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Introduction: Patients on continuous flow left ventricular assist devices (CF-LVADs) often require CF-LVAD exchange. The purpose of this study was to investigate the incidence of infection following CF-LVAD exchange performed for non-infectious indications. Methods: An electronic literature search was performed to identify all studies of patients undergoing CF-LVAD exchange for pump thrombosis or device malfunction. Of 2,698 articles identified, 6 studies with 81 total patients met the inclusion criteria. Cohort-level data were pooled for meta-analysis. Results: Mean patient age was 60 years (95% CI: 41–78), and 74% were male (95% CI: 61–84). Pump thrombosis was the most common indication for exchange in 70% of patients (95% CI: 47–86). Other indications were driveline fracture and electrical malfunction in 21% (95% CI: 5–56) and 12% (95% CI: 4–33) of patients, respectively. Prior to exchange, 95% of patients were on HeartMate II (HM2) LVADs (95% CI: 86–98) and average duration of support for these patients was 27.1 months (95% CI: 9.3–44.8). The majority were placed on a HM2 following exchange (88% (95% CI: 45–98)) versus HM3 (12% (95% CI: 2–55)). Follow-up was an average of 16.4 months (95% CI: 6.8–26.0). Following exchange, 16 of 81 patients developed infection, with pooled mean incidence of 24% (95% CI: 14–38). 30-day mortality was 14% (95% CI: 7–26). Survival at follow-up was 65% (95% CI: 52–76). Conclusions: Infection following CF-LVAD exchange can occur at rates higher than those observed with primary implantation; therefore, effective strategies need to implemented early and consistently to help lower infections rates and help improve outcomes following exchange.

Hemocompatibility-related adverse events (HRAE) negatively influence survival. However, no study has examined the impact of these events on health-related quality of life (HRQOL) and functional outcomes following continuous-flow left ventricular assist device implantation (CF-LVAD). We assessed the impact of HRAE events on HRQOL and hypothesized that HRAE's adversely impact HRQOL and functional outcomes.INTERMACS database identified patients undergoing primary CF-LVAD implantation from 2008 to 2017. HRAEs included stroke, non-surgical bleeding, hemolysis, and pump thrombosis and were identified as defined in the literature. HRAEs were further stratified as Tier 1-2 and disabling stroke events. Time-series analysis was executed for HRAE patients with values pre-HRAE, post-HRAE, and closest to 12 months follow up. Local polynomial regression curves modeling individual patients were superimposed into "spaghetti" plots.All HRQOL and functional metrics improved in patients over time, despite HRAE complications. However, these patient metrics were significantly reduced compared to the non-HRAE cohort. Advanced data visualization techniques noted a decline after experiencing an HRAE with a subsequent recovery to baseline levels or higher. Six-minute walk test (6MWT) was noted to be most affected in the post-HRAE period but recovered similar to other metrics.The burden of HRAE following CF-LVAD implantation did not negatively impact the quality of life. However, the 6MWT did not increase in the post-HRAE period in all HRAE patients. Improvement of heart failure symptoms after CF-LVAD coupled with optimal management following the HRAE act to preserve the enhanced quality of life.

Background Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial as a result of variable outcomes. This review investigates patient outcomes after surgical embolectomy for acute PE. Methods An electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review. Results Mean patient age was 56.3 years (95% confidence interval [CI], 52.5, 60.1), and 50% were male (95% CI, 46, 55); 82% had right ventricular dysfunction (95% CI, 62, 93), 80% (95% CI, 67, 89) had unstable hemodynamics, and 9% (95% CI, 5, 16) experienced cardiac arrest. Massive PE and submassive PE were present in 83% (95% CI, 43, 97)] and 13% (95% CI, 2, 56) of patients, respectively. Before embolectomy, 33% of patients (95% CI, 14, 60) underwent systemic thrombolysis, and 14% (95% CI, 8, 24) underwent catheter embolectomy. Preoperatively, 47% of patients were ventilated (95% CI, 26; 70), and 36% had percutaneous cardiopulmonary support (95% CI, 11, 71). Mean operative time and mean cardiopulmonary bypass time were 170 minutes (95% CI, 101, 239) and 56 minutes (95% CI, 42, 70), respectively. Intraoperative mortality was 4% (95% CI, 2, 8). Mean hospital and intensive care unit stay were 10 days (95% CI, 6, 14) and 2 days (95% CI, 1, 3), respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from the preoperative period (sPAP 57.8, mm Hg; 95% CI, 53, 62.7) to the postoperative period (sPAP, 31.3 mm Hg; 24.9, 37.8); P Conclusions Surgical embolectomy is an acceptable treatment option with favorable outcomes.

A body mass index (BMI) > 35 kg/m2 is a relative contraindication to heart transplantation in patients with end-stage heart failure. Bariatric surgery can be considered either concomitantly with continuous-flow left ventricular assist device (CF-LVAD) placement, or staged after CF-LVAD has been placed. We sought to evaluate the outcomes of these approaches. An electronic search was performed to identify all relevant studies. After assessment for inclusion and exclusion criteria, eight studies were pooled for systematic review and metaanalysis. Overall, of 59 patients, 22 (37%) underwent simultaneous sleeve gastrectomy with CF-LVAD implantation while 37 (63%) underwent staged sleeve gastrectomy after CF-LVAD. The mean age of patients was 46 years (95% CI: 39–53) with 40% females. Mean BMI at most recent follow-up (33.4 kg/m2, 95% CI: 30.2–36.6) was significantly lower compared with mean preoperative BMI (46.7 kg/m2, 95% CI: 42.9–50.6) (p

