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Abstract Background The diagnosis of acute cellular rejection (ACR) is a major objective in the management of heart transplant recipients. The aim of this study was to assess the utility of speckle-tracking derived parameters in identifying patients at risk of graft rejection. Methods A prospective, single-center study was carried out involving 45 consecutive heart transplant patients who underwent a total of 220 routine endomyocardial biopsies (EMBs) with correlative echocardiographic examination. Results No significant ACR (grade 0-1R) was seen in 190 biopsies (81.2% of the ACR-free group), and moderate ACR requiring specific treatment (grade 2R) was detected in 30 biopsies (13.6% of the ACR group). Grade 3R was not observed. All longitudinal left ventricular (LV) and right ventricular (RV) strain parameters were greater in the ACR-free group than in patients with ACR, while no differences were observed between radial and circumferential strain parameters. In our analysis, we selected RV free wall longitudinal strain (RV FW) ≤ 16.8% and 4-chamber longitudinal strain (4CH LS) ≤ 13.8%, which related to the presence of ACR requiring treatment. We assigned 1 point for each parameter (minimum 0, maximum 2 points) and derived a new echocardiographic index, the Strain Rejection Score (SRS). Our proposed approach—a combination of the 2 abovementioned indices—for screening patients at risk of ACR ≥ 2R, when expressed by a score 2 points, showed good specificity, strong negative predictive value, and the highest area under the curve. Conclusions Our study demonstrated that combination of 4CH LS and RV FW as a new echocardiographic index, the Strain Rejection Score, can be useful as a noninvasive assessment of ACR during the first year of follow-up after heart transplant. Highlights • Noninvasive detection of rejection is a major objective in the management of heart transplant recipients. • We evaluated a new echocardiographic index, Strain Rejection Score (SRS), in the assessment of cardiac allograft rejection. • The new index includes RV free wall longitudinal strain and 4-chamber longitudinal strain analysis. • According to our results, SRS is sufficient for use as an auxiliary diagnostic tool for identifying most patients with a high degree of ACR suspicion. [ABSTRACT FROM AUTHOR]

Abstract Background Left ventricular assist devices (LVADs) are used for treatment of end-stage heart failure. Outcomes are dependent on right ventricle (RV) function. Prediction of RV function after LVAD implantation is crucial for device selection and patient outcome. The aim of our study was to compare early LVAD course in patients with optimal and borderline echocardiographic parameters of RV function. Material and methods We retrospectively reviewed 24 male patients with LVAD implantation. The following echocardiographic data of RV function were collected: FAC (fractional area change) with optimal value > 20%, tricuspid annulus plane systolic excursion >15 mm, RV diameter < 50mm, and right-to-left ventricle ratio < 0.57 (RV/LV). Patients were divided into group 1 (12 patients) with transthoracic echocardiography parameters in optimal ranges and group 2 (12 patients) with suboptimal transthoracic echocardiography findings. Study endpoints were mortality, discharge from the intensive care unit, and RV dysfunction. Demographics, postoperative clinical outcomes, comorbidities, complications, and results in a 30-day period were analyzed between groups. Results Echocardiography parameters differed significantly between groups 1 and 2 according to FAC (31.8% vs 24.08%; P =.005), RV4 (45.08 mm vs 51.69 mm; P =.02), and RV/LV ratio (0.6 vs 0.7; P =.009). Patients did not differ according to course of disease, comorbidities before implantation, or complications. One patient from each group died. Patients in group 2 experienced more pulmonary hypertension, required increased doses of catecholamines, and stayed in the intensive care unit longer. No RV dysfunction was noted. Conclusions Borderline FAC, tricuspid annulus plane systolic excursion, and RV4 add RV/LV ratio prolonged recovery after LVAD implantation even with no RV failure. Parameters chosen for qualification are in safe ranges. Highlights • Prediction of RV function for LVAD implantation is crucial for patient outcome. • We showed comparable outcome between groups of optimal and borderline RV function. • Our results with the continuous flow LVAD are encouraging; there was no RV dysfunction. [ABSTRACT FROM AUTHOR]

