Basiliximab induction versus no induction in adult heart transplantation.

BACKGROUND: Induction immunosuppression in heart transplant recipients varies greatly by center. Basiliximab (BAS) is the most commonly used induction immunosuppressant but has not been shown to reduce rejection or improve survival. The objective of this retrospective study was to compare rejection, infection, and mortality within the first 12 months following heart transplant in patients who received BAS or no induction. METHODS: This was a retrospective cohort study of adult heart transplant recipients given BAS or no induction from January 1, 2017 to May 31, 2021. The primary endpoint was incidence of treated acute cellular rejection (ACR) at 12-months post-transplant. Secondary endpoints included ACR at 90 days post-transplant, incidence of antibody-mediated rejection (AMR) at 90 days and 1 year, incidence of infection, and all-cause mortality at 1 year. RESULTS: A total of 108 patients received BAS, and 26 patients received no induction within the specified timeframe. There was a lower incidence of ACR within the first year in the BAS group compared to the no induction group (27.7 vs. 68.2%, p < .002). BAS was independently associated with a lower probability of having a rejection event during the first 12-months post-transplant (hazard ratio (HR) .285, 95% confidence interval [CI] .142-.571, p < .001). There was no difference in the rate of infection and in mortality after hospital discharge at 1-year post-transplant (6% vs. 0%, p = .20). CONCLUSION: BAS appears to be associated with greater freedom from rejection without an increase in infections. BAS may be a preferred to a no induction strategy in patients undergoing heart transplantation.

Reduction of HLA donor specific antibodies in heart transplant patients treated with proteasome inhibitors for antibody mediated rejection.

In this project, we describe proteasome inhibitor (PI) treatment of antibody-mediated rejection (AMR) in heart transplantation (HTX). From January 2018 to September 2021, 10 patients were treated with PI for AMR: carfilzomib (CFZ) n = 8; bortezomib (BTZ) n = 2. Patients received 1-3 cycles of PI. All patients had ≥1 strong donor-specific antibody (DSA) (mean fluorescence intensity [MFI] > 8000) in undiluted serum. Most DSAs (20/21) had HLA class II specificity. The MFI of strong DSAs had a median reduction of 56% (IQR = 13%-89%) in undiluted serum and 92% (IQR = 53%-95%) at 1:16 dilution. Seventeen DSAs in seven patients were reduced > 50% at 1:16 dilution after treatment. Four DSAs from three patients did not respond. DSA with MFI > 8000 at 1:16 dilution was less responsive to treatment. 60% (6/10) patients presented with graft dysfunction; 4/6 recovered ejection fraction > 40% after treatment. Pathologic AMR was resolved in 5/7 (71.4%) of patients within 1 year after treatment. 9/10 (90%) patients survived to 1 year after AMR diagnosis. Using PI in AMR resulted in significant DSA reduction with some resolution of graft dysfunction. Larger studies are needed to evaluate PI for AMR.

Prospective Evaluation of Coronavirus Disease 2019 (COVID-19) Vaccine Responses Across a Broad Spectrum of Immunocompromising Conditions: the COVID-19 Vaccination in the Immunocompromised Study (COVICS).

