Search

Significant scarcity of a donor pool exists for heart transplantation (HT) as the prevalence of patients with end-stage refractory heart failure is increasing exceptionally. With the discovery of effective direct-acting antiviral and favorable short-term outcomes following HT, the hearts from hepatitis C virus (HCV) patient are being utilized to increase the donor pool. Short-term outcomes with regards to graft function, coronary artery vasculopathy, and kidney and liver disease is comparable in HCV-negative recipients undergoing HT from HCV-positive donors compared to HCV-negative donors. A significant high incidence of donor-derived HCV transmission was observed with great success of achieving sustained viral response with the use of direct-acting antivirals. By accepting HCV-positive organs, the donor pool has expanded with younger donors, a shorter waitlist time, and a reduction in waitlist mortality. However, the long-term outcomes and impact of specific HCV genotypes remains to be seen. We reviewed the current literature on HT from HCV-positive donors.

With the implementation of the new heart transplant (HT) allocation system, patients requiring biventricular support systems have the highest priority, a shorter waitlist time, and a higher frequency of HT. However, the short-term and long-term outcomes of such patients are often disputed. Hence, we examined the outcomes of these patients who underwent HT before change in allocation scheme. Additionally, we compared post-HT outcomes of extracorporeal membrane oxygenation (ECMO) with other nondischargeable biventricular (BiVAD) supported patients. We identified adult ECMO or BiVAD supported HT recipients between 2000 and 2018 in the Scientific Registry of Transplant Recipients database. We compared survival with the Kaplan-Meier method. Using overlap propensity score weighting, we constructed Cox proportional hazards regression models to determine the risk-adjusted influence of BiVAD versus ECMO on survival. Of the 730 patients HT recipients; 528 (72.3%) and 202 (27.7%) were bridged with BiVAD and ECMO, respectively. For BiVAD versus ECMO patients, the 30-day, 1-year, 3-year, and 5-year mortality rates were 8.0% versus 14.4%, 16.3% versus 21.3%, 22.4% versus 25.3%, and 26.3% versus 25.7%, respectively. Risk-adjusted post-HT survival of BiVAD and ECMO patients at 30-day (HR 1.24 [95% CI, 0.68-2.27]; P = 0.4863), 1-year (HR 1.29 [95% CI, 0.80-2.09]; P = 0.3009), 3-year (HR 1.27 [95% CI, 0.83-1.94]; P = 0.2801), and 5-year (HR 1.35, 95% CI, 0.90-2.05; P = 0.1501) were similar. Around three-fourth of the ECMO or BiVAD supported patients were alive at 5-years post-HT. The short-term and long-term post-HT survivals of groups were comparable.

In a multicenter, retrospective analysis of 435 patients with refractory COVID-19 placed on V-V ECMO, cannulation by a single, dual-lumen catheter with directed outflow to the pulmonary artery was associated with lower inpatient mortality.To determine if a cannulation method for venovenous extracorporeal membrane oxygenation (V-V ECMO) is related to patient outcome.A retrospective, multicenter study of adult patients (≥18 years old) placed on V-V ECMO for severe respiratory failure due to COVID-19 between March 1, 2020, to April 30, 2021. Patients were divided into the following three groups based on the initial cannulation method: (1) femoral vein-femoral vein or femoral vein-internal jugular vein (dual-site, C-DS), (2) single, dual-lumen cannula in internal jugular vein with tip positioned in the pulmonary artery (C-PA), and (3) single, dual-lumen cannula in internal jugular vein with tip positioned in the inferior vena cava (C-IVC). The primary outcome was in-hospital mortality assessed by a time-to-event analysis.Overall, 435 patients from 17 centers comprised the study cohort. C-DS was performed in 247 (57%, age: 49, IQR:39-57 years; 30% female) cases, 99 (23%, age: 53, IQR: 42-59 years; 26% female) received C-PA, and 89 (20%) patients got C-IVC (age: 46, IQR 35-54; 33% female). At 90-days, in-hospital mortality was 60% (C-DS), 41% (C-PA), and 61% (C-IVC), p = 0.06. After adjustment for clinical characteristics, the likelihood of in-hospital mortality in comparison to C-DS, was lower with C-PA (aHR: 0.52, 95%CI 0.32-0.85, p = 0.009) and similar with C-IVC (aHR: 0.96, 95%CI 0.63-1.47, p = 0.86).Catheter-directed flow into the PA bypassing the right ventricle with a single dual-lumen cannula is associated with reduced mortality during V-V ECMO for COVID-19. These findings are limited by residual confounding and site-clustering. Further investigation is urgently warranted with randomized studies.

OBJECTIVE To examine if older age (>70 years) should be a relative contraindication for heart transplantation, we evaluated the characteristics and outcomes of patients with age ≥70 years listed for heart transplantation; and whether post-transplantation survival was inferior to younger counterparts. DESIGN Retrospective cohort analysis. SETTING The scientific registry of transplant recipients (SRTR). PARTICIPANTS Adults (≥18 years) listed for heart transplantation in the SRTR between 2000 and 2018. INTERVENTIONS Heart transplantation. MEASUREMENTS Characteristics and outcomes were compared for adults ≥70 years and

