Surgeon and Hospital Factors Associated With Outcomes in the New York State Database.

INTRODUCTION: We sought to explore the relationship between various surgeon-related and hospital-level characteristics and clinical outcomes among patients requiring cardiac surgery. METHODS: We searched the New York State Cardiac Data Reporting System for all coronary artery bypass grafting (CABG) and valve cases between 2015 and 2017. The data were analyzed without dichotomization. RESULTS: Among CABG/valve surgeons, case volume was positively correlated with years in practice (P = 0.002) and negatively correlated with risk-adjusted mortality ratio (P = 0.014). For CABG and CABG/valve surgeons, our results showed a negative association between teaching status and case volume (P = 0.002, P = 0.018). Among CABG surgeons, hospital teaching status and presence of cardiothoracic surgery residency were inversely associated with risk-adjusted mortality ratio (P = 0.006, P = 0.029). CONCLUSIONS: There is a complex relationship between case volume, teaching status, and surgical outcomes suggesting that balance between academics and volume is needed.

Outcomes of outflow graft stenting in HeartMate 3 left ventricular assist devices: A systematic review and individual patient data meta-analysis.

PURPOSE: LVAD outflow graft stenosis continues to remain prevalent with a high complication rate. We sought to pool the existing evidence on indications, utilization patterns, and outcomes of transcatheter interventions for outflow graft stenosis in the HeartMate 3 LVAD. METHODS: An electronic search was performed to identify all studies in the English literature reporting on HeartMate 3 LVAD outflow graft stenting. Patient-level data were extracted for analysis. RESULTS: Thirteen published reports and one unpublished case comprising a total of 28 patients were included. Median patient age was 68.5 years [Interquartile range: 58, 71] and 25.9% (7/27) were female. Dyspnea [60.7% (17/28)] was the most common presenting symptom. Low flow alarms were present in 60% (15/25) of patients. Findings included external compression [35.7% (10/28)], graft twist [21.4% (6/28)], graft twist and external compression [14.3% (4.28)], intraluminal thrombus [10.7% (3/28)], graft twist and intraluminal thrombus [3.6% (1/28)], and pseudoaneurysm of outflow graft [3.6% (1/28)]. Median time from LVAD implantation to stenting was 2.1 years [1.4, 3]. Immediate flow normalization after stenting was observed in 85.7% (24/28). The 30-day mortality was 12% (3/25). Overall mortality was 12% (3/25) at a median follow-up of 3.9 months [1, 17]. CONCLUSION: Outflow graft stenting in the HeartMate 3 LVAD appears to be a reasonable treatment option for outflow graft stenosis, with low overall rates of complications and mortality. Further refinement of indications and approaches may improve outcomes.

The impact of the OPTN policy change on patients with a durable left ventricular assist device and chronic kidney disease: Analysis of the UNOS database.