BACKGROUND AND AIM OF THE STUDY Ventricular septal defect (VSD) following myocardial infarction (MI) is a relatively infrequent complication with high mortality. We sought to investigate the effect of concomitant coronary artery bypass graft (CABG) on outcomes following post-MI VSD repair. METHODS Electronic search was performed to identify all relevant studies published from 2000 to 2018. Sixty-seven studies were selected for the analysis comprising 2174 patients with post-MI VSD. Demographic information, perioperative variables, and outcomes including survival data were extracted and pooled for systematic review and meta-analysis. RESULTS Single-vessel disease was most common (47%, 95% confidence interval [CI], 42-52), left anterior descending coronary artery was the most commonly involved vessel (55%, 95% CI, 46-63), and anterior wall was the most commonly affected territory (57%, 95% CI, 51-63). Concomitant CABG was performed in 52% (95% CI, 46-57) of patients. Of these, infarcted territory was re-vascularized in 54% (95% CI, 23-82). A residual/recurrent shunt was present in 29% (95% CI, 24-34) of patients. Of these, surgical repair was performed in 35% (95% CI, 28-41) and transcatheter repair in 11% (95% CI, 6-21). Thirty-day mortality was 30% (95% CI, 26-35) in patients who had preoperative coronary angiogram, and 58% (95% CI, 43-71) in those who did not (P

There is no widely accepted donor to recipient size-match metric to predict outcomes in cardiac transplant. The predictive ability of size-match metrics has not been studied when recipients are stratified by heart failure etiology. We sought to assess the performance of commonly used size metrics to predict survival after heart transplant, accounting for restrictive versus non-restrictive pathology.The UNOS registry was queried from 2000 to 2017 for all primary isolated heart transplants. Donor-recipient ratios were calculated for commonly used size metrics and their association with survival was assessed using continuous, nonlinear analysis.29 817 patients were identified. Height (P .001), predicted heart mass (PHM) (P = .003), ideal body weight (IBW) (P .001) and body mass index (BMI) (P = .003) ratios were significantly associated with survival, while weight and body surface area (BSA) ratios were not. When stratified, only BMI ratio retained significance for both restrictive (P = .051) and non-restrictive (P = .003) subsets. Recipients with restrictive etiology had increased risk of mortality with both a lower and higher BMI ratio.While many metrics show association with survival in the non-restrictive subset, BMI is the only metric that retains significance in the restrictive subset. Recipients with restrictive and non-restrictive etiologies of heart failure tolerate size mismatch differently.

BackgroundTIGIT, an inhibitory immune checkpoint, is a target of interest for immuno-oncology combination therapies. TIGIT is part of a complex molecular network containing four receptors (DNAM1, TIGIT, PVRIG and CD96) and two ligands (PVR and PVRL2). Here we describe Dual Signaling Protein 502 (DSP502), a novel, multi-functional IgG1-Fc-fusion protein targeting this molecular pathway in a unique way. DSP502, comprising the extracellular domains of TIGIT and PD1, is designed to simultaneously bind its two respective ligands, PVR and PD-L1, overexpressed on cancer and myeloid cells in the tumor microenvironment. DSP502 binds PVR preventing inhibitory signaling through TIGIT and CD96 and promoting DNAM1 costimulatory signaling on activated T- and NK-cells. DSP502's PD1 arm binds PD-L1 to unleash effector T-cells through checkpoint inhibition. In parallel, DSP502's IgG1-Fc delivers an immune-activating signal via Fc receptors. The net effect is enhanced anti-tumor immunity (figure 1).MethodsDSP502 heterodimer was successfully produced in a mammalian expression system. DSP502 was evaluated for binding to its cognate ligands on cells and in ELISA-based assays, with and without competing antibodies. NK and PBMC killing activity were evaluated against human K562 CML cells overexpressing PVR. Simultaneous binding of DSP502 to fluorescently-labeled tumor and NK-cells was evaluated by FACS. In vivo activity of DSP502 was evaluated in a humanized NSG A549 NSCLC xenograft mouse model.ResultsBoth DSP502 arms were shown to bind their cognate ligands in ELISA and on cell surface. DSP502 binding was dependent on the presence of both ligands on cells and was abolished by competing antibodies to the respective targets, demonstrating binding specificity and the 'AND-gate' phenomenon. Overexpression of PVR reduced the sensitivity of K562 cells to NK-cell mediated killing, while DSP502 treatment restored it as measured by target cell killing and granzyme-B secretion. Increased, dose-dependent, complexation of NK- and tumor cells was observed following DSP502 treatment and was abolished by both PVR and FcR antibodies. Treatment with DSP502 markedly inhibited tumor growth of A549-NSCLC xenograft in a humanized NSG mouse model, with all mice being tumor-free at the end of the experiment, compared to control PBMC-injected mice.ConclusionsHere we report the design and function of a novel immunotherapeutic fusion protein, DSP502, that offers multiple functionalities that can coordinately and synergistically drive anti-tumor immunity. Beyond targeting PVR and PDL1, DSP502 has the potential to additionally impact the TIGIT pathway through its effects on CD96 and DNAM1. DSP502 is currently in IND-enabling studies and CMC development.Ethics ApprovalThe study was conducted at the Authority of Biological and Preclinical Models, the Hebrew University of Jerusalem, Ein Kerem, Sharet Specific Pathogen-Free (SPF) Unit under the Hebrew university ethic committee board approval (number MD-19-15815-5).Abstract 790 Figure 1

Purpose Infective endocarditis (IE) is a rare but potentially fatal complication following heart transplantation (HTx). There is a lack of literature regarding the patterns and clinical course of IE development following HTx. We sought to pool the existing data in regards to defining characteristics, management options, and outcomes of IE following HTx. Methods An electronic search of Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, and the Scopus databases were performed to identify all articles in the English literature that report IE following HTx in adult patients. Patient-level data were extracted and analyzed. Results Systematic search yielded 57 patients from 32 articles. Median patient age was 52 [IQR 43, 59] and 75% of patients (43/57) were male. Median time to IE presentation post-HTx was 8.4 [IQR 3.0, 35.8] months. IE of the mitral valve was observed in 36.8% (21/57) of patients, followed by mural IE in 24.6% (14/57), and tricuspid valve IE in 21.1% (12/57). The most common organisms were Staphylococcus aureus in 26.3% (15/57), Aspergillus fumigatus in 19.3% (11/57), Enterococcus faecalis in 12.3% (7/57), and an undetermined or unspecified organism in 14.0% (8/57) patients. Overall case fatality was 44.6% (25/56). Fungal IE was associated with a significantly higher case fatality 75.0% (9/12) than that of bacterial IE 36.1% (13/36) (p = 0.02). Surgical management of post-HTx IE was observed in 35.1% (20/57) of patients. This included valve surgery for 70.0% (14/20), including the mitral valve in 50.0% (7/14), aortic valve in 35.7% (5/14), and the tricuspid valve in 14.3% (2/14) of patients. Conclusion In addition to bacterial organisms, fungi also represent a frequent cause of IE in post-HTx patients. Overall HTx patient survival in the setting of IE is poor and may be worse if caused by A. fumigatus.

