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The sixth annual report of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) summarizes the first 8 years of patient enrollment. The analysis is based on data from >10,000 patients and updates demographics, survival, adverse events and risk factors. Among patients with continuous-flow pumps, actuarial survival continues to be 80% at 1 year and 70% at 2 years. The report features a comparison of two eras of continuous-flow durable devices in the USA in terms of device strategy, patient profiles, adverse event burden, survival and quality of life. [Copyright &y& Elsevier]

Abstract: The Extracorporeal Life Support Organization Registry has collected outcome data of almost 56,000 patients receiving extracorporeal life support (ECLS) over the last 24 years. The use of neonatal respiratory ECLS declined from a peak of 1516 cases in 1992 to 750–865 cases from 2008 to 2012. The 26,583 cases of neonatal respiratory ECLS (75% survival) represent the largest patient population in the registry. Indicating the rapid growth in other patient populations, 2013 marks the first year where the number of neonatal respiratory ECLS cases is less than 50% of the registry. Stagnant at ~200 cases/year from 1993 to 2004, growth is occurring in the use of pediatric respiratory ECLS with 331–448 cases/year from 2008 to 2012 (58% survival). Similarly, adult respiratory ECLS use increases have been seen from ~100 cases/year from 1996 to 2007 to 480–846 cases/year from 2009 to 2012 (58% survival). Just over 15,000 cardiac ECLS patients have survival rates of 40%, 49%, and 40% for neonates, pediatric, and adults, respectively. [Copyright &y& Elsevier]

The prevalence of patients living with advanced heart failure continues to rise. For a subset of these patients, continuous-flow left ventricular assist devices (LVADs) are a life-saving therapy. Given the efficacy and durability of contemporary LVAD devices, their use has increased exponentially in recent years. The medical management of patients with an LVAD is an area of expertise for advanced heart failure clinicians, but a general understanding of the initial approach to, and stabilization of, LVAD patients is an important skillset for many health care providers. The rapidly changing field of the medical management of LVAD patients is largely based on clinical experience and limited published data. In this manuscript, we integrate the available published data on the medical management of LVAD patients with the growing clinical experience. [ABSTRACT FROM AUTHOR]

Objective: The COVID-19 pandemic presents a high mortality rate amongst patients who develop severe acute respiratory distress syndrome (ARDS). The purpose of this study was to evaluate the outcomes of venovenous extracorporeal membrane oxygenation (VV-ECMO) in COVID-19-related ARDS and identify the patients who benefit the most from this procedure., Methods: Adult patients with COVID-19 and severe ARDS requiring VV-ECMO support at 4 academic institutions between March and October 2020 were included. Data were collected through retrospective chart reviews. Bivariate and multivariable analyses were performed with the primary outcome of in-hospital mortality., Results: Fifty-one consecutive patients underwent VV-ECMO with a mean age of 50.4 years; 64.7% were men. Survival to hospital discharge was 62.8%. Median intensive care unit and hospitalization duration were 27.4 days (interquartile range [IQR], 17-37 days) and 34.5 days (IQR, 23-43 days), respectively. Survivors and nonsurvivors had a median ECMO cannulation time of 11 days (IQR, 8-18) and 17 days (IQR, 12-25 days). The average postdecannulation length of stay was 17.5 days (IQR, 12.4-25 days) for survivors and 0 days for nonsurvivors (IQR, 0-6 days). Only 1 nonsurvivor was able to be decannulated. Clinical characteristics associated with mortality between nonsurviors and survivors included increasing age ( P  = .0048), hemorrhagic stroke ( P  = .0014), and postoperative dialysis ( P  = .0013) were associated with mortality in a bivariate model and retained statistical significance in a multivariable model., Conclusions: This multicenter study confirms the effectiveness of VV-ECMO in selected critically ill patients with COVID-19-related severe ARDS. The survival of these patients is comparable to non-COVID-19-related ARDS., (© 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery.)

Complex and higher-risk indicated percutaneous coronary interventions at times require mechanical circulatory support, most often with Impella devices. The use of such devices traditionally required additional arterial access site(s), increasing risk of vascular complications. The Single-access for Hi-risk percutaneous coronary intervention (SHiP) technique was described to overcome this issue but was limited to the use of 7F guides. Larger 8F guides often provide incremental support and space compared to 7F guides, sometimes needed in complex procedures. We described a modified SHiP technique using an 8 Fr guide delivered sheathless using Rotaglide., (© 2022 Wiley Periodicals LLC.)

