Search

BACKGROUND: In heart transplant recipients, right ventricular (RV) dysfunction may occur for a variety of reasons. Whether RV dysfunction in the stable phase after heart transplantation is associated with long-term adverse outcomes is unknown. We aimed to determine the long-term prognostic significance of RV dysfunction identified on cardiovascular magnetic resonance imaging (CMR) at least 1 year after heart transplantation. METHODS: In consecutive heart transplant recipients who underwent CMR for surveillance, we assessed 2 CMR measures of RV function: RV ejection fraction and RV global longitudinal strain (RVGLS). We investigated associations between RV dysfunction and a composite end point of death or major adverse cardiac events, including retransplantation, nonfatal myocardial infarction, coronary revascularization, and heart failure hospitalization. RESULTS: A total of 257 heart transplant recipients (median age, 59 years; 75% men) who had CMR at a median of 4.3 years after heart transplantation were included. Over a median follow-up of 4.4 years after the CMR, 108 recipients experienced death or major adverse cardiac events. In a multivariable Cox regression analysis adjusted for age, time since transplantation, indication for transplantation, cardiac allograft vasculopathy, history of rejection, and CMR covariates, RV ejection fraction was not associated with the composite end point, but RVGLS was independently associated with the composite end point with a hazard ratio of 1.08 per 1% worsening in RVGLS ([95% CI, 1.00-1.17]; P=0.046). RVGLS provided incremental prognostic value over other variables in multivariable analyses. The association was replicated in subgroups of recipients with normal RV ejection fraction and recipients with late gadolinium enhancement imaging. A similar association was seen with a composite end point of cardiovascular death or major adverse cardiac events. CONCLUSIONS: CMR feature tracking-derived RVGLS assessed at least 1 year after heart transplantation was independently associated with the long-term risk of death or major adverse cardiac events. Future studies should investigate its role in guiding clinical decision-making in heart transplant recipients. [ABSTRACT FROM AUTHOR]

Heart failure affects millions of individuals worldwide with further anticipated growth in the future. Echocardiography (TTE) and right heart catheterization (RHC) are commonly utilized to establish the diagnosis, longitudinally follow, and risk stratify these patients while also providing therapeutic guidance. There is a growing need for non-invasive hemodynamic monitoring systems that are cost effective, easy to use, and provide reliable/actionable information. To evaluate the feasibility and clinical utility of the Cardiac Performance System (CPS) developed by Sensydia. 50 consecutive patients presenting for RHC were enrolled in the study. Assessment using the CPS system takes 3 minutes during which the biosensors attached to the skin collect acoustic and ECG signals that are analyzed by proprietary machine learning algorithms. Immediately following, RHC was performed per routine protocol. Safety and tolerability were evaluated. In addition, data collected from CPS were correlated to the hemodynamic parameters obtained invasively, including pulmonary artery and wedge pressures, as well as cardiac output. Echocardiographic data from within 6 months were also collected. Investigators were blinded to the recorded information. The protocol was approved by the institutional IRB. All 50 approached individuals were successfully enrolled. There were no complications or adverse reactions related to the CPS assessment, and patients tolerated the measurement well. As previously shown, there was close correlation with left ventricular ejection fraction measurement on TTE. Final comparison between the CPS data and invasive hemodynamic parameters is under way, but preliminary information suggests good accuracy. The development of non-invasive, low-cost, easy to use hemodynamic assessment tools are gaining momentum and have the potential to revolutionize heart failure management. Once accuracy and reproducibility are proven, measurements could be taken daily in the hospital or at the home setting enabling personalized treatment adjustments. In addition, they would eliminate the risks associated with obtaining invasive hemodynamics, reduce healthcare costs, and improve patient and caregiver quality of life significantly. [ABSTRACT FROM AUTHOR]

The Revivent TC System (BioVentrix Inc, San Ramon, CA) enables a less invasive approach for left ventricular reshaping and scar exclusion in selected patients with ischemic cardiomyopathy. Although the system is designed to improve quality of life and to promote reverse remodeling, patients can still progress to end-stage heart failure requiring advanced therapies. This report describes a case of left ventricular assist device surgery in a patient 16 months after Revivent System implantation. The planning process and surgical technique proved to be complex. This case report can help provide guidance to advanced heart failure teams who encounter patients with the Revivent System who require left ventricular assist device support. [ABSTRACT FROM AUTHOR]

