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Desensitization therapy for heart transplantation (HT) candidates can shorten transplant wait times and broaden the donor pool. Specific evidence-based recommendations on both protocols and indications are lacking. We retrospectively assessed left ventricular assist devices-bridged candidates who received pre-HT desensitization therapy. The therapeutic protocol consisted of intravenous immunoglobulin and rituximab followed by bortezomib and plasmapheresis if an insufficient response was achieved. Desensitization was attempted in 10 patients; only 7 tolerated therapy and underwent transplant. For those patients, median decrease in unacceptable calculated panel reactive antibody was 11%; there was no significant decrease for 3 patients. Post-desensitization adverse events were observed in all patients which included coagulopathy, bone marrow suppression, and infection. Median time to first infection was 16 days. One patient had clinically significant rejection and 3 patients had uptrending donor-specific antibodies. Decisions to proceed with desensitization should be individualized understanding potential risks and benefits.

Mechanical heart valves left in situ at the time of left ventricular assist device (LVAD) implantation are thought to potentially increase the risk of thromboembolism. Recommendations exist to replace dysfunctional mechanical mitral valves and any mechanical aortic valves at the time of LVAD implantation. Due to potential increases in cardiopulmonary bypass time and associated comorbidities with valve replacement, leaving a functional mechanical valve in place at LVAD implantation has been suggested to be a safe option. We retrospectively reviewed all patients with prior mechanical mitral or aortic valves undergoing LVAD implantation at our center between 2012 and 2017. Echocardiograms were read by a single cardiologist to assess for mechanical valve dysfunction. We identified 15 patients. Five patients had major bleeding requiring transfusion. On follow-up, 2 patients had hemorrhagic stroke and 2 had transient ischemic attach/ischemic stroke. In addition, 2 patients had LVAD thrombosis and 2 patients had LVAD driveline malfunction. Mild mechanical valve regurgitation was identified on follow-up echocardiograms of 2 patients. Rate of complications in patients with mechanical valves undergoing LVAD implantation was comparable to that reported for the general LVAD population. Leaving a functional mechanical valve in place at the time of LVAD implantation could be a reasonable alternative to valve replacement. More data are required to further guide patient care in these individuals.

Outside of heart and lung transplantation, only few cases have been reported describing venoarterial extracorporeal membrane oxygenation (VA-ECMO) use in solid organ transplantation. We present a case of a staged combined heart–kidney transplant in which VA-ECMO was utilized after a complicated orthotopic heart transplantation to successfully complete the subsequent renal transplantation.

Background There is significant geographical variation in heart failure ( HF ) mortality across the United States. County socioeconomic factors that influence these outcomes are unknown. We studied the association between county socioeconomic factors and HF mortality and compared it with coronary heart disease ( CHD ) mortality. Methods and Results This is a cross‐sectional analysis of socioeconomic factors and mortality in HF and CHD across 3135 US counties from 2010 to 2015. County‐level poverty, education, income, unemployment, health insurance status, and cause‐specific mortality rates were collected from the Centers for Disease Control and Prevention and US Census Bureau databases. Poverty had the strongest correlation with both HF and CHD mortality, disproportionately higher for HF ( r =0.48) than CHD ( r =0.24). HF mortality increased by 5.2 deaths/100 000 for each percentage increase in county poverty prevalence in a frequency‐weighted, demographic‐adjusted, multivariate regression model. The greatest attenuation in the poverty regression coefficient (66.4%) was seen after adjustment for prevalence of diabetes mellitus and obesity. Subgroup analysis by census region showed that this relationship was the strongest in the South and weakest in the Northeast (6.1 versus 1.4 deaths/100 000 per 1% increase in county poverty in a demographics‐adjusted model). Conclusions County poverty is the strongest socioeconomic factor associated with HF and CHD mortality, an association that is stronger with HF than with CHD and varied by census region. Over half of the association was explained by differences in the prevalence of diabetes mellitus and obesity across the counties. Health policies targeting improvement in these risk factors may address and possibly minimize health disparities caused by socioeconomic factors.

