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Purpose: Caregivers (CGs) for patients with advanced heart failure (HF) assist in HF-specific disease management. In the SUSTAIN-IT study, we reported CG perception of difficulty and time needed to perform tasks for patients awaiting surgery in 3 groups: HF patients awaiting heart transplant (HT) without mechanical support (HT-non-MCS), HF patients awaiting HT bridged with mechanical support (HT-MCS), and HF patient awaiting left ventricular device implantation as destination therapy (DT-MCS). In this report, we compare CG perceived burden from baseline to 1 year after surgery. Methods: We enrolled 301 CGs of HF patients between 10/1/15-12/31/18 from 12 U.S. hospitals: 193 awaiting HT (92 with and 101 without MCS), and 108 scheduled for DT-MCS. Prior to surgery and 3, 6, and 12 months after surgery, CGs completed the Oberst Caregiver Burden Scale (OCBS) which has 15 items with 2 subscales: (1) time and (2) difficulty: range=1-5, higher score=more time required for tasks and more task difficulty. Analyses included t-tests, chi-square tests, and baseline-adjusted linear regression models. Results: CGs were age 61.0±10.3 years, the majority were spouses (85%), female (86%), and white (86%). Average time spent on caregiving was moderate and decreased significantly from baseline to 12 months after surgery for all groups (Figure). DT-MCS CGs spent significantly more time than HT CGs on tasks 12 months after surgery. There were no significant differences in perceived difficulty (which was low) in performing CG tasks in all groups from baseline to 12 months. DT-MCS CGs did perceive tasks to be more difficult than HT CGs at 12 months. Conclusion: CGs of advanced HF patients adapted well to assisting with care, without increased burden, 1 year after HT and DT-MCS surgery. CGs of DT-MCS patients required more time and reported CG tasks to be more difficult than HT CGs. Understanding differences in CG burden will aid in pre surgical risk discussions and post-surgical follow-up.

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.

Background The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic "non-full sternotomy approaches" using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, there remains a lack of consensus regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. Methods A worldwide group of LT-VAD experts was convened to openly discuss these key topics. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. Results This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts´ opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This paper also emphasizes the critical need for multidisciplinary teams and specified training. Conclusions This expert consensus paper provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

International audience; Airports across the world are expanding by building multiple ground control towers and resorting to complex taxiway and runway system, in response to growing air traffic. Current outcome- based ground safety management at the airside may impede our potential to learn from and adapt to evolving air traffic scenarios, owing to the sparsity of accidents when compared with number of daily airside operations. To augment airside ground safety at Singapore Changi airport, in this study, we predict dynamic hot spots- areas where multiple aircraft may come in close vicinity on taxiways, as pre-cursor events to airside conflicts. We use airside infrastructure and A-SMGCS operations data of Changi airport to model aircraft arrival at different taxiway intersections both in temporal and spatial dimensions. The statistically learnt spatial-temporal model is then used to compute conflict probability at identified intersections, in order to evaluate conflict coefficients or hotness values of hot spots. These hot spots are then visually displayed on the aerodrome diagram for heightened attention of ground ATCOs. In the Subjective opinion of Ground Movement Air Traffic Controller, highlighted Hot Spots make sense and leads to better understanding of taxiway movements and increased situational awareness. Future research shall incorporate detailed human-in-the-loop validation of the dynamic hot spot model by ATCOs in 360 degree tower simulator.

The increasing demand in air transportation is pushing the current air traffic management system to its limits in the airspace capacity and workload of air traffic controllers (ATCOs). ATCOs are in an urgent need of assistant tools to aid them in dealing with increased traffic, specifically in resolving potential conflict. Because current automated conflict resolutions are not in conformance with the thinking or preferences of individual ATCOs, consequently, they are unlikely accepted by the ATCOs. In this work, an artificial intelligence (AI) system is built as a digital assistant to support ATCOs in resolving potential conflicts. Our system consists of two core components: an intelligent interactive conflict solver (iCS) to acquire ATCOs’ demonstrations, and an AI agent. The AI agent is based on reinforcement learning to suggest conflict resolutions. It is observed that providing the AI agent with the human resolutions, which are acquired and characterized by our intelligent interactive conflicts solver, not only improves the agent’s performance but also gives it the capability to suggest more humanlike resolutions. That could help to increase the ATCOs’ acceptance rate of the agent’s suggested resolutions. Our system could be further developed as personalized digital assistants of ATCOs to maintain their workloads manageable when they have to deal with sectors with increased traffic. Civil Aviation Authority of Singapore (CAAS) National Research Foundation (NRF) Accepted version This research / project* is supported by the National Research Foundation, Singapore, and the Civil Aviation Authority of Singapore, under the Aviation Transformation Programme.

