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Background: Bioprosthetic surgical aortic valve replacement (SAVR) using the Trifecta valve was frequently chosen because of its large opening area and low transvalvular gradient. However, long-term follow-up revealed the potential for early structural valve deterioration. To further assess the long-term clinical outcomes and management considerations for patients implanted with the Trifecta valve, a real-world study using Medicare fee-for-service claims data was conducted with a focus on Trifecta valve reintervention., Methods: De-identified patients undergoing SAVR with the Trifecta™ valve (Abbott) in the U.S. between 1/1/2011-12/31/2021 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality and freedom from Trifecta valve reintervention with repeat SAVR or valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) were evaluated at 10-years using the Kaplan Meier method. Independent predictors for reintervention and clinical outcomes following reintervention were assessed., Results: Among 242,160 Medicare beneficiaries undergoing SAVR during the study period, 23,197 were implanted with the Trifecta valve. Mean age was 75.2 ± 7.4 years. At 10-years survival was 32.3 % (95 % CI, 31.4 %-33.3 %) and the freedom from valve reintervention was 82.4 % (95 % CI, 81.1 %-83.5 %). Independent predictors for reintervention included younger age, female, obesity, and implants with a small valve size (19 mm, 21 mm). Reintervention with ViV-TAVI (N = 796) was associated with better operative survival (3.8 % vs. 12.5 %, p < 0.001) than repeat SAVR (N = 577)., Conclusion: This real-world nationwide study of Medicare beneficiaries receiving the Trifecta valve demonstrates >80 % freedom from all-cause valve reintervention at 10-years post-implant with reintervention using ViV-TAVI having improved operative survival compared to repeat SAVR., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dan Gutfinger reports financial support was provided by Abbott. Dan Gutfinger reports a relationship with Abbott that includes: employment and equity or stocks. Ibrahim Sultan reports institutional research support from Abbott, Atricure, Artivion, Gore, Edwards, Medtronic, and Terumo Aortic. Gorav Ailawadi reports consulting with Abbott, Anteris, Arthrex, Atricure, Avania, Capstan, Edwards, JenaValve, Johnson & Johnson, Medtronic, Nyra, Philips, and WL Gore. Danny Ramzy reports consulting with Abbott. Tsuyoshi Kaneko reports consulting with Abbott. Yang Yu reports a relationship with Abbott that includes: employment and equity or stocks. Geetanjali Meka reports a relationship with Abbott that includes: employment. Julie B. Prillinger reports a relationship with Abbott that includes: employment and equity or stocks. Joseph E. Bavaria reports consulting with Abbott., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background/Objectives : Minimally invasive techniques for mitral valve repair have evolved over the past thirty years and include mini-thoracotomies and the robotic platform. This study provides a historical perspective on minimally invasive mitral valve approaches and evaluates long-term outcomes of a large series of robotic mitral valve repairs. Methods : A single-institution, prospectively maintained registry was used to evaluate robotic mitral valve repairs performed by four surgeons from 2005 to 2023. There were 1412 robotic mitral valve repairs performed during this time and stratified by the first 120 and subsequent patients. We evaluated operative outcomes and freedom from more than 2+ mitral regurgitation at five years as well as ten-year survival. Results : Of the 1412 robotic mitral valve repairs performed, 93.6% ( n = 1322) were for degenerative disease. Compared to the first 120 patients, the subsequent patients had a significant reduction in cross-clamp time (112 (IQR = 103-130) versus 75 (IQR = 65-88) min) and cardiopulmonary bypass time (153.5 (IQR = 134.5-177.5) versus 116 (IQR = 103-136) min), and all with p < 0.01. The majority of patients had posterior leaflet prolapse (65.6%, n = 926). The repair rate was 98.1%, n = 1385. Survival at ten-year follow-up for the patients included in the first 120 procedures was 91.5% (95% confidence interval (CI) = 86.4-96.6%) versus 92.8% (95% CI = 91.7-93.9%) for the patients who were in the latter group, p = 0.58. Freedom from >2+ mitral regurgitation at 5 years was 97.0% (95% CI = 95.3-98.7%) for the patients in the first 120 procedures and 92.7% (95% CI = 91.5-93.9%), p = 0.22, for those in the latter group. Conclusions : The robotic platform offers an excellent durable repair for mitral regurgitation in our experience of over 1400 patients. The robotic platform for mitral valve repair offers a teachable and safe approach to mitral valve disease for patients.