BACKGROUND: We studied humoral responses after coronavirus disease 2019 (COVID-19) vaccination across varying causes of immunodeficiency. METHODS: Prospective study of fully vaccinated immunocompromised adults (solid organ transplant [SOT], hematologic malignancy, solid cancers, autoimmune conditions, human immunodeficiency virus [HIV]) versus nonimmunocompromised healthcare workers (HCWs). The primary outcome was the proportion with a reactive test (seropositive) for immunoglobulin G to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain. Secondary outcomes were comparisons of antibody levels and their correlation with pseudovirus neutralization titers. Stepwise logistic regression was used to identify factors associated with seropositivity. RESULTS: A total of 1271 participants enrolled: 1099 immunocompromised and 172 HCW. Compared with HCW (92.4% seropositive), seropositivity was lower among participants with SOT (30.7%), hematological malignancies (50.0%), autoimmune conditions (79.1%), solid tumors (78.7%), and HIV (79.8%) (P < .01). Factors associated with poor seropositivity included age, greater immunosuppression, time since vaccination, anti-CD20 monoclonal antibodies, and vaccination with BNT162b2 (Pfizer) or adenovirus vector vaccines versus messenger RNA (mRNA)-1273 (Moderna). mRNA-1273 was associated with higher antibody levels than BNT162b2 or adenovirus vector vaccines after adjusting for time since vaccination, age, and underlying condition. Antibody levels were strongly correlated with pseudovirus neutralization titers (Spearman r = 0.89, P < .0001), but in seropositive participants with intermediate antibody levels, neutralization titers were significantly lower in immunocompromised individuals versus HCW. CONCLUSIONS: Antibody responses to COVID-19 vaccines were lowest among SOT and anti-CD20 monoclonal recipients, and recipients of vaccines other than mRNA-1273. Among those with intermediate antibody levels, pseudovirus neutralization titers were lower in immunocompromised patients than HCWs. Additional SARS-CoV-2 preventive approaches are needed for immunocompromised persons, which may need to be tailored to the cause of immunodeficiency.

The predictive value of preimplant pulmonary function testing in LVAD patients.

BACKGROUND: The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. METHODS: LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on the presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included 1-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. RESULTS: The total of 333 patients underwent LVAD implant, 46.5% (n = 155) with normal PFTs and 53.5% (n = 178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs. 15.1%, p = .049). In multivariable analysis, the impact of PFTs was most significant when forced expiratory volume in 1 s/forced expiratory volume (FEV1/FVC) ratio was less than 0.5 (hazard ratio [HR] 16.32, 95% confidence interval [CI], 1.70-156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs. 68.8%, p = .3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63, 95% CI, 1.51-4.60 and HR 18.92, 95% CI, 2.10-170.40, respectively). CONCLUSIONS: The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.

Pre-implant right ventricular free wall strain predicts post-LVAD right heart failure.

BACKGROUND: The aim of this study is to evaluate the predictive utility of preoperative right ventricular (RV) global longitudinal strain (GLS) and free wall strain (FWS) on outcomes following left ventricular assist devices (LVADs) implantation. METHODS: Preoperative transthoracic echocardiograms were retrospectively reviewed in adults undergoing continuous-flow LVAD implantation between 2004 and 2018 at a single center. Patients undergoing pump exchange were excluded. RV GLS and FWS were calculated using commercially available software with the apical four-chamber view. The primary outcome was RV failure as defined by the Interagency Registry for Mechanically Assisted Circulatory Support within 1-year post-LVAD insertion. RESULTS: A total of 333 patients underwent continuous-flow LVAD implantation during the study period and 137 had adequate preoperative studies for RV strain evaluation. RV FWS was found to be a significant predictor of postoperative RV failure in univariate analysis (odds ratio [OR] = 1.12, p = .03), and this finding persisted after risk adjustment in multivariable analysis (OR = 1.14, p = .04). Using the optimal cutoff value of -5.64%, the c-index of FWS in predicting RV failure was 0.65. RV GLS was not associated with post-LVAD RV failure (OR = 1.07, p = .29). PCWP was the only additional significant predictor of RV failure using multivariable analysis (OR = 0.90, p = .02). CONCLUSION: Pre-implant RV FWS is predictive of RV failure in the first postoperative year after LVAD implantation.

Twenty-year survival following orthotopic heart transplantation in the United States.

