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Background: Acute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases. Case Presentation: A 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient's hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient's hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission. Conclusion: Although IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Impella 5.5 is a temporary left ventricular assist device utilized to support patients with cardiogenic shock and those undergoing high‐risk cardiac interventions.From October 2019 to January 2023, 226 patients received Impella 5.5 support at Cleveland Clinic main campus. Patients were stratified by Society for Cardiovascular Angiography and Interventions (SCAI) shock stages. Immediate post‐Impella 5.5 trajectories were compared across groups. Trajectories were defined as mortality on Impella 5.5, transition to advanced heart failure therapies (durable left ventricular assist device/heart transplantation), or survival to Impella 5.5 removal without advanced therapies.Overall, 148 (65%) patients with cardiogenic shock and 78 (35%) undergoing high‐risk cardiac interventions received Impella 5.5 support. SCAI stage was A in 63 (28%), B in 10 (4.4%), C in 29 (13%), D in 104 (46%), and E in 20 (8.8%). Mortality on Impella 5.5 was highest in SCAI stage E (A: 3.2%, B: 10%, C: 14%, D: 27%, E: 35%; p < 0.01). Transition to advanced therapies (durable left ventricular assist device or heart transplantation) was highest in SCAI stages C‐D (A: 1.6%, B: 0.0%, C: 45%, D: 36%, E: 20%; p < 0.01). Survival to Impella removal without advanced therapies was highest in SCAI stages A‐B (A: 95%, B: 90%, C: 41%, D: 38%, E: 45%; p < 0.01).Stratification by presentation acuity in candidates for Impella 5.5 insertion may help identify which patients may and may not benefit from this escalation of tailored temporary mechanical circulatory support. [ABSTRACT FROM AUTHOR]

Aims: Artificial intelligence (AI) has emerged as a potential useful tool to support clinical treatment of heart failure, including the setting of mechanical circulatory support (MCS). Modern Impella pumps are equipped with advanced technology (SmartAssist), enabling real‐time acquisition and display of data related to both pump performance and the patient's haemodynamic status. These data emerge as an 'ideal' source for data‐driven AI applications to predict the clinical course of an ongoing therapeutic protocol. Yet, no evidence of effective application of AI tools in the setting of Impella support is available. On this background, we aimed at identifying possible future applications of AI‐based tools in the setting of temporary MCS with an Impella device. Methods: We explored the state of research and development at the intersection of AI and Impella support and derived future potential applications of AI in routine Impella clinical management. Results: We identified different areas where the future implementation of AI tools may contribute to addressing important clinical challenges in the setting of Impella support, including (i) early identification of the best suited pathway of care according to patients' conditions at presentation and intention to treat, (ii) prediction of therapy outcomes according to different possible therapeutic actions, (iii) optimization of device implantation procedures and evaluation of proper pump position over the whole course of support and (iv) prevention and/or rationale management of haemocompatibility‐related adverse events. For each of those areas, we discuss the potential advantages, challenges and implications of harnessing AI‐driven insights in the setting of MCS with an Impella device. Conclusions: Temporary MCS with an Impella device has great potential to benefit from the integration of AI‐based tools. Such tools may indeed translate into groundbreaking innovation supporting clinical decision‐making and therapy regulation, in particular in complex scenarios such as the multidevice MCS strategy. [ABSTRACT FROM AUTHOR]

The Impella 5.0 and 5.5 pumps (Abiomed, Danvers, MA) are large-bore transvalvular micro-axial assist devices used in cardiogenic shock (CS) for patients requiring high-capacity flow. Despite their increasing use, real-world data regarding indications, rates of utilization and clinical outcomes with this therapy are limited. The objective of our study was to examine clinical profiles and outcomes of patients in a contemporary, real-world CS registry of patients who received an Impella 5.0/5.5 alone or in combination with other temporary mechanical circulatory support (tMCS) devices. The CS Working Group (CSWG) Registry includes patients from 34 US hospitals. For this analysis, data from patients who received an Impella 5.0/5.5 between 2020–2023 were analyzed. Use of Impella 5.0/5.5 with or without additional tMCS therapies, duration of support, adverse events and outcomes at hospital discharge were studied. Adverse events including stroke, limb ischemia, bleeding and hemolysis were not standardized by the registry but reported per individual CSWG Primary Investigator discretion. For those who survived, rates of native heart recovery (NHR) or heart replacement therapy (HRT) including heart transplant (HT), or durable ventricular assist device (VAD) were recorded. We also assessed outcomes based on shock etiology (acute myocardial infarction or MI-CS vs. heart failure-related CS or HF-CS). Among 6,205 patients, 754 received an Impella 5.0/5.5 (12.1%) , including 210 MI-CS (27.8%) and 484 HF-CS (64.1%) patients. Impella 5.0/5.5 was used as the sole tMCS device in 32% of patients, while 68% of patients received a combination of tMCS devices. Impella cannulation sites were available for 524/754 (69.4%) of patients, with 93.5% axillary configuration. Survival to hospital discharge for those supported with an Impella 5.0/5.5 was 67%, with 20.4% NHR and 45.5% HRT. Compared to HF-CS, patients with MI-CS supported on Impella 5.0/5.5 had higher in-hospital mortality (45.2% vs 26.2%, p < 0.001) and were less likely to receive HRT (22.4% vs 56.6%, p < 0.001. For patients receiving a combination of tMCS during hospitalization, this was associated with higher rates of limb ischemia (9% vs. 3%, p < 0.01), bleeding (52% vs 33%, p < 0.01), and mortality (38% vs 25%; p < 0.001) compared to Impella 5.0/5.5 alone. Among Impella 5.0/5.5 recipients, the median duration of pump support was 12.9 days (IQR: 6.8–22.9) and longer in patients bridged to HRT (14 days; IQR: 7.7–28.4). In this multi-center cohort of patients with CS, use of Impella 5.0/5.5 was associated with an overall survival of 67.1% and high rates of HRT. Lower adverse event rates were observed when Impella 5.0/5.5 was the sole support device used. Further study is required to determine whether a strategy of early Impella 5.0/5.5 use for CS improves survival. High capacity Impella heart pumps are capable of provide up to 5.5 liter/min of flow while upper body surgical placement allows for ambulation. Patients with advanced cardiogenic shock from acute myocardial infarction or heart failure requiring temporary mechanical circulatory support may benefit from upfront use of Impella 5.5 to improve overall survival, including native heart recovery or successful bridge to durable left ventricular assist device surgery or heart transplantation. [ABSTRACT FROM AUTHOR]

Abstract Background Acute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases. Case Presentation A 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient’s hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient’s hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission. Conclusion Although IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery.