Aortic lesions, exemplified by bicuspid aortic valves (BAVs), can complicate congenital heart defects, particularly in Turner syndrome patients. The combination of BAV, dilated ascending aorta, and an elongated aortic arch presents complex hemodynamics, requiring detailed analysis for tailored treatment strategies. While current clinical decision-making relies on imaging modalities offering limited biomechanical insights, integrating high-performance computing and fluid-structure interaction algorithms with patient data enables comprehensive evaluation of diseased anatomy and planned intervention. In this study, a patient-specific workflow was utilized to biomechanically assess a Turner syndrome patient's BAV, dilated ascending aorta, and elongated arch. Results showed significant improvements in valve function (effective orifice area, EOA increased approximately twofold) and reduction in valve stress (~ 1.8-fold) following virtual commissurotomy, leading to enhanced flow dynamics and decreased viscous dissipation (~ twofold) particularly in the ascending aorta. However, increased viscous dissipation in the distal transverse aortic arch offset its local reduction in the AAo post-intervention, emphasizing the elongated arch's role in aortic hemodynamics. Our findings highlight the importance of comprehensive biomechanical evaluation and integrating patient-specific modeling with conventional imaging techniques for improved disease assessment, risk stratification, and treatment planning, ultimately enhancing patient outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: To date, there is a lack of studies conducted on males with secondary azoospermia as a potential cause of male infertility who had previously fathered children through natural conception. The current study aims to investigate the potential causes of secondary azoospermia as a presentation of male infertility as well as the prognostic factors that can impact sperm retrieval rate (SRR) while undergoing microdissection testicular sperm extraction (microTESE)., Results: Thirty two patients were recruited from the andrology outpatient clinic from August 2023 till January 2024. The mean age of the patients was sixty-two years old. All patients had varicoceles. Twenty seven patients (84%) had palpable varicocele grade 2 and 3 on both sides. Further multivariate logistic regression analysis of the significant factors in the univariate regression revealed that younger age (OR 0.7, 95% C.I. 0.7-1.0, p = 0.03) and having a history of coronary artery disease (CAD) were predictable factors for negative TESE outcome (OR 123.1, 95% C.I. 3.2-4748.5, P = 0.01)., Conclusion: It appears that the etiopathogenesis of secondary azoospermia are multifactorial. Varicocele and CAD are major factors to be considered. Future studies should be implemented deploying larger pools of patients suffering from the same condition to affirm the findings of this primary study., (© 2024. The Author(s).)

Objective: Routine left atrial appendage closure during mitral repair in patients without atrial fibrillation (AF) is controversial. We aimed to compare the incidence of stroke after mitral repair in patients without recent AF according to left atrial appendage closure., Methods: An institutional registry identified 764 consecutive patients without recent AF, endocarditis, prior appendage closure, or stroke undergoing isolated robotic mitral repair between 2005 and 2020. Left atrial appendages were closed via left atriotomy using a double-layer continuous suture in 5.3% (15 out of 284) patients before 2014, versus 86.7% (416 out of 480) after 2014. The cumulative incidence of stroke (including transient ischemic attack) was determined using statewide hospital data. Median follow-up was 4.5 years (range, 0-16.6 years)., Results: Patients undergoing left atrial appendage closure were older (63 vs 57.5 years, P < .001), with higher prevalence of remote AF requiring cryomaze (9%, n = 40 vs 1%, n = 3, P < .001). After appendage closure there were fewer reoperations for bleeding (0.7% [n = 3] vs 3% [n = 10]; P = .02), and more AF (31.8% [n = 137] vs 25.2% [n = 84]; P = .047). Two-year freedom from >2+ mitral regurgitation was 97%. Six strokes and 1 transient ischemic attack occurred after appendage closure compared with 14 and 5 in patients without (P = .002), associated with a significant difference in 8-year cumulative incidence of stroke/transient ischemic attack (hazard ratio, 0.3; 95% CI, 0.14-0.85; P = .02). This difference persisted in the sensitivity analysis, excluding patients undergoing concomitant cryomaze procedures., Conclusions: Routine left atrial appendage closure during mitral repair in patients without recent AF appears safe and was associated with a lower risk of subsequent stroke/transient ischemic attack., (Copyright © 2023. Published by Elsevier Inc.)