BACKGROUND: This study evaluated 20-year survival after adult orthotopic heart transplantation (OHT). METHODS: The United Network of Organ Sharing Registry database was queried to study adult OHT recipients between 1987 and 1998 with over 20-year posttransplant follow-up. The primary and secondary outcomes were 20-year survival and cause of death after OHT, respectively. Multivariable logistic regression was used to identify significant independent predictors of long-term survival, and long-term survival was compared among cohorts stratified by number of predictors using Kaplan Meier survival analysis. RESULTS: 20,658 patients undergoing OHT were included, with a median follow-up of 9.0 (IQR, 3.2-15.4) years. Kaplan-Meier estimates of 10-, 15-, and 20-year survival were 50.2%, 30.1%, and 17.2%, respectively. Median survival was 10.1 (IQR, 3.9-16.9) years. Increasing recipient age (>65 years), increasing donor age (>40 years), increasing recipient body mass index (>30), black race, ischemic cardiomyopathy, and longer cold ischemic time (>4 h) were adversely associated with a 20-year survival. Of these 6 negative predictors, presence of 0 risk factors had the greatest 10-year (59.7%) and 20-year survival (26.2%), with decreasing survival with additional negative predictors. The most common cause of death in 20-year survivors was renal, liver, and/or multisystem organ failure whereas graft failure more greatly impacted earlier mortality. CONCLUSIONS: This study identifies six negative preoperative predictors of 20-year survival with 20-year survival rates exceeding 25% in the absence of these factors. These data highlight the potential for very long-term survival after OHT in patients with end-stage heart failure and may be useful for patient selection and prognostication.

Direct bridging to cardiac transplantation with the surgically implanted Impella 5.0 device.

This study evaluated outcomes of direct bridging to orthotopic heart transplantation (OHT) with the Impella 5.0 device. Adult recipients in the United Network for Organ Sharing registry bridged to OHT with the Impella 5.0 device between 2010 to 2018 were included. Outcomes included waitlist and post-transplant survival. A total of 236 patients were wait-listed with Impella 5.0 support, and 24% (n = 57) underwent bridge to OHT. Early and late post-transplant survival was excellent at 96.5% at 30 day, 93.8% at 90-day, and 90.3% at 1-year follow-up. Post-transplant complications were infrequent, but the most common were renal failure requiring dialysis (8.8%, n = 5), cerebrovascular accidents (1.8%, n = 1), and pacemaker implant (1.8%, n = 1). The rate of waitlist removal for death or clinical deterioration was 20.0% (n = 47); however, the majority of patients were bridged to OHT (24%, n = 57) or durable continuous-flow left ventricular assist device (37.0%, n = 87). The median time supported on the device, while waitlisted was 13 days (Interquartile range [IQR] 7, 20 days). The Impella 5.0 device can be used as a direct bridge to OHT with excellent survival and minimal post-transplant morbidity. Overall, these data support the utilization of Impella 5.0 as a bridge to OHT in select patients with refractory cardiogenic shock.

Concomitant abdominal exploration with durable left ventricular assist device implantation.

A 45-year-old male presented in decompensated heart failure from nonischemic cardiomyopathy and was implanted with a right transaxillary intra-aortic balloon pump. He was listed for heart transplantation but after 9 days, he developed abdominal pain with evidence of embolization on computed tomography scan despite a well-positioned balloon pump. He underwent concomitant abdominal exploration with small bowel resection and durable left ventricular assist device implantation. He recovered well and was discharged home. This case highlights the challenges of decision-making in the current era where intra-aortic balloon pumps are being utilized more frequently as a bridge to heart transplantation.

Temporary left ventricular assist devices as a bridge to heart transplantation.

BACKGROUND: To create equitable access to donor organs for the highest mortality patients, the cardiac transplant allocation system now prioritizes patients with surgically implanted temporary left ventricular assist devices (T-LVADs). The outcomes following a direct bridge from a T-LVAD to orthotopic heart transplant (OHT) are not well delineated. AIM: This study investigates the T-LVAD waitlist outcomes and compares the posttransplant outcomes in patients bridged to OHT with surgically implanted T-LVADs to patients bridged with durable continuous-flow left ventricular assist devices (CF-LVADs). METHODS: Adults recorded in the United Network for Organ Sharing registry bridged to OHT with a durable CF-LVAD and T-LVADs, with or without temporary right ventricular assist devices (T-RVADs), between 2010 and 2018 were included. Propensity matching and multivariable Cox regression were utilized to compare outcomes. RESULTS: Of 504 patients waitlisted with T-LVADs, the majority were transplanted (50%), bridged to CF-LVAD (17%), or recovered (9%). A total of 9047 recipients were bridged to OHT during the study period with 8875 CF-LVADs and 172 T-LVADs. Early survival in propensity-matched T-LVAD ± T-RVAD patients was similar to CF-LVAD ± T-RVAD patients but reduced at a 1-year follow-up. This difference in survival at 1-year follow-up was attributable to significantly reduced survival in patients with combined T-LVAD + T-RVAD support when compared with CF-LVAD, isolated T-LVAD and combined CF-LVAD + T-RVAD support (80% vs 90% vs 90% vs 91%; P = .005). CONCLUSIONS: This study demonstrates that most patients waitlisted with a T-LVAD are successfully bridged to durable therapy or recover, and those bridged to OHT have acceptable posttransplant outcomes, particularly when T-RVADs are not required.

