Benefits of both physical assessment and electronic health record review to assess frailty prior to heart transplant.

INTRODUCTION: Frailty status affects outcomes after heart transplantation, but the optimal way to assess frailty prior to transplant remains unknown. METHODS: This single-center, observational study assessed 44 heart transplant candidates for frailty using three methods. The Short Physical Performance Battery (SPPB) and Fried Frailty Phenotype (FFP) were used as two physical assessments of frailty. The Frailty Risk Score (FRS) was used as a chart-review based assessment measuring 20 different biopsychosocial and functional components, including biomarkers, depression, cognitive impairment, and sleep. RESULTS: We determined the correlation between FRS, SPPB, and FFP and how each correlated with clinical outcomes. Of 44 participants, mean age was 60 years. FRS correlated with SPPB and FFP (P = .043, P < .001, respectively). Higher frailty as measured by SPPB and FRS was significantly associated with lack of achieving waitlist status (P = .022; P = .002) and not being transplanted (P = .026; P = .008). Higher frailty by SPPB and FFP was also associated with mortality (P = .010; P = .025). CONCLUSION: SPPB and chart-review FRS showed potential for predicting waitlist and transplant status of heart transplant candidates, while SPPB and FFP were associated with mortality. Additional studies may serve to validate these observations.

Impact of solid organ transplant status on outcomes of hospitalized patients with COVID-19 infection.

BACKGROUND: The COVID-19 pandemic has caused significant morbidity and mortality in solid organ transplant (SOT) recipients. However, it remains unclear whether the risk factor for SOT patients is the immunosuppression inherent to transplantation versus patient comorbidities. METHODS: We reviewed outcomes in a cohort of SOT (n = 129) and non-SOT (NSOT) patients (n = 708) admitted to the University of California, Los Angeles for COVID-19 infection. Data analyses utilized multivariate logistic regression to evaluate the impact of patient demographics, comorbidities, and transplant status on outcomes. SOT patients were analyzed by kidney SOT (KSOT) versus nonkidney SOT (NKSOT) groups. RESULTS: SOT and NSOT patients with COVID-19 infection differed in terms of patient age, ethnicity, and comorbidities. NKSOT patients were the most likely to experience death, with a mortality rate of 16.2% compared with 1.8% for KSOT and 8.3% for NSOT patients (p = .013). Multivariable analysis of hospitalized patients revealed that patient age (odds ratio [OR] 2.79, p = .001) and neurologic condition (OR 2.66, p < .001) were significantly associated with mortality. Analysis of ICU patients revealed a 2.98-fold increased odds of death in NKSOT compared with NSOT patients (p = .013). CONCLUSIONS: This study demonstrates the importance of transplant status in predicting adverse clinical outcomes in patients hospitalized or admitted to the ICU with COVID-19, especially for NKSOT patients. Transplant status and comorbidities, including age, could be used to risk stratify patients with COVID-19. This data suggests that immunosuppression contributes to COVID-19 disease severity and mortality and may have implications for managing immunosuppression, especially for critically ill patients admitted to the ICU.

COVID-19 in a high-risk dual heart and kidney transplant recipient.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly infecting people worldwide, resulting in the infectious disease coronavirus disease 19 (COVID-19) that has been declared a pandemic. Much remains unknown about COVID-19, including its effects on solid organ transplant (SOT) recipients. Given their immunosuppressed state, SOT recipients are presumed to be at high risk of complications with viral infections such as SARS-CoV-2. Limited case reports in single SOT recipients, however, have not suggested a particularly severe course in this population. In this report, we present a dual-organ (heart/kidney) transplant recipient who was found to have COVID-19 and, despite the presence of a number of risk factors for poor outcomes, had a relatively mild clinical course.

Heart transplantation in the early phase of the COVID-19 pandemic: A single-center case series.

The infectious disease coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization in March 2020. The impact of COVID-19 on solid organ transplantations, including heart transplantation, is currently unclear. Many transplant programs have been forced to swiftly re-evaluate and adapt their practices, leading to a marked decrease in transplants performed. This trend has been due to various factors, including increased donor COVID-19 screening scrutiny and recipient waiting list management in anticipation of COVID-19 critical care surge capacity planning. In the face of these unknown variables, determining when and how to proceed with transplantation in our population of patients with end-stage cardiomyopathies is challenging. Here, we describe our center's experience with orthotopic heart transplantation (OHT) in one of the country's pandemic epicenters, where we performed eight OHTs in the first 2 months after community spread began in late February 2020.