The United Network of Organ Sharing (UNOS) enacted a significant update to the heart allocation policy in October 2018. One of the aims of this change was to reduce waitlist mortality by allocating organs to those with the most urgent need. While published data indicate favorable consequences for heart alone recipients, little information exists for simultaneous heart-kidney (SHK) candidates. This study was designed to evaluate the effect of the UNOS heart allocation policy update on SHK transplant efficiency and waitlist mortality. Utilizing the Scientific Registry of Transplant Recipients (SRTR) standard analysis file, we identified all adults with eGFR<45, and either an LVAD or no device, who were listed for SHK transplantation (defined as a heart and kidney listing within one day) between 1/1/2010 and 3/2/2022. Recipients were stratified into pre- and post-allocation policy update cohorts based on the date of SHK listing, and all further comparisons were made between these. Patients were further categorized into 3 sub-groups: those on dialysis, eGFR 0-30 mL/min, and 30-45 mL/min. For each of these three groups, the cumulative incidence of 30-day waitlist mortality, and SHK transplant were considered within a Fine-Gray competing risks framework, and the subdistribution compared between allocation cohorts. All analyses were performed in R, version 4.2.1 A total of 1662 patients were included in this analysis (821 from the pre- and 841 from the post-heart allocation change era). There was no significant difference in baseline demographic parameters. The number of SHK candidates with a durable LVAD was lower, and pre-transplant temporary mechanical circulatory support device utilization was higher in the post-allocation change era. There was a significant difference in the likelihood of undergoing SHK transplant within 30 days (with increased utilization in the post-allocation cohort), both for those on dialysis and with eGFR 0-30 mL/min (p<0.001 for both). The 30-day cumulative incidence of SHK transplant for the pre- and post-cohorts was 13.2% vs. 34.4% (dialysis cohort) and 18.9% vs. 33.4% for patients with eGFR 0-30 mL/min. There was no difference for those with eGFR 30-45 mL/min (p=0.071); 30-day estimates were 23.8% vs. 31.5%, respectively (Figure). We found no difference in the incidence of 30-day waitlist mortality for any of the groups (p>0.75 in all cases). Transplant efficiency of SHK candidates increased significantly following the heart allocation policy change with the effect most profound for those on dialysis. Further, long-term follow-up using larger cohorts will be necessary to verify and extend these early findings. [ABSTRACT FROM AUTHOR]

Background: In PARADIGM-HF, sacubitril/valsartan improved quality of life (QOL) versus enalapril in heart failure with reduced ejection fraction (HFrEF), yet limited data are available regarding QOL changes after sacubitril/valsartan initiation in routine practice.Methods: PROVIDE-HF was a prospective study within a national research network (Patient-Centered Outcomes Research Network) of HFrEF outpatients recently initiated on sacubitril/valsartan versus controls with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change. The primary end point was mean Kansas City Cardiomyopathy Questionnaire (KCCQ) change through 12 weeks. Other end points included responder analyses: ≥5-point and ≥20-point KCCQ increase. Adjusted QOL change was estimated after propensity score weighting.Results: Overall, 270 patients had both baseline and 12-week KCCQ data (151 sacubitril/valsartan; 119 control). The groups had similar demographics and HF details: median EF 28% and N-terminal pro-brain natriuretic peptide 1083 pg/mL. Sacubitril/valsartan patients had larger improvements in KCCQ (mean difference +4.76; P = .027) and were more likely to have a ≥5-point and ≥20-point response (all P < .05). Adjusted comparisons demonstrated similar numerical improvements in the change in KCCQ (+4.55; 95% CI -0.89 to 9.99; P = .101) and likelihood of ≥5-point increase (odds ratio 1.55; 95% CI: 0.84-2.86; P = .16); ≥20-point increase remained statistically significant (odds ratio 3.79; 95% CI 1.47-9.73; P = .006).Conclusions: In this prospective HFrEF study of sacubitril/valsartan initiation compared with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change, the between-group difference in the primary end point, mean KCCQ change at 12 weeks was not statistically significant following adjustment, but sacubitril/valsartan initiation was associated with early improvements in QOL and a higher likelihood of ≥20-point improvement in KCCQ at 12 weeks. These data add additional real-world evidence related to patient-reported outcomes following the initiation of sacubitril/valsartan in routine clinical practice. [ABSTRACT FROM AUTHOR]

