Search

Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair.We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared.PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04).Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.

Invasive hemodynamic variables obtained from right heart catheterization have been used for risk-stratifying patients with advanced heart failure (HF). However, there is a paucity of data on the prognostic value of invasive hemodynamic variables in patients with left ventricular assist devices (LVAD). We hypothesized that cardiac power output (CPO), cardiac power efficiency (CPE), and left ventricular stroke work index (LVSWI) can serve as prognostic markers in patients with LVADs.Baseline hemodynamic data from patients who had LVAD ramp studies at our institution from 4/2014 to 7/2018 were prospectively collected, from which advanced hemodynamic variables (CPO, CPE, and LVSWI) were retrospectively analyzed. Univariate and multivariable analyses were performed for hemocompatibility-related adverse events (HRAE), HF admissions, and mortality.Ninety-one participants (age 61 ± 11 years, 34% women, 40% Black or African American, and 38% ischemic cardiomyopathy) were analyzed. Low CPE was significantly associated with mortality (HR 2.42, 95% CI 1.02-5.74, p = 0.045) in univariate analysis and Kaplan-Meier analysis (p = 0.04). Low LVSWI was significantly associated with mortality (HR 2.13, 95% CI 1.09-4.17, p = 0.03) in univariate analysis and Kaplan-Meier analysis (p = 0.02). CPO was not associated with mortality. CPO, CPE, and LVSWI were not associated with HRAE or HF admissions.Advanced hemodynamic variables can serve as prognostic indicators for patients with LVADs. Low CPE and LVSWI are prognostic for higher mortality, but no variables were associated with HF admissions or HRAEs.

A female presented 2 weeks after birth with an unbalanced atrioventricular canal, double outlet right ventricle, mild pulmonary stenosis, and patent ductus arteriosus that eventually caused pulmonary over circulation. After pulmonary artery banding, she experienced myocardial ischemia, suggesting interference with coronary blood flow by the band that had been placed on the main pulmonary trunk. The band was removed and revised to bilateral branch pulmonary artery banding, and cardiac function improved. An anomalous left coronary artery from the underside of the right pulmonary artery was identified. Eight weeks later, the patient underwent coronary transfer and reimplantation of the left coronary artery into the aorta followed by main pulmonary artery banding. She subsequently underwent bidirectional Glenn.

Patients with concomitant anemia and congestive heart failure have poor outcomes. The prevalence and clinical risk of anemia in patients receiving durable left ventricular assist devices (LVAD) remain unknown.We retrospectively analyzed patients who underwent LVAD implantation between 2014 and 2018. The association between hemoglobin level at the time of index discharge and the one-year composite endpoint of heart failure readmissions or hemocompatibility-related adverse events was investigated.A total of 168 patients (57 [48, 66] years old, 123 males) were included and stratified into a classification of anemia (hemoglobin9.7 g/dl, N = 99) or non-anemia (N = 69). The anemia group had a higher one-year incidence of the composite endpoint (56% vs 36%, p = .013) with an adjusted hazard ratio of 1.83 (95% confidence interval 1.08-2.82). Patients with anemia also experienced suboptimal bi-ventricular unloading.Anemia was prevalent in LVAD patients and associated with a greater risk of heart failure and hemocompatibility-related adverse events. The optimal threshold for therapeutic intervention in response to post-LVAD anemia needs further investigation.

Background: Both hypo- and hyperkalemia are associated with adverse events in heart failure patients. Their effects on patients with left ventricular assist devices (LVADs) remains unknown. Methods and Results: The cohort included consecutive patients undergoing LVAD implantation between 2014 and 2018. In all, 170 patients (median age 56 years; 117 males) were stratified according to serum potassium levels 1 month after implantation into 3 groups: hypokalemia (5.0 mEq/L; n=9). Compared with the normokalemia group, the adjusted hazard ratios for 1-year mortality were 0.91 (95% confidence interval [CI] 0.21–3.92) for hypokalemia and 4.14 (95% CI 1.47–11.65) for hyperkalemia. In the hyperkalemia group, the prevalence of renin-angiotensin-aldosterone system inhibitors decreased and serum potassium levels normalized following the first month. Conclusions: Hyperkalemia was associated with increased mortality during LVAD support. Management of serum potassium needs further investigation.