Higher-risk SIPAT score predicts increased risk of long-term mortality in orthotopic heart transplant recipients.

BACKGROUND: Orthotopic heart transplantation (OHT) improves survival in eligible patients. Organ scarcity necessitates extensive clinical and psychosocial evaluations before listing. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) predicts risk for poor psychosocial outcomes and morbidity in the first year post-transplant, yet it is unknown whether it predicts long-term outcomes. METHODS: Blinded examiners obtained data from a retrospective cohort of 51 OHT recipients from a high-volume center. Patients with "Excellent" or "Good" SIPAT score indicating low psychosocial risk for transplant (E/G) were compared with those who met "Minimum Acceptable Criteria" or were "High Risk" (MAC/HR). Associations were examined between SIPAT group and outcomes. RESULTS: MAC/HR versus E/G recipients had significantly reduced survival in the 10 years post-OHT (mean 6.7 vs 8.8 years, p = 0.027; 55% vs 82% survival proportions, p = 0.037). MAC/HR patients were more likely to live in a county with greater income inequality (p = 0.025) and have psychiatric history pre-OHT (p = 0.046). Both groups had otherwise similar demographics and medical history. A lower proportion of MAC/HR patients adhered to medications post-OHT and a greater proportion had psychiatric illness, though differences were not significant. CONCLUSIONS: Higher-risk SIPAT scores predict reduced long-term survival post-OHT. Further efforts are crucial to improve outcomes in higher-risk patients.

Observations and Single-Center Outcomes in Orthotopic Heart Transplant for Patients With Adult Congenital Heart Disease: A Call for Equity and Parity.

BACKGROUND: For persons with adult congenital heart disease (ACHD), optimum patient selection and eligibility for orthotopic heart transplant (OHT) is not well defined. There is difficulty quantifying risk in patients with ACHD, leading to variability in OHT listing time and status. They are often disadvantaged due to a lack of mechanical support options, a shortage of congenital surgeons, and encounters with risk adverse health care programs. We examined patient characteristics and outcomes of a contemporary cohort of patients with ACHD undergoing OHT at a single high-volume Adult Congenital Heart Association accredited transplant center. METHODS: Retrospective analysis of 49 consecutive patients with ACHD who underwent OHT from November 2010 through March 2020 was performed. Survival analysis was performed using Kaplan-Meier analysis. RESULTS: Survival at 1 month, 1 year, 3 years, and 10 years was 94%, 92%, 92%, and 83%, respectively. CONCLUSIONS: This study highlights the diversity and complexity of the population with ACHD proceeding to OHT as well as the multispecialty care needed to overcome disadvantages and optimize survival. Continued national discussions and policy adjustments will be necessary to bring parity and equity to this unique population.

Variability in Donor-Derived Cell-Free DNA Scores to Predict Mortality in Heart Transplant Recipients - A Proof-of-Concept Study.

BACKGROUND: Over the last decade, expanding use of molecular diagnostics in heart transplantation has allowed implementation of non-invasive surveillance strategies for monitoring allograft health. The commercially available HeartCare platform combines the AlloMap gene expression profiling assay and the AlloSure donor-derived cell-free DNA test (dd-cfDNA). Beyond their established use for assessment of rejection, evidence is building for predictive utility, with the longitudinal AlloMap Variability score previously shown to correlate with the risk of future rejection, graft dysfunction, re-transplantation, or death. In this single-center, retrospective pilot study, we evaluated the performance of a novel AlloSure Variability metric in predicting mortality in a cohort of heart transplant recipients. METHODS: Seventy-two adult heart transplant recipients with at least 3 concurrent AlloMap/AlloSure results were included. Demographic, clinical, imaging, and laboratory parameters were captured. Variability was defined as the standard deviation of longitudinal AlloMap/AlloSure results. A Cox multivariable adjusted proportional hazards model was used to evaluate the variability metrics as predictors of mortality. Associations between AlloMap/AlloSure variability and donor specific antibody (DSA) status were also assessed. RESULTS: A total of 5 patients (6.9%) died during a median follow-up of 480 days. In a univariate Cox proportional hazards model, higher AlloSure variability (HR 1.66, 95%CI 1.14 - 2.41), but not AlloMap variability or the cross-sectional AlloSure/AlloMap results was associated with increased mortality risk. Longitudinal AlloSure variability was also higher among patients with both preformed DSA and those developing de novo DSA. CONCLUSION: Our results suggest that increased variability of dd-cfDNA in heart transplant patients is associated with both mortality risk and the presence of donor specific antibodies. These findings highlight the added value of longitudinal data in the interpretation of AlloMap/AlloSure scores in this population and open the door to larger studies investigating the utility of these metrics in shaping post-transplant clinical care paradigms.