Abstract Background Model for End-Stage Liver Disease (MELD) score predicts multisystem dysfunction and death in patients with heart failure (HF). Left ventricular assist devices (LVADs) have been used for the treatment of end-stage HF. Aim of the study We evaluated the prognostic values of MELD, MELD-XI, and MELD-Na scores in patients with POLVAD MEV LVAD. Materials and methods We retrospectively analyzed data of 25 consecutive pulsatile flow POLVAD MEV LVAD patients (22 men and 3 women) divided in 2 groups: Group S (survivors), 20 patients (18 men and 2 women), and Group NS (nonsurvivors), 5 patients (4 men and 1 woman). Patients were qualified in INTERMACS class 1 (7 patients) and class 2 (18 patients). Clinical data and laboratory parameters for MELD, MELD-XI, and MELD-Na score calculation were obtained on postoperative days 1, 2, and 3. Study endpoints were mortality or 30 days survival. MELD scores and complications were compared between Groups S and NS. Results 20 patients survived, and 5 (4 men and 1 woman) died during observation. Demographics did not differ. MELD scores were insignificantly higher in patients who died (Group 2). Values were as follows: 1. MELD preoperatively (21.71 vs 15.28, P =.225) in day 1 (22.03 vs 17.14, P =.126), day 2 (20.52 vs 17.03, P =.296); 2. MELD-XI preoperatively (19.28 vs 16.39, P =.48), day 1 (21.55 vs 18.14, P =.2662), day 2 (20.45 vs 17.2, P =.461); and 3. MELD-Na preoperatively (20.78 vs 18.7, P =.46), day 1 23.68 vs 18.12, P =.083), day 2 (22.00 vs 19.19, P =.295) consecutively. Conclusions The MELD scores do not identify patients with pulsatile LVAD at high risk for mortality in our series. Further investigation is needed. Highlights • Mechanical circulatory system POLVAD MEV is used for treatment of heart failure. • MELD scores have predictive value for heart failure patients. • Assessment of predictive value of the MELD score after POLVAD MEV. • MELD scores do not predict morbidity or mortality in patients with POLVAD MEV. [ABSTRACT FROM AUTHOR]

Abstract Background Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration is elevated in patients with pulmonary hypertension (PH); however, its role in the detection of PH associated with lung disease is not well established. Aim The aim of this study was to assess the value of NT-proBNP in the detection of PH in patients with end-stage lung disease (esLD) referred for lung transplantation. Materials and methods The study population consisted of 65 patients: 37 with idiopathic pulmonary fibrosis (IPF), 20 with chronic obstructive pulmonary disease, and 8 patients with other interstitial lung diseases (75% men, mean age 53.3 ± 9.5 years). Serum concentration of NT-proBNP was assessed with an immunoradiometric assay kit. The mean pulmonary artery pressure (mPAP) was measured using a Swan-Ganz catheter. PH was defined as mPAP ≥ 25 mm Hg. Results Median NT-proBNP concentrations were significantly higher in patients with PH than in patients without PH: 139 (49–1236) pg/mL vs 67 (38–116) pg/mL, respectively; P =.016. Receiver operating characteristic (ROC) analysis revealed that NT-proBNP concentration higher than 131.5 pg/mL was a predictor of PH with good specificity (81%) and positive predictive value (78.9%) but low sensitivity (55.6%) and negative predictive value (58.6%). The area under the ROC curve of serum NT-proBNP concentration for PH was 0.71 (95% confidence interval 0.57–0.85, P =.039). Conclusion Serum concentration of NT-proBNP may be useful in the diagnosis of PH in patients with esLD referred for lung transplantation. Highlights • The usefulness of NT-proBNP in the diagnosis of hypoxic pulmonary hypertension was assessed. • Elevated serum concentration of NT-proBNP in patients with end-stage lung diseases referred for lung transplantation may reflect early changes in pulmonary circulation as well as right ventricle dysfunction. • NT-proBNP is useful as a non-invasive predictor for pulmonary hypertension in patients with end-stage lung diseases, that is, candidates for lung transplantation. [ABSTRACT FROM AUTHOR]

Abstract Background Red blood cell markers (RBCM) have been found to be predictors of mortality in various populations. However, there is no information regarding the association between the values of RBCM and long-term outcomes after orthotopic heart transplantation (OHT). The aim of this study was to assess whether the values of inflammatory markers and RBCM obtained directly before OHT are associated with mortality in patients diagnosed as having end-stage heart failure undergoing OHT. Methods We retrospectively analyzed data of 173 nonanemic adult patients diagnosed as having end-stage heart failure undergoing primary OHT between 2007 and 2014. Clinical and laboratory data were obtained at the time of admission for the OHT. RBCM were analyzed using an automated blood counter (Sysmex XS-1000i and XE-2100, Sysmex Corporation, Kobe, Japan). Results Mean age of the patients was 54 (41–59) and 72% of them were male. During the observation period, the mortality rate was 32%. Multivariable analysis of Cox proportional hazard confirmed that elevated pretransplantation red blood cell distribution width value (hazard ratio [HR], 1.38 [1.25–1.48], P <.001) was the sole independent predictor of death during long-term follow-up. Other red blood cell distribution width such as mean corpuscular volume, mean corpuscular hemoglobin concentration, and mean corpuscular hemoglobin (HR, 0.88 [0.84–0.91]; P <.001; HR, 0.75 [0.53–1.05]; P <.05; HR, 0.78 [0.64–0.96]; P <.05, respectively) had predictive value in univariable analysis. Conclusions In summary, we have demonstrated that elevated red blood cell distribution width immediately before OHT is an independent predictor of all-cause mortality in heart transplant recipients. Other factors associated with posttransplantation mortality include lower values of mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration. Highlights • We identified the perioperative risk factors impacting the occurrence of death. • We have demonstrated that elevated RDW immediately before OHT is an independent predictor of all-cause mortality in heart transplant recipients. • Other factors associated with posttransplantation mortality include lower values of MCV, MCH, and MCHC—hematologic indices related to iron stores. [ABSTRACT FROM AUTHOR]

Abstract Background Pulmonary hypertension (PH) is a common complication in end-stage lung disease (esLD). The aim of this study was to establish the best threshold values for mean, systolic, and diastolic artery pressure (mPAP, dPAP, and sPAP, respectively) to identify patients with esLD referred for lung transplantation and to predict 1-year prognosis. Methods Sixty-five patients were enrolled in the study (75% men) with a mean age of 53.3 ± 9.5 years; 31% had chronic obstructive pulmonary disease (COPD), 57% had idiopathic pulmonary fibrosis (IPF), and 12% had interstitial lung diseases (ILDs). The mean period of observation was 14.4 ± 5 months. We assessed invasively mPAP, dPAP, and sPAP, as well as pulmonary capillary wedge pressure (PCWP), using a Swan-Ganz catheter. Receiver-operating characteristic (ROC) curves were constructed to identify the best cutoff points for mPAP, dPAP, and sPAP to predict survival. The study endpoint was defined as 1-year mortality before transplantation. Survival analysis was completed according to the Kaplan-Meier method. Results During follow-up, 30 (46.1%) patients died and 19 (29%) underwent lung transplantation. Based on ROC curve analysis, we estimated mPAP ≥30 mm Hg, dPAP ≥20 mm Hg, and sPAP ≥44 mm Hg as the best threshold values with the highest sensitivity (70%, 70%, and 73%, respectively) and specificity (76%, 69%, and 72%, respectively) and the acceptable area under curve (0.67, 0.68, and 0.72, respectively). The negative predictive values for mPAP, dPAP, and sPAP were higher than the positive predictive values (79%, 77%, and 81% vs 67%, 61%, and 64%, respectively). We also constructed Kaplan-Meier curves for mPAP, dPAP, and sPAP threshold values. There were significant differences in 1-year survival between patients with and without PH for mPAP, dPAP, and sPAP threshold values (P =.005, P =.035, and P <.001; respectively). Conclusion Elevated mPAP, dPAP, and sPAP are related to worse prognosis in patients with esLD referred for lung transplantation. Highlights • The best cutoff values of mean, diastolic, and systolic pulmonary artery pressure for predicting 1-year survival in patients with end-stage diseases referred for lung transplantation were assessed. • Mean, diastolic, and systolic pulmonary artery pressure are related to a worse prognosis in patients with end-stage lung diseases. • The right heart catheterization in patients with end-stage lung diseases, candidates for lung transplantation is an important part of the prognostic assessment in this group of patients. [ABSTRACT FROM AUTHOR]

Background Left ventricular assist device (LVAD) support is increasingly used in patients with heart failure. The right ventricle (RV) plays a main role in LVAD support. Little is known about the effects of pulsatile Polvad MEV devices or continuouseconds flow pumps on RV function. We compared hemodynamic parameters of RV in patients after implantation of Polvad MEV (PM) and Heartware (HW) or Heartmate II (HMII) LVADs. Methods Forty-four patients were retrospectively reviewed after implantation of PM (group P; n = 24 [21 M, 3 F]) or HW or HMII (group C; n = 20 [20 M, 0 F]) LVADs from April 2007 to February 2014. Hemodynamic data—mean pulmonary pressure (mPAP), central venous pressure (CVP), cardiac output (CO), and cardiac index (CI)—were collected before surgery, after surgery, and every 2 hours in the intensive care unit, with the time points numbered from 1 to 120. Right ventricular work (RVW) was calculated according to the equation: RCW = CO × (mPAP − CVP) × 0.0144 (g·m). Results Baseline characteristic of the patients were similar. mPAP values were similar between groups. CVP values were higher in group P, significantly at time points 5 and 7–33. CO values were higher in group C, significantly from point 3 and almost all the time to point 43. CI reached significance at point 9, 12–14, 16–19, and 30–41. RCW was higher in group P before implantation. Post-implantation RCW values were higher in group C, significantly at time points 19, 20, 32–34, 51–53, and 55–57. Conclusions Continuous-flow pumps more effectively optimize RV function than pulsatile LVADs, which can result in more effective prevention of RV failure or insuffiency in that group. [ABSTRACT FROM AUTHOR]

Background The Model for End-Stage Liver Disease (MELD) scoring system incorporating a combination of hepatic and renal laboratory parameters does not adequately reflect the degree of multi-organ dysfunction in patients with heart failure, who need oral anticoagulation. In order to exclude the impact of oral anticoagulation on the international normalized ratio (INR), we used the MELD excluding INR (MELD-XI) score. The aims of the study were to calculate the individual preoperative MELD-XI score and its ability to predict 1-year mortality after heart transplantation and to identify other preoperative laboratory prognostic parameters. Methods We retrospectively analysed data of 87 consecutive adults undergoing heart transplantation between 2011 and 2014. Clinical data and laboratory parameters for the calculation of the MELD-XI score were obtained at the time of admission for the heart transplantation. Results The average age of the patients was 48.8 ± 13.3 years and 68.9% of them were male. During the observation period, the mortality rate was 18.4%. Multivariate analysis of Cox proportional hazard confirmed that the pretransplantation MELD-XI score (hazard ratio [HR] = 1.625 [1.286–2.053]; P < .001), sodium serum concentration (HR = 0.824 [0.677–1.001]; P < .05) and highly sensitive C-reactive protein (hs-CRP) serum concentration (HR = 1.045 [1.008–1.083]; P < .02) were independent predictors of death during the first year after heart transplantation. Area under the receiver operating characteristic (ROC) curve (AUC) indicated a good discriminatory power of MELD-XI (AUC 0.997; P < .04) and plasma sodium concentration (AUC 0.901; P < .01) in death prediction. Conclusions Our study confirms that the pretransplantation MELD-XI score, as well as serum sodium and hsCRP concentrations, may be used to estimate postoperative risk in heart transplant recipients during a 1-year follow-up. [ABSTRACT FROM AUTHOR]

