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Purpose: Donation after cardiac death (DCD) from Maastrict category 3 donors consisted of approximately 12% of our lung transplant activity in 2008. We will review the results of our DCD lung transplants and discuss the future direction of the program at St Vincent's Hospital. Methodology: Since commencing in November 2007 there have been 19 referrals for DCD, leading to 9 attempted retrievals. Only seven retrievals resulted in lung donation. Elective withdrawal of life-sustaining support and certification of death (limit of 60 minutes from withdrawal) occurred in the Intensive Care Unit or Operating Theatre. Results: The donor group average age was 34 years (range 14–56) and average PaO2/FiO2 ratio 407 (±57). Causes of death included subarachnoid haemorrhage (2), Traumatic head injury (2), hypoxic brain injury (2) and embolic CVA (1). Average recipient age was 32 years (range 15–61) and aetiology of respiratory failure included cystic fibrosis (2), bronchiectasis (1), bronchiolitis obliterans (1), emphysema (1), interstitial lung disease (1) and pulmonary hypertension (1). Mean time to asystole after withdrawal of treatment was 23 minutes (range 9–57), mean warm ischaemic time 19 minutes (range 10–31) and mean cold ischaemic time (left lung) 275 minutes (range 241–320). Early gas exchange was good: an average PaO2/FiO2 of 324 (141–503). Average intensive care stay was 5 days (3–10) and length of stay 23 days (12–36). All patients are still alive. Conclusion: Despite the period of warm ischaemia the early results are excellent. Future challenges will present when the program considers donors with longer warm ischaemic times and more “marginal” gas exchange. [ABSTRACT FROM AUTHOR]

Competing Interests: Disclosures Angela Velleca None Michael A Shullo Consulting- Natera Kumud Dhital None Estela Azeka MD None Monica Colvin MD Grants- Natera-Grant funding; Advisory board- Natera; Consulting- Mescape Eugene DePasquale Grants- CareDX; Advisory Board- Yale Marta Farrero Speakers bureaus- Novatris, AstraZeneca, Boehringer, Chiesi; Meeting support- Novartis, Chiesi; Material support/ Other Services- AstraZeneca Luis García-Guereta None Gina Jamero None Kiran Khush Grants- National Institutes of Health, Enduring Hearts; Royalties- Stanford; Consulting, speakers bureaus- CareDx Jacob Lavee None Stephanie Pouch None Jignesh Patel Grants- Alexion; Consulting- CareDx, Natera; Advisory Board- CareDx, Natera; CJ Michaud None Stephan Schubert Consulting- Medtronic, Edwards; Speakers Bureaus- Abbott, Lifetech, Medtronic; Meeting support- Medtronic, Edwards Annalisa Angelini None Lilibeth Carlos None Sonia Mirabet None Michael Pham Grants- CareDx, Royalties-Up to Date Simon Urschel Grants- Canadian Institute for Health Research, Enduring Hearts, Heart and Stroke foundation; Speaker/Educational- University of Alabama; Meeting support- Lange Symposium; Advisory Board- SMB of the Canadian Donation and Transplantation Research Program Kyung-Hee Kim None Shelly Miyamoto None Sharon Chih Grants- Heart and Stroke Foundation Ontario, Canadian Institutes of Health Research Kevin Daly Grants- US Department of Defense, Novartis, AHA/Enduring Hearts, Consulting- AstraZeneca; Advisory Board- CareDx Paolo Grossi Consulting- Merck, Sharp & Dohme Allovir, Takeda; Speakers Bureaus- Atara, Gilead, Shionogi; Advisory Board- Reithera Doug Jennings None In-cheol Kim None Hoong Sern Lim Speakers bureaus- Abiomed Tara Miller None Luciano Potena Consulting- Biotest, Novartis; Speakers bureaus- Biotest, Takada, Paragonix, Boeringher Ingheleim, AstraZeneca Howard Eisen None Lavanya Bellumkonda Grants- Natera, CareDx; Meeting support- Conformal Medical; Advisory Board- CareDx Lara Danziger-Isakov Grants- NIH, Ansun BioPharma, Astellas, Merck, Pfizer, Takada, AiCuris; Consulting- Takeda; Speakers Bureaus- RMEI; Meeting support- ID SAFE: Swiss Infectious Disease; Advisory Board/DSMB- Merck Fabienne Dobbels None Michelle Harkess None Daniel Kim None Haifa Lyster None Yael Peled None Zdenka Reinhardt None

Background: We recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures., Methods: Between August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried's Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx-including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention., Results: Frail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention., Conclusions: Frail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity., Competing Interests: The authors declare no funding or conflicts of interest.