Background: Comorbidities complicate recovery and contribute to mortality after implant of a left ventricular assist device (LVAD). Coexistent cardiac and renal dysfunction (so-called cardiorenal syndrome) increases the risk of death, both with advanced heart failure and after LVAD implantation. We analyzed patients from the Interagency Registry for Mechanically Assist Circulatory Support to better estimate postimplant mortality according to the severity of renal dysfunction. Methods: Patients with a continuous-flow LVAD were grouped according to their pre-implant level of renal dysfunction: severe was defined as dialysis and/or estimated glomerular filtration rate (eGFR) < 30 ml/min; moderate if eGFR was 30 to 59 ml/min or blood urea nitrogen (BUN) was > 60 mg/dl; and mild or no renal dysfunction if eGFR was ≥ 60 ml/min and BUN was < 60 mg/dl. Results: Of the 4,917 patients with a continuous-flow LVAD implanted between June 2006 and March 2012, 3,160 (64%) were identified with mild or no renal dysfunction, 1,475 (30%) with moderate dysfunction, and 282 (6%) with severe dysfunction. Worsening renal dysfunction correlated with decreased survival, with nearly a 20% reduction in the 2-year survival going from low to severe dysfunction. The major negative survival effect occurred during the first 3 months. Combination of severe renal dysfunction and cardiogenic shock predicted the highest early mortality. Conclusions: Pre-implant renal dysfunction predicts higher mortality after LVAD implant. The progressive reduction in survival with higher grades of renal dysfunction supports consideration of LVAD implant before cardiorenal syndrome is advanced. For patients with severe renal dysfunction and other major comorbidities, initial support with a temporary device while awaiting organ recovery before implanting a durable pump could be considered. [Copyright &y& Elsevier]

This article reviews some of the complex ethical issues that accompany the diffusion of ventricular assist devices (VADs) for heart failure patients, with a particular emphasis on issues unique to older adults. In doing so, the ethical issues are centered on three decision points: (a) patient selection; (b) informed consent (i.e., initiation of the device); and (c) end of life (i.e., deactivation of the device.) It is contended that, with the technological improvements in heart failure treatments and new indications, the decision making process for VAD placement and deactivation has become more clinically and ethically challenging, particularly for older adults. Areas for potential future research are identified. [ABSTRACT FROM AUTHOR]

The article discusses Fiber-optic intra-aortic balloon therapy and its role within cardiac surgery, where it states that Fiber-optic manometers provide accurate and fast, high quality measurements. It also mentions effect of fiber-optic IABP therapy on clinical management. It is concluded that Fiber-optic IAB technology and improved algorithms provide better beat per beat mechanical support.

The 5th annual report of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) summarizes and analyzes the first 6 years of patient and data collection. The current analysis includes more than 6000 patients and updated risk factors for continuous flow pumps. Among continuous flow pumps, actuarial survival is 80% at 1 year and 70% at 2 years. Quality of life indicators are generally favorable and adverse event burden will likely influence patient selections of advanced heart failure therapies. [ABSTRACT FROM AUTHOR]

Acute decompensated refractory cardiogenic shock is an emergency in which the prompt instauration of mechanical circulatory support improves outcomes. The typical, initial approach for device delivery is via femoral vessels due to easy access and safety. If longer support is needed, the femoral access will severely impair the patient's mobility and can also limit the amount of support given as the new-generation devices are too large for direct arterial insertion. Upper-body arterial conduits (UBACs) are used for the delivery of larger, percutaneous ventricular assist devices (pVADs). The Impella 5.5 (Abiomed, Danvers, MA, USA) is a pVAD that can be deployed through a UBAC by either axillary/subclavian access or a transaortic approach. The latter approach is typically used in cases of postcardiotomy shock, in which the ascending aorta is already exposed through a full sternotomy. However, in some cases, the axillary artery is not suitable due to size (<6 mm in diameter), and a smaller pVAD is delivered into the heart. To avoid providing suboptimal support, we present an alternative, minimally invasive approach in which the larger device is delivered through the ascending aorta. This article summarizes the details of this approach through a mini upper partial sternotomy and reviews the relevant technical considerations.

