Veno-venous ECLS rescue for a heart transplant recipient with COVID-19, a case report.

The potential for increased rates of morbidity of SARS-CoV-2 within immunocompromised populations has been of concern since the pandemic's onset. Transplant providers and patients can face particularly challenging situations, in the current settings as data continues to emerge for the prevention and treatment of the immunocompromised subpopulation. This case report details a patient 9-months post orthotopic heart transplant that developed SARS-CoV-2 infection despite two prior doses of the Pfizer-BioNtech COVID-19 vaccine, and had successful rescue from refractory hypoxemia with veno-venous extracorporeal membrane oxygenation (VV ECLS).

Positive donor blood cultures are not associated with worse heart transplant survival.

BACKGROUND: Recent evidence has demonstrated that transplantation of hearts with blood culture positive donors (BCPDs) to pediatric recipients is safe and effective. Few studies have analyzed the effect of BCPD on adult heart transplant recipients. METHODS: The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from September, 1987 to March, 2021. Exclusion criteria included pediatric donors/recipients, donor ejection fraction <10% or >85%, inactive listed recipients, donors missing blood cultures, and recipients missing follow-up time. Outcomes were compared with fully adjusted logistic models. To account for discrepancies in BCPD and non-BCPD covariates, an inverse proportionally weighted model with regression adjustment (IPWRA) was used. RESULTS: A total of 60 592 donors were non-BCPD, while 4009 were BCPD. 7% of hearts not transplanted were BCPD, while 6% of hearts transplanted were BCPD (p = .001). These rates have been nearly constant since 2005. There were no differences in short term survival between the two groups in the adjusted or IPWRA models (p = .103 and .277, respectively). Additionally, the BCPD group had longer ischemic time (3.24 vs. 3.06 h, p < .001), older donor age (32.73 vs. 31.65 years, p < .001), and older recipient age (52.76 vs. 52.09 years, p = .001). The IPWRA revealed an average additional 3.4 years of overall survival and 2.25 years of graft function for BCPD versus non-BCPD recipients, although these results failed to reach statistical significance (p = .387 and .527, respectively). CONCLUSIONS: Given the need for more donor hearts, donors with positive blood cultures should be considered. Great care in evaluating such patients is advised to eliminate donors with untreated infections, while carefully selected donors can be considered and used.

Functional status of heart transplant recipients predicts survival.

INTRODUCTION: Recipient functional status prior to transplantation can significantly impact post-transplant survival. METHODS: The United Network for Organ Sharing database was queried for adult heart transplants including data on functional capacity and from February 1, 2005 to March 1, 2021; there were 32 875 cases included. The four functional categories studied were based on adult daily activities of living and were separated into total assistance required, some assistance required, no assistance required, and near death. Survival outcomes were compared for recipient's pretransplant level of functional status versus those with near death status. These were compared using adjusted logistic regression (odds of death at 30 days and 1 year) and conditional Cox models (overall survival and time until post-transplant rejection). All models were adjusted for donor age, sex, ethnicity, ischemic time, as well as recipient age, sex, ethnicity, length of stay, UNOS region, ventricular assist device, creatinine, days on the waiting list, and status at transplant. RESULTS: There were 12 953 recipients classified as "near death" or "severely disabled"; 7711 "required total assistance in daily living", 7,328 "needed some", and 4883 "needed none". In adjusted models, the probabilities of death for the lowest functioning groups within 30 days and 1 year were 5% and 10%, respectively. Those "requiring total assistance" had analogous probabilities of 3% (OR = 0.58; p < 0.001) and 9% (OR = 0.81; p < 0.001). Those "requiring some assistance" had probabilities of 3% (OR = 0.56; p < 0.001) and 9% (OR = 0.74; p < 0.001). Lastly, those "requiring no assistance" had probabilities of death of 2% (OR = 0.35; p < 0.001) and 7% (OR = 0.63; p < 0.001). CONCLUSION: Recipient functional status assessed pre-transplant and recorded in the UNOS database is a strong predictor of post-transplant survival.

Isolated left ventricular assist device implantation produces variable changes to patient body mass index.

