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Background Since 1998, there has been a national programme for paediatric heart transplantations (HT) in the Netherlands. In this study, we investigated waiting list mortality, survival post-HT, the incidence of common complications, and the patients’ functional status during follow-up. Methods All children listed for HT from 1998 until October 2020 were included. Follow-up lasted until 1 January 2021. Data were collected from the patient charts. Survival, post-operative complications as well as the functional status (Karnofsky/Lansky scale) at the end of follow-up were measured. Results In total, 87 patients were listed for HT, of whom 19 (22%) died while on the waiting list. Four patients were removed from the waiting list and 64 (74%) underwent transplantation. Median recipient age at HT was 12.0 (IQR 7.2–14.4) years old; 55% were female. One-, 5‑, and 10-year survival post-HT was 97%, 95%, and 88%, respectively. Common transplant-related complications were rejections (50%), Epstein-Barr virus infections (31%), cytomegalovirus infections (25%), post-transplant lymphoproliferative disease (13%), and cardiac allograft vasculopathy (13%). The median functional score (Karnofsky/Lansky scale) was 100 (IQR 90–100). Conclusion Children who undergo HT have an excellent survival rate up to 10 years post-HT. Even though complications post-HT are common, the functional status of most patients is excellent. Waiting list mortality is high, demonstrating that donor availability for this vulnerable patient group remains a major limitation for further improvement of outcome.

Iron deficiency (ID) is a common comorbidity in heart failure (HF). In these patients, intravenous iron administration can improve clinical outcomes and quality of life (QoL). However, data on ID are lacking in patients who have transitioned toward left ventricular assist device (LVAD) or heart transplantation (HTx). All patients who underwent LVAD (n = 84) surgery or HTx (n = 67) at our center between 2012 and 2019, aged ≥18 years with a follow-up of ≥3 months, were included. Retrospectively, the prevalence of ID up to 1 year preoperatively, and up to February 2020 postoperatively, as well as all iron administrations were assessed during this period. Iron status was assessed in 61% and 51% of the LVAD and HTx patients preoperatively, and 81% and 84%, respectively, postoperatively. Of these patients, 53% and 71% of the LVAD and HTx patients preoperatively were diagnosed with ID preoperatively, and 71% and 77%, respectively, postoperatively. ID was more frequently diagnosed >3 months postoperatively. Sixty-three percent of the LVAD (mostly intravenous) and 63% of the HTx patients (mostly oral) received iron administration. ID is highly prevalent pre- and post-LVAD and HTx. It is plausible that substitution can have similar QoL gains as in regular HF patients.

Background: Patients with end-stage heart failure refractory to medication can be treated with a heart transplant (HTx). These patients are subjected to a preoperative screening procedure according to International Society for Heart and Lung Transplantation guidelines. Additionally, in our hospital, a routine ear, nose, and throat (ENT) screening is performed, directed toward the identification of asymptomatic infections and head and neck neoplasms. There are no studies demonstrating that this screening has additional value in these patients. Methods: To investigate the yield of protocolled ENT screening in candidates for HTx, we retrospectively reviewed the medical records of patients who were subjected to the screening procedure between 2012 and 2020. Results: The study population consisted of 251 patients of whom 177 (70.5%) were male with a median age of 52 years (IQR, 45-59 years). Ten patients (4.0%) were diagnosed with an infection (sinus) or a neoplasm, resulting in a number needed to screen of 25. In all cases, ENT consultation or sinus radiography did not influence the decision to list patients for HTx. Furthermore, no major ENT infections or occurrence of de novo head and neck malignant neoplasm were observed during follow-up after HTx. Conclusions: The clinically relevant yield of protocolled ENT screening in candidates for HTx is low. Based on these findings, we believe that only patients with abnormal findings on a routine sinus computed tomography scan and/or specific ENT complaints should be referred to an otorhinolaryngologist.

Objectives Increasing evidence suggests a role for epicardial fat in the development of coronary artery disease in the general population. Heart transplantation patients are at increased risk of developing a specific form of coronary artery disease, cardiac allograft vasculopathy (CAV), which has far-reaching consequences in terms of morbidity and mortality. Until now, the role of epicardial fat volume (EFV) in the development of CAV remains unknown. Hence, we investigated the relationship between EFV and CAV as well as the influence of donor/recipient sex on EFV. Methods Adult heart transplant patients who underwent coronary computed tomography angiography (CCTA) for CAV screening who were four or more years post-HT were included. Using the CT examinations, we quantified the EFV and the degree of CAV. Ordinal and linear regression models were used to assess the association of EFV with CAV. Results In total, 149 (median age 44.5 years, 36% women) patients were included. The median time between HT and the CT scan was 11.0 (7.3–16.1) years. CAV grade 0, 1, 2 and 3 were seen in 85 (57%), 32 (22%), 14 (9%), and 18 (12%) patients, respectively. The median EFV was 208.4 (128.9–276.0) mL. Larger EFV were related to higher degrees of CAV (median of 164.7 to 290.6 mL for CAV grade 0 and 3, respectively, OR 5.23 (2.47–11.06), p < 0.001). Male recipients had significantly more EFV than female recipients irrespective of the donor sex (232.7 mL vs. 147.2 mL respectively, p < 0.001). Determinants for EFV were recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus. Conclusions EFV was associated with higher degrees of CAV. The recipient sex influenced the EFV more than the donor sex. Key Points • Patients after heart transplantation have a high amount of epicardial fat while larger amounts of epicardial fat are related to higher grades of cardiac allograft vasculopathy. • Determinants of higher epicardial fat volume included recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus. • Longitudinal studies are needed to further disentangle the role of epicardial fat in the development and progression of cardiac allograft vasculopathy. Graphical abstract