Aim: Cardiogenic shock (CS) is a hemodynamically complex multisystem syndrome associated with persistently high morbidity and mortality. As CS is characterized by progressive failure to provide adequate systemic perfusion, supporting end-organ perfusion using mechanical circulatory support (MCS) seems intriguing. Since most patients with CS present in the catheterization laboratory, percutaneously implantable systems have the widest adoption in the field. We evaluated feasibility, outcomes, and complications after the introduction of a full-percutaneous program for both the Impella CP device and venoarterial extracorporeal membrane oxygenator (VA-ECMO)., Methods: PREPARE CardShock (PRospective REgistry of PAtients in REfractory cardiogenic shock) is a prospective single-center registry, including 248 consecutive patients between May 2019 and April 2021, who underwent cardiac catheterization and displayed advanced cardiogenic shock. The median age was 70 (58-77) years and 28% were female. Sixty-five percent of the cases had cardiac arrest, of which 66% were out-of-hospital cardiac arrest. A local standard operating procedure (SOP) indicating indications as well as relative and absolute contraindications for different means of MCS (Impella CP or VA-ECMO) was used to guide MCS use. The primary endpoint was in-hospital death and secondary endpoints were spontaneous myocardial infarction and major bleedings during the hospital stay., Results: Overall mortality was 50.4% with a median survival of 2 (0-6) days. Significant independent predictors of mortality were cardiac arrest during the index event (odds ratio [OR] with 95% confidence interval [CI]: 2.53 [1.43-4.51]; p = 0.001), age > 65 years (OR: 2.05 [1.03-4.09]; p = 0.036]), pH < 7.30 (OR: 2.69 [1.56-4.66]; p < 0.001), and lactate levels > 2 mmol/L (OR: 4.51 [2.37-8.65]; p < 0.001)., Conclusions: Conclusive SOPs assist target-orientated MCS use in CS. This study provides guidance on the implementation, validation, and modification of newly established MCS programs to aid centers that are establishing such programs., (© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Peripartum cardiomyopathy is diagnosed in women who develop systolic heart failure in the last month of pregnancy or within 5 months of delivery. This diagnosis should not be made in women with pre-existing cardiac disease or another cause of cardiac dysfunction. To prevent delay in diagnosis and treatment, a high index of suspicion is required given the overlapping symptoms of late pregnancy and heart failure. Traditional heart failure medical therapies are indicated, although drugs must be carefully reviewed for safety during pregnancy and lactation. Long-term prognosis is largely determined by the degree of ventricular recovery. Patients with acute or persistent hemodynamic compromise despite medical therapy should be considered for mechanical circulatory support and evaluated promptly for cardiac transplantation. A multidisciplinary team is required to care for patients with peripartum cardiomyopathy through parturition and beyond. All peripartum cardiomyopathy patients should be counseled that repeat pregnancy can negatively impact cardiac function and lead to recurrent heart failure or even death. Patients with persistent ventricular dysfunction should be strongly advised against another pregnancy. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices (LVADs) are increasingly being used as a bridge to heart transplantation or destination therapy. It is unclear which antithrombotic regimen should be used to reduce the risk of stroke. We systematically reviewed the literature on all types of antithrombotic regimens and stroke in patients with any type of LVADs. Our primary outcome measure was the mean incidence of any type of stroke. Twenty-six articles were selected as relevant, comprehending 1989 patients with a mean LVAD support of 200 days (range 30–621). The mean proportion of patients affected with stroke was 20% (range 0–55%), with a mean incidence of 0.74 (range 0–6.91) events/patient-year. Support with HeartMate II and a regimen of postoperative heparin converted to coumarins, acetylsalicylic acid (ASA) and dipyridamole resulted in 0.17 (mean; range 0.06–0.29) strokes/patient-year. HeartMate II support and the same regime without heparin was associated with 0.07 (mean; range 0.03–0.11) strokes/patient-year. A Novacor device with heparin, converted to coumarins, was associated with 3.82 (mean; range 1.03–6.91) strokes/patient-year, while ASA added to this regime resulted in 0.97 ischaemic strokes/patient-year (mean; range 0.53–1.48). Other combinations of assist devices and antithrombotic regimes were investigated in one or two studies only. This systematic review provides risk estimates for stroke for various LVADs and antithrombotic regimes. Our findings indicate that the postoperative use of heparin in HeartMate II patients is doubtful, and suggest an important role for antiplatelet drugs to prevent stroke in patients supported with a Novacor device. [ABSTRACT FROM AUTHOR]

Abstract: Mechanical support of the heart can be offered to patients who are refractory to pharmacological treatment, therapy for coronary or valvular disease or resynchronization therapy. Ventricular assist devices enable end-organ perfusion in the setting of heart failure. This can be temporary (as a bridge to recovery or transplantation) or permanent (destination therapy). Devices can be extracorporeal or implanted, and generated flows can be pulsatile or non-pulsatile. Implantation usually requires sternotomy with or without cardiopulmonary bypass, but percutaneous devices exist. Cardiostable anaesthesia with inotropic support is vital. Problems include bleeding versus thrombosis, high pulmonary vascular resistance, right heart failure and late infections. Transoesophageal echocardiography can be used to detect potential right-to-left atrial shunts, aortic regurgitation and cannula malposition, and to monitor filling and right ventricular function after implantation. In the future, total implantability of the devices, including the power source, is likely to occur. Eventually, they are likely to become a widespread alternative to transplantation. [Copyright &y& Elsevier]

