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.

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.

Continuous-flow LVAD exchange to a different pump model: Systematic review and meta-analysis of the outcomes.

Despite improved outcomes of modern continuous-flow left ventricular assist devices (CF-LVADs), device exchange is still needed for various indications. While the majority of CF-LVADs are exchanged to the same model, exchange to a different pump model is occasionally warranted. In this meta-analysis, we sought to consolidate the existing evidence to better elucidate the indications and outcomes in these cases. A comprehensive systematic search of adult patient cohorts who underwent CF-LVAD exchange to a different CF-LVAD model was performed. Study-level data from 10 studies comprising 98 patients were extracted and pooled for analysis. Mean patient age was 58 (95% CI: 48-65) and 81% were male. Indication for initial CF-LVAD was ischemic cardiomyopathy in 45% (34-57). Initial device was HeartMate II LVAD (HMII) in 93 (94.9%) and HeartWare HVAD (HW) in 5 (5.1%) patients. After mean CF-LVAD support time of 18.8 (15.2-22.4) months, exchange indications included thrombosis in 71% (43-89), infection in 21% (8-47) and device malfunction in 12% (7-21). HMII to HW exchange occurred in 53 (54.1%) patients, HMII to HeartMate III (HM3) in 32 (32.7%), and HM II to either HW or HM3 in 13 (13.2%) patients. Postoperatively, right ventricular assist device was required in 16% (8-32). Overall, 20% (8-40) of patients experienced a stroke, while HW patients had a significantly higher stroke incidence than HM3 patients (HW: 21% (8-47) vs. HM3: 5% (1-24), P < .01). Overall 30-day mortality was 10% (6-17), while HW had a significantly worse 30-day mortality than HM3 (HW: 13% (7-24) vs. HM3: 5% (1-24), P = .03). Following device exchange from a different CF-LVAD model, HM3 is associated with lower stroke and higher survival when compared to HW.

Characterizing Adaptive Changes and Patient Survival After 2018 Donor Allocation Restructuring: A UNOS Database Analysis.

PURPOSE: We sought to characterize adaptive changes to the revised United Network for Organ Sharing donor heart allocation policy and estimate long-term survival trends for heart transplant (HTx) recipients. METHODS: Patients listed for HTx between October 17, 2013 and September 30, 2021 were identified from the United Network for Organ Sharing database, and stratified into pre- and postpolicy revision groups. Subanalyses were performed to examine trends in device utilization for extracorporeal membranous oxygenation (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical circulatory support (non-MCS). Survival data post-HTx were fitted to parametric distributions and extrapolated to 5 years. RESULTS: We identified 27,523 HTx waitlist candidates during the study period, most of whom (n = 16,376) were waitlisted in the prepolicy change period. Overall, 19,554 patients underwent HTx during the study period (pre: 12,037 and post: 7517). Listings increased after the policy change for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients. Listings for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients decreased. HTx increased for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients after the policy change and decreased for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients. Waitlist survival increased for the overall ( P < 0.01), ECMO ( P < 0.01), IABP ( P < 0.01), and non-MCS ( P < 0.01) groups. Waitlist survival did not differ for the LVAD ( P = 0.8) and Impella ( P = 0.1) groups. Post-transplant survival decreased for the overall ( P < 0.01), LVAD ( P < 0.01), and non-MCS ( P < 0.01) populations. CONCLUSIONS: Allocation policy revisions have contributed to greater utilization of ECMO, Impella, and IABP, decreased utilization of LVADs and non-MCS, increased waitlist survival, and decreased post-HTx survival.

Symptomatic Presentation of Acute Myocardial Infarction in Heart Transplantation Patients.

Patients with acute myocardial infarction with a history of an orthotopic heart transplantation rarely present with classic anginal symptoms, secondary to cardiac denervation. We present 2 cases, the first of a patient with a ST-segment elevation myocardial infarction and the second who presented with a non-ST-segment elevation myocardial infarction. Both patients presented with typical symptoms and were treated with percutaneous coronary intervention. (Level of Difficulty: Intermediate.).

COVID-19 and Acute Pulmonary Embolism: A Case Series and Brief Review.