Background: Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess post-operative and long-term outcomes of patients receiving either pericardial or synthetic repairs. Methods: We conducted a single center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N=38) with either autologous pericardium (n=30) or CorMatrix (n=8) between April 2009 and July 2016. Short and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, post-operatively, and at outpatient follow-up. Results: At five years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (P = 0.01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between pre- and post-operative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) post-operatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, 8 (100%) had moderate to severe AR which improved to 3 (38%) post-operatively and increased to 7 (88%) at time of follow-up. Conclusion: In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.

The allocation system for heart donors in the United States changed on October 18, 2018. The typical distance from donor hospitals to recipient hospitals has increased as has the ischemic time. We investigated patient outcomes with the new allocation system and the differential effects of ischemic time under both the old and new allocation schemas.The United Network for Organ Sharing Registry (UNOS) was queried for data regarding heart transplants occurring from October 1, 1987 to March 1, 2021. In total, 62,301 adult heart transplants were examined. Survival outcomes at 30 days and 1 year and ischemic times were compared via adjusted logistic and Cox models (overall survival and time until post-transplant rejection).Mean ischemic time was slightly increased in the new system (3.43 h vs. 3.03 h, p .001). Survival differences between old versus new systems were not observed in adjusted models (p = .818). However, there was evidence to suggest longer ischemic times are more detrimental to long-term survival under the new system (hazard ratio [HR] = 1.15 per hour increase; p = .001) versus the old system (HR = 1.08 per hour increase; p .001), although this relationship did not reach statistical significance (p = .150).Although travel distances have significantly increased under the new allocation system, survival outcomes remain largely unchanged. Ischemic time is an influential factor in recipient survival that should be limited during organ transport. Further studies on the impact of travel distances and ischemic time under the new allocation system are needed.

The negative impact of baseline hypoalbuminemia on clinical outcome following left ventricular assist device (LVAD) implantation is well known. However, the implications of perioperative change in serum albumin levels on post-LVAD outcomes remain uninvestigated.Among consecutive patients with baseline serum albumin3.5 g/dl who received durable LVAD implantation between April 2014 and August 2017 and were followed for 1 year, the impact of perioperative change in serum albumin level from baseline to 3 months post-LVAD on the incidence of adverse events was investigated.Sixty-eight patients (median 60 years and 69% male) were included. Serum albumin change was an independent predictor of the occurrence of adverse events with an adjusted hazard ratio of 0.32 (95% confidence interval, 0.13-0.78) and a cutoff change of 0.7 g/dl. Those with albumin increase0.7 g/dl had higher 1-year freedom from adverse events (45% vs. 14%, p = .008), dominantly due to lower incidence of death or sepsis compared with those without (p .05 for both).Among those with baseline hypoalbuminemia, a considerable perioperative increase in serum albumin levels following LVAD implantation was associated with lower mortality and morbidity. The implication of aggressive nutrition intervention on LVAD patients is the next concern.

Background: The seasonal variation of incidence and severity of heart failure is well known. However, the impact of seasonal variation on clinical outcomes following left ventricular assist device (LVAD) implantation remains unknown. Methods: We retrospectively reviewed consecutive patients who received LVAD implantation between January 2014 and December 2016 along with their first year of post-implant outcomes. Clinical outcomes were compared between those with winter LVAD implantation (between October and March) and those with non-winter LVAD implantation. Results: 168 patients with a median age of 57 years and 130 males were included. There was no seasonal difference in the number of LVAD implantations. One-year survival free from major adverse events was significantly lower in the winter implant group ( n = 88) compared to the non-winter group ( n = 80) (44% vs 61%) with an adjusted hazard ratio of 1.81 (95% confidence interval 1.11–2.90, p = 0.014), largely due to a higher rate of heart failure readmission in the winter implant patients (incidence rate ratio 2.29, 95% confidence interval 0.89–5.84). Conclusion: Patients who underwent LVAD implantation during the winter season had a higher heart failure readmission rate. A detailed mechanism and therapeutic strategy given our findings warrant further investigation.