BACKGROUND: The Organ Procurement and Transplantation Network (OPTN) implemented modifications in 2018 to the adult heart transplant allocation system to better stratify the most medically urgent transplant candidates. We evaluated the impact of these changes on patients supported by a durable left ventricular assist device (LVAD) with chronic kidney disease (CKD). OBJECTIVE: To evaluate the impact of the OPTN policy change on patients supported by durable left ventricular assist devices (LVAD) with chronic kidney disease (CKD). METHODS: We performed an analysis of patients from the United Network of Organ Sharing Database supported by durable LVAD listed for a heart transplant (HT) between October 17, 2016 and September 30, 2021. Patients were divided into two groups: pre- and postpolicy, depending on whether they were listed on or prior to October 17, 2018. Patients who were on dialysis prior to surgery or discharge were excluded from the analysis. Patients with simultaneous heart and kidney transplants were excluded. Patients who were listed for transplant prepolicy change but transplanted postpolicy change were excluded. This cohort was then subdivided into degrees of CKD based on estimated glomerular filtration rate (eGFR), which resulted in 678 patients (23.7%) in Stage 1 (GFR ≥89.499) (Prepolicy: 345, Postpolicy: 333), 1233 (43.1%) in Stage 2 (89.499 > GFR ≥ 59.499) (Prepolicy: 618, Postpolicy: 615), 613 (21.4%) in Stage 3a (59.499 > GFR ≥ 44.499) (Prepolicy: 291, Postpolicy: 322), 294 (10.3%) in Stage 3b (44.499 > GFR ≥ 29.499) (Prepolicy: 143, Postpolicy: 151), 36 (1.3%) in Stage 4 (29.499 > GFR ≥ 15) (Prepolicy: 21, Postpolicy: 15), and 9 (0.3%) in Stage 5 (15 > GFR) (Prepolicy: 4, Postpolicy: 5). The primary outcome was 1-year and 2-year post-HT survival. RESULTS: There were 2863 patients who met the study criteria (1422 prepolicy, 1441 postpolicy). Overall survival, regardless of CKD stage, was lower following the policy change (p < 0.01). There was a similar risk of primary graft failure (PGF) in the pre- and postpolicy period (1.8% vs. 1.2%, p = 0.26). 1-year overall survival was 93% (91, 94) and 89% (87, 91) in the pre- and postpolicy periods, respectively. 2-year overall survival was 89% (88, 91) and 85% (82, 87) in the pre- and postpolicy periods, respectively. For CKD Stages 1, 2, 3a, 3b, 4, and 5, 1 -year survival was 93% (91, 95), 92% (90,93), 89% (86, 91), 89% (86, 93), 80% (68, 94), and 100% (100, 100), respectively. For CKD Stages 1, 2, 3a, 3b, 4, and 5, 2-year survival was 91% (88, 93), 88% (86, 90), 84% (81, 88), 84% (80, 89), 73% (59, 90), and 100% (100, 100), respectively. Patients with CKD 1 and 2 had better survival compared to those with CKD 3 (p < 0.01) and CKD 4 and 5 (p = 0.03) in the pre- and postpolicy periods. Patients with CKD 3 did not have a survival advantage over those with CKD 4 and 5 (p = 0.25). On cox regression analysis, advancing degrees of CKD were associated with an increased risk of mortality. CONCLUSIONS: Patients with LVAD support had decreased overall survival after the OPTN policy change. Patients with more advanced CKD had lower survival than patients without advanced CKD, though they were not impacted by the OPTN policy change.

Peri-operative fever and LVAD: SIRS or impaired right ventricular strain?

BACKGROUND: An inflammatory milieu after left ventricular assist device (LVAD) implantation is associated with multi-organ dysfunction and pre-operative heightened inflammatory state is associated with right ventricular failure after LVAD implantation. METHODS: We performed a retrospective analysis of 30 LVAD patients in our institution within the last 2 years for the development of fever and compared them to 30 non-LVAD open-heart surgery patients. RESULTS: Our results suggest that patients undergoing LVAD implantation are more likely to develop fever in the immediate post-operative period compared to other open-heart surgeries. This is independent of pharmacological treatment, age, or ethnical background. Females and obese patients were more likely to develop fever. CONCLUSION: Patients with right ventricular dysfunction, as demonstrated by elevated central venous pressure (CVP), had the strongest correlation with fever development. These results pose the question if there is a systemic inflammatory response-like phenomenon driven by increased right ventricular dysfunction.

Isolated Tricuspid Valve Surgery for Functional Tricuspid Regurgitation.