Nationwide variability in the use of induction immunosuppression for adult heart transplantation.

BACKGROUND: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes. METHODS: Adult OHT patients between 2010 and 2018 were identified from the United Network for Organ Sharing registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1 year as primary endpoint and individual centers as a random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes. RESULTS: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n = 8411) with substantial variability between centers (interquartile range, 21.4%-79.1%). There were 36, 30, and 34 centers in the low (<29%), intermediate (29%-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1 year among centers after adjusting for donor and recipient factors (p = .20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p > .05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r = .03) or high (r = .04) baseline risks for acute rejection at 1 year. CONCLUSIONS: This analysis demonstrates that there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT.

Outcomes of left ventricular assist device implantation in hypercoagulable patients.

BACKGROUND: The aim of this study was to evaluate outcomes of left ventricular assist devices (LVADs) in patients who tested positive for hypercoagulable hematologic disorders. METHODS: Adults undergoing continuous-flow LVAD implantation with preoperative hypercoagulability testing between 2004 and 2018 at a single center were reviewed. Hypercoagulability was defined as testing positive for antiphospholipid antibody, anticardiolipin antibody, lupus anticoagulant, protein C, protein S, factor V Leiden, and/or heparin-induced thrombocytopenia. The primary outcome was survival on the original LVAD. Secondary outcomes included rates of thromboembolic complications and readmission for intravenous heparin treatment. RESULTS: A total of 270 LVAD patients with pre-implant hypercoagulability testing were included, and 157 (58%) tested positive for a hypercoagulable disorder. Of those testing positive, 10 (6.4%) had a clinical pre-LVAD history of thromboembolic events. Survival was comparable between hypercoagulable and non-hypercoagulable patients (1 year: 73.3% vs 78.9%, P = .2195, 2-year: 60.7% vs 62.8%, P = .3627). Rates of pump thrombosis (14.0% vs 13.3%, P = .8618), hemolysis (4.5% vs 3.5%, P = .3536), stroke (18.5% vs 14.2%, P = .3483) and readmission for IV heparin therapy (87.3% (n = 137) vs 77.9% (n = 88), P = .7560) were similar. Outcomes were comparable in patients with positive hypercoagulable tests when stratified by pre-implant clinical history of hypercoagulability as well as stratified by recent preoperative exposure to heparin or warfarin. CONCLUSIONS: In this series, positive laboratory tests for hypercoagulability were common amongst patients undergoing LVAD implantation although few had positive clinical histories. Survival and freedom from thromboembolic complications were comparable to non-hypercoagulable patients. Hypercoagulability alone should therefore not serve as a contraindication to LVAD implantation.

Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone?

BACKGROUND: Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT). METHODS: We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors. RESULTS: Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083). CONCLUSIONS: PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.

Hemodynamic transesophageal echocardiography after left ventricular assist device implantation.