Introduction Vasodilatory shock is characterized by peripheral vasodilation, hypotension and preserved cardiac output. Management involves identifying and treating the underlying cause and reestablishing adequate blood pressure. Contemporary vasopressors include catecholamines and vasopressin, and their use is limited by adverse effects. Adjunctive use of Angiotensin II (Ang II) has been shown to increase mean arterial pressure (MAP) in patients with vasodilatory shock. We describe the first successful use of Ang II in a patient with a HM3 left ventricular assist device (VAD). Case Report 58-year-old gentleman with long-standing NICM, LV EF 20-25%, atrial fibrillation (AF), CKD stage III, recent COVID-19, presented with an ST elevation myocardial infarction and progressed to refractory cardiogenic shock. He was supported with inotropes and an intra-aortic balloon pump and implanted with a HM3. VAD course was complicated by right ventricular dysfunction, respiratory failure, and renal failure, necessitating initiation of continuous dialysis. Patient developed sepsis due to clostridium dificile colitis and pneumonia that progressed to refractory vasodilatory shock on post-op day 20. He was supported on HM3 at 5600 rpm, inotropes and escalating doses of pressors. He developed AF with rapid ventricular response, limiting further uptitration, thus, Ang II was initiated. Initial dose was 20 ng/kg/min, with a robust response in MAPs from 60s to 80s mmHg in 2 minutes. Within 24 hours he was weaned off of Ang II and within 72 hours, he was weaned off of all pressors (Table). He was subsequently transitioned to HD and weaned off of inotropic and ventilatory support. Summary Treatment options for patients with catecholamine-resistant vasodilatory shock are limited. In patients with refractory vasodilatory shock supported with durable LVAD therapies, information on the use of Ang II is limited. In our patient with multi-system organ failure and impending death, we were able to utilize Ang II to provide hemodynamic stability and rescue him from septic shock.

Introduction During the COVID-19 pandemic, there has been an increase in mortality and complications following STEMI. The rarity of ventricular septal rupture (VSR) in the age of primary percutaneous coronary intervention has resulted in a lack of expertise in its management. Our strategy has been to stabilize patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) then evaluate for surgical repair with revascularization as well as advanced options, such as heart transplantation. Here we present two cases. Case 1 A 65-year-old man with a history of hypertension presented to the hospital with an inferior STEMI and cardiogenic shock. He was found to have acute occlusion of the right coronary artery (RCA) through which a wire was not able to be passed. He also had severe disease in the left anterior descending artery (LAD) and left circumflex artery (LCx). An intra-aortic balloon pump (IABP) was placed. On hospital day 6, hemodynamics worsened and he was found to have a large VSR of the basal inferoseptum and biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 10-15%. He was placed emergently on VA ECMO. Ten days later, he underwent repair of VSR and coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to LAD, and saphenous vein graft to an obtuse marginal. He underwent ECMO decannulation on post operative day 6. He was discharged home on post operative day 23 on medical therapy with an LVEF of 35%. He remains on medical therapy at 6 months. Case 2 A 43-year-old man with a history of hypertension and diabetes suffered an inferoposterior STEMI. Coronary angiography showed acute occlusion of the RCA. He underwent thrombectomy and placement of two bare metal stents with no reflow, and placement of an IABP. He also had chronic occlusion of the LCx and 80% stenosis in the proximal LAD. A post procedure echocardiogram showed LVEF of 35-40%, severe right ventricular dysfunction, and VSR in the mid inferoseptum. He had worsening cardiogenic shock and underwent VA ECMO placement. On hospital day 9, he underwent VSR repair and single vessel CABG with LIMA to LAD. Due to inability to wean off bypass, he required placement of dual-pump biventricular support with Centrimag pumps after which he had persistent ventricular tachycardia. He was listed status 1A and underwent successful heart transplantation on hospital day 20. He is doing well at follow up. Summary We presented two cases of ventricular septal rupture complicating myocardial infarction, both with successful outcomes. During the COVID-19 pandemic, clinicians will need to maintain a high index of suspicion of mechanical complications of late presenting STEMI.