In air traffic control, the airspace is divided into several smaller sectors for better management of air traffic and air traffic controller workload. Such sectors are usually managed by a team of two air traffic controllers: planning controller (D-side) and executive controller (R-side). D-side controller is responsible for processing flight-plan information to plan and organize the flow of traffic entering the sector. R-side controller deals with ensuring safety of flights in their sector. A better understanding and predictability of D-side controller actions, for a given traffic scenario, may help in automating some of its tasks and hence reduce workload. In this paper, we propose a learning model to predict D-side controller actions. The learning problem is modeled as a supervised learning problem, where the target variables are D-side controller actions and the explanatory variables are the aircraft 4D trajectory features. The model is trained on six months of ADS-B data over an en-route sector, and its generalization performance was assessed, using crossvalidation, on the same sector. Results indicate that the model for vertical maneuver actions provides highest prediction accuracy (99%). Besides, the model for speed change and course change action provides predictability accuracy of 80% and 87%, respectively. The model to predict the set of all the actions (altitude, speed, and course change) for each flight achieves an accuracy of 70% implying for 70% of flights; D-side controller’s action can be predicted from trajectory information at sector entry position. In terms of operational validation, the proposed approach is envisioned as ATCO assisting tool, not an autonomous tool. Thus, there is always ATCO discretion element, and as more ATCO actions are collected, the models can be further trained for better accuracy. For future work, we will consider expanding the feature set by including parameters such as weather and wind. Moreover, human in the loop simulation will be performed to measure the effectiveness of the proposed approach. Civil Aviation Authority of Singapore (CAAS) National Research Foundation (NRF) Published version This research was supported by the National Research Foundation, Singapore, and the Civil Aviation Authority of Singapore, under the Aviation Transformation Programme.

Prior to the widespread adoption of the arterial switch operation, patients with transposition of the great arteries (TGA) commonly underwent atrial switch operation (Mustard or Senning). It is not uncommon for these patients to progress to end stage heart failure and increasingly ventricular assist devices (VADs) are used to support these patients as a bridge to transplantation, though there is limited experience with this worldwide. A retrospective review of our institution's VAD database was undertaken and revealed seven adult patients with a history of TGA and subsequent systemic ventricular failure were implanted with a VAD: four of whom received the VAD as a bridge to transplantation (BTT) at the time of implantation, two who were initially designated as destination therapy secondary to severe pulmonary hypertension, and one who was designated as destination therapy secondary to a high risk of life-threatening non-compliance. Seven patient cases who received a VAD for severe systemic ventricular failure were included in this study. The mean age of the patients was 40 years and the majority of patients were male (6/7, 85%). Five of the patients (71.4%) had previously undergone an atrial switch operation and all of these were Mustard procedures. Two of the seven patients (28.5%) had congenitally corrected transposition of the great arteries (CC-TGA). Two of the seven patients (28.5%) had supra-systemic pulmonary pressures before VAD implantation and were designated as destination therapy (DT). One of these patients was later designated as BTT as an improvement in his pulmonary vascular resistance was observed, and subsequently underwent heart transplantation. Because of anatomic considerations, four of the patients (57%) underwent redo-sternotomy with outflow cannula anastomosis to the ascending aorta, one patient underwent VAD implantation via a left subcostal incision with anastomosis of the outflow graft to the descending thoracic aorta, and two patients (28.5%) underwent VAD implantation via a left thoracotomy and anastomosis of the outflow cannula to the descending thoracic aorta. Six of the seven patients had a HeartWare HVAD VAD implanted; one received a Thoratec Heartmate II VAD. Two patients underwent VAD explant and orthotopic heart transplant, 222 days and 444 days after VAD implant, respectively. One patient died on postoperative day 17 after complications from recurrent VAD thrombosis despite multiple pump exchanges. Four patients remain on VAD support, three of these patients are awaiting transplantation at last follow-up (mean days on support, 513 days). Bridge to transplantation with a durable VAD is technically feasible and relatively safe in patients with TGA. Multiple redo-sternotomies can be avoided with a left posterior thoracotomy approach and outflow graft anastomosis to the descending thoracic aorta after careful anatomic considerations.

BACKGROUND Severe right ventricular failure necessitating a right ventricular assist device (RVAD) complicates 6% to 11% of left ventricular assist device (LVAD) implants. Patient outcomes for those receiving durable continuous-flow VADs in a biventricular configuration (i.e., BiVAD) have been reported in limited case series. METHODS Data from United States centers with ≥ 6 BiVAD implants were collected. Characteristics and outcomes of patients receiving contemporaneous (i.e., same surgery) vs staged implantation of the HVAD as a BiVAD were compared. RESULTS From 2011 to 2017, 46 patients received durable BiVADs and had the following characteristics: median age, 46 years (interquartile range [IQR], 19–67 years), non-ischemic cardiomyopathy (80%), bridge to transplant (83%), Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 or 2 (92%), use of temporary circulatory support (37%), right atrial pressure 19 mm Hg (IQR, 14–23 mm Hg), and cardiac index of 1.6 liters/min/m 2 (IQR, 1.2–2.1 liters/min/m2 ). Operative mortality was 33%. Equal numbers of patients received a right atrial or right ventricular implant. Contemporaneous BiVAD implantation occurred in 31 patients (67%), and compared with 15 patients (33%) with staged implants, these patients had a shorter intensive care unit length of stay of 12 days (IQR, 7–23 days) vs 42 days (IQR, 28–48 days, p = 0.035) and were more likely to be discharged from the hospital on BiVAD support (61% vs 27%, p = 0.04). RVAD thrombosis developed in 17 patients (37%). Patients with contemporaneous BiVAD implants had a 1-year survival of 74% compared with 40% in staged BiVAD patients (p = 0.11). CONCLUSIONS Patients receiving durable BiVADs represent a critically ill patient population with severe biventricular failure who have high operative mortality and RVAD thrombosis rates. The 1-year survival for patients receiving contemporaneous BiVADs in experienced centers mirrors other contemporary durable biventricular support strategies.

