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Background: Preoperative amiodarone effects on postorthotopic heart transplant (OHT) outcomes remain controversial. Objective: The purpose of this study was to determine the effect of cumulative pre-OHT amiodarone exposure on severe primary graft dysfunction (PGD). Methods: We retrospectively reviewed adult OHT recipients between August 2012 and June 2018. Primary outcome was severe PGD in patients receiving amiodarone at 3, 6, and 12 months prior to OHT compared with those not receiving amiodarone. Secondary outcomes included intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, early graft failure (EGF), mortality at 3, 6, and 12 months post-OHT, and 30-day incidence of postoperative tachyarrhythmias, bradycardia, permanent pacemaker implantation, and rejection. Results: Incidence of severe PGD was 12.5% in those who received amiodarone compared to 6.8% in those who did not (14 vs 6, P = 0.18). Cumulative preoperative amiodarone significantly increased the odds of severe PGD at 3 months (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.001-1.06; P = 0.044) and 6 months (OR: 1.02, 95% CI: 1.003-1.044; P = 0.024) in a multivariate logistic regression. Patients on amiodarone had significantly higher rates of postoperative bradycardia (13.4% vs 4.5%, P = 0.03). Conclusion and Relevance: A trend toward increased PGD was present in patients receiving preoperative amiodarone. This finding combined with the regression showing significantly increased odds of PGD with increasing 3 and 6 month cumulative amiodarone dose is clinically concerning. Escalation of care with pacemaker implantation was required more frequently in patients on pre-OHT amiodarone. [ABSTRACT FROM AUTHOR]

A 63-year-old male with a history of coronary artery disease and severe aortic stenosis status post mechanical aortic valve replacement and coronary artery bypass presented with atypical chest pain and group B streptococcal bacteremia. His transesophageal echo (TEE) was read as negative for vegetations, and chest computed tomography (CT) was reportedly unremarkable. He was started on antibiotics, and coronary angiography showed severe triple-vessel disease, patent left internal mammary artery graft, and complete occlusion in all vein grafts. Percutaneous intervention with stenting of the left anterior descending and circumflex artery was performed. During the diagnostic angiography, nonselective contrast injection showed an anterior aortic root "pouch" (A, Online video 1), but since the CT was unremarkable, no further investigation was done. A month later, the patient presented with fatigue and persistent bacteremia. TEE showed a large circumferential hypoechoic space with radial strands around the sewing ring of the mechanical valve (B) along with new moderate perivalvular leak (C). A CT scan showed extensive perivalvular and para-aortic contrast collections extending from below the aortic annulus to mid-ascending aorta, consistent with abscesses/pseudoaneurysms (D, E). Both right and left coronary arteries were coursing through these abscesses/ pseudoaneurysms (E, arrows). The mechanical valve was sitting on the abscesses and appeared to be dehiscent (D). Retrospective review of the initial TEE (F) and CT (G) showed evidence of aortic root infection (arrows). The patient underwent aortic root repair and aortic valve replacement. An aortic root pathology specimen showed fibrous growth with calcification and focal acute and chronic inflammation. After a complicated hospital course, the patient was discharged to a rehabilitation facility. Meticulous evaluation with imaging and high index of suspicion is necessary when there is a question about infection in patients with prosthetic valves. [ABSTRACT FROM AUTHOR]