Graft function and incidence of cardiac allograft vasculopathy in donation after circulatory-determined death heart transplant recipients.

Experience in donation after circulatory-determined death (DCD) heart transplantation (HTx) is expanding. There is limited information on the functional outcomes of DCD HTx recipients. We sought to evaluate functional outcomes in our cohort of DCD recipients. We performed a single-center, retrospective, observational cohort study comparing outcomes in consecutive DCD and donation after brain death (DBD) HTx recipients between 2015 and 2019. Primary outcome was allograft function by echocardiography at 12 and 24 months. Secondary outcomes included incidence of cardiac allograft vasculopathy, treated rejection, renal function, and survival. Seventy-seven DCD and 153 DBD recipients were included. There was no difference in left ventricular ejection fraction at 12 months (59% vs 59%, P = .57) and 24 months (58% vs 58%, P = .87). There was no significant difference in right ventricular function at 12 and 24 months. Unadjusted survival between DCD and DBD recipients at 5 years (85.7% DCD and 81% DBD recipients; P = .45) was similar. There were no significant differences in incidence of cardiac allograft vasculopathy (odds ratio 1.59, P = .21, 95% confidence interval 0.77-3.3) or treated rejection (odds ratio 0.60, P = .12, 95% confidence interval 0.32-1.15) between DBD and DCD recipients. Post-transplant renal function was similar at 1 and 2 years. In conclusion, cardiac allografts from DCD donors perform similarly to a contemporary population of DBD allografts in the medium term.

Comparing Cardiac Mechanics and Myocardial Fibrosis in DBD and DCD Heart Transplant Recipients.

BACKGROUND: Heart transplantation (HTx) after donation after circulatory death (DCD) is an expanding practice but is associated with increased warm ischemic time. The impact of DCD HTx on cardiac mechanics and myocardial fibrosis has not been reported. We aimed to compare cardiac mechanics and myocardial fibrosis using cardiovascular magnetic resonance (CMR) imaging in donation after brain death (DBD) and DCD HTx recipients and healthy controls. METHODS AND RESULTS: Consecutive HTx recipients between March 2015 and March 2021 who underwent routine surveillance CMR imaging were included. Cardiac mechanics were assessed using CMR feature tracking to compute global longitudinal strain, global circumferential strain, and right ventricular free-wall longitudinal myocardial strain. Fibrosis was assessed using late gadolinium enhancement imaging and estimation of extracellular volume. There were 82 (DBD n = 42, DCD n = 40) HTx recipients (aged 53 years, interquartile range 41-59 years, 24% female) who underwent CMR imaging at median of 9 months (interquartile range 6-14 months) after transplantation. HTx recipients had increased extracellular volume (29.7 ± 3.6%) compared with normal ranges (25.9%, interquartile range 25.4-26.5). Myocardial strain was impaired after transplantation compared with controls (global longitudinal strain -12.6 ± 3.1% vs -17.2 ± 1.8%, P < .0001; global circumferential strain -16.9 ± 3.1% vs -19.2 ± 2.0%, P = .002; right ventricular free-wall longitudinal strain -15.7 ± 4.5% vs -21.6 ± 4.7%, P < .0001). There were no differences in fibrosis burden (extracellular volume 30.6 ± 4.4% vs 29.2 ± 3.2%; P = .39) or cardiac mechanics (global longitudinal strain -13.1 ± 3.0% vs -12.1 ± 3.1%, P = .14; global circumferential strain -17.3 ± 2.9% vs -16.6 ± 3.1%, P = .27; right ventricular free-wall longitudinal strain -15.9 ± 4.9% vs -15.5 ± 4.1%, P = .71) between DCD and DBD HTx. CONCLUSIONS: HTx recipients have impaired cardiac mechanics compared with controls, with increased myocardial fibrosis. There were no differences in early CMR imaging characteristics between DBD and DCD heart transplants, providing further evidence that DCD and DBD HTx outcomes are comparable.

Coronary imaging of cardiac allograft vasculopathy predicts current and future deterioration of left ventricular function in patients with orthotopic heart transplantation.