Patients with isolated right ventricular (RV) failure have poor outcomes and minimal treatment options. We report a case where a durable RV assist device (RVAD) was implanted for end-stage RV failure from combined pre- and postcapillary pulmonary hypertension (PH) due in part to chronic thromboembolic PH using a temporary percutaneous RVAD as a bridging strategy. While the patient ultimately died from non-cardiovascular causes, there was significant improvement in markers of cardiogenic shock and hemodynamic RV function parameters without adverse effects from increased pulmonary artery pressures. More research is needed to identify an appropriate long-term mechanical support strategy for this patient population.

Purpose To evaluate the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) generic measures of social and physical function in patients with a left ventricular assist device (LVAD). Methods Adult heart failure (HF) patients at 12 U.S. sites in 2016-2020 enrolled in The Mechanical Circulatory Support: Measures of Adjustment and Quality Of Life Study (n=361). Post-LVAD implant, they completed PROMIS Ability to Participate in Social Roles and Activities, Satisfaction with Social Roles and Activities, and Physical Function; and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) Social and Physical Limitation measures. PROMIS is standardized to a general population (mean=50; SD=10). KCCQ-12 range is 0-100. Higher scores represent better outcomes. Construct validity was evaluated by Pearson correlations between PROMIS and KCCQ-12 scores. Known-groups validity was evaluated by analysis of variance to distinguish PROMIS means across NYHA and self-reported financial difficulties. Results Mean age was 58 years; 80% were male, 70% were Non-Hispanic White, 79% had financial difficulties due to condition/treatment, and 61% were NYHA I-II. Similar numbers enrolled at 3, 6, 12-26, and > 26 months post-implant. Mean scores for PROMIS and KCCQ-12 measures decreased (worsened) as NYHA worsened (p Conclusion PROMIS measures of social and physical function were associated with well-accepted measures commonly assessed in HF and post-LVAD. Unlike condition-specific measures, PROMIS scores can be compared to the general population or other clinical conditions, thus providing a useful way to interpret social and physical function after LVAD implant.

Purpose The purpose of this study is to compare short term results of patients undergoing a third generation (HVAD™or HeartMate™ 3) Left Ventricular Assist Device (LVAD) implantation through either minimally-invasive, thoracotomy approach or standard median sternotomy. Methods We prospectively collected data on all patients at our institution that received an LVAD from September 2008 to February 2020. Surgical approach was decided by the implanting surgeon. We used 1:1 propensity score (PS) matching to compare the sternotomy versus thoracotomy groups. A logistic regression model based on 19 explanatory variables was used to estimate the propensity score. Overall survival post-implantation was summarized using Kaplan-Meier curves and compared using the log-rank test. Results A total of 272 patients were included, of whom 194 had sternotomy and 78 had either left thoracotomy and hemi-sternotomy or bilateral thoracotomies. Using PS matching, 128 (64/64) patients were selected. Demographics and operative characteristics were well balanced between groups. Overall, there was a trend towards better survival in thoracotomy group (33.1% vs 66.4%, p=0.06) at 5 years, but higher stroke rate (11% in sternotomy group vs 21% in thoracotomy group, p = 0.035). Following PS-matching, however, there was no difference in early or late mortality (Graph 1) but there was a higher rate of pump exchange in the thoracotomy group (2% vs 9%, p = 0.052). There was no difference in perioperative stroke rates (sternotomy 6% vs thoracotomy 9%), extubation time (2.5 days vs 2.5 days), right ventricular failure (13% vs 14%), renal failure (8% vs 5%) or hospital readmissions (81% vs 88%). Conclusion Minimally invasive LVAD implantation is feasible and safe in the current LVAD era. In a PS matched analysis, patients in the minimally invasive group displayed lower overall mortality, but without reaching statistical significance. Adverse events were similar in both groups.

Purpose For patients with end stage heart failure, orthotopic heart transplant (OHT) remains the definitive management. Advances in immunosuppression have led to improved long-term survival. Malignancy is an important cause of long-term morbidity and mortality with a reported rate of occurrence between 20-40% within 10 years of transplant. To date, significant evidence into mechanisms and risk profiles for post OHT malignancy is lacking. The purpose of this study is to identify patient and donor related factors associated with post OHT malignancy. Methods We performed a retrospective analysis of 51,218 OHT recipients captured in the United Network for Organ Sharing (UNOS) registry. Included in this analysis were adults 18 years and older who received a heart transplant between 1987 and 2019. The patients were categorized by the presence of post OHT malignancy (“yes”, “no”). Baseline characteristics were compared using chi-squared analysis for categorical variables and Mann-Whitney test for continuous variables. Logistic regressions were applied to evaluate the association between post OHT malignancy and the risk factors. Results Within the study period (1987-2019), 13,060 OHT recipients (25.5%) developed a malignancy. Denovo solid tumors comprised 82% of all malignancy types. OHT recipients with malignancy were older (56 vs 50.9 years, p= Conclusion In this study, we reported the prevalence of post OHT malignancy as well as recipient and donor factors associated with post OHT malignancy. Further analysis based on malignancy subtype should be performed to aid in risk stratification and surveillance.