Background: We analyzed the use of Extracorporeal Membranous Oxygenation (ECMO) in acute care surgery patients at our Level-1 trauma center. We hypothesized that this patient population has improved ECMO outcomes. Methods: This was a retrospective analysis of emergency general surgery and trauma patients placed on ECMO between the periods of October 2013 and February 2020. There were 10 surgical and 12 trauma patients studied, who eventually required ECMO support. ECMO support and ECMO type/modality were analyzed with injury and survival prognostic scores examined. Main results: Overall, 16 of the 22 patients survived to hospital discharge, for a survival rate of 73%. Mean age was 34.18 years. Mean hospital length of stay was 23.4 days with mean days on ECMO equal to 7.5. The net negative fluid balance was 5.36 L. Conclusions: The survival of our ECMO cohort is notably higher than previously cited studies. Our group demonstrated decreased length of time on ECMO, decreased length of stay in the hospital, and similar rates of complications compared to prior reports. ECMO is a useful modality in acute care surgical patients and should be considered in these patient populations. Our focus on net negative fluid balance for ECMO patients demonstrates improved survival. ECMO should be considered early in surgical patients and early in advanced trauma life support.

Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center. Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.

Implantable cardioverter-defibrillator (ICD) shocks are associated with increased mortality risk in heart failure patients. Whether ICD shocks are associated with mortality in continuous flow LVAD (CF-LVAD) patients is unknown. We studied the relationship of ICD shocks and ventricular arrhythmias (VAs) to morbidity and mortality in CF-LVAD-supported patients in our institution. Single-center, retrospective study of prospectively collected ICD and LVAD databases. We analyzed data on VA which received ICD therapy in patients who underwent CF-LVAD implantation at Hartford Hospital between 2008 and 2018. A total of 157 patients were studied. During a median follow-up of 10 months (interquartile range 5–20 months), 48 patients (30.6%) experienced post-LVAD sustained VA. Thirty patients (19.1%) had appropriate shocks for VA and 5 patients (3.1%) had inappropriate shocks. Shocks for any arrhythmia were not associated with an increased risk of death (OR 0.836, 95% CI 0.224–3.115, p = 0.789). Neither post-LVAD VA nor the rate of VA was associated with an increased mortality risk (OR 0.662 [0.329–1.334], p = 0.248; OR 1.001 [0.989–1.014], p = 0.817, respectively). Cox multivariate regression analysis revealed pre-LVAD VA as a significant predictor of VA post LVAD implantation (OR 3.284 [1.584–6.808], p = 0.001). Symptoms with VA occurred in 22 (45.8%) patients, ranging from palpitations to near syncope/syncope. None of the variables including the rate of VA was associated with death or symptoms. VAs are common in CF-LVAD patients and occur with higher frequency in those with pre-LVAD VA and frequently cause symptoms. Neither VA nor ICD shocks are associated with mortality risk.

Background Historically, there is perceived pressure to achieve therapeutic levels of tacrolimus quickly after heart transplant (HT). We evaluated the association between time within therapeutic tacrolimus range and time to therapeutic trough and rejection in the 30 days following HT. Methods This is a single-center retrospective cohort study of consecutive adult HT patients receiving immunosuppression. Goal trough tacrolimus levels were 10-15 ng/ml. Surveillance endomyocardial biopsies were performed weekly for 4 weeks. Outcomes included the effect of time to and time-in-therapeutic tacrolimus range (Rosendaal method) on 30-day clinical rejection, 1R/1B, and 2R or higher histologic occurrences. Results We reviewed 67 HT patients (median age 58.8 yrs). For clinical rejection versus no-rejection groups, the median (25th, 75th percentile) time to therapeutic tacrolimus levels was 9.5 (8, 12.3) days versus 9.0 (7, 13) days (p=0.623). The median time-in-therapeutic tacrolimus range was 34.1% (23.2, 42.2) versus 36.2% (19.9, 51.2), respectively (p=0.512). Similarly, we observed no significant differences in time to and time-in-therapeutic tacrolimus range in patients who developed grade 1R/1B (p=0.650 and p=0.725) or grade 2R or higher histology (p=0.632 and p=0.933). Conclusions Our small single-center analysis suggests that neither time to nor time in therapeutic tacrolimus range predicted acute rejection within 30 days of HT.

The coronavirus disease 2019 pandemic disrupted health care delivery in every respect, including critical care resources and the transport of patients requiring extracorporeal membrane oxygenation. Innovative solutions allowing for safe helicopter air transport of these critical patients is needed because extracorporeal membrane oxygenation resources are only available in specialty centers. We present a case demonstrating the interfacility collaboration of care for a patient with coronavirus disease 2019 infection and the lessons learned from the air transport. Careful planning, coordination, communication, and teamwork contributed to the safe transport of this patient and several others subsequently.

Cardiac injury secondary to non-penetrating trauma is more common than thought, albeit, the injury is usually minor and goes undiagnosed without significant sequelae in most cases. Blunt cardiac rupture is much rarer accounting for