Aims: Lifestyle changes, such as increasing physical activity (PA), are a cornerstone of treatment of patients with chronic heart failure (HF). However, improving PA in HF patients is challenging, and low participation rates for cardiac rehabilitation (CR) as well as relapse to low PA levels after CR are major issues. We designed a randomized controlled trial to investigate if PA monitoring with motivational feedback before and after centre-based CR in HF patients with reduced ejection fraction (HFrEF) will lead to a clinically meaningful increase in physical fitness. Methods and results: A randomized controlled trial will be conducted in a sample of 180 HFrEF patients (New York Heart Association Class II/III) who are referred to 12-week standard CR. Patients will be randomized (2:1) to (1) standard of care (SoC) plus wearing a PA monitoring device (Fitbit Charge 3) with personalized step goals, feedback and motivation or (2) SoC only. The intervention lasts ±7 months: 4–5 weeks before CR, 12 weeks during CR and 12 weeks after CR. Measurements will take place at three time points. The primary endpoint is the change in the distance in 6-min walking test (6MWT) over the entire study period. Other endpoints include step count, grip strength, quality of life and all-cause mortality or hospitalization. Conclusions: HF-aPProACH will provide novel information on the effectiveness of remote PA stimulation and feedback before, during and after standard CR using a commercially available device to improve physical fitness in HFrEF patients.

Summary Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects long‐term outcomes in heart transplant (HTx) patients. We prospectively evaluated the feasibility of coronary computed tomography angiography (CCTA) for the detection of CAV during clinical implementation at our center. All consecutive HTx patients >4 years post‐transplant were actively converted from myocardial perfusion imaging to CCTA for the annual assessment of CAV. Between February 2018 and May 2019, 129/172 (75%) HTx patients underwent a CCTA. Renal impairment (n = 21/43) was the most frequent reason for patients could not undergo CCTA. CCTA image quality was good–excellent in 118/129 (92%) patients, and the radiation dose was 2.1 (1.6–2.8) mSv. CCTA showed obstructive CAV in 19/129 (15%) patients. Thirteen (10%) patients underwent additional tests, of which 8 patients underwent coronary revascularization within 90 days of CCTA. After 1 year, 3 additional coronary angiograms were performed, resulting in one revascularization in a patient with known severe CAV who developed ventricular tachycardia. One myocardial infarction after coronary stenting and 2 non‐cardiac deaths were observed. CCTA can be successfully implemented for routine detection of CAV with good image quality and low radiation dose. CCTA allows CAV evaluation with the limited need for additional invasive testing., CCTA can be safely and successfully implemented as a noninvasive alternative for routine detection of CAV in HTx patients with good image quality and low radiation dose.

All transplant recipients receive tacrolimus, mycophenolate and glucocorticoids and these drugs have many side-effects and drug-drug interactions. Common complications include surgical complications, infections, rejection and acute kidney injury. Infections as CMV and PJP can be prevented with prophylactic treatment. Given the complexity of organ transplant recipients a multi-disciplinary team of intensivists, surgeons, pharmacists and transplant specialists is essential. After heart transplantation a temporary pacemaker is required until the conduction system recovers. Stiffening of the heart and increased cardiac markers indicate rejection. An endomyocardial biopsy is performed via the right jugular vein, necessitating its preservation. For lung transplant patients, early intervention for aspiration is warranted to prevent chronic rejection. Risk of any infection is high, requiring active surveillance and intensive treatment, mainly of fungal infections. The liver is immunotolerant requiring lower immunosuppression. Transplantation surgery is often accompanied by massive blood loss and coagulopathy. Other complications include portal vein or hepatic artery thrombosis and biliary leakage or stenosis. Kidney transplant recipients have a high risk of cardiovascular disease and posttransplant anemia should be treated liberally. After postmortal transplantation, delayed graft function is common and dialysis is continued. Ureteral anastomosis complications can be diagnosed with ultrasound.

