hand a high prevalence of subpulmonic LV failure was noted in the non TVR group (50% vs 8.3%; p=0.03) resulting in higher mortality. After six months on support, 63% of patients were suitable for transplantation. VAD implantation for patients with SRVF in TGA or ccTGA is feasible, and significantly reduces the TPG to transplantable limits. Concomitant TVR at the time of implant associates better haemodynamic and echocardiographic results. [ABSTRACT FROM AUTHOR]

Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) in transposition of the great arteries (TGA) patients has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. Tricuspid valve replacement (TVR) at the time of implant to address severe tricuspid regurgitation (TR) may be beneficial to achieve optimal unloading of the systemic right ventricle (SRV). We report successful decommissioning of a SRV VAD following device thrombosis in a patient who underwent TVR at VAD implant. A 37-year-old man who underwent a Mustard procedure for TGA at 10 months of age presented with acute heart failure, triggered by leg cellulitis and pulmonary embolism. He was found to have a severely impaired SRV, severe TR and a dilated and moderately impaired subpulmonic left ventricle (LV). Despite medical management and anticoagulation, he worsened requiring admission to the ICU for inotropic support. A right heart catheter (RHC) showed a mean pulmonary artery (PA) pressure of 48 mmHg and TPG of 15 mmHg, therefore ineligible for heart transplant. He underwent successful HeartWare-VAD implantation into his failing SRV with concomitant systemic TVR. His post-operative course was uneventful and he was discharged after 25 days. After six months, his TPG came down to 4 mmHg and he was listed for heart transplantation. He remained stable and free from VAD complications until he presented with thrombosis of the outflow graft after 27 months. Anticoagulation with bivalirudin was started without success and persistent reduced VAD flow of < 1 lpm. The patient remained asymptomatic throughout and underwent a decommissioning study. A RHC at minimum speed showed a mean PA pressure of 15 mmHg with TPG of 6 mmHg and cardiac index of 3.8 l/min/m2. An echocardiogram showed ongoing impairment of the SRV but a normally functioning TVR and normal size and function of the subpulmonic LV. Although no signs of SRV recovery, the patient was decommissioned and his driveline was removed without complications. He is now 3 months after decommissioning, functioning in NYHA class I without signs of congestion or low output. VAD implantation is a feasible strategy for those with SRVF. Concomitant TVR to address severe TR may have additional benefit and in this particular case, likely to have contributed to successful VAD decommissioning following device thrombosis. [ABSTRACT FROM AUTHOR]

Systemic right ventricular failure and significant systemic tricuspid regurgitation (TR) are common late complications in ccTGA and after atrial switch for TGA. VADs in the failing systemic right ventricle (SRV) have been used as bridge to transplant or candidacy. However, the impact of residual significant TR has not been established. The purpose of this study is to describe outcomes and hemodynamic changes of concomitant tricuspid valve replacement (TVR) at VAD implant. Retrospective analysis of all adult patients who received an HVAD for SRV failure from 2010 to 2018 in our centre. Clinical characteristics, echocardiographic and right heart catheter studies performed before and at 6 months post VAD were analyzed and compared between those with concomitant TVR and those with significant residual TR. A total of 18 patients (15 atrial switch, 3 ccTGA) underwent VAD implant. At least 15 patients had moderate TR, of whom 12 had significant subpulmonic left ventricular (SLV) impairment. TVR was performed at time of VAD in 6 patients. Patients with TVR showed significant reduction of SLV end-diastolic diameter after 6 months (44.3 vs 39.6mm; p=0.03), improvement of systolic LV function and significant reduction of pulmonary pressures compared to those with residual TR (figure 1). In those without concomitant TVR, there were 5 deaths, 2 related to SLV failure after 13 and 58 months, the other 4 patients were transplanted at a median length on support of 2353.5 days. There was 1 death in the TVR group after 10 months related to therapy non-compliance, the other 5 patients are in NYHA class I-II and listed for heart transplant (median length on support of 479 days). TVR at the time of VAD implant in patients with SRV failure and TR is associated with a significant reduction of intracardiac pressures and improved LV dimension at 6 months post VAD. Whether or not concomitant TVR will prevent late SLV failure is to be determined. [ABSTRACT FROM AUTHOR]

To determine parameters of exercise intolerance in a group of patients with HeartWare Ventricular Assist Device(HVAD) compared to a group of heart failure(HF)patients This was a single-centre parallel prospective group-study.Echocardiograms,right heart catheterisation(RHC) and cardiopulmonary exercise tests were performed in 42patients admitted for a heart transplant assessment between August2017 and October2018:20 belonged to the HVAD group and 22 to the HF group HVADpatients had a better exercise capacity than HFpatients, although no significant differences were noted(14.0±5.0ml/kg/min vs 11.3±3.9ml/kg/min, p=0.06).To determine exercise tolerance,both HVAD and HFgroups were subdivided into 2 groups based on the median peakVO2.The table shows the comparison between preserved and non-preserved exercise tolerance in HF and HVADpatients. In the HVAD group,all resting RHC pressures were significantly lower in the preserved exercise capacity group.However,in HFpatients there were no statistically significant differences between both subgroups in right-sided pressures,but Thermodilution exercise-induced change in cardiac output(ΔCO) and cardiac index(ΔCI) was significantly higher in the patients with preserved exercise tolerance.In the HVADgroup the right ventricle was significantly larger in the reduced exercise tolerance subgroup.Patients with lower peakVO2 had more significant tricuspid regurgitation.Nevertheless,in HFpatients none of the echocardiographic parameters were related to the exercise capacity Right-sided parameters in the echocardiogram and RHC pressures discriminate between preserved and non-preserved exercise capacity in HVADpatients,but not in HFpatients.In these last patients only ΔCO and ΔCI were statistically correlated with peak exercise oxygen consumption. [ABSTRACT FROM AUTHOR]