Objective To determine characteristics, outcomes, and clinical factors associated with death in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support. Methods A multicenter, retrospective cohort study was conducted. The cohort consisted of adult patients (18 years of age and older) requiring ECMO in the period from March 1, 2020, to September 30, 2020. The primary outcome was in-hospital mortality after ECMO initiation assessed with a time to event analysis at 90 days. Multivariable Cox proportional regression was used to determine factors associated with in-hospital mortality. Results Overall, 292 patients from 17 centers comprised the study cohort. Patients were 49 (interquartile range, 39-57) years old and 81 (28%) were female. At the end of the follow-up period, 19 (6%) patients were still receiving ECMO, 25 (9%) were discontinued from ECMO but remained hospitalized, 135 (46%) were discharged or transferred alive, and 113 (39%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%). Factors associated with in-hospital mortality were age (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.06-1.61 per 10 years), renal dysfunction measured according to serum creatinine level (aHR, 1.21; 95% CI, 1.01-1.45), and cardiopulmonary resuscitation before ECMO placement (aHR, 1.87; 95% CI, 1.01-3.46). Conclusions In patients with severe COVID-19 necessitating ECMO support, in-hospital mortality occurred in fewer than half of the cases. ECMO might serve as a viable modality for terminally ill patients with refractory COVID-19., Graphical abstract A multicenter, retrospective cohort study of 292 patients with COVID-19 given extracorporeal membrane oxygenation (ECMO) in 17 centers across the United States from March 1, 2020 to September 30, 2020. Clinical characteristics and outcomes were entered into a Research Electronic Data Capture (REDCap) database. The primary outcome of cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%).

Introduction: A recent trend favoring donor allocation to sicker patients has led to a rise in the number of patients undergoing heart transplantation (HT) on ECMO or non-dischargeable biventricular mechanical circulatory devices (BiVAD). While suboptimal short-term outcomes of such patients have raised concerns, long-term outcomes are unknown. We examined long-term survival in patients bridged with BiVAD or ECMO in the contemporary era before the donor allocation policy changed. Methods: We identified the adult patients listed for HT and bridged with ECMO or BiVAD between 2000 and 2018 in the Scientific Registry of Transplant Recipients. We compared 3- and 5-year survival with the Kaplan-Meier method. Using overlap propensity score weighting, we constructed doubly-robust Cox proportional hazards regression models to determine the risk-adjusted influence of support type on survival. Results: Of the 1495 listings; 868 (58.1%) were bridged with BiVAD and 627 (41.9%) with ECMO. 730 underwent successful HT; 528 (72.3%) and 202 (27.7%) were bridged with BiVAD and ECMO, respectively. The ECMO group had higher prevalence of pre-transplant ventilator support (30.7% vs 6.3%, p Conclusions: A minority of patients on BiVAD and ECMO underwent HT suggesting high complication and waitlist mortality rates. Besides, the transplantation rate was disproportionately lower in patients on ECMO compared to BiVAD support. Patients with heart failure bridged with BiVAD or ECMO experienced similar long-term outcomes despite worse clinical and hemodynamic profile of patients in the ECMO group.

Background Severe obesity (Body Mass Index (BMI) ≥40 kg/m2) is associated with a higher risk of developing severe symptoms and complications of coronavirus disease 19 (COVID-19), independent of other illnesses. Despite this, patients with severe obesity are less likely to receive Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) support for severe Acute Respiratory Distress Syndrome (ARDS). Given this paradox, we examined the impact of severe obesity on outcomes of adult patients who underwent VV-ECMO implantation for ARDS at our center. Methods We reviewed our ECMO database from May 2013 through May 2020. Adults, who had received VV-ECMO, either in-house or through our mobile ECMO program, were included. We grouped patients into those with BMI ≥40 kg/m2 or not and compared survival at 48 hours, survival to hospital discharge, and hospital length of stay. We conducted multiple logistic and linear regression analyses to analyze the association with categorical and continuous variables, respectively, controlling for patient age, gender, and use of mobile ECMO. Results We identified 112 consecutive adult VV-ECMO patients; median age was 48 (34, 59) years, 61 (54.5%) were male, 56 (50%) were started on ECMO in-house, the median BMI was 31.7 (27.6, 38.8) Kg/ m2; and 23 (20.5%) had a BMI ≥40 kg/m2. Survival at 48 hours and hospital discharge were 69.6% and 61.6%, respectively; and, median hospital length of stay was 20 (9, 33) days. Logistic regression showed no evidence of an association between severe obesity and either 48-hour (OR 1.04, 95% CI 0.37-2.96) or hospital discharge survival (OR 1.06, 95% CI 0.38-2.93). There was, however, a significant correlation between increasing BMI and longer total hospital length of stay (R2 = 0.34; p = 0.0002) which remained significant in linear regression (p = 0.0002) (Figure). Conclusions We found no association between severe obesity and survival at 48-hour and hospital discharge in patients supported on VV-ECMO. Severe obesity was associated with a longer hospital stay, however. Our experience suggests that severe obesity alone should not exclude candidacy for VV-ECMO support.

The clinical course and outcomes of immunocompromised patients, such as transplant recipients, with COVID‐19 remains unclear. It has been postulated that a substantial portion of the disease burden seems to be mediated by the host immune activation to the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Herein, we present a simultaneous heart‐kidney transplant (SHKT) recipient who was hospitalized for the management of respiratory failure from volume overload complicated by failure to thrive, multiple opportunistic infections, and open non‐healing wounds in the setting of worsening renal dysfunction weeks prior to the first case of SARS‐CoV‐2 being detected in the state of Connecticut. After his third endotracheal intubation, routine nucleic acid testing (NAT) for SARS‐CoV‐2, in anticipation of a planned tracheostomy, was positive. His hemodynamics, respiratory status and ventilator requirements remained stable without any worsening for 4 weeks until he had a negative NAT test. It is possible that the immunocompromised status of our patient may have prevented significant immune activation leading up to clinically‐significant cytokine storm that could have resulted in acute respiratory distress syndrome and multisystem organ failure.