Objectives: National registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR., Methods: A prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk., Results: Repair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P < .05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P < .01)., Conclusions: A near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up., (Copyright © 2022. Published by Elsevier Inc.)

Background: The risks and benefits of desensitization therapy (DST) in highly sensitized mechanical circulatory support (MCS) patients are not well known. We investigated 3 year post-transplant outcomes of desensitized durable MCS patients., Methods: Among 689 consecutively enrolled heart transplantation recipients between 2010 and 2016, we categorized them into Group A (desensitized MCS patients, n = 21), Group B (desensitized non-MCS patients, n = 28) and Group C (all nondesensitized patients, n = 640). Post-transplant outcomes included the incidence of primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, antibody mediated rejection (AMR) and infectious complications., Results: The types of DST in Groups A and B were similar and included combinations of rituximab/intravenous immunoglobulin and plasmapheresis/bortezomib. Group A, compared with Group B, showed significantly higher pre-DST panel reactive antibody (PRA) (92.2 ± 9.8 vs. 83.3 ± 15.6, P = 0.007) and higher PRA reduction after DST (-22.2 ± 26.9 vs. -6.3 ± 7.5, P = 0.015). Groups A and C showed comparable primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, and AMR. Although statistically not significant, Group A showed numerically higher 3-year freedom from AMR than Group B. Infectious complications were similar in both Groups A and B., Conclusions: DST for MCS patients showed significant PRA reduction, resulting in an expansion of the donor pool. The post-transplant outcome of desensitized MCS patients showed comparable clinical outcomes to non-desensitized control patients in the same study period, revealing the safety and efficacy of DST., Competing Interests: Disclosure statement This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Ministry of Science and ICT (NRF-2021R1F1A1063430), by the Catholic Medical Center Research Foundation (2023) and by the grant from the Korean Society for Transplantation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. D.H.C. received research grants from Amgen, Biocardia, and Mesoblast and has moderate stock interest in Abbot Laboratories, Abbvie Inc., Repligen Corporation, Amarin Corporation, and Portola Pharmaceuticals. J.K.P. received research grants from Alexion Pharmaceuticals, Pfizer, Alnylam Pharmaceuticals, and Astra Zeneca. J.D.M. received research grant from SynCardia, honoraria from Abiomed, and a consultancy fee from Medtronic Vascular. D.R. received research grants from Abiomed, Cardiac Assist, Inc., and Thoratec LLC, a consultancy fee from Abbot Laboratories and Baxter Healthcare, and non-financial support from Medtronic Vascular. F.E. received research grant from TransMedics Inc. J.A.K. received research grants from CareDx Inc., Sanofi-Genzyme, and CSL-Behringer. All other authors have no conflicts of interest to disclose., (Copyright © 2023 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

A redesigned surgically implanted heart pump incorporates several design changes from the prior device generation, but no published comparative data demonstrate if these changes translate to improved outcomes. We retrospectively compared clinical characteristics and outcomes, drawn from an FDA-mandated QA database, for contemporary patients treated with the Impella 5.5 or Impella 5.0 for acute myocardial infarction complicated by cardiogenic shock (AMICS), cardiomyopathy, or postcardiotomy cardiogenic shock (PCCS). A total of 1238 patients at 290 US sites were included for analysis. Patients receiving the Impella 5.5 had significantly higher survival through explant (i.e., successfully weaned or bridged to heart replacement therapy) than those receiving the Impella 5.0 in all 3 settings: AMICS (70.5% vs 