Background: The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT)., Methods: Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), "cognitive frailty" (CogF ≥ 3 of 6 = frail), "depressive frailty" (DepF ≥ 3 of 6 = frail), and "cognitive-depressive frailty" (ComF ≥ 3 of 7 = frail) in predicting outcomes., Results: Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality., Conclusions: The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failure patients referred for HT who are at high risk of early death., (Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Frailty is a clinically recognized syndrome of decreased physiological reserve. The heightened state of vulnerability in these patients confers a greater risk of adverse outcomes after even minor stressors. Our aim was to assess the prevalence and prognostic significance of the frailty phenotype in patients referred for heart transplantation., Methods: Consecutive patients referred or on the waiting list for heart transplantation from March 2013 underwent frailty assessment. Frailty was defined as a positive response to 3 or more of the following 5 components: weak grip strength, slowed walking speed, poor appetite, physical inactivity, and exhaustion. In addition, markers of disease severity were obtained, and all patients underwent cognitive (Montreal Cognitive Assessment) and depression (Depression in Medical Illness-10) screening., Results: One hundred twenty patients (83 men:37 women; age, 53 ± 12 years, range, 16-73 years; left ventricular ejection fraction, 27 ± 14%) underwent frailty assessment. Thirty-nine of 120 patients (33%) were assessed as frail. Frailty was associated with New York Heart Association class IV heart failure, lower body mass index, elevated intracardiac filling pressures, lower cardiac index, anemia, hypoalbuminemia, hyperbilirubinemia, cognitive impairment, and depression (all ρ < 0.05). Frailty was independent of age, sex, heart failure duration, left ventricular ejection fraction, or renal function. Frailty was an independent predictor of increased all-cause mortality: 1 year actuarial survival was 79 ± 5% in the nonfrail group compared with only 54 ± 9% for the frail group (P < 0.005)., Conclusions: Frailty is prevalent among patients with advanced symptomatic heart failure referred for heart transplantation and is associated with increased mortality.

Objective: Studies have shown that pump output by continuous-flow left ventricular assist devices (LVADs) increases with graded exercise testing. However, data on pump behavior during activities of daily living and sleep, where cardiac output requirements vary markedly, are lacking. We sought to determine pump parameters and activity levels in stable patients receiving outpatient LVAD therapy., Methods and Results: Eleven outpatients (mean age 51 ± 14 years, 9 male) with centrifugal continuous-flow LVADs underwent monitoring of LVAD flow, heart rate (HR), energy expenditure, and physical activity over 1 week in an outpatient setting. Physical activity was recorded with the use of a combined pedometer, accelerometer, and calorimeter Sensewear armband. Pump, HR, and physical activity parameters were time matched for correlation analysis. Outpatients had an average pump flow of 5.67 ± 1.27 L/min and engaged predominately in low levels of physical activity (mean daily step count 3,249/day). Across the entire cohort, pump flow exhibited strong univariate relationships with patients' energy expenditure (r = 0.73), step count (r = 0.69), HR (r = 0.73), sleep (r = -0.89), and skin temperature (r = -0.85; P < .0001 for all). Multivariate analysis suggested that pump output was predominantly affected by recumbent position, energy expenditure and skin temperature (r(2) = 0.84; P < .0001). Pump flow and power consumption were significantly lower during sleep than during wake periods (5.48 ± 1.31 L/min vs 5.80 ± 1.26 L/min; P < .001)., Conclusions: Pump output from continuous-flow LVADs is adaptive to changes in activities of daily living. Circadian variation in pump flow is mostly explained by recumbency and activity levels. Despite adequate pump flow, many LVAD patients continue to live sedentary lifestyles., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Context: Little is known about adolescents' and young adults' experience with cystic fibrosis while waiting for or after receiving a lung transplant. The psychological and psychosocial factors that may influence these patients' transplant outcomes are yet to be fully explored., Objective: To explore the psychosocial impact of the lung transplant journey on adolescents and young adults with cystic fibrosis., Design: A questionnaire-based pilot study was used to enable descriptive, comparative, and correlational analyses between pretransplant and posttransplant groups., Setting: A major lung transplant unit in Australia., Participants: Twenty-seven patients (9 before and 18 after transplantation) participated in the study. The mean ages were 18.7 years (SD 4.2) and 22.6 years (SD 3.9) in the pretransplant and posttransplant groups, respectively., Results: In all domains of the Short Form 36 except Mental Health and Social Functioning, the posttransplant group had significantly higher scores (P < .05) compared to the pretransplant group. The Hospital and Anxiety and Depression Scale total Distress score in the posttransplant group was related to the number of rejection episodes (r = 0.47, P = .049) as well as hospital admissions (r = 0.51, P = .012), The number of rejection episodes was significantly related to patients' perceived level of self-efficacy (P = .025), importance to health (P = .001), and ease (P =.10) of monitoring their symptoms., Conclusion: This study provides some insight into the needs of adolescents and young adults with cystic fibrosis and the differences between those who are awaiting a transplant and those who have received a transplant. Assessing the young person's perceptions in relation to activities such as exercising, monitoring symptoms, and taking medications can give helpful insights into the transition phase, but require further research.