BACKGROUND: Body mass index (BMI) is an important consideration for transplant-eligible left ventricular assist device (LVAD) recipients. LVAD therapy's impact on BMI is unclear. We evaluated BMI changes in patients who underwent LVAD implantation. The association between these patients' BMI and the transplant was studied. METHODS: This was a retrospective cohort study of patients who underwent LVAD implantation between January 1, 2012 and December 31, 2018 at our institution. Patients were stratified by preoperative BMI (kg/m2 ) into four groups: <30, 30-34.9, 34.9-39.9, and ≥40. BMI data were collected at 12 and 6 months prior to implantation, time of implantation, and 3- and 6- months postimplantation. RESULTS: A total of 107 patients underwent LVAD implantation at our institution. Data were available for 80 patients. Baseline characteristics included a mean age of 56.0 years, 69% male, and a mean implant BMI of 29.9 ± 6.8 kg/m2 . The mean BMI (kg/m2 ) for each of the BMI (kg/m2 ) groups <30, 30-34.9, 35-39.9, and ≥40 (n = 60, 25, 12, and 10, respectively) was 25.1, 32.5, 36.8, and 43.8, respectively. There was no consistent pattern with weight change across differing implant BMIs. No patient with a BMI of <30 gained sufficient weight to impact transplant candidacy. Twenty-three percent of patients with a BMI of 30-34.9 kg/m2 , 60% of patients with a BMI of 35-39.9 kg/m2 , and 87.5% of patients with a BMI of ≥40 kg/m2 had a 6-month BMI potentially affecting transplant. CONCLUSIONS: Associated weight changes during LVAD support may significantly impact transplant candidacy. Higher BMI groups may benefit from multimodal and multidisciplinary targeted weight-loss interventions.

Successful recovery with venovenous ECMO for ARDS after LVAD HeartMate 3 implantation: A case report.

Acute respiratory distress syndrome (ARDS) following left ventricular assist device (LVAD) implantation is a rare complication. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is used as a treatment for severe ARDS and pneumonia. We report the successful use of VV ECMO for ARDS Klebsiella pneumonia following urgent LVAD HeartMate 3 implantation.

Impella 5.0: An intermediate strategy for bridging a patient from infected durable LVAD to cardiac transplant.

Cardiac transplant remains the gold-standard treatment for end-stage heart failure more than 50 years after the procedure was first pioneered. The number of transplant operations performed annually has been limited by the global imbalance of donor organs to recipients. This imbalance helped fuel the development of left ventricular assist devices (LVADs) first as a bridge to cardiac transplant and subsequently as destination therapy. Driveline infection is one of several problems that continue to plague LVADs through several generations of improvement. We present a patient with an infected LVAD driveline exit site that progressed to mediastinitis, pericardial and pump infection. The device was explanted, and the patient supported with an axillary Impella 5.0 as a bridge until the time of transplant. An Impella 5.0 (or 5.5) can be used as an intermediate tool to be able to explant an infected LVAD, with mediastinitis, allowing the patient to clear the infection, and prepare the patient for transplant free of infection. METHODS: The patient consented to the study and case report. The patient signed an informed consent and permission for publication.

Ischemic time and patient outcomes after the 2018 UNOS donor heart allocation system change.

BACKGROUND: The allocation system for heart donors in the United States changed on October 18, 2018. The typical distance from donor hospitals to recipient hospitals has increased as has the ischemic time. We investigated patient outcomes with the new allocation system and the differential effects of ischemic time under both the old and new allocation schemas. METHODS: The United Network for Organ Sharing Registry (UNOS) was queried for data regarding heart transplants occurring from October 1, 1987 to March 1, 2021. In total, 62,301 adult heart transplants were examined. Survival outcomes at 30 days and 1 year and ischemic times were compared via adjusted logistic and Cox models (overall survival and time until post-transplant rejection). RESULTS: Mean ischemic time was slightly increased in the new system (3.43 h vs. 3.03 h, p < .001). Survival differences between old versus new systems were not observed in adjusted models (p = .818). However, there was evidence to suggest longer ischemic times are more detrimental to long-term survival under the new system (hazard ratio [HR] = 1.15 per hour increase; p = .001) versus the old system (HR = 1.08 per hour increase; p < .001), although this relationship did not reach statistical significance (p = .150). CONCLUSIONS: Although travel distances have significantly increased under the new allocation system, survival outcomes remain largely unchanged. Ischemic time is an influential factor in recipient survival that should be limited during organ transport. Further studies on the impact of travel distances and ischemic time under the new allocation system are needed.

Pre-emptive intraoperative administration of PCC4 in cardiac surgery patients at high risk of bleeding: A pilot study.