Background Active smoking is associated with worse clinical outcomes following left ventricular assist device (LVAD) implantation. However, the effect of sex differences in conjunction with smoking status remains uninvestigated. Methods Consecutive patients who underwent LVAD implantation between January 2013 and September 2018 were included. Clinical outcomes were retrospectively compared between the current smokers and never smokers among male cohorts and female cohorts separately. Results About 130 patients, with a median age of 56 years, were included. Among the male cohort (N = 85), the current smokers (N = 25/85) had a higher total readmission rate than the never smokers (N = 60/85) with an adjusted incidence rate ratio of 2.38 (95% confidence interval, 1.16-3.85, P = .014), dominantly due to higher rates of gastrointestinal bleeding, stroke, and hemolysis. Among the female cohorts (N = 45), never smokers (N = 36/45) had a statistically comparable total readmission rate (2.80 vs 2.50 events per year; P = .37) compared with current smokers (N = 9/45). Conclusion Among male patients with LVAD, active smoking was associated with higher rates of adverse events. Female patients with LVAD had a high rate of adverse events irrespective of smoking status. Gender-specific therapeutic approaches might be required to prevent LVAD-related comorbidities.

The use of opioids during left ventricular assist device (LVAD) support is increasing, but the implication remains unknown. We investigated the association between the use of opioid and morbidities during LVAD supports. We retrospectively reviewed the clinical data of patients who received LVAD between 2014 and 2017, which were stratified by the use of opioid at post-LVAD 3 months. Among 136 patients, 77 (57%) were in the opioid group. Hemoglobin and albumin were lower, and C-reactive protein was higher at baseline and 3 months later in the opioid group (P < 0.05 for all). The opioid group displayed worse hemodynamics, with higher pulmonary capillary wedge pressure and central venous pressure (P < 0.05 for both). Furthermore, the opioid group had higher incidences of gastrointestinal bleeding (31% versus 17%, P = 0.043) and sepsis (30% versus 13%, P = 0.036) during the 1 year observational period, whereas survivals were not stratified by the use of opioid (83% versus 90%, P = 0.27). Opioid use was associated with morbidities accompanied by poor hemodynamics during LVAD supports. The detailed causality of opioid use on morbidities remains a future concern.

Until recently, combined heart-liver-kidney transplantation was considered too complex or too high-risk an option for patients with end-stage heart failure who present with advanced liver and kidney failure as well.The objective of this paper is to present our institution's best practices for successfully executing this highly challenging operation. At our institution, referral patterns are most often initiated through the cardiac team.Determinants of successful outcomes include diligent multidisciplinary patient selection, detailed perioperative planning, and choreographed care transition and coordination among all transplant teams. The surgery proceeds in three distinct phases with three different teams, linked seamlessly in planned handoffs. The selection and perioperative care are executed with determined collaboration of all of the invested care teams.Combined heart-liver-kidney transplantation can be successfully done by careful selection, coordination, and execution.

Unplanned readmissions frequently occur following the implantation of a durable left ventricular assist device (LVAD) due to complications such as gastrointestinal bleeding and driveline infection. There is a paucity of literature describing the incidence of unplanned readmission in patients with a HeartMate 3 (HM3) Left Ventricular Assist System. In this report, we present the successful outcome of a patient with an HM3 LVAD who has experienced no unplanned readmissions in the 4-year post-implant phase. To our knowledge, this is the longest readmission-free case after HM3 implantation. A successful patient outcome was enabled by the use of the modular HM3 device, the postoperative prescription of beta-blockers and omega-3, the presence of strong social support, and open communication between the patient's caregivers and the LVAD team. Reducing the instance of unplanned readmission confers clinical benefits to the patient, as well as reducing the cost burden on the patient and the healthcare system.