Objectives: To identify possible etiology-specific differences in preoperative risk factors for major adverse events during Impella 5.5 support in patients with ischemic (ICM) and nonischemic cardiomyopathy (NICM). Methods: From October 2019 to January 2023, 228 Impella 5.5 devices were inserted at our institution. Patients were stratified into ICM (n = 124) and NICM (n = 104) cohorts. The primary outcome was a composite of death/stroke/new-onset dialysis while actively receiving Impella 5.5 support. Random forests identified preoperative factors predictive of the primary outcome separately for each cohort, with ranking by variable importance. Results: The primary outcome occurred in 42 (34%) patients with ICM and 35 (34%) patients with NICM. Twenty-one (17%) patients with ICM and 21 (20%) patients with NICM died on Impella 5.5; stroke occurred in 12 (9.7%) patients with ICM and 3 (2.9%) patients with NICM, and new-onset dialysis was initiated in 23 (19%) patients with ICM and 24 (23%) patients with NICM while actively receiving Impella 5.5 support. Risk factors reflecting systemic and myocardial cellular injury, end-organ and cardiopulmonary failure, right ventricular dysfunction, and smaller left ventricular dimensions were most predictive of adverse outcomes in both cohorts. Indications for Impella 5.5 and device strategy (bridge to recovery, advanced therapies, or decision) were not top risk factors in either cohort. Conclusions: Risk factors related to preoperative stability, right ventricular dysfunction, and left ventricular size were more predictive of adverse outcomes while actively receiving Impella 5.5 support than indication or device strategy. These factors could help identify high-risk patients who may benefit from additional tailored management to reduce their risk for these impactful adverse outcomes while on Impella 5.5 support.

Abstract Aims Artificial intelligence (AI) has emerged as a potential useful tool to support clinical treatment of heart failure, including the setting of mechanical circulatory support (MCS). Modern Impella pumps are equipped with advanced technology (SmartAssist), enabling real‐time acquisition and display of data related to both pump performance and the patient's haemodynamic status. These data emerge as an ‘ideal’ source for data‐driven AI applications to predict the clinical course of an ongoing therapeutic protocol. Yet, no evidence of effective application of AI tools in the setting of Impella support is available. On this background, we aimed at identifying possible future applications of AI‐based tools in the setting of temporary MCS with an Impella device. Methods We explored the state of research and development at the intersection of AI and Impella support and derived future potential applications of AI in routine Impella clinical management. Results We identified different areas where the future implementation of AI tools may contribute to addressing important clinical challenges in the setting of Impella support, including (i) early identification of the best suited pathway of care according to patients' conditions at presentation and intention to treat, (ii) prediction of therapy outcomes according to different possible therapeutic actions, (iii) optimization of device implantation procedures and evaluation of proper pump position over the whole course of support and (iv) prevention and/or rationale management of haemocompatibility‐related adverse events. For each of those areas, we discuss the potential advantages, challenges and implications of harnessing AI‐driven insights in the setting of MCS with an Impella device. Conclusions Temporary MCS with an Impella device has great potential to benefit from the integration of AI‐based tools. Such tools may indeed translate into groundbreaking innovation supporting clinical decision‐making and therapy regulation, in particular in complex scenarios such as the multidevice MCS strategy.

To evaluate the safety of cangrelor administered concurrently with heparin or bivalirudin in patients on mechanical circulatory support. A single-center, retrospective cohort study of adult patients consecutively admitted between January 2016 and October 2020. A tertiary medical center. Adult patients admitted to the cardiovascular intensive care unit put on mechanical circulatory support for acute myocardial infarction (AMI) or non-AMI indications. Patients who received cangrelor underwent percutaneous coronary intervention with stenting during the index event or within the last year. None. The primary outcome was the incidence of major bleeding, defined by the Extracorporeal Life Support Organization criteria, in patients with mechanical circulatory support receiving cangrelor plus anticoagulation with heparin or bivalirudin with or without aspirin versus patients who did not receive cangrelor. Sixty-eight patients were included in the study. Twenty-nine patients received cangrelor, and 39 did not. Cangrelor was not associated with an increase in major bleeding; however, the CI was wide (adjusted hazard ratio 1.93, 95% CI 0.61-6.11; p = 0.262). Patients receiving cangrelor did not appear to be at higher risk of major bleeding compared to patients not receiving cangrelor. Larger trials should be conducted to better evaluate the safety of cangrelor in patients with mechanical circulatory support. [ABSTRACT FROM AUTHOR]

This review highlights key studies examining perioperative management of cardiothoracic transplantation published in 2023. Articles were manually screened after searching Scopus, PubMed, and Google Scholar databases for manuscripts related to cardiothoracic transplantation, which yielded 343 papers with 15 qualitatively selected as the most salient for readers. Overarching themes include differences in outcomes across the various etiologies of end-stage lung disease, novel developments to expand the donor pool, and multi-organ transplantation. [ABSTRACT FROM AUTHOR]

Background: Use of temporary mechanical circulatory support (tMCS) for peripartum cardiomyopathy (PPCM) shock has been described in small cohorts, but not on a national scale. This study compares tMCS, durable MCS (dMCS), and no MCS as bridge to transplant strategies for PPCM. Methods: Female patients ≥14 years, listed for first-time isolated heart transplant (HT) between January 1, 2000 and June 30, 2021, were identified in the United Network for Organ Sharing database. Patients were stratified by receipt of MCS at any point during the waitlist period. Patients on multiple devices were excluded. Results: A total of 1,043 PPCM patients were listed for HT, including 575 bridged on no MCS, 177 on tMCS, and 291 on dMCS. The tMCS cohort included 10 patients on extracorporeal membrane oxygenation, 113 on intra-aortic balloon pump, and 54 on nondischargeable ventricular assist device (VAD) or percutaneous device. The dMCS group primarily received durable VADs. Compared to dMCS, tMCS recipients were more likely to require inotropes, mechanical ventilation, and longer hospitalizations pretransplant (all p 0.05). After multivariable risk adjustment, neither tMCS (adjusted hazard ratio 0.56 [0.06-5.43]) nor dMCS (adjusted hazard ratio 0.36 [0.05-2.82]) significantly predicted 3-year graft survival. Conclusions: Compared to patients bridged to HT on dMCS or no MCS, PPCM patients receiving tMCS are higher acuity candidates but have equivalent post-transplant graft survival.