Aims Heart failure (HF) and diabetes mellitus (DM) often coexist and have bidirectional association. Advanced HF is associated with worsened glycaemic control. This meta-analysis investigated the effects of left ventricular assist device (LVAD) implantation on markers of DM control. Methods and results We performed a systematic search of MEDLINE and Cochrane through October 2017 to identify studies evaluating advanced HF patients who had received an LVAD and reported markers of glycaemic control. The primary outcome was glycosylated haemoglobin A1c (HbA1c), and the secondary outcomes included fasting glucose, daily insulin requirements, and body mass index (BMI). Outcomes were pooled using a Hartung-Knapp random-effects model producing a mean difference (MD) and 95% confidence interval (CI). Thirteen studies, including 820 participants, were included. HbA1c was 1.23% lower following LVAD implantation (95% CI -1.49 to -0.98). Greater HbA1c reductions were seen with higher pre-LVAD values. Similarly, fasting plasma glucose (-24.4 mg/dL, 95% CI -33.4 to -15.5), daily insulin requirements (-18.8 units, 95% CI -28.8 to -8.7), and serum creatinine levels (MD -0.20, 95% CI -0.35 to -0.06) were significantly lower than pre-LVAD levels. We saw no difference in BMI (MD 0.09, 95% CI -1.24 to 1.42). Conclusions LVAD implantation was associated with significant improvement in HbA1c, fasting plasma glucose, and daily insulin need in advanced HF patients.

Purpose While thought to increase short-term mortality, the effect of amiodarone use prior to heart transplant (HT) on long-term survival is not well established. We therefore sought to examine the effect of amiodarone use on long-term survival following HT after adjustment for known risk factors. Methods We included adult patients who underwent HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients according to pre-transplant amiodarone use. We constructed logistic regression models using recipient and donor characteristics to calculate propensity scores. We then used overlap propensity score weighting to construct Cox proportional hazards regression models (adjusted for IMPACT score and PHM ratio) for mortality outcomes. Adjusted logistic regression compared the odds of primary graft failure and drug-treated rejection. Results 25,394 adult HT recipients were included: median (inter-quartile range) age was 55 (46, 62) years, and 25.5% were female. Amiodarone users had a significantly higher prevalence of hypertension (46.7% v. 50.2%; p Conclusion While pre-transplant amiodarone was associated with higher short-term mortality, its use did not affect long-term survival. Whether the short-term outcomes are related to greater graft failure risk is unclear.

Purpose Post heart transplant (HT) outcome of patients with body mass index ≥ 35 kg/m2 (morbidly obese) remain suboptimal. However, outcome of morbidly obese patients listed for heart transplant (HT) is unknown. We sought to examine the characteristic and outcome of such patients who were listed for HT in the United States. Methods Adults listed for HT with BMI information on the Scientific Registry of Transplant Recipients database between 2000 and 2018 were included. Characteristics and outcomes of patients with BMI≥ 35 kg/m2 or = 18.5-34.99 kg/m2 were compared. The patients were followed until death, transplant or end of data availability. Waitlist mortality and successful HT were compared between groups using a Fine and Gray competing risk hazard regression model adjusted for known risk factors. Results 55,717 patients identified: 5022 (9.0%) had a BMI ≥ 35 kg/m2; 13,058 (23.4%) were female. The median (25th, 75th percentile) age was 55 (45, 61) years, and the median waitlist time was 101 (27, 299) days. Morbidly obese patients were significantly younger (51 vs. 55 years; p Conclusion Listing of patients with BMI≥ 35 kg/m2 is on rise. However, this cohort is at significantly higher risk for death and lower HT rates.

The main stay pharmacotherapy for heart failure (HF) is targeted towards rennin-angiotensin-aldosterone (RAAS) and neprilysin pathways (NP). Both therapeutic strategies decreases morbidity and mortality but also carry considerable adverse effects. This review of the literature highlights the new generation of HF drug, sacubitril-valsartan (SV), trade name Entresto (researched as LCZ696, Novartis) which simultaneously blocks RAAS and NP. This dual action of angiotensin receptors blocker and neprilysin inhibitor (NPi) has improved HF prognosis and it is an evolution in the management of HF. Although the initial follow-up of patients treated with SV has yielded promising results, there are concerns regarding potential side effects especially an increase in the risk of Alzheimer’s disease (AD) and young onset of AD. NPi interferes with the breakdown and clearing of beta-amyloid peptides, the plaques seen in AD, raising concern for AD in SV patients. On the other hand, hypertension and cardiovascular diseases are established risk factors for AD which can be decreased by SV therapy. It is therefore essential that SV treated patients are followed up over an extended period of time to detect any adverse cognitive changes.

Background A recent trend favoring donor allocation to sicker patients has led to a rise in the number of patients undergoing heart transplantation (HT) on Extracorporeal membrane oxygenation (ECMO) support. Traditionally, these sick patients in cardiogenic shock were managed with biventricular support while awaiting HT. In this context, we examined short-term survival in patients bridged with biventricular devices (BiVAD) or ECMO in the contemporary era of heart transplantation before the change in the donor allocation strategy. Methods We identified adult patients listed for HT who were bridged with an ECMO or BiVAD between 2000 and 2018 in the Scientific Registry of Transplant Recipients. We compared 30-day and 1-year survival with the Kaplan-Meier method. Using inverse propensity treatment weighting, we constructed doubly-robust Cox proportional hazards regression models to determine the risk-adjusted influence of support type on survival. Results Of the 1495 listings, 868 (58.1%) were bridged with BiVAD and 627 (41.9%) with ECMO. 730 underwent successful HT; 528 (72.3%) and 202 (27.7%) were bridged with BiVAD, or ECMO, respectively. The patients in ECMO group had higher prevalence of pre-transplant ventilator support (30.7% vs 6.3%, p Conclusions A minority of patients on BiVAD and ECMO support underwent HT. Besides, the transplantation rate was disproportionately lower in patients on ECMO support. Patients with heart failure bridged to HT with an ECMO experienced worse short-term post-transplant survival. This observation favors a relook into the current heart transplant allocation strategy.

