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Background This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. Methods Drawing from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42,932 records for elective, urgent, and emergency cardiac surgery procedures between July 1, 2017, to December 31, 2019. Using propensity score weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes (stroke, encephalopathy, coma, and operative mortality). Results The rate of pEEG use during anesthesia use was 32.8% (n=14,086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95%CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95%CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95%CI, 0.97-1.42) or coma (OR, 1.44; 95%CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95%CI, 1.05-1.44). This association remained significant after adjusting for POD (OR: 1.21, 95%CI: 1.03-1.41), stroke (OR: 1.21, 95%CI:1.04-1.42), and encephalopathy (OR: 1.28, 95%CI: 1.07-1.52). Conclusions This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.

Pulmonary venous thrombosis (PVT) is a rare but potentially devastating disease state with a largely unknown incidence. The most common etiologies of PVT are secondary to complications of lung surgery, malignancy, catheter ablation for atrial fibrillation, and idiopathic causes. Diagnosis can be challenging because presenting symptoms often are vague and nonspecific, or even asymptomatic, and traditional diagnostic modalities, such as chest radiography and arterial phase computed tomography scans, are poor techniques for diagnosis. The authors present a case of a patient presenting for pulmonary thromboendarterectomy for a presumed diagnosis of chronic thromboembolic pulmonary hypertension who was found incidentally to have a PVT, on intraoperative transesophageal echocardiography. Due to significant thrombus burden, the new finding of PVT, and known association of PVT and malignancy, a biopsy of mediastinal lymph nodes was obtained, which revealed metastatic cervical carcinoma. The pulmonary endarterectomy procedure was aborted.

Background Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts from DCD donors. Methods Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval. Results The mean age of the DCD donors was 23 ± 7 years and average time on TA-NRP was 56 ± 8 minutes. Total ischemic time was 183 ± 31 minutes and distance from transplant center was 373 ± 203 nautical miles. Recipient age was 55 ± 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days. Conclusions Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport.

Objectives The aim of this study was to evaluate clinical characteristics, mechanisms of failure, and outcomes of transcatheter aortic valve replacement (TAVR) explantation. Background Surgical explantation following TAVR may be required for structural valve degeneration, paravalvular leak, infection, or other reasons. However, in-depth data on indications and outcomes are lacking. Methods Data from a multicenter, international registry (EXPLANT-TAVR) of patients who underwent TAVR explantation were reviewed retrospectively. Explantations performed during the same admission as initial TAVR were excluded. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 6.7 months (interquartile range [IQR]: 1.0-18.8 months) after TAVR explantation and was 97.7% complete at 30 days and 86.1% complete at 1 year. Results From November 2009 to September 2020, 269 patients across 42 centers with a mean age of 72.7 ± 10.4 years underwent TAVR explantation. About one quarter (25.9%) were deemed low surgical risk at index TAVR, and median Society of Thoracic Surgeons risk at TAVR explantation was 5.6% (IQR: 3.2%-9.6%). The median time to explantation was 11.5 months (IQR: 4.0-32.4 months). Balloon-expandable and self-expanding or mechanically expandable valves accounted for 50.9% and 49.1%, respectively. Indications for explantation included endocarditis (43.1%), structural valve degeneration (20.1%), paravalvular leak (18.2%), and prosthesis-patient mismatch (10.8%). Redo TAVR was not feasible because of unfavorable anatomy in 26.8% of patients. Urgent or emergency cases were performed in 53.1% of patients, aortic root replacement in 13.4%, and 54.6% had concomitant cardiac procedures. Overall survival at last follow-up was 76.1%. In-hospital, 30-day, and 1-year mortality rates were 11.9%, 13.1%, and 28.5%, respectively, and stroke rates were 5.9%, 8.6%, and 18.7%, respectively. Conclusions The EXPLANT-TAVR registry reveals that surgical risks associated with TAVR explantation are not negligible and should be taken into consideration in the lifetime management of aortic stenosis.

