Prognostic Implications of Quantifying Vasoactive Medications in Cardiogenic Shock.

None.

Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock.

BACKGROUND: Pulmonary artery catheters (PACs) are increasingly used to guide management decisions in cardiogenic shock (CS). The goal of this study was to determine if PAC use was associated with a lower risk of in-hospital mortality in CS owing to acute heart failure (HF-CS). METHODS AND RESULTS: This multicenter, retrospective, observational study included patients with CS hospitalized between 2019 and 2021 at 15 US hospitals participating in the Cardiogenic Shock Working Group registry. The primary end point was in-hospital mortality. Inverse probability of treatment-weighted logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CI), accounting for multiple variables at admission. The association between the timing of PAC placement and in-hospital death was also analyzed. A total of 1055 patients with HF-CS were included, of whom 834 (79%) received a PAC during their hospitalization. In-hospital mortality risk for the cohort was 24.7% (n = 261). PAC use was associated with lower adjusted in-hospital mortality risk (22.2% vs 29.8%, OR 0.68, 95% CI 0.50-0.94). Similar associations were found across SCAI stages of shock, both at admission and at maximum SCAI stage during hospitalization. Early PAC use (≤6 hours of admission) was observed in 220 PAC recipients (26%) and associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, OR 0.54, 95% CI 0.37-0.81). CONCLUSIONS: This observational study supports PAC use, because it was associated with decreased in-hospital mortality in HF-CS, especially if performed within 6 hours of hospital admission. CONDENSED ABSTRACT: An observational study from the Cardiogenic Shock Working Group registry of 1055 patients with HF-CS showed that pulmonary artery catheter (PAC) use was associated with a lower adjusted in-hospital mortality risk (22.2% vs 29.8%, odds ratio 0.68, 95% confidence interval 0.50-0.94) compared with outcomes in patients managed without PAC. Early PAC use (≤6 hours of admission) was associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, odds ratio 0.54, 95% confidence interval 0.37-0.81).

A manifesto of collaborative longitudinal cardiovascular care in heart failure.

In this document, we outline the challenges faced by patients and clinicians in heart failure, specifically centered around the needed coordination of care among the various subspecialties within cardiovascular medicine. We call for a more organized and collaborative effort among clinicians in primary care, general cardiology, electrophysiology, interventional cardiology, cardiothoracic surgery, cardiac imaging, and heart failure-all caring for mutual patients. Care is contextualized within the framework of two phases: a cardiomyopathy phase and an advanced heart failure phase, each of which lends to different considerations in therapy. Ultimately multidisciplinary coordinated care within cardiovascular medicine may lead to greater patient and clinician satisfaction as well as improved outcomes, but this remains to be investigated.

Gut microbial diversity, inflammation, and oxidative stress are associated with tacrolimus dosing requirements early after heart transplantation.

INTRODUCTION: Effective tacrolimus (TAC) dosing is hampered by complex pharmacokinetics and significant patient variability. The gut microbiome, a key mediator of endotoxemia, inflammation and oxidative stress in advanced heart failure (HF) patients, is a possible contributor to interindividual variations in drug efficacy. The effect of alterations in the gut microbiome on TAC dosing requirements after heart transplant (HT) has not been explored. METHODS: We enrolled 24 patients (mean age = 55.8 ±2.3 years) within 3 months post-HT. Biomarkers of endotoxemia ((lipopolysaccharide (LPS)), inflammation (tumor necrosis factor-α (TNF-α)) and oxidative stress (8,12-iso-Isoprostane F-2alpha-VI) were measured in 16 blood samples. 22 stool samples were analyzed using 16S rRNA sequencing. TAC dose and serum trough level were measured at the time of stool and blood collection. TAC doses were reported in mg/kg/day and as level-to-dose (L/D) ratio, and categorized as ≤ vs. > median. RESULTS: The median TAC dose was 0.1 mg/kg/day and L/D ratio was 100.01. Above the median daily weight-based TAC dose was associated with higher gut microbial alpha diversity (p = 0.03); similarly, TNF-α and 8,12-iso-Isoprostane F-2alpha-VI levels were lower and LPS levels were higher in the above median TAC group, although these findings were only marginally statistically significant and dependent on BMI adjustment. We observed n = 37 taxa to be significantly enriched among patients with > median TAC dose (all FDR<0.05), several of which are potential short-chain fatty acid producers with anti-inflammatory properties, including taxa from the family Subdoligranulum. CONCLUSIONS: Our pilot study observed gut microbial alpha diversity to be increased while inflammation and oxidative stress were reduced among patients requiring higher TAC doses early after HT.