BACKGROUND: Four-factor prothrombin complex (PCC4), a concentrate of factors II, VII, IX, and X and proteins C and S, has been used selectively for reversal of oral anticoagulation before surgery. There is data to support PCC4 as opposed to supplemental fresh frozen plasma (FFP) to manage postoperative bleeding following cardiac surgery. The preemptive, intraoperative use of PCC4 in cardiothoracic surgery has not been studied though it may prevent postoperative bleeding, the need for blood transfusion and the risk of transfusion-related acute lung injury, volume overload, and right ventricular (RV) heart failure. The purpose of this study is to evaluate the intraoperative administration of PCC4 to decrease bleeding and lower the rate of blood transfusion. METHODS: A single institution retrospective chart review was conducted from May 2020 to November 2021 of patients who received PCC4 intraoperatively during cardiothoracic surgery of high-risk variety. Patients were evaluated for the type of surgery, demographics, baseline anticoagulation, PCC4 dose, type and quantity of blood transfusion within 72 hours (h) postoperatively, chest tube output, the incidence of RV failure, hypersensitivity reactions, acute kidney injury (AKI), thrombosis, acute lung injury, and mortality within 45 days of the operative dose of PCC4. RESULTS: Thirty-five patients received PCC4 at a mean dose of 2920 units (U). Sixty-five percent of cases were left ventricular assist devices (LVADs) or heart transplants. The protocol is to use PCC4 30 units (U)/kg immediately after the completion of protamine administration. Inclusion criteria are cardiothoracic surgery with increased risk of postoperative right heart failure commonly secondary to blood product transfusion, or cardiothoracic surgery associated with increased risk of bleeding, including heart transplant, LVAD implant, aortic dissection, and redo sternotomy (e.g., coronary artery bypass). Total chest tube output was recorded as a mean of 757 ml for 24 h after surgery (32 ml/h). Overall median event rates of FFP and red blood cell (RBC) transfusions were 0 (interquartile range [IQR]: 0-3 U) and 4 (IQR: 2-5 U). Overall, 43% and 89% of cases received FFP and RBC, respectively. There was one occurrence of RV failure, one occurrence of AKI requiring renal replacement therapy, one occurrence of venoarterial extracorporeal membrane oxygenation, one occurrence of venous thromboembolism related to a central venous access line, and one death unrelated to surgery or PCC4 that was attributed to advanced heart failure not amenable to advanced therapies. CONCLUSION: Overall patients received a low rate of blood transfusion, had minimal chest tube output, and there was a small incidence of right heart failure. Patients did not have an increased risk of adverse effects such as AKI or venous thromboembolism. A randomized controlled clinical trial comparing the observed dose and timing of PCC4 versus routine postoperative bleeding management with blood product transfusion is recommended.

Seasonal trends in donor heart availability: an analysis of the UNOS database.

Despite the widespread belief that donor organ availability varies around holidays and seasons, there is little empirical data supporting this long-held belief. Variations in donor heart availability may be of interest to patients and clinicians. The UNOS/OPTN registry was queried for all heart donations from October 1987 through March 2017. Daily heart donation rates were modeled nationally using Poisson regression including splines for year and day of the year. Seasonality was assessed using a likelihood ratio test for the spine terms for day of the year. The holiday effect was assessed using conditional logistic regression. Seasonal plots suggest a significant, although modest, increase in organ availability during the summer months, except for region 1. The regions with the highest amplitude were region 7 (peak: June 21, amplitude: 16.63%) and region 6 (peak: July 5, amplitude: 11.29%). There was no significant difference in the odds of heart donation when comparing holidays vs. non-holidays using national data (odds ratio [95% CI]: 1.01 [0.98, 1.03], P = 0.560) or any regional subsets. There was no observable correlation between donor heart availability and holidays. However, a significant seasonality effect was observed with higher donation rates occurring during warmer months.

Thrombus in Transit through a Patent Foramen Ovale: Surgical Prevention of Impending Stroke.

A Transesophageal Echocardiography (TEE) is essential in identifying thrombus in transient in patients with deep venous thrombosis (DVT) presenting with symptoms suggesting potential systemic emboli. We present a case of a 71-year-old gentleman with recent DVT who developed slurred speech and was assumed to have transient ischemia attack (TIA). TEE showed the presence of a large Thrombus in Transit (TIT) through a patent foramen ovale (PFO). Surgical intervention in low to intermediate risk is probably the best option associated with fewer complications of recurrent embolic events than both thrombolysis and anticoagulation.

Low-temperature synthesis of high-entropy amorphous metal oxides (HEOs) for enhanced oxygen evolution performance.