56.8%; p = 0.005), cardiomyopathy (88.1% vs 76.9%; p = 0.001), and PCCS (76.1% vs 55.7%; p = 0.003). Duration of support was significantly longer for Impella 5.5 patients with AMICS (9.2 vs 6.1 days; p = 0.008) and cardiomyopathy (10.7 vs 8.1 days; p < 0.001)., Competing Interests: Disclosure statement D.R. reports honoraria from Abiomed, Medtronic, and Abbott. E.G. Soltesz reports honoraria from Abiomed. S.S. reports consulting fees from Abbott and Abiomed. M.D. reports funding for clinical trial work to the institution from Abiomed, Abbott, and TransMedics; travel support from Abbott and Abiomed for HM3 and Impella 5.5 Users Meetings, respsectively. M.K. reports consulting fees from Abiomed and CareDx. D.A.D'A. reports honoraria from Abiomed and Paragonix. Auxiliary medical writing services were provided by the device manufacturer (acknowledged above)., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

At a time when transplantable organs are in a shortage, few cases have noted the reuse of donor hearts in a second recipient in an effort to expand the donor network. Here, we present a case in which an O Rh-positive donor heart was first transplanted into a B Rh-positive recipient and later successfully retransplanted into a second O Rh-positive recipient 10 days after the initial transplant at the same medical center. On postoperative day 1, the first recipient, a 21-year-old man with nonischemic cardiomyopathy, sustained a devastating cerebrovascular accident with progression to brain death. With preserved left ventricle and mildly depressed right ventricle function, the heart was allocated to the second recipient, a 63-year-old male patient with familial restrictive cardiomyopathy. The bicaval technique was used, and the total ischemic time was 100 minutes. His postoperative course was uncomplicated with no evidence of rejection on 3 endomyocardial biopsies. Follow-up transthoracic echocardiogram revealed a left ventricular ejection fraction of 60% to 70%. Seven months posttransplant, the second recipient was doing well with appropriate left and right ventricular function. With careful organ selection, short ischemic time, and proper postoperative care, retransplant of donor hearts may be an option for select patients in need of heart transplant., (© 2023 by the Texas Heart® Institute, Houston.)

In patients with severe cardiogenic shock, temporary mechanical circulatory support has become a viable strategy to bridge patients to heart transplantation. However, end-stage heart failure is often associated with progressive organ dysfunction of the liver or kidney. This can require a dual organ transplant for definitive management (combined heart-liver [HL] or heart-kidney [HK] transplantation). We evaluated temporary mechanical support to bridge patients to HL or HK transplant at a single, high-volume center. All patients who underwent Impella 5.0 placement from January 2014 to October 2018 were identified. From this dataset, patients who underwent placement as a bridge to dual organ transplant were selected, as were those who underwent Impella as a bridge to isolated heart transplant. Over the 5 years of evaluation, 104 patients underwent Impella 5.0 placement. Of these, 14.3% (n = 15) were identified as potential dual organ recipients (11 HK, 4 HL). In total, 80% (12/15) successfully underwent dual organ transplant (8 HK, 4 HL), with a 1-year survival of 100% in both transplanted groups. Among patients undergoing Impella 5.0 placement as a bridge to isolated heart transplant (n = 33), 78.8% (26) were successfully bridged, and 1-year survival was 92% after transplantation. Impella 5.0 is a viable bridge to dual organ transplantation and should be considered as a management strategy in these complex patients at experienced institutions., Competing Interests: Disclosure: D.E. and D.R. report a financial relationship with Abiomed, Inc. A.R. is supported by a grant from the National Institutes of Health for advanced heart disease research (T32HL116273). Other authors have no conflicts of interest to report., (Copyright © ASAIO 2022.)