BACKGROUND: Severe tricuspid regurgitation (TR) adversely affects long-term survival; however, isolated tricuspid valve (TV) surgery has been rarely performed due to high operative mortality. In addition, the previous literature included heterogeneous TR etiologies. Therefore, we aimed to elucidate early and long-term outcomes of isolated TV surgery for functional TR. METHODS: An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. RESULTS: This meta-analysis included seven studies. Pooled analyses showed that 68% (35, 89) of patients had preoperative atrial fibrillation or flutter, and 58% (11, 94) had a history of left-sided valve surgery. Seventy-three percent (65, 80) of patients had at least one physical exam finding of right-sided heart failure, and 57% (44, 69) were in New York Heart Association class III or IV. TV replacement was more common than repair. In TV replacement, bioprosthetic valve (39%, 13, 74) was more common than mechanical prosthesis (22%, 18, 26). The early mortality rate was 7%. Twenty percent of patients required a permanent pacemaker postoperatively. The overall 1- and 5-year survival rates were 84.5 and 69.1%, respectively. CONCLUSION: More than half of the patients who underwent isolated TV surgery for functional TR had undergone left-sided valve surgery and had significant heart failure symptoms at the time of surgery. Further studies on the surgical indication for concomitant TV surgery at the time of left-sided valve surgery and the appropriate timing of surgery for isolated functional TR are needed to improve survival.

Hepatitis B in Heart Transplant Donors and Recipients: A Systematic Review and Meta-Analysis.

INTRODUCTION: Expanding the heart donor pool to include patients with hepatitis B virus (HBV) could help ameliorate the organ shortage in heart transplantation. We performed a systematic review and meta-analysis to evaluate the management and recipient outcomes of D+/R- and D-/R+ heart transplants. METHODS: An electronic search was performed to identify all relevant studies published on heart transplants involving HBV+ donors and/or HBV+ recipients. A comparison was performed between two groups where heart transplants were performed a) D+/R- (n = 98) versus b) D-/R+ (n = 65). RESULTS: Overall, 13 studies were selected, comprising 163 patients. Mean patient age was 55 y (95% CI: 39, 78) and 79% (69, 86) were male. Active post-transplant HBV infection requiring antiviral treatment occurred in 11% (1, 69) of D+/R- recipients and 33% (9, 71) of D-/R+ recipients. Post-transplant antiviral therapy was given to 80% (6, 100) of D+/R- recipients compared to 72% (42, 90) of D-/R+ recipients (P = 0.84). Hepatitis-related mortality was observed in no D+/R- recipients and 7% (2, 27) of D-/R+ recipients. Survival 1-y post-transplant was comparable between both groups at 83% (83, 92) and 81% (61, 92) for D+/R- and D-/R+ transplants, respectively. CONCLUSIONS: Our review found that HBV D+/R- heart transplantation was associated with fewer active hepatitis infections and lower hepatitis-related mortality than D-/R+ transplantation, with comparable survival at 1 y. Additional studies utilizing HBV nucleic acid testing (NAT) to compare outcomes with HBsAg+ and anti-HBc+ donors are crucial to reach more definitive conclusions about the risk of donor-derived infections in this context.

A proposed objective scale for extracorporeal membrane oxygenation circuit thrombosis.

Patients undergoing extracorporeal membrane oxygenation (ECMO) are susceptible to thrombosis, which is a major cause of death and morbidity. However, there is no objective ECMO thrombosis grading scale to standardize evaluation, guide treatment, and facilitate further research. In this letter, we propose an objective grading scale for ECMO circuit thrombosis based on physical characteristics and location within the circuit. This ECMO thrombosis scale will allow for protocolized escalation of ECMO thrombosis treatment, ranging from watchful observation, intensified anticoagulation, and circuit exchange.

Predicted heart mass based on ideal body weight for donor-to-recipient size matching.

BACKGROUND: Predicted heart mass (PHM) is a commonly used tool for donor-to-recipient size matching. However, incorporating body weight as part of PHM can be considered problematic given its high variability, and low metabolic nature of fat. We sought to assess whether substituting the actual donor and recipient weight with the ideal body weight (IBW) would affect the association of donor-to-recipient PHM ratio with 1-year and overall survival after heart transplantation. METHODS: The United Network for Organ Sharing (UNOS) database was queried for adult patients who received a primary heart transplant between January 2000 and September 2021. RESULTS: Both PHM and ideal PHM (IPHM) ratios were associated with one-year (PHM: p = .003; IPHM: p = .0007) and overall (PHM: p = .02; IPHM: p = .02) survival. In the continuous analysis with restricted cubic splines, both PHM (p = .0003) and IPHM (p = .00001) were associated with relative hazards of death. CONCLUSION: IPHM is significantly associated with post-transplant survival and may be a useful compliment to PHM.