We report a case of successful heart and liver transplantation requiring intraoperative extracorporeal membrane oxygenation (ECMO) for primary cardiac allograft dysfunction in a patient with Fontan failure. A successful outcome for both the heart and the liver can be achieved with the timely management of ECMO support. In describing our experiences treating a Fontan patient requiring multiorgan transplantation, we have shown that challenging cases such as this one can have successful outcomes if multidisciplinary collaborations and proper treatment strategies are utilized at the optimal timing, along with family support and patient cooperation.

Bulky processing tasks are expected to burden the limited resources of energy harvesters by draining the stored energy, and thereby, reaching rapidly to energy causality constraint. In such scenario, energy harvesters flip into sleep mode, and thereby, the execution time of the next task will be delayed until the energy harvesters revert back into active mode. To tackle this problem, this paper proposes a novel energy harvesting network (EHN) that deploys wireless distributed computing (WDC) network within the decision making process (DMP). The DMP is formulated as constrained partially observable Markov decision process in order to enable the energy harvesters to act under uncertainty. Furthermore, various challenges of WDC networks, e.g., nominating the collaborating nodes and task allocation, have been addressed herein. Unlike conventional research works on WDC networks, a system model is proposed for WDC network based on divisible load theory instead of graph theory. In addition, an adaptive task allocation algorithm is proposed to distribute the task efficiently among the collaborating nodes. Finally, the novel EHN system is analyzed and compared against the conventional research works on WDC, offloading computing, and local computing-EHN, where the proposed system is found to outperform in terms of energy and delay.

Background Smoking would have a negative impact on clinical outcomes following left ventricular assist device (LVAD) implantation. However, its impact on male and female cohorts separately remains uninvestigated. Purpose We aimed to investigate the association between smoking and post-LVAD outcomes among male and female cohorts separately. Methods Data of consecutive patients who received LVAD implantation at our institute between Jan 2013 and Sep 2018 were retrospectively reviewed. Clinical outcomes were compared between the never smokers and the current smokers among male and female cohorts separately. Those with former smoking were excluded. Results Of all, 85 male patients (median 56 years old) and 45 female patients (median 56 years old) were included. Among the male cohort, total readmission rate was higher in the current smokers than never smokers (incidence rate ratio 1.51, p=0.09). Rates of gastrointestinal bleeding, stroke, and hemolysis trended to be higher in current smokers (Figure 1A). Among the female cohort, these rates were not different irrespective of the smoking status (Figure 1B). Survival was not different irrespective of smoking status among both male and female cohorts. Conclusion The impact of smoking on post-LVAD outcomes seems to be different between males and females. Different therapeutic strategy might be required for the LVAD candidates with active smoking between male and female cohort. Figure 1 Funding Acknowledgement Type of funding source: None

Worsening systemic congestion is often the central trigger of hospitalization in patients with heart failure. However, accurate assessment of congestion is challenging. The prognostic impact of systemic congestion following durable continuous-flow left ventricular assist device (LVAD) implantation remains unknown. Consecutive patients who received durable continuous-flow LVAD implantation between January 2014 and June 2017 and were followed for 1 year were included. The association of preoperative plasma volume status, which was calculated using patients' body weight and hematocrit and expressed as a deviation from ideal plasma volume, with 1-year mortality following LVAD implantation was investigated. In total, 186 patients (median 57 years and 138 males) were included. Baseline plasma volume status was -30.1% (-37.1%, -19.4%) on median. Eighty-eight patients (47%) had higher plasma volume status (>-29.8%), and their 1-year survival was significantly lower than those without (67% vs. 87%, P = .001). High plasma volume status was an independent predictor of 1-year death with an adjusted hazard ratio of 4.52 (95% confidence interval 1.52-13.5). Baseline systemic congestion, as defined by the high plasma volume status, was associated with higher mortality following durable continuous-flow LVAD implantation. The implication of improving preoperative plasma volume remains an area of needed investigation.