The application of robot-assisted thoracoscopy to cardiac surgery affords an opportunity to leverage the exceptional intraoperative exposure, visualization, and dexterity of the robotic platform. Here, we report the case of a 72-year-old woman who presented to our institution for evaluation of a left ventricular mass that was identified following workup for an embolic event. We present an intraoperative video that provides technical details of the robot-assisted resection of the lesion, which was found to be a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus. This case highlights the advantages provided by the robotic platform, which permitted complete, minimally invasive surgical excision of the lesion while minimizing the burden of surgical trauma.

We aimed to investigate the characteristics and outcomes of HTx recipients with a history of pretransplant malignancy (PTM). Among 1062 HTx recipients between 1997 and 2013, 73 (7.1%) patients had PTMs (77 cancer cases). We analyzed post-HTx outcome, recurrence of PTM, and development of de novo malignancies. Post-HTx outcome included overall survival, 10-year survival, 10-year freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Four most common PTMs were lymphoproliferative disorders (18.2%), prostate cancers (18.2%), non-melanoma skin cancers (18.2%), and breast cancers (13.0%). Median time from PTM and HTx was 9.0 years. During a median follow-up of 8.6 years after HTx, patients with PTM, compared to those without, showed significantly higher incidence of posttransplant malignancies (43.8% vs. 20.8%, p < .001) including 9.6% (n = 7) of PTM recurrences. However, patients with PTM, compared to those without, showed comparable overall survival, 10-year survival, 10-year freedom from CAV, NF-MACE, ATR, ACR, and AMR. Therefore, a history of PTM should not disqualify patients from HTx listing, while further research is necessary for early detection of posttransplant malignancies in these patients., (© 2022 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Purpose: Heart transplantation remains limited by donor availability. Currently, only some programs accept older donors, and their use remains contentious. We compared outcomes of heart transplant recipients who received donor hearts ≥55 years with those who received donor hearts <55 years., Methods: Records of first-time adult heart transplant recipients between 2010 and 2019 were reviewed. Endpoints included 30-day and 1-, 3-, and 5-year survival; freedom from cardiac allograft vasculopathy; freedom from nonfatal major adverse cardiac events; and freedom from any rejections. The effect of donor age ≥55 years was analyzed with Cox proportional hazards modeling, 1:2 propensity score matching, and Kaplan-Meier survival analysis., Results: Sixty-six patients received donor hearts ≥55 years and 766 received donor hearts <55 years. In the unmatched cohort, there was no significant difference in survival between the 2 groups at 30 days (93.9% vs 97.3%, P = .127), 1 year (87.9% vs 91.6%, P = .325), 3 years (86.4% vs 86.5%, P = .888), or 5 years (78.8% vs 83.8%, P = .497). The ≥55 years group had a significantly lower freedom from cardiac allograft vasculopathy and fatal major adverse cardiac events. In propensity-matched patients, recipients of donors ≥55 years had similar survival and freedom from cardiac allograft vasculopathy but significantly lower 1-year (76.7% vs 88.3%, P = .026), 3-year (68.3% vs 84.2%, P = .010), and 5-year (63.3% vs 83.3%, P = .002) freedom from nonfatal major adverse cardiac events when compared to recipients of younger donors., Conclusions: Carefully selected older donors can be considered for a carefully selected group of recipients with acceptable outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Post-transplant malignancy (PTM) causes long-term morbidity and mortality in heart transplant (HTx) recipients. However, the detailed characteristics or predictors of PTM are not well-known. We evaluated the incidence, characteristics, long-term outcomes, and predictors of de novo PTM using a single center large-volume database., Methods: We retrospectively analyzed the types and characteristics of de novo PTM in 989 patients who underwent HTx. Univariate and multivariate logistic regression analyses were used for the PTM prediction model., Results: Two hundred and six patients (20.8%) had de novo PTMs (241 cancers) during a median follow-up of 11.5 years. PTM patients were older than non-PTM patients, received immunosuppressive therapy for a longer period, and were more