Current status and future directions in the development and optimization of thoracic and abdominal artificial organs.

INTRODUCTION: Artificial organs are engineered devices with the capacity to be implanted or integrated into a living body to replace a failing organ, or to duplicate or augment one or multiple functions of the diseased organ. AREAS COVERED: We evaluate the present landscape and future possibilities of artificial organ engineering by exploring the spectrum of four distinguishable device features: mobility, compatibility, functionality, and material composition. These mechanical and functional differences provide the framework through which we examine the current status and future possibilities of the abdominal and thoracic artificial organs. EXPERT OPINION: Transforming the artificial organs landscape in ways that expand the scope of existing device capabilities and improve the clinical utility of artificial organs will require making improvements upon existing technologies and multidisciplinary cooperation to create and discover new capacities.

Impact of continuous-flow mechanical circulatory support on cerebrospinal fluid motility.

BACKGROUND: Mechanical circulatory support (MCS), including ventricular assist devices (VADs), have emerged as promising therapeutic alternatives for end-stage congestive heart failure (CHF). The latest generation of these devices are continuous flow (CF) blood pumps. While there have been demonstrated benefits to patient outcomes due to CF-MCS, there continue to be significant clinical challenges. Research to-date has concentrated on mitigating thromboembolic risk (stroke), while the downstream impact of CF-MCS on the cerebrospinal fluid (CSF) flow has not been well investigated. Disturbances in the CSF pressure and flow patterns are known to be associated with neurologic impairment and diseased states. Thus, here we seek to develop an understanding of the pathophysiologic consequences of CF-MCS on CSF dynamics. METHODS: We built and validated a computational framework using lumped parameter modeling of cardiovascular, cerebrovascular physics, CSF dynamics, and autoregulation. A sensitivity analysis was performed to confirm robustness of the modeling framework. Then, we characterized the impact of CF-MCS on the CSF and investigated cardiovascular conditions of healthy and end-stage heart failure. RESULTS: Modeling results demonstrated appropriate hemodynamics and indicated that CSF pressure depends on blood flow pulsatility more than CSF flow. An acute equilibrium between CSF production and absorption was observed in the CF-MCS case, characterized by CSF pressure remaining elevated, and CSF flow rates remaining below healthy, but higher than CHF states. CONCLUSION: This research has advanced our understanding of the impact of CF-MCS on CSF dynamics and cerebral hemodynamics.

Channel impeller design for centrifugal blood pump in hybrid pediatric total artificial heart: Modeling, magnet integration, and hydraulic experiments.

BACKGROUND: The purpose of this research is to address ongoing device shortfalls for pediatric patients by developing a novel pediatric hybrid total artificial heart (TAH). The valveless magnetically-levitated MCS device (Dragon Heart) has only two moving parts, integrates an axial and centrifugal blood pump into a single device, and will occupy a compact footprint within the chest for the pediatric patient population. METHODS: Prior work on the Dragon Heart focused on the development of pump designs to achieve hemodynamic requirements. The impeller of these pumps was shaft-driven and thus could not be integrated for testing. The presented research leverages an existing magnetically levitated axial flow pump and focuses on centrifugal pump development. Using the axial pump diameter as a geometric constraint, a shaftless, magnetically supported centrifugal pump was designed for placement circumferentially around the axial pump domain. The new design process included the computational analysis of more than 50 potential centrifugal impeller geometries. The resulting centrifugal pump designs were prototyped and tested for levitation and no-load rotation, followed by in vitro testing using a blood analog. To meet physiologic demands, target performance goals were pressure rises exceeding 90 mm Hg for flow rates of 1-5 L/min with operating speeds of less than 5000 RPM. RESULTS: Three puck-shaped, channel impellers for the centrifugal blood pump were selected based on achieving performance and space requirements for magnetic integration. A quasi-steady flow analysis revealed that the impeller rotational position led to a pulsatile component in the pressure generation. After prototyping, the centrifugal prototypes (3, 4, and 5 channeled designs) demonstrated levitation and no-load rotation. Hydraulic experiments established pressure generation capabilities beyond target requirements. The pressure-flow performance of the prototypes followed expected trends with a dependence on rotational speed. Pulsatile blood flow was observed without pump-speed modulation due to rotating channel passage frequency. CONCLUSION: The results are promising in the advancement of this pediatric TAH. The channeled impeller design creates pressure-flow curves that are decoupled from the flow rate, a benefit that could reduce the required controller inputs and improve treatment of hypertensive patients.

