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Background Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock. Methods and Results We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy (n = 11) or by clinical history without angiographic evidence of coronary disease (n = 23). A total of 34 patients received an Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42 ± 17 years, left ventricular ejection fraction (LVEF) 18% ± 10%, cardiac index 1.82 ± 0.46 L·min−1·m−2, pulmonary capillary wedge pressure 25 ± 7 mm Hg, and lactate 27 ± 31 mg/dL. Before Impella placement, 32% (n = 11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91 ± 74 hours; 21 of 34 patients (62%) survived the index hospitalization and were discharged with an improved mean LVEF of 37.32% ± 20.31% (P = .001); 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplantation. Ten patients required transition to another mechanical circulatory support device. Conclusions This is the largest analysis of Impella-supported myocarditis cases to date. The use of Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Introduction Currently under investigation, HeartCare® surveillance combines both AlloMap® (immune activity mRNA) and Allosure ® (graft cell free DNA) data and is purported to be a comprehensive method of assessing cellular and antibody mediated graft rejection in the orthotopic heart transplant (OHT) patient population. Prior literature suggests that increased Allomap® scores are observed in setting of Cytomegalovirus (CMV) viremia, which is one of the most common infections following transplantation. Furthermore, decreased scoring trends have also been reported once the once viremia is resolved. The likely mechanism has been thought to be immune activation/modulation of one or more of the 11 genes in the Gene Expression Profiling (GEP) signature. To date there is a paucity of data supporting this phenomenon occurring in tangent with Allosure® use. Methods Herein is a retrospective review of two heart transplant recipients that had HeartCare and CMV surveillance. CMV donor/ recipient data, graft assessment via echocardiograms, biopsy data, Beta natriuretic peptide (BNP) trends, and presence of human leukocyte antigens (HLA) were also analyzed. Results Patient #1 is a 57 y/o Caucasian male status post OHT 9/2019 due to ischemic cardiomyopathy (ICM), CMV Recipient+/Donor- (R+/D-), with normal left and right ventricular (LV and RV), and Ejection Fraction (EF) 50%. Biopsy History #1: 1R, p AMR0, #2 1R, pAMR0. Mild elevations in BNP (peak 127) throughout viremia course, negative DSA Class I or Class II. Patient #2 is a 57 y/o Hispanic male status post OHT 9/9/2019 due to ICM, CMV R+/D+ with normal LV and RV and EF 50% as of 5/2020. Biopsy History #1: 1R, pAMR0 #2: 0R, pAMR0. Mild BNP elevations throughout viremia course (peak 147), negative DSA Class I and Class II. Discussion Based on prior studies, CMV infection can trigger allograft rejection/acute rejection thus triggering CMV reactivation. Our case series describes CMV viral load increased as did increased HeartCare® values, in the absence of graft dysfunction and rejection. This observation underscores the importance of simultaneous rejection and infection monitoring to guide clinical treatment. Although Allosure® rise was diagnostically subtle, trend surveillance is critical to avoid overtreatment and repeat cardiac biopsies.

Background Donors with hepatitis C (HCV) viremia are rarely used for orthotopic heart transplantation (HT) owing to post-transplantation risks. New highly effective HCV antivirals may alter the landscape. Methods An adult patient unsuitable for bridging mechanical support therapy accepted a heart transplant offer from a donor with HCV viremia. On daily logarithmic rise in HCV viral load and adequate titers to ensure successful genotyping, once daily sofosbuvir (400 mg)–velpatasvir (100 mg) (Epclusa; Gilead) was initiated empirically pending HCV genotype (genotype 3a confirmed after initiation of therapy). Results We report the kinetics of acute hepatitis C viremia and therapeutic response to treatment with a new pangenotypic antiviral agent after donor-derived acute HCV infection transmitted incidentally with successful cardiac transplantation to an HCV-negative recipient. Prompt resolution of viremia was noted by the 1st week of a 12 week course of antiviral therapy. Sustained virologic remission continued beyond 12 weeks after completion of HCV therapy (SVR-12). Conclusions The availability of effective pangenotypic therapy for HCV may expand donor availability. The feasibility of early versus late treatment of HCV remains to be determined through formalized protocols. We hypothesize pharmacoeconomics to be the greatest limitation to widespread availability of this promising tool.