The HeartWare Ventricular Assist System (HVAD) provides significant improvements in survival and quality of life, and here, we seek to evaluate temporal differences in the adverse event (AE) rates. Patients (n = 382) in the ADVANCE bridge-to-transplant and continued access protocol trial were assessed for bleeding, cardiac arrhythmia, infection, ischemic and hemorrhagic stroke, and right heart failure during predetermined time periods (≤30,30-180,180-365,365-730,730-1,095 days) after HVAD implant. The Kaplan-Meier survival at 30 days, 6 months, 1, 2, and 3 years was 98%, 90%, 84%, 71%, and 63%, respectively. There were significantly fewer total AEs in days30-180 (events per patient year [EPPY] = 5.34) compared with the first 30 days post HVAD implantation (EPPY = 30.36; p0.0001). The total AE rate in days180-365 (EPPY = 4.09) was also significantly lower than the event rate in days30-180 (EPPY = 5.34; p0.0001). Incidence of cardiac arrhythmias, infections, strokes, and right heart failure were highest immediately post implant and lower rates occurred after 6 months. After 1 year, all AEs exhibited stable rates that were comparable up to 3 years of support (all p0.05). This changing risk over time has clinically meaningful implications toward improving patient management.

Background Current practices for the reversal of warfarin before cardiac surgery include the use of vitamin K and fresh frozen plasma (FFP) to reduce the risk of bleeding. Although the 2010 International Society of Heart and Lung Transplantation guidelines acknowledge the use of prothrombin complex concentrate (PCC), there is no clear consensus on its efficacy. The objective of this study was to assess the efficacy of four-factor (4-F) PCC administration in patients requiring warfarin reversal before heart transplantation by determining blood product utilization perioperatively. Methods Twenty-one patients who received 4-F PCC for warfarin reversal before heart transplantation were compared to a similar cohort of 39 patients who did not receive 4-F PCC, from January 2011 to July 2015. Blood product utilization was collected retrospectively for the 24-hour preoperative, intraoperative, and 48-hour postoperative periods. Results Patients receiving 4-F PCC required fewer blood products in all three time periods. In the 24-hour preoperative period, 22 (56%) patients in the control group and 2 (10%) patients in the 4-F PCC groups received blood products (p

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.

Purpose Factors related to health-related quality of life (HRQOL) of older patients (pts) with advanced heart failure (HF) scheduled for left ventricular assist device (LVAD) implantation as destination therapy (DT) or while a candidate for heart transplantation (HT) with or without an LVAD, may guide therapeutic strategies. We sought to identify pt and caregiver (cg) factors related to HRQOL of pts (60-80 years) awaiting these surgeries. Methods From 10/1/15-12/31/18, we enrolled 302 pts with cgs (n=302) from 13 U.S. sites: 193 pts awaiting HT (92 with and 101 without LVAD) and 109 DT LVAD pts. Pts completed the EQ-5D-3L Visual Analog Scale (VAS): 0-100 (worst-best) health; KCCQ-12 summary score (SS), 0-100=low-high; PHQ-8 (0-24; score > 10=significant depressive symptoms) and STAI-state (20-80; higher score=more anxiety). Cgs completed the EQ-5D, STAI, PHQ-8 and Oberst Caregiving Burden Scale (OCBS): 2 subscales (time and difficulty, 1-5; higher score=more time and more task difficulty). Analyses included multivariable logistic regression models; the binary outcomes were whether individual EQ-5D VAS and KCCQ-12 SSs were higher than the cohort median of 60 and 46, respectively. Results Pts were 66.1±4.5 years, 82% male, and 86% white. Pts reported relatively low generic HRQOL (VAS mean=55.3±23.5) and low HF-specific HRQOL (SS mean=47.5±22.5), both with significant group differences. HT pts with LVADs were more likely to have higher EQ-5D VAS scores; DT pts had the lowest VAS scores (p > 10 was related to lower VAS scores (p > 10 was related to lower KCCQ-12 SSs (p Conclusion Implant strategy, pt depression, and cg time spent on care were significantly related to older advanced HF pt HRQOL. Findings may inform interventions for HF pts awaiting surgery.

Purpose Heart transplantation (HT) and mechanical circulatory support (MCS) has improved heart failure (HF) patient (PT) outcomes; it has also led to increased caregiver (CG) responsibility pre and post-surgery. We assessed whether PT and CG factors were related to baseline CG perceived burden in 3 groups of CGs of HF PTs (60-80 years): (1) PT supported with MCS as a bridge to HT (HT BTT), (2) PT awaiting HT without MCS (HT non BTT), and (3) PT prior to MCS for destination therapy (DT MCS). Methods Between 10/1/15-12/31/18, we enrolled 302 CGs from 13 U.S. sites: 92 HT BTT, 101 HT non BTT, and 109 DT MCS. CG burden was measured with the Oberst Caregiving Burden Scale (OCBS: [1] time: higher score=more time spent on task and [2] difficulty: higher score=more difficulty of task). CGs also completed the EQ-5D-3L (Visual Analog Scale [VAS]: 0 [worst] to 100 [best] imaginable health state and 5 dimensions); STAI-State (higher score=more anxiety); PHQ-8 (score ≥10=significant depressive symptoms), and demographic/health history/impact of caregiving on own health questions. PTs completed the KCCQ-12, MoCA (measure of cognitive dysfunction) and all above measures except the OCBS. Analyses included multivariable logistic regression models in which the binary outcomes were whether individual OCBS difficulty and time scores were higher than the cohort median values of 1.20 and 2.26, respectively. Results CGs were 61.1±9.7 years, 85% spouses, 85% female, and 85% white. Overall CG difficulty was low and CG time spent was moderate. CGs who reported more difficulty on tasks perceived more impact on their own health and had more anxiety, with no differences by PT implant strategy (table). CGs with Conclusion Only CG factors, and not PT factors, were related to CG perceived burden. Understanding factors that affect CG burden may aid in preoperative advanced therapies discussions.