Background: Tobacco smoking is a significant source of morbidity in patients with a durable left ventricular assist device. While various cessation strategies have been investigated, the ability of ventricular assist device centers to implement a successful tobacco cessation program remains uncertain. We explored various cessation strategies employed by ventricular assist device centers and assessed perspectives of their effectiveness, as well as institutional investment in these programs. Methods: A 37-question online self-report survey was created using Survey Monkey® and distributed worldwide. We investigated (1) programmatic strategies utilized for smoking cessation, (2) the respondent’s perspective on the effectiveness of these strategies, (3) the structure with which these therapies are administered, and (4) overall organizational support for these treatments. Results: A total of 47 centers worldwide completed the survey. The most common methods of tobacco cessation were pharmacologic and nicotine replacement therapy (78% and 66%). However, only about half (47% and 50%, respectively) of the centers indicated that these strategies were effective. When asked whether a respondent’s center perceives that tobacco smoking should be a deciding factor in destination therapy evaluations, nearly a third (15, 32%) responded in the affirmative. Conclusion: While significant overlap exists among centers regarding treatments used for smoking cessation with left ventricular assist device patients, the most common treatments are not thought to be effective. While the current recommendations require tobacco smoking cessation in only bridge-to-transplant patients and not destination therapy patients, a number of centers disagree with the national guidelines and believe smoking should be prohibited in both populations.

Despite the well-established correlation between the tobacco use and cardiovascular disease, little is known about postoperative outcomes following the left ventricular assist device (LVAD) implantation. We aimed to elucidate the effect of tobacco smoking on post-LVAD implant outcomes. Patients who received LVADs from 2013 to 2018 were retrospectively characterized as current, former, or never smokers at the time of implant. We examined 1-year survival, total hospital readmissions, and specific hospital readmissions for LVAD-related adverse events based on patient's smoking status. Of the enrolled patients (n = 292), 55% were former smokers, 33% were never smokers, and 11% were current smokers. The majority of patients were African-American (48%) with a median age of 58 years. Never smokers were younger and less likely to be Caucasian compared to former or current smokers (P .05, for both). The category of former smokers had statistically comparable total readmission rates with never smokers (2.49 vs. 2.13 event/year), whereas current smokers had significantly higher rates compared to never smokers (2.81 events/year, P .05), with odds ratio 2.12 (95% CI = 1.35-3.32) adjusted for age and Caucasian race for 5 times of total readmissions per year. The rates of driveline infection, stroke, and hemolysis were statistically comparable between the never smokers and former smokers, while current smokers had significantly higher rates compared to never smokers (P .05 for all).

Purpose Hemocompatibility-related clinical adverse events (HRAE) are thought to be driven by the pump-patient interaction. We hypothesized that the hemodynamic variables cardiac power output (CPO) and cardiac power efficiency (CPE), which reflect underlying ventricular contribution, have prognostic value in patients with left ventricular assist devices (LVADs). Methods Prospectively collected hemodynamic data from patients with LVADs who had undergone invasive hemodynamic ramp study at our institution between 4/2014-7/2018 were analyzed. CPO [(mean arterial pressure x cardiac output)/451], cardiac power index (CPI) (CPO/body surface area), and CPE (CPI/ pulmonary capillary wedge pressure) were calculated. Patients were divided into groups of high and low CPO and CPE using ROC-derived cutoff values of 0.847W and 0.0552 WmmHg/m2 respectively. Hemocompatibility scores (HCS) were also calculated for each patient based on their HRAE. Univariate and multivariate logistic regression analyses were performed to determine the association between CPO and CPE with primary endpoints of HRAE, HCS, heart failure readmissions, and mortality. Results 91 patients (average age 61 ± 11 years, 34% women, 40% Black, 38% ischemic cardiomyopathy) were included in the analysis. Low CPO was significantly associated with higher rates of HRAE, HR 2.02 (95% CI 1.12-3.66, p=0.02, Figure 1A). CPO was not significantly associated with mortality or heart failure readmission, HR 1.84 (95% CI 0.68-3.32, p=0.31) and HR 1.84 (95% CI 0.92-3.68, p=0.083), respectively. Low CPE was significantly associated with higher rates of HRAE, heart failure readmission (Figure 1B), and mortality (Figure 1C) when adjusted for LVAD type: HR 1.97 (95% CI 1.02-3.81, p=0.043), HR 3.11 (95% CI 1.28-7.58, p=0.012), and HR 3.41 (95% CI 1.18-9.88, p=0.024), respectively. Conclusion CPO and CPE demonstrate prognostic value in patients with LVADs, showing significant associations with HRAE, heart failure readmissions, and mortality.