BACKGROUND: Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) improve sensitivity of cardiac allograft vasculopathy (CAV) detection compared to invasive coronary angiography (ICA), but their ability to predict clinical events is unknown. We determined whether severe CAV detected with ICA, IVUS, or OCT correlates with graft function. METHODS: Comparison of specific vessel parameters between IVUS and OCT on 20 patients attending for angiography 12-24 months post-orthotopic heart transplant. Serial left ventricular ejection fraction (EF) was recorded prospectively. RESULTS: Analyzing 55 coronary arteries, OCT and IVUS correlated well for vessel CAV characteristics. A mean intimal thickness (MIT)OCT  > .25 mm had a sensitivity of 86.7% and specificity of 74.3% at detecting Stanford grade 4 CAV. Those with angiographically evident CAV had significant reduction in graft EF over 7.3 years follow-up (median ΔEF -2% vs +1.5%, P = .03). Patients with MITOCT  > .25 mm in at least one vessel had a lower median EF at time of surveillance (57% vs 62%, P = .014). Two MACEs were noted. CONCLUSION: Imaging with OCT correlates well with IVUS for CAV detection. Combined angiography and OCT to screen for CAV within 12-24 months of transplant predicts concurrent and future deterioration in graft function.

Size matching in heart transplantation: Is predicted heart mass the optimal method in a United Kingdom cohort?

Predicted heart mass (PHM) equations have been proposed as an alternative method for size matching in heart transplantation. We assessed association between donor-recipient size mismatch, defined using PHM equations, and survival post-heart transplant in the United Kingdom. Data from all adult patients who received a heart transplant between 1995 and 2017 were obtained from the United Kingdom Transplant Registry. PHM was calculated using published equations. Primary outcome was 1-year survival post-heart transplantation. Recipients of undersized organs had reduced 1-year survival (HR 1.31, 95% CI 1.03-1.67, p = .03). Oversizing had no impact on survival (HR 0.99, 95% CI 0.78-1.26, p = .96). Gender mismatching had no impact on survival in the cohort matched by PHM (HR 1.12, 95% CI 0.86-1.47, p = .4). In recipients without pulmonary hypertension, undersizing by PHM had no impact on 1-year survival (HR 0.95, 95% CI 0.61-1.49, p = .83). In recipients with pulmonary hypertension, oversizing donor RV by using PHM RV equation (PHMRV ) results in improved survival at 1 year (HR 0.65, 95% CI 0.5-0.83, p = .001). In conclusion, receiving an organ undersized by PHM was associated with decreased 1-year survival. Subgroup analyses demonstrated that undersizing only impacted survival in recipients with pulmonary hypertension and that these recipients had improved outcomes if they received an organ with an RV oversized by >10% by PHMRV .

Insaka: mobile phone support groups for adolescent pregnant women living with HIV.

BACKGROUND: Mobile phone-based interventions have been demonstrated in different settings to overcome barriers to accessing critical psychosocial support. In this study, we aimed to assess the acceptability and feasibility of a phone-based, peer-to-peer support group intervention for adolescent pregnant women aged 15-24 years living with HIV in Zambia. METHODS: Sixty-one consenting participants were recruited from Antenatal Clinics of two large urban communities in Lusaka. They were invited to participate in the mobile phone-based intervention that allowed them to anonymously communicate in a small group led by a facilitator for 4 months. A mixed methods approach was used to assess acceptability and feasibility, including a focus group discussion, pre- and post-intervention interview and analysis of the content of the text message data generated. RESULTS: Participants reported finding the platform "not hard to use" and enjoyed the anonymity of the groups. Seventy-one percent of participants (n = 43) participated in the groups, meaning they sent text messages to their groups. Approximately 12,000 text messages were sent by participants (an average of 169 messages/user and 6 mentors in 6 groups. Topics discussed were related to social support and relationships, stigma, HIV knowledge and medication adherence. CONCLUSION: The study showed that the intervention was acceptable and feasible, and highlighted the potential of the model for overcoming existing barriers to provision of psychosocial support to this population.

Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes. DESIGN: A retrospective case series. SETTING: A tertiary referral cardiothoracic transplantation center. PARTICIPANTS AND INTERVENTIONS: Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central). MEASUREMENTS AND MAIN RESULTS: All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%. CONCLUSIONS: The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.

Provision of magnetic resonance imaging for patients with 'MR-conditional' cardiac implantable electronic devices: an unmet clinical need.

AIMS: Increasing need for magnetic resonance imaging (MRI) has driven the development of MR-conditional cardiac implantable electronic devices (CIEDs; pacemakers and defibrillators); however, patients still report difficulties obtaining scans. We sought to establish current provision for MRI scanning of patients with CIEDs in England. METHODS AND RESULTS: A survey was distributed to all hospitals in England with MRI, to assess current practice. Information requested included whether hospitals currently offer MRI to this patient group, the number and type of scans acquired, local safety considerations, complications experienced and perceived obstacles to service provision in those departments not currently offering it. Responses were received from 195 of 227 (86%) of hospitals surveyed. Although 98% of departments were aware of MR-conditional devices, only 46% (n = 89) currently offer MRI scans to patients with CIED's; of these, 85% of departments perform ≤10 scans per year. No major complications were reported from MRI scanning in patients with MR-conditional devices. Current barriers to service expansion include perceived concerns regarding potential risk, lack of training, logistical difficulties, and lack of cardiology support. CONCLUSION: Provision of MRI for patients with CIEDs is currently poor, despite increasing numbers of patients with MR-conditional devices and extremely low reported complication rates.

Glucagon-like peptide-1 protects against ischemic left ventricular dysfunction during hyperglycemia in patients with coronary artery disease and type 2 diabetes mellitus.

BACKGROUND: Enhancement of myocardial glucose uptake may reduce fatty acid oxidation and improve tolerance to ischemia. Hyperglycemia, in association with hyperinsulinemia, stimulates this metabolic change but may have deleterious effects on left ventricular (LV) function. The incretin hormone, glucagon-like peptide-1 (GLP-1), also has favorable cardiovascular effects, and has emerged as an alternative method of altering myocardial substrate utilization. In patients with coronary artery disease (CAD), we investigated: (1) the effect of a hyperinsulinemic hyperglycemic clamp (HHC) on myocardial performance during dobutamine stress echocardiography (DSE), and (2) whether an infusion of GLP-1(7-36) at the time of HHC protects against ischemic LV dysfunction during DSE in patients with type 2 diabetes mellitus (T2DM). METHODS: In study 1, twelve patients underwent two DSEs with tissue Doppler imaging (TDI)-one during the steady-state phase of a HHC. In study 2, ten patients with T2DM underwent two DSEs with TDI during the steady-state phase of a HHC. GLP-1(7-36) was infused intravenously at 1.2 pmol/kg/min during one of the scans. In both studies, global LV function was assessed by ejection fraction and mitral annular systolic velocity, and regional wall LV function was assessed using peak systolic velocity, strain and strain rate from 12 paired non-apical segments. RESULTS: In study 1, the HHC (compared with control) increased glucose (13.0 ± 1.9 versus 4.8 ± 0.5 mmol/l, p < 0.0001) and insulin (1,212 ± 514 versus 114 ± 47 pmol/l, p = 0.01) concentrations, and reduced FFA levels (249 ± 175 versus 1,001 ± 333 µmol/l, p < 0.0001), but had no net effect on either global or regional LV function. In study 2, GLP-1 enhanced both global (ejection fraction, 77.5 ± 5.0 versus 71.3 ± 4.3%, p = 0.004) and regional (peak systolic strain -18.1 ± 6.6 versus -15.5 ± 5.4%, p < 0.0001) myocardial performance at peak stress and at 30 min recovery. These effects were predominantly driven by a reduction in contractile dysfunction in regions subject to demand ischemia. CONCLUSIONS: In patients with CAD, hyperinsulinemic hyperglycemia has a neutral effect on LV function during DSE. However, GLP-1 at the time of hyperglycemia improves myocardial tolerance to demand ischemia in patients with T2DM. TRIAL REGISTRATION: http://www.isrctn.org . Unique identifier ISRCTN69686930.