Evaluating factors of greater patient satisfaction with outpatient cardiology telehealth visits during the COVID-19 pandemic.

BACKGROUND: The impact of telehealth on cardiovascular care during the COVID-19 pandemic on patient satisfaction and factors associated with satisfaction are not well characterized. METHODS: We conducted a nonrandomized, prospective cross-sectional survey study for outpatient telehealth cardiovascular visits over a 169-day period utilizing a validated telehealth usability questionnaire. For each variable, patients were divided into 2 groups-1 with scores above the median, labeled "greater satisfaction," and the other with scores below the median, labeled "less satisfaction." RESULTS: A total of 13,913 outpatient telehealth encounters were successfully completed during the study period. A total of 7327 unique patients were identified and received a survey invitation; 5993 (81.8%) patients opened the invitation, and 1034 (14.1%) patients consented and completed the survey. Overall mean and median scores were 3.15 (standard deviation 0.74) and 3.37 (interquartile range 2.73-3.68) (maximum score 4.00). Greater satisfaction was noted among younger patients (mean age 63.3 ± 14.0 years, P = .005), female gender (46.3%, P = .007), non-White ethnicity (24.2% P = .006), self-identified early adopters and innovators of new technology (49.8%, P < .001), 1-way travel time greater than 1 hour (22.3%, P < .001), 1-way travel distance greater than 10 miles (49.0%, P < .001), patients needing child care arrangement (16.4%, P < .001), and history of orthotopic heart transplant (OHT) (5.1%, P = .04). CONCLUSION: Patients reported overall satisfaction with telehealth during the COVID-19 pandemic. Factors associated with patient convenience, along with female gender, younger age, and non-White ethnicity, correlated with greater satisfaction. Cardiovascular comorbidities did not correlate with greater satisfaction except for OHT. Further research into the impact of telehealth on patient satisfaction, safety, and clinical outcomes is needed.

Sodium-Glucose Cotransporter-2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Orthotopic Heart Transplant in a Prediabetic Patient: A Case Report.

Postoperative euglycemic diabetic ketoacidosis (euDKA) associated with sodium-glucose cotransporter-2 (SGLT2) inhibitor use has been well-documented and carries a Food and Drug Administration recommendation to hold SGLT2 inhibitors 3 to 4 days before a planned surgical procedure. Unfortunately, many surgical procedures, such as orthotopic heart transplant (OHT), are unplanned and unpredictable. With the increasing use of SGLT2 inhibitors in diabetic and non-diabetic heart failure patients, new challenges in patient management and perioperative risk have arisen. We report a case in which SGLT2 inhibitor-associated euDKA complicated the postoperative course of a prediabetic patient who had undergone OHT.

Anatomical variance in acetabular anteversion does not predict hip fracture patterns in the elderly: a retrospective study in 135 patients.

It has been suggested that variances in the anatomy of the acetabulum determine the type of hip fracture in elderly patients. Based on this concept, an overly anteverted acetabulum would lead to impingement of the femoral neck against the posterior rim of the acetabulum, causing a femoral neck fracture, whereas with a retroverted acetabulum, external rotation of the hip would be limited by the capsular tissues attached to the trochanteric region, causing a trochanteric fracture. To test the hypothesis that acetabular version predicts hip fracture type in elderly patients, we measured acetabular version using computed tomography scans for 135 patients with hip fracture. Logistic regression analysis was used to check for an association between version angle and fracture type. No significant relationship between acetabular version and fracture type was found. Therefore, we conclude that acetabular version angle does not predict hip fracture type in the elderly, and our data do not support the impingement concept as the mechanism of hip fractures.