Objective Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. Methods Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. Results General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours; P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes; P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days; P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%; P < 0.001). There was no difference in 30-day mortality (0% vs 3%; P = 0.15). Conclusions Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.

With the continuous innovation in mechanical circulatory support as an option for the management of patients in cardiogenic shock from myocardial infarction, it is important to understand the current evidence and recommendations for the use of these devices for patients who require or underwent coronary artery bypass surgery.The use of mechanical circulatory support (MCS) in patients with cardiogenic shock who require or underwent coronary artery bypass surgery has not been well studied. Observational studies have shown that the use of intra-aortic balloon pump or percutaneous ventricular assist devices prior to revascularization lead to better survival. Extracorporeal membrane oxygenation (ECMO) still carries significant risk of mortality and complications; the use of additional MCS devices for left ventricular unloading during ECMO improves outcomes.MCS will continue to play an important role in coronary artery surgery patients. Multidisciplinary Cardiac Shock Team can assist in proper patient selection and device choice, whereas prospective clinical trials are required to provide evidence-based guidance towards the management of these patients.

Background Aortic valve insufficiency can have significant hemodynamic consequences for patients with left ventricular assist devices. A circulation loop can limit systemic blood flow and increase left ventricular filling pressure. Case presentation A 64-year-old male with non-ischemic dilated cardiomyopathy underwent Heartware™ HVAD left ventricular assist device implantation with successful concomitant aortic valve replacement with an Edwards Intuity rapid deployment prosthetic valve. Conclusions The use of this rapid deployment valve may have benefits over other techniques including shorter cross clamp times during surgery, intermediate-long term durability, and preservation of aortic valve opening to allow for potential ventricular recovery. The Intuity rapid deployment valve should thus be considered a viable and suitable option for aortic insufficiency intervention during LVAD implantation.

With the continuous growth in the air transportation demand, air traffic controllers will have to handle increased traffic and consequently more potential conflicts. This gives rise to the need for conflict resolution advisory tools that can perform well in high-density traffic scenarios given a noisy environment. Unlike model-based approaches, learning-based or machine learning approaches can take advantage of historical traffic data and flexibly encapsulate the environmental uncertainty. In this study, we propose an artificial intelligent agent that is capable of resolving conflicts, in the presence of traffic and given uncertainties in conflict resolution maneuvers, without the need for prior knowledge about a set of rules mapping from conflict scenarios to expected actions. The conflict resolution task is formulated as a decision-making problem in a large and complex action space, which is applicable for employing the reinforcement learning algorithm. Our work includes the development of a learning environment, scenario state representation, reward function, and learning algorithm. As a result, the proposed method, inspired by Deep Q-learning and Deep Deterministic Policy Gradient algorithms, can resolve conflicts, with a success rate of over 81%, in the presence of traffic and varying degrees of uncertainties. Civil Aviation Authority of Singapore (CAAS) This research is partially supported by Air Traffic Management Research Institute (NTU-CAAS) Grant No. M4062429.052

Less invasive techniques for left ventricular assist device implantation have been increasingly prevalent over past years and have been associated with improved clinical outcomes. The procedural economic impact of these techniques remains unknown. We sought to study and report economic outcomes associated with the thoracotomy implantation approach.The LATERAL clinical trial evaluated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare centrifugal-flow ventricular assist device system (HVAD). We collected UB-04 forms in parallel to the trial, allowing analysis of index hospitalization costs. All charges were converted to costs using hospital-specific cost-to-charge ratios and were subsequently compared with Medicare cost data for the same period (2015-2016). Because thoracotomy implants were off-label for all left ventricular assist devices during that period, the Medicare cohort was assumed to consist predominately of traditional sternotomy patients.Thoracotomy patients demonstrated decreased costs compared with sternotomy patients during the index hospitalization. Mean total index hospitalization costs for thoracotomy were $204,107 per patient, corresponding to 21.6% reduction (P.001) and $56,385 savings per procedure compared with sternotomy. Across almost all cost categories, thoracotomy implants were less costly.In LATERAL, a clinical trial evaluating the safety and efficacy of the thoracotomy approach for HVAD, costs were lower than those reported in Medicare patient claims occurring over the same period. Because Medicare data can be presumed to consist of predominately sternotomy procedures, thoracotomy appears less expensive than traditional sternotomy.

Objectives During degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late echocardiographic and clinical outcomes, and influence of surgical experience in decision making. Methods From April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed. Results Mild mitral regurgitation was present in 73 patients (6%). Propensity score–matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P = .033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P = .016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P = .10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P = .027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P = .002). Conclusions Residual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair.

Conflict detection is one of the fundamental elements in air traffic control. The output of conflict detection is the important input for conflict resolution which is an important task in maintaining safety and efficiency for flights. Even though there are tools to support air traffic controller in detect potential conflict, their quality and accuracy are still limited since the difficulty in encapsulating uncertainty in predicting flight trajectory. To tackle that challenge, several studies focus on applying probabilistic approaches by modelling aircraft dynamic and uncertainty. Those approaches share common limitations such as their assumption about uncertainty distribution and high computational cost for locating and computing the probability of conflict. In this work, we propose a data-driven approach to model the uncertainty of flight trajectory combining with technique for quickly locating position with highest conflict probability. Firstly, we use generative models to capture the complex trajectory pattern and its uncertainty directly from ADS-B data. Those model are used to predict aircraft position in future with uncertainty given current aircraft information. To compute the time at which two aircraft have highest probability of conflict, Monte Carlo method will be applied. Since conflict is a rare event so that the cost will be expensive, Bayesian Optimization algorithm is applied to quickly identify that time. Final the performance and computational cost of our approach is compared with Monte Carlo method using simulated data.