Purpose We hypothesized that the change in hemodynamic values after milrinone infusion would predict clinical outcomes. Methods We reviewed 177 patients undergoing right heart catheterization and milrinone loading at our center between January 2013 and December 2018. Percent increase in aortic pulsatility index (piAPI) was calculated as 100 * (aortic pulsatility index after milrinone infusion - aortic pulsatility index prior to milrinone infusion)/aortic pulsatility index prior to milrinone infusion, and percent increase in pulmonary artery pulsatility index (piPAPI) was calculated as 100 * (pulmonary artery pulsatility index after milrinone infusion - pulmonary artery pulsatility index prior to milrinone infusion)/pulmonary artery pulsatility index prior to milrinone infusion. Cutpoints were determined by ROC analysis, and patients were stratified as follows: (1) High piAPI, High piPAPI; (2) High piAPI, Low piPAPI; (3) Low piAPI, High piPAPI; and (4) Low piAPI, Low piPAPI. Univariate and multivariate logistic and cox regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Cutpoints of 70% and 103% were determined for piAPI and piPAPI, respectively. Low piAPI, Low piPAPI was associated with escalation of therapy or death at 30-days (OR 2.42, 95% CI 1.16 - 5.3, p = 0.022; OR). In multivariate analysis, Low piAPI, Low piPAPI and High piAPI, Low piPAPI were predictors of the one-year endpoint (OR 8.95, 95% CI 2.43 - 43.1, p = 0.002; OR 6.87, 95% CI 1.79 - 34.16, p = 0.008; respectively). Grouping patients according to whether they possessed Low piAPI, Low piPAPI showed a greater hazard for the endpoint at 30-days and one-year (HR 2.27, 95% CI 1.24 - 4.15, p = 0.0076; HR 1.58, 95% CI 1.01 - 2.28, p = 0.014; respectively). Conclusion Low piAPI, Low piAPI status may indicate lower myocardial reserve and predict poorer outcomes.

Purpose We evaluated the utility of combined assessment of left and right ventricular function for prediction of clinical outcomes in hospitalized heart failure patients. Methods The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial individual-level data were used. Aortic pulsatility index (API), (systolic - diastolic blood pressure)/pulmonary capillary wedge pressure, and pulmonary artery pulsatility index (PAPI), (systolic pulmonary arterial pressure - diastolic pulmonary arterial pressure)/right atrial pressure, were computed from the final hemodynamic measurements. Participants were grouped as: Low API/Low PAPI, Low API/High PAPI, High API/Low PAPI, and High API/High PAPI based on cut-points of 2.9 and 2.6 for API and PAPI, respectively, which were previously determined by our group using receiver operator characteristic analysis. The primary outcome was need for left ventricular assist device or heart transplant, or death at six-months post-hospital discharge. Secondary outcomes included any rehospitalization and cardiac rehospitalization. Results Of 433 participants enrolled in the ESCAPE trial, 142 had complete final hemodynamic data with which to calculate API and PAPI. Low API/Low PAPI was associated with the primary outcome when compared to the 3 other groups, HR 3.58 (95%CI 1.95-6.57), p Conclusion Combined measurements of left and right ventricular function using API and PAPI is associated with significant clinical outcomes in patients hospitalized with acute decompensated heart failure, and may be useful for prognostic risk stratification.