Introduction Many known risks are associated with cardiac transplantation. Although dangers surround the transplant itself, immunosuppression increases the vulnerability to infection and malignancy. Without expertise in transplant medicine, diagnosing and managing patients with complications of immunosuppression can become challenging. Case Description : A 67-year-old male 4 months post orthotopic heart transplant (OHT), without induction therapy, tolerating appropriate immunosuppression and antimicrobial prophylaxis presented to an outside hospital (OSH) for new-onset seizures and fevers of up to 104° F. At the OSH he was started on Keppra and underwent a brain MRI showing enhancing masses with edema, suspicious for metastatic disease with primary lung carcinoma, as the patient had a known lung nodule pre-OHT. The OSH called us for transfer, however, the patient refused due to wanting to stay near his home to take care of his cats. However, he continued to deteriorate despite being on steroids and anti-epileptics and on day 3, he agreed to be transferred to our facility. Transthoracic echocardiogram showed normal ejection fraction, no vegetations or abscess or evidence of graft dysfunction. Repeat MRI at our institution revealed 3 ring-enhancing lesions within the supratentorial parenchyma consistent with cerebral abscesses. CT scan showed a 2.5 cm pulmonary nodule in the left lingula. Lumbar puncture indicated white blood cells and predominant neutrophils. He was originally scheduled for a lung biopsy, but pre-procedure CT revealed the lung nodule decreased in size, suggesting an infectious etiology. He began IV Meropenem and Bactrim since all evidence was suggestive of infection and not malignancy. Brain biopsy revealed the lesions were abscesses and culture demonstrated gram-positive filamentous rods, consistent with Nocardia. Linezolid was added to his current antibiotic regiment for better broader coverage. Bacterial speciation detected Nocardia cyriacigeorgica. The patient continued to improve after antibiotic initiation and was discharged to rehab. Conclusion : Immunosuppressed patients are susceptible to opportunistic infections, such as that of N. cyriacigeorgica, especially in the first year following OHT. These infections can lead to clinical manifestations that may be mistaken for malignancy at centers lacking expertise in transplant medicine. Transplant patients should be aware of the risks of chronic immunosuppression therapy and counseled to return to the implanting center for serious conditions.

Introduction Left ventricular assist device (LVAD) has emerged as an effective treatment of end-stage heart failure either as bridge to transplant or destination therapy. However, the need for anticoagulation with LVAD comes with the trade-off of increased bleeding risk and worsening anemia requiring blood transfusions. We describe a case of acute hemorrhagic shock in a Jehovah's Witness with a HeartMate 3 (HM3) - LVAD successfully treated without any transfusion of blood products Case A 65-year-old African American Jehovah's Witness male with a three months history of HM3 implantation for end-stage non-ischemic cardiomyopathy presented to the hospital for loss of consciousness, melanotic stool, hypotension and hemorrhagic shock. Initial laboratory included an elevated INR of 5.4 and hemoglobin of 5.4 g/dL. The LVAD remained in good function without low flow alarms at a speed of 4900 rpm and a SBP of 40mmHg. Patient's hypotension and decompensation was attributed to his acute blood loss anemia, however, given his religious beliefs, transfusion of blood products was not an option. As a result, the patient was intubated and resuscitated with IV iron, colloids and darbepoetin alfa for RBC stimulation in addition to inotropes and pressor support. Gastroenterology declined urgent endoscopic procedure due to the hemodynamic instability of this case. The patient's hemoglobin further declined to 2.4 g/dL with persistent, refractory shock. Only after an increase in LVAD speed from 4900 rpm to 5600 rpm cardiac output and overall hemodynamic status improved to MAP of 70 mmHg allowing de-escalation of inotropes and pressors. Over the next two weeks, INR corrected, bleeding subsided, and the patient was extubated without any neurological deficits or signs of mesenteric ischemia. His hemoglobin trended up to > 8 g/dL by discharge. Conclusion Bleeding is common in heart failure patients with LVADs. Blood transfusion, at times, can provide a simple and quick life-saving resolution to this problem. The severity of anemia in our case without administration of any blood products is usually not consistent with life. Our case highlights a potential role of augmenting LVAD support to maintain cardiac output in patients presenting with hypovolemic, hemorrhagic shock as a bridge to recovery of endogenous RBC mass regeneration with IV iron and darbepoetin alfa without the need of foreign blood products. Future studies are necessary to determine whether LVAD optimization is sufficient to avoid blood products and preventing the risk of sensitization BTT LVAD patients against potential future heart transplant offers.