Background: With increased use of continuous-flow left ventricular assist devices (CF-LVAD), development of malignant tumors in this population is not uncommon. We sought to evaluate malignancies in CF-LVAD patients and evaluate the outcomes of treatment strategies. Methods: Overall, 18 articles consisting of 28 patients were identified who developed malignancies after CF-LVAD placement. Patient-level data were extracted for systematic review. Results: Median patient age was 60 years [59–67] and 85.7% (24/28) were male. CF-LVAD was placed as bridge-to-transplant (BTT) in 60.9% (14/23) of patients. The three most common malignancy types were GI in 35.7% (10/28) of patients, lung in 21.4% (6/28) and skin in 10.7% (3/28). Median time from CF-LVAD implant to malignancy diagnosis was 6.9 [2.5–12.8] months. Metastatic disease occurred in 17.9% (5/28) over a median time of 5.0 [1.0–82.0] months from the diagnosis. Surgical resection of the malignancy was performed in 57.1% (16/28) of patients. Our results showed that while there was a significantly higher probability of survival among patients who underwent surgery versus those who did not, when only stage I and II patients were included in the analysis, this difference was no longer statistically significant. Three patients were relisted for heart transplant after surgical treatment, and two received the transplant. Conclusions: Surgical management of malignancies in patients on CF-LVADs may improve survival and transplant eligibility status, therefore, a CF-LVAD should not always preclude surgical treatment.

Prothrombin complex concentrate (PCC) administration has increased among cardiac surgery patients in recent years; however, use in LVAD implantation/exchange is not widespread due to the fear of thrombotic complications. The purpose of this study was to compare the clinical outcomes of patients undergoing LVAD implantation/exchange with intraoperative PCC administration versus traditional transfusion practices alone. Adult LVAD implants/exchanges at our institution between 2015 and 2018 were included. Patients were categorized as receiving intraoperative PCC or no-PCC (traditional). The primary outcome was the need for allogenic transfusion and transfusion volume at 48 hours after initial intensive care unit (ICU) admission. Secondary outcomes included metrics of morbidity and mortality. A total of 160 patients (39 PCC, 121 traditional) were analyzed. In unadjusted analysis, patients in the PCC group received lower intraoperative transfusion volumes compared to the traditional group although not statistically significant (1464 mL [IQR 796, 4876] vs. 2568 mL [IQR 1292, 3606]; P value .37). In the fully adjusted analysis, patients in the PCC group had increased odds of transfusion within 48 hours of ICU admission (OR 4.06, 95% CI: 1.35-12.20; P < .01); however, there was no significant difference in transfusion volumes (P = .09). Patients receiving PCCs had higher incidence of deep vein thrombosis (10.3% vs. 0%; P

Background Carcinoid heart disease (CaHD) develops from vasoactive substances released by neuroendocrine tumors, which can cause significant patient morbidity and mortality without surgical intervention. We performed a systematic review and meta-analysis to elucidate granular perioperative details and long-term outcomes in these patients. Methods Electronic search of Ovid, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to examine surgical treatment of carcinoid disease. Nine articles comprising 416 patients were selected. Study-level data were extracted and pooled for meta-analysis. Results Mean patient age was 63 years (95% confidence interval, 57-70) with 53% (95% confidence interval, 46-61) of patients being male. In addition, 75% (95% confidence interval, 54-96) of neuroendocrine tumors originated from the small bowel or colon and 98% (95% confidence interval, 93-100) had liver metastases. Right heart failure was present in 48% (95% confidence interval, 14-81). Moderate or severe regurgitation was present in 97% (95% confidence interval, 95-99) of tricuspid and 72% (95% confidence interval, 58-83) of pulmonary valves. In addition, 99% (95% confidence interval, 98-100) of tricuspid and 59% (95% confidence interval, 38-79) of pulmonary valves were replaced. Bioprosthetic valves were used in 80% (95% confidence interval, 68-93) of tricuspid positions. Mean hospital duration of stay was 16 days (95% confidence interval, 7-25). Thirty-day mortality was 9% (95% confidence interval, 6-12). Mean follow-up was 25 months (95% confidence interval, 11-39). Median survival was 3 years (95% confidence interval, 2.5-3.5). Conclusion For patients >18 years of age, surgical treatment of carcinoid heart disease can be performed with a reasonable safety profile. However, overall survival appears to have ongoing effects of the primary disease.

Percutaneous biventricular assist devices (BiVAD) are a recently developed treatment option for severe cardiogenic shock. This systematic review sought to identify indications and outcomes of patients placed on percutaneous BiVAD support. An electronic search was performed to identify all appropriate studies utilizing a percutaneous BiVAD configuration. Fifteen studies comprising of 20 patients were identified. Individual patient survival and outcomes data were combined for statistical analysis. All 20 patients were supported with a microaxial LVAD, 12/20 (60%) of those patients were supported with a microaxial (RMA) right ventricular assist device (RVAD), and the remaining 8/20 (40%) patients were supported with a centrifugal extracorporeal RVAD (RCF). All patients presented with cardiogenic shock, and of these, 12/20 (60%) presented with a non-ischemic etiology vs 8/20 (40%) with ischemic disease. For the RMA group, RVAD support was significantly longer [RMA 5 (IQR 4-7) days vs RCF 1 (IQR 1-2) days, p = 0.03]. Intravascular hemolysis post-BiVAD occurred in three patients (27.3%) [RMA 3 (33.3%) vs RCF 0 (0%), p = 0.94]. Five patients received a durable left ventricular assist device, one patient received a total artificial heart, and one patient underwent a heart transplantation. Estimated 30-day mortality was 15.0%, and 78.6% were discharged alive. Both strategies for percutaneous BiVAD support appear to be viable options for severe cardiogenic shock.