Background Allosensitization as measured by presence of panel reactive antibodies (PRA) negatively impacts survival in adult heart transplant (HT) recipients. Questions remain whether these trends remain in more contemporary cohorts. We examined the interaction between long-term survival and pre-transplant PRA level in HT recipients from 2000-2018. Methods We identified adult HT recipients between 2000 and 2018 who had a pretransplant PRA in the Scientific Registry of Transplant Recipients. Study cohort was divided into groups with PRA levels; group with 0%, 1-10%, 11-24% and ≥25% PRA levels. We compared 3- and 5-year survival with the Kaplan-Meier method. We constructed Cox proportional hazards regression models to determine the risk adjusted influence of PRA category and PRA as a continuous value on survival. Results We included 24,655 HT recipients. PRA was 0% in 17,391 (70.5%) recipients, 1-10% in 3,331 (13.5%) recipients, 11-24% in 1,330 (5.4%) recipients, and ≥25% in 2,603 (10.6%) recipients. Patients with a PRA ≥25% were younger, had fewer comorbidities, and were more likely to be on ECMO or LVAD prior to HT. Unadjusted 3- and 5-year estimated survival was lower with increasing PRA category (Figure). After risk-adjustment, 5-year survival was higher for the 0% cohort compared to the 1-10% (HR 1.10, 95% CI 1.02-1.18), 11-24% (HR 1.20, 95%CI 1.08-1.34), and ≥25% (HR 1.16, 95% CI 1.07-1.26). When analyzed continuously, increasing PRA was associated with a lower survival (HR 1.003, 95% CI 1.002-1.005). Sensitivity analysis of those transplanted from 2013-2018 showed similar results. Conclusions In this contemporary cohort of HT recipients, increasing pretransplant PRA was associated with lower survival. Given the appreciable portion of HT recipients with elevated PRA, improvements in recipient selection and HT management may help improve outcomes.

In recent decades, the vast majority of violent mass conflicts have been between groups within a country, rather than between different countries. As such, conflict resolution efforts invariably have involved some re-allocation of access to public power and resources and thus often have required reform or replacement of the constitution. While much has been written on the effects of the design of a federal constitution on the resolution or recurrence of conflict in divided societies, much less has been examined on how the same conflict dynamics inform the design of the constitutional reform process that is meant to lead to the new federal arrangement. Especially in contexts of ‘holding together’ federalism, the questions of who writes the constitution and how and when sub-national boundaries are delineated can be highly contentious and may undermine the constitutional project before it begins. Current cases where such debates are, or have recently been, taking place include Libya, Myanmar, Nepal, Solomon Islands, Philippines, Somalia, South Sudan, Sri Lanka and Yemen.

Purpose Both underweight and overweight recipients have poor outcomes after heart transplant (HT). However, the precise threshold of body mass index (BMI) as a predictor of heightened risk is unclear. We, therefore, examined the effect of BMI on short term survival as a continuous metric. Methods We identified adult patients listed for HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients with recorded BMI at the time of listing. We calculated survival at 30 days and one year after HT and constructed Cox proportional hazards regression models adjusted for known recipient and donor risks. Recipient BMI was modeled using a restricted cubic spline with knots at 18, 25, 30, and 35 kg/m2 with a value of 22 used as a referent. Results 37,068 adult HT recipients were included: median (25th, 75th percentile) BMI of 27 (23, 30) kg/m2, recipient age 55 (46, 62) years, 27,668 (74.6%) men, and 9,683 (26.1%) with diabetes. After risk-adjustment, Cox proportional hazards regression showed a 3% increase in both 30-day (HR 1.031, 95% CI 1.024-1.037; p Conclusion Increases in recipient BMI was associated with an incremental risk of 30-days and 1-year mortality following HT.

Purpose Post heart transplantion (HT) outcomes of patients with body mass index ≥ 40 kg/m2 (morbidly obese) remain suboptimal. However, outcomes of morbidly obese patients listed for heart transplant (HT) is unknown. We sought to examine the characteristic and outcome of such patients who were listed for HT in the United States. Methods Adults listed for HT with BMI information on the Scientific Registry of Transplant Recipients database between 2000 and 2018 were included. Characteristics and outcomes of patients with BMI≥ 40 kg/m2 or = 18.5-39.99 kg/m2 were compared. The patients were followed until death, transplant or end of data availability. Waitlist mortality and successful HT were compared between groups using a Fine and Gray competing risk hazard regression model adjusted for known risk factors. Results 55,717 patients identified: 656 (1.2%) had a BMI ≥ 35 kg/m2; 13,058 (23.4%) were female. The median (25th, 75th percentile) age was 55 (45, 61) years, and the median waitlist time was 101 (27, 299) days. Severely obese patients were significantly younger (46 vs. 55 years; p Conclusion Listing of patients with BMI≥ 40 kg/m2 is declining. This cohort is at significantly higher risk for death and lower HT rates.

Purpose Mobile ECMO program supports patients with refractory acute respiratory failure deemed at high risk for transfer to an ECMO center. Transesophageal or transthoracic echocardiography and/or radiographic imaging is routinely done to confirm cannula position before departure to the receiving center. We herein report the feasibility and outcomes of the first case-series with transportation of VV-ECMO patients without confirmatory imaging. Methods Adult patients who underwent mobile VV-ECMO implantation. Results 71 adult VV-ECMO recipients were included, all with dual cannula implant schema: 14 (19.7%) transferred without confirmation; median (inter-quartile range) age was 51 (18, 80) years, BMI was 33.05 (21.7, 62.8) and 43.7% were female. Baseline characteristics of patients were similar in groups with and without cannula confirmation (Table). No complications occurred during cannulation or transportation. Two cannula malpositions were identified: 1) imaging group - venous inflow was noted to course from right femoral vein to the left without flow issues and was changed at the sending center; 2) non-imaging group a “kink” in IVC cannula was noted after arrival without flow issues. Conclusion With the use of point of care ultrasound, line placement safety is drastically improved, and transportation of patients with ARDS on VV ECMO with a stable flow is feasible without cannula position confirmation. This approach can decrease resource utilization, healthcare cost and minimize out-of facility time for the implant team.

Purpose Severe obesity, defined as body mass index (BMI) ≥ 40 kg/m2, is a contraindication for a heart transplant (HT). However, practice varies across transplant centers. This study examined the post-transplant survival of these patients who underwent HT in the United States. Methods We included adult patients who underwent HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients with available BMI information. We compared 30-day, 1-, 5- and 10-year survival of those with a BMI≥ 40 kg/m2 with BMI = 18.5-39.99 kg/m2 using the Kaplan-Meier method. Cox proportional hazards regression models then determined the influence of BMI category on survival adjusting for known recipient and donor risk factors, including Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score and predicted heart mass ratio. Results 36,115 adult HT recipients were included: 275 (0.8%) severely obese. The median (inter-quartile range) age was 55 (46, 62) years, and 25.4% were female. Severely obese patients had more hypertension (p=0.0019), diabetes (p Conclusion Survival following HT was significantly lower in recipients with severe obesity. Severe obesity should be addressed before HT is considered.

Background Longer wait time and poor outcomes after heart transplant (HT) have been reported among blacks and minor ethnic groups. Whether racial disparity exists in the utilization of mechanical circulatory support, waitlist mortality, and HT rates is unknown. Methods We identified the adult patients listed for HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients. Recipient characteristics, including hemodynamic and biochemical variables, are compared between racial groups-blacks, Asians, and others. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared between racial groups using a Fine and Gray competing risk regression model adjusted for known risk factors. Results Of the 57,285 listings; 43,485 (75.9%) were whites; 11,640 (20.3%) were blacks; 1,547 (2.7%) were Asians and 613 (1.1%) were listed as others. Blacks were significantly younger, had higher BMI, non-ischemic cardiomyopathy, hypertension, renal dysfunction, and dialysis (Table). Although more blacks were listed with LVAD bridge vs. whites, ECMO utilization was significantly lower. In the 37,164 patients who received a successful HT, the median wait time to transplant was lower (p Conclusions Overall, waitlist mortality and successful transplantation rates were similar across racial groups. Black HT candidates were less likely to be bridged with ECMO compared with Whites. Asians had higher transplantation rates while supported on ECMO or IABP.

Background The patients in cardiogenic shock supported with Extracorporeal Membrane oxygenation (ECMO) or non-dischargeable biventricular mechanical support (BiVAD) are more likely to receive heart transplantation (HT) since the donor allocation system was revamped in 2018, to favor sick patients and reduce waitlist mortality. However, the patients' characteristics and outcomes bridged with BiVAD or ECMO and listed for HT in the contemporary era before the policy changed are not explored. Methods We queried the Scientific Registry of Transplant Recipients database for adults listed for HT with BiVAD or ECMO between 2000 and 2018. Recipient characteristics, including hemodynamic and biochemical variables, are compared between groups. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared using a Fine and Gray competing risk regression model adjusted for known risk factors. Results Of the 1495 patients identified, 868 (58.1%) and 627 (41.9%) were bridged with BiVAD or ECMO. Since 2004, a more significant proportion of patients were on BiVAD, but that trend reversed over the past 5 years with more candidates on ECMO (pTrend Conclusions In recent years, there has been a rise in patients bridged to HT with ECMO. However, patients on ECMO suffered higher waitlist mortality and lower transplantation rates. This could, in part, be explained by the sicker profile of patients on ECMO.

Background Women continue to be under-represented as heart transplant (HT) recipients. Past studies on survival rates following HT and gender have suggested conflicting data. We compare long-term survival between male and female HT recipients in the contemporary heart transplantation era from 2000-2018 using novel methods. Methods We identified adult HT recipients between 2000 and 2018 in the Scientific Registry of Transplant Recipients. Men and women were matched using overlap propensity score weighting. We compared 10-year survival with the Kaplan-Meier method. We constructed doubly-robust Cox proportional hazards regression models to determine the risk-adjusted influence of gender on survival. Models were adjusted for recipient and donor characteristic including IMPACT score and donor-recipient predicted heart mass (PHM) ratio. The proportionality assumption was tested by inspection of Shoenfeld residuals with covariates being converted to time-varying if significant. Results We included 36,606 HT recipients. When compared with men, women tended to be younger, have fewer comorbidities, higher PRA, larger IMPACT score and donor-recipient PHM ratio. Unadjusted 10-year estimated survival was similar between men and women (Figure). After risk-adjustment, women had a similar risk of 10-year survival than men (HR 0.94, 95% CI 0.82-1.02; p=0.0974). When comparing between men and women at 1 (p Conclusions In this contemporary cohort of HT recipients, women had similar long-term survival to men despite an overall lower risk profile and greater likelihood to receive a size mismatched heart.