Introduction: Since the 2018 change in the US adult heart allocation policy, more patients are bridged‐to‐transplant on temporary mechanical circulatory support (tMCS). Previous studies indicate that durable left ventricular assist devices (LVAD) may lead to allosensitization. The goal of this study was to assess whether tMCS implantation is associated with changes in sensitization. Methods: We included patients evaluated for heart transplants between 2015 and 2022 who had alloantibody measured before and after MCS implantation. Allosensitization was defined as development of new alloantibodies after tMCS implant. Results: A total of 41 patients received tMCS before transplant. Nine (22.0%) patients developed alloantibodies following tMCS implantation: 3 (12.0%) in the intra‐aortic balloon pump group (n = 25), 2 (28.6%) in the microaxial percutaneous LVAD group (n = 7), and 4 (44.4%) in the veno‐arterial extra‐corporeal membrane oxygenation group (n = 9)—p =.039. Sensitized patients were younger (44.7 ± 11.6 years vs. 54.3 ± 12.5 years, p =.044), were more likely to be sensitized at baseline ‐ 4 of 9 (44.4%) compared to 1 out of 32 (3.1%) (p =.001) and received more transfusions with red blood cells (6 (66.7%) vs. 8 (25%), p =.02) and platelets (6 (66.7%) vs. 5 (15.6%), p =.002). There was no significant difference in tMCS median duration of support (4 [3,15] days vs. 8.5 [5,14.5] days, p =.57). Importantly, out of the 11 patients who received a durable LVAD after tMCS, 5 (45.5%) became sensitized, compared to 4 out of 30 patients (13.3%) who only had tMCS—p =.028. Conclusions: Our findings suggest that patients bridged‐to‐transplant with tMCS, without significant blood product transfusions and a subsequent durable LVAD implant, have a low risk of allosensitization. Further studies are needed to confirm our findings and determine whether risk of sensitization varies by type of tMCS and duration of support. [ABSTRACT FROM AUTHOR]

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care. [ABSTRACT FROM AUTHOR]

Background: Cardiogenic shock in children still carries a high mortality risk despite advances in medical therapy. The use of temporary mechanical circulatory supports is an accepted strategy to bridge patients with acute heart failure to recovery, decision, transplantation or destination therapy. These devices are however limited in children and extracorporeal membrane oxygenation (ECMO) remains the most commonly used device. Veno-arterial ECMO may provide adequate oxygen delivery, but it does not significantly unload the left ventricle, and this may prevent recovery. To improve the likelihood of left ventricular recovery and minimize the invasiveness of mechanical support, the Impella axial pump has been increasingly used in children with acute heart failure in the last decade. Purpose: There are still limited data describing the Impella indications, management and outcomes in children, therefore, we aimed to provide a comprehensive narrative review useful for the pediatric nurses to be adequately trained and acquire specific competencies in Impella management. [ABSTRACT FROM AUTHOR]

The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device. [Display omitted] • Impella is a minimally invasive left ventricular assist device. • Impella is indicated for cardiogenic shock, high-risk percutaneous coronary intervention, and ventricular tachycardia ablation. • It is used as a bridge to recovery, durable device, transplantation, and heart surgery. • It provides powerful hemodynamic support with minimal invasiveness. [ABSTRACT FROM AUTHOR]

Background Cardiac resynchronization therapy (CRT) is recommended for patients with symptomatic heart failure in sinus rhythm with left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 150 ms, and left bundle branch block (LBBB) morphology. However, when severe left ventricular dysfunction and cardiogenic shock are present, treatment paradigms are often limited to palliative medical therapy or advanced therapies with durable left ventricular assist device or heart transplant as the functional and survival benefit of CRT in these patients remains uncertain. Case summary A 77-year-old white man with long-standing LBBB with dyssynchrony, severely reduced LVEF of 4%, and severe bicuspid aortic stenosis (AS) presented with worsening heart failure symptoms. After multidisciplinary heart team evaluation and pre-operative optimization, the patient underwent a surgical aortic valve replacement with simultaneous intraoperative initiation of CRT with pacemaker (CRT-P) and temporary mechanical circulatory support. Echocardiography at 44 days and 201 days post-discharge showed an LVEF of 29% and 40%, respectively. Discussion This case demonstrates that reverse remodelling and native heart recovery were successfully achieved in a patient with advanced structural heart disease, presenting with cardiogenic shock, through an early and aggressive approach involving multidisciplinary heart team evaluation, treatment of severe AS with surgical aortic valve replacement, prophylactic intraoperative initiation of temporary mechanical circulatory support, and early initiation of CRT-P. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to explore the associations between percutaneous ventricular assist device (pVAD) insertion timing relative to cardiac surgery and patient outcomes. Methods: The Nationwide Inpatient Sample was queried for patients undergoing cardiac surgery and pVAD insertion in the same admission from 2016 to 2019. Patients were stratified by timing of pVAD insertion. Preoperative characteristics, postoperative complications, and mortality were compared among groups. Results: Overall, 3695 patients underwent cardiac surgery and pVAD insertion during the same hospitalization (pre: 1130, intra: 1690, and post: 875). The distribution of cardiac surgery procedures was similar across groups. Median Elixhauser Comorbidity Index was 13 for pre-, 15 for intra-, and 17 for postoperative pVAD patients (P = .021). Patients who received a postoperative pVAD were associated with increased mortality (pre: 18%, intra: 39%, and post: 54%; P

