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PURPOSE To evaluate the effect of the new heart transplant (HT) allocation system in left ventricular assist device (LVAD) supported patients listed as bridge to transplantation (BTT). METHODS Adult patients who were listed for HT between October 18, 2016 and October 17, 2019, and were supported with an LVAD, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or transplanted before or after October 18, 2018, respectively. RESULTS A total of 3261 LVAD patients were listed for transplant. Of these, 2257 were classified in the old and 1004 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status at 360-days after listing was lower in the new system (4% vs. 7%, P = .011). LVAD Patients listed in the new system had a lower frequency of transplantation within 360-days of listing (52% vs. 61%, P

Del Nido cardioplegia offers equivalent myocardial protection and clinical outcomes to blood cardioplegia in adult isolated CABG and valve patients, but the safety and efficacy of del Nido in complex cases with prolonged aortic cross-clamp times is still unknown. 443 patients at our center underwent replacement of the ascending aorta using either del Nido (n = 182) or blood (n = 261) cardioplegia. Two surgeons used del Nido exclusively and 6 used blood exclusively over the study period. Propensity matching of preoperative characteristics yielded 172 well matched pairs. Emergency and reoperative cases were included. Clinical data were extracted from our local database. Troponin levels were drawn at 12 hours postop in all patients. Rates of perioperative mortality (4.7% vs 5.2%), stroke (5.8% vs 7.0%), renal failure (11.6% vs 12.2%), atrial fibrillation (36.0% vs 31.4%), intra-aortic balloon pump insertion (2.3% vs1.2%), and extra corporeal membrane oxygenation use (4.7% vs 4.1%) did not differ between blood and del Nido groups. Postop Troponin T levels were 0.50[0.35, 0.86] ng/mL and 0.40[0.20, 0.70] ng/mL for blood and del Nido, respectively (P0.0001). Postop echocardiography was available in 333 of 344 (96.8%) patients, and there was no difference in change in EF from pre- to postop between blood 0.0[-6.0, 5.0]% and del Nido 0.0 [-6.0, 3.5]% (P = 0.201). Subgroup analysis of patients with aortic cross-clamp time greater than 180 minutes (blood = 77, del Nido = 27) revealed no difference in troponins, ejection fraction, or clinical outcomes. Five-year survival was 85.9[76.8, 91.7]% and 79.8[71.2, 86.1]% for blood and del Nido, respectively (P = 0.151). In ascending aortic surgery with prolonged operative times, no differences were observed in myocardial protection or clinical outcomes with the use of del Nido cardioplegia compared to blood cardioplegia.

Historically, adult congenital patients have longer waitlist time and worse outcomes on the heart transplant waitlist as well as poorer early post-transplant survival. A new heart transplantation allocation system was implemented in the United States on October 18, 2018. The effect of the new allocation system on adult congenital patients is unknown. Adult congenital patients listed for transplantation between November 1, 2015 and September 30, 2019 registered in the United Network for Organ Sharing were included in the study. October 18, 2018 was used as the limit to distribute listed and transplanted patients into old and new groups. A total of 399 patients were listed for heart transplant only, 284 in the old system and 115 in the new system. Clinical characteristics were similar between both groups. The cumulative incidence of poor outcome on the transplant list was similar in both groups (P = .23), but the cumulative incidence of transplant was higher in the new system group (P