Ventricular arrhythmias (VA) are not uncommon after continuous-flow left ventricular assist device (CF-LVAD) implantation. In this systematic review, we sought to identify the patterns of VA that occurred following CF-LVAD implantation and evaluate their outcomes. An electronic search was performed to identify all articles reporting the development of VA following CF-LVAD implantation. VA was defined as any episode of ventricular fibrillation (VF) or sustained (>30 seconds) ventricular tachycardia (VT). Eleven studies were pooled for the analysis that included 393 CF-LVAD patients with VA. The mean patient age was 57 years [95%CI: 54; 61] and 82% [95%CI: 73; 88] were male. Overall, 37% [95%CI: 19; 60] of patients experienced a new onset VA after CF-LVAD implantation, while 60% [95%CI: 51; 69] of patients had a prior history of VA. Overall, 88% of patients [95%CI: 78; 94] were supported on HeartMate II CF-LVAD, 6% [95%CI: 3; 14] on HeartWare HVAD, and 6% [95%CI: 2; 13] on other CF-LVADs. VA was symptomatic in 47% [95%CI: 28; 68] of patients and in 50% [95%CI: 37; 52], early VA (

Purpose Gastrointestinal bleeding (GIB) is a frequent post left ventricular assist device (LVAD) co-morbidity, and many patients require multiple endoscopic interventions. While GI bleeding events have been shown to impact subsequent outcomes, the association of the burden of GI bleeding interventions with subsequent outcomes has not been specifically analyzed. Methods Between February 2007 and June 2019, 389 patients underwent primary LVAD implantation at our Clinic. Median age at implant was 62 years (range, 18-82 years) and 306 (79%) were male. Etiology of heart failure was ischemic in 182 patients (47%) and indication for implant was destination therapy in 266 (69%). Axial flow pump was utilized in 282 (73%) and centrifugal flow in 105 (27%). Median preoperative duration of heart failure was 8.9 years. Results Early mortality occurred in 27/387 patients (7%). Follow-up was available in all 350 early survivors for a median of 1.8 years (920 years of patient support). There were 462 GI bleeding events in the 350 early survivors during the follow up time period. During these 462 bleeding events, endoscopic procedures were performed in 341/462 instances (74%) and intervention was performed in 96/341 (28%). Figure 1 shows the relative hazard of outcomes as related to burden of GI interventions for bleeding; late survival (p=0.95) and thrombotic complications (p=0.69) were not significantly impacted by increasing number of required GI interventions. However, risk of subsequent stroke (p=0.04) was significantly increased with higher number of procedures required. Conclusion GI bleeding events are common after LVAD implant and endoscopic interventions are often required. Anticoagulation cessation is often required during these instances, and subsequent risk of stroke may be increased as the number of these procedures required is increased. Careful attention to peri-procedural anticoagulation and management may be critical to reduce subsequent unintended adverse events.

Background: The domino-donor operation occurs when a “conditioned” heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure. Methods: An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis. Results: HLT indications included cystic fibrosis in 58% (95% CI: 27–84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12–24%), bronchiectasis in 5% (95% CI: 3–10%), emphysema in 5% (95% CI: 0–45%), and Eisenmenger’s syndrome in 4% (95% CI: 2–8%). HT indications included ischemic heart disease in 40% (95% CI: 33–47%), non-ischemic disease in 39% (95% CI: 25–56%), and re-transplantation in 10% (95% CI: 1–59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14–5.95). The overall mortality in the HLT group was 28% (95% CI: 18–41%) at an average follow-up of 15.68 months (95% CI: 0.82–30.54), and 35% (95% CI: 17–58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68–67.84). Freedom from rejection in HT was 94% (95% CI: 75–99%) at 1 month, 77% (95% CI: 30–96%) at 6 months, and 41% (95% CI: 33–50%) at 1 year. Conclusions: The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.

Background: Left ventricular assist device (LVAD)-associated endocarditis remains poorly studied, especially in newer continuous-flow LVADs (CF-LVADs). The aim of this review was to assess outcomes of patients with LVAD-associated endocarditis, as stratified by CF-LVAD and pulsatile LVAD (P-LVAD) use as well as by different interventions and pathogen types. Methods: An electronic search was performed to identify studies in the English literature on LVAD-associated endocarditis. Results: Overall, 16 articles with 26 patients were included; seven had CF-LVADs and 19 had P-LVADs; time to development of endocarditis was 91 days (152 vs . 65 days, respectively, P=0.05). Eleven of 25 patients were treated with antibiotics only. Remaining 14 patients received antibiotics, however, they also underwent additional surgical intervention. One patient was treated with embolization alone for mycotic aneurysm and was therefore excluded. At a median follow-up time of 344 days post implant, there was no difference in overall mortality between CF-LVAD and P-LVAD-associated endocarditis patients (57.9% vs . 42.9%, P=0.81). Patients who underwent additional surgical intervention had higher overall survival compared to those treated with antibiotics alone (71.4% vs . 27.3%, P=0.07); with no difference in outcomes amongst those who underwent surgical device exchange as compared to heart transplantation (80.0% vs . 66.7%; P=0.23) Conclusions: Compared to patients with P-LVADs, CF-LVAD patients appeared to be resistant to early development of LVAD-associated endocarditis. There was a trend towards high survival observed amongst patients who underwent additional surgical intervention as compared to those treated with antibiotics alone, with no difference amongst surgical device exchange as compared to heart transplantation. Advantages of additional surgical intervention vs . medical therapy alone deserves further exploration to determine its applicability in CF-LVADs.