Background A new technology known as Molecular Microscope Diagnostic System® (MMDx) uses microarrays to analyze RNA transcripts of transplanted heart tissue and provides sophisticated differentiation amongst cellular mediated rejection (TCMR), antibody mediated rejection (ABMR), injury and healthy tissue. Yet, incorporation of this new data into practice can be challenging. We report the results from our single center experience. Methods Endomyocardial biopsies (EMB) and corresponding MMDx results from 65 adult heart transplant patients from our single center were retrospectively reviewed. Rejection by EMB was defined as TCMR greater than 1R and/or ABMR greater than pAMR0 utilizing ISHLT grading schematics. Results A total of 97 specimen results were reviewed. There was concordant findings between the EMB and MMDx in 83.5% (81/97) of the specimens. Of the 81 specimens, 76 of those were negative for rejection on both tests and 5 had positive EMB for ABMR/TCMR with correlating MMDx suggestive of rejection. There was a discordance in 16.5% (16/97) of specimens reviewed. Of the 16 specimens, 15 had negative EMB with the MMDx concerning for rejection. One of the 16 patients had a positive EMB however the MMDX was consistent with healthy tissue. These complex cases with discordant data were reviewed during our multi-disciplinary meeting which includes transplant cardiologists, coordinators, APPs, pharmacists, pathologists and immunology partners to adjudicate further management. The team approached each case individually, reviewing other factors such clinical symptoms, graft function by TTE, hemodynamics, cell-free DNA and donor specific antibodies when available. For five discordant patients with negative EMB and concerning MMDx, the team favored treatment for rejection if there were other corresponding factors present such as high cell-free DNA or clinical symptoms. For one patient admitted with clinic concerns for rejection aggressive treatment had already been initiated prior to positive EMB and negative MMDx being available. For the remaining patients with negative EMB and positive MMDx we advocated for a second round of data, including repeat biopsy and continued surveillance, before deciding on course of treatment for rejection. Conclusion MMDx is an additional tool to provide potentially more accuracy in patient diagnoses but should be utilized in combination with all other diagnostic data. In the cases of conflicting findings, a multi-disciplinary approach should be used to discuss further steps. Larger studies are needed to validate these preliminary findings.

Introduction Little is known about the use of a wireless pulmonary artery pressure monitoring device, CardioMEMS, in the Veteran's Affair (VA) patient population. We report our results of the effectiveness of this wireless device in reducing heart failure re-admissions in the largest known VA patient cohort. Methods We retrospectively analyzed all patients with heart failure-related admissions pre- and post-implantation of their CardioMEMS device. Results A total of 63 patients (93% male, 44% Caucasian and 54% HFrEF), with NYHA Class 3 HF were followed for 12 months. At device implantation, average pulmonary artery systolic/ diastolic /mean pressures were 51/24/34 mgHg while at 6 months were 45/22/31 mmHg and 12 months were 43/21/29 mmHg. The total number of heart failure hospital admissions for patients who were followed for 12 months prior to device implantation was 130, while the total number for the post-implantation period was 57. Post implant patients had 0.47 times the rate of heart failure hospitalizations compared to pre-implant patient (95% CI: 0.31, 0.70; p-value Conclusion In the largest patient population at a VA real-world setting, the implantation of a CardioMEMS results in decreased pulmonary artery pressures and decreased heart failure re-admissions. Further studies are needed to confirm these preliminary findings.