Continuous-flow left ventricular assist devices associated survival awaiting heart and heart-kidney transplant.

BACKGROUND: Improvement in continuous-flow left ventricular assist device (CF-LVAD) technology has translated to better outcomes for patients on CF-LVAD support as a bridge-to-transplant. However, data are lacking regarding the subset of CF-LVAD patients with renal failure awaiting simultaneous heart-kidney transplant (HKTx). We sought to better understand the characteristics and outcomes of patients in this group. METHODS: The United Network for Organ Sharing (UNOS) database was used to identify adult patients listed for heart transplant (HTx) or HKTx from January 1, 2009 to March 31, 2017. Patients were followed from time on waitlist to either removal from waitlist or transplantation. Demographic and clinical data for HTx and HKTx patients were assessed. Kaplan-Meier analysis assessed waitlist and post-transplant survival. For waitlisted patients, both death and removal from the waitlist due to deteriorating medical condition were considered events. RESULTS: Overall, 26 638 patients registered for transplant were analyzed. 25 111 (94%) were listed for HTx, and 1527 (6%) for HKTx. 7683 (29%) patients listed for HTx had CF-LVAD support. For those listed for HKTx, 441 (28%) underwent dialysis alone, 256 (17%) had CF-LVAD support alone, and 85 (6%) were treated with both CF-LVAD and dialysis. 15 567 (58%) underwent HTx, and 621 (2%) underwent HKTx. In these groups, post-transplant survival was similar (p = 0.06). Patients listed for HKTx treated with both dialysis and CF-LVAD had significantly worse waitlist survival compared to HKTx recipients (p < 0.001). CONCLUSION: Post-transplant survival is comparable between HTx and HKTx, and early survival is similar between HTx patients and those listed for HTx with CF-LVAD support. However, outcomes on the waitlist for HKTx in CF-LVAD patients on dialysis is significantly worse compared to HKTx recipients. This highlights the need to better account for this patient population when allocating organs.

PCI for acute myocardial infarction in patients with a pre-existing LVAD, does it improve survival?

BACKGROUND: It is well established that percutaneous coronary intervention (PCI) is a life-saving procedure for acute myocardial infarction (AMI) in the general population and is guideline-recommended for both STEMI and NSTEMI. There is little literature regarding its use in patients with a pre-implanted Left Ventricular Assist Device (LVAD). METHODS: We retrospectively analyzed data from the National Inpatient Sample (NIS) Database to select all US adult patients (>18 years) with an LVAD diagnosed with an AMI divided into two groups; those who received PCI during the hospitalization and those who did not. RESULTS: A total of 3722 LVAD patients with AMI were identified, of these 17% of patients received PCI and 83% did not. After propensity matching of LVAD patients with AMI, there were 626 patients who received PCI and 623 who did not. Of patients receiving PCI, 37.5% had a STEMI while 29.7% of patients who did not receive PCI had STEMI. Rates of kidney injury (36.5% vs. 43.3%, OR 0.75, 95% CI 0.60-0.94, p = 0.016), sepsis (3.2% vs. 11.4%, OR 0.26, 95% CI 0.15-0.43, p < 0.001), cardiogenic shock (44.1% vs. 50.4%, OR 0.78, 95% CI 0.62-0.97, p = 0.03) and mortality (17.4% vs. 28.9%, OR 0.52, 95% CI 0.40-0.68, p < 0.001) were all better for patients receiving PCI. Vascular complications (1.4% vs. 0%, p = 0.008) and intracerebral hemorrhage (ICH) (1.6% vs. 0, p = 0.004) were both more common in the group receiving PCI. CONCLUSIONS: In this study, patients supported by LVAD with AMI had an elevated risk of mortality compared to generally accepted mortality rates of patients without LVAD. In this analysis PCI was associated with a decreased risk of mortality, cardiogenic shock, and kidney injury while increasing the risk for vascular complications and intracranial hemorrhage.