The rational design of multiple metal ions into high-entropy oxide electrode material via a single-step hydrothermal process is applicable to the evolution of oxygen molecules (O2) through simple water electrolysis. Their cost-effectiveness, high performance, and durable nature are the key factors of non-precious high-entropy multiple metal-based electrocatalysts, which can be used as replaceable catalysts instead of precious ones. This article reports a low-temperature synthesis of the cauliflower-type morphology of high-entropy amorphous metal oxides, and their electrochemical performances towards the oxygen evolution reaction (OER) are investigated. The multiple metal ion (Mn2+, Fe3+, Co2+, Ni2+, Cu2+) oxide electrode material shows an acceptable oxygen evolution reaction (OER) with an overpotential of 290 mV at a current density of 10 mA cm-2 and a lower Tafel slope value of 85 mV dec-1, respectively. Moreover, the 20 h durability test with negligible change in overpotential shows the efficacy of the modified electrode material in harsh alkaline media. The observed electrochemical results towards the OER correspond to the amorphous nature of the active material that displayed a cauliflower-type morphology, having a large specific surface area (240 m2 g-1) and providing higher electrochemical active sites as well. Consequently, post-stability characterization studies (such as PXRD, FESEM, TEM, and XPS) provide more information for understanding the post-structural and morphological results of the high-entropy amorphous metal oxide.

Quality of life and chronic heart failure therapy guided by natriuretic peptides: results from the ProBNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) study.

BACKGROUND: Heart failure (HF) treatment guided by amino-terminal pro-B type natriuretic peptide (NT-proBNP) may reduce cardiovascular event rates compared to standard-of-care (SOC) management. Comprehensive understanding regarding effect of NT-proBNP guided care on patient-reported quality of life (QOL) remains unknown. METHODS: One hundred fifty-one subjects with HF due to left ventricular systolic dysfunction were randomized to either SOC HF management or care with a goal to reduce NT-proBNP values ≤1000 pg/mL. Effects of HF on QOL were assessed using the Minnesota Living with HF Questionnaire (MLHFQ) quarterly, with change (Δ) in score assessed across study procedures and as a function of outcome. RESULTS: Overall, baseline MLHFQ score was 30. Across study visits, QOL improved in both arms, but was more improved and sustained in the NT-proBNP arm (repeated measures P = .01); NT-proBNP patients showing greater reduction in MLHFQ score (-10.0 vs -5.0; P = .05), particularly in the physical scale of the questionnaire. Baseline MLHFQ scores did not correlate with NT-proBNP; in contrast, ∆MLHFQ scores modestly correlated with ∆NT-proBNP values (ρ = .234; P = .006) as did relative ∆ in MLHFQ score and NT-proBNP (ρ = .253; P = .003). Considered in tertiles, less improvement in MLHFQ scores was associated with a higher rate of HF hospitalization, worsening HF, and cardiovascular death (P = .001). CONCLUSIONS: We describe novel associations between NT-proBNP concentrations and QOL scores among patients treated with biomarker guided care. Compared to SOC HF management, NT-proBNP guided care was associated with greater and more sustained improvement in QOL (Clinical Trial Registration: www.clinicaltrials.govNCT00351390).

Heart failure outcomes and benefits of NT-proBNP-guided management in the elderly: results from the prospective, randomized ProBNP outpatient tailored chronic heart failure therapy (PROTECT) study.

BACKGROUND: Elderly patients with heart failure (HF) have a worse prognosis than younger patients. We wished to study whether elders benefit from natriuretic peptide-guided HF care in this single-center study. METHODS AND RESULTS: A total of 151 patients with HF resulting from left ventricular systolic dysfunction (LVSD) were treated with HF treatment by standard-of-care (SOC) management or guided by N-terminal pro-B type natriuretic peptide (NT-proBNP) values (with a goal to lower NT-proBNP ≤1000 pg/mL) over 10 months. The primary end point for this post-hoc analysis was total cardiovascular events in 2 age categories (<75 and ≥75 years). In those ≥75 years of age (n = 38), NT-proBNP values increased in the SOC arm (2570 to 3523 pg/mL, P = .01), but decreased in the NT-proBNP-guided arm (2664 to 1418 pg/mL, P = .001). Elderly patients treated with SOC management had the highest rate of cardiovascular events, whereas the elderly with NT-proBNP management had the lowest rate of cardiovascular events (1.76 events per patient versus 0.71 events per patient, P = .03); the adjusted logistic odds for cardiovascular events related to NT-proBNP-guided care for elders was 0.24 (P = .008), whereas in those <75 years (n = 113), the adjusted logistic odds for events following NT-proBNP-guided care was 0.61 (P = .10). CONCLUSIONS: Natriuretic peptide-guided HF care was well tolerated and resulted in substantial improvement in cardiovascular event rates in elders (ClinicalTrials.Gov #00351390).