An otherwise healthy 47-year-old man presented to the emergency department in cardiogenic shock after suffering a massive myocardial infarction due to left main occlusion. He was initially supported by extracorporeal membrane oxygenation and subsequently was converted to paracorporeal support with a Levitronix left ventricular assist device. He experienced multiple postoperative complications including renal failure, respiratory failure, retroperitoneal hematoma requiring suspension of anticoagulation, and fungal bloodstream infection precluding transition to an implantable device. He was reconditioned and successfully underwent orthotopic heart transplant 183 days after presentation. A discussion of the relevant issues is included. [ABSTRACT FROM AUTHOR]

Mechanical circulatory support after congenital heart surgery is uncommon, but not unusual. Stunning of ischemic myocardium after cardiopulmonary bypass could occur due to many reasons. According to the literature, this complication is rare in our center, but some options about implantation of a postcardiotomy left ventricular assistance device (LVAD) in toddlers deserve attention. Furthermore, although the VAD has been a well-established therapy for larger adolescents and adult patients with advanced heart failure, current experience with the use of VAD for mechanical circulatory support in infants and young children with small body surface area is still limited. [ABSTRACT FROM AUTHOR]

Background: Patients bridged to heart transplantation with left ventricular assist devices (LVADs) have been reported to have higher post-transplant mortality compared with those without LVADs. Our aim was to determine the impact of the type of LVAD and implant era on post-transplant survival. Methods: In this study we included 8,557 patients from the registry of the International Society for Heart and Lung Transplantation. We examined post-transplant outcomes in 1,100 patients bridged to transplant with pulsatile-flow LVADs between January 2000 and June 2004 (first era), 880 patients bridged with pulsatile-flow LVADs between July 2004 and May 2008 (second era), and 417 patients bridged with continuous-flow LVADs in the second era. Patients who required intravenous inotropes but not LVAD support (n = 2,728) and patients who did not require either LVAD or inotropes (n = 3,432) served as controls. Results: Post-transplant survival of patients bridged with pulsatile LVADs improved significantly between the first and the second era (p = 0.03). In the second era, there was no significant difference in post-transplant survival of patients bridged with pulsatile- vs continuous-flow LVADs (p = 0.26), and survival rates in the 2 groups were not statistically different from that of the non-LVAD group. Graft rejection was similar in patients bridged with LVADs compared to those without LVADs. Conclusions: In the most recent era, the use of either pulsatile- or continuous-flow LVADs did not result in increased post-transplant mortality. This finding is important as the proportion of patients with LVADs at the time of transplant has been rising. [ABSTRACT FROM AUTHOR]

Left ventricular assist device (LVAD) support is an accepted treatment of patients with end-stage heart failure. The increased applicability and excellent results with LVADs have revolutionized the treatment options available for such patients. Success with LVADs as bridge-to-transplant therapy has led to their successful use as an alternate to a transplant (ie, as destination therapy [DT]). The use of these devices as DT represents a relatively newer but growing indication. Until recently, most patients who have undergone LVAD implantation have been supported by pulsatile devices. Newer continuous-flow (CF) pumps have resulted in superior outcomes, including significantly reduced complication rates with improved durability over first-generation pulsatile design pumps. However, as with all new technology, the newer LVADs have introduced management challenges that were either unimportant or absent with pulsatile LVADs. This article reviews the current state of left ventricular devices, focusing on the CF pumps that currently dominate the field, including clinical outcomes, the physiologic and pathologic effects that are associated with CF pumps, and their unique management issues and complications. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Full mechanical support with a left-ventricular assist device (LVAD) is generally limited to end-stage heart-failure patients. We have been studying the safety and efficacy of the partial support Synergy® Pocket Micro-pump as bridge-to-transplant in a less-sick group of patients as a prelude to a study of its use for destination therapy. Methods: The CircuLite® Synergy device is implanted via a small right-sided thoracotomy with an inflow cannula in the left atrium and an outflow graft connected to the right subclavian artery without the use of extracorporeal circulation. The micro-pump is the size of an AA battery, sits in the ‘pacemaker’ pocket subcutaneously in the right clavicular groove and pumps up to 3.0lmin−1 from the left atrium to the right subclavian artery. Results: The device has been implanted in 27 patients awaiting cardiac transplant (22 males), age 54.8±10.0 years with ejection fraction (EF) 21±6%, mean arterial pressure 73.5±8.8mmHg, pulmonary capillary wedge pressure (PCWP) 27.5±7.8mmHg and cardiac index (CI) 2.0±0.4lmin−1 m−2. Duration of support has ranged from 6 to 281 days. Right-heart catheterization showed significant hemodynamic improvement in the short- and intermediate term after implant, with increases in CI from 2.0±0.4 to 2.8±0.6lmin−1 m−2 (p <0.001) and reductions in PCWP from 28±6 to 18±7mmHg (p =0.002) at an average of 9.5±5.5 weeks. Conclusions: The Synergy device provides partial hemodynamic support and its use is associated with significantly improved hemodynamics, thus appearing to interrupt and partially reverse the progressive hemodynamic deterioration typical of end-stage heart failure. Ongoing efforts are aimed at demonstrating additional clinical benefits and continuing to further improve the risk/benefit ratio. [Copyright &y& Elsevier]