Association between recipient blood type and heart transplantation outcomes in the United States.

BACKGROUND: In heart transplantation (HT), although blood type O organs can go to any blood type, non-O organs may not be allocated to adult O recipients. Therefore, O candidates wait longer than non-O candidates and frequently require bridging with left ventricular assist devices (LVADs). The effects of this discrepancy are rarely investigated in a large registry. The purpose of this study was to assess the association between candidates' blood type and their outcomes after HT listing. METHODS: This is a retrospective cohort study using the United Network for Organ Sharing Registry, including 34,352 candidates listed for a single-organ, primary HT from January 2000 through December 2015. Main outcome measures were waitlist mortality and post-HT mortality, using blood type A as reference. We conducted inverse-probability weighting to adjust for baseline profiles. RESULTS: Among 34,352 candidates (median age 55, interquartile range 46-62; female 24.8%; blood type A: 13,258, AB: 1,572, B: 4,599, O:14,923), 22,714 candidates (A: 71.5%, AB: 82.1%, B: 73.0%, O: 57.5%; p < 0.001) underwent HT during the study period. Among recipients, bridging LVAD rate was highest in O recipients (A: 23.0%, AB: 15.3%, B: 23.4%, O: 32.1%; p < 0.001). After inverse-probability weighting, O patients demonstrated a significantly higher hazard of death after listing (adjusted hazard ratio 1.11, 95% confidence interval [CI] 1.07-1.16) and after HT (adjusted hazard ratio 1.07, 95% CI 1.01-1.13) as compared with A. CONCLUSIONS: There is a survival discrepancy among blood types. Our findings should facilitate more prospective studies to revisit current policies regarding equity in allocation, where possible.

Endoscopic Algorithm for Management of Gastrointestinal Bleeding in Patients With Continuous Flow LVADs: A Prospective Validation Study.

BACKGROUND: Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization. METHODS: We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. RESULTS: We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%). CONCLUSIONS: Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.

Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution.

Background: When left ventricular assist device (LVAD) therapy no longer is able to achieve patients' desired quality of life, withdrawal of LVAD therapy (WLVAD) may be requested. Objectives: To evaluate factors associated with WLVAD, including the time taken before WLVAD. Setting/Subjects: Sixty-two patients who newly underwent initial LVAD therapy during January 1, 2010 and October 30, 2018 and subsequently underwent WLVAD by December 31, 2018 were divided into those who participated in the decision of WLVAD (defined as PT+, n = 14), and those who could not participate in the decision because of the medical reasons (defined as PT-, n = 48). Measurements: Time to WLVAD in PT+ and PT- was defined as WD_PT+ (days between patients' request and WLVAD) and WD_PT- (days between when patients became unable to express themselves and WLVAD), respectively. Circumstances around WLVAD, including location of death and use of palliative care (PC), were reviewed. Results: Mean age at WLVAD was 65.4 ± 10.1 years and 52 (83.9%) were men. Median days on LVAD support was 166.5 days (interquartile range = 838). The majority of WLVAD occurred in the intensive care unit (ICU) (83.6%) but less frequent in PT+ than in PT- (64.3% vs. 89.4%, p = 0.041). The median number of PC visits in the last month was higher in PT+ than in PT- (4.5 vs. 0.5, p = 0.005). The median WD_PT+ was 5.5 days and was significantly shorter in the ICU (1 day vs. 46 days, p = 0.013). The median WD_PT- was 5.5 days and tended to be shorter in the ICU (4 days vs. 13 days, p = 0.072). A multivariate analysis showed that male gender and ICU setting were both negatively associated with WD_PT- (p = 0.025 for men, p = 0.005 for ICU setting). Conclusions: The majority of WLVAD occurred in the ICU and required PC involvement. Time to WLVAD was shorter in the ICU. Requests for WLVAD directly made by patients, especially in a non-ICU setting, seemed to have posed more difficulty.

Atrial Fibrillation Is Associated with Recurrent Ventricular Arrhythmias After LVAD Implant: Incidence and Impact in a Consecutive Series.