Post-transplant diabetes mellitus (PTDM) is a frequent complication post-heart transplantation (HT), however long-term prevalence studies are missing. The aim of this study was to determine the prevalence and determinants of PTDM as well as prediabetes long-term post-HT using oral glucose tolerance tests (OGTT). Also, the additional value of OGTT compared to fasting glucose and glycated hemoglobin (HbA1c) was investigated. All patients > 1 year post-HT seen at the outpatient clinic between August 2018 and April 2021 were screened with an OGTT. Patients with known diabetes, an active infection/rejection/malignancy or patients unwilling or unable to undergo OGTT were excluded. In total, 263 patients were screened, 108 were excluded. The included 155 patients had a median age of 54.3 [42.2–64.3] years, and 63 (41%) were female. Median time since HT was 8.5 [4.8–14.5] years. Overall, 51 (33%) had a normal range, 85 (55%) had a prediabetes range and 19 (12%) had a PTDM range test. OGTT identified prediabetes and PTDM in more patients (18% and 50%, respectively), than fasting glucose levels and HbA1c. Age at HT (OR 1.03 (1.00–1.06), p = 0.044) was a significant determinant of an abnormal OGTT. Prediabetes as well as PTDM are frequently seen long-term post-HT. OGTT is the preferred screening method.

Objectives Invasively measured fractional flow reserve (FFR) is associated with outcome in heart transplant (HTx) patients. Coronary computed tomography angiography (CCTA)–derived FFR (FFRct) provides additional functional information from anatomical CT images. We describe the first use of FFRct in HTx patients. Methods HTx patients underwent CCTA with FFRct to screen for cardiac allograft vasculopathy. FFRct was measured distal to each coronary stenosis > 30% and FFRct ≤ 0.8 indicated hemodynamically significant stenosis. FFRct was also measured at the most distal location of each vessel. Overall distal FFRct was calculated as the mean of the distal values in the left, right, and circumflex coronary artery in each patient. Results Seventy-three patients (age 56 (42–65) years, 63% males) at 11 (8–16) years after HTx were included. Eighteen (25%) patients had a focal hemodynamically significant stenosis (stenosis > 30% with FFRct ≤ 0.8). In the 55 patients without a hemodynamically significant focal FFRct stenosis (FFRct > 0.80), the distal left anterior descending artery FFRct was p = 0.93). Conclusions FFRct performed on CCTA scans of HTx patients demonstrated that 25% of patients had a focal coronary stenosis with FFRct ≤ 0.8. Even without a focal stenosis, FFRct values are often abnormal in HTx patients. Key Points • This is the first report describing the use of FFRct in in heart transplant patients. • FFRct identifies patients after heart transplantation with hemodynamically significant coronary stenosis. • Even without a focal stenosis, FFRct values are often abnormal in heart transplant patients.

Aims: Many heart transplant recipients will develop end-stage renal disease in the post-operative course. The aim of this study was to identify the long-term incidence of end-stage renal disease, determine its risk factors, and investigate what subsequent therapy was associated with the best survival. Methods and results: A retrospective, single-centre study was performed in all adult heart transplant patients from 1984 to 2016. Risk factors for end-stage renal disease were analysed by means of multivariable regression analysis and survival by means of Kaplan–Meier. Of 685 heart transplant recipients, 71 were excluded: 64 were under 18 years of age and seven were re-transplantations. During a median follow-up of 8.6 years, 121 (19.7%) patients developed end-stage renal disease: 22 received conservative therapy, 80 were treated with dialysis (46 haemodialysis and 34 peritoneal dialysis), and 19 received a kidney transplant. Development of end-stage renal disease (examined as a time-dependent variable) inferred a hazard ratio of 6.45 (95% confidence interval 4.87–8.54, P < 0.001) for mortality. Tacrolimus-based therapy decreased, and acute kidney injury requiring renal replacement therapy increased the risk for end-stage renal disease development (hazard ratio 0.40, 95% confidence interval 0.26–0.62, P < 0.001, and hazard ratio 4.18, 95% confidence interval 2.30–7.59, P < 0.001, respectively). Kidney transplantation was associated with the best median survival compared with dialysis or conservative therapy: 6.4 vs. 2.2 vs. 0.3 years (P < 0.0001), respectively, after end-stage renal disease development. Conclusions: End-stage renal disease is a frequent complication after heart transplant and is associated with poor survival. Kidney transplantation resulted in the longest survival of patients with end-stage renal disease.

Supplemental Digital Content is available in the text., Background. Previous studies on the association between cytomegalovirus (CMV) infection and cardiac allograft vasculopathy (CAV) were conducted on patients transplanted in the prevalganciclovir prophylaxis era. The aim of our study is to evaluate this relation in heart transplantation (HTx) recipients treated according to current prophylactic and immunosuppressive regimens. Methods. This single-center retrospective study included all consecutive adult patients that underwent HTx between January 1, 2000, and May 31, 2018. Clinically relevant CMV infection was defined as either plasma CMV DNAemia ≥ 1000 IU/mL with/without clinical symptoms or