Abstract: Objective: Infants and young children are considered the most difficult group to bridge to orthotopic heart transplantation (OHT) and data regarding outcomes are scarce. Methods: We reviewed our patients ≤10kg with those who were bridged to OHT using ventricular assist device (VAD) Berlin Heart (BH) Excor±extracorporeal membrane oxygenation (ECMO) between 2004 and 2009. Results: Eleven children ≤10kg with end-stage heart failure (cardiomyopathy or myocarditis) were treated with VAD as bridge to OHT: the median weight was 8.0 (range 3.9–10.0kg)kg and median age was 12.3 (range 1.2–33.9 months) months. Five (45%) required ECMO support pre-BH and six were on mechanical ventilation and inotropes. In 9/11 (82%), the support mode was left ventricular assist device (L-VAD) (all alive): one of two patients needing Bi-VAD support died. On BH, the median support time was 27 days and time to extubation was 8 days. Two out of 11 (18%) suffered strokes confirmed on brain imaging; both recovered and one underwent resection of infarcted small bowel. Ten out of 11 (91%) were transplanted, one remains in hospital and nine are at home in good health. When compared to patients >10kg bridged with BH (n =15), the mortality (p =0.51) and rates of neurological complications (p =0.54) were similar. Post-transplant recovery (ventilation times and time to home discharge) was similar between the bridged children ≤10kg and non-bridged children ≤10kg who underwent OHT. Conclusions: Mechanical bridging to transplantation is clinically feasible in children ≤10kg, achieving excellent outcomes. Judicious use of VADs in smaller children will optimise the use of donor organs; however, the effect on overall OHT waiting times, if mechanical bridging was extended to a large number of small children, is unknown. [Copyright &y& Elsevier]

While great strides have been made in the management of heart failure syndromes, acute refractory cardiogenic shock carries a dismal prognosis. Initial treatment with inotropes and balloon counterpulsation can restore hemodynamics, but many patients deteriorate and succumb to multisystem organ failure if timely mechanical circulatory support is not established. Institution of support is intended as a life-saving measure where the final treatment strategy remains uncertain. This scenario is referred to as 'bridge to decision.' Notably, most of these patients present to community hospitals, where advanced mechanical support technologies are scarce or nonexistent. Delays in referral to a tertiary center contribute to the bleak outcomes. Herein, we review the initial management of acute heart failure and refractory cardiogenic shock, profile the typical patient, delineate current options for mechanical support in patients with acute refractory cardiogenic shock, and propose suggestions for the establishment of a seamless transfer process of these ill patients to tertiary centers. [ABSTRACT FROM AUTHOR]

Abstract: Building on the success of the current KEKB Flavour Factory and the Belle experiment, which helped to firmly establish the CKM picture of quark mixing and CP violation in the Standard Model, a luminosity upgrade of the asymmetric e+e− machine is planned. This new Super Flavour Factory, SuperKEKB, will deliver a luminosity of 8×1035 cm−2 s−1, a factor 40 of increase over the present luminosity world record. It is foreseen to begin its operation in 2013. With these increased statistics, a new silicon vertex detector is needed in order to obtain precise decay vertex resolution measurements; these new precise measurements in the flavour sector can probe new physics well beyond the scales accessible to direct observations. [ABSTRACT FROM AUTHOR]

Since its initial application in the pediatric patient population, the Berlin Heart EXCOR ventricular assist device has become a widely accepted form of mechanical circulatory support in Europe and the USA. The versatility of the device makes it ideal for pediatric patients because it can be tailored to the size and needs of the patient. In this review, we will explore the broad range of clinical applications of this device including bridge to cardiac transplantation, bridge to recovery, and bridge to bridge implantation where the need for cardiac transplantation may be unclear but long-term mechanical support may be required. [ABSTRACT FROM AUTHOR]