Utility of speckle tracking echocardiography to characterize dysfunctional myocardium in patients with ischemic cardiomyopathy referred for cardiac resynchronization therapy.

BACKGROUND: Assessment of transmural scar at the site of latest mechanical activation is relevant to maximize outcomes in cardiac resynchronization therapy (CRT). Few studies have assessed the ability of speckle tracking echocardiography (STE)-derived short-axis strain to identify segmental myocardial scar, defined by contrast-enhanced cardiac magnetic resonance imaging (CMR), in patients referred for CRT. METHODS: A total of 26 patients with ischemic cardiomyopathy who underwent preprocedure echocardiography and CMR were studied. Extent of transmural scar was assessed using contrast-enhanced CMR and corresponding peak segmental radial and circumferential strains were derived using two-dimensional (2D) STE. Total left ventricle (LV) scar volume was compared with parameters of global strain. CRT response was defined as >15% reduction in LV end systolic volume (LVESV) at 6 months. RESULTS: Speckle tracking short-axis strain analysis was technically possible in over 90% of LV segments. Applying a segmental radial strain cutoff value of 10% distinguished segments with >50% scar area with a high negative predictive value (98%). Global longitudinal strain <-5% predicted CRT response. CONCLUSIONS: Two-dimensional STE offers potential to characterize dysfunctional myocardium and define segmental scar offering an integrated imaging approach to guide LV lead placement for CRT.

Digital Intervention to Improve Health Services for Young People in Zimbabwe: Process Evaluation of 'Zvatinoda!' (What We Want) Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Framework.

BACKGROUND: Youth in Southern Africa face a high burden of HIV and sexually transmitted infections, yet they exhibit low uptake of health care services. OBJECTIVE: The Zvatinoda! intervention, co-designed with youth, aims to increase the demand for and utilization of health services among 18-24-year-olds in Chitungwiza, Zimbabwe. METHODS: The intervention utilized mobile phone-based discussion groups, complemented by "ask the expert" sessions. Peer facilitators, supported by an "Auntie," led youth in anonymous online chats on health topics prioritized by the participants. Feedback on youth needs was compiled and shared with health care providers. The intervention was tested in a 12-week feasibility study involving 4 groups of 7 youth each, totaling 28 participants (n=14, 50%, female participants), to evaluate feasibility and acceptability. Mixed methods process evaluation data included pre- and postintervention questionnaires (n=28), in-depth interviews with participants (n=15) and peer facilitators (n=4), content from discussion group chats and expert guest sessions (n=24), facilitators' debrief meetings (n=12), and a log of technical challenges. Descriptive quantitative analysis and thematic qualitative analysis were conducted. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was adapted to analyze and present findings on (1) reach, (2) potential efficacy, (3) adoption, (4) implementation, and (5) maintenance. RESULTS: Mobile delivery facilitated engagement with diverse groups, even during COVID-19 lockdowns (reach). Health knowledge scores improved from pre- to postintervention across 9 measures. Preintervention scores varied from 14% (4/28) for contraception to 86% (24/28) for HIV knowledge. After the intervention, all knowledge scores reached 100% (28/28). Improvements were observed across 10 sexual and reproductive health (SRH) self-efficacy measures. The most notable changes were in the ability to start a conversation about SRH with older adults in the family, which increased from 50% (14/28) preintervention to 86% (24/28) postintervention. Similarly, the ability to use SRH services even if a partner does not agree rose from 57% (16/28) preintervention to 89% (25/28) postintervention. Self-reported attendance at a health center in the past 3 months improved from 32% (9/28) preintervention to 86% (24/28) postintervention (potential efficacy). Chat participation varied, largely due to network challenges and school/work commitments. The key factors facilitating peer learning were interaction with other youth, the support of an older, knowledgeable "Auntie," and the anonymity of the platform. As a result of COVID-19 restrictions, regular feedback to providers was not feasible. Instead, youth conveyed their needs to stakeholders through summaries of key themes from chat groups and a music video presented at a final in-person workshop (adoption and implementation). Participation in discussions decreased over time. To maintain engagement, introducing an in-person element was suggested (maintenance). CONCLUSIONS: The Zvatinoda! intervention proved both acceptable and feasible, showing promise for enhancing young people's knowledge and health-seeking behavior. Potential improvements include introducing in-person discussions once the virtual group has established rapport and enhancing feedback and dialog with service providers.