Increasing evidence suggests a role for epicardial fat in the development of coronary artery disease in the general population. Heart transplantation patients are at increased risk of developing a specific form of coronary artery disease, cardiac allograft vasculopathy (CAV), which has far-reaching consequences in terms of morbidity and mortality. Until now, the role of epicardial fat volume (EFV) in the development of CAV remains unknown. Hence, we investigated the relationship between EFV and CAV as well as the influence of donor/recipient sex on EFV.Adult heart transplant patients who underwent coronary computed tomography angiography (CCTA) for CAV screening who were four or more years post-HT were included. Using the CT examinations, we quantified the EFV and the degree of CAV. Ordinal and linear regression models were used to assess the association of EFV with CAV.In total, 149 (median age 44.5 years, 36% women) patients were included. The median time between HT and the CT scan was 11.0 (7.3-16.1) years. CAV grade 0, 1, 2 and 3 were seen in 85 (57%), 32 (22%), 14 (9%), and 18 (12%) patients, respectively. The median EFV was 208.4 (128.9-276.0) mL. Larger EFV were related to higher degrees of CAV (median of 164.7 to 290.6 mL for CAV grade 0 and 3, respectively, OR 5.23 (2.47-11.06), p0.001). Male recipients had significantly more EFV than female recipients irrespective of the donor sex (232.7 mL vs. 147.2 mL respectively, p0.001). Determinants for EFV were recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus.EFV was associated with higher degrees of CAV. The recipient sex influenced the EFV more than the donor sex.• Patients after heart transplantation have a high amount of epicardial fat while larger amounts of epicardial fat are related to higher grades of cardiac allograft vasculopathy. • Determinants of higher epicardial fat volume included recipient sex, number of rejections, donor age, time between HT and CT scan, recipient BMI, and diabetes mellitus. • Longitudinal studies are needed to further disentangle the role of epicardial fat in the development and progression of cardiac allograft vasculopathy. Demonstration of four patients (from CAV grade 0 to CAV grade 3) in whom epicardial fat volume was determined. In red, the voxels identified as epicardial fat.

This report describes the first heart transplantation recipient with acute biventricular heart failure symptoms caused by a post-myocarditis state, late after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No other viral pathogens could be detected. Computed tomography angiography did not show cardiac allograft vasculopathy, and myocardial biopsy demonstrated no clinically relevant rejection. Subsequent cardiovascular magnetic resonance imaging revealed extensive epicardial delayed enhancement without myocardial edema. Heart failure medication was initiated and an implantable cardioverter defibrillator was implanted (due to non-sustained ventricular tachycardias), leading to a partial recovery of the ejection fraction. Further studies are needed to investigate the number of heart transplant recipients with myocardial damage after a SARS-CoV-2 infection.

We describe the first patient with a left ventricular assist device (LVAD) driveline infection caused by Mycobacterium chelonae presenting with persistent infection despite conventional antibiotics. Treatment was successful with surgical debridement, driveline exit relocation, and a 4-month period of antibiotics. In the case of a culture-negative LVAD driveline infection, non-tuberculous mycobacteria should be considered. This case illustrates that multidisciplinary collaboration is essential in providing optimal care for LVAD patients.

Background With more patients qualifying for heart transplantation (HT) and fewer hearts being transplanted, it is vital to look for other options. To date, only organs from brain-dead donors have been used for HT in the Netherlands. We investigated waiting list mortality in all Dutch HT centres and the potential of donation after circulatory death (DCD) HT in the Netherlands. Methods Two different cohorts were evaluated. One cohort was defined as patients who were newly listed or were already on the waiting list for HT between January 2013 and December 2017. Follow-up continued until September 2018 and waiting list mortality was calculated. A second cohort of all DCD donors in the Netherlands (lung, liver, kidney and pancreas) between January 2013 and December 2017 was used to calculate the potential of DCD HT. Results Out of 395 patients on the waiting list for HT, 196 (50%) received transplants after a median waiting time of 2.6 years. In total, 15% died while on the waiting list before a suitable donor heart became available. We identified 1006 DCD donors. After applying exclusion criteria and an age limit of 50 years, 122 potential heart donors remained. This number increased to 220 when the age limit was extended to 57 years. Conclusion Waiting list mortality in the Netherlands is high. HT using organs from DCD donors has great potential in the Netherlands and could lead to a reduction in waiting list mortality. Cardiac screening will eventually determine the true potential.