Introduction Cardiac re-transplantation represents a small but growing proportion of total transplants being performed. Medical, ethical, moral and social dynamics continue to remain individualized and highly debated but more evolved with advancement in medicine for patients needing cardiac re-transplantation. We describe a case of a successful outcome in a patient requiring her third orthotopic heart transplant. Case A 26 year old female with history of orthotopic heart transplant at age 11 for hypertrophic cardiomyopathy and subsequent re-transplantation for cardiac allograft vasculopathy (CAV) ten years later presented to our emergency room with cardiac arrest. Prior to the index hospitalization, the patient had an echocardiogram with a mildly reduced ejection fraction and an angiogram with chronic total occlusions of the right coronary artery and left circumflex artery with excellent collaterals and preserved cardiac output. Nuclear stress test showed no evidence of ischemia. Cardiac allograft vasculopathy prophylaxis with aspirin and pravastatin in addition to a triple regimen of immunosuppression of tacrolimus, sirolimus and mycophenolate mofetil were verified. The hospitalization was complicated by rapidly deteriorating biventricular function and three more episodes of cardiac arrest ultimately requiring extracorporeal membrane oxygenation (ECMO). Fortunately, the patient had negative HLAs with 0% CPRA and preserved end organ function. The selection committee thoughtfully considered her history of intermittent social marijuana use, active COVID 19 precautions in the hospital and a third sternotomy at such a young age, with likely need of possible 4th heart transplant in the future, but ultimately approved the patient for listing. Despite being Status 1, the patient had near daily loss of pulsatility for greater than 10-15 minutes which made us consider the possibility of total artificial heart. Fortunately, the patient received a local heart due to the COVID travel restrictions with total ischemic time of 98 minutes. She was induced with basiliximab and had negative retrospective and prospective crossmatches. There were no intra-op complications and post-op the patient had mild RV dysfunction requiring 4 days of inotropes. Patient was successfully discharged 9 days following her third OHT. Conclusion Patients undergoing re-transplantation have overall poorer outcomes than those undergoing primary transplantation. Several factors influence these outcomes including timing from prior transplant, previous sternotomy, sensitization status, and renal dysfunction. With advances in medicine and pediatric patients living well into adulthood, there will be more patients requiring re-transplantation. As these trends emerge, individualized patient selection remains the key factor to improved outcomes. Our case presents an otherwise healthy young woman with graft failure without evidence of sensitization who underwent a successful third transplantation.

Background Ischemic cardiomyopathy is associated with multiple comorbidities including diabetes, hypertension, hyperlipidemia, and kidney disease. Patients with end-stage renal disease (ESRD) and left ventricular systolic heart failure have a 2-year cumulative survival as low as 33%. Chronic kidney disease (CKD) increases the risk of contrast-induced nephropathy and progression to ESRD in patients undergoing PCI. Hypothesis Patients with preoperative CKD undergoing elective revascularization with PCI for ischemic cardiomyopathy will have worse periprocedural outcomes. Methods Hospitalizations for systolic heart failure and PCI (and no acute myocardial infarction (MI)) were identified from the 2006-2014 National Inpatient Sample based on ICD-9 codes. Patients were categorized into normal renal function, preoperative CKD stages 1-4, or preoperative ESRD, and compared in terms of demographics, comorbidities, inpatient mortality, length of stay (LOS), and cost of care. Trends over time were determined using the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using the NIS discharge weights and adjusted for age and comorbidities including hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of MI. Results Patients with ESRD were at increased odds of dying during the perioperative period compared to normal renal function (OR = 2.54; 95%-c.i.=2.17-2.98). In-hospital mortality was 1.1% in normal renal function vs. 2.84% in patients with ESRD. LOS increased over time for the normal function group (mean 5.1 days) (p 0.05). LOS was on average 1.1 days longer (0.9-1.3) in the CKD stage 1-4 and 2.6 days longer (2.3-3.0) in the ESRD group compared to normal renal function. Although total charges increased over the study period in the normal renal function and ESRD groups (p Conclusions Patients with ESRD and CKD stages 1-4 undergoing PCI for ischemic cardiomyopathy have greater in-hospital mortality, LOS, and total charges and carry a higher rate of post-procedural complications.