To describe the clinical presentation, triage, resuscitation and outcome of acute fulminant myocarditis in children presenting to district hospitals and referred for cardiac intensive care. Case series describing five patients (from 2 weeks to 12 years old) with a diagnosis of acute fulminant myocarditis, presented to outlying hospitals between December 2006 and December 2007 and retrieved to a cardiac intensive care unit. All children were admitted with non-specific symptoms such as vomiting, cough and poor feeding to their local hospital, where various provisional diagnoses such as viral gastroenteritis, bronchitis or renal failure were considered. Acute physiological deterioration usually prompted the referral for intensive care. Two children died at the referring hospital during stabilisation by the retrieval team. Three children survived transport to intensive care and to hospital discharge; two received mechanical support and one underwent urgent orthotopic heart transplantation. Enterovirus and parvovirus were identified as causative agents in two patients. In one case, macrophage activation syndrome was diagnosed although no clear viral trigger was identified. Median length of hospitalisation among survivors was 33 days, and mechanical cardiac support was required for a median of 12 days. The diagnosis and initial management of acute fulminant myocarditis is extremely challenging. Prognosis for patients admitted to a cardiac centre for early mechanical support can be very favourable, while a delay in considering the diagnosis may result in poor outcome. The diagnosis of myocarditis should be considered in any previously well child presenting with a viral prodrome and non-specific organ dysfunction associated with dysrhythmias, shock or acute heart failure, even in the absence of cardiomegaly. [ABSTRACT FROM AUTHOR]

Background: Rejection is a major cause of morbidity and mortality after pediatric heart transplantation (HTx). Survival after pediatric HTx has improved over time, but whether there has been an era-related improvement in the occurrence of allograft rejection is unknown. Methods: The Pediatric Heart Transplant Study (PHTS) database was queried for patients who underwent HTx from January 1993 to December 2005 to determine the incidence of rejection and identify factors associated with the first episode of rejection in the first year after HTx. Results: Data were reviewed in 1,852 patients from 36 centers. The incidence of rejection declined over 13 years at a rate of −2.58 ± 0.41 (p < 0.001) from approximately 60% to 40% (p < 0.001). The mean number of episodes of rejection also significantly fell at a rate of −0.05 ± 0.01 per patient/year from 1.19 to 0.66 (p < 0.001). The incidence of rejection with hemodynamic compromise and death from rejection did not change. Multivariate analysis for the risk of a first rejection episode demonstrated decreased risk of rejection with later year of HTx (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.85–0.91; p < 0.001) and use of mechanical support (OR, 0.65; 95% CI, 0.42–0.99; p = 0.046). Increased risk of rejection was associated with positive donor-specific crossmatch (OR, 1.85; 95% CI, 1.18–2.88; p = 0.007) and older recipient age (OR, 1.05; 95% CI, 1.02–1.07; p < 0.001). Conclusions: Although the overall incidence and prevalence of rejection has substantially decreased over time in pediatric HTx recipients in the first year after HTx, the rate of rejection with hemodynamic compromise or death from rejection remains unchanged. [Copyright &y& Elsevier]

Cardiac cachexia, associated with excessive activation of the sympathetic nervous system together with immune activation, is an important prognostic indicator in heart failure. Anecdotally, the prevalence of cardiac cachexia appears to be falling, perhaps due to the increased use of beta-blockers. However, chronic heart failure is so common that many patients continue to lose weight and continue to deteriorate to a point where transplantation or mechanical support is considered. The origin of cachexia remains elusive and further research is needed to explore the relation between weight, sympathetic activation, and the response to cardiac surgery or transplantation. [Copyright &y& Elsevier]

Background: Pulmonary hypertension associated with chronic congestive heart failure posses a significant risk of morbidity and death after heart transplantation. Isolated observations suggest that chronic ventricular unloading may lead to normalization of pulmonary pressures and thus render a patient likely to be a heart transplant candidate. Methods: This study is a retrospective analysis of 9 heart failure patients with secondary pulmonary hypertension (transpulmonary gradient [TPG] > 15 mm/Hg). Two were treated with a pulsatile left ventricular assist device (LVAD) and 7 with an axial-flow LVAD. Results: After LVAD support, mean pulmonary artery pressure decreased from 39 ± 7 to 31 ± 5 mm Hg, and the TPG decreased from 19 ± 3 to 13 ± 4 mm Hg (p < 0.01). The 1-year Kaplan–Meier survival curve for patients with pre-LVAD TPG > 15 mm Hg vs those with TPG < 15 mm Hg showed no difference in survival (p = 0.6). This finding was supported by analysis of a large multi-institutional cohort obtained from the Organ Procurement and Transplantation Network database, where no differences in survival were found in the same groups. Conclusions: Pulmonary hypertension that is secondary to congestive heart failure, as defined by a TPG > 15 mm Hg can be reversed by the use of pulsatile and axial-flow LVADs; furthermore, post-transplant survival for patients with secondary pulmonary hypertension treated with an LVAD was no different than for those without pulmonary hypertension who received LVAD support. [Copyright &y& Elsevier]