PURPOSE: Invasively measured fractional flow reserve (FFR) is associated with outcome in heart transplant (HTx) patients. Non-invasive coronary computed tomography angiography (CCTA)-derived FFR (FFRct) provides additional functional information from anatomical CT images. The anatomical model of the coronary arteries derived from CCTA is used to calculate the FFRct values at each point in the coronary arteries. We describe the first use of FFRct in a cohort of HTx patients. METHODS: HTx patients underwent CCTA with FFRct as part routine follow-up to screen for cardiac allograft vasculopathy (CAV). FFRct was performed off-site by a company. FFRct was measured distal to each coronary stenosis >30% and at the most distal location of each of the 3 major coronary arteries (right, left anterior descending and circumflex coronary artery). Overal distal FFRct was calculated as the mean of 3 vessels per patient. During 90-day follow-up, performance of additional tests for coronary assessment and revascularization were recorded. RESULTS: 73 patients (age 56 (42-65) years, 63% males) at 11 (8-16) years after HTx were included. In the 54 patients without a hemodynamically significant focal FFRct stenosis (FFRct >0.80), the distal left anterior descending artery FFRct was

PURPOSE: Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects heart transplant patients (HTx). Routine screening for CAV is warranted. We evaluated the feasibility and utility of cardiac CT to screen for CAV in 100 consecutive HTx patients at our center. METHODS: From Feb 2018 to Jan 2019 all consecutive HTxs who were more than five-years post-transplant were converted from using stress myocardial perfusion imaging to cardiac CT for the annual assessment of CAV. CAV was scored (0 (absent), 1 (mild), 2 (moderate), 3 (severe)) based on coronary CT angiography (CCTA) findings and compared with the most recently known CAV score before CCTA. RESULTS: CCTA was performed in 99 out of 100 patients who were planned for cardiac CT (56 (42-63) years, 65% men, and 11 (8-16) years post-transplant), 1 patient underwent only a calcium scan due to IV access problems. The median Agatston calcium score was 6 (0-85), and 38 patients had no detectable calcium. CCTA showed new obstructive coronary disease (>50% stenosis) in 20 patients. The CAV score was reclassified based on CCTA findings in 37 patients (p

Data on the risk of aortic root thrombosis in patients with aortic valve replacement (AVR) and left ventricular assist device (LVAD) surgery are scarce. Two out of nine patients receiving AVR concomitant with LVAD surgery and two out of two patients receiving AVR on LVAD support, at our centre, developed an aortic root thrombus, all diagnosed with computed tomography (CT) angiography. These results demonstrate that patients with concomitant AVR and LVAD surgery, or AVR on LVAD support, have an increased risk of aortic root thrombosis. Therefore, early anti‐thrombotic therapy and vigilant diagnostic follow‐up, using CT scans, are warranted to prevent thromboembolic events.

Purpose The difference in renal function between bridge-to-transplantation (BTT) and medically managed patients undergoing heart transplantation (HTx) is unknown. This study aimed to depict the difference in renal function between BTT and medically managed patients pre- and post-HTx. Methods A retrospective single-center cohort study was conducted including all HTx patients that were transplanted since the introduction of left ventricular assist device (LVAD) therapy in our center in 2006. Patients were dichotomized according to BTT and medical management strategy. Results In total, 164 patients were included, of whom 135 were medically managed (mean age 49.3±10.4), and 29 BTT patients (mean age 48.5±11.8). Median time on LVAD support pre-HTx was 551 days, interquartile range [230-863]. At 12 months prior to HTx, the BTT patients had higher mean eGFR compared to the medically managed patients (87 ml/min/1.73m2 vs 63 ml/min/1.73m2, p Outcomes, including mortality and primary graft dysfunction, following HTx were not significantly different Conclusion In conclusion, patients who are bridged with LVAD therapy had a higher mean renal function at the time of HTx. Additionally, patients who received BTT therapy preserved longer an improved renal function at 1-year pre- and post-HTx.

Purpose Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects heart transplant (HT) patients. Routine surveillance for CAV is warranted. We evaluated the feasibility, utility and safety of cardiac CT to screen for CAV in HT patients. Methods From Feb 2018 to Jul 2019 all HT patients >four years post-HT were converted from using stress myocardial perfusion imaging for the annual CAV surveillance to cardiac CT (calcium score scan and CT angiography (CTA)). All first scans were included. Scans were scored for image quality (non-diagnostic, moderate, good, excellent), Agatston calcium score and coronary stenosis (0%, Results In total, 141 CT scans were included. CTA was performed in 140 out of 141 patients who were planned for cardiac CT (55 (43-64) years, 66% men, and 11 (8-16) years post-HT). One patient only had a calcium score due to no IV access. Mean heart rate during CTA was 75±11 beats per minute with beta-blockers given in 90 patients. Image quality was good/excellent in 124 (89%) scans. Median radiation dose was 2.1 (1.6-2.9) mSv. Median Agatston calcium score was 4 (0-73), 56 (40%) patients had no detectable calcium. CTA showed new obstructive coronary disease (≥50% stenosis) in 25 (18%) patients (Figure 1). CTA reclassified CAV score in 49 (35%) patients (p Conclusion Cardiac CT can be performed successfully in HT patients with good/excellent image quality and low radiation dose. CTA successfully detects significant CAV which leads to substantial reclassification of CAV grades.