Utilization and outcomes of V-AV ECMO: A systematic review and meta-analysis.

BACKGROUND: Veno-arterial-venous extracorporeal membrane oxygenation (V-AV ECMO) is a less commonly used configuration of ECMO. We sought to understand the indications, utilization patterns, and outcomes of V-AV ECMO by quantitatively pooling the existing evidence from the literature. METHODS: Electronic search was performed to identify all relevant studies reporting V-AV ECMO usage. Five studies comprising 77 patients were selected and cohort-level data were extracted for further analysis. RESULTS: Mean patient age was 61 (95% CI: 55.2, 66.5) years and 30% (23/77) were female. The majority of cases [91% (70/77)] were transitioned to V-AV ECMO from another pre-existing ECMO configuration: V-A ECMO in 55% (42/77) vs. V-V ECMO in 36% (28/77), p = 0.04. Only 9% (7/77) of cases were directly placed on V-AV ECMO. The mean duration of hospital stay was 42.3 (95% CI: 10.5, 74.2) days, while ICU mortality was 46% (29, 64). Transition to durable left ventricular assist device was performed in 3% (2/64) of patients, while 3% (2/64) underwent heart transplantation. V-AV ECMO was successfully weaned to explantation in 33% (21/64) of patients. CONCLUSION: V-AV ECMO is a viable option for optimizing cardiopulmonary support in selected patients. Survival to weaning or bridging therapy appears comparable to more common ECMO configurations.

Microaxial circulatory support for percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: Microaxial circulatory support devices have been used to support patients treated with percutaneous coronary intervention (PCI) for acute myocardial infarction complicated by cardiogenic shock (AMICS). The purpose of this systematic review and meta-analysis was to pool and analyze the existing evidence on the baseline characteristics, periprocedural data, and outcomes of microaxial support before and after PCI in AMICS. METHODS: An electronic database search was performed to identify all cohort studies on Impella and PCI for cardiogenic shock in the English language. A total of five articles comprising 543 patients were included. These patients received microaxial support either before (pre-PCI) or after (post-PCI) undergoing PCI. Comparative analyses were done between both groups. RESULTS: The mean patient age was 66 years [95% Confidence Interval (58-74)], and 22% (89/396) of patients were female. ST-elevation myocardial infarctions (MI) comprised 64% (44-80) of MIs and 50% (44-56) of MIs involved the left anterior descending artery. The mean number of diseased vessels was 2.21 (1.62-2.80). The mean left ventricular ejection fraction was 31% (23.4-38.6). The mean arterial pressure was 66.3 mm Hg (54.1-78.5). Mean serum lactate [6.1 mmol/L (3.3-8.9)] and serum creatinine [1.4 mg/dl (1.0-1.7)] were similar between groups. 30-day mortality was lower in the pre-PCI group [41% (34%-49%)] compared to the post-PCI group [61% (42%-77%), p < 0.01]. Pooled Kaplan-Meier analysis showed better early survival in the pre-PCI group (p < 0.001). CONCLUSION: Patients presenting with AMICS were similar at baseline in both pre-PCI and post-PCI groups. Nevertheless, pre-PCI group showed better early survival compared to post-PCI group.

Utility of Recipient Cardiothoracic Ratio in Predicting Delayed Chest Closure after Heart Transplantation.