Furoscix is a 80mg/10mL buffered formulation of furosemide developed for subcutaneous self-administration in the outpatient setting via a wearable, pre-programmed infusor over 5 hours. In the FREEDOM-HF observational study and the AT HOME-HF randomized trial, patients received Furoscix at study entry, transitioned back to oral diuretics when clinically indicated and were followed for 30 days. The objective of this analysis was to describe Furoscix dosing patterns and associated short-term changes in renal function (SCr) and potassium level (K+). Both studies enrolled hemodynamically stable patients with NYHA Class II-IV chronic HF with worsening signs and symptoms of congestion requiring augmented diuresis (FREEDOM-HF in ED before discharge, AT-HOME HF as outpatient). Changes from baseline in SCr and K+ were assessed in both trials at Day 3, and incidence of worsening renal function (WRF) (> 25% increase in SCr) and hypokalemia (mild: K+<3.5 mg/dL; moderate: K+<3.0 mg/dL) were captured. Results were stratified based on number of Furoscix doses administered and baseline daily total oral furosemide equivalent dosage (<120 mg or > 120 mg). A total of 58 patients were included, 24 from FREEDOM-HF and 34 from AT-HOME. The mean (range) number of per patient doses over the study duration was 6 (2-10) in FREEDOM-HF and 4 (1-9) in AT-HOME. All patients received at least one Furoscix dose within 3 days of enrollment; 11 received 1 dose and 47 two or more doses. 83% of total Furoscix doses administered in the 30-day study period were administered within the first 7 days, and 61% were administered within the first 3 days. Twice daily dosing was utilized < 5% of study days. At baseline, 38% of patients had Stage 2 CKD (n=22) followed by Stages 3A and 3B (n=13, 24% for each). Mean increase in SCr was 0.11±0.2 mg/dL; 5 (9%) patients experienced WRF (2 patients after 1 dose, 2 patients after 3 doses and 1 patient after 4 doses). All cases of WRF resolved spontaneously and/or with transient holding of diuretics. Overall, serum K+ increased by a mean of 0.01±0.6 mg/dL. 5 patients (9%) developed hypokalemia during the first 3 days; 4 mild and 1 moderate. 35 patients (60%) received K+ with their Furoscix dosing. Neither the number of Furoscix doses nor baseline furosemide equivalent dose had a statistically significant impact on change in SCr or K+. Across both studies, over 80% of Furoscix doses were administered within the first 7 days and over 60% were administered within the first 3 days. At day 3 (first clinic visit in both trials), the incidence of hypokalemia and worsening renal function was <10% and was not related to number of Furoscix doses given or baseline renal function. [ABSTRACT FROM AUTHOR]