The last decade has brought tremendous interest in the problem of cardiogenic shock. However, the mortality rate of this syndrome approaches 50%, and other than prompt myocardial revascularization, there have been no treatments proven to improve the survival of these patients. The bulk of studies have been in patients with acute myocardial infarction, and there is little evidence to guide the clinician in those patients with heart failure cardiogenic shock (HF-CS). An International Society for Heart and Lung Transplant consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals) with vast clinical and published experience in CS, representing 42 centers worldwide. This consensus report summarizes the results of a premeeting survey answered by participants and the breakout sessions where predefined clinical issues were discussed to achieve consensus in the absence of robust data. Key issues discussed include systems for CS management, including the "hub-and-spoke" model vs a tier-based network, minimum levels of data to communicate when considering transfer, disciplines that should be involved in a "shock team," goals for mechanical circulatory support device selection, and optimal flow on such devices. Overall, the document provides expert consensus on some important issues facing practitioners managing HF-CS. It is hoped that this will clarify areas where consensus has been reached and stimulate future research and registries to provide insight regarding other crucial knowledge gaps. [ABSTRACT FROM AUTHOR]

Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision‐making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub‐satisfactory outcomes. In this review, we discuss the identification of high‐risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision‐making designed to optimize both short‐ and long‐term patient outcomes. [ABSTRACT FROM AUTHOR]

This special article is the 16th in an annual series for the Journal of Cardiothoracic and V ascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease. [ABSTRACT FROM AUTHOR]

Background: Little is known about de novo human luekocyte antigen (HLA) antibody development with Impella 5.5 temporary mechanical circulatory assist support and downstream effects following heart transplantation in the new heart allocation system. Methods: Thirteen Impella and 17 control patients without device support were prospectively enrolled between December 2020 and June 2022. HLA antibodies with calculated panel reactive antibodies (cPRA) were assessed pre and postdevice implantation and within 1-year postheart transplantation. Results: Baseline prevalence of HLA antibodies and median cPRA were similar between groups. Patients in the study arm were on Impella support for a median of 7 days. No significant differences in HLA antibodies were observed postdevice or postheart transplant. One patient in the Impella arm developed rejection and required treatment. One Impella patient died due to infection and 1 control patient died due to primary graft dysfunction. Conclusions: Short-term use of Impella 5.5 in the new heart allocation system does not appear to increase risk of de novo HLA antibody development. Further studies are needed to validate these preliminary findings.

The outcomes and management of bloodstream infection (BSI) in patients on temporary mechanical circulatory support (TMCS) awaiting heart transplant (HT) are poorly understood. We present outcomes of patients on TMCS with BSI (TMCS-I) relative to matched uninfected patients (TMCS-U) and discuss their management. Between January 1, 2013, and April 30, 2023, N = 136 patients were bridged to transplant with TMCS at Emory Transplant Center. Twenty-one (15.4%) patients were TMCS-I. Two (9.5%) had infective endocarditis. Median duration of antimicrobial treatment was 24 days (interquartile range 28.3). All TMCS-I were reactivated for transplant within 48 to 72 hours of negative blood cultures. None developed recurrent BSI. Post-transplant survival did not differ between TMCS-I and TMCS-U (p = 0.38). HT for TMCS-I may be safe as soon as blood cultures clear. Duration of antimicrobial therapy is individualized and depends on the organism, duration of bacteremia, presence of endocarditis, and timing of HT. Additional research is needed to determine optimal duration of treatment. [ABSTRACT FROM AUTHOR]

Background Post-infarction ventricular septal defect (PIVSD) is a rare, life-threatening complication of acute myocardial infarction (AMI). Few studies report the use of mechanical circulatory support (MCS) for the treatment of cardiogenic shock in this setting. We describe our experience using a microaxial, transvalvular device (Impella, Abiomed, Danvers, MA, USA) as a bridge-to-closure for PIVSD. Case summary We identified 13 patients from two centres with cardiogenic shock due to PIVSD who received an Impella device between January 2016 and February 2022. Nine patients were transferred from another hospital, three with MCS devices [two intra-aortic balloon pumps (IABP), 1 Impella CP]. Eight patients received Impella 5.0, three received Impella 5.5 (one escalated from Impella CP), and two received Impella CP. The median time from AMI to Impella insertion was 5 (3–6) days. Five patients died on Impella support without an attempt to close the ventricular septum (VSD). Seven patients underwent successful VSD closure: six had surgical and one had percutaneous closure. One patient died during attempted percutaneous closure. Time from Impella insertion to VSD closure was 10.5 (7.8–14.0) days. Time from AMI to Impella was 5.0 (2.0–5.3) days in the group that survived to closure, and 6.0 (4.0–7.0) days in those who did not. Thirty-day mortality was 46%. Discussion Support with Impella improved clinical stability in most patients, yet multi-system organ failure leading to death occurred in many patients. Patients who survived closure had earlier time from AMI to Impella, underscoring that prompt recognition of PIVSD and initiation of MCS may improve survival to surgical or percutaneous closure. [ABSTRACT FROM AUTHOR]

Although a role for percutaneous Impella devices has been established, there is a paucity of data regarding the utility and outcomes of larger surgically implanted Impella devices. We conducted a retrospective review of all surgical Impella implants at our institution. All Impella 5.0 and Impella 5.5 devices were included. The primary outcome was survival. Secondary outcomes included hemodynamic and end-organ perfusion as well as commonly encountered surgical complications. From 2012 to 2022, 90 surgical Impella devices were implanted. The median age was 63 [53–70] years, the mean creatinine was 2.07 ± 1.22 mg/dL, and the average lactate level was 3.32 ± 2.90 mmol/L. Prior to implantation, 47 patients (52%) were supported with vasoactive agents, while 43 (48%) were also supported with another device. The most common etiology of shock was acute on chronic heart failure (50, 56%), followed by acute myocardial infarction (22, 24%), and postcardiotomy (17, 19%). Overall, 69 patients (77%) survived to device removal, and 57 (65%) survived to hospital discharge. One-year survival was 54%. Neither etiology of heart failure nor device strategy was associated with 30-day or 1-year survival. On multivariable modeling, the number of vasoactive medications prior to device implantation was strongly associated with 30-day mortality (hazard ratio 1.94 [1.27–2.96], P < 0.01). Surgical Impella placement was associated with a significant decreased need for vasoactive infusions (P < 0.01) and decreased acidosis (P = 0.01). Surgical Impella support for patients in acute cardiogenic shock is associated with lower vasoactive medication use, improved hemodynamics, increased end-organ perfusion, and acceptable morbidity and mortality. [ABSTRACT FROM AUTHOR]