Transcarotid Approach to Placement of an Impella 5.0.

Microaxial left ventricular assist devices (mLVADs) have traditionally been placed through a transfemoral or transaxillary arterial approach. Transfemoral access is restrictive, significantly limiting postoperative patient ambulation. Transaxillary placement is preferred but not feasible in a subset of patients due to small arterial diameter or tight angulation of the thoracic outlet. Transcarotid delivery has been utilized for other cardiovascular device deployment with good success; however, this approach has not been described for mLVAD support. We present a case series of transcarotid placement of mLVADs in cases where a transaxillary and transfemoral approach was not feasible. From May 2017 to April 2019, six patients in cardiogenic shock required mLVAD support achieved via a transcarotid approach. Technical success was achieved in all patients. One patient was directly weaned from mLVAD support and two patients died on mLVAD support. Escalation to venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required for three patients, two of whom subsequently died. There were no bleeding or valvular complications related to device placement, and no obvious or known neurologic complications related to mLVAD support. Transcarotid placement of mLVADs expands the utility of these devices as an alternative to traditional support strategies or prohibitive arterial anatomy; however, further study is needed to determine its efficacy.

High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography.

BACKGROUND: For evaluation of patients with chest pain and suspected acute coronary syndrome (ACS), consensus guidelines recommend use of a cardiac troponin cut point that corresponds to the 99 th percentile of a healthy population. Most conventional troponin methods lack sufficient precision at this low level. METHODS AND RESULTS: In a cross-sectional study, 377 patients (mean age 53.7 years, 64.2% male) with chest pain and low to intermediate likelihood for ACS were enrolled in the emergency department. Blood was tested with a precommercial high-sensitivity troponin T assay (hsTnT) and compared with a conventional cardiac troponin T method. Patients underwent a 64-slice coronary computed tomography coronary angiogram at the time of phlebotomy, on average 4 hours from initial presentation. Among patients with acute chest pain, 37 (9.8%) had an ACS. Using the 99th percentile cut point for a healthy population (13 pg/mL), hsTnT had 62% sensitivity, 89% specificity, 38% positive predictive value, and 96% negative predictive value for ACS. Compared with the cardiac troponin T method, hsTnT detected 27% more ACS cases (P=.001), and an hsTnT above the 99 th percentile strongly predicted ACS (odds ratio 9.0, 95% confidence interval 3.9 to 20.9, P<0.001). Independent of ACS diagnosis, computed tomography angiography demonstrated that concentrations of hsTnT were determined by numerous factors, including the presence and severity of coronary artery disease, left ventricular mass, left ventricular ejection fraction, and regional left ventricular dysfunction. CONCLUSIONS: Among low- to intermediate-risk patients with chest pain, hsTnT provides good sensitivity and specificity for ACS. Elevation of hsTnT identifies patients with myocardial injury and significant structural heart disease, irrespective of the diagnosis of ACS.

Efficacy and safety of quinine loading dose in patients with severe falciparum malaria at a tertiary care hospital in Pakistan.

OBJECTIVE: To compare the clinical outcomes of a loading dose regimen of quinine with a uniform dose regimen in patients with severe falciparum malaria. METHODS: A retrospective chart review of 315 patients admitted with severe falciparum malaria and treated with quinine at a tertiary care teaching hospital of Karachi, Pakistan during 1999-2006 was conducted. Group A with 103 patients (32.7%) was given an initial loading dose of quinine while group B with 212 patients (67.3%) did not receive the loading dose. The two groups were compared in terms of reduction of parasite load, resolution of fever, recovery of consciousness and incidence of adverse effects. Outcome parameters were measured on the third day of therapy. RESULTS: More individuals in group A (62.1%) were afebrile as compared to group B (54.7%) at day 3 of therapy. Patients in group B showed greater reduction in parasitaemia (47.2% at baseline to 4.7% on day 3) as compared to group A (56.3 % at baseline to 9.7% on day 3). Following therapy, fewer patients in group B had altered consciousness (7.1% at baseline to 4.7% on day 3) as compared to patients in group A (7.8% at baseline to 5.8% on day 3). However, these associations were not statistically significant. The incidence of thrombocytopenia was higher in Group A (5.8%) as compared to Group B (0.9%). CONCLUSION: Although quinine loading dose may be more effective than uniform dose in rapid fever clearance; it also appears to be associated with higher toxicity. Uniform dose of quinine may be prescribed in severe falciparum malaria in view of its better safety profile.