Cardiopulmonary stress test (CPT) is widely used in patients with heart failure to objectively determine functional capacity and to aid in establishing advanced therapy candidacy. We have recently shown that hypotensive blood pressure (BP) response on CPT performed within 1 year of LVAD implantation is associated with worse perioperative and 90-days mortality. Here we extended the study and examined the association in patients undergoing orthotopic heart transplant (OHT). We performed a retrospective, single-center analysis of consecutive patients that underwent OHT between January 2011 and June 2020 at the University of Minnesota. Patients that had a valid CPT performed within 1 year prior to organ acceptance were included. Those with a durable mechanical circulatory support device, multi-organ recipients and those with re-transplantation were excluded. The final cohort was divided into two groups: 1) hypotensive BP response; 2) normal BP response to exercise on CPT. Hypotensive BP response was defined as peak exercise systolic BP lower than the value obtained at rest. Population characteristics were collected through EMR review. Kaplan-Meier survival curves were generated to compare survival up to 4 years between the two groups. Of the identified 256 first-time OHT recipients, 56 met inclusion criteria and were included in the final cohort. The most common reasons to exclude recipients were the presence of LVAD at the time of transplant and the lack of pre-OHT CPT. The mean age was 57.0±11 years and 37 were male (66%). 21 patients (38%) showed hypotensive BP response on CPT. Recipient age, gender distribution, routine laboratory values, temporary mechanical circulatory support device use, and all other CPT parameters were similar between the groups, including peak exercise heart rate, VO 2max , RER, and VE/VCO 2 slope. While those with a hypotensive response had longer median index hospitalization [22 (12, 30) vs. 16 (12, 26) days], the difference was not statistically significant (p=0.89). In addition, we found no difference in ICU length of stay, duration of vasoactive medication use, or incidence of post-transplant end-organ dysfunction. Post-transplant survival rates for up to 4 years were similar between the groups (p=0.74). Hypotensive blood pressure response on CPT performed pre-OHT is not associated with worse post-transplant outcomes and survival up to 4 years. These findings are different from that in LVAD recipients and further studies are needed to clarify the underlying pathophysiological mechanisms. [ABSTRACT FROM AUTHOR]

Copyright of Blood Reviews is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

To evaluate the hypothesis that weight gain after left ventricular assist device (LVAD) occurs after the nadir of natriuretic peptides (nt-proBNP), and that persistently elevated natriuretic peptides is associated with failure to gain weight after LVAD implantation. Body mass index (BMI) and nt-proBNP trends before and after LVAD in a single center continuous flow cohort (n=505) were computed and plotted using Locally Estimated Scatterplot Smoothing (LOESS). Linear mixed effects modeling was performed to test the association between nt-proBNP and BMI. CT measures of sarcopenia (pectoralis muscle mass index to body surface area and tissue attenuation, n=194) was correlated with pre-LVAD BMI trend. The plots of BMI and log nt-proBNP for the entire cohort before and after LVAD are demonstrated (Figure). The rise in BMI did not occur until after the nadir of post implant nt-proBNP. Downward slope of BMI prior to LVAD was associated with lower pectoralis muscle measures prior to implantation. Patients who failed to gain weight post LVAD had the highest 6 month post LVAD natuetic peptides (lowest pecent BMI gain tertile nt-proBNP: 2,208 vs. highest 1,635 pg/mL, p <0.001). Post LVAD nt-pro BNP and BMI trends were significantly associated (a decrease of 1 unit log nt-proBNP was associated with an increase in 0.81 BMI, 95 % CI: 0.53-1.09, p < 0.001). Weight gain post LVAD did not occur until the nadir of natriuretic peptides. Failure to gain weight post LVAD was associated with persistently elevated natriuretic peptides. These data collectively suggest that gains in body mass may be dependent on resolution of heart failure. [ABSTRACT FROM AUTHOR]