Purpose The use of durable ventricular assist devices (VADs) as bridge to transplant continues to grow. Despite an increase in overall survival, VAD therapies continue to have serious adverse events. Infection represents a significant complication that contributes to increased morbidity and mortality while awaiting heart transplantation. This is further complicated by the recent changes in the heart allocation system, which allow these patients to receive upgrade to a higher status only if they fulfill strict criteria. We aimed to determine if severe infections led to decreased 1-year survival after heart transplantation. Methods Single-center retrospective study on 120 VAD patients who received a heart transplant between 2010 and 2018. Utilizing ISHLT's 2011 standardized definitions as a framework, we developed a classification system that staged VAD related and VAD specific infections by severity. The severe VAD infection group included patients with concurrent deep driveline infections, bacteremia, and mediastinal infections. All other VAD related and VAD specific infections were classified as non-severe. Other factors analyzed included sex, device type, BMI, and HgbA1C. Student's t-test and Wilcoxon Rank Sum test were used for continuous bivariate analysis. Chi-square analysis and Fisher's exact test were used for categorical variables, with a p-value of Results Of the 120 patients, 63 had VAD related or VAD specific infections at the time of transplant. Of those 63 patients, 54 were categorized as having non-severe infections, and 9 were categorized as having severe infections. Four percent of patients in the non-severe infection group and 22% in the severe infection group died at less than one year, compared to 2% of patients without infection (p= .04). There were no significant findings when comparing survival based on sex, device type, BMI or HgbA1C. Conclusion Our findings suggest that patients with severe VAD infection have decreased survival at 1-year post-transplant compared to patients with no infection or a non-severe VAD related or VAD specific infection. These findings are pertinent as the bridge to transplant population continues to grow, especially in light of the current revised allocation system. Future studies with a larger sample size could provide more conclusive results.

Introduction With the advent of newer heart failure (HF) medications and devices such as implantable cardioverter-defibrillator (ICD), the survival benefits of long-term intravenous (IV) inotropes might be underestimated. 1-year mortality from outpatient IV inotropes (continuous and intermittent) have been reported between 25% to 47.6%. However, a study solely based on outpatient continuous inotropes for palliation has not been done in the past. This study hypothesizes that the survival rate of patients with end stage HF on palliative intravenous inotrope is better than previously expected (6 months) and may be a viable option for certain patients. Methods and Results We performed a single-center, retrospective chart review of HF patients who were discharged with an inotrope (milrinone or dobutamine) for palliation. Inclusion criteria included age > 18, diagnosis of HF, and patients discharged on inotropes after January 1, 2010. Exclusion criteria included patients who had received mechanical circulatory support (MCS) or patients who had received a heart transplant. Data were collected on 119 patients from the existing database of the Advocate Christ Medical Center's heart failure clinic. Primary outcome was survival on inotropes. Secondary outcomes included number of hospitalizations, number of clinic visits, infection rates and incidence of arrhythmia on inotrope. SAS software was used for statistical analysis. 87.38% of patients were discharged on Milrinone whereas 13.51% were discharged on dobutamine. Demographics, comorbidities, medications and devices are shown in table 1. The mean follow-up time was 255.36±23.93 days. 27.03% were alive on inotrope, 15.32% were alive but weaned off of inotrope, 18.92% were on hospice, 17.12% had expired, and 21.62% were lost to follow-up. Using product-limiting survival estimates, the unconditional probability of surviving beyond 6.5 months was 84%. Mean number of hospitalizations after discharge on inotrope was 1.92±0.25. Mean number of clinic visits in 3, 6 and 12 months were 2.61±0.26, 4.48±0.49, 7.92±0.95 respectively. The rate of peripherally inserted central catheter infection and arrhythmia were 8.11% and 9.91% respectively. Conclusions Palliative inotrope after diagnosis of end-stage heart failure is a safe option with moderate survival benefit in patients who opt out of or who do not meet criteria for MCS or transplant.

Introduction Left ventricular assist device (LVAD) implantation remains a valuable long-term option for patients with end-stage heart failure. Often these patients present with multiple comorbidities, including concomitant renal dysfunction. Patients with renal dysfunction prior to LVAD implantation are considered to be at increased risk for bleeding, right ventricular dysfunction, and mortality. Due to this increased risk, it is suggested that patients with end-stage renal disease (ESRD) should be excluded from LVAD implantation, unless they are being considered for heart and kidney transplantation. No current guidelines are provided for chronic kidney disease (CKD) stage 3-5 patients who are implanted with an LVAD. We intend to examine outcomes in these patients. Methods We retrospectively investigated all patients with CKD stage 3-5 who received a durable LVAD at our institution from January 2015 until December 2017. Those patients who underwent a second LVAD implantation or were lost to follow up were excluded from the analysis. CKD stage 3-5 was defined by eGFR Results Of the 293 patients who underwent LVAD implantation between January 2015 until December 2017, 135 were identified to have CKD stage 3-5. 82.2% of patients had CKD stage 3, 9.6% had CKD stage 4, and 8.2% had CKD stage 5. The median eGFR was 44 mL/min/1.73m3 prior to LVAD implantation and 51 mL/min/1.73m3 after implantation. 62.2% had diabetes and 76.3% had hypertension. The adverse event rates were as follows: 62.2% bleeding (including gastrointestinal bleeding, epistaxis, and mediastinal hemorrhage), 29.9% bacteremia, 22.2% hemolysis, 20% stroke, and 11.9% had home inotropes for right ventricular dysfunction. After implantation, 28.2% required renal replacement therapy (RRT). 7% of patients requiring RRT had persistent renal failure, and required hemodialysis at the time of discharge. 74% of patients were implanted as DT, and 11.9% underwent heart transplantation. The 1- year survival rate was 80.7%, with 63.7% of the cohort alive presently. Conclusions Our findings suggest that those patients with eGFR