Background: Optimal surgical treatment of infective tricuspid valve endocarditis in patients with intravenous drug use (IVDU) remains controversial. Tricuspid valvectomy has been proposed for infective tricuspid valve endocarditis in this patient population given the inherent social concerns. The aim of this systematic review and meta-analysis was to compare outcomes of valvectomy versus replacement for the surgical treatment of isolated infective tricuspid valve endocarditis. Methods: An electronic search was performed to identify all relevant studies published. After assessment for inclusion and exclusion criteria, 16 original studies were pooled for systematic review and meta-analysis. Results: There were a total of 752 patients with infective tricuspid valve endocarditis, of which 14% underwent valvectomy and 86% underwent replacement (mean follow-up 4.2 years, 95% CI, 1.9–6.4 years). The most common indications for surgical intervention were septic pulmonary embolism in the valvectomy group (74%, 95% CI, 28–95%) and persistent sepsis in the replacement group (62%, 95% CI, 31–86%). There were no differences in rates of stroke [valvectomy 4% (95% CI, 1–11%) vs. replacement 3% (95% CI, 1–16%), P=0.85] but there was increased likelihood of prolonged ventilation in those who underwent valvectomy [valvectomy 40% (95% CI, 30–51%) vs. replacement 26% (95% CI, 23–30%), P

Gastrointestinal bleeding (GIB) is a common adverse event after continuous-flow left ventricular assist device (CF-LVAD) implantation. We sought to evaluate patterns of GIB development and related outcomes in CF-LVAD recipients. An electronic search was performed to identify all articles related to GIB in the setting of CF-LVAD implantation. A total of 34 studies involving 1087 patients were pooled for analysis. Mean patient age was 60 years (95% CI 57-64) and 24% (95% CI 21-28%) were female. The mean time from CF-LVAD implantation to the first GIB was 54 days (95% CI 24-84) with 40% (95% CI 34-45%) of patients having multiple episodes of GIB. Anemia was present in 75% (95% CI 41-93%) and the most common etiology of bleeding was arteriovenous malformations (36% [95% CI 24-50%]). The mean duration of follow-up was 14.6 months (95% CI 6.9-22.3) during which the all-cause mortality rate was 21% (95% CI 12-36%) and the mortality rate from GIB was 4% (95% CI 2-9%). Thromboembolic events occurred in 32% (95% CI 22-44%) of patients with an ischemic stroke rate of 16% (95% CI 3-51%) and a pump thrombosis rate of 8% (95%CI 3-22%). Heart transplantation was performed in 31% (95% CI 18-47%) of patients, after which 0% (95% CI 0-10%) experienced recurrent GIB. GIB is a major source of morbidity among CF-LVAD recipients. While death due to GIB is rare, cessation of anticoagulation during treatment increases the risk of subsequent thrombotic events. Heart transplant in these patients appears to reliably resolve the risk of future GIB.

A body mass index (BMI) 35 kg/mAn electronic search was performed to identify all relevant studies. After assessment for inclusion and exclusion criteria, eight studies were pooled for systematic review and metaanalysis.Overall, of 59 patients, 22 (37%) underwent simultaneous sleeve gastrectomy with CF-LVAD implantation while 37 (63%) underwent staged sleeve gastrectomy after CF-LVAD. The mean age of patients was 46 years (95% CI: 39-53) with 40% females. Mean BMI at most recent follow-up (33.4 kg/mBoth simultaneous and staged bariatric surgeries with CF-LVAD placement have comparable outcomes and significantly reduce BMI. This can allow previously ineligible patients to undergo heart transplantation.

Background In patients who require orthotopic liver transplant (OLT), cardiac surgery may be needed to optimize preoperative cardiac status for OLT. The aim of this systematic review was to evaluate patient characteristics and outcomes of those undergoing staged versus concomitant cardiac procedures with OLT. Methods An electronic search was performed to identify all case reports and series, from which patient-level data was extracted regarding cardiac procedures associated with OLT. After assessment for inclusion and exclusion criteria, 26 articles were pooled for systematic review. Results Overall, 49 patients were included in the analysis, of whom 12 (24%) underwent staged procedures and 37 (76%) underwent concomitant procedures. The median age was lower in the staged group [staged: 51 (IQR, 43.8–59.2) years vs. concomitant: 60 (IQR, 55.0–64.0) years, p = .02]. Other baseline characteristics were comparable between the two groups. For staged procedures, the median time between heart procedures and OLT was 2 (IQR, 1.0–3.5) months. The most commonly reported cardiac procedures were coronary artery bypass graft (CABG) [staged: 4/12 (33.3%) vs. concomitant: 21/37 (56.8%), p = .28], aortic valve replacement (AVR) [staged: 3/12 (25.0%) vs. concomitant: 19/37 (51.2%), p = .21], and transcatheter aortic valve replacement (TAVR) [staged: 4/12 (33.3%) vs. concomitant: 0/37 (0%), p = .002]. Regarding outcomes, there was a significantly shorter post-OLT hospital stay for those who had staged procedures versus those who had concomitant procedures [staged: 8 (IQR, 5–13) days vs. concomitant: 17 (IQR, 14–24) days, p = .007]. However, both groups had similar in-hospital mortality rates [staged: 1/12 (8.3%) vs. concomitant: 4/37 (10.8%), p = 1.0]. Overall survival stratified between the two groups was comparable. Conclusions Patients who underwent the staged approach had a shorter post-transplant hospital stay, but comparable survival with respect to those who underwent concomitant cardiac procedures and OLT.