This study examined left-ventricular assist device (LVAD) patients with pre-LVAD ventricular arrhythmias (VAs) to determine the rate of recurrent post-LVAD VAs and the impact of pre-LVAD atrial fibrillation (AF) on recurrent post-LVAD VAs. Medical records of 195 consecutive LVAD patients were reviewed. Descriptive statistics were generated and Cox proportional hazard models were used to assess the association of clinical variables with the time to recurrent VA. Forty-seven percent of 195 CHF patients who received LVAD-manifested significant VAs prior to LVAD implant (82% Heartmate II, 14% HVAD, 4% other; median follow-up = 17 months), 41% of whom manifested recurrent post-LVAD VAs. Pre-LVAD AF was associated with recurrent VAs (hazard ratio = 3.73; 95% CI 1.33, 10.48; p = 0.012). Recurrent VAs were associated with increased mortality (hazard ratio = 3.06; 95% CI 1.17, 7.98; p = 0.023). A history of AF is prevalent in over half of LVAD patients with recurrent VAs and is associated with time to recurrence of VA.

Effect of Pulmonary Hypertension on Transplant Outcomes in Patients With Ventricular Assist Devices.

BACKGROUND: Although extremely high pulmonary vascular resistance (PVR) is a relative contraindication for heart transplantation (HTx), recent data with continuous-flow left ventricular assist devices (LVADs) indicate HTx outcomes may be different when high PVR is managed with an LVAD. This study clarifies the contemporary association between PVR at HTx and posttransplant survival in LVAD vs non-LVAD cohorts. METHODS: We reviewed the United Network for Organ Sharing registry for adults who received a transplant from 2008 to 2015. In those with continuous-flow LVADs and those with no VADs at HTx, (non-VAD), we grouped patients by low PVR (PVR <3), intermediate PVR (PVR 3 to <6), and high PVR (PVR ≥6) groups. Adjusted hazard ratios (aHRs) for death after HTx were calculated by Cox regression. RESULTS: The non-LVAD cohort included 6270 patients (4385 in low, 1643 in intermediate, and 242 in high PVR), and the LVAD cohort included 4111 patients (3227 in low, 798 in intermediate, and 86 in high PVR). The high PVR LVAD group had the worst survival, which was not significant, likely to low power (P = .300). The aHR for death in non-LVAD was 1.047 (95% confidence interval, 1.010-1.088) and in LVAD was 1.063 (95% confidence interval, 1.010-1.119). Cubic spline analysis demonstrated nonlinear associations between PVR and the aHR, especially in the LVAD cohort. CONCLUSIONS: There was no significant evidence to conclude the effect of pretransplant PVR on posttransplant survival is higher in LVAD vs non-LVAD patients, based on analysis of the United Network for Organ Sharing database. However, further investigations are indicated to clarify HTx candidacy in those with extremely high PVR even after LVAD.

Meta-Analysis Comparing Risk for Adverse Outcomes After Left Ventricular Assist Device Implantation in Patients With Versus Without Diabetes Mellitus.

Patients with diabetes mellitus (DM) are known to have reduced life expectancy and be at increased risk for multiple morbidities including serious infection. However, published data on DM outcomes after left ventricular assist device (LVAD) implantation are sparse, inconsistent and individual studies are small with limited power. We conducted a systematic review and meta-analysis to compare survival and adverse events post-LVAD in DM versus non-DM (NDM) patients. Medline, Scopus, and Cochrane Central databases were searched for studies comparing outcomes in DM and NDM patients who underwent LVAD implantation for advanced heart failure. Results were reported as random effect risk ratios (RR) with 95% confidence intervals. We identified 5 retrospective cohort studies, at low risk of bias, reporting on 1,351 patients (n = 488 DM). There was increased 30-day mortality (RR 1.57 [1.00, 2.47]; p = 0.05; I2 = 0%) among DM versus NDM. The DM and NDM groups did not differ significantly in terms of 1-year mortality (RR 1.15 [0.98, 1.35]; p = 0.08; I2 = 39%), device-related infection (RR 1.05 [0.92, 1.19]; p = 0.88; I2 = 0%), ischemic stroke (RR 1.29 [0.91, 1.83]; p = 0.69; I2 = 0%), hemorrhagic stroke (RR 1.10 [0.42, 2.83]; p = 0.85; I2 = 69%), or bleeding (RR 1.06 [0.80, 1.40]; p = 0.70; I2 = 27%). After LVAD implantation, patients with DM, versus patients without, have a modestly elevated 30-day mortality rate. However, 1-year mortality and morbidity did not differ.