likely to be male and white. Skin cancers were the most frequent types of malignancy (60.6%) followed by prostate (9.5%), lung (7.1%), and breast (4.1%) cancers. Although most cancers (88.8%) were surgically resected at initial presentation, about half (47.3%) recurred or progressed. Patients with skin cancer and non-skin cancer had significantly lower overall survival ( P < 0.001) than patients without cancer. Older age ( P < 0.001), white race ( P = 0.001), and longer time receiving immunosuppressive therapy ( P < 0.001) were independent predictors for PTM., Conclusion: Older age, white race, and longer administration of immunosuppressive therapies were independent risk factors for PTM, which was associated with increased mortality. Further research is necessary for the prevention and early detection of PTM in HTx recipients., Competing Interests: DC received research grants from Amgen, Biocardia, and Mesoblast and has moderate stock interest in Abbot Laboratories, Abbvie Inc, Repligen Corporation, Amarin Corporation, and Portola Pharmaceuticals. JP received research grants from Alexion Pharmaceuticals, Pfizer, Alnylam Pharmaceuticals, and Astra Zeneca. DR received research grants from Abiomed, Cardiac Assist, Inc., and Thoratec LLC, consultancy fees from Abbot Laboratories and Baxter Healthcare, and non-financial support from Medtronic Vascular. FE received a research grant from TransMedics Inc. JK received research grants from CareDx Inc., Sanofi-Genzyme, and CSL-Behringer. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Youn, Kim, Kim, Lee, Choi, Jeon, Nishihara, Kransdorf, Chang, Kittleson, Patel, Ramzy, Esmailian and Kobashigawa.)

We present a case of rapidly growing disseminated Mycobacterium tuberculosis (MTB) that presented as an empyema necessitans (EN) in a 65-year-old woman with a single right lung transplant admitted for progressive dyspnea. While hospitalized, she had daily fevers and was found to have a right-sided chest wall abscess and pleural effusion. Acid-fast bacilli cultures from the abscess and pleural fluid grew MTB within 4 and 6 days, respectively. Blood cultures later grew MTB as well. Upon initiation of rifampin, isoniazid, pyrazinamide, and ethambutol, she developed hemorrhagic pancreatitis and distributive shock secondary to antituberculosis medications and disseminated MTB. Noteworthy features of this case include the rapid rate of MTB culture growth in less than a week, the development of a likely donor-derived MTB EN, and the clinical challenges of MTB screening and MTB infection management in a solid organ transplant recipient.

Background: Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique., Methods: An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005 and 2020: 87% (n = 902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior or bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from greater than 2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years., Results: Of patients with isolated posterior leaflet prolapse, 87% (n = 506) had standardized repairs and 13% (n = 76) had additional or nonresectional techniques vs 24% (n = 65) and 76% (n = 203), respectively, for anterior or bileaflet prolapse (P < .001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n = 50) and commissural sutures (3.4%, n = 20). Overall, median clamp time was 80 (interquartile range, 68-98) minutes, 17 patients required intraoperative re-repair, and 6 required mitral replacement. Freedom from greater than 2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (vs 83% for anterior or bileaflet prolapse). Anterior or bileaflet prolapse was associated with late greater than 2+ regurgitation (hazard ratio, 3.0; 95% confidence interval, 1.3-7.0)., Conclusions: Posterior leaflet prolapse may be repaired in greater than 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse preoperatively., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The COVID-19 pandemic initially brought forth considerable challenges to the field of heart transplantation. To prevent the spread of the virus and protect immunocompromised recipients, our center made the following modifications to post-transplant outpatient management: eliminating early coronary angiograms, video visits for postoperative months 7, 9, and 11, and home blood draws for immunosuppression adjustments. To assess if these changes have impacted patient outcomes, the current study examines 1-year outcomes for patients transplanted during the pandemic. Between March and September 2020, we assessed 50 heart transplant patients