Purpose Infective endocarditis (IE) is a rare but potentially fatal complication following heart transplantation (HTx). There is a lack of literature regarding the patterns and clinical course of IE development following HTx. We sought to pool the existing data in regards to defining characteristics, management options, and outcomes of IE following HTx. Methods An electronic search of Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, and the Scopus databases were performed to identify all articles in the English literature that report IE following HTx in patients greater than 17 years of age. Systematic search yielded 37 patients from 29 articles. Patient-level data were extracted and analyzed. Results Median patient age was 53 [IQR 43, 62] years and 78.4% (29/37) were male. Median time to IE presentation post-HTx was 6.5 [2.6, 16.2] months. IE of the mitral valve was observed in 45.9% (17/37) of patients, followed by mural IE in 24.3% (9/37), and tricuspid valve IE in 24.3% (9/37). The most common organisms were Staphylococcus aureus in 27.0% (10/37), Aspergillus fumigatus in 18.9% (7/37), Enterococcus faecalis in 10.8% (4/37), and an undetermined or unspecified organism in 16.2% (6/37) patients. Aspergillus fumigatus associated mortality occurred in 85.7% (6/7). Surgical management of post-HTx IE was observed in 43.2% (16/37). This included valve surgery for 35.1% (13/37), particularly of the mitral valve in 46.2% (6/13), aortic valve 38.5% (5/13), tricuspid valve 15.4% (2/13), and pulmonic artery graft in 15.4% (2/13). Kaplan-Meier analysis of the survival is shown in the figure. Conclusion In addition to bacterial organisms, Aspergillus fumigatus also represents a frequent cause of IE in post-HTx patients. Overall HTx patient survival after IE occurs is poor, and may be worse with Aspergillus fumigatus IE.

Purpose Cardiac mass ratio (CMR) is validated for donor-recipient sizing, and as a predictor of transplant outcomes. However, there is a lack of data reviewing the role CMR plays in transplant recipients with pulmonary hypertension (pHTN). In particular, the right ventricular (RV) mass ratio (RVMR) is a component of CMR not yet studied separately for this purpose. We aimed to review the relationship of CMR and RVMR with pHTN in terms of development of primary graft dysfunction (PGD) and overall survival. Methods The United Network for Organ Sharing (UNOS) database was queried for primary heart transplant patients from 1987 to 2020. Missing data was imputed using a Bayesian network. Left ventricular (LV), RV, total cardiac mass (CM), and their ratios were calculated for donors and recipients. Relevant hemodynamic variables were included in logistic regression and cox proportional-hazards models to evaluate a relationship to PGD and overall survival. A stepwise regression created parsimonious models. Covariates with statistically significant relationships to the outcomes were included in tensor product spline models. Results 62,169 patients were identified. A parsimonious logistic model for odds of PGD included RVMR (OR 0.99, p Conclusion In patients with pHTN, RVMR is significantly associated with odds of developing PGD, and CMR is with overall survival. Some RV oversizing may be beneficial to mitigate the risk of PGD.

Background Left ventricular assist devices are increasingly being used in patients with advanced heart failure as both destination therapy and bridge to transplant. We aimed to identify histomorphometric, structural and inflammatory changes after pulsatile- and continuous-flow left ventricular assist device placement. Methods Clinical and echocardiographic data were collected from medical records. Aortic wall diameter, cellularity and inflammation were assessed by immunohistochemistry on aortic tissue collected at left ventricular assist device placement and at explantation during heart transplantation. Expression of adhesion molecules was quantified by Western blot. Results Decellularization of the aortic tunica media was observed in patients receiving continuous-flow support. Both device types showed an increased inflammatory response after left ventricular assist device placement with variable T-cell and macrophage accumulations and increased expression of vascular E-selectin, ICAM and VCAM in the aortic wall. Conclusions Left ventricular assist device implantation is associated with distinct vascular derangements with development of vascular inflammation. These changes are pronounced in patients on continuous-flow left ventricular assist and associated with aortic media decellularization. The present findings help to explain the progressive aortic root dilation and vascular dysfunction in patients after continuous-flow device placement.

Background: Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO). Methods: An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed. Results: Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs . VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs . VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs . VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs . VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300). Conclusions: Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.

Background Combined heart-liver transplantation (CHLT) has become a viable option for treating concomitant heart and liver failure. However, data are lacking with respect to long-term outcomes. Methods An electronic search was performed to identify all studies on CHLT. Following application of inclusion and exclusion criteria, a total of seven studies consisting of 99 CHLT patients were included from the original 1864 articles. Results CHLT recipient mean age was 53.0 years (95% CI 48.0–58.0), 67.5% of which (95% CI 56.5–76.9) were male. 65.5% (95% CI 39.0–85.0) of patients developed heart failure due to amyloidosis whereas 21.6% (95% CI 12.3–35.2) developed heart failure due to congenital causes. The most common indication for liver transplant was amyloidosis [65.5% (95% CI 39.0–85.0)] followed by liver failure due to hepatitis C [13.8% (95% CI 2.1–54.4)]. The mean intensive care unit length of stay was 8 days (95% CI 5–11) with a mean length of stay of 24 days (95% CI 17–31). Cardiac allograft rejection within the first year was 24.7% (95% CI 9.5–50.7), including antibody mediated [5% (95% CI 1.7–15.2)] and T-cell mediated rejection [22.7% (95% CI 8.8–47.1)]. Overall survival was 87.5% (95% CI 78.6–93.0) at 1 year and 84.3% (95% CI 75.4–90.5) at 5 years. Conclusions CHLT in select patients with coexisting end-stage heart and liver failure appears to offer high survival and low rejection rates.

Left ventricular assist device (LVAD) withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. The aim of this systematic review was to examine the patient outcomes of device withdrawal via minimally invasive pump decommissioning as compared with reoperation for pump explantation. An electronic search was performed to identify all studies in the English literature assessing LVAD withdrawal. All identified articles were systematically assessed for inclusion and exclusion criteria. Overall, 44 studies (85 patients) were included in the analysis, of whom 20% underwent decommissioning and 80% underwent explantation. The most commonly used LVAD types included the HeartMate II (decommissioning 23.5% vs. explantation 60.3%; p = 0.01) and HeartWare HVAD (decommissioning 76.5% vs. explantation 17.6%; p < 0.001). At median follow-up of 389 days, there were no significant differences in the incidence of cerebrovascular accidents (p = 0.88), infection (p = 0.75), and survival (p = 0.20). However, there was a trend toward a higher recurrence of heart failure in patients who underwent decommissioning as compared with explantation (decommissioning 15.4% vs. explantation 8.2%, cumulative hazard; p = 0.06). Decommissioning appears to be a feasible alternative to LVAD explantation in terms of overall patient outcomes.