We investigated how the 2018 Organ Procurement and Transplantation Network heart allocation policy change was associated with changes in characteristics and outcomes of candidates receiving multiple temporary mechanical circulatory support (mtMCS) devices. We included adult heart transplant candidates listed October 2014-January 2018 and October 2018-January 2022 in the United Network of Organ Sharing dataset. Prepolicy and postpolicy mtMCS recipients were compared at listing, transplant, 90-days, and 1-year post-transplant. Time between first and second devices and time between first device and transplant were modeled via multivariable linear regression. Transplantation likelihood was modeled using competing risks analysis. Postpolicy, a higher proportion of transplant candidates received mtMCS (4% versus 1%, P < 0.001), and received their second device an adjusted 49 d sooner versus prepolicy (P = 0.001). Time to transplant was also an adjusted 35 d shorter postpolicy, with an 80% increased transplantation likelihood versus prepolicy (95% confidence interval: 1.6-1.9, P < 0.001). Postpolicy patients experienced reduced waitlist mortality (8% versus 14%, P = 0.04) with marked improvements in 90-day (93% versus 85%, P < 0.001) and 1-year (88% versus 70%, P = 0.01) post-transplant survival. Postpolicy mtMCS recipients are more likely to progress to transplantation sooner on the waitlist and their shorter waitlist course together with earlier change to a secondary device was associated with improved post-transplant survival versus prepolicy. [ABSTRACT FROM AUTHOR]

Intra-aortic balloon pump (IABP) utilization has significantly outpaced other Status 2 eligibility criteria for heart transplant. The risk of waitlist mortality of IABP-supported patients relative to other Status 2 listed patients has not been described. We performed a retrospective analysis of all adult patients listed Status 2 for heart transplantation under the current U.S. allocation policy, using data from the United Network for Organ Sharing. Patients listed status 1 and status 3 for high-dose inotropes were included for reference. Mortality and waitlist decompensation were modeled as a function of time-varying status in cause-specific Cox survival models. We identified 3638 Status 2 listings, of whom 1676 (46%) were Status 2 due to IABP. Relative to patients supported with IABP, status 2 patients with ventricular tachycardia/fibrillation [VT/VF] (HR 4.0, p <.001), right-or-biventricular assist device configurations (HR 2.3, p =.002), or temporary surgical left ventricular assist devices [LVAD] (HR 2.6, p =.003) had greater risk of waitlist mortality and decompensation. Other Status 2 subgroups had mortality comparable to IABP Status 2. Risk of waitlist mortality and decompensation for IABP Status 2 was similar to Status 3 patients listed for high-dose inotropes (HR 1.2, p =.27) and lower than Status 1 patients (HR 0.7, p =.002). Waitlist mortality varies significantly by Status 2 eligibility criteria and is highest among patients listed for VT/VF, right-or-biVAD configurations, or temporary surgical LVADs. IABP-supported patients were among those with the lowest Status 2 waitlist mortality risk and comparable to Status 3 inotrope-supported patients. [ABSTRACT FROM AUTHOR]

Little is known about the development of human leukocyte antigen antibodies with use of the temporary transvalvular pump 5.5 mechanical circulatory support device. This case reports a patient who developed de novo antibodies prior to his heart transplantation and remains free of any episodes of rejection post transplantation to date. (Level of Difficulty: Advanced.)

Background: In the United Network of Organ Sharing (UNOS) allocation scheme prior to October 18, 2018, heart transplant (HTx) candidates with extracorporeal membrane oxygenation (ECMO), temporary mechanical circulatory support (MCS), or pulmonary artery (PA) catheter inotropic support all received Status 1A priority. In revised scheme, patients with PA catheter and inotropic support are Status 3 after those on ECMO (Status 1) or temporary MCS (Status 2). We examined the impact of the allocation change on HTx candidates listed Status 1A versus Status 3 at a high‐volume transplant center. Methods: Between January 2017 and January 2021, 75 patients were listed with a PA catheter and inotropic support prior to the allocation change (Era 1) and 48 were listed after (Era 2). Clinical characteristics and outcomes were compared for these 123 patients. Results: Heart transplant (HTx) candidates in Era 2 had higher median inotrope doses at listing. There was no significant difference in inpatient wait list days (12 vs. 20 days, P =.15), transition to temporary MCS (33.3% vs. 22.7%, P =.15), or wait list mortality (6.3% vs. 4.0%, P =.68). There was also no significant difference in survival to transplantation (91.7% vs. 94.7%, P =.71). There were no differences in post‐transplant outcomes including 1‐year survival (88.6% vs. 93.0%, P =.38). Conclusion: At a high‐volume transplant center, the UNOS allocation change did not result in increased wait list time, use of temporary MCS, or mortality on the waitlist or post‐transplant for candidates on inotropic support with continuous hemodynamic monitoring. [ABSTRACT FROM AUTHOR]

This study aimed to characterize the use of temporary mechanical circulatory support (tMCS) among patients undergoing transcatheter aortic valve replacement (TAVR) using a nationally representative database. The 2012-2018 National Inpatient Sample was queried for adult patients who underwent isolated TAVR. The tMCS group was comprised of those who required extracorporeal membrane oxygenation, percutaneous ventricular assist device, or intra-aortic balloon pump during index hospitalization. We evaluated temporal trends in the utilization of tMCS using Cuzick's test. Furthermore, a multivariable logistic regression was used to identify factors associated with tMCS use and its impact on in-hospital mortality, selected complications, and nonhome discharge. Of an estimated 215,925 patients who underwent TAVR, 3085 (1.4%) required tMCS during their hospital course. The most common modality of tMCS was intra-aortic balloon pump (49%), followed by extracorporeal membrane oxygenation (27%) then percutaneous ventricular assist device (18%). Seven percent of tMCS patients were supported by > 1 device. The annual incidence of tMCS usage decreased over the study period, from 3% in 2012 to 1% in 2018 (P -trend < 0.01). Nonelective admission, congestive heart failure, coagulopathy, and liver disease were strong independent predictors of requiring tMCS. Patients requiring tMCS had a 31.8% in-hospital mortality rate (adjusted odds ratio = 23, 95% confidence interval 18.5-28.5), longer length of stay (9 d versus 3, P < 0.001), and higher costs ($84,600 versus $48,100, P < 0.001) than those who did not. The use of tMCS during TAVR has decreased over time but remains associated with a 23-fold increased mortality rate and significant clinical and resource utilization burden. [ABSTRACT FROM AUTHOR]