Historically, patients bridged on extracorporeal membrane oxygenation (ECMO) to heart transplantation (HT) have very high post-transplant mortality. In the new heart transplant allocation system, ECMO-supported patients have the highest priority for HT. However, data are lacking on the outcomes of these critically ill patients. We compared the waitlist and post-transplant outcomes of ECMO-supported patients in the new and old allocation systems.Adult patients supported by ECMO at the time of listing or transplantation who were registered in the United Network for Organ Sharing database between November 1, 2015 and September 30, 2019 were included. Clinical characteristics, outcomes in the waitlist, and post-transplant survival were compared between the old and new systems. Cox Proportional and subdistribution hazard regression models were used to evaluate the variables contributing to the post-transplant and waitlist outcomes RESULTS: A total of 296 ECMO-supported patients were listed for HT. Of these, 191 were distributed to the old system, and 105 were distributed to the new system. Patients listed in the new system had a higher cumulative incidence of HT (p0.001) and lower incidence of death or removal (p = 0.001) from the transplant list than patients listed in the old system. The 6-month survival after transplantation was 74.6% and 90.6% for the old- and new-era patients, respectively (p = 0.002). Among ECMO-supported patients, being listed or transplanted on the new system was independently associated with improved outcomes in the waitlist and after transplantation.With the implementation of the new heart transplant allocation system, ECMO-supported patients have a shorter waitlist time, improved frequency of HT, and improved short-term post-transplant survival.

Historically, patients with restrictive (RCM) and hypertrophic cardiomyopathy (HCM) experienced longer wait-times for heart transplant (HT) and increased waitlist mortality. Recently, a new HT allocation system was implemented in the United States. We sought to determine the impact of the new HT system on RCM/HCM patients. Adult patients with RCM/HCM listed for HT between November 2015 and September 2019 were identified from the UNOS database. Patients were stratified into two groups: old system and new system. We identified 872 patients who met inclusion criteria. Of these, 608 and 264 were classified in the old and new system groups, respectively. The time in the waitlist was shorter (25 vs. 54 days, P

Background: Limited data are available regarding the outcomes of patients supported by extracorporeal membrane oxygenation (ECMO) who undergo durable mechanical circulatory support implantation (dMCS). We analyzed the clinical characteristics, outcomes, and risk factors for mortality in patients who were bridged with ECMO to dMCS. Methods: Adult patients who received dMCS between January 2008 and December 2017 (n=19 824), registered in the Society of Thoracic Surgeons-Interagency Registry for Mechanical Assisted Circulatory Support (STS-INTERMACS) database were included. Baseline characteristics, outcomes, risk factors, and adverse events were compared between ECMO-supported patients (n=933) and INTERMACS profile 1 (IP-1) patients not supported by ECMO (n=2362). A propensity match analysis was performed. Results: ECMO patients had inferior survival at 12 months (66.1%) than non-ECMO patients (75.4%; P P =0.49). A multiphase parametric hazard model identified 2 different periods based on risk of death. ECMO patients had a high hazard for death in the first 6 months after implantation (hazard ratio, 2.18 [1.79–2.66]; P P Conclusions: ECMO-supported patients before dMCS have lower survival compared with other IP-1 patients. A multivariable analysis showed that ECMO is an independent risk factor of poor outcome after dMCS. However, a propensity matched analysis suggested that when important clinical variables are controlled the outcome of both groups is similar. These data support the implantation of dMCS in carefully selected ECMO patients.

Purpose Highly sensitized recipients remain a challenge in lung transplantation. There are no standardized protocols among lung transplant centers to guide management of these patients. Some centers choose not to transplant highly sensitized patients due to the risk of graft dysfunction and death. We describe our center's experience and outcomes managing lung transplant recipients with positive flow-cytometric prospective cross matches (FXM). Methods We retrospectively analyzed patients who underwent lung transplantation with positive FXM from August 2015 to November 2019. Outcomes included overall length of stay, 1-year survival, graft function at one year, and incidence of antibody mediated rejection (AMR) and CLAD (BOS). Results There were 11 patients with FXM (6 females, 5 males; 6 with restrictive lung disease, 3 with obstructive lung disease, 1 with cystic fibrosis, and 1 with pulmonary vascular disease). 7 (63%) had concomitant positive virtual cross matches. 10 (91%) were managed with high-dose IVIg alone immediately post-op. 3 patients additionally received intra and/or post-op plasma exchange, rituximab and/or bortezimab. Median length of hospital stay was 50 days. Median length of follow up is 30 months (range 11-63 months). KM estimate of one-year survival was 90%. Clinical episodes of AMR requiring treatment occurred in 1 (9%) patient at 3 years post-transplant. DSA cleared in 8 patients (73%). Infections occurred in 5 patients (45%). None were life threatening. CLAD grade ≥ 1 occurred in only 2 patients (18%), one at 1.5 years and the other 3 years post-transplant. FEV1 at one year was >89% of personal best in all patients. Conclusion Successful lung transplantation of highly sensitized recipients is feasible. Using our center's approach results in longer hospital stay but excellent one-year outcomes. Further study is needed to identify patients at risk for graft dysfunction and death due to AMR who benefit from early aggressive treatment, and to avoid unnecessary treatment in lower risk patients.