Background: Saphenous vein grafts (SVG) are a commonly used conduit for coronary artery bypass graft (CABG) surgery and can be harvested by either an open or endoscopic technique. Our goal was to evaluate long-term angiographic and clinical outcomes of open compared to endoscopic SVG harvest for CABG. Methods: Electronic search was performed to identify all studies in the English literature that compared open and endoscopic SVG harvesting for CABG with at least one year of follow-up. The primary outcome was graft patency. Secondary outcomes included perioperative morbidity and mortality. Results: Of 3,255 articles identified, a total of 11 studies were included for analysis. Of 18,131 patients, 10,873 (60%) patients underwent open SVG harvest and 7,258 (40%) patients underwent endoscopic SVG harvest. The mean age of patients was 65 years and 87% were male. The overall mean follow-up period was 2.6 years. During follow-up, patients who underwent open SVG harvest had superior graft patency per graft [open 82.3% vs. endoscopic 75.1%; OR: 0.61 (95% CI, 0.43–0.87); P=0.01], but higher rates of overall wound complications in the immediate post-operative period [open 3.3% vs. endoscopic 1.1%; OR: 0.02 (95% CI, 0.01–0.06); P

No standardized treatment algorithm exists for the management of continuous-flow left ventricular assist device (CF-LVAD)-specific infections. The aim of this systematic review and meta-analysis was to compare the outcomes of CF-LVAD-specific infections as managed by device exchange to other treatment modalities not involving device exchange. Electronic search was performed to identify all studies in the English literature relating to the management of CF-LVAD-specific infections. All identified articles were systematically assessed for selection criteria. Thirteen studies with 158 cases of CF-LVAD-specific infection were pooled for analysis. Overall, 18/158 (11.4%) patients underwent CF-LVAD exchange, and 140/158 (88.6%) patients were treated with non-exchange modalities. The proportion of patients with isolated driveline infections or pump or pocket infections did not differ significantly between the groups. During a mean follow-up of 290 days, there were no significant differences in the overall mortality [exchange 17.6% (4.3-50.6) vs. non-exchange 23.3% (15.8-32.9), P = 0.67] and infection recurrence rates [exchange 26.7% (8.7-58.0) vs. non-exchange 38.6% (15.4-68.5), P = 0.56]. In the setting of CF-LVAD-specific infections, device exchange does not appear to confer an advantage in the overall mortality and infection recurrence as compared to non-exchange modalities.

Introduction The domino-donor operation is a procedure applicable to heart-lung transplantation (HLT) for septic or hypertensive lung disease. Often a "conditioned" heart from the HLT recipient is transplanted (HT) into a recipient with increased pulmonary vascular resistance. The procedure is thought to maximize the number of donor organs but is very rarely performed in the current era. The purpose of this systemic review was to investigate the indications and outcomes associated with the domino procedure. Methods An electronic search was performed to identify all studies on the domino procedure in the English literature. Eight studies reporting on a total of 183 HLT recipients and 266 HT recipients were included for final analysis. Results HLT indications included cystic fibrosis in 58% (95%CI: 27-84) of recipients, primary pulmonary hypertension in 17% (95%CI: 12-24), bronchiectasis in 5% (95%CI: 3-10), emphysema in 5% (95%CI: 0-45), and Eisenmenger's syndrome in 4% (95%CI: 2-8). HT indications included ischemic heart disease in 40% (95%CI: 33-47), nonischemic disease in 39% (95%CI: 25-56), and retransplantation in 10% (95%CI: 1-59). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95%CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95%CI: 18-41) at an average follow-up of 15.7 months (95%CI: 0.82-30.5), and 35% (95%CI: 17-58) in the HT group at average follow-up of 37.3 months (95%CI: 6.7-67.8). Freedom from rejection in HT was 94% (95%CI: 75-99) at 1 month, 77% (95%CI: 30-96) at 6 months, and 41% (95%CI: 33-50) at 1 year. A subgroup comparison between HLT and HT groups demonstrated a significant difference in the age [mean HLT age, 26.7 years (95%CI: 21.3-32.2) vs mean HT age, 40.4 years (95%CI: 32.2-48.6) p ≤ 0.01] and a trend towards significance in male sex [45% males in HLT group (95%CI: 29-63), vs 68% males in the HT group (95%CI: 52-80) p=0.06]. Pooled survival over time for both groups is shown in the figure. Conclusions The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.

Purpose In patients who require orthotopic liver transplant (OLT), cardiac surgery may be needed to optimize preoperative cardiac status for OLT. The aim of this systematic review was to evaluate patient characteristics and outcomes undergoing staged versus concomitant cardiac procedures with OLT. Methods An electronic search was performed to identify all case reports and series, from which patient-level data was extracted regarding cardiac procedures associated with OLT. After assessment for inclusion and exclusion criteria, 26 articles were pooled for systematic review. Results Overall, 49 patients were included in the analysis, of whom 12 (24%) underwent staged procedures and 37 (76%) underwent concomitant procedures. The median age was lower in the staged group [staged: 51.0 (IQR, 43.8-59.2) years vs. concomitant: 60.0 (IQR, 55.0-64.0) years, p=0.02]. Other baseline characteristics were comparable between the two groups. For staged procedures, the median time between heart procedures and OLT was 2 months. The most commonly reported cardiac procedures were coronary artery bypass graft (CABG) [staged: 4/12 (33.3%) vs. concomitant: 21/37 (56.8%), p=0.28], aortic valve replacement (AVR) [staged: 3/12 (25.0%) vs. concomitant: 19/37 (51.2%), p=0.21], and transcatheter aortic valve replacement (TAVR) [staged: 4/12 (33.3%) vs. concomitant: 0/37 (0%), p=0.002]. There was a significantly shorter post-OLT hospital stay for those who had staged procedures versus those who had concomitant procedures [staged: 8 (IQR, 5-13) days vs. concomitant: 17 (IQR, 14-24) days, p=0.007]. However, both groups had similar in-hospital mortality [staged: 1/12 (8.3%) vs. concomitant: 4/37 (10.8%), p=1.0]. Stratified survival between the two groups is shown in the figure. Conclusion Patients who underwent the staged approach had a shorter post-transplant hospital stay, but survival appeared comparable with respect to those who underwent concomitant cardiac procedures with OLT.

