Temporary mechanical support in the peripartum patient as a bridge to postpartum recovery: A report of three cases.

Cardiogenic shock (CS) is a severe complication of peripartum cardiomyopathy (PPCM). Patients with deteriorating CS often require temporary mechanical circulatory support. In PPCM, this can be used as a bridge to postpartum recovery or bridge to decision. The outcomes are unclear, especially if prolonged utilization is required. We present a case series of three patients with PPCM in deteriorating CS who were successfully supported with a ventricular assist device or veno-arterial extracorporeal membrane oxygenation as a bridge to postpartum recovery.

Variation in Hemodynamic Assessment and Interpretation: A Call to Standardize the Right Heart Catheterization.

BACKGROUND: Invasive hemodynamic measurement via right heart catheterization has shown divergent data in its role in the treatment of patients with heart failure (HF) and cardiogenic shock. We hypothesized that variation in data acquisition technique and interpretation might contribute to these observations. We sought to assess differences in hemodynamic acquisition and interpretation by operator subspecialty as well as level of experience. METHODS AND RESULTS: Individual-level responses to how physicians both collect and interpret hemodynamic data at the time of right heart catheterization was solicited via a survey distributed to international professional societies in HF and interventional cardiology. Data were stratified both by operator subspecialty (HF specialists or interventional cardiologists [IC]) and operator experience (early career [≤10 years from training] or late career [>10 years from training]) to determine variations in clinical practice. For the sensitivity analysis, we also look at differences in each subgroup. A total of 261 responses were received. There were 141 clinicians (52%) who self-identified as HF specialists, 99 (38%) identified as IC, and 20 (8%) identified as other. There were 142 early career providers (54%) and late career providers (119 [46%]). When recording hemodynamic values, there was considerable variation in practice patterns, regardless of subspecialty or level of experience for the majority of the intracardiac variables. There was no agreement or mild agreement among HF and IC as to when to record right atrial pressures or pulmonary capillary wedge pressures. HF cardiologists were more likely to routinely measure both Fick and thermodilution cardiac output compared with IC (51% vs 29%, P < .001), something mirrored in early career vs later career cardiologists. CONCLUSIONS: Significant variation exists between the acquisition and interpretation of right heart catheterization measurements between HF and IC, as well as those early and late in their careers. With the growth of the heart team approach to management of patients in cardiogenic shock, standardization of both assessment and management practices is needed.

Impact of Laparoscopic Sleeve Gastrectomy on Cardiovascular Pharmacotherapy in Left Ventricular Assist Device Patients.

ABSTRACT: Left ventricular assist device (LVAD) implantation is increasingly utilized in patients with advanced heart failure and morbid obesity. Laparoscopic sleeve gastrectomy (LSG) can facilitate weight loss in this population and can ultimately change the pharmacokinetics of heart failure therapeutics. In this study, we aimed to explore the changes in cardiovascular pharmacotherapy post LSG intervention. We conducted a retrospective observational cohort study of morbidly obese LVAD patients between 2013 and 2019 at the University of Florida with available pharmacotherapeutic data at 1 and 6 months. Thirteen post-LSG patients and 13 control subjects were included in the final analysis. In the post-LSG group, the mean body mass index decreased significantly (44 ± 5 vs. 34 ± 4.9, P < 0.001), and 7 patients were successfully bridged to cardiac transplantation. Only 3 patients required adjustment of their LVAD speed. Mean return to flow decreased by 8 mm Hg, despite a 45% reduction in the mean number of vasodilators per patient (1.2 vs. 0.7, P = 0.03). Mean weekly warfarin dose decreased by 35% after 6 months (32.9 ± 20.9 vs. 50.7 ± 26.6, P = 0.01). The use of diuretics, vasodilators, and beta-blockers was significantly reduced by 50%, 45%, and 35%, respectively. None of these changes were observed in the control group at 6-month follow-up post LVAD. In this single-center experience, weight loss post LSG is associated with decreased vasodilator, diuretic, and anticoagulant medication requirements in LVAD patients.

Triple therapy temporary mechanical circulatory support as a bridge to triple-organ transplantation.

Temporary mechanical circulatory support (MCS) systems are indicated to stabilize hemodynamically decompensating patients in cardiogenic shock refractory to medical management. These devices are currently used as short-term hemodynamic support to facilitate organ recovery or bridge to definitive therapy with durable MCS or heart transplantation. We present the sequential use of intra-aortic balloon pump, Impella 5.5®, and venoarterial extracorporeal membrane oxygenation as a bridge to heart-liver-kidney transplantation. The patient was supported for 78 days on Impella 5.5 and 95 days total temporary MCS. He had an uncomplicated postoperative course after triple-organ transplantation and was stable with no signs of rejection at 1-, 3-, 6-, and 12-month follow-up.