transplanted during the pandemic. These patients were compared to patients who were transplanted during the same months between 2011 and 2019 (n = 482). Endpoints included subsequent 1-year survival, freedom from cardiac allograft vasculopathy, any-treated rejection, acute cellular rejection, antibody-mediated rejection, nonfatal major adverse cardiac events (NF-MACE), and hospital and ICU length of stay. Patients transplanted during the pandemic had similar 1-year endpoints compared to those of patients transplanted from years prior apart from 1-year freedom from NF-MACE which was significantly higher for patients transplanted during the pandemic. Despite necessary changes being made to outpatient management of heart transplant recipients, heart transplantation continues to be safe and effective with similar 1-year outcomes to years prior., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Patients with cardiogenic shock may require extracorporeal membrane oxygenation (ECMO) prior to durable mechanical circulatory support (dMCS) or heart transplantation (HTx)., Methods: We investigated the clinical characteristics and outcomes of adult patients with ECMO support as bridge to dMCS or HTx between 1/1/13 and 12/31/20., Results: Of 57 patients who underwent bridging ECMO, 41 (72%) received dMCS (approximately half with biventricular support) and 16 (28%) underwent HTx, 13 (81%) after the 2018 UNOS allocation system change. ECMO → HTx patients had shorter ventilatory time (3.5 vs 7.5 days; p  = 0.018), ICU stay (6 vs 18 days; p  = 0.001), and less need for inpatient rehabilitation (18.8% vs 57.5%; p  = 0.016). The 1-year survival post HTx was 81.3% in the ECMO → HTx group and 86.4% in the ECMO → dMCS group ( p  = 0.11). For those patients in the ECMO → dMCS group who did not undergo HTx, 1-year survival was significantly lower, 31.6% ( p  = 0.001)., Conclusion: Patients on ECMO who undergo HTx, with or without dMCS bridge, have acceptable post-HTx survival. These findings suggest that HTx from ECMO is a viable option for carefully selected patients deemed acceptable to proceed with definitive advanced therapies, especially in the era of the new UNOS allocation system.

Introduction: The Organ Care System (OCS) is an ex vivo perfusion platform for donor heart preservation. Short/mid-term post-transplant outcomes after its use are comparable to standard cold storage (CS). We evaluated long-term outcomes following its use., Methods: Between 2011 and 2013, 38 patients from a single center were randomized as a part of the PROCEED II trial to receive allografts preserved with CS (n = 19) or OCS (n = 19). Endpoints included 8-year survival, survival free from graft-related deaths, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejections., Results: Eight-year survival was 57.9% in the OCS group and 73.7% in the CS group (p = .24). Freedom from CAV was 89.5% in the OCS group and 67.8% in the CS group (p = .13). Freedom from NF-MACE was 89.5% in the OCS group and 67.5% in the CS group (p = .14). Eight-year survival free from graft-related death was equivalent between the two groups (84.2% vs. 84.2%, p = .93). No differences in rejection episodes were observed (all p > .5)., Conclusions: In select patients receiving OCS preserved allografts, late post-transplant survival trended lower than those transplanted with an allograft preserved with CS. This is based on a small single-center series, and larger numbers are needed to confirm these findings., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Mitral valve repair is infrequently performed in patients undergoing corrective surgery for failed mitral transcatheter edge-to-edge repair in current United States practice. This article describes surgical techniques for reconstructive surgery after failed transcatheter edge-to-edge repair. Nine patients underwent robotic-assisted mitral surgery after failed transcatheter edge-to-edge repair between 2008 and 2020 at a single center. Repair was completed in 88.9% (n = 8) patients, and freedom from >2+ mitral regurgitation was 87.5% (n = 7) at a median follow-up of 1.9 years., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients., Methods: Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR)., Results: Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01)., Conclusions: Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Mechanical circulatory support device (MCSD) patients with positive heparin-induced thrombocytopenia (HIT) screening pose a unique challenge, as clinicians must make rapid decisions about