Left ventricular decompression on Veno-arterial extracorporeal membrane oxygenation with intra-aortic balloon Counterpulsation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used increasingly to support patients with cardiogenic shock (CS). There has been growing recognition of the favorable and unfavorable hemodynamic effects of this therapy and recent interest in the use of other percutaneous circulatory support devices to offset some of the potentially harmful hemodynamic effects. Herein, we provide visual evidence of the effects of intra-aortic balloon pump (IABP) counterpulsation for a patient with peripheral VA-ECMO cannulation. CASE PRESENTATION: A 68 year old man who had undergone orthotopic heart transplantation presented with 2 days of fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, he was tachycardic, hypotensive and hypoxic with cool extremities, consistent with CS. Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with a left ventricular ejection fraction of 15%, right heart catheterization demonstrated elevated filling pressures and low output. An IABP was inserted via the left femoral artery with minimal improvement in hemodynamics. He was escalated to VA-ECMO. Repeat TTE demonstrated aortic valve (AV) opening with each cardiac cycle and mild MR. With placement of the IABP on standby Additional file 1: Video 1 (video 0:03), the AV no longer opened. Re-initiation of balloon counterpulsation resulted in resumed AV opening with each beat Additional file 1: Video 1 (video 0:17). He was treated for presumed acute allograft rejection with methylprednisolone, thymoglobulin, intravenous immunoglobulin and plasmapheresis with improvement in allograft function. However, he developed an Enterobacter aerogenes pneumonia and rapidly fatal septic shock. CONCLUSIONS: This case visually demonstrates effective LV decompression by IABP counterpulsation in VA-ECMO support. While the overall effects of LV decompression in patients on VA-ECMO with IABP are still unclear, this report demonstrates one potential mechanism of benefit in the prevention of stagnation of blood flow that may lead to intra-cardiac or aortic root thrombus formation.

Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is an established method of short-term mechanical support for patients in cardiogenic shock, but can create left ventricular (LV) distension. This paper analyzes the physiologic basis of this phenomenon and treatment methods. This is a retrospective review of the existing literature on VA ECMO and LV distension. We undertook a PubMed review of all peer-reviewed papers focusing on VA ECMO, LV distension, and LV venting. We reviewed these papers and synthesized our findings. We also will discuss the various methods of LV venting and venting strategies we use at Columbia. LV distension is becoming an increasingly appreciated aspect of caring for patients on VA ECMO support. The literature demonstrates that the consequences of failing to anticipate, recognize, and treat LV distension are grave, and will worsen an already distended and hypocontractile LV. Myocardial recovery will be hindered, and LV thrombus formation more likely. Early recognition and aggressive management of LV distension is paramount in helping care for this critically ill patient population.

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. METHODS: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. RESULTS: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. CONCLUSIONS: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.

Outcomes of bridge to cardiac retransplantation in the contemporary mechanical circulatory support era.

BACKGROUND: Outcomes have improved in patients bridged to heart transplant on contemporary continuous-flow ventricular assist devices over the past decade. We evaluated mechanical circulatory support as a means to bridge patients to cardiac retransplantation. METHODS: We retrospectively reviewed 464 patients who underwent cardiac retransplant from the United Network for Organ Sharing database between January 2006 and November 2016. Pre- and post-transplant data were compared between patients bridged to retransplant with mechanical circulatory support (n = 81) and those without mechanical circulatory support (n = 383). RESULTS: The mean ages for the patients in the mechanical circulatory support and nonmechanical circulatory support cohorts were 41.2 ± 16 years and 42.1 ± 15.7 years, respectively (P = .64). Patients bridged with mechanical circulatory support were placed on extracorporeal membrane oxygenation (n = 29, 35.8%), a total artificial heart (n = 13, 16.0%), or a temporary or durable ventricular assist device (n = 39, 48.1%). Twelve patients (14.8%) were placed on a second device before retransplant. Thirty-nine percent of the mechanical circulatory support group were indicated for listing because of primary graft dysfunction or acute rejection versus 6% of the nonmechanical circulatory support group (P < .01). Likewise, 30% of patients in the mechanical circulatory support group were listed for cardiac allograft vasculopathy compared with 59% of the nonmechanical circulatory support group (P < .01). Thirty-day mortality was significantly higher in the mechanical circulatory support group (17.8% vs 4.8%, P < .01). However, patients who were bridged with a ventricular assist device or total artificial heart had comparable midterm outcomes to the nonmechanical circulatory support group. CONCLUSIONS: Patients who require mechanical circulatory support bridge to retransplantation belong to a high-risk cohort. Comparable midterm outcomes to the nonmechanical circulatory support cohort were demonstrated when patients' conditions allow for bridge with a ventricular assist device or total artificial heart. Bridging to retransplantation with extracorporeal membrane oxygenation remains a relative contraindication.