Florida sleeve is a safe and effective technique for valve salvage in acute stanford type A aortic dissection.

OBJECTIVE: Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute type-A aortic dissection (ATAAD). The Florida sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the FS repair in patients with dilated roots in the setting of an ATAAD. METHODS: We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. RESULTS: Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range, 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. CONCLUSION: FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.

Fixed-dose aspirin monotherapy compared with thromboelastography directed antiplatelet therapy in long-term management of left ventricular assist devices.

BACKGROUND AND AIM: The role of thromboelastography (TEG) in managing antiplatelet therapy (APT) in left ventricular assist devices (LVADs) is controversial. Our aim was to determine whether removal of TEG from an LVAD-specific APT protocol reduced late-onset bleeding without increasing thromboembolic complications. METHODS: We performed a single-center, retrospective cohort study including all recipients of a continuous-flow LVAD between April 2005 and November 2019 (n = 293). LVAD recipients before June 1, 2017 (n = 221) whose APT was monitored and adjusted using TEG were compared with LVAD recipients after June 1, 2017 (n = 72) where TEG was not utilized. Occurrence of late-onset bleeding events after postoperative Day 7 and thromboembolic events were collected. APT doses, warfarin use and International normalized ratio (INR) values were collected at discharge and at 1, 3, 6, and 12-months postimplantation. RESULTS: Over a median 12-month follow-up, INTERMACS major bleeding events occurred in 35% of patients where TEG was utilized compared with 29% where TEG was not utilized (p = 0.375), and procedural intervention was required in 29% compared with 18%, respectively (p = 0.058). Use of TEG was associated with higher doses of aspirin (>325 mg) (41% compared with none) and use of a second antiplatelet (dipyridamole) (43% compared to 1%). Despite this, there was no significant difference in thromboembolic events (15% in each). CONCLUSIONS: Our study suggests the use of TEG led to increased doses of aspirin as well as adding a second antiplatelet agent, without improving outcomes in LVAD recipients. Furthermore, the removal of TEG from an LVAD-specific APT protocol did not worsen thromboembolic outcomes.

Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction.

BACKGROUND: With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. METHODS: This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. RESULTS: A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. CONCLUSIONS: In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients.

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

A mini-thoracotomy approach for walking veno-arterial extracorporeal membranous oxygenation.

Fulminant myocarditis is a rapidly progressive myocardial inflammation that commonly requires advanced circulatory support therapies. We report our management of a 36-year-old gentleman with fulminant myocarditis who we managed with extracorporeal membranous oxygenation (ECMO) and subsequently durable bi-ventricular assist devices as a bridge to heart transplantation. The patient was admitted after a 1-week history of malaise with severe lethargy, jugular venous distension to greater than 10 cm, and troponin elevation to greater than 27 K. He was taken immediately for a heart catheterization which showed no obstructive coronary disease, and hemodynamics consistent with bi-ventricular failure. We proceeded with ECMO for hemodynamic support, utilizing a mini-thoracotomy for cannulation. A Protek Duo Rapid Deployment (LivaNova) was inserted via a modified Seldinger technique through the left ventricular apex, terminating in the ascending aorta. Percutaneous right IJ bicaval via a y-ed Avalon Elite (Getinge) was employed for venous drainage. This case highlights an alternate strategy for central walking veno-arterial ECMO in a patient presenting with fulminant myocarditis with a platform that minimizes upper/lower extremity over/under perfusion complications, while providing sternal sparring antegrade arterial flow with simultaneous ventricular unloading/venting.

Simultaneous aortic valve endocarditis and mycotic pseudoaneurysm of aortic coarctation.

OBJECTIVE: This study highlights the management strategy in simultaneous bicuspid aortic valve infective endocarditis and mycotic pseudoaneurysm of an aortic coarctation. METHODS: A staged repair of mycotic pseudoaneurysm of aortic coarctation and infective bicuspid aortic valve endocarditis. RESULTS: We present a 19-year old gentleman who was admitted with aching pain in his bilateral lower extremities with associated purpuric rash and fevers. Work-up was significant for severe aortic valve regurgitation and a pseudoaneurysm in the distal aortic arch. He underwent operative repair through a left posterior-lateral thoracotomy with femoral-femoral partial cardiopulmonary bypass. Intraoperative findings were significant for a juxta-ductal coarctation and pseudoaneurysm. The mycotic pseudoaneurysm and remnant ligamentum arteriosum were completely resected and were replaced with a 18 mm Gelweave graft (Terumo Cardiovascular Group, Ann Arbor, MI) from the distal arch to the descending thoracic aorta. The patient underwent a planned secondary washout and omental flap for biologic coverage of the graft. Subsequently, a staged aortic valve replacement was completed 1 week later. The patient's postoperative course was uncomplicated, and he was discharged with intact motor and sensory function. CONCLUSIONS: A staged approach is a prudent strategy to manage a patient with simultaneous endocarditis and aortic mycotic pseudoaneurysm, with precedence toward the most critical lesion.