Giant cell myocarditis (GCM) classically presents in a dramatic fashion. Initial manifestations may include fulminant heart failure, refractory ventricular arrhythmias, and high degree AV block. Treatment includes aggressive immunosuppression, but even with proper treatment, the risk of progression to end stage heart failure is high. Although the clinical scenario can strongly suggest GCM, endomyocardial biopsy (EMB) remains the gold diagnostic standard. A 70-year-old female with hypertension and hyperlipidemia presented to the hospital with syncope. She was found to have new systolic heart failure with a left ejection fraction of 32%. She had a new first degree AV block with intermittent 2:1 AV block. Cardiac MRI showed multiple areas of delayed enhancement thought to be consistent with RCA territory infarct pattern versus infiltrative cardiomyopathy, specifically, sarcoidosis. Subsequent coronary angiogram demonstrated mild, non-obstructive coronary artery disease. EMB at this time showed focal histiocytic infiltrate with scattered eosinophils. No granulomas or giant cells were identified. Given the clinical picture and EMB findings, presentation was felt to be most consistent with cardiac sarcoidosis, although other inflammatory etiologies remained in the differential. Prednisone and neurohormonal blockade were started. Given her intermittent AV block, a CRT-D device was implanted. The remainder of the patient's index admission was uneventful and she had NYHA Class II symptoms on discharge. However, the patient quickly returned to the emergency department after 17 appropriate ICD discharges in the setting of VT storm. She quickly deteriorated requiring emergent peripheral VA-ECMO cannulation. A second EMB was obtained at this time which showed profound inflammation as well as giant cells (Figure 1). She was treated for giant cell myocarditis with aggressive immunosuppression but had worsening end-organ dysfunction and continued to deteriorate clinically. Ultimately, the decision was made to transition to comfort measures and the patient expired. Both GCM and cardiac sarcoidosis can present with new onset heart failure, refractory ventricular arrhythmias, and life-threatening conduction abnormalities. Endomyocardial biopsy is critical to establish the diagnosis, yet the yield is not 100%. Given the exceedingly high mortality without proper treatment, repeat EMB may be necessary to establish the diagnosis of GCM. [ABSTRACT FROM AUTHOR]

Refractory respiratory failure caused by the coronavirus SARS-CoV-2 is associated with a significant mortality rate. Patients unresponsive to conventional medical therapy may benefit from temporary veno-venous extracorporeal membrane oxygenation (VV-ECMO), which provides complete gas exchange while allowing the patient to recover. We sought to investigate the role of right ventricular failure in the outcomes of these patients since clinical and echocardiographic characteristics that predict survival are not yet defined in patients with respiratory failure caused by SARS-CoV-2. We performed a single center retrospective cohort study enrolling consecutive patients that required VV-ECMO for the management of refractory respiratory failure between January and December 2020. Seventeen consecutive patients with COVID-19 infection were included in the reported cohort. Demographics, comorbidities, laboratory parameters and echocardiographic features of left and right ventricular (LV/RV) function were compared between patients who survived and those who could not be weaned from VV-ECMO and died. Ten of the 17 patients failed to wean from VV-ECMO and died in the hospital on average 41.5 ± 10.9 days post admission. Seven were successfully decannulated and survived to hospital discharge on average 39.0 ± 19.8 days after admission. There were no significant differences in demographics, comorbidities, laboratory parameters between the groups. LV size and function were also similar. However, moderate to severe RV dysfunction was significantly more frequent in the group of patients who died (8/10, 80%) compared to the survivors (0/7, 0%) (p=0.0017). Severe RV dysfunction is associated with increased mortality among patients with severe COVID-19 associated respiratory failure treated with VV-ECMO. Measures to support RV function, including temporary mechanical RV support devices, should be considered for these patients aiming to improve survival. [ABSTRACT FROM AUTHOR]

Patients with continuous flow left ventricular assist devices (CF-LVAD) typically have a narrow pulse pressure. This may pose a challenge for transcutaneous automated pulse oximeter devices to accurately measure arterial blood saturation. This study aimed to assess their accuracy in a CF-LVAD population by comparing pulse oximetry readings to invasive arterial blood gas (ABG) measurements. A total of eighteen patients with a CF-LVAD were identified using chart review at the University of Minnesota and Minneapolis Heart Institute. All, except one patient were implanted with a HeartMate III device (Abbott Laboratories, Minneapolis, MN). Non-invasively assessed oxygen saturation was compared to simultaneously obtained arterial blood oxygen saturation. Two patients were receiving mechanical ventilation, one received BiPAP support, and 15 patients were either breathing room air or receiving supplemental oxygen by nasal cannula. A non-invasive pulse oximeter read was obtained on every patient. There was a moderate correlation between the invasively and non-invasively obtained oxygen saturation values as shown in Figure 1 (R2=0.624). Waveform quality, as assessed by the treating physician, qualified as good or acceptable in 16 cases and as poor for 2 patients. Data points for these 2 patients are marked in red in Figure 1. Despite a narrow pulse pressure in patients with CF-LVAD, non-invasive pulse oximetry provided a reliable assessment of arterial blood saturation when compared to the gold standard ABG measurement. This finding presents an opportunity to conduct future studies in this patient population in which continuous monitoring of oxygen saturation may be necessary, such as evaluation for obstructive sleep apnea. [ABSTRACT FROM AUTHOR]