Background The development of right ventricular failure (RVF) is common following continuous-flow left ventricular assist device (CF-LVAD) implantation, occurring in 13%-40% of patients. With the LVAD and right heart operating in series, LVAD function relies heavily on RV function for adequate preload. Severe RVF can lead to systemic hypoperfusion, multi-organ failure, prolonged hospitalization, poor quality of life, and death. Hypothesis Identifying patients at risk of developing severe RVF post-implantation may assist the care team in taking the necessary precautions to potentially avoid RVF or to be aggressive in its management. Methods This was a single-center review of CF-LVAD implantations from 2014 to 2016. Excluded were INTERMACS1 patients, redo LVADs, preoperative advanced RVF, refractory pulmonary vascular resistance >6 WU, and prosthetic mitral or tricuspid valve. RVF was defined as requiring RVAD or inhaled nitric oxide or other pulmonary vasodilator post-op for ≥48h or inotropic therapy for ≥7d any time post-op. Assessment of pre-implant RV function was based on an extensive set of echocardiographic parameters ( Tables 1 & 2 ). Results Of 55 patients (95% were HeartMate II), a total of 46 (84%) developed significant RVF. Those with and without RVF did not differ in gender or age. RV stroke volume (P=0.04), RV stroke volume index (P=0.04), and mitral valve regurgitation jet area (P=0.05) were significantly lower in patients with RVF ( Table 1 ). Conclusion RV cardiac output is calculated as RV stroke volume x heart rate. Thus, early RVF post-LVAD may be explained by low RV stroke volume. In standard practice, however, RV stroke volume and RV stroke volume index are not routinely calculated from the pre-implant echocardiogram. This study, despite its small sample size, suggests potential prognostic value for these echo parameters for the evaluation of RVF. Larger studies are needed to validate these results.

Background Acute cellular rejection (ACR) among heart transplant recipients is common with up to 20% to 40% of patients developing an episode in the first year. Yet, stability is the norm after the first year. Late graft dysfunction is less common and can result in the need for re-transplantation. We present a case in which medical therapy was used in lieu and resulted in resolution of graft dysfunction. Case report A 48 year old man who underwent orthotopic heart transplant in July 2014 had an uncomplicated early transplant course with negative endomyocardial biopsy (EMBx) for allograft rejection through 21 months. At that time he presented with dyspnea, lower extremity swelling and excess sinus tachycardia (140 bpm). Given new heart failure symptoms, rejection evaluation was completed, including EMBx. Pathology revealed International Society for Heart and Lunt Transplantation (ISHLT) grade 2R ACR. Staining for antibody mediated rejection was negative. An echocardiogram (TTE) revealed a decline in allograft function from 70% to 40% with restrictive filling pattern. Treatment with anti-thymocyte globulin, high dose prednisone taper, plasmapheresis and bortezomib was given. Despite treatment the patient returned for heart failure hospitalization 3 months later. Right heart catheterization (RHC) showed pulmonary capillary wedge pressure of 24 mmHg, mean right atrial pressure of 12 mmHg and cardiac index of 1.9 L/min/m^2. Due to reluctance on the part of the patient to immediately consider re-transplantation, intravenous milrinone and titration of guideline-directed medical therapy was completed. Fortunately, the graft ejection fraction normalized on subsequent TTE and he was successfully weaned off milrinone over 5 months. Repeat RHC showed normal filling pressures and normal cardiac index. Conclusions Patients who develop graft dysfunction with cellular rejection may continue to experience residual graft dysfunction after treatment. Continued medical therapy with standard heart failure regimen and inotropes helped support this patient during decompensation. This case suggests the possibility of late allograft recovery with medical support and avoidance of re-transplantation. Further research is needed regarding effective medical management of graft dysfunction.