Pasteurella Multiocida infection resulting in a descending thoracic aorta mycotic pseudoaneurysm.

OBJECTIVE: Highlight our management of a Pasteurella Multiocida-infected descending thoracic aorta mycotic pseudoaneurysm. METHODS: Report a case of a canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm. RESULTS: We present a 61-year-old gentleman who was initially seen in an emergency department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks after discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete pseudoaneurysm resection and aortic replacement with a 24-mm Gelweave graft. Given purulence and gross infection, we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with 6-week intravenous course of antibiotics. CONCLUSIONS: The patient's clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.

Protek Duo Rapid Deployment cannulation utilized to bridge to durable heartware left ventricular assist device.

A 43-year-old gentleman was transferred for management of acute on chronic cardiogenic shock (left ventricular ejection fraction < 10%). Upon arrival, we inserted a left axillary intra-aortic balloon pump for hemodynamic support. He underwent an emergent left and right-heart catheterization which showed patent stents and coronaries, in the setting of severely elevated pulmonary artery and pulmonary capillary wedge pressure. On hospital day 35, we escalated support to Centrimag in conjunction with a 31 French Protek Duo Rapid Deployment cannula. A centrimag cannula apical sewing cuff was sewn in continuous fashion along the left ventricular apex. Via modified seldinger technique, we tunneled the Protek Duo Rapid Deployment cannula through the silastic sewing cuff and the ventricular apex, traversing the aortic valve. On hospital day 50, he underwent left anterior thoracotomy and mini-sternotomy for implantation of durable Heartware left ventricular assist device. He was discharged home off inotropes and had resumed his normal activities. He is currently listed as status four for heart transplantation.

Utilizing the index for mortality prediction after cardiac transplantation risk score to predict hospital resource consumption.

OBJECTIVE: The index for mortality prediction after cardiac transplantation (IMPACT) risk score incorporates 12 preoperative recipient-specific variables, and has been validated as an accurate predictor of short- and long-term mortality after orthotopic heart transplantation (OHTx). We believe it can also be used to predict hospital costs, and we hypothesize that higher preoperative IMPACT risk scores are associated with increased hospital resource consumption. METHODS: All OHTx patients ≥18 years of age at our institution were reviewed from 1 January 2000 to 31 December 2014. Total index hospitalization costs post-transplant were extracted and presented in 2014 consumer price index inflation-adjusted US dollars. Patients were stratified into quartiles (Q) according to IMPACT risk scores. Logarithmic transformation normalized cost data, and linear regression assessed for correlation. A comparison of cost between Q of IMPACT risk score was performed using rank-sum and Kruskal-Wallis tests. Survival was estimated using the Kaplan-Meier method. RESULTS: Three hundred fifty-six (n = 356) OHTx were performed during the study period. The median IMPACT score for the cohort was five (interquartile range [IQR] 3-6). Eight (2.2%) patients died within 30-days and 1-year Kaplan-Meier survival was 88.3%. The median length of stay (LOS) was 16 (IQR 14-24) days. The median hospital cost for index admission was $222 200 (IQR:$169 200-$313 700). Median LOS was longer in Q4 vs Q1 (18 days vs 15 days, P = .01) and index hospital costs in Q4 were significantly higher compared to Q1 patients ($280 400 vs $205 000, P < .01). There was a significant positive correlation between IMPACT risk score and cost (regression coefficient .04, P < .01). CONCLUSION: This is the first study in adult cardiac transplantation to identify a positive correlation between hospital cost and recipient risk using the IMPACT risk score. Cost and resource consumption for the index admission after OHTx were significantly higher in the highest IMPACT risk Q compared with patients in the lowest Q.

Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit.

AIMS AND OBJECTIVES: The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients. BACKGROUND: Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting. METHODS: An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed. RESULTS: Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia. CONCLUSIONS: Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs. RELEVANCE TO CLINICAL PRACTICE: Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.

Left Ventricular Assist Device and Bariatric Surgery: A Bridge to Heart Transplant by Weight and Waiting Time Reduction.

Obesity poses significant challenges in advanced heart failure patients who otherwise meet criteria for listing for heart transplant. We present a patient who underwent bariatric surgery while on LVAD support that subsequently lost weight and was successfully bridged to heart transplantation.

Inferior Vena Cava Stent-Graft Sepsis.

We present the case of a patient with a complicated medical history, which included stent grafting as a life-saving measure for an iatrogenic inferior vena cava (IVC) injury. For persistent sepsis secondary to stent-graft infection, the patient underwent extraction of 2 IVC stent grafts, primary repair of a duodenal-caval fistula, and repair of the IVC with an allograft vein patch. Discussion of this case sought to shed light on the intricacies involved in medical decision making in an era of advanced medical technology.