Computed tomography pericoronary adipose tissue density predicts coronary allograft vasculopathy and adverse clinical outcomes after cardiac transplantation.

AIMS: To assess pericoronary adipose tissue (PCAT) density on coronary computed tomography angiography (CCTA) as a marker of inflammatory disease activity in coronary allograft vasculopathy (CAV). METHODS AND RESULTS: PCAT density, lesion volumes, and total vessel volume-to-myocardial mass ratio (V/M) were retrospectively measured in 126 CCTAs from 94 heart transplant patients [mean age 49 (SD 14.5) years, 40% female] who underwent imaging between 2010 and 2021; age- and sex-matched controls; and patients with atherosclerosis. PCAT density was higher in transplant patients with CAV [n = 40; -73.0 HU (SD 9.3)] than without CAV [n = 86; -77.9 HU (SD 8.2)], and controls [n = 12; -86.2 HU (SD 5.4)], P < 0.01 for both. Unlike patients with atherosclerotic coronary artery disease (n = 32), CAV lesions were predominantly non-calcified and comprised of mostly fibrous or fibrofatty tissue. V/M was lower in patients with CAV than without [32.4 mm3/g (SD 9.7) vs. 41.4 mm3/g (SD 12.3), P < 0.0001]. PCAT density and V/M improved the ability to predict CAV from area under the receiver operating characteristic curve (AUC) 0.75-0.85 when added to donor age and donor hypertension status (P < 0.0001). PCAT density above -66 HU was associated with a greater incidence of all-cause mortality {odds ratio [OR] 18.0 [95% confidence interval (CI) 3.25-99.6], P < 0.01} and the composite endpoint of death, CAV progression, acute rejection, and coronary revascularization [OR 7.47 (95% CI 1.8-31.6), P = 0.01] over 5.3 (SD 2.1) years. CONCLUSION: Heart transplant patients with CAV have higher PCAT density and lower V/M than those without. Increased PCAT density is associated with adverse clinical outcomes. These CCTA metrics could be useful for the diagnosis and monitoring of CAV severity.

Surgical intervention for left ventricular assist device outflow graft obstruction due to external compression.

Left ventricular assist device outflow graft obstruction is an uncommon but serious complication. The causes of left ventricular assist device outflow graft obstruction include thrombus, outflow graft kink or torsion and external compression. The HeartMate 3 left ventricular assist device was reported to have a low risk of thromboembolic events. However, the deposition of bio-debris between the semi-permeable left ventricular assist device outflow graft and the impermeable bend relief has been increasingly recognized as a cause of external compression. The potential treatment options include percutaneous insertion of a stent, surgical removal of the bio-debris, change of left ventricular assist device, and an urgent heart transplant. We report a case of left ventricular assist device outflow graft compression successfully treated by removal of the bio-debris via a subxiphoid approach.

Prognostic value of three iron deficiency definitions in patients with advanced heart failure.