BACKGROUND: Predicted cardiac mass (PCM) has been well validated for size matching donor hearts to heart transplantation recipients. We hypothesized that cardiothoracic ratio (CTR) could be reflective of recipient-specific limits of oversizing, and sought to determine the utility of donor to recipient PCM ratio (PCMR) and CTR in predicting delayed chest closure after heart transplantation. METHODS: A retrospective review of prospectively collected data on 38 consecutive heart transplantations performed at our institution from 2017 to 2020 was performed. Donor and recipient PCM were estimated using Multi-Ethnic Study of Atherosclerosis predictive models. Receiver operating characteristic analysis was performed to determine the discriminatory power of the ratio of PCMR to CTR in predicting delayed sternal closure. RESULTS: Of the 38 patients, 71.1% (27/38) were male and the median age at transplantation was 58 (interquartile range [IQR]: 47-62) years. Ischemic cardiomyopathy was present in 31.6% of recipients (12/38). Median recipient CTR was 0.63 [IQR: 0.59-0.66]. Median donor to recipient PCMR was 1.07 [IQR: 0.96-1.19], which indicated 7% oversizing. Thirteen out of 38 (34.2%) underwent delayed sternal closure. Primary graft dysfunction occurred in 15.8% (6/38). PCMR/CTR showed good discriminatory power in predicting delayed sternal closure [area under the curve: 80.4% (65.3-95.6%)]. PCMR/CTR cut-off of 1.7 offered the best trade-off between the sensitivity (69.6%) and specificity (91.7%). CONCLUSION: CTR could be helpful in guiding the recipient-specific extent of oversizing donor hearts. Maintaining the ratio of PCMR to CTR below 1.7 could avoid excessive oversizing of the donor heart.

Association of Heart Transplant Volume with Presence of Lung Transplant Programs and Heart Transplant's SRTR One-year Survival Rating.

BACKGROUND: Several factors affect heart transplant (HTx) and lung transplant (LTx) program outcomes. Variabilities in institutional and community characteristics have been shown to influence survival. At present, half of HTx centers in the United States do not possess a concomitant LTx program. This study sought to better understand the characteristics of HTx with and without LTx programs. METHODS: Nationwide transplant data were collected from the Scientific Registry of Transplant Recipients (SRTR) in August 2020. SRTR star rating ranges from tier 1 (lowest) to tier 5 (highest). HTx volumes and SRTR star ratings for survival were compared between the centers with heart-only (H0) programs and the centers with heart-lung (HL) programs. RESULTS: SRTR star ratings were available for 117 transplant centers with one or more HTx reported. The median number of HTx performed over 1 year was 16 (interquartile range [IQR]: 2-29). The number of HL centers (n = 67, 57.3%) were comparable to H0 centers (n = 50, 42.7%; p = 0.14). The HTx volume at the HL centers (28 [IQR: 17-41]) exceeded the HTx volume at the H0 centers (13 [IQR: 9-23]; p < 0.01), but were comparable to the LTx volume at the HL centers (31 [IQR: 16-46]; p = 0.25). The median HTx one-year survival rating was 3 (IQR: 2-4) at both the H0 and HL centers (p = 0.85). The HTx and LTx volumes were positively associated with the respective 1-year survivals (p < 0.01). CONCLUSION: While the presence of an LTx program is not directly associated with HTx survival, it has a positive association with the HTx volume. The HTx and LTx volumes are positively associated with the 1-year survival.

Evaluation of donor heart for transplantation.

Cardiac transplantation is considered the gold-standard treatment option for patients suffering from end-stage heart failure refractory to maximum medical therapy. A major determinant of graft function and recipient survival is a comprehensive evaluation of the donor allograft. Challenges arise when designing and implementing an evidence-based donor evaluation protocol due to the number of influential donor-specific characteristics and the complex interactions that occur between them. Here, we present our systematic approach to donor evaluation by examining the impact that relevant donor variables have on graft function and recipient outcomes.

Outcomes of percutaneous temporary biventricular mechanical support: a systematic review.

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

Assessing donor-recipient size metrics for heart transplant outcomes: UNOS database analysis.

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