The Automatic Dependent Surveillance-Broadcast (ADS-B) protocol is equipped in aircraft as an alternative to secondary radar. This emerging technology produces such a prospective type of data to effectively broadcast the aircraft's status (location, velocity, etc.,) in a specific area, which is very useful in air traffic management (ATM). However, there is still a limited number of advanced studies from machine learning/data mining perspectives relying on this kind of data in ATM research. On the other hand, Locality Sensitive Hashing (LSH) is a data mining technique often used to find similar items in the data with high-dimension properties. It is thus relatively suitable for handling with trajectories data to group similar flight paths. From these factors, we reveal in this paper an adaptive LSH- based algorithm, used in near-duplicated documents detection, for the problem of clustering the nearest trajectories by representing the trajectories as a bag-of-words used popularly in text mining. To illustrate our proposed method, an experiment is designed and carried out in thirty successive days, employing the raw ADS-B data collected from FlightAware for the case of Changi International Airport, Singapore. The evaluation based on Silhouette score shows promising results of measuring the clustering performance.

Recently, the advances in reinforcement learning have enabled an artificial intelligent agent to solve many challenging problems (e.g. AlphaGo) at unprecedented levels. However, the robustness of reinforcement learning in safety critical operation remains unclear. In this work, the applicability of reinforcement learning in Air Traffic Control was explored. We focus on building an algorithm to automate flight conflict resolution which is the ultimate goal of air traffic control. For that purpose, a simulator, that provides a learning environment for reinforcement learning, was developed to simulate a variety of air traffic scenarios. We propose a variant of the reinforcement learning approach to resolve conflict in airspace and investigate the performance of the method in achieving that. A reinforcement learning model, specifically a deep deterministic policy gradient, was adopted to learn the conflict resolution with continuous action spaces. Experimental results demonstrate that our proposed method is effective in resolving the conflict between two aircraft even in the presence of uncertainty. The accuracy of our model is 87% at different uncertainty levels. Our findings suggest that reinforcement learning is a promising approach to conflict resolution. Civil Aviation Authority of Singapore (CAAS) Accepted version This research has been partially supported under Air Traffic Management Research Institute (NTU-CAAS) Grant No. M4062429.052

The increasing demand in air transportation is pushing the current air traffic management (ATM) system to its limits in the airspace capacity and workload of air traffic controllers (ATCOs). ATCOs are in an urgent need of assistant tools to aid them in dealing with increased traffic. To address this issue, the application of artificial intelligence (AI) in supporting ATCOs is a promising approach. In this work, we build an AI system as a digital assistant to support ATCOs in resolving potential conflicts. Our system consists of two core components: an intelligent interactive conflict solver (iCS) to acquire ATCOs' preferences, and an AI agent based on reinforcement learning to suggest conflict resolutions capturing those preferences. We observe that providing the AI agent with the human resolutions, which are acquired and characterized by our intelligent interactive conflicts solver, not only improves the agent's performance but also gives it the capability to suggest more human-like resolutions, which could help increase the ATCOs' acceptance rate of the agent's suggested resolutions. Our system could be further developed as personalized digital assistants of ACTOs to maintain their workloads manageable when they have to deal with sectors with increased traffic. Civil Aviation Authority of Singapore (CAAS) Accepted version This research / project* is supported by the Civil Aviation Authority of Singapore and Nanyang Technological University, Singapore under their collaboration in the Air Traffic Management Research Institute. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not reflect the views of the Civil Aviation Authority of Singapore.

Electroencephalography based brain computer interface has enabled communication of human’s intention to a computer directly from the brain by decoding signatures that relay the intention information. Error-related potential has been adopted as a signature for natural communication and performance monitoring, among others. In this work, we investigate the use of error-related potential as an input channel to transfer human preference of a strategical advisory to a computer. Air traffic control task was used as a case study to make an empirical inquiry of error-related potential for higher level cognitive tasks (i.e. situation awareness in air traffic control tasks). The experimental task requires the subjects to monitor and assess air traffic scenarios presented on a simulated environment that provides conflict resolution advisories. The task is known to be highly mental demanding as it requires continuous situation awareness of the traffic. An interface and experimental protocol were developed for this experiment to validate that error-related potential can be used a new channel for preference. The implementation of the complete design was described together with the experimental evidence of error-related potential. According to the results, we found error-related potential that is in line with existing literature. We also discussed how the preliminary findings of this work can be used as an integral part of an intelligent conflict resolution advisory system that can learn from human preference and duplicate the decision making. Accepted version This research has been partially supported under Air Traffic Management Research Institute (NTU-CAAS) Grant No. M4062429.052.

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.