AIMS: There is uncertainty about the definition of iron deficiency (ID) and the association between ID and prognosis in patients with advanced heart failure. We evaluated three definitions of ID in patients referred for heart transplantation. METHODS AND RESULTS: Consecutive patients assessed for heart transplantation at a single UK centre between January 2010 and May 2022 were included. ID was defined as (1) serum ferritin concentration of <100 ng/ml, or 100-299 ng/ml with transferrin saturation <20% (guideline definition), (2) serum iron concentration ≤13 µmol/L, or (3) transferrin saturation <20%. The primary outcome measure was a composite of all-cause mortality, urgent heart transplantation or need for mechanical circulatory support. Overall, 801 patients were included, and the prevalence of ID was 39-55% depending on the definition used. ID, defined by either serum iron or transferrin saturation, was an independent predictor of the primary outcome measure (hazard ratio [HR] 1.532, 95% confidence interval [CI] 1.264-1.944, and HR 1.595, 95% CI 1.323-2.033, respectively), but the same association was not seen with the guideline definition of ID (HR 1.085, 95% CI 0.8827-1.333). These findings were robust in multivariable Cox regression analysis. ID, by all definitions, was associated with lower 6-min walk distance, lower peak oxygen consumption, higher intra-cardiac filling pressures and lower cardiac output. CONCLUSIONS: Iron deficiency, when defined by serum iron concentration or transferrin saturation, was associated with increased frequency of adverse clinical outcomes in patients with advanced heart failure. The same association was not seen with guideline definition of ID.

Exploring the impact of a complex intervention for women with depression in contexts of adversity: A pilot feasibility study of COURRAGE-plus in South Africa.

BACKGROUND: Depression is a leading cause of disease burden worldwide but is often undertreated in low- and middle-income countries. Reasons behind the treatment gap vary, but many highlight a lack of interventions which speak to the socio-economic and structural realties that are associated to mental health problems in many settings, including South Africa. The COURRAGE-PLUS intervention responds to this gap, by combining a collective narrative therapy (9 weeks) intervention, with a social intervention promoting group-led practical action against structural determinants of poor mental health (4 weeks), for a total of 13 sessions. The overall aim is to promote mental health, while empowering communities to acknowledge, and respond in locally meaningful ways to social adversity linked to development of mental distress. AIM: To pilot and evaluate the effectiveness of a complex intervention - COURRAGE-PLUS on symptoms of depression as assessed by the Patient Health Questionnaire (PHQ-9) among a sample of women facing contexts of adversity in Gauteng, South Africa. METHODS: PHQ-9 scores were assessed at baseline, post collective narrative therapy (midline), and post social intervention (endline). Median scores and corresponding interquartile ranges were computed for all time points. Differences in scores between time points were tested with a non-parametric Friedman test. The impact across symptom severities was compared descriptively to identify potential differences in impact across categories of symptom severity within our sample. RESULTS: Participants' (n = 47) median depression score at baseline was 11 (IQR = 7) and reduced to 4 at midline (IQR = 7) to 0 at endline (IQR = 2.5). The Friedman test showed a statistically significant difference between depression scores across time points, χ2(2) = 49.29, p < .001. Median depression scores were reduced to 0 or 1 Post-Intervention across all four severity groups. CONCLUSIONS: COURRAGE-PLUS was highly effective at reducing symptoms of depression across the spectrum of severities in this sample of women facing adversity, in Gauteng, South Africa. Findings supports the need for larger trials to investigate collective narrative storytelling and social interventions as community-based interventions for populations experiencing adversity and mental distress.

Supporting community-based mental health initiatives: insights from a multi-country programme and recommendations for funders.

Community-based mental health initiatives are uniquely positioned to understand the mental health needs of their local population and provide relevant, culturally appropriate and sustainable responses. However, at the grassroots level, mental health initiatives in low- and middle-income countries face key challenges, such as inadequate funding, barriers to demonstrating impact and difficulty engaging with stakeholders. The Ember Mental Health programme establishes 12-month partnerships with community-based mental health initiatives in low- and middle-income countries to support them to address these challenges, grow and achieve sustainability. This paper outlines a longitudinal qualitative study conducted to evaluate the 2020-2021 Ember Mental Health programme. Data were collected from March 2020 to March 2021 through semistructured interviews conducted with 11 initiatives at various time points throughout their Ember Mental Health partnership. A framework approach was used to analyse all data in its original language. Findings indicated that initiatives particularly benefited from provision of side-by-side mentorship; opportunities for skills strengthening and strategic thinking; occasions to network with other like-minded initiatives and/or experts in global mental health; and support on team empowerment and well-being. Based on these findings, we put forward various recommendations for funders and other stakeholders working to support community-based mental health initiatives in low- and middle-income countries. Through establishing collaborative partnerships that challenge more top-down, traditional funder-grantee relationships, it is possible to support the rich ecosystem of initiatives working to address the mental health needs of communities.