Objective: Approximately 10% of infrainguinal bypass surgeries are complicated by early conduit failure. The cause is unclear in most cases. A prospective study was conducted to monitor the development and function of platelet factor 4 (PF4)/heparin antibodies after infrainguinal bypass procedures and to evaluate their clinical significance in early graft occlusion. Methods: Blood samples were obtained before surgery and at the 7-, 14-, and 28-day postsurgical evaluation. Relevant demographic and laboratory data were collected, and plasma samples were assayed for the presence and function of PF4/heparin-antibody by enzyme-linked immunosorbent assay (ELISA) and a two-point platelet aggregation assay. All tests were performed in duplicate or triplicate. Results: Of the 79 patients who were enrolled, 67 reported previous heparin exposure. Six patients (7.6%) tested positive for the presence of PF4/heparin antibodies before surgery with ELISA, and four of these (67%) also had a positive result on the aggregation assay. During the 28-day follow-up, 22 subjects (32%) converted to positive according to the ELISA results; and five (22.7%) of these also tested positive for platelet-activating antibodies. No participants presented with thrombocytopenia or a ≥50% decrease in platelet count during the study period. Early graft occlusion was detected in three patients, all with negative ELISA and functional assay results throughout the study. Conclusion: Patients undergoing vascular surgery frequently develop PF4/heparin antibodies, with platelet-activating antibodies detected in up to 11% of these individuals. However, thrombocytopenia and vascular graft thrombosis both appear to be an uncommon consequence. [Copyright &y& Elsevier]

Cardiopulmonary stress test (CPX) and right heart catheterization (RHC) are integral part of the routine evaluation for ventricular assist device (LVAD) therapy. A hypotensive response, or failure to augment systolic blood pressure at peak stress above resting values might be a marker of high-risk physiology. We sought to evaluate the association between hypotensive response on CPX and invasive hemodynamics in patients undergoing LVAD evaluation. This was a retrospective single center study of consecutive adult patients who underwent LVAD surgery at our center between 1/2011 and 1/2019. Only patients with both CPX and RHC performed within 12 months of implantation were included. Hypotensive response was defined as a peak exercise systolic blood pressure lower than the resting systolic blood pressure. Central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP) and cardiac index determined using the thermodilution method (CI) were collected from RHC data. Multivariable Cox regression analysis was performed to evaluate the association between CPX data and hemodynamics. A total of 313 patients were included in the study and 115 met inclusion criteria. The mean age was 60.1 years, 66% were designated bridge to transplant (BTT) and the majority (85%) were classified as INTERMACS 3-5. Forty seven percent (54/115) developed a hypotensive response during testing. The group had a mean PCWP of 23.7 mmHg and a mean CI of 1.7 L/min/m2. In contrast, patients with normal blood pressure response had a significantly lower PCWP (19.8 mmHg; P=0.011) and significantly higher CI (2.0 L/min/m2; p=0.030). There was no difference in CVP values between the groups. Mean exercise duration was 6 minutes and 1 seconds in the hypotensive group, and 7 minutes 8 seconds in the group with normal blood pressure response. A hypotensive response on CPX performed prior to LVAD implantation is associated with more severely abnormal hemodynamics. Identification of this high risk feature earlier has the potential to improve outcomes by preventing late LVAD implantation. [ABSTRACT FROM AUTHOR]