Purpose Cardiac allograft vasculopathy (CAV) is a poorly understood, accelerated form of coronary artery disease in patients that underwent heart transplantation (HT), and substantially contributes to post-transplantation morbidity and mortality. Increasing evidence shows an active role for epicardial fat (EF) in the development of coronary artery disease, as a result of its inflammatory properties. Yet, whether the amount of EF is also related to CAV remains unknown. Hence, we investigated the association of epicardial fat volume (EFV) with CAV. Methods For this pilot study, we included post HT-patients whom underwent cardiac computed tomography (CCT) for CAV screening between February 2018 and January 2019. CCT included a non-enhanced CT (NECT) and CT angiography (CCTA). Using the NECT, we quantified the EFV using an automated algorithm (Fig 1.). CAV was graded on CCTA similar to the guidelines of the International Society for Heart and Lung Transplantation. The association of EFV with the presence and grade of CAV was investigated using binary- and ordinal logistical regression models, adjusted for recipient age and gender, time since HT and number of rejections pre-CCT. Results We included 74 patients, with a median age of 45 years [IQR 27-51] at HT of whom 29 were women. Median time since HT was 10.0 years [IQR 8.0-15.3]. CAV was prevalent in 28 (38%) patients, of whom 17 (61%) had CAV 1, 5 (18%) had CAV 2 and 6 (21%) had CAV 3. Median EFV was 198.5 [IQR 123.4-262.1] mm3. The median EFV was larger with higher CAV grades: 162.2 (CAV 0), 211.5 (CAV 1), 230.0 (CAV 2) and 278.3 (CAV 3) mm3 (p=0.031). Albeit not statistically significant, we found an association of EFV with the presence of CAV (odds ratio (OR) per 1-standard deviation increase in log-transformed EFV: 1.48 (95%CI: 0.80-2.72), p=0.21) and with CAV grade (OR 1.52 (95%CI: 0.85-2.71), p=0.15). Conclusion Our preliminary results show a promising trend towards an association of the amount of epicardial fat and the presence of CAV, which should be confirmed in larger studies.

Purpose Post-transplant diabetes mellitus (PTDM) is a frequent complication post-heart transplantation (HT). Moreover, PTDM has been associated with cardiovascular adverse events long-term post-HT. The golden standard to diagnose PTDM is an oral glucose tolerance test (OGTT). Studies investigating the incidence of PTDM long-term post-HT are missing. The aim was to investigate the prevalence of unknown PTDM long-term post-HT. Methods Data were prospectively collected from all adult HT patients who had an OGTT between August 2018 and October 2020. Patients with known DM, an active infection or active treatment of a malignancy were excluded as well as patients who did not want to undergo an OGTT. Either the patient came sober to the outpatient clinic for a regular appointment or visited the general practitioner when the distance to the hospital was too far. A fasting glucose was determined after which the patient was administered 75 grams of glucose in a 200 mL solution as advised by the American Diabetes Association. After two hours, glucose was measured again. Furthermore, glycated hemoglobin (HbA1c) was determined. Definitions of PTDM, pre-diabetes and no diabetes are mentioned in Table 1. Diabetes range tests were repeated after six weeks with another OGTT to confirm PTDM. Results Out of 251 patients, 148 patients were tested excluding 71 patients with known DM and 32 patients not able or willing to undergo an OGTT. Median age at OGTT was 54.5 [IQR 42.4-64.8] years and 60 (41%) were female. Main reason for HT was non-ischemic cardiomyopathy (n=118, 80%). Median time from HT until OGTT was 8.6 [IQR 4.8-14.4] years. Steroids were used in 90 (61%) patients and 134 (91%) patients used tacrolimus at the time of OGTT. In total, OGTT demonstrated new PTDM in 21 (14%) patients, pre-diabetes in 41 (28%) patients and no diabetes in 86 (58%) patients. Conclusion PTDM as well as pre-diabetes are frequently seen long-term post-HT. As such, systematic screening by OGTT is warranted for timely intervention as this may improve the long-term outcome.

Visual Abstract, Highlights In swine with and without diabetes mellitus fed a fast-food diet: • OCT, NIRS, CCTA, vascular function testing, and histology can be consecutively and longitudinally performed to assess gradual coronary atherosclerosis development • OCT and NIRS enabled detailed assessment of early coronary atherosclerosis development, whereas CCTA was not able to detect discrete early atherosclerotic changes. • OCT, NIRS, vascular function testing, and histology demonstrated no differences in early atherosclerosis development., Summary Patients with diabetes mellitus (DM) are at increased risk for atherosclerosis-related events compared to non-DM (NDM) patients. With an expected worldwide epidemic of DM, early detection of anatomic and functional coronary atherosclerotic changes is gaining attention. To improve our understanding of early atherosclerosis development, we studied a swine model that gradually developed coronary atherosclerosis. Interestingly, optical coherence tomography, near-infrared spectroscopy (NIRS), vascular function, and histology demonstrated no differences between development of early atherosclerosis in fast-food-fed (FF) DM swine and that in FF-NDM swine. Coronary computed tomography angiography did not detect early atherosclerosis, but optical coherence tomography and near-infrared spectroscopy demonstrated coronary atherosclerosis development in FF-DM and FF-NDM swine.