Midterm Outcomes of Bridge-to-Recovery Patients After Short-Term Mechanical Circulatory Support.

BACKGROUND: The use of short-term mechanical circulatory support (ST-MCS) has increased for refractory cardiogenic shock. However, there are scant data about bridge-to-recovery patients. METHODS: We retrospectively reviewed 502 patients with cardiogenic shock who received venoarterial extracorporeal membrane oxygenation or a temporary surgical ventricular assist device as ST-MCS between 2010 and 2016. There were 178 patients (35.5%) who survived through device explantation. Of these, 149 patients (29.7%) survived to discharge and were included for analysis. The primary outcome was midterm survival without undergoing heart replacement therapy. RESULTS: In our bridge-to-recovery cohort, 101 patients (67.8%) were men, and the median age was 59 years (interquartile range, 51 to 67 years). Etiology of cardiogenic shock included postcardiotomy shock in 35.6% of patients (n = 53), allograft failure in 26.8% (n = 40), acute myocardial infarction (AMI) in 24.2% (n = 36), and other acute decompensated heart failure in 14.4% (n = 20). There were 24 major events (16.1%) recorded, including 21 patients who died and 3 patients who received heart replacement therapy during median follow-up of 306 days (interquartile range, 58.25 to 916.75 days). Overall freedom from event at 3 years was 74.2%. In subgroup analysis, AMI patients had a significantly worse freedom-from-event rate at 40.4% (p < 0.001). By univariate Cox analysis, AMI etiology (p = 0.003), length of ST-MCS (p = 0.06), blood urea nitrogen (p = 0.012), and left ventricular ejection fraction (p = 0.005) at discharge were predictors for adverse events. CONCLUSIONS: The overall midterm outcome of patients explanted from ST-MCS is favorable except for AMI patients.

Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study.

BACKGROUND: Little is known about palliative care consultation (PCC) for patients with cardiogenic shock requiring short-term mechanical circulatory support (STMCS). OBJECTIVE: To describe the utilization of PCC in this population. DESIGN: Retrospective cohort study in a university medical center intensive care unit (ICU). SETTING/PARTICIPANTS: In total, 195 patients aged >18 years with cardiogenic shock requiring STMCS were included. The cohort was divided into three categories: no PCC, early PCC (within seven days of STMCS), and late PCC (eight or more days after STMCS). Follow-up occurred during the index hospitalization. RESULTS: Mean age was 59.3 ± 13.9 years; 67.9% were men. Mean follow-up period was 33.8 ± 37.7 days. Overall inpatient mortality was 52.3%. Ninety-four patients (48.2%) received PCC; 49 (25.1%) and 45 (23.1%) received early and late PCCs, respectively. STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, p < 0.001; 11 vs. 19 days, p = 0.004; and 16 vs. 19 days, p = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, p < 0.001; 19 vs. 49 days, p < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, p = 0.13). CONCLUSIONS: PCC was utilized in almost half of patients with cardiogenic shock requiring STMCS. PCC tends to occur toward the end of life regardless of the duration of STMCS. The optimal PCC timing remained unclear.

Aortic root thrombosis in patients supported with continuous-flow left ventricular assist devices.