Abstract: Mechanical support of the heart can be offered to patients who are refractory to pharmacological treatment, therapy for coronary or valvular disease or resynchronization therapy. Ventricular assist devices enable end-organ perfusion in the setting of heart failure. This can be temporary (as a bridge to recovery or transplantation) or permanent (destination therapy). Devices can be extracorporeal or implanted, and generated flows can be pulsatile or non-pulsatile. Implantation usually requires sternotomy with or without cardiopulmonary bypass, but percutaneous devices exist. Cardiostable anaesthesia with inotropic support is vital. Problems include bleeding versus thrombosis, high pulmonary vascular resistance, right heart failure and late infections. Transoesophageal echocardiography can be used to detect potential right-to-left atrial shunts, aortic regurgitation and cannula malposition, and to monitor filling and right ventricular function after implantation. In the future, total implantability of the devices, including the power source, is likely to occur. Eventually, they are likely to become a widespread alternative to transplantation. [Copyright &y& Elsevier]

Abstract: Objective: To study the achievability of device weaning in patients receiving left ventricular assist devices (LVADs) as a bridge to transplantation. Methods: Eighteen consecutive patients receiving a LVAD between September 1997 and June 2002 were included in the study. During a four-month follow-up, patients were repeatedly evaluated with right heart catheterization and echocardiography and, if functional improvement was observed, studied with the device turned off. Cardiac recovery was defined as off-pump LVEF≥40% together with a significant improvement in invasive haemodynamic measurements (CI≥2.5 and PCWP≤10–12 mm Hg). Patients fulfilling these criteria were considered for weaning. Results: Three patients fulfilled the predefined criteria for cardiac recovery and were subjected to device explantation. In one patient, a young female with acute myocarditis, the following course was uneventful. In the second patient, a male with dilated cardiomyopathy, heart failure reoccurred only a few days later. The third patient had a relapse of giant cell myocarditis and was transplanted. One patient underwent transplantation before follow-up evaluation could be performed. Conclusion: In our experience, patients with severe advanced heart failure are unlikely to show significant cardiac recovery following treatment with LVAD, in contrast to previous suggestions. [Copyright &y& Elsevier]

Abstract: Heart transplantation not only enables children with end-stage heart failure to live longer, but also improves their quality of life. Peritransplant survival has improved with advances in intensive care and better mechanical support systems for the failing heart. Heart–lung transplantation is the only option for some children near the end of life from disease affecting both organs and remains a challenge, with much poorer outcomes than heart transplantation alone. All thoracic transplants require scrupulous attention to follow-up care and, despite improving outcomes, can be regarded only as palliative solutions. The medical and surgical management of heart failure and congenital heart disease has also improved in recent years, and these options are thoroughly explored before considering listing for heart transplantation. [Copyright &y& Elsevier]

Advanced revascularization strategies continue to uncover a growing number of patients with symptomatic diffuse coronary artery disease. Transmyocardial laser revascularization (TMR) provides significant benefit in terms of improved quality of life and more complete revascularization for these difficult to treat patients when TMR is used as sole therapy or in combination with coronary artery bypass grafting. The safe clinical application of this important procedure relies on diligent perioperative management with appropriate patient selection, intraoperative care that avoids myocardial ischemia, and postoperative pain control along with expeditious reinstitution of antianginal medications. The treatment paradigms learned with the safe application of TMR should prove useful as new therapies to extend our revascularization options are developed. [Copyright &y& Elsevier]

Abstract: The pixel vertex detector is critical to the success of the BTeV experiment. It will provide very high-precision space points along charged particle trajectories with a readout fast enough so that this information can be used by the lowest level trigger. The detector will be placed in a 1.6T dipole magnet, inside the beam vacuum, and with the innermost region as close as 6mm from the colliding beams. The status of the technical design of this unique vertex detector is presented in this paper. [Copyright &y& Elsevier]

The stress state surrounding wounds in the skin plays an important role in the healing process; it affects the tissue strength, its aesthetic, and its resistance to infections. In this paper, the collagen fibril and elastin matrix damage mechanics following suture point application is investigated at the nanoscale; to this purpose, a model has been developed, which accounts for the architectural and mechanical features of the tissue components. Results indicate that the force displacement caused by the suture point application curve initially stiffens and subsequently softens. Softening occurs due at first to the enlargement of the elastin matrix damaged area and second to the collagen fibril disruption. Three regions may be identified: the first one, (0-0.38 N) refers to skin withstanding the force both in the collagen and elastin components; the second one (0.38-0.75 N) concerns the mechanism of elastin matrix damage; in the last one (>0.75 N), the collagen fibrils also fail. Accordingly, by properly choosing the number of suture points, it is possible to define the optimal suture points number for a given wound closure force. [ABSTRACT FROM PUBLISHER]

The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.