Purpose Several studies report the negative consequences of tobacco smoking on ventricular assist device (VAD) patient outcomes, but it is not a contraindication for VAD implantation in destination therapy (DT) patients. This international survey seeks to assess the importance of smoking cessation in DT VAD recipients, as well as center support and strategies in place to achieve cessation Methods A survey was created using Survey Monkey® and sent to VAD centers worldwide. The survey consisted of 37 multiple-choice and open response questions. Results Of the 47 respondents, 18 (38%) centers implanted 50 per year. Twenty-four (83%) larger-volume centers implant all patients indicated for DT regardless of smoking status, while five (17%) do not implant current smokers. Conversely, 14 (78%) smaller-volume centers implant all patients, while three (17%) do not implant current smokers, and one does not implant previous smokers. Twenty (69%) larger centers offered cessation programs prior to implant, as did 14 (78%) smaller centers. Twenty-three (79%) respondents from larger centers and 11 (61%) from smaller centers believed bridge-to-transplant (BTT) patients were more likely to achieve cessation than DT patients. Sixteen (55%) respondents from larger centers and 11 (61%) from smaller centers thought their center provides adequate support for cessation programs. Smaller centers were more likely to believe that tobacco smoking should be a deciding factor in DT evaluations (50% vs 21%, p = 0.055). Conclusion The importance of smoking cessation in DT VAD patients and the adequacy of center support varies by program. A considerable number of centers believed that tobacco smoking should be a deciding factor in DT evaluations. Open discussion regarding the role of tobacco cessation prior to LVAD implant should be encouraged. External confounder and sampling bias may affect these results, so further studies should be conducted for validation.

Purpose To assess the prognostic role of simultaneous biventricular function using hemodynamic parameters in advanced heart failure patients. Methods We retrospectively analyzed 184 patients undergoing a milrinone drug study at time of right heart catheterization (RHC) at our institution from January 2013 to January 2019. Aortic pulsatility index (API) was calculated as (systolic blood pressure - diastolic blood pressure)/pulmonary capillary wedge pressure, and pulmonary artery pulsatility index (PAPI) was calculated as (systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure. Using our team's previous identification of cutpoint values for API and PAPI, 1.45 and 2.3, respectively, we stratified patients into the following groups: (1) High API, High PAPI; (2) High API, Low PAPI; (3) Low API, High PAPI; and (4) Low API, Low PAPI. Univariate and multivariate logistic regression analyses were performed to determine association with escalation of therapy, defined as left ventricular assist device implantation, heart transplantation, or death. Results Low API, Low PAPI was associated with escalation of therapy or death at 30-days (OR 3.2, 95% CI 1.23 - 9.49, p = 0.024). Low API, Low PAPI and Low API, High PAPI were also associated with the one-year endpoint of freedom from escalation of therapy or death (OR 3.63, 95% CI 1.55 - 8.75, p = 0.003; OR 4.13, 95% CI 1.5 - 12.45, p = 0.008; respectively). In multivariate analysis, both of these risk statuses remained significant predictors of the one-year endpoint when adjusting for Fick cardiac index (OR 3.72, 95% CI 1.5 - 9.48, p = 0.005; OR 4.18, 95% CI 1.49 - 12.82, p = 0.009; respectively). Conclusion The combined use of API and PAPI possesses utility for risk stratification regarding both short- and long-term freedom from escalation of therapy or death.

Purpose The non-invasive AlloMap gene expression profiling test has been demonstrated to possess high negative predictive value for detecting cardiac allograft rejection and dysfunction after heart transplant. We assessed longitudinal trends in AlloMap score post-transplant. Methods We retrospectively analyzed AlloMap scores, organized by season and year post-transplant, for patients undergoing heart transplantation at our center. Patients with multiple tests in one season had their scores averaged. Relative AlloMap score was calculated for each patient as (AlloMap score)/(average AlloMap score across all tests). The association between season and AlloMap score was also investigated. Seasons were defined as the following: (1) Winter: January - March, (2) Spring: April - June, (3) Summer: July - September, (4) Fall: October - December. Results A total of 658 tests were included in our study. AlloMap scores were significantly greater in tests done more than one-year post-transplant compared to those completed in the first year (median: 32 (29, 34) vs 28 (24.5, 32), p Conclusion We observed longitudinal trends of rising absolute and relative AlloMap scores after one-year post-transplant. Clinically, the variability score may be more meaningful than the raw score in the long-term due to more specific comparison of patient level variation from baseline. Further analyses with multicenter data are warranted.