Cardiopulmonary stress testing (CPX) is widely used to evaluate patients with end stage heart failure who may benefit from advanced therapies, such as durable left ventricular assist devices (LVAD). A hypotensive systolic blood pressure response on CPX may identify a subpopulation with the highest risk physiology. We sought to evaluate long term outcomes among LVAD recipients with a pre-implantation hypotensive response. This was a retrospective single center study using consecutive patients implanted with a continuous flow LVAD between 1/2011 and 1/2019 at our Institution. Patients with CPX performed within 12 months before implantation were included. Hypotensive response was defined as a peak exercise systolic blood pressure lower than the resting systolic blood pressure. The primary outcome was 1-year mortality. Multivariable cox regression analysis was performed to evaluate the relationship between hypotensive exercise blood pressure response and mortality. Multivariate linear regression analysis was used to determine pre-implant variables and mortality. 313 patients were enrolled in the study and 123 were identified to meet our inclusion criteria. The mean age was 60.1 years, 58% had ischemic cardiomyopathy and 85% were classified as INTERMACS 3-5. 54 patients had a hypotensive response on CPX (44%). A total of 14 patients died at 1 year, 10 from the hypotensive cohort (p=0.043), hazard ratio 3.54 with 95% CI (1.1, 11.3, p=0.033). Post-implantation ICU and overall hospital length of stay were similar to the group with normal blood pressure response. There was also no significant difference in post-operative complications and the risk of re-hospitalization at 1 month, 6 months and 1 year. Hypotensive blood pressure response on the CPX performed pre-LVAD implantation is independently associated with increased 1-year mortality. Additional studies are needed to further characterize this high-risk patient population and to identify strategies to improve survival rates. [ABSTRACT FROM AUTHOR]

The allocation system for heart transplantation changed in the United States on October 18, 2018. In this analysis, we report donor quality metrics by UNOS status for patients transplanted under the new allocation system. We suspect higher quality (male, younger, less under-sized) donors will be allocated to patients with the highest acuity UNOS status recipients. Adults (18 years and older) who underwent first-time heart transplantation were identified from the United Network for Organ Sharing (UNOS) registry after October 18, 2018. Donor characteristics by UNOS recipient status then were compared with one-way ANOVA and chi-squared tests, where appropriate. To determine the percent of donors that were under-sized, predicted total ventricular mass for each donors and recipient pair was calculated utilizing previously published models based on age, sex, height, and weight. Under-sizing was defined as a calculated donor mass of more than 10% under the recipient cardiac mass, based on previously reported ideal ranges. The analysis included 1,817 patients (Status 1: 141, Status 2: 807, Status 3: 478, Status 4: 319, Status 5: 72). Statistically significant differences were observed across the UNOS status groups, with higher acuity status recipients receiving younger donors with less donor hypertension (Table). Higher acuity status recipients were less likely to receive female donors into male recipients or to be under-sized (Status 1 & 2: 18.7% under-sized vs. Status 3, 4, & 5: 23.8% under-sized, p=0.007). Ischemic times were longer for Status 1 and 2 recipients. Donor alcohol and cocaine use were similar across UNOS statuses. Initial analysis reveals that heart transplant recipients with the highest acuity UNOS status are receiving donor hearts with more favorable donor characteristics although with longer ischemic times. More detailed analysis of the donor characteristics and longer follow-up time will be need to further quantify and assess the impact of this measurable variation in donor quality on post-transplant outcomes. [ABSTRACT FROM AUTHOR]

To quantify the change in heart failure (HF) hospitalizations observed in the early phase of the COVID-19 pandemic across a large, multi-center health care system. MHealth Fairview encompasses four hospitals (one academic, three community-based) in the Minneapolis, Minnesota metro area. To compare HF hospitalization trends, two inpatient samples were created using HF discharges in the following time periods: pre COVID-19 (February 28, 2019-February 28, 2020) and post COVID-19 (April 1, 2020- May 15, 2020). March 2020 was excluded as this represented a transition point of the pandemic in the United States. Average number of discharges per day as well as demographics, diagnosis related group (DRG) codes, and inpatient mortality was then compared between the two inpatient HF samples. The pre COVID-19 group had 2,601 patients with an average of 7.1 (+/-3) discharges per day. The post COVID-19 group had 210 patients with an average of 4.7 (+/-1.7) discharges per day, which represented a 34% reduction in HF discharges (p <0.001). No statistically significant differences were observed between the pre and post COVID-19 inpatient samples with respect to age (76 vs. 75 years, p = 0.25), gender (46% vs. 48% male, p = 0.7), and DRG codes (DRG 291: 78% vs. 85% p = 0.15). Inpatient HF mortality pre and post COVID-19 was not significantly different (3% vs. 2.9%, p = 0.99). HF hospitalizations have decreased significantly during the early phase of the COVID-19 pandemic in this multi-center health care system, however the make-up of hospitalized patients remains similar. There is an urgent need to provide continued access to safe hospital care during the pandemic and to inform HF patients that inpatient care remains available. [ABSTRACT FROM AUTHOR]