Bariatric surgery in patients with advanced heart failure: A proposed multi-disciplinary pathway for surgical care in medically complex patients.

BACKGROUND: The objective of this study was to develop a multi-disciplinary care pathway to minimize perioperative complications in patients with advanced heart failure undergoing bariatric surgery. Patients with severe obesity and heart failure carry increased perioperative surgical risk compared to patients with no heart failure due to the severity of their cardiac disease state and associated comorbidities. Our bariatric program routinely excluded patients with advanced heart failure from undergoing bariatric surgery due to the high reported perioperative risk. However, knowing the potential beneficial impact of bariatric surgery for advanced heart failure, our program hoped that the thoughtful development of a perioperative pathway before inclusion of patients with advanced heart failure in the bariatric surgery program could minimize the morbidity of these high-risk patients in comparison to prior publications in the literature. METHODS: Two multi-disciplinary care pathways were developed, including advanced heart failure, anticoagulation specialists, and transplant cardiologists, to optimize bariatric care for severely obese patients with advanced heart failure with or without mechanical circulatory support and implementation was evaluated for short-term 30-day complications and 6 month cardiac and weight-loss outcomes. RESULTS: Two multi-disciplinary care pathways were developed and implemented on 5 patients with heart failure with reduced ejection fraction (pathway 1) and 3 patients requiring mechanical circulatory support (pathway 2). There were no in-hospital complications or mortality following either pathway, and there was only 1 emergency room visit and 1 re-admission. The average length of stay for patients with heart failure with reduced ejection fraction without mechanical circulatory support was 2.4 days and for heart failure with reduced ejection fraction with mechanical circulatory support was 4.3 days. Three patients met body mass index criteria for transplant listing at 6 months. Ejection fraction increased an average of 9% at 6 months postoperatively for patients with heart failure with reduced ejection fraction not requiring mechanical circulatory support. CONCLUSION: With multi-disciplinary care pathway development designed to maximize safety by intensely supporting preoperative cardiac optimization and medication titration postoperatively, bariatric surgery can be performed in patients with advanced heart failure with or without mechanical circulatory support, allowing patients the opportunity for weight loss as a bridge to transplant or potentially meaningful cardiac recovery.

Sustained Use of the Impella 5.0 Heart Pump Enables Bridge to Clinical Decisions in 34 Patients.

We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.

Prospective, comprehensive assessment of cardiac troponin T testing after coronary artery bypass graft surgery.

BACKGROUND: The significance and clinical role of cardiac troponin testing after coronary artery bypass grafting remain unclear. METHODS AND RESULTS: Cardiac troponin T (cTnT) was measured during the first 24 hours after coronary artery bypass graft surgery in 847 consecutive patients. Only 17 patients (2.0%) had new Q waves or left bundle-branch block after surgery; however, cTnT elevation was observed in nearly all subjects, with a median cTnT concentration of 1.08 ng/mL overall. Direct predictors of postoperative cTnT values included preoperative myocardial infarction (P<0.001), preoperative intraaortic balloon pump (P<0.001), intraoperative/postoperative intraaortic balloon pump (P<0.001), number of distal anastomoses (P=0.005), bypass time (P<0.001), and number of intraoperative defibrillations (P=0.009), whereas glomerular filtration rate (P<0.001), off-pump coronary artery bypass grafting (P=0.003), and use of warm cardioplegia (P=0.02) were inversely associated with cTnT values. A linear association was seen between cTnT levels and length of stay and ventilator hours, and in an analysis adjusted for the Society for Thoracic Surgery Risk Model, cTnT remained independently prognostic for death (odds ratio, 3.20; P=0.003), death or heart failure (odds ratio, 2.04; P=0.008), death or need for vasopressors (odds ratio, 2.70; P<0.001), and the composite of all 3 (odds ratio, 2.57; P<0.001). In contrast to consensus-endorsed cTnT cut points for postoperative evaluation, a cTnT <1.60 ng/mL had a negative predictive value of 93% to 99% for excluding various post-coronary artery bypass graft surgery complications. CONCLUSIONS: cTnT concentrations after coronary artery bypass graft surgery are nearly universally elevated, are determined by numerous factors, and are independently prognostic for impending postoperative complications when used at appropriate cut points.