The SARS-CoV-2 virus, or COVID-19, is responsible for the current global pandemic and has resulted in the death of over 400,000 in the United States. Rates of venous thromboembolism have been noted to be much higher in those infected with COVID-19. Here we report a case-series of COVID-19 patients with diverse presentations of pulmonary embolism (PE). We also briefly describe the pathophysiology and mechanisms for pulmonary embolism in COVID-19. These cases indicate a need to maintain a high index of suspicion for PE in patients with COVID-19, as well as the need to consider occult COVID-19 infection in patients with PE in the right clinical circumstance.

Fifteen-Year Trends in Incidence of Cardiogenic Shock Hospitalization and In-Hospital Mortality in the United States.

Background There is a lack of contemporary data on cardiogenic shock (CS) in-hospital mortality trends. Methods and Results Patients with CS admitted January 1, 2004 to December 31, 2018, were identified from the US National Inpatient Sample. We reported the crude and adjusted trends of in-hospital mortality among the overall population and selected subgroups. Among a total of 563 949 644 hospitalizations during the period from January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to CS. There has been a steady increase in hospitalizations attributed to CS from 122 per 100 000 hospitalizations in 2004 to 408 per 100 000 hospitalizations in 2018 (Ptrend<0.001). This was associated with a steady decline in the adjusted trends of in-hospital mortality during the study period in the overall population (from 49% in 2004 to 37% in 2018; Ptrend<0.001), among patients with acute myocardial infarction CS (from 43% in 2004 to 34% in 2018; Ptrend<0.001), and among patients with non-acute myocardial infarction CS (from 52% in 2004 to 37% in 2018; Ptrend<0.001). Consistent trends of reduced mortality were seen among women, men, different racial/ethnic groups, different US regions, and different hospital sizes, regardless of the hospital teaching status. Conclusions Hospitalizations attributed to CS have tripled in the period from January 2004 to December 2018. However, there has been a slow decline in CS in-hospital mortality during the studied period. Further studies are necessary to determine if the recent adoption of treatment algorithms in treating patients with CS will further impact in-hospital mortality.

3 Cases of Superior Vena Cava Syndrome Following Percutaneous Right Ventricular Assist Device Placement.

We present 3 cases of superior vena cava (SVC) syndrome following percutaneous right ventricular assist device (RVAD) placement. Each case underscores the importance of early recognition of SVC syndrome in patients with percutaneous RVAD insertion via the internal jugular vein and calls for heightened awareness of device-associated complications. (Level of Difficulty: Advanced.).

Outcomes With Ultrafiltration Among Hospitalized Patients With Acute Heart Failure (from the National Inpatient Sample).

Acute heart failure (HF) management is a complex and often involves a delicate balance of both cardiac and renal systems. Although pharmacologic diuresis is a mainstay of the pharmacologic management of decompensated HF, ultrafiltration (UF) represents a nonpharmacologic approach in the setting of diuretic resistance. We conducted a cross-sectional analysis of the 2009 through 2014 hospitalization data from the National Inpatient Sample. The study population consisted of hospitalizations with a discharge Diagnosis Related Groups of HF who were older than 18 years of age, did not have end-stage kidney disease, acute kidney injury and had not undergone hemodialysis or hemofiltration. There were 6,174 hospitalizations which included UF among the 7,799,915 hospitalizations for HF. Hospitalizations which included UF were among patients significantly younger in age (68.1 ± 1.0 vs 73.8 ± 0.1 years), male (61.9% vs 47.7%), and with higher prevalence of co-morbid conditions including chronic kidney disease (58% vs 31%), diabetes mellitus (53% vs 42%), and higher rates of co-morbidity (Charlson comorbidity score ≥2, 92% vs 80%). All-cause mortality was significantly higher among hospitalizations which included an UF (4.68% vs 2.24%). Hospitalizations with UF had a longer mean length of stay (6.2 vs 4.3 days, p <0.01) average total charges ($42,035 vs 24,867 USD, p <0.01) as compared with those without UF. Hospitalizations with UF were associated with a greater adjusted odds of all-cause mortality (odds ratio: 3.36, [95% confidence interval 1.76,6.40]), greater than DRG-level target length of stay (odds ratio, 2.46; [95 confidence interval 1.65,3.67]), and a 72% increase in the average hospital charges. In conclusion, hospitalizations which included UF identified a subgroup of HF patients with more co-morbid conditions who are at higher risk of mortality and increased resource burden in terms of length of stay and costs. These findings also highlight that the need for UF may identify patients who are most likely to benefit from a multidisciplinary cardiorenal approach to alter the trajectory of their disease.