Background Ischemic cardiomyopathy is associated with multiple comorbidities including diabetes, hypertension, hyperlipidemia, and kidney disease. Patients with end-stage renal disease (ESRD) and left ventricular systolic heart failure have a 2-year cumulative survival as low as 33%. Chronic kidney disease (CKD) dramatically increases the Society of Thoracic Surgeons (STS) risk score for CABG. Hypothesis Patients with preoperative CKD undergoing elective revascularization with CABG for ischemic cardiomyopathy will have worse periprocedural outcomes. Methods From the 2006-2014 National Inpatient Sample, we identified hospitalizations for systolic heart failure (ICD-9 codes 428.1, 428.X, 428.4X, or 428.9) undergoing CABG (ICD-9 procedure codes 36.1X). Those with acute myocardial infarction (code 410.X) were excluded. Patients were categorized into normal preoperative renal function, preoperative CKD stages 1-4 (diagnosis codes 585.1-4 or 585.9), and preoperative ESRD (diagnosis codes 585.5-6), and compared in terms of demographics, comorbidities, in-hospital mortality, length of stay (LOS), cost of care, and postoperative complications. Trends over time were assessed with the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using NIS discharge weights and adjusted for age and comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction). Results Over the study period, trends showed a decline in in-hospital mortality in normal preoperative renal function and CKD stages 1-4 (p Conclusions Patient with ESRD undergoing CABG for ischemic cardiomyopathy continue to have elevated in-hospital mortality despite an overall improvement in the non ESRD cohorts.

Background The degree of left ventricular dysfunction has a well-defined impact on survival in patients with ischemic cardiomyopathy. The clinical benefit from revascularization is difficult to ascertain and depends on the amount of hibernating myocardium at risk. The decision to achieve complete myocardial revascularization by CABG vs. PCI in patients with chronic kidney disease (CKD) is complex and typically based on clinical gestalt with limited literature available on in-hospital mortality, cost, and outcomes for both strategies. Hypothesis Patients with ischemic cardiomyopathy undergoing revascularization with CABG will have worse periprocedural outcomes and higher cost compared to PCI. Methods All hospitalizations of patients with CKD (ICD-9 diagnosis codes 585.X) and systolic heart failure (diagnosis codes 428.1, 428.2x, 428.4x, or 428.9) were identified from the 2006-2014 National Inpatient Sample. Within this cohort, patients with PCI (ICD-9 procedure codes 36.06 or 36.07) and with CABG (procedure code 36.1) were compared in terms of demographics, comorbidities, in-hospital mortality, length of stay (LOS), and cost of care. Trends over time were determined using the Cochran Armitage and Cuzick tests. Multivariate models were constructed with weighted logistic and linear regression (gamma function) using the NIS discharge weights and adjusted for age and comorbidities including hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of heart disease. Results Overall, trends in in-hospital mortality (p=0.25) and LOS (p=0.91) remained unchanged for the PCI group, but decreased in the CABG group (p Conclusions Revascularization can be successfully achieved by both PCI and CABG in CKD patients. However, PCI appears to have lower in-hospital mortality, fewer postoperative complications, shorter LOS, and significant cost savings.

Background Left ventricular assist devices (LVADs) are increasingly used as a bridge to transplant or destination therapy. Renal dysfunction often precludes patients from single organ heart transplantation. However, the effect of preoperative renal dysfunction on LVAD outcomes is often debated, with limited literature available. Hypothesis Patients with preoperative chronic kidney disease undergoing LVAD implantation have worse periprocedural outcomes. Methods All hospitalizations of patients with systolic heart failure with index LVAD implantation (ICD-9 procedure code 37.66) were identified from the 2008-2014 National Inpatient Sample. Patients were stratified based on whether they had preoperative chronic kidney disease (CKD stage 1-4) (diagnosis codes 585.X) or normal renal function. Outcomes including in-hospital mortality, LOS, cost of care, and postoperative complications were analyzed. Trends over time were determined using the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using the discharge weights provided under NIS guidelines. These models were adjusted for age and comorbidities including hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction. Results In the 880 hospitalizations involving pre-op CKD and 2209 without CKD, no statistically significant differences were noted in in-hospital mortality, LOS or total charges (p>0.05) after adjusting for age and comorbidities. No significant trends were noted over the study period for in-hospital mortality, LOS, and cost for the two groups (p>0.05). Average cost of hospitalization was $852,745 and average LOS was 37 days. Patients with CKD tended to be older (58.6 vs. 54.0 years) with a higher proportion of males (84% vs. 74%) and included more patients of African American race (29% vs. 21%). Patients with CKD also had a higher proportion of Medicare patients. There were no significant differences between the two groups in postoperative atrial fibrillation or stroke, or the post-procedural need for dialysis catheters or hemodialysis. Conclusions CKD (Stage 1-4) did not have a significant impact on index LVAD implant hospitalization in terms of inpatient mortality, LOS, total charges, and postoperative complications.