OBJECTIVE: The authors hypothesized that the clinical profile of patients undergoing hTEE after continuous flow left ventricular assist device (CF-LVAD) implant would be in patients with greater acuity, more blood product utilization, and longer length of ICU stay, and that hTEE would change clinical management. DESIGN: Retrospective review. SETTING: University hospital. PARTICIPANTS: One hundred consecutive patients receiving a CF-LVAD. INTERVENTIONS: Retrospective review using a standardized electronic form of a miniaturized disposable transesophageal echocardiography probe that documented not only physical findings but also changes in hemodynamic management (hTEE) in CF-LVAD patients. MEASUREMENTS AND MAIN RESULTS: Of the 100 patients, 41 received an hTEE probe. The INTERMACS score, Leitz-Miller Score, and Kormos score indicated the hTEE group had a statistically significant greater risk of morbidity and mortality. Interoperatively, the hTEE group received more blood products and was more likely to have an open chest. Postoperatively, the hTEE group received more blood products, had a longer total length of stay, and had increased mortality. ICU length of stay, days on inotropes and days on mechanical ventilation were not statistically significant between the 2 groups. Information obtained from hTEE changed ICU management in 72% of studies. CONCLUSION: Retrospective review of CF-LVAD patients revealed that postoperative hTEE is used in sicker CF-LVAD patients and frequently leads to changes in ICU clinical management.

Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors.

OBJECTIVE: To quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. METHODS: The United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. RESULTS: A total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score-matched cohorts of DBD and DCD recipients. CONCLUSIONS: The use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.

Improved waitlist and comparable post-transplant outcomes in simultaneous heart-kidney transplantation under the 2018 heart allocation system.

OBJECTIVE: This study aimed to investigate the clinical trends and the impact of the 2018 heart allocation policy change on both waitlist and post-transplant outcomes in simultaneous heart-kidney transplantation in the United States. METHODS: The United Network for Organ Sharing registry was queried to compare adult patients before and after the allocation policy change. This study included 2 separate analyses evaluating the waitlist and post-transplant outcomes. Multivariable analyses were performed to determine the 2018 allocation system's risk-adjusted hazards for 1-year waitlist and post-transplant mortality. RESULTS: The initial analysis investigating the waitlist outcomes included 1779 patients listed for simultaneous heart-kidney transplantation. Of these, 1075 patients (60.4%) were listed after the 2018 allocation policy change. After the policy change, the waitlist outcomes significantly improved with a shorter waitlist time, lower likelihood of de-listing, and higher likelihood of transplantation. In the subsequent analysis investigating the post-transplant outcomes, 1130 simultaneous heart-kidney transplant recipients were included, where 738 patients (65.3%) underwent simultaneous heart-kidney transplantation after the policy change. The 90-day, 6-month, and 1-year post-transplant survival and complication rates were comparable before and after the policy change. Multivariable analyses demonstrated that the 2018 allocation system positively impacted risk-adjusted 1-year waitlist mortality (sub-hazard ratio, 0.66, 95% CI, 0.51-0.85, P < .001), but it did not significantly impact risk-adjusted 1-year post-transplant mortality (hazard ratio, 1.03; 95% CI, 0.72-1.47, P = .876). CONCLUSIONS: This study demonstrates increased rates of simultaneous heart-kidney transplantation with a shorter waitlist time after the 2018 allocation policy change. Furthermore, there were improved waitlist outcomes and comparable early post-transplant survival after simultaneous heart-kidney transplantation under the 2018 allocation system.

Impact of post-transplant stroke and subsequent functional independence on outcomes following heart transplantation under the 2018 United States heart allocation system.