The levelized cost of electricity (LCOE) of photovoltaic (PV) systems is determined by, among other factors, the PV module reliability. Better prediction of degradation mechanisms and prevention of module field failure can consequently decrease investment risks as well as increase the electricity yield. An improved knowledge level can for these reasons significantly decrease the total costs of PV electricity. In order to better understand and minimize the degradation of PV modules, the occurring degradation mechanisms and conditions should be identified. This should preferably happen under combined stresses, since modules in the field are also simultaneously exposed to multiple stress factors. Therefore, two 'Combined Stress test with in situ measurement' setups have been designed and constructed. These setups allow the simultaneous use of humidity, temperature, illumination, and electrical biases as independently controlled stress factors on solar cells and minimodules. The setups also allow real-time monitoring of the electrical properties of these samples. This protocol presents these setups and describes the experimental possibilities. Moreover, results obtained with these setups are also presented: various examples about the influence of both deposition and degradation conditions on the stability of thin film Cu(In,Ga)Se2 (CIGS) as well as Cu2ZnSnSe4 (CZTS) solar cells are described. Results on the temperature dependency of CIGS solar cells are also presented.

The levelized cost of electricity (LCOE) of photovoltaic (PV) systems is determined by, among other factors, the PV module reliability. Better prediction of degradation mechanisms and prevention of module field failure can consequently decrease investment risks as well as increase the electricity yield. An improved knowledge level can for these reasons significantly decrease the total costs of PV electricity. In order to better understand and minimize the degradation of PV modules, the occurring degradation mechanisms and conditions should be identified. This should preferably happen under combined stresses, since modules in the field are also simultaneously exposed to multiple stress factors. Therefore, two 'Combined Stress test with in situ measurement' setups have been designed and constructed. These setups allow the simultaneous use of humidity, temperature, illumination, and electrical biases as independently controlled stress factors on solar cells and minimodules. The setups also allow real-time monitoring of the electrical properties of these samples. This protocol presents these setups and describes the experimental possibilities. Moreover, results obtained with these setups are also presented: various examples about the influence of both deposition and degradation conditions on the stability of thin film Cu(In,Ga)Se2 (CIGS) as well as Cu2ZnSnSe4 (CZTS) solar cells are described. Results on the temperature dependency of CIGS solar cells are also presented.

Despite all the research carried out to date, LID is not yet fully understood as it has many origins that affect differently several types of crystalline solar cells. Latest available high-tech equipment allows to test modules under a wide range of elevated temperatures while simultaneously light-soaking them with Class AAA light and doing in-situ measurements, for a prolonged time of weeks or months. Employing this setup, the timelines of LID degradation and regeneration under different temperatures and light intensities can be assessed in detail. The present abstract performs this analysis on mono-crystalline silicon (mono-Si) p-type PERC PV modules at elevated temperatures and quantifies the losses due to degradation, which becomes 0.8 to 1.0 % in maximum 12 hours at 92°C under 1000 W/m2, followed by a regeneration of 1 % which can take between 24 and 60 hours. The complete work based on this abstract extends the research to micro-crystalline Silicon (mc-Si) PERC PV modules as well as perform the analysis at different temperatures and light intensities, while relating the output to outdoor long-term exposure data for different locations.

Dobutamine stress myocardial perfusion imaging (MPI) is a useful alternative for the evaluation of coronary artery disease (CAD) in elderly patients who are unable to perform an exercise stress test. However, data on the long-term prognostic value of stress MPI in elderly patients are lacking. Therefore, this study evaluated the long-term prognostic value of dobutamine stress MPI in elderly patients unable to perform an exercise test. The study population consisted of 247 elderly patients (mean age 71 ± 5 years) who underwent dobutamine stress single-photon emission computed tomography (SPECT) MPI. An abnormal SPECT study was defined as the presence of fixed and/or reversible perfusion defects. A summed stress score (SSS) was obtained to estimate the extent and severity of perfusion defects. End points during follow-up were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI). During a median follow-up of 14 years (range 12-16), 168 (68%) patients died (all-cause mortality), of which 56 (23%) were due to cardiac causes. Nonfatal MI occurred in 19 (8%) patients. Kaplan-Meier survival curves showed that MPI provided optimal risk stratification in patients with normal and abnormal MPI. Multivariable analysis identified an abnormal MPI as a strong significant predictor of all-cause mortality and cardiac events. A multivariable analysis also revealed that a reversible defect and SSS were strong long-term predictors of cardiac mortality and hard cardiac events. Dobutamine stress 99mTc-tetrofosmin SPECT provides incremental prognostic information for the prediction of long-term cardiovascular outcomes in elderly patients, unable to perform exercise testing. Dobutamine stress MPI is useful in risk classifying elderly patients.