Introduction Patients with end stage HF not responsive to GDMT are often referred for OHT. IABP are often utilized to support these patients as a bridge. Frailty has been shown to correlate with increased morbidity in such patients. Gait speed is well described in the frailty phenotype in patients with HF. We postulate that interventions to prevent or treat frailty may result in better outcomes after OHT. To that end, our center has an aggressive physical and occupational therapy program in place to assist patients with ambulation and improvement in gait speed prior to surgery. To date, no published literature describes the efficacy of ambulation in patients with femoral IABP. We review the feasibility of ambulation on femoral IABP for patients who eventually underwent OHT at our center. Methods A retrospective analysis was performed from January 2018-March 2019, which identified four patients with advanced HF who ambulated with femoral IABP prior to OHT. A KREG catalyst standing bed was utilized to advance patients (with femoral IABP) from supine immobility to in-bed tilting, standing, and finally, ambulating off the bed and into the environment with a rolling walker. The first patient was a 26 year old male with HOCM who presented in acute cardiogenic shock. He was optimized with inotropes and had a femoral IABP in place for 128 days prior to OHT. The patient progressed from standing to ambulating, and his preoperative gait speed improved from 0.23 to 1.21 m/s. He had one episode of minor bleed at the site of IABP which resolved with localized pressure. No other complications occurred. The second patient was a 58 year old male with dilated cardiomyopathy on inotropes. He had a femoral IABP for 21 days prior to OHT. He progressed from in-bed standing to ambulating, reaching a preoperative gait speed of 0.46 m/s. No complications occurred. The third patient was a 59 year old male with ICM on inotropes and high-dose diuretics. He had a femoral IABP for 43 days and improved his gait speed from 0.56 to 1.43 m/s. His IABP was displaced once, requiring a device exchange, but no other complications occurred. The fourth patient was a 38 year old male with restrictive cardiomyopathy on inotropic support. He was supported by a femoral IABP for 9 days prior to OHT and progressed from in-bed standing to ambulating, reaching a preoperative gait speed of 0.46 m/s. No complications occurred. All patients did well post-transplant. Average post-operative length of stay was 31 days. All patients walked more than 1000 feet prior to discharge. Conclusions From our small sample size of four patients ambulating with femoral IABP who eventually underwent OHT, we believe ambulation of such patients is safe and feasible. A larger sample size is needed to establish which patients are safe for ambulation with a femoral IABP and if this method can improve patient outcomes.

Introduction Cardiogenic shock requiring mechanical circulatory support as a bridge to recovery continues to pose challenges. For patients who are unable to be weaned off of temporary device support, durable assist devices are an option. Unfortunately, patients receiving durable biventricular ventricular assist devices (BiVADs) represent a critically ill population with high operative mortality and RVAD thrombosis rates. Case A 58 year-old male with hypertension underwent an elective laparoscopic hemicolectomy. Post-surgery, he developed chest pain. ECG showed an anterior STEMI and transthoracic echocardiogram revealed a new ejection fraction of 30% with anterolateral and lateral wall hypokinesis. Cardiac catheterization revealed a 100% occluded left anterior descending artery, which prompted percutaneous coronary intervention and intra-aortic balloon placement. Due to worsening hemodynamics, he required emergent central veno-arterial extracorporeal membrane oxygenation (VA ECMO) placement. Due to sustained ventricular fibrillation and biventricular dysfunction on VA ECMO, he underwent ECMO revision, with placement of temporary CentriMag BiVADs. After 60 days of inability to wean temporary biventricular support, durable Medtronic Heartware BiVADs were placed as bridge to transplant. One week after durable BiVAD placement, patient developed low flows on the RVAD and profound hypoxia. He was taken to operating room emergently, and was found to have RVAD thrombosis and an apical ventricular septal defect (VSD). The RVAD was replaced and the VSD was repaired. After 18-months on BiVAD support he had a successful orthotropic heart transplant and continues to do well post-transplant. Conclusion Our case demonstrates challenges associated with selecting appropriate mechanical circulatory support devices for adequate cardiovascular support and navigating potential device related complications. Frequent reassessment is necessary to impact positive outcomes in this critically ill patient population.