BACKGROUND: This study evaluates the clinical trends, risk factors, and effects of post-transplant stroke and subsequent functional independence on outcomes following orthotopic heart transplantation under the 2018 heart allocation system. METHODS: The United Network for Organ Sharing registry was queried to identify adult recipients from October 18, 2018 to December 31, 2021. The cohort was stratified into 2 groups with and without post-transplant stroke. The incidence of post-transplant stroke was compared before and after the allocation policy change. Outcomes included post-transplant survival and complications. Multivariable logistic regression was performed to identify risk factors for post-transplant stroke. Sub-analysis was performed to evaluate the impact of functional independence among recipients with post-transplant stroke. RESULTS: A total of 9,039 recipients were analyzed in this study. The incidence of post-transplant stroke was higher following the policy change (3.8% vs 3.1%, p = 0.017). Thirty-day (81.4% vs 97.7%) and 1-year (66.4% vs 92.5%) survival rates were substantially lower in the stroke cohort (p < 0.001). The stroke cohort had a higher rate of post-transplant renal failure, longer hospital length of stay, and worse functional status. Multivariable analysis identified extracorporeal membrane oxygenation, durable left ventricular assist device, blood type O, and redo heart transplantation as strong predictors of post-transplant stroke. Preserved functional independence considerably improved 30-day (99.2% vs 61.2%) and 1-year (97.7% vs 47.4%) survival rates among the recipients with post-transplant stroke (p < 0.001). CONCLUSIONS: There is a higher incidence of post-transplant stroke under the 2018 allocation system, and it is associated with significantly worse post-transplant outcomes. However, post-transplant stroke recipients with preserved functional independence have improved survival, similar to those without post-transplant stroke.

An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device.

Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.

Impact of 2018 allocation system change on outcomes in patients with durable left ventricular assist device as bridge to transplantation: A UNOS registry analysis.

BACKGROUND: This study compared outcomes of patients waitlisted for orthotopic heart transplantation with durable left ventricular assist devices (LVAD) before and after the October 18, 2018 heart allocation policy change. METHODS: The United Network of Organ Sharing database was queried to identify 2 cohorts of adult candidates with durable LVAD listed within seasonally-matched, equal-length periods before (old policy era [OPE]) and after the policy change (new policy era [NPE]). The primary outcomes were 2-year survival from the time of initial waitlisting, as well as 2-year post-transplant survival. Secondary outcomes included incidence of transplantation from the waitlist and de-listing due to either death or clinical deterioration. RESULTS: A total of 2,512 candidates were waitlisted, 1,253 within the OPE and 1,259 within the NPE. Candidates under both policies had similar 2-year survival after waitlisting, as well as a similar cumulative incidence of transplantation and de-listing due to death and/or clinical deterioration. A total of 2,560 patients were transplanted within the study period, 1,418 OPE and 1,142 within the NPE. Two-year post-transplant survival was similar between policy eras, however, the NPE was associated with a higher incidence of post-transplant stroke, renal failure requiring dialysis, and a longer hospital length of stay. CONCLUSIONS: The 2018 heart allocation policy has conferred no significant impact on overall survival from the time of initial waitlisting among durable LVAD-supported candidates. Similarly, the cumulative incidence of transplantation and waitlist mortality have also been largely unchanged. For those undergoing transplantation, a higher degree of post-transplant morbidity was observed, though survival was not impacted.

Impact of a Medication Optimization Clinic on Heart Failure Hospitalizations.

Efforts to optimize guideline-directed medical therapy (GDMT) through team-based care may affect outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This study evaluated the impact of an innovative medication optimization clinic (MOC) on GDMT and outcomes in patients with HFrEF. Patients with HFrEF who are not receiving optimal GDMT are referred to MOC and managed by a team comprised of a nurse practitioner or physician assistant, clinical pharmacist, and HF cardiologist. We retrospectively evaluated the impact of MOC (n = 206) compared with usual care (n = 412) with a 2:1 propensity-matched control group. The primary clinical outcome was the incidence of HF hospitalizations at 3 months after the index visit. Kaplan-Meier cumulative event curves and Cox proportional hazards regression models with adjustment were conducted. A significantly higher proportion of patients in MOC received quadruple therapy (49% vs 4%, p <0.0001), angiotensin receptor neprilysin inhibitor (60% vs 27%, p <0.0001), mineralocorticoid receptor antagonist (59% vs 37%, p <0.0001), and sodium-glucose cotransporter-2 inhibitor (60% vs 10%, p <0.0001). The primary outcome was significantly lower in the MOC versus the control group (log-rank, p = 0.0008). Cox regression showed that patients in the control group were more than threefold more likely to be hospitalized because of HF than those in the MOC group (p = 0.0014). In conclusion, the MOC was associated with improved GDMT and lower risk of HF hospitalizations in patients with HFrEF.