Khuluma: Using Participatory, Peer-Led and Digital Methods to Deliver Psychosocial Support to Young People Living With HIV in South Africa.

Khuluma is a psychosocial and peer-to-peer mHealth intervention that uses text messaging to facilitate support groups for adolescents living with HIV (ALWH) with the aim of contributing toward positive health outcomes. Although use of mobile technology in the form of mHealth interventions has proliferated recently in the field of health, published literature describing methods and processes of its application are limited. We present a set of methods and processes utilised to develop and pilot the Khuluma mHealth intervention amongst young people (15-20 years) in South Africa. We recruited and enrolled 52 adolescents (15-20-year olds) from four clinics in Pretoria and Cape Town to participate in a 6-month pilot of Khuluma. Participants were ALWH, aware of their status, on antiretroviral therapy for more than 12 months, and not suffering from severe depression. We conducted four pre and post intervention focus group discussions (FGDs) with a proportion of ALWH (n = 36) enrolled in the pilot study using participatory methods. Several processes were utilised to then implement this pilot study. These included engaging ALWH for minor study implementation modifications; forming virtual groups; activating the mHealth platform; facilitating and delivering the Khuluma intervention. The acceptability of the intervention was informed by follow-up focus group discussions and text message data. The initial participatory processes helped to tailor the intervention design to participants' needs. The peer-led facilitation of the groups allowed for the provision of sensitive psychosocial support that allowed young people to express themselves freely, develop a sense of self-worth, and interact more. The nature of the mobile technology also allowed participants to build friendships beyond their geographic area and interact with their peers in real time. Within the evolving context of COVID-19, establishing evidence-based processes and methods for intervention design and curation in virtual spaces is critical.

Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes.

BACKGROUND: Vasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx. METHODS: Patients undergoing LVAD explant followed by HTx from 01/2013-12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 µg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database. RESULTS: During the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 vs. 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% vs. 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% vs. 100% P=0.99) and 1-year (67.7% vs. 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period. CONCLUSIONS: Vasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.

A 5-year single-center early experience of heart transplantation from donation after circulatory-determined death donors.

BACKGROUND: In an effort to address the increasing demand for heart transplantation within the United Kingdom (UK), we established a clinical program of heart transplantation from donation after circulatory-determined death (DCD) donors in 2015. After 5 years, we report the clinical early outcomes and impact of the program. METHODS: This is a single-center, retrospective, matched, observational cohort study comparing outcomes of hearts transplanted from DCD donors from March 1, 2015 to February 29, 2020 with those from matched donation after brain death (DBD) donors at Royal Papworth Hospital (RPH) (Cambridge, UK). DCD hearts were either retrieved using thoracoabdominal normothermic regional perfusion or the direct procurement and perfusion technique. All DBD hearts were procured using standard cold static storage. The primary outcomes were recipient 30-day and 1-year survival. RESULTS: During the 5-year study, DCD heart donation increased overall heart transplant activity by 48% (79 for DCD and 164 for DBD). There was no difference in survival at 30 days (97% for DCD vs 99% for DBD, p = 1.00) or 1 year (91% for DCD vs 89% for DBD, p = 0.72). There was no difference in the length of stay in the intensive care unit (7 for DCD vs 6 for DBD days, p = 0.24) or in the hospital (24 for DCD vs 25 for DBD days, p = 0.84). CONCLUSIONS: DCD heart donation increased overall heart transplant activity at RPH by 48%, with no difference in 30-day or 1-year survival in comparison with conventional DBD heart transplantations. DCD heart donation is set to make a dramatic difference in the number of patients who can benefit from heart transplantation.