BACKGROUND: Aortic root thrombosis (ART) is a recently recognized complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. However, little is known about the prevalence or clinical significance of this complication. The aim of our study was to systematically evaluate the incidence and significance of ART on CF-LVAD support. METHODS: We retrospectively reviewed all patients who underwent HeartMate II or HeartWare HVAD CF-LVAD implantation from April 2004 through June 2016 at the Columbia University Medical Center. Echocardiography studies were systematically reviewed to identify patients who developed ART. Study outcomes included post-ART survival on CF-LVAD support, stroke, pump thrombosis, and clinically significant myocardial infarction (MI). RESULTS: The study cohort consisted of 436 CF-LVAD patients with 21 patients (4.8%) diagnosed with confirmed ART at a median time of 22 days (interquartile range [IQR] 3 to 56 days) after CF-LVAD implantation. Involvement of the non-coronary cusp was the most common location of the ART (n = 15, 71.4%) and concomitant RV failure occurred in 14 patients (66.7%). Actuarial survival at 1 and 2 years after diagnosis of ART was 73.8% and 44.3%, respectively. ART was associated with a high rate of complications, including stroke (28.6%, 0.337 episode per patient-year [EPPY]) and clinically significant MI (28.6%, 0.337 EPPY). CONCLUSIONS: ART is not uncommon after CF-LVAD implantation and is associated with significant morbidity and mortality in CF-LVAD patients. Given the early occurrence and high incidence of stroke and MI in patients who develop ART, surveillance and treatment strategies should be implemented to address this potentially devastating complication.

Impact of Sharing O Heart With Non-O Recipients: Simulation in the United Network for Organ Sharing Registry.

BACKGROUND: Blood type O heart transplant recipients wait longer than non-O recipients and frequently require bridging left ventricular assist devices (LVADs). However, rarely has the effect of this disparity been shown in a large registry. This study used Markov simulation to clarify the outcome difference between O and non-O candidates and how allocation change could affect survival. METHODS: We reviewed the United Network for Organ Sharing registry for adults listed for heart transplantation from 2008 to 2015. Cumulative incidences of death or transplant and survival after listing were compared between O and non-O using propensity matching. A four-state Markov model-waiting without LVAD, waiting with LVAD, transplantation, and death-was created to simulate survival after listing. Sensitivity analysis was performed to see how the percentage of O hearts in non-O recipients would affect survivals. RESULTS: A total of 8,187 O and non-O candidates were included after matching. The cumulative incidence of transplantation was lower in O (p < 0.001), and death after listing was significantly higher (p < 0.001). During a median follow-up of 2.1 years, 69.6% of non-O candidates were transplanted, compared with 54.9% of O candidates (p < 0.001). Despite this disparity, 19% of non-O recipients received O hearts. Our simulated survival demonstrated that decreasing the O heart percentage in non-O recipients from the current 19% to 5% would provide similar survival in O and non-O after listing. CONCLUSIONS: Under the current strategy, there are death and transplant rate differences between O and non-O candidates. Our simulation-based allocation strategy might aid in mitigating this discrepancy across blood types.

VA-ECMO for cardiogenic shock in the contemporary era of heart transplantation: Which patients should be urgently transplanted?

With the impending United Network for Organ Sharing (UNOS) heart allocation policy giving VA-ECMO supported heart transplant (HT) candidates highest priority status (Tier 1), identifying patients in cardiogenic shock (CS) with severe and irreversible heart failure (HF) appropriate for urgent HT is critically important. In a center where wait times currently preclude this approach, we retrospectively reviewed 119 patients (ages 18-72) with CS from 1/2014 to 12/2016 who required VA-ECMO for >24 hours. Underlying aetiologies included postcardiotomy shock (45), acute coronary syndromes (33), and acute-on-chronic HF (16). Eighty-four percent of patients (100) had ≥1 contraindication to HT with 61.3% (73) having preexisting contraindications (eg, multiorgan dysfunction and substance abuse), and 68.1% (81) experienced preclusive complications (eg, renal failure, coagulopathy, and infection). Potential HT candidates were significantly more likely to survive to discharge (potential HT candidates 84.2% vs preexisting contraindications 43.8% vs contraindications developing on VA-ECMO 33.3%, P = 0.001). Among potential HT candidates, 11 (68.8%) were discharged without advanced therapies and 4 received durable left ventricular assist device (25.0%). Importantly, 1-year survival was 100% for the 11 patients with follow-up. Thus, further work is critical to define appropriate candidates for HT from VA-ECMO while avoiding preemptive transplantation in those with otherwise favorable outcomes.