Background Left ventricular assist devices (LVADs) improve survival, quality of life (QOL), and functional capacity (FC) among patients with end-stage heart failure. Few data are available regarding characteristics associated with QOL and FC response. Methods and Results Patients enrolled in the Heartmate II clinical trials that were alive with ongoing LVAD support at 6 months were included. QOL response criteria included scoring above the lowest quartile on either the Minnesota Living With Heart Failure Questionnaire or the Kansas City Cardiomyopathy Questionnaire. FC responder criteria included improvement in 6-minute walk distance (6MWD) >70 meters from baseline, a 6MWD >220 meters at 6 months, or New York Heart Association functional class I or II. Independent variables associated with QOL nonresponse included history of diabetes (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.20–2.78), lower mean pulmonary arterial pressure (OR 0.97, 95% CI 0.95–0.99), or a Heartmate II right ventricular risk score >2 (OR 1.77, 95% CI 1.00–3.12). Variables associated with FC nonresponse included history of COPD (OR 1.92, 95% CI 1.22–3.03) or diabetes (OR 1.52, 95% CI 1.01–2.27). Compared with responders, QOL and FC nonresponders had reduced long-term survival. Conclusions Preoperative comorbidities, including diabetes, COPD, and right heart failure, may limit the QOL and FC response to LVAD therapy and should be considered during the shared decision-making process.

Right ventricular failure (RVF) is a major cause of morbidity and mortality after CF-LVAD implantation. We explored the association of pulmonary artery compliance (PAC), pulmonary artery elastance (PAE), and pulmonary artery pulsatility index (PAPi) in addition to established parameters as preoperative determinants of postoperative RVF after CF-LVAD surgery.We retrospectively reviewed 132 consecutive CF-LVAD implantations at Tufts Medical Center from 2008 to 2013. Clinical, hemodynamic, and echocardiographic data were studied. RVF was defined as the unplanned need for a right ventricular assist device or inotrope dependence for ≥14 days. Univariate analysis was performed. RVF occurred in 32 of 132 patients (24%). PAC and PAE were not changed, whereas the PAPi was lower among patients with versus without postoperative RVF (1.32 ± 0.46 vs 2.77 ± 1.16; P .001). RA pressure, RA to pulmonary capillary wedge pressure ratio (RA:PCWP), and RV stroke work index (RVSWI) were also associated with RVF. Using receiver operating characteristic curve-derived cut-points, PAPi 1.85 provided 94% sensitivity and 81% specificity (C-statistic = 0.942) for identifying RVF and exceeded the predictive value of RA:PCWP, RVSWI, or RA pressure alone.PAPi is a simple hemodynamic variable that may help to identify patients at high risk of developing RVF after LVAD implantation.

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.

Objectives Heart transplantation (HT) and mechanical circulatory support (MCS) as destination therapy (DT) are life-saving options for 60-80 year-old patients (pts) with advanced heart failure (HF). We compared pt health-related quality of life (HRQOL) before and 1 year (yr) after surgery in pts undergoing HT (with or without MCS) and DT MCS. Methods Among 393 pts at 13 US sites awaiting HT (n=239; 118 awaiting HT with MCS, 121 awaiting HT without MCS; 66% transplanted) and DT MCS (n=154) between 10/1/15-12/31/18, we collected self-report data on: HRQOL (EQ-5D-3L Visual Analog Scale [VAS]: 0-100=worst to best) and (KCCQ-12: 0-100=lowest to highest), depressive symptoms (PHQ-8: 0-24=fewer to more) and anxiety (STAI-state: 20-80=lower to higher]). There were 337 pts at 1 year follow up. Statistical analyses included paired t-tests, chi-square tests, and baseline-adjusted linear regression models. Results The majority of pts were white and male. DT pts were older than HT pts (DT = 68.6±5.2 vs HT with MCS = 64.4±3.3 vs HT without MCS = 64.0±2.9 years, p Conclusions HRQOL and mood improved in all 3 groups over time with better overall 1-yr scores observed in those undergoing HT. These unique findings may guide HRQOL-related therapeutic strategies.

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.

Background: Active cigarette smoking (CS) is a contraindication for Orthotopic Heart Transplantation (OHT) with a recommendation that HT candidates be free from CS for at minimum 6 months prior to HT. Animal studies have shown that a history of CS is associated with increased risk of allograft rejection, but few studies have examined the association of past CS and HT outcomes. Methods: Data were analyzed from HT recipients captured in the United Network for Organ Sharing (UNOS) transplant registry. Adults aged 18–79 who underwent HT from 1987 to 2018 and with data for all covariates (N = 32,260) were included in this study. The cohort was categorized by past smoking history (CS vs non-CS). Post-transplant outcomes of interest included survival, graft failure, treated rejection, malignancy and hospitalization for infection. Baseline characteristics were compared between the two groups using the chi-squared analysis. Unadjusted associations between CS and patient survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. Results: HT recipients with a history of CS were older (55 vs 50, p =

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.

Leiomyosarcomas are an uncommon malignant subset of tumors accounting for approximately 20% of soft tissue sarcomas. Primary vascular leiomyosarcomas (PVLs) are a rare subset of leiomyosarcomas that may originate in the arterial or venous circulation but most commonly affect the inferior vena cava (IVC). PVLs more commonly affect women to men in a 2:1 ratio and most frequently occur in the fourth to sixth decades of life. Few reports have described this infrequent pathologic state in the setting of advanced pregnancy. Presented is a case of a 44-year-old 30-week pregnant woman who presented with a PVL of the retrohepatic IVC, which was complicated by occlusion of the IVC and tumor thrombus extension into the hepatic veins and right atrium. Herein, we describe our multidisciplinary management of this rare problem with successful surgical resection of her tumor and IVC reconstruction.