BackgroundAcute decompensated heart failure (HF) and cardiogenic shock (CS) frequently are refractory to conservative treatment and require mechanical circulatory support (MCS). We report our early clinical experience and evaluate patient outcomes with the newer generation surgical Impella 5.5.MethodsSeventy patients that underwent Impella 5.5 implantation between October 2019 and December 2021 at a single center were enrolled in this study. Pre-operative characteristics, peri-operative clinical course information, and post-operative outcomes were retrospectively collected.ResultsFifty-seven (81%) patients survived to discharge, and 51 (76%) patients survived at the time of the first 30 days post-discharge visit. Thirty-one patients (44%) received Impella support for a bridge to advanced surgical heart failure therapy (transplant or durable left ventricular assist device [LVAD]), 27 (39%) cases were used for a bridge to recovery/decision and 12 (17.1%) cases was used for planned perioperative support for high-risk cardiac surgery procedure.ConclusionOur results suggest that Impella 5.5 provides favorable survival in the management of HF and CS, particularly used for a bridge to heart transplant or LVAD. Early extubation and mobilization with high flow circulatory support allowed effective tailoring of MCS approaches from peri-operative support for high-risk cardiac surgery, bridge to recovery, and to advanced surgical heart failure therapy.

Background and Aims: Over the past decades, the number of cardiac patients (e.g., with advanced heart failure or existing cardiovascular comorbidities that expose them to a heightened risk of acute cardiovascular decompensation) requiring noncardiac surgery is rising. For this patient population, potentially curative surgical treatments may be denied due to their prohibitive perioperative risk. Around 30% of patients undergoing general thoracic surgery experience cardiovascular complications of varying severity that may ultimately result in refractory heart failure and/or hemodynamic instability. In both these scenarios, perioperative implantation of temporary mechanical circulatory support (tMCS) may improve patient outcomes by both expanding preoperative surgical eligibility criteria and enabling safer management of unexpected periprocedural complications. This scoping review seeks to summarize the current existing evidence on the role of tMCS for cardiac assistance in thoracic surgery and provide a thorough overview., Methods: We will perform a scoping review adhering to the Joanna Briggs Institute (JBI) methodology and the extension for Scoping Reviews of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist (PRISMA). We will carry out a comprehensive search of several online databases to identify studies on the perioperative implantation of tMCS in patients undergoing thoracic surgery to provide cardiac assistance either due to their heightened preoperative cardiac risk (pre-emptive tMCS) or for acute cardiac failure due to inherent surgical complications (bail-out tMCS). Standardized forms will be employed to perform data charting and extraction., Results: Retrieved studies will be presented through a narrative synthesis following initial categorization, supplemented by descriptive statistical analyses of quantitative data if adequate inter-study homogeneity is observed and further complemented by figures and tables., Conclusion: The planned scoping review aims to assess the safety and feasibility of perioperative implantation of tMCS in patients undergoing thoracic surgery either to mitigate their heightened cardiovascular risk or as a rescue strategy in the event of life-threatening surgical complications. It will identify knowledge gaps, offer direction for future research, and improve clinical practices within the field., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Health Science Reports published by Wiley Periodicals LLC.)

Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The intra-aortic balloon pump (IABP) is widely used to rescue patients from complications following cardiac surgery. Given improvements in rescue strategies over the past decade, the appropriateness of IABP must be reexamined. This study assessed the risk factors, outcomes, and predictors of survival of rescue IABP placement., Methods: Patients receiving an isolated rescue IABP during or after cardiac surgery from 2012 to 2020 were studied. All adult patients undergoing cardiac surgery except transplantation and primary mechanical circulatory support (MCS) procedures were included., Results: Of 10,591 patients, 397 (3.7%) received a perioperative IABP, including 182 (45.8%) with rescue IABP placement. The indications for rescue IABP were postcardiotomy shock (n = 66; 36.3%), failure to wean off cardiopulmonary bypass (n = 58; 31.9%), myocardial ischemia (n = 30; 16.5%), cardiac arrest (n = 25; 13.7%), and ventricular arrhythmia (n = 3; 1.6%). The in-hospital failure to rescue rate was 17.6% (n = 32 of 182) with a 90-day survival of 80.8% and 1-year survival of 76.9%. The most common etiology of mortality was ongoing cardiogenic shock (61.9%; n = 26 of 42). IABP use for >4 days and cardiac arrest as an indication for IABP were risk factors for 1-year mortality (adjusted hazard ratio, 2.68 [95% confidence interval (CI), 1.31-5.50] and 2.69 [95% CI, 1.11-6.54], respectively)., Conclusions: Rescue IABP following cardiac surgery is associated with increased early and 1-year mortality. Prolonged IABP use beyond 4 days or cardiac arrest as an indication portended a significantly worse prognosis. Rescue IABP may not be the optimal first-line temporary MCS for all patients, as the level of support provided might not match the severity of cardiogenic shock. Alternative MCS strategies should be considered early., Competing Interests: Conflict of Interest Statement Dr Adams reports royalty agreements with Edwards Lifesciences and Medtronic regarding the following: Physio Flex annuloplasty ring, Physio II mitral annuloplasty ring, IMR ETlogix mitral annuloplasty ring, and TriAd tricuspid annuloplasty ring. He is also the national co-principal investigator for the Triluminate US Pivotal trial, Medtronic Apollo US Pivotal trial, ReChord US Pivotal trial, and Medtronic CoreValve US Pivotal trial. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