Purpose Left ventricular assist device (LVAD) therapy improves survival and quality of life in patients with advanced systolic heart failure. Right heart failure (RHF) is not uncommon following LVAD implantation and is associated with poor prognosis. Management of RHF post LVAD often involves inotropic therapy. Refractory RHF may require discharge on home inotropes. Outcomes in LVAD patients discharged on inotropic therapy has not been well studied. We report our experience with LVAD patients discharged home on inotropic therapy. Methods We retrospectively reviewed 520 durable LVAD implants at our center between 1/1/13 and 4/1/18. All patients discharged on home inotropic therapy following LVAD implantation were included. Age, device type, duration of inotropic therapy, infection, ICD shocks, rehospitalizations, and outcomes were recorded. Results 39 LVAD patients were discharged on inotropic therapy and included in this analysis. The average age was 56.7±13.6 years. 31 (79%) were male. 20 (51%) patients were implanted as destination therapy (DT). We included 16 (41%) patients with HeartWare LVADs and 28 with HeartMate2 LVADs. Average time on device support was 950±523 days. Average time on inotropes was 319±236 days. 6 patients (15%) had initiation of inotropes during index admission (early RHF), while the remaining patients had late RHF. Average time from implant to initiation of inotropes was 474±453 days. 18 (46%) patients developed PICC line site infections and 29 (74%) patients developed bacteremia. 21 (54%) patients developed driveline infections. There was a total of 246 readmissions following inotrope initiation. 18 (46%) patients received ICD shocks while on inotropic therapy. 11 (28%) patients died on inotropes at an average of 325±251 days from initiation of inotropes with RHF being the primary cause of death in 9 (81%) patients. Nine (23%) patients underwent successful heart transplantation. Conclusion Home inotropic therapy following LVAD implantation is associated with significant risk. Infections, including PICC line infections and bacteremia occurred at high rates. Late RHF was more common than early RHF. Overall, there is a high morbidity and mortality associated with home inotropic therapy post-LVAD. Further analysis of post-LVAD care may provide insight regarding opportunities to avoid late RHF given the lack of viable options for its management.

Purpose Patient selection for durable ventricular assist device (VAD) involves a comprehensive medical and psychosocial evaluation. Although there are guidelines for evaluation of medical comorbidities, psychosocial risk assessment remains somewhat subjective. There is ongoing concern that patients may be denied VAD due to perceived high-risk psychosocial characteristics that may not impact survival after VAD implantation. The purpose of this study was to evaluate the patient psychosocial risk profile and its impact on outcomes after VAD implantation. Methods This study was a single center, retrospective analysis of 93 patients who underwent durable VAD implantation at Advocate Christ Medical Center in 2016. Psychosocial factors on outcomes were evaluated using the Student's t-test, Fischer's exact test, and one-way analysis of variance. Results Of 93 patients, mean age was 55 ± 13 years, 73% were males, 46% were African American, 69% had non-ischemic cardiomyopathy, and 60% received destination therapy. Most prevalent psychosocial factors were: 27% had a pre-existing psychiatric diagnosis, 53% were not married, 22% had no children, 11% lived alone, 19% did not complete a high school education, 26% were chronically unemployed, 55% formerly abused tobacco, 13% formerly abused alcohol, and 24% formerly abused illicit drug. Mean days on device was 589 ± 321, mean number of readmissions within the first year was 2.5 ± 2.6, and mean number of days to first readmission was 80 ± 91. Those with less than a high school education were 55% more likely to experience an adverse event (driveline infection, bacteremia, stroke, hemolysis, GI bleed, other bleed) compared to those with a graduate level education (p Conclusion These results suggest that certain psychosocial factors may not influence mortality or adverse event rates after VAD implantation. Although, education level impacted adverse event rates, further delineation is required. A larger sample size is needed to elucidate exactly which psychosocial characteristics affect VAD outcomes.

A coronary artery anomaly (CAA) is a rare finding in orthotropic heart transplant (OHT). CAAs are benign and the incidence is 0.7-1.96%, but surgery may be needed in malignant courses. A malignant, or interarterial course, refers to a coronary artery coursing between the aorta and the pulmonary

Source Citation Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrill...