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We hypothesized that a team-based protocolized treatment framework improve survival from mechanical circulatory support (MCS) bridging to heart transplantation (HT) or left ventricular assist device (LVAD) in patients with cardiogenic shock (CS) from end-stage heart failure (ESHF) by minimizing and reversing multi-organ dysfunction (MOD) before HT or LVAD. We introduced a team-based protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF in 2018. We compared 6-month survival before (G1) and after (G2) adoption of this framework. The Sequential Organ Failure Assessment (SOFA) score was used as a measure of MOD. We included 101 consecutive patients with CS due to ESHF. Adoption of ROSE led to earlier MCS in G2 before severe MOD (INTERMACS 2, lower lactate and SOFA score - TABLE). Ecpella was more common in G2 (32% vs 3%, p<0.001). MCS lowered SOFA score in both groups; achieving lower SOFA scores prior to HT/LVAD in G2 (4 (2-7) vs 2 (1-5), p=0.012 FIGURE). The duration of MCS bridging were comparable (p=0.417). In G1 and G2 - 44% vs 55% (p=0.292) were bridged to HT, 13% vs 13% (p=0.947) to LVAD; and 2% vs 3% to recovery. 6-month survival was higher in G2 (FIGURE p=0.001) due to lower pre-HT/LVAD SOFA score and lactate on Cox model. Pre-HT/LVAD SOFA score of ≥9 was 73% sensitive and 100% specific (AUC 0.932) for mortality post-HT/LVAD. Our ROSE protocol improved 6-month survival in patients with CS due to ESHF by minimizing and reducing MOD prior to HT/LVAD therapy. Pre-HT/LVAD SOFA score of ≥9 is specific for mortality post-HT/LVAD. [ABSTRACT FROM AUTHOR]

To describe our experience with percutaneous right ventricular assist device (RVAD) as part of temporary mechanical circulatory support (tMCS) strategy. Prospectively data from 2017-21. Indications: (i) post-LVAD, (ii) post-heart transplant, and (iii) miscellaneous indications. Deployment: primary tMCS or as planned staged weaning from VA-ECMO. Staged weaning was considered to minimise ECMO run in isolated RV failure. Configurations : (i) single dual lumen cannula (RVAD1) or (ii) two single lumen cannula (RVAD2). Centrifugal flow pump was used in both configurations. 2-single lumen cannula was preferred if >3.5L/min is anticipated. An oxygenator may be added for respiratory support. Complications : displacement, SVC obstruction and hemolysis were recorded. 44 patients received 49 RVADs over 45 separate in-patient episodes. 12 patients died within 90 days (27%). By indications : 1/13 (8%) death in heart transplant, 6/20 (28%) in post-LVAD and 5/11 (45%) in the miscellaneous group [ Figure ]. By deployment : As primary tMCS, RVAD was used in isolation in 18 patients and in combination with Impella in 2 patients. 2/20 (10%) staged ECMO weaning vs 10/24 (41%) of primary treatment died <90 days. Both RVAD+Impella patients died <90 days. Configuration : RVAD1 in 32 patients, RVAD2 in 12 patients. Oxygenator was added in 10 RVAD1 for 7 (5-12) days and 4 RVAD2 for 6 (2-15) days, p=0.768. Lactate 24-hours post-RVAD was lower in RVAD2 compared to RVAD1: 1.21 (0.91-1.39) vs 1.45 (1.14-1.77)mmol/l, p=0.024. Complications : There were 2 displacements (1 death), 2 hemolysis and 2 SVC obstruction in RVAD1 but none in RVAD2. SVC obstruction resolved after conversion to RVAD2. 1. Survival with RVAD is highest in post-LVAD or transplant, especially as planned staged VA ECMO weaning. 2. Outcomes are poor as primary tMCS (+/-Impella) in cardiogenic shock. 3. RVAD2 may have lower complication rates and better lactate clearance than RVAD1. [ABSTRACT FROM AUTHOR]

This case describes multiple forms of short term mechanical circulatory support (sMCS) used sequentially in the same patient, and illustrates the role of different clinical goals of sMCS. A 59 year old man with previous coronary artery bypass surgery attended with troponin positive acute coronary syndrome. After workup, he went for PCI to a native coronary chronic total occlusion using anterograde/retrograde wires. Unfortunately, the left internal mammary graft was dissected, and he suffered cardiac arrest. Day 0: Impella CP as bridge to recover y : During resuscitation an Impella CP was placed via his right femoral artery and resolved circulatory arrest. Further PCI was performed to the LIMA ostium with restoration of flow. He was transferred to ITU. Day 3: Peripheral VA-ECMO as bridge to decision: His clinical status improved, but he remained in shock. His support was upgraded to peripheral veno-arterial (VA) extra-corporeal membrane oxygenation (ECMO), leaving the Impella in place as an LV vent. Day 14: BIVAD as bridge to transplantation: He remained MCS-dependent, and had no absolute contraindications to advanced therapies. He went to theatre for implantation of bilateral short term ventricular assist devices (BI-VAD) to optimise his organ support prior to transplantation. He was placed on the super-urgent waiting list. He had intermittent ventricular fibrillation but continued to mobilise on the ITU. Day 48: Transplantation and bridge to recovery with central ECMO: After 34 days on BIVAD, he underwent orthotopic cardiac transplantation. Due to vasoplegia and RV dysfunction, he was weaned from cardiopulmonary bypass onto central ECMO. Day 50: Weaning support - percutaneous RVAD as bridge to recover y : There was persistent RV dysfunction. Central ECMO was exchanged for a Protek RVAD. Day 56: Explant of RVAD: His status continued to improve. The RVAD was weaned and explanted after 6 days. Day 73: Discharge home: He required intense physiotherapy. After 73 days in hospital he was discharged home. At the time of submission he is alive at 291 days post transplant. This man's successful outcome was facilitated by judicious use of sMCS, on each occasion with a clear strategy in mind. Surgically implanted and percutaneous modes were used. Collaboration between cardiologists, intensivists and cardiac surgeons was essential to facilitate optimal care. [ABSTRACT FROM AUTHOR]

Trichosporonosis and complications at the aorto-allograft anastomosis are rare after cardiac transplantation (CTx). We report a case of Trichosporon endocarditis and mycotic pseudoaneurysm. A 51 year old female with dilated cardiomyopathy and adult polycystic kidney disease underwent bilateral nephrectomy and was listed for renal transplant (RTx). While waiting, her cardiac status progressed and she was assessed for combined CTx-RTx. Staged surgery was planned, with CTx followed by urgent RTx. She underwent orthotopic CTx in 2017. Early complications (including 2R rejection, drug-induced leucopenia, cytomegalovirus viraemia, and an infected fistula) delayed listing for RTx. Eventually, she underwent cadaveric RTx in 2019. Two weeks after RTx she was admitted with fevers, skin lesions and renal graft dysfunction. She had erythematous papules developing into bullae with ulceration and central necrosis, and loss of vision due to endophalmitis. Mycology from her skin and eye identified fungus of the Trichosporon species and she was treated with antifungal therapy comprising liposomal amphotericin B, Voriconzaole and Flucytosine. Transoesophageal echocardiography showed a large pseudoaneurysm at the aortic anastomosis with vegetations on the suture line and in the cavity. Serial computed tomography showed the pseudoaneurysm increasing in size despite medical therapy, and she underwent aortic valve and root replacement. Explanted tissue confirmed endocarditis with Trichlosporon species. She made a good surgical recovery. Five months after admission she was discharged with good cardiac and renal graft function, on lifelong voriconazole. This is the first report of Trichosporon endocarditis and suture-line pseudoaneurysm after CTx. Haemodialysis was a key risk factor for infection, potentially avoided by earlier RTx. She remains free of recurrent fungaemia on long term suppression after 1 year, but there remains a risk of recurrent infection in the aortic root. [ABSTRACT FROM AUTHOR]