The HeartMate 3 (HM3) left ventricular assist device (LVAD) has a low reported rate of pump thrombosis. In this case series, we report two HM3 LVAD recipients who developed acute pump thrombosis in the early post-operative period. A 69 M with ischemic cardiomyopathy who underwent HM 3 implant as destination therapy (DT). Apical calcium was noted intra-operatively and was removed at the time of surgery. On post-operative day 3, the patient developed low flows alarms, high powers, and increased arterial line pulsatility. Lactate dehydrogenase (LDH) was within normal limits and heparin was therapeutic. Pump interrogation demonstrated rising pump temperature (70°C) with intermittent pump stops. The decision was made to return to the operating room (OR) and during this time the patient developed hypotension and lactic acidosis. In the OR fresh thrombus of the inflow, pump and outflow graft was encountered. The pump was exchanged to a new HM3 and the patient had full recovery with no further thrombotic events. A 58-year-old woman with Adriamycin associated cardiomyopathy underwent DT HM3 implantation with tricuspid valve annuloplasty. The LV cavity size decreased from 5.9 cm pre- operatively to 4.0 cm post-operatively, causing septal contact with the inflow cannula and intermittent ventricular tachycardia. On post-operative day 3 the patient developed low flow alarms, followed by elevated pump flows and powers and return of arterial line pulsatility. LVAD interrogation demonstrated a high pump temperature (75 °C) with intermittent pump stops. Similar to the first patient, the second patient had a normal LDH, was therapeutic on a heparin drip, and developed hemodynamic instability. The same findings (inflow, outflow, and intra pump thrombus) were present at in the OR. This second patient's pump was re-positioned reduce septal contact at the time of exchange. Here we report 2 cases of acute HM3 pump thrombosis shortly after LVAD implantation. Full investigation into these events internally and with the manufacturer did not reveal pump malfunction. The first event was felt to be caused by ingestion of calcified material from the left ventricle leading to rotor misplacement and subsequent thrombus formation. The second case was thought to be triggered by sustained low flow from the septal contact with subsequent thrombus formation. In each case, the patients developed high powers, return arterial line pulsatility, and dangerously high internal pump temperatures. The purpose of this case series is to help the community develop pattern recognition in order to be able to quickly diagnose this rare but serious event. [ABSTRACT FROM AUTHOR]

A 66-year-old male with recent diagnosis of heart failure with reduced ejection fraction was referred to our institution for management of cardiogenic/vasodilatory shock. During his evaluation, he suffered a sudden cardiac arrest from refractory ventricular tachycardia/fibrillation (VT/VF) despite normal electrolytes and no evidence of prior ventricular arrhythmias. He was placed on rescue peripheral veno-arterial extracorporeal membrane oxygenation support (VA-ECMO) for 4 days and was decannulated without end-organ damage. Continued workup revealed Mayo stage IV immunoglobulin light chain (AL) amyloidosis. Unfortunately, he developed acute cerebellar hemorrhage several days later. Autopsy findings were consistent with AL amyloidosis, with extensive cardiac fibrosis and amyloid deposition in the myocardium and vasculature. While the most common cause of cardiac death in patients with amyloidosis is severe bradycardia and pulseless electrical activity, sustained ventricular arrhythmias have been reported. The use of implantable cardioverter defibrillators (ICD) is highly debated in this population given the lack of survival benefit. Our patient also developed refractory VT/VF arrest, and ICD shocks would not have rescued him while causing significant distress. Emergent VA-ECMO cannulation allowed us to make a diagnosis, yet this intervention cannot be routinely recommended given the limited survival of patients with AL amyloidosis. [ABSTRACT FROM AUTHOR]