Intro : Solid organ transplantation (SOT) is uncommon in persons living with HIV infection (PLWHIV), as historically, HIV infection was a contraindication to transplantation. However, advancements in antiretroviral therapy (ART) and immunosuppression has led to successful organ transplantation, including heart, in PLWHIV. Here, we present a case of dual-organ transplant in a PLWHIV. Case Report : A 46 yo African American man with Stage D heart failure due to dilated cardiomyopathy, end-stage renal disease (ESRD) on peritoneal dialysis (PD), and longstanding HIV infection (CD4 726 cells/µl, HIV RNA less than 20 copies/mL) presented in cardiogenic shock. On hospital day 5, an axillary intra-aortic balloon pump (IABP) was placed, and the patient was upgraded to a status 2 on the UNOS waitlist for heart-kidney transplantation. On hospital day 33, he received a heart transplant, followed the next day with a deceased donor renal transplant from the same donor. He underwent induction with basiliximab 20 mg, on POD#0 and #4, followed by immunosuppression with mycophenolate mofetil 1g BID, tacrolimus 3mg BID, and prednisone 10mg BID. The pre-transplant ART with dolutegravir/rilpivirine was resumed and he was initiated on standard anti-infective prophylaxis with valganciclovir, atovaquone, and clotrimazole. Hospital course was complicated by hospital-acquired pneumonia and delayed kidney graft function with acute tubular necrosis, initially requiring hemodialysis. There was no evidence of antibody mediated or acute cellular rejection on endomyocardial biopsies. Two months after transplant, the patient was found to have BK viremia, initiated on cidofovir. Four months post-transplant, he was no longer requiring dialysis, had preserved graft function on echocardiogram, and transitioned from atovaquone to sulfamethoxazole-trimethoprim for a lifelong course. Most recent labs notable for sCr 1.66 mg/dL, eGFR 54 mL/min/1.73m2, CD4 890 cells/µl, HIV RNA less than 20 copies/mL, BK virus quantitative PCR 23,875 copies/mL. His current immunosuppressive regimen includes mycophenolate mofetil 250mg BID and tacrolimus 2mg BID. Summary Patients with advanced heart failure who are concomitantly HIV+ are a unique and growing population. Multi-organ transplantation involving heart and kidney in this patient population has not been reported in the literature. As demonstrated in this case, with special considerations to patient selection, immunosuppression, and anti-infective regimens, and collaboration of a multidisciplinary team of heart and kidney transplant physicians and surgeons, along with infectious disease specialists, a successful multi-organ heart-kidney transplant in PLWHIV is feasible with excellent outcomes early after transplant.

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 Ventricular assist device (VAD) infections are an important cause of morbidity and mortality. Fungal infections are associated with poor outcomes and risk factors to predict infection warrant characterization. Methods A retrospective cohort study of continuous-flow 2nd or 3rd generation VAD devices placed at Northwestern Memorial Hospital from July 2008 to September 2018 was performed. VAD-specific and VAD-related infections were characterized according to 2013 ISHLT definitions. Early infections were defined as occurring less than or equal to 60 days from the date of VAD implantation, late infections were defined as greater than 60 days. Binary logistic regression analysis comparing fungal to non-fungal bacterial infections identified significant risk factors. Summary and comparative statistics were performed using IBM® SPSS Statistics version 25.0. Results 86 infections occurred in 433 VAD implantations. 93.0% (n = 80) were non-fungal and 7.0% (n = 6) were fungal. Independent risk factors for fungal infection when compared to bacterial infections were early VAD infection (66.6% vs 11.3%, p = 0.000), ischemic cardiomyopathy as an underlying diagnosis (83.3% vs 38.7%, p = 0.033), 3rd generation VAD device (100% vs 53.7%, p = 0.027), polymicrobial infection (83.3% vs 28.8%, p = 0.006), concurrent infection with a multi-drug resistant organism in the same device (66.6% vs 21.2%, p = 0.013) as shown in Table 1. Patients with fungal infections had a higher mortality rate (66.6% vs 27.5%, p = 0.044). Conclusion Risk factors for fungal infection compared to bacterial infections in VADs are ICM, 3rd generation devices, polymicrobial infection, and concurrent MDRO infections. Mortality is higher in VAD patients with fungal infections.

Purpose Caregivers (CGs) of patients (PTs) with heart failure (HF) experience substantial CG burden. Poor PT health-related quality of life (HRQOL) correlates with increased CG burden in other chronic disease. We evaluated the relationship between PT HRQOL and CG burden in older PTs receiving left ventricular assist devices (LVAD) as destination therapy (DT) or awaiting heart transplant (HT) with or without an LVAD. Methods Data were from SUSTAIN-IT, a study of PT and CG HRQOL in adults age 60-80 receiving DT LVAD or HT. PT HRQOL was assessed by EQ-5D-3L Visual Analog Scale (VAS) score: 0-100 (worst-best) & HF-specific KCCQ-12 summary score (SS), 0-100=low-high. CG burden was assessed by Oberst Caregiving Burden Scale (OCBS) assessing perceptions of CG difficulty & time (1-5; higher score=more time & difficulty). Baseline CG burden, PT HRQOL, and changes from 0 to 6 months were compared by linear regression. Results Data from 302 PTs and CGs were analyzed: 109 DT LVAD, 193 HT (101 without LVAD & 92 with LVAD). KCCQ-12 and EQ-5D VAS scores increased significantly from 0 to 6 months (p Conclusion PT HRQOL generally correlated with CG burden in older HF PTs before and early after DT and HT. Improved PT HRQOL did not correlate with decreased CG burden in HT, but may be associated in DT LVAD. These findings may guide support needs of CGs of PTs undergoing advanced therapies.