Introduction Treatment guidelines for asymptomatic acute cellar rejection of ISHLT grade 2 (2R ACR) are dictated by clinical judgement and patient risk. In higher risk cases, a course of intravenous (IV) corticosteroids may be recommended, while in others a short course of oral steroids is given. There is also variability in pathologic rejection grading on endomyocardial biopsy. We aimed to determine if treatment choice predicts outcomes in 2R ACR patients. Methods We reviewed all patients with biopsy-proven 2R ACR following heart transplantation at our institution from 2012-2016. Treatment strategies were classified as IV corticosteroids or “other” (ie, pulse oral corticosteroids or adjustment of baseline immunosupprants.) These two strategies were compared for time to re-hospitalization, time to recurrence of ≥2R ACR, development of cardiac allograft vasculopathy or renal insufficiency, and 1-year survival. Results Among 305 heart transplant recipients, 73 patients developed 117 separate episodes of 2R ACR. 37 patients (51%) received IV corticosteroids and were more likely to be hospitalized (24% versus 3%) for treatment. However, the two strategy groups did not differ in time to re-hospitalization (46% versus 33%, p=0.78) (Fig 1), time to recurrence (98 days versus 51 days, p=0.48), development of cardiac allograft vasculopathy (67% versus 57%, p=0.47) or renal insufficiency (58% versus 65%, p=0.634). Admission for infection was the reason for re-hospitalization in 19% vs 3% of cases. Additionally there was no difference in 1-year survival (95% versus 94%, p=0.45) (Fig 2). Conclusions While this study is limited by a small cohort, results suggests there is no significant difference in outcomes among patients treated with either aggressive IV steroids versus adjustment of oral immunosuppressants, including oral corticosteroids. Aggressive treatment may not be needed for biopsy proven 2R ACR in patients without hemodynamic compromise.

Introduction: Although surgically-placed continuous-flow left ventricular assist devices (cf-LVADs) improve cardiac output, the consequence of long-term continuous flow on peripheral vascular function, a significant predictor of adverse outcomes, remains unclear. Hypothesis: We hypothesized that patients (pts) with cf-LVADs would have increased arterial stiffness and diminished vascular endothelial function compared to pts with chronic heart failure (HF) and heart transplant (HT) recipients. Methods: We compared pts with at least 6 months of cf-LVAD support (n520) to pts with medically managed chronic HF (n519) and HT recipients (n519). Digital vascular function measurements with peripheral artery tonometry were utilized to assess arterial stiffness (augmentation index, AIx) and microvascular endothelial function following 5 minutes of arm arterial occlusion (reactive hyperemia index, RHI). Brachial artery ultrasound was used simultaneously to assess endothelial-dependent flow mediated dilation (FMD) of the conduit arteries. Results: Compared to HT recipients, pts with cf-LVADs demonstrated significantly higher AIx (23.75 6 20.35 vs. 5.58 6 10.24; p50.006) and lower RHI (1.38 6 0.51 vs. 1.94 6 0.49; p50.01) (Table 1). Pts with cf-LVADs demonstrated higher AIx than those with chronic HF (23.75 6 20.35 vs. 10.84 6 17.63; p50.07), however those differences did not reach statistical significance. There were no significant differences in RHI between cfLVAD and chronic HF pts. In addition, there were no significant differences in FMD between cf-LVAD pts and HT recipients, or cf-LVAD and chronic HF pts. Conclusion: This is the first demonstration that pts with long-term cf-LVADs have increased arterial stiffness and diminished microvascular endothelial function compared to HT recipients. These findings also suggest that, despite an increase in cardiac output, pts with cf-LVADs have increased arterial stiffness compared to those with chronic HF. The mechanisms behind these vascular findings remain unclear, but might be related to reduced pulsatility. The impact of persistent abnormal vascular function on outcomes in pts with cf-LVADs merits further investigation.