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Purpose To study the impact of temporary circulatory support (TCS) on hemometabolic shock and the relation between the duration of TCS and resulting markers of end-organ function. Methods We studied 45 patients with acute cardiogenic shock (median age 57 (IQR 49-65), 84% male) treated with TCS (59% VA ECMO, 41% temporary LVAD) as a bridge to durable LVAD implantation. Laboratory parameters of end-organ function and perfusion (AST, ALT, lactates and eGFR) were measured/calculated at onset and end of TCS. Adjusted associations between time on TCS and laboratory parameters were plotted using multivariable restricted cubic splines models with three knots. Results The median time on TCS was 7 days (IQR 4-20). One- and three-month survival following durable LVAD was 85% and 80%, respectively; median time to hospital discharge was 74 days (IQR 55-106). Median AST decreased from 300 (74-1494) to 61 U/l (32-117, p<0.0001), ALT from 186 (47-1700, p=0.001) to 61 U/l (33-104), lactates from 3.1 (2.2-6.1) to 1.3 (1.0-1.7, p=0.041) and mean eGFR increased from 51±26 to 85±27 ml/min/m2, p=0.015. Figure 1 shows the relation of time on TCS to AST, ALT, lactates and eGFR at the end of short-term MCS, adjusted for baseline levels of these variables. The relation was significant for AST, ALT and lactates for which the inflection point is reached rapidly, with normal AST and ALT values being associated with around 6 and 10 days of TCS, respectively (p values given in Figure 1). Patients on temporary VAD were at lower risk of retaining elevated AST and ALT values, compared to those on VA ECMO (HR 0.11, CI 0.04-0.35, p<0.0001). Conclusion In addition to a substantial improvement in markers of end-organ function, we have observed a significant relation between the time on TCS, lactates and in particular AST/ALT following TCS, as opposed to eGFR. The first 6-10 days of support were associated with normalisation of AST and ALT values post TCS, respectively. An analysis of a larger cohort should allow to study the association of these changes with survival. [ABSTRACT FROM AUTHOR]

Percutaneous coronary intervention in patients with cardiac allograft vasculopathy is burdened with a lot of difficulties. Although they have allowed significant progress in comparison with plain balloon angioplasty and bare metal stents, drug-eluting stents have not fully overcome problems of diffuse lesions and small-vessel disease that are so common in transplant coronary artery disease. There is growing evidence that drug-eluting balloons might be a better choice for patients with small vessel atherosclerotic coronary disease and yet there is no experience with this technology in patients with cardiac allograft vasculopathy. Herein we report a case series of successful percutaneous coronary interventions in patients with cardiac allograft vasculopathy. [ABSTRACT FROM AUTHOR]

Introduction Right ventricular perforation during endomyocardial biopsy is an unusual, although potentially life-threatening, complication caused with the tip of the bioptome. The majority of perforations in heart transplant patients can be managed without surgery owing to adhesions nearly obliterating pericardial space. Case Report We report a case of heart transplant patient who suffered right ventricular perforation as a consequence of incidental extraction of a temporary epicardial pacemaker wire during a routine endomyocardial biopsy sampling. Conclusions The patient suffered no clinical consequences. [ABSTRACT FROM AUTHOR]

Pancyclic aortic regurgitation (AR) following continuous flow left ventricular assist device implantation (cf-LVAD) adversely impacts device performance. We present the incidence and mortality burden of progressive AR after cf-LVAD placement. We conducted a retrospective analysis of a database encompassing the cf-LVAD experience of 12 European centers. Patients were dichotomized according to the progression of AR over time. Patients with de-novo AR or AR progression (group AR were compared to patients without worsening aortic valve function (group AR_0). Clinical and laboratory data were collected and compared between patient groups. Kaplan-Meier analysis was used to evaluate overall survival between cohorts. Out of a total of 372 eligible patients, 147 (40%) have shown progression of AR over a mean follow-up of 3.2±2.6 years. Patients in group AR_1 were comparable to group AR_0 with respect to age (57±11 vs 56±13 yrs, p=0.612), gender (81% vs 82% male, p=0.681) and preoperative INTERMACS profile (2.9±1.2 vs 2.8±1.3, p=0.715), but were found to have a lower body mass index (25±4 vs 26±5, p=0.003) and were less likely to be diabetic (14% vs 27%, P=0.003). Progressive AR did not adversely impact overall survival (Figure). The NT-pro-BNP values at index discharge were similar between groups AR_1 and AR_0 (median 2376 (IQR, 1613-4186) vs 2153 (IQR, 1357-3348), p=0.093) pg/mL and at 6-month follow-up (1632 (IQR, 1031-2567) vs 1460 (795-2331), p=0.455) pg/mL. Six-minute walk test results mirrored these data, with no observable intergroup variability at two time points (368±123 vs 386±139 meters, p=0.480 in groups AR_1 and AR_0) and (415±132 vs 487±55 meters, p=0.068). Patients commonly experience worsening AR when exposed to the continuous flow of contemporary LVADs. While harboring potential to reduce effective forward flow by recycling the regurgitant volume, progression of AR in our study did not influence survival or functional status. [ABSTRACT FROM AUTHOR]

There are conflicting data related to the use of implantable cardioverter-defibrillators (ICDs) in patients supported with continuous-flow ventricular assist devices (LVADs). Several US studies have shown a neutral effect on mortality, whereas a recent European study suggested better outcomes in LVAD patients who have an ICD. We aimed to investigate the benefit of ICDs in patients bridged to transplant with a LVAD in the TRans-Atlantic registry on VAd and TrAnsplant (TRAViATA). Data from consecutive patients that received a LVAD as a bridge to transplantation between January 2008 and April 2017 were collected in 7 EU (n=299) and 3 US centers (n=225). Survival analysis was performed using Kaplan-Meier and Cox proportion hazard regression analysis. Patients were censored at time of transplantation. Patients with an ICD at the time of LVAD (n=350) implantation were older (56 vs. 53 years, p<0.05), less likely to be female (13% vs. 21%, p<0.05) and to have ischemic cardiomyopathy (39% vs. 52%, p<0.05) compared to patients without an ICD (n=174). The proportion of patients with an ICD/LVAD was 66% in the EU and 68% in the US (p=0.49). Overall survival after LVAD was 86% at one year and 76% at two years. There was no difference in survival in patients with and without an ICD (Figure). These results were consistent when analyzing patients from each continent separately (Figure). In univariate Cox-regression age at time of implant and INTERMACS profile were associated with mortality (p<0.05) whereas presence of ICD was not. Sensitivity analysis excluding patients who received their ICD (n=25) after LVAD confirmed the results. In this retrospective study of LVAD patients from the EU and US ICD therapy conferred no survival advantage irrespective of geographic location. A prospective, randomized, trial of LVAD patients who have an existing ICD randomized to tachyarrhythmia therapy discontinuation is needed to validate these findings. [ABSTRACT FROM AUTHOR]