their anticoagulation and whether they can safely undergo cardiopulmonary bypass. We identified screening practices at our institution and other institutions nationwide that differed from American Society of Hematology (ASH) guidelines. This discovery prompted a data review to confirm the applicability of guidelines to this unique population and to highlight complications of "gestalt" screening., Methods: Our study included MCSD patients with HIT testing from April 2014 to August 2020. We evaluated 510 PF4 IgG ELISA results., Results: HIT was confirmed in 4.2% of patients. There was an increased prevalence of HIT in patients with nondurable (5.3%) vs durable devices (2.9%) or those in the preimplantation setting (1.3%), however this difference was not statistically significant (p = 0.26). None of the patients with a low probability 4T Score had HIT. All patients with a high probability 4T Score and PF4 immunoassay OD >2.0 had HIT. False positive results occurred in 22% of assays ordered for patients with a low probability 4T Score. Twelve patients with a low probability 4T Score and a false positive immunoassay were switched to a direct thrombin inhibitor (DTI) while awaiting confirmatory results. Two patients experienced clinically significant bleeding after conversion to a DTI. An organ was refused in one patient with false positive HIT screening., Conclusions: Our findings demonstrate that an opportunity exists to improve clinical outcomes by re-emphasizing the utility of established guidelines and highlighting their safe use in the MCSD patient population., Competing Interests: Disclosure statement Lawrence Czer MD receives current/ongoing grant support made to his institution from Abbot Laboratories. Dominic Emerson MD is a member of the Speaker's Bureau and receives current/ongoing payment from Abiomed. Fardad Esmailian MD is a consultant and receives current/ongoing grant support from Edwards Life Sciences. Current/ongoing grant support is made to his institution from TransMedics. Danny Ramzy MD is a consultant for Abbot Laboratories, a member of the Speaker's Bureau for Abiomed and LivaNova, and a travel education grant recipient from Medtronic. Current/ongoing payments are made to him from these companies. His institution receives grant support from LivaNova. No other authors have conflicts of interest to disclose., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD., Methods: We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression., Results: PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD., Conclusions: Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed., Competing Interests: Disclosures No authors have financial relationships relevant to this work., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: To report the initial clinical experience with the Impella 5.5 ® with SmartAssist ® , a temporary left ventricular assist device that provides up to 6.2 L/min forward flow, with recent FDA approval for up to 14 days., Methods: From October 2019 to March 2020, 200 patients at 42 US centers received the Impella 5.5 and entered into the IQ registry, a manufacturer-maintained quality database that captures limited baseline/procedural characteristics and outcomes through device explant. Post hoc subgroup analyses were conducted to assess the role of baseline and procedural characteristics on survival, defined as successful device weaning or bridge to durable therapy., Results: Median patient age was 62 years (range, 13 to 83 years); 83.4% were male. The device was most commonly used for cardiomyopathy (45.0%), acute myocardial infarction complicated by cardiogenic shock (AMICS; 29.0%), and post cardiotomy cardiogenic shock (PCCS; 16.5%). Median duration of support was 10.0 days (range, 0.001 to 64.4 days). Through device explant, overall survival was 74.0%, with survival of 80.0%, 67.2%, 57.6%, and 94.7% in cardiomyopathy, AMICS, PCCS, and others (comprising high-risk revascularization, coronary artery bypass graft, electrophysiology/ablation, and myocarditis), respectively. Patients requiring extracorporeal membrane oxygenation and Impella support (35 patients, 17.5%) had significantly lower survival (51.4% vs 78.8%, P = 0.002)., Conclusions: In the first 200 US patients treated with the Impella 5.5, we observed overall survival to explant of 74%. Survival outcomes were improved compared to historic rates observed with cardiogenic shock, particularly PCCS. Prospective studies assessing comparative performance of this device to conventional strategies are warranted in future.