Background Pre-transplant sensitization is a limiting factor in solid-organ transplantation. In heart transplants, ventricular assist device (VAD) implantation has been associated with sensitization to human leukocyte antigens (HLA). The effect of VAD on non-HLA antibodies is unclear. We have previously shown that polyreactive natural antibodies (Nabs) contribute to pre-sensitization in kidney allograft recipients. Here we assessed generation of Nabs after VAD implantation in pre-transplant sera and examined their contribution to cardiac allograft outcome. Methods IgM and IgG Nabs were tested in pre-transplant serum samples collected from 206 orthotopic heart transplant recipients, including 128 patients with VAD (VAD patients) and 78 patients without VAD (no-VAD patients). Nabs were assessed by testing serum reactivity to apoptotic cells by flow cytometry and to the generic oxidized epitope, malondialdehyde, by enzyme-linked immunosorbent assay. Results No difference was observed in serum levels of IgM Nabs between VAD and no-VAD patients. However, serum IgG Nabs levels were significantly increased in VAD compared with no-VAD patients. This increase was likely due to the presence of the VAD, as revealed by lower serum IgG Nabs levels before implantation. Elevated pre-transplant IgG Nabs level was associated with development of primary graft dysfunction (PGD). Conclusions Our study demonstrates that VAD support elicits IgG Nabs reactive to apoptotic cells and oxidized epitopes. These findings further support broad and non-specific B-cell activation by VAD, resulting in IgG sensitization. Moreover, the association of serum IgG Nabs levels with development of PGD suggests a possible role for these antibodies in the inflammatory reaction accompanying this complication.

Purpose Landmark work has demonstrated that hemocompatibility-related adverse event (HRAE) burden is significant lower with the newest centrifugal flow pump compared to the established axial flow pump. No study has compared HRAE among the approved centrifugal and axial flow pumps. The objective of this study was to evaluate the burden of HRAE between HeartMate II (HMII) and HeartWare HVAD (HW). Methods We performed a retrospective analysis of hemocompatibility related adverse events (nonsurgical bleeding, thromboembolic event, pump thrombosis , or neurological event) in patients following implantation of HMII or HW through 6 months follow-up. HRAE were categorized by type and severity of adverse event and assigned a hemocompatibility score (HCS) of 0-4 for no HRAE through life ending or disabling HRAE, respectively. Statistical analysis included assessment of survival free from HRAE from implantation to 6-month follow-up using Kaplan-Meier and Cox proportional-hazard models and comparison of net hemocompatibility score using proportional odds regression. Results The study cohort included 331 patients with 268 patients (81%) in the HMII group and 63 patients (19%) in HW group. Overall median age was 62.2 years; HMII patients were older (median 63.5 versus 58.1years, p Conclusion Freedom from and burden of HRAE were not significantly different between the HeartMate II and HeartWare HVAD which is distinct from findings in the MOMENTUM trial. This indicates that hemocompatibility may differ significantly among available centrifugal flow technology and direct comparison of centrifugal flow pumps is required.

Purpose Expanding the donor pool to include patients with hepatitis B virus (HBV) could help ameliorate the organ shortage in heart transplantation. While the safety of heart transplant from HBV- donors to HBV+ recipients (D-/R+) is well-documented, there are no standard guidelines for heart transplants from HBV+ donors to HBV- recipients (D+/R-). We performed a systematic review and meta-analysis to evaluate the management and outcomes of heart transplants for HBV+ donors and recipients. Methods Electronic search was performed to identify all relevant studies published on heart transplants with HBV+ donors or recipients. Number of transplants from HBV+ donors to HBV+ recipients was too limited (n=7). Therefore, comparison was performed between two groups where heart transplants were performed a) D+/R- (n=98) versus b) D-/R+ (n=65). Overall, 15 studies were selected. Demographic and perioperative variables along with outcomes including survival rates were extracted, pooled and compared for systematic review and meta-analysis. Results Mean patient age was 55 years (95% CI: 39 - 78) and 79% (95% CI: 69 - 86) were male, with no significant differences between the two groups. For D+/R- transplants, donor pre-transplant HBcAb and HBsAg seropositivity were 95% (95% CI: 86 - 98%) and 26% (95% CI: 5 - 68%), respectively. In D-/R+ transplants, all recipients were HBcAb+, and 84% (95% CI: 41 - 98%) were HBsAg+ pre-transplant. One D+/R- recipient seroconverted to HBsAg+ after transplant, which required antiviral treatment. Post-transplant HBV flare-up occurred in 33% (95% CI: 9 - 71%) of D-/R+ recipients. Post-transplant antiviral treatment was given to 80% (95% CI: 6 - 100%) of D+/R- recipients compared to 72% (95% CI: 42 - 90%) of D-/R+ recipients (p = 0.84). Hepatitis-related mortality was observed in 7% (95% CI: 2 - 27%) of D-/R+ recipients and zero D+/R- recipients. Survival one-year post-transplant was comparable between both groups at 83% (95% CI: 83 - 92%) and 81% (95% CI: 61 - 92%) for D+/R- and D-/R+ transplants, respectively. Conclusion Heart transplantation from HBV+ donors to HBV- recipients was associated with fewer hepatitis flare-ups and lower hepatitis-related mortality than transplants from HBV- donors to HBV+ recipients, with comparable survival at one year.