Background: We recently demonstrated that a novel intra-ventricular membrane pump (IVMP) was able to increase the pump function of isolated beating porcine hearts. In follow-up, we now investigated the impact of the IVMP on myocardial oxygen consumption and total mechanical efficiency (TME) and assessed the effect of IVMP-support in acutely failing hearts., Methods: In 10 ex vivo beating porcine hearts, we studied hemodynamic parameters, as well as arterial and coronary venous oxygen content. We assessed cardiac power (CP), myocardial oxygen consumption (MVO 2 ), and TME (CP divided by MVO 2 ) under baseline conditions and during IVMP-support. Additionally, five isolated hearts were subjected to global hypoxia to investigate the effects of IVMP-support on CP under conditions of acute heart failure., Results: Under physiological conditions, baseline CP was 0.36 ± 0.10 W, which increased to 0.65 ± 0.16 W during IVMP-support (increase of 85% ± 24, p  < 0.001). This was accompanied by an increase in MVO2 from 18.6 ± 6.2 ml/min at baseline, to 22.3 ± 5.0 ml/min during IVMP-support (+26 ± 31%, p  = 0.005). As a result, TME (%) increased from 5.9 ± 1.2 to 8.8 ± 1.8 (50 ± 22% increase, p  < 0.001). Acute hypoxia-induced cardiac pump failure reduced CP by 35 ± 6%, which was fully restored to baseline levels during IVMP-support in all hearts., Conclusion: IVMP-support improved mechanical efficiency under physiological conditions, as the marked increase in cardiac performance only resulted in a modest increase in oxygen consumption. Moreover, the IVMP rapidly restored cardiac performance under conditions of acute pump failure. These observations warrant further study, to evaluate the effects of IVMP-support in in vivo animal models of acute cardiac pump failure.

New mechanistic insight into how the kidney responds to cardiac injury during acute myocardial infarction (AMI) is required. We hypothesized that AMI promotes inflammation and matrix metalloproteinase-9 (MMP9) activity in the kidney and studied the effect of initiating an Impella CP or veno-arterial extracorporeal membrane oxygenation (VA-ECMO) before coronary reperfusion during AMI. Adult male swine were subjected to coronary occlusion and either reperfusion (ischemia-reperfusion; IR) or support with either Impella or VA-ECMO before reperfusion. IR and ECMO increased while Impella reduced levels of MMP-9 in the myocardial infarct zone, circulation, and renal cortex. Compared to IR, Impella reduced myocardial infarct size and urinary KIM-1 levels, but VA-ECMO did not. IR and VA-ECMO increased pro-fibrogenic signaling via transforming growth factor-beta and endoglin in the renal cortex, but Impella did not. These findings identify that AMI increases inflammatory activity in the kidney, which may be attenuated by Impella support., (© 2021. The Author(s).)

What started with 41 hospitalized patients identified as having laboratory-confirmed coronavirus disease 2019 (COVID-19) in Wuhan, China, by January 2, 2020, turned into an unprecedented pandemic with more than 113 million confirmed cases and a mortality exceeding 2.5 million deaths worldwide by the beginning of March 2021. Although the course of the disease is uneventful in most cases, there is a percentage of patients who become critically ill and need admission in the intensive care unit for severe respiratory failure. Numerous of these patients undergo invasive mechanical ventilation and have an extremely high mortality rate. For these patients, extracorporeal membrane oxygenation (ECMO) has emerged as a last standing resource. In the present study, the literature was reviewed to evaluate the worldwide data regarding the use of ECMO in the management of critically ill COVID-19 patients. ISI Thomson Web of Science was searched for articles with English language abstracts from inception to March 1, 2021, with 'ECMO in COVID-19' as key words. A total of 214 abstracts were screened (case reports, guidelines, reviews) and the most relevant articles were included in the present review. The use of ECMO in the management of critically ill patients with COVID-19-induced acute respiratory distress syndrome refractory to conventional mechanical invasive ventilation is increasing. By increasing the survival rate from less than 20% to more than 50%, ECMO proved to be a valuable resource in the management of the most challenging critically ill COVID-19 patients. [ABSTRACT FROM AUTHOR]