Background Cardiac allograft vasculopathy (CAV) still remains to be one of the most important limiting factors for heart transplant recipients' long-term survival. The aim of our study was to identify the perioperative risk factors impacting the occurrence of CAV during the long-term follow-up. Methods We retrospectively analysed the data from 198 consecutive adult patients, who underwent heart transplantation between 2007 and 2012, in whom at least one routine coronarography (CAG) was performed. CAV onset was defined as any lesion seen at least at one routine CAG. Results The average follow-up was 63.6 ± 14.7 months. The frequency of CAV in the analysed population was 36 (18.1%). Multivariate stepwise logistic regression analysis confirmed that NT-proBNP plasma concentration directly before heart transplant [logNT-proBNP OR = 16.455 (4.587–31.036), P < .0001], fibrinogen plasma concentration a month after heart transplant [OR = 1.022 (1.009–1.035), P < .001] and occurrence of diabetes [OR = 12.355 (1.417–35.750), P < .001], were independent predictors of CAV. Area under the ROC curves (AUC) indicated a well discriminatory power of plasma fibrinogen [AUC 0.9278, P < .001] and plasma NTproBNP concentration [AUC 0.9514, P < .001] in CAV prediction. The optimal cut-off value of fibrinogen was 509 mg/dL, and of NT-proBNP was 10080 pg/mL. Conclusions Our data show that NT-proBNP and fibrinogen plasma concentrations as well as occurence of diabetes, both preexisting and new onset after heart transplant can be used to identify patients at risk of developing CAV. [ABSTRACT FROM AUTHOR]

Background Limited data exist about the effects of continuous-flow versus pulsatile-flow left ventricular assist devices (LVADs) on end-organ function. We hypothesized that a pulsatile Polvad MEV (PM) would result in outcomes similar to those of similarly ill patients implanted with a continuous-flow LVAD (Heartware [HW] or Heartmate II [HMII]). We aimed to compare renal, hepatic, and hematologic functions in the 1st 30 days of support. Methods We retrospectively reviewed patients with 24 PM (21 M, 3 F; group P) and 15 HW and 5 HMII (20 M, 0 F); group C LVAD implantations from April 2007 to February 2014. Creatinine, bilirubin, aspartate (AST) and alanine (ALT) transaminases, hematocrit, platelet count, international normalized ratio (INR), and activated partial thromboplastin time (APTT) parameters were analyzed before implantation and during 30 days of support. Demographic parameters were similar. Results No significant differences were found between the groups regarding baseline renal, hepatic, or hematologic function. Baseline INR and APTT were significantly higher in group P. Levels of creatinine were similar between groups. They increased from baseline to postoperative day (POD) 1 and then decreased. Bilirubin levels were insignificantly higher in group P. Transaminases were significantly higher in group P (AST in PODs 3–6, ALT in PODs 3–7). INR values were significantly higher at baseline and in POD 0. APTT values were insignificantly higher in group P. Conclusions The use of LVAD improved renal and hepatic function in our series. Patients in group P had more decreased hepatic function and presented slower regeneration. [ABSTRACT FROM AUTHOR]

Background The evaluation of prognosis and determination of a long-term treatment strategy is an important element of management in patients with heart failure (HF). Methods The aim of the study was to determine the prognostic value of the Model for End-Stage Liver Disease (MELD) and its modifications, MELD and serum sodium (MELD-Na) and MELD excluding the international normalized ratio (MELD-XI), as well as other independent risk factors for death during a 4-year follow-up. We analyzed retrospectively 143 patients with advanced HF, evaluated for heart transplant between 2009 and 2011. Patients using warfarin were excluded from the study. The long-term follow-up data were obtained during follow-up visits and/or phone contact with the patients or their families. Results The age of the patients was 54 (48–59) years and 88.1% of patients were male. Mortality rate during the follow-up period was 49%. The MELD scores (hazard ratio [HR], 1.12; P < .001), as well as serum high-sensitivity C-reactive protein (hs-CRP; HR, 1.01; P < .01) and N-terminal pro-brain natriuretic peptide (NT-proBNP; HR, 1.01; P < .05) levels, were independent risk factors for death. Receiver operator characteristic analysis indicated that a MELD cutoff of 10 (area under the curve [AUC], 0.756; P < .0001], MELD-XI cutoff of 13.0 (AUC, 0.720; P < .0001), MELD-Na cutoff of 13.0 (AUC, 0.813; P < .0001), hs-CRP cutoff of 4.02 (AUC, 0.686; P < .001), and NT-proBNP cutoff of 1055 (AUC, 0.722; P < .001) were the best predictive values as predictors of death. Conclusions MELD, MELD-Na, and MELD-XI scores are prognostic factors for death during a 4-year follow-up. A high MELD score is an independent prognostic factor for death. NT-proBNP and hs-CRP serum concentrations are other independent factors influencing death. [ABSTRACT FROM AUTHOR]