Left Ventricular Assist Device Use in Minorities: An Analysis of the National Inpatient Sample.

Minorities are less likely to receive a left ventricular assist device (LVAD). This, however, is based on total implant data. By examining rates of LVAD implant among patients admitted with heart failure complicated by cardiogenic shock, we sought to further elucidate LVAD utilization rates and racial disparities. Utilizing the National Inpatient Sample from 2013 to 2019, all patients admitted with a primary diagnosis of heart failure complicated by cardiogenic shock were included for analysis. Those who then received an LVAD during that hospitalization defined the LVAD utilization which was examined for any racial disparities. Left ventricular assist device utilization was low across all racial groups with no significant difference noted in univariate analysis. Non-Hispanic Blacks had the highest length of stay (LOS), the highest proportion of discharge to home (71.52%), and the lowest inpatient mortality (6.33%). Multivariable modeling confirmed the relationship between race and LOS; however, no differences were noted in mortality. Non-Hispanic Blacks were found to be less likely to receive an LVAD; however, when controlling for payer, median household income, and comorbidities, this relationship was no longer seen. Left ventricular assist devices remain an underutilized therapy in cardiogenic shock. When using a multivariable model, race does not appear to affect LVAD utilization.

Reconsidering FDA Guidelines: A Single-Center Experience of Prolonged Impella 5.5 Support.

OBJECTIVE: Impella 5.5 (Abiomed, Danvers, MA, USA) is approved by the US Food and Drug Administration (FDA) for mechanical circulatory support for ≤14 days. It is unknown whether prolonged support is associated with worse outcomes. We sought to review our single-center experience with Impella 5.5 and compare outcomes based on support duration. METHODS: We retrospectively reviewed adult patients (≥18 years old) supported with Impella 5.5 at our institution (May 2020 to April 2023). Patients on prolonged support (>14 days) were compared with those supported for ≤14 days. RESULTS: There were 31 patients supported with Impella 5.5 including 14 (45.2%) supported >14 days. Median support duration for those on prolonged support was 43.5 (interquartile range [IQR] 25 to 63.5) days versus 8 (IQR 6, 13) days for those who were not (P < 0.001). Overall, the device-related complication rate was 9.7% and did not differ between groups (P = 0.08). Overall, 30-day postimplant survival was 71% and did not differ by support duration (P = 0.2). In-hospital mortality was 32% and did not differ between cohorts (P > 0.99). Among those surviving to explant (n = 22), long-term strategy included bridge to durable ventricular assist device (18%, n = 4), cardiac transplant (55%, n = 12), and cardiac recovery (27%, n = 6). CONCLUSIONS: High-risk patients with cardiogenic shock may be supported with Impella 5.5 beyond the FDA-approved duration without increased risk of complications or mortality.

PREDICT HF: Risk stratification in advanced heart failure using novel hemodynamic parameters.

BACKGROUND: Invasive hemodynamics are fundamental in assessing patients with advanced heart failure (HF). Several novel hemodynamic parameters have been studied; however, the relative prognostic potential remains ill-defined. HYPOTHESIS: Advanced hemodynamic parameters provide additional prognostication beyond the standard hemodynamic assessment. METHODS: Patients from the PRognostic Evaluation During Invasive CaTheterization for Heart Failure (PREDICT-HF) registry who underwent right heart catheterization (RHC) were included in the analysis. The primary endpoint was survival to orthotopic heart transplant (OHT) or durable left ventricular assist device (LVAD), or death within 6 months of RHC. RESULTS: Of 846 patients included, 176 (21%) met the primary endpoint. In a multivariate model that included traditional hemodynamic variables, pulmonary capillary wedge pressure (PCWP) (OR: 1.10, 1.04-1.15, p < .001), and cardiac index (CI) (OR: 0.86, 0.81-0.92, p < .001) were shown to be predictive of adverse outcomes. In a separate multivariate model that incorporated advanced hemodynamic parameters, cardiac power output (CPO) (OR: 0.76, 0.71-0.83, p < .001), aortic pulsatility index (API) (OR: 0.94, 0.91-0.96, p < .001), and pulmonary artery pulsatility index (OR: 1.02, 1.00-1.03, p .027) were all significantly associated with the primary outcome. Positively concordant API and CPO afforded the best freedom from the endpoint (94.7%), whilst negatively concordant API and CPO had the worst freedom from the endpoint (61.5%, p < .001). Those with discordant API and CPO had similar freedom from the endpoint. CONCLUSION: The advanced hemodynamic parameters API and CPO are independently associated with death or the need for OHT or LVAD within 6 months. Further prospective studies are needed to validate these parameters and elucidate their role in patients with advanced HF.