Objective Inter-facility transport of extracorporeal membrane oxygenation (ECMO) patients is usually by ground when within 300 miles of receiving facility. In suburban/rural environments, highway travel may not be possible and travel time may be disproportionately increased due to traffic conditions, type of roads traveled, weather, etc. Helicopter transport, when available, is more temporally consistent and can mitigate many of these travel barriers while minimizing out of hospital time; however, not all patients qualify for air transport. At our institution, where both ground ambulances and EC-145 helicopters are available for ECMO transport, we sought to develop a tool to identify potential ECMO patients for helicopter transfer as it could safely diminish out-of-hospital time. Methods Utilizing our ECMO database, we identified patient weight, estimated ground transport time, number of intravenous infusions, therapy type (veno-arterial vs. veno-venous ECMO), and mean arterial pressure (MAP) post-ECMO initiation as major factors affecting patient transport apart from travel distance. We then developed a weighted scale comprising of these variables with score ranging from 0 -15 (Figure). Patients with a score of 2-8 were considered eligible for helicopter transport (at the discretion of the ECMO team). Using this novel triage tool, we retrospectively reviewed our ECMO transports between 2017 and 2019 and determined which ground transfers were eligible for air transfer. Ground transport time was defined as total time that the patient spends in the ambulance and measured in statute miles based on roadway travel. Flight transport time was similarly defined as total time that the patient spends in the helicopter, and measured in nautical miles, as a straight line from sending to receiving hospital. Results 47 primary ECMO missions were performed, 6 by air and 41 by ground. Median ground transport time was 22 (7-54) minutes and median ground distance was 13 (3-54) statute miles. Median flight transport time was 18 (7-28) minutes and median flight distance was 15 (7-40) nautical miles/24 (13-58) statute miles. Of the ground transports, 22 (56.4%) patients had a triage score 8 or less (5 to 8) and were eligible for helicopter transfer. 17 patients had a triage score of 9 or greater (9-13) and were deemed ineligible for helicopter transfer. The most frequent factors leading to higher triage scores were high body weight and larger number of IV infusions. Upon review by the authors, this tool accurately predicted potential flight candidates. There were no differences in safety outcomes based on mode of transport. Conclusions ECMO patients appropriate for helicopter transfer can be predicted using this simple tool, minimizing patient travel distance and out-of-hospital time. Prospective validation, cost and feasibility analysis is warranted.

Introduction: Short-term mechanical circulatory support devices (ST-MCS) include intra-aortic balloon-pump (IABP), extracorporeal membrane oxygenation (ECMO) and the CentriMag® and Impella® ventricular assist systems (VAS). Despite an exponential increase in their use, data regarding stroke prevalence and predictors are lacking. Objective: To identify the prevalence and predictors of stroke in ST-MCS. Methods: Data was collected prospectively into a database from January 2016 to June 2018 and retrospectively extracted and analyzed. Primary analysis was performed between acute-stroke vs. non-stroke diagnoses. Dichotomous and continuous variables were analyzed using Chi-Square test of proportions and Wilcoxon Ranked Sum test respectively. Results: Out of 203 ST-MCS-patients [IABP 31.5% (n=64), Impella 24.6% (n=50), ECMO 31% (n=63) and CentriMag®VAS 12.8% (n=26)], 8.4% (n=17) had an acute stroke. Among them 6.4% (n=13) had ischemic stroke and 1% (n=2) had hemorrhagic stroke, with 1% (n=2) having both. CentriMag®VAS had a higher stroke rate than the other devices (23.1% [n=6] vs. 6.2% [n=11]; p=0.011, OR 4.53). Predictors of stroke in all patients were central cannulation (p=0.044, OR 3.08), duration >4 days (p=0.025, OR 3.21) and use of another ST-MCS device before primary device (p=0.043, OR 1.45). Flow-rate (p=0.86) and catheter size (p=0.15) did not predict stroke. Only 1 patient was eligible for thrombolytic therapy and received IV tPA, with the most common reasons to hold treatment being unknown last-seen-normal (n=8), coagulopathy (n=2) and established infarct on head CT (n=2). A large vessel occlusion was present in 20% (n=3), but none underwent a mechanical thrombectomy due of established infarction. All hemorrhagic strokes and 47% (n=7) ischemic strokes led to withdrawal of care. Conclusion: About 1 in 12 patients placed on a ST-MCS device may have an acute stroke, but this can be as high as 1 in 5 with the use of the CentriMag®VAS. Factors such as central cannulation, duration >4 days and use of another ST-MCS device before the primary device may be predictive of acute stroke in these patients. Further research in the identification of such predictors, in conjunction with early symptom recognition could help improve treatment rates.