Industrial production of bifacial photovoltaic modules is becoming more and more cost-effective in recent years. For this reason, the development of an agreed international standard test that provides the guidelines to measure the current-voltage characteristics of bifacial modules, especially under standard test conditions, is of utmost importance [1]. In order to contribute to the international norm, the goal of this research is to compare the two main bifacial indoor testing methods under several irradiance and temperature conditions, combining a flash simulator and a steady-state simulator. Among other insights, the results successfully quantify the offset in maximum power measurements between methods.

Purpose Extreme shortage in donors in the Netherlands has led to increasingly aging donors in heart transplantations (HT). The aim of the study was to evaluate the relationship between donor age and the need for a permanent pacemaker (PPM) implantation after HT. Methods All HTs in our centre between 1984 and august 2018 were retrospectively analysed. Retransplantation within 30 days (n=2) and patients who died within 30 days after HT (n=53) were excluded from the study. In this study 664 HTs were included. Based on the donor age, the HTs were divided into three groups: Group I ( 50 years, n=96). Primary outcome was the implantation of a PPM post-HT, either early (≤ 90 days) or late (> 90 days). Results The biatrial technique was performed in 659 HTs and only 5 using the bicaval technique. Before 2000 (the moment of immunosuppressive regime switch from cyclosporine- to tacrolimus-based therapy), the median donor age was 26 [IQR 20-35] and after 2000 42 [IQR 25-51] (P 90 days (median 7.6 years [IQR 3.4-13.4]) post-HT. The early PPM rate was 1.5% before 2000 vs 11% late PPM rate, while after 2000 the rates were 10.6% and 5.9% respectively. Indications for PPM implantation were sinus node dysfunction in 52.1% and atrioventricular block in 47.9%. Total PPM rates were 10% (Group I), 18% (Group II) and 25% (Group III) (P Conclusion The need for an early PPM is statistically higher in HTs with a donor age > 50 years. However, the long-term survival was non-inferior in patients with a PPM.

Purpose The risk of developing thromboembolic events is elevated in the first 3 months after an aortic valve replacement (AoVR). Therefore, the current guidelines recommends very early (at day 1) introduction of low dose aspirin or therapeutic warfarin therapy after AoV replacement. Following Left Ventricular Assist Device (LVAD) implantation, AoVR with a bioprothesis is advised in patients with a moderate to severe aortic regurgitation (AR). Aim of this study was to evaluate the clinical outcome of bioprothesis post-LVAD, especially in relation to thromboembolic events. Methods We revised all LVAD implantations in our center (64 HeartMate II and 40 HeartMate 3 LVAD patients) starting from 2006 for AoVR and thromboembolic events diagnosed on CT-angiography (CT-a). Results Nine patients (8.7%; median age 53 years, 89% male) had concomitant AoVR at the time of LVAD implantation, one patient (1.0%; 56 years of age, male) had AoVR 520 days post-LVAD, one patient (1.0%; 59 years of age, female) had a Transcatheter Aortic Valve Implantation (TAVI) after 337 days post-LVAD. An overview of the clinical data is shown in the Table. Median follow-up time on LVAD support was 750 days [range: 86-2065]. Median time to therapeutic heparin/warfarin therapy was 4 days [range: 1-7] and median time to start of aspirin was 11.5 days [range: 5-39] after implantation. Three patients developed an aortic root thrombus within the first month after implantation, all primarily diagnosed with CT-a, and subsequently confirmed by transthoracic echocardiography. Furthermore, two patients suffered from a stroke, one ischemic and one hemorrhagic. Conclusion In our cohort, consisting of eleven patients with LVAD and AoVR, almost one third had LVOT/AoV thrombosis at CT-a, one of them developed an ischemic stroke. We hypothesize that concomitant AoVR at the time of LVAD implantation in selected patients may be associated with less risk for thrombus formation on LVOT/AoV as compared to a later intervention on the aortic valve.

Dobutamine stress myocardial perfusion imaging (MPI) is a useful alternative for the evaluation of coronary artery disease (CAD) in elderly patients who are unable to perform an exercise stress test. However, data on the long-term prognostic value of stress MPI in elderly patients are lacking. Therefore, this study evaluated the long-term prognostic value of dobutamine stress MPI in elderly patients unable to perform an exercise test.The study population consisted of 247 elderly patients (mean age 71 ± 5 years) who underwent dobutamine stress single-photon emission computed tomography (SPECT) MPI. An abnormal SPECT study was defined as the presence of fixed and/or reversible perfusion defects. A summed stress score (SSS) was obtained to estimate the extent and severity of perfusion defects. End points during follow-up were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI).During a median follow-up of 14 years (range 12-16), 168 (68%) patients died (all-cause mortality), of which 56 (23%) were due to cardiac causes. Nonfatal MI occurred in 19 (8%) patients. Kaplan-Meier survival curves showed that MPI provided optimal risk stratification in patients with normal and abnormal MPI. Multivariable analysis identified an abnormal MPI as a strong significant predictor of all-cause mortality and cardiac events. A multivariable analysis also revealed that a reversible defect and SSS were strong long-term predictors of cardiac mortality and hard cardiac events.Dobutamine stress