Purpose To evaluate the effect of the new heart transplant allocation system on LVAD supported patients listed as bridge to transplantation (BTT). Methods Adult patients, who were listed for heart transplant between October 1,2016 and September 30, 2019, and were supported with an LVAD, enrolled in the UNOS database were enrolled in this study. Patients were classified according in the old or new system if they were listed or transplanted before or after October 18, 2018. Results A total of 2184 LVAD patients were listed for transplant. Of these, 1229 were classified in the old and 955 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status, 1 year after listing, was lower in the new system (5% vs. 9%, p Conclusion With the implementation of the new HT allocation system, LVAD-BTT patients have a lower frequency of transplantation and similar short-term post-transplant survival. LVAD-BTT patients are more likely to receive Hep C (+) donor hearts.

Purpose To evaluate the effect of the new heart transplant allocation system on patients listed for re-transplantation. Methods Adult patients, who were listed for heart re-transplant between Jan 1, 2017 and September 30, 2019, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or re-transplanted before or after October 18, 2018, respectively. Results A total of 214 patients were listed for re-transplant in the study period. Of these, 127 and 87 patients were classified in the old and new systems, respectively. Patients listed in the new system had a higher frequency of transplantation within 1 year of listing (HR: 1.63 (1.23-2.17), p=0.001) (Figure 1A). Patient listed for re-transplant in the new system had a higher frequency of ECMO (16.1% vs. 6.8%, p=0.037) and IABP (20.7% vs. 4.7%, p=0.001) support. A total of 72 and 93 patients were re-transplanted in the old and new systems, respectively. Clinical characteristics did not differ between re-transplanted patients in old vs. new systems. The 1-year post-transplant survival was 91.5% and 86.4% for the old and new systems, respectively (Figure 1B, p=0.35). Conclusion With the implementation of the new HT allocation system, Patients listed for re-transplantation have an increased access to a second heart transplant with similar 1-year post-re-transplant survival.

Purpose To analyze the clinical characteristics and outcomes of patients who were bridged with ECMO to durable mechanical circulatory support (dMCS). Methods Adult patients who received dMCS between Jan 2008 and Dec 2017, registered in INTERMACS were included. Baseline characteristics, outcomes, risk factors and adverse events were analyzed in patients supported by ECMO (ECMO group) prior to dMCS implantation, and compared with INTERMACS profile 1 patients not supported by ECMO (non-ECMO group). Results Patients bridged to dMCS on ECMO were younger, more likely to have acute heart failure, ischemic etiology, and a bridge to candidacy implantation compared to other INTERMACS profile 1 patients (Table 1). Patients who received dMCS on ECMO had 1, 6, and 12 month survival of 83.8%, 71.2%, and 66.1%, inferior to non-ECMO group patients (91.4% 81.7% and 75.4%, p Conclusion Patients bridged by ECMO to dMCS have lower survival compared with other INTERMACS profile 1 patients. Older age and longer duration of HF are associated with worse outcomes. ECMO implantation was independently associated with poorer outcome.