BACKGROUND Arginine vasopressin (AVP) is a naturally occurring peptide with diverse effects mediated through selective V1 and V2 receptors. About 10% of patients undergoing cardiopulmonary bypass develop postoperative vasodilatory shock requiring high-dose catecholamines. We sought to examine the role of AVP therapy in cardiac surgery. METHODS A search of Medline was conducted through September 2018 using key words and medical subject headings (MeSH) relating to AVP, copeptin, and cardiac surgery. A systematic review was performed on articles as they pertained to AVP for use as a vasopressor after cardiovascular surgery complicated by vasodilatory shock. RESULTS A relative or absolute deficiency of Arginine vasopressin is associated with vasodilatory shock after cardiopulmonary bypass. Physiologic replacement with exogenous Arginine vasopressin results in significant increases in systemic vascular resistance and mean arterial pressure with decreased requirements of catecholamines. At doses of

Purpose Extracorporeal membrane oxygenation (ECMO) treats acute reversible severe heart/lung failure in adults at high mortality risk. While often initiated in-hospital, ECMO's portability allows for experienced centers to implant it off site. We examined the impact mobile ECMO on survival in patients with severe cardiopulmonary failure. Methods This is a retrospective review of patients with in-hospital or mobile ECMO from January 2013 to October 2019. Participants were included if they were ≥ 18 years old and received ECMO performed at Hartford Hospital or through the mobile, “ECMO on the Go” unit. The Survival After Veno-Arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores were calculated. The primary endpoints were 48-hour and hospital discharge survival. Results We included 201 patients with a median (25th, 75th percentile) age 54.0 (39.5, 64.0) years and median ECMO time of 5.0 (3.0, 8.0) days. VA (median SAVE score -6.5 [-9.0, -3.0]) and VV ECMO (median RESP score 2.0 [-1.0, 5.0]) were initiated in 51.7% and 48.3% of patients, respectively. Mobile ECMO was initiated in 61 (30.3%) patients. 48-hour survival was higher in the mobile (65.6%) vs hospital ECMO patients (55.7%, p=0.192). Survival to hospital discharge was also higher with mobile (59.0%) vs hospital ECMO patients (41.4%, p=0.097). Baseline SAVE and RESP scores were higher in patients surviving to 48-hr and hospital discharge (p Conclusion We showed that mobile ECMO is effective for treatment of severe cardiopulmonary failure refractory to standard modalities. Mobile ECMO trended towards improved survival compared with in-hospital initiation. SAVE and RESP scores may be predictive of survival using mobile ECMO applications.

Our aim was to identify relevant literature supporting the use of phosphodiesterase-5 (PDE5) inhibitors in patients with persistent pulmonary hypertension with signs of postprocedural right ventricular (RV) dysfunction following left ventricular assist device (LVAD) implantation. We searched MEDLINE, SCOPUS, and Web of Science from inception through November 27, 2014 for citations evaluating patients with end-stage heart failure necessitating LVAD, continuous and pulsatile, who received a PDE5 inhibitor to prevent RV failure. Outcomes of interest included changes in mean pulmonary artery pressure, pulmonary vascular resistance, central venous pressure, cardiac index, and mean arterial pressure. Results are presented qualitatively. Four citations (n = 83 patients) were included. These included a single case report, two retrospective case series, and a prospective open-label study with a historical control. All four studies utilized the PDE5 inhibitor sildenafil with various doses for up to 3 months. Sildenafil routinely reduced mean pulmonary artery pressures as soon as 90 min after administration. Reductions in pulmonary vascular resistance were also seen shortly after the procedure and maintained through 12-15 weeks. While one study saw improvements in postoperative central venous pressures, another did not. Evidence supporting PDE5 inhibitor use to attenuate RV failure in patients requiring an LVAD is weak.

Background: Left ventricular assist devices (LVAD) have emerged as the mainstay in advanced heart failure patients either as a bridge to transplant (BTT) or destination therapy (DT). Strokes, ischemic from pump thrombosis and hemorrhagic from combination of anti-platelets and anti-coagulants, remain a major cause of morbidity and mortality. Objective: To identify the prevalence, timing and risk factors of ischemic and hemorrhagic in LVAD patients Methods: A retrospective analysis of all the LVAD implantations at HH from July 2012 to December 2016 comprising a total of 78 patients with 63 HMII (axial flow) and 15 Heartware (centrifugal flow) implantations to serve as DT in 51 and BTT in 37 patients. Demographics and clinical variables were collected and analyzed. Categorical variables were analyzed using Chi-square test of proportions with statistical significance set at 0.05. Results: For all patients the median age was 65 years, 82% Caucasian and 16% female. The overall stroke incidence was 27% (n=21, 16 ischemic in 12 patients and 9 hemorrhagic in 9). Age > 65 years had a higher incidence of stroke (36% vs 14%; p Conclusion: In our study, 1/3 of strokes occurred in the perioperative period with high risk after age 65 years. Non-Caucasians, high mean arterial pressure and high INR were associated with hemorrhagic stroke. Further studies are needed to evaluate modifiable risk factors among LVAD patients.

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.

Electrical storm (ES) is a cardiac emergency requiring management in a cardiac intensive care unit. On occasion ES can be refractory to treatments such as beta blockade, antiarrhythmics, sedation, ablation and hemodynamic support. Stellate ganglion blockade (SGB) can be a last resort temporary

The use of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in peripartium cardiomyopathy is reported with limited data. We report a case of peripartum cardiomyopathy causing refractory acute hypoxic respiratory failure managed with Veno-venous ECMO (VV ECMO). A 23-year-old female at 35

Implantable cardioverter defibrillator (ICD) shocks are associated with increased mortality in heart failure patients. The purpose of this study was to analyze ICD shocks and ventricular arrhythmias (VA) in continuous-flow LVAD (CF-LVAD) patients and their effects on clinical outcomes including