A 66-year-old man with post-myocardial infarction ventricular septal rupture, apical aneurysm, and pseudoaneurysm presenting in cardiogenic shock received a surgically placed temporary microaxial transvalvular left ventricular assist device. This stabilized hemodynamics and end-organ function, and he subsequently underwent successful heart transplantation. A temporary microaxial transvalvular left ventricular assist device can effectively bridge patients with select mechanical complications of myocardial infarction beyond ventricular septal rupture., Competing Interests: Dr Soltesz is the Donna and Ken Lewis Endowed Chair in Cardiothoracic Surgery; and has received honoraria from Abbott, Abiomed, Atricure, and Dilon. Dr Smedira is the Polly and W. Neal Rossborough Endowed Chair in Heart Transplantation Research. Dr Tong has received honoraria from Abbott and Abiomed. Dr Higgins has received lecture honoraria from Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Data on shock severity and bleeding events in patients with temporary mechanical circulatory support (tMCS) are limited. We investigated the relationship between the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification and bleeding events in patients with tMCS., Methods: We evaluated the data of 285 consecutive patients with tMCS who were admitted to our institution between June 2019 and May 2022. At the time of tMCS initiation, 81 patients (28.4%) were in SCAI stage A, 38 (13.3%) in stage B, 69 (24.2%) in stage C, 33 (11.6%) in stage D, and 64 (22.5%) in stage E. Multivariable logistic regression modeling was used to assess the association between the SCAI shock stage and in-hospital bleeding events., Results: In-hospital bleeding occurred in 100 patients (35.1%). The bleeding event rate increased incrementally across the SCAI shock stages (stage A, 11.1%; stage B, 15.8%; stage C, 37.7%; stage D, 54.6%; stage E, 64.1%). In-hospital bleeding was associated with the SCAI shock stage (p < 0.001). Compared with stage A, the adjusted odds ratios for in-hospital bleeding were 1.48 (95% confidence interval [CI] 0.47-4.66), 6.47 (95% CI 2.61-10.66), 11.59 (95% CI 3.77-35.64), and 7.85 (95% CI 2.51-24.55) for stages B, C, D, and E, respectively., Conclusions: The SCAI shock stage predicted subsequent bleeding events in patients with tMCS. This simple scheme may be useful for tailored risk-based clinical assessment and management of patients with tMCS., (© 2024 Wiley Periodicals LLC.)

Competing Interests: Conflicts of Interest The following authors reported no actual or potential conflicts of interest in relation to this document: A.N., S.M.C., S.P.C., M.A.D., N.K.K., G.B.M., V.M., RF.S., B.X. The following authors reported relationships with one or more commercial interests: JD.E has participated as consultant to Abbott and Getinge and medical advisor to Medtronic; J.C. has received consulting fees from Boston Scientific and Abbott Vascular and has been a speaker for Medtronic, Circle Cardiovascular Imaging, and Siemens Healthineers; J.C. has participated as speaker and consultant to Abbott and Medtronic; B.D.H. has participated as speaker for Philips Medical; E.K. has participated as clinical consultant for Lantheus Medical Imaging.

Cardiogenic shock is a state of circulatory collapse due to low cardiac output resulting from heart failure. Heart failure in this setting may be due to left, right, or biventricular dysfunction. Acute myocardial infarctions remain the most common cause of cardiogenic shock, although in contemporary patient populations, the increasing prevalence of end-stage heart failure has resulted in a growing population of heart failure cardiogenic shock presentations. Clinicians practicing in the cardiac intensive care unit are challenged with these increasingly complex patients. Such patients often require hemodynamic support to improve end-organ perfusion and reduce mortality. Mechanical devices, collectively known as temporary mechanical circulatory support, provide clinicians with additional tools in our armamentarium to combat the increased mortality associated with cardiogenic shock. In this article, we provide an overview of cardiogenic shock and its phenotypic clinical presentations, in addition to providing a description of temporary mechanical circulatory support devices that are currently utilized in the management of cardiogenic shock. [ABSTRACT FROM AUTHOR]

Faced with a chronic donor shortage, clinicians and regulators both struggle to develop allocation systems which balance the challenges of waitlist mortality and donor availability. Most organ allocation systems across the globe have prioritized transplantation of patients supported on temporary mechanical circulatory support (tMCS) with regional variations. There are concerns that this approach might not produce optimal outcomes and is not without major drawbacks including lack of strict criteria for tMCS as bridge strategy, choice of optimal devices and wait time on tMCS. The current manuscript outlines characteristics and limitations of current devices used for tMCS as a bridging strategy. The outcomes of transplantation following device support are evolving and are highlighted as well. Lastly, the allocation schema for heart transplantation in various countries are reviewed and compared. Additionally, we propose key principles to guide changes in next iteration of donor allocation systems to balance waitlist mortality with optimal post-transplant outcomes. First, allocation should be on the basis of calculated scores which take into account a variety of pre-and post-transplant factors and cannot be easily manipulate by choice of support therapy. Next, time at high urgency statuses should be time-limited with strict criteria for renewal. Emphasis should be placed on the further refinement of durable mechanical support therapies. Patients on durable support need a pathway to qualify for transplantation in the absence of complications, and lastly, peer review of exceptions to organ allocation policy are critically important to ensure the appropriate allocation of donor organs. [ABSTRACT FROM AUTHOR]