Purpose Primary Graft Dysfunction (PGD) is the most prevalent cause of one-month mortality following heart transplant(1). With the increase need to use marginal donor, because of the limited pool of donor available, an algorithm to predict PGD following heart transplantation could help identify marginal donors that are still suitable for transplantation. Methods 64 patients who underwent heart transplantation procedure without the use of organ care system were analyzed. PGD was defined as described before (2) and was present in 21. Donor, procedural and Recipient factors were run in an machine learning algorithm with lasso regression based on the coordinate descent technique provided by the glmnet algorithm. The predictive algorithm was generated for the outcome Primary Graft Dysfunction by continuous cross-referencing and re-sampling. Depending on the importance and distribution of each predictor in the model was assigned a score. The sum score was tested in a ROC-analysis with optimal cut-off calculated Results The following variables were found to be high risk to develop PGD (in descendant order): Cardiopulmonary bypass time, units of red blood cells given, cold ischemia time, cardioplegia amount, Time from brain death to recovery, Troponin T level in donor, diabetes in recipient and post-op creatinine level were left for the final algorithm. Scores were assigned in proportion to the weight given to them in the algorithm.). A ROC- analyze for the prediction of PGD showed a AUC (95% conf interval) 0.93(0.86-0.99). The optimal cut off was determined at 10 (0-29) Conclusion GREAT score can intra -operatively be used to prepare the transplantation team for who needs post-procedural support.

Purpose We compared those who got a VAD exchange primarily vs those who got eptifibatide treatment to establish which strategy was most beneficial in avoiding the primary endpoint of death or re-thrombosis Methods In a retrospective cohort study of patients with primary pump thrombosis (n=52), split into those that received an initial pump exchange (n=16) vs those who were treated with eptafibatide (n=36) a survival analysis was performed with the primary combined endpoint of death or new pump thrombosis at six months. The Kaplan-Meier curves created were tested for significant differences with a log-rank test. Univariate analysis of background parameters was performed between cohorts and relevant factors were built in a multiple logistic regression analysis to identify important predictors of the primary endpoint Results Although the Eptafibatide treatment was successful in 40% of the cases in avoiding death or the need for re-addressing pump-thrombosis a primary change of the pump was successful in about 80 % (p= 0.021) of the cases at six months. The frequency of major bleeds was also higher in the eptifibatide group (37.5% vs 52.8%; p=0.009) Conclusion Patients with a significant VAD thrombosis are better served with a primary pump exchange than eptifibatide treatment.

Introduction Continuous-Flow Left Ventricular Assist Devices (CFLVADs) improve mortality and quality of life in end-stage cardiomyopathy patients. Adverse events however remain high. Hypothesis We hypothesize time in therapeutic range (TTR) correlates with adverse events compared to most recent INR. Methods The study group comprised of patients who suffered suspected/confirmed pump thrombosis, stroke or major bleeding event as defined by INTERMACS after ≥ 1 month at home with ≥ 1 month of INR values. Controls (CON) had at least 3 months of INR values after being home for 1 month from LVAD implant and who did not experience any adverse events (AE). Standard statistical methods were employed as indicated: Chi-square, Fishers Exact test, two-sample t-test, Wilcoxon Rank sum test, One way ANOVA and Kruskal Wallis Analysis. Patients with multiple adverse events were excluded. Results From June 2010 - December 2016, 132 patients underwent CFLVAD implantation at our institution who met entry criteria. Mean age was 57±13 yrs and 106 (80%) were male. Seventy-seven (58%) were implanted as bridge to transplant (BTT). There was no statistically significant difference in TTR (p=0.39, Table 1 ) or most recent INR (p=0.33, Table 2 ) prior to AE. Patients who suffered AEs were older than those who did not (59.3± 12 vs. 54.4±14.3 yrs, p=0.04). There was no association of AEs when stratified by gender, LVAD indication, LVAD device type, race, BMI or hospital length of stay (p=ns). Conclusions Neither time in therapeutic range nor most recent INR correlated with major bleeding, neurological dysfunction or pump thrombosis in CFLVAD patients in this analysis. Further investigation beyond strict INR control and anticoagulation is needed to reduce adverse events in this patient population.

Coronary artery aneurysms are a rare condition with left-main trunk aneurysms occurring in only about 0.1 % of the population. We report on a giant left-main coronary artery aneurysm in a young male status post two previous open-heart operations. The aneurysm was successfully treated by patch occlusion of the ostial orifice and coronary revascularization of the left anterior descending and circumflex arteries.