Background: Intra‐aortic balloon pumps (IABP) are used to bridge select end‐stage heart disease patients to heart transplant (HT). IABP use and exception requests both increased dramatically after the UNOS policy change (PC). The purpose of this study was to evaluate the effect of PC and exception status requests on waitlist and post‐transplant outcomes in patients bridged to HT with IABP support. Methods: We analyzed adult, first‐time, single‐organ HT recipients from the UNOS Registry either on IABP at the time of registration for HT or at the time of HT. We compared waitlist and post‐HT outcomes between patients from the PRE (October 18, 2016 to May 30, 2018) and POST (October 18, 2018 to May 30, 2020) eras using Kaplan‐Meier curves and time‐to‐event analyses. Results: A total of 1267 patients underwent HT from IABP (261 pre‐policy/1006 post‐policy). On multivariate analysis, PC was associated with an increase in HT (sub‐distribution hazard ratio (sdHR): 2.15, p <.001) and decrease in death/deterioration (sdHR: 0.55, p =.011) on the waitlist with no effect on 1‐year post‐HT survival (p =.8). The exception status of patients undergoing HT was predominantly seen in the POST era (29%, 293/1006); only four patients in the PRE era. Exception requests in the POST era did not alter patient outcomes. Conclusions: In patients bridged to heart transplant with an IABP, policy change is associated with decreased rates of death/deterioration and increased rates of heart transplantation on the waitlist without affecting 1‐year post‐transplant survival. While exception status use has markedly increased post‐PC, it is not associated with patient outcomes. [ABSTRACT FROM AUTHOR]

Objectives . Temporary mechanical circulatory support (TMCS) has become a component in the therapeutic strategy for treatment of cardiogenic shock as a bridge-to-decision. TMCS can facilitate recovery of cardiopulmonary function, end-organ function, and potentially reduce the surgical risk of left ventricular assist device (LVAD) implantation. Despite the improvements of hemodynamics and end-organ function, post-LVAD operative morbidity might be increased in these high-risk patients. The aim of the study was to compare outcomes after Heartmate 3 (HM3) implantation in patients with and without TMCS prior to HM3 implant. Methods. In this retrospective cohort study of all HM3 patients in the period between November 2015 and October 2021, patients with and without prior TMCS were compared. Patients' demographics, baseline clinical characteristics, laboratory tests, intraoperative variables, postoperative outcomes, and adverse events were collected from patient records. Results. The TMCS group showed an improvement in hemodynamics prior to LVAD implantation. Median TMCS duration was 19.5 (14-26) days. However, the TMCS group were more coagulopathic, had more wound infections, neurological complications, and more patients were on dialysis compared with patient without TMCS prior to HM3 implantation. Survival four years after HM3 implantation was 80 and 82% in the TMCS ( N  = 22) and non-TMCS group ( N  = 41), respectively. Conclusion . Patients on TMCS had an acceptable short and long-term survival and comparable to patients receiving HM3 without prior TMCS. However, they had a more complicated postoperative course.

Temporary mechanical circulatory support (tMCS) is increasingly used in patients with cardiogenic shock as a bridge to further treatment. We present the case of a 52-year-old female patient with biventricular heart failure who was bridged to heart transplantation employing biventricular tMCS through a non-femoral access. The 'groin-free' tMCS concept facilitates pre-habilitation while awaiting heart transplantation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Cardiogenic shock (CS) represents one of the foremost concerns in the field of acute cardiovascular medicine. Despite major advances in treatment, mortality of CS remains high. International societies recommend the development of expert CS centers with standardized protocols for CS diagnosis and treatment. In these terms, devices for temporary mechanical circulatory support (MCS) can be used to support the compromised circulation and could improve clinical outcome in selected patient populations presenting with CS. In the past years, we have witnessed an immense increase in the utilization of MCS devices to improve the clinical problem of low cardiac output. Although some treatment guidelines include the use of temporary MCS up to now no large randomized controlled trial confirmed a reduction in mortality in CS patients after MCS and additional research evidence is necessary to fully comprehend the clinical value of MCS in CS. In this article, we provide an overview of the most important diagnostic and therapeutic modalities in CS with the main focus on contemporary MCS devices, current state of art and scientific evidence for its clinical application and outline directions of future research efforts. [ABSTRACT FROM AUTHOR]

Timing and causes of hospital mortality in adult patients undergoing veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V‐A ECMO and subsequently define the "V‐A ECMO gap," which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V‐A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%‐41.9%) during V‐A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%‐19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8‐52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one‐third of V‐A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the "V‐A ECMO gap." Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V‐A ECMO patients to better understand the effectiveness and complications of this support. [ABSTRACT FROM AUTHOR]

As a leading cause of death worldwide, heart failure is a serious medical condition in which many critically ill patients require temporary mechanical circulatory support (MCS) as a bridge‐to‐recovery or bridge‐to‐decision. In many cases, the TandemHeart system is used to unload the left heart by draining blood from the left atrium (LA) to the femoral artery via a transseptal multistage cannula. However, even though the correct positioning of the cannula is crucial for a safe treatment, the long cannula tip currently used in transseptal cannulas complicates positioning, making the cannula vulnerable to displacement during MCS. To overcome these limitations, we propose the development of a new tipless transseptal cannula with improved hemodynamic properties. We discuss the tipless cannula concept by comparing it to the common multistage cannula concept using computational fluid dynamics simulations and assess the flow field in the LA, the wall shear stresses (WSS), and the pressure loss. Across the two distinct time points of end‐systole and end‐diastole and two drainage flow rates of 3.5 and 5.0 L/min, we find a more homogeneous inlet flow pattern for the tipless cannula concept, accompanied by a remarkably reduced area of platelet‐activating WSS (up to 10‐times smaller area compared to the multistage cannula). Moreover, pressure loss is up to 14.5% lower in the tipless cannula concept, confirming overall improved hemodynamic properties of the tipless cannula concept. Finally, a diameter‐dependent study reveals that lower WSS and pressure losses can be further reduced by large‐lumen designs for any simulation setting. Overall, our results suggest that a tipless cannula concept remedies the crucial disadvantages of a long‐tip multistage cannula by reducing the risk of misplacement, and it furthermore promotes optimized hemodynamics. With this successful proof‐of‐concept, we underscore the potential for and encourage the realization of further experimental investigations regarding the development of a tipless transseptal cannula for MCS. [ABSTRACT FROM AUTHOR]

The management of biventricular heart failure presents a significant challenge. Recently, percutaneous options for univentricular support that may be combined to provide full biventricular support have come to market. These support configurations allow patients to be bridged to recovery, durable mechanical circulatory support, or to transplantation. Due to the minimally invasive nature of these systems, patients may be rapidly extubated, and some may be mobilized with full biventricular support. Varied approaches for implementation of these temporary support systems exist, with some of the most common techniques presented here. [ABSTRACT FROM AUTHOR]