Objectives The aim of this study was to determine clinical and echocardiographic characteristics, mechanisms of failure, and outcomes of mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). Background Although >100,000 mitral TEER procedures have been performed worldwide, longitudinal data on MV surgery after TEER are lacking. Methods Data from the multicenter, international CUTTING-EDGE registry were retrospectively analyzed. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 9.0 months (interquartile range [IQR]: 1.2-25.7 months) after MV surgery, and follow-up was 96.1% complete at 30 days and 81.1% complete at 1 year. Results From July 2009 to July 2020, 332 patients across 34 centers underwent MV surgery after TEER. The mean age was 73.8 ± 10.1 years, median Society of Thoracic Surgeons risk for MV repair at initial TEER was 4.0 (IQR: 2.3-7.3), and primary/mixed and secondary mitral regurgitation were present in 59.0% and 38.5%, respectively. The median interval from TEER to surgery was 3.5 months (IQR: 0.5-11.9 months), with overall median Society of Thoracic Surgeons risk of 4.8% for MV replacement (IQR: 2.8%-8.4%). The primary indication for surgery was recurrent mitral regurgitation (33.5%), and MV replacement and concomitant tricuspid surgery were performed in 92.5% and 42.2% of patients, respectively. The 30-day and 1-year mortality rates were 16.6% and 31.3%, respectively. On Kaplan-Meier analysis, the actuarial estimates of mortality were 24.1% at 1 year and 31.7% at 3 years after MV surgery. Conclusions In this first report of the CUTTING-EDGE registry, the mortality and morbidity risks of MV surgery after TEER were not negligible, and only

Objective The aim of this study was to model the short term and 2-year overall survival (OS) for intermediate-risk and low-risk patients with severe symptomatic aortic stenosis (AS) undergoing timely or delayed transcatheter aortic valve replacement (TAVR) during the 2019 novel coronavirus (COVID-19) pandemic. Methods We developed a decision analysis model to evaluate 2 treatment strategies for both low-risk and intermediate-risk patients with AS during the COVID-19 novel coronavirus pandemic. Results Prompt TAVR resulted in improved 2-year OS compared with delayed intervention for intermediate-risk patients (0.81 vs 0.67) and low-risk patients (0.95 vs 0.85), owing to the risk of death or the need for urgent/emergent TAVR in the waiting period. However, if the probability of acquiring COVID-19 novel coronavirus is >55% (intermediate-risk patients) or 47% (low-risk patients), delayed TAVR is favored over prompt intervention (0.66 vs 0.67 for intermediate risk; 0.84 vs 0.85 for low risk). Conclusions Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe AS results in improved 2-year survival when local healthcare system resources are not significantly constrained by the COVID-19., Graphical abstract

Background Single-site, dual-lumen venovenous extracorporeal membrane oxygenation ECMO) facilitates mobilization, reduces recirculation, and mitigates insertion and infectious risks of an additional access site. This study reports the experience with a bicaval dual-lumen cannula that comprises a robust physical design allowing for easy and safe cannulation, precise positioning and monitoring, and appropriate physiologic support for patients with acute respiratory failure. Methods Statistical analysis was performed from data gathered retrospectively from the electronic medical records of 20 adult patients who were cannulated for ECMO with this bicaval dual-lumen cannula from August 2018 through May 2019. Results Gas exchange and blood flow were optimized in all patients after cannulation (median pH, 7.42 [interquartile range {IQR}, 7.39, 7.44], ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, 186.5 [Pa o 2:Fi o 2, 116.5, 247.0]; pump flow, 3.9 L/min [IQR, 3.1, 4.3]). Eleven patients (55%) were able to be freed from mechanical ventilation after cannulation, 9 (45%) patients underwent a tracheostomy procedure while undergoing ECMO, and no patients required reintubation. No morbidity or mortality was related to the cannulation strategy or the catheter. Two patients required cannula repositioning. Survival to decannulation was 90%, and survival to hospital discharge was 80%. Conclusions The bicaval dual-lumen cannula maintains the advantages of upper body single-site configuration to provide the adjunctive respiratory support necessary to facilitate awakening and rehabilitation while minimizing the use of invasive mechanical ventilation. This cannula introduces design qualities that may offer advantages for acute respiratory failure requiring venovenous ECMO.

As a result of improvements in care for patients with congenital heart disease (CHD), >90% of children born with CHD are expected to survive to adulthood. For those adults, heart failure (HF) is the leading cause of death. Advances in recognition of, and treatments for, these patients continue to improve. Specifically, adults with CHD are candidates for both heart transplantation and mechanical circulatory support. However, challenges remain that require investigation to improve outcomes.

Minimally invasive mitral valve surgery (mini-MVS) with hypothermic fibrillatory arrest has been associated with an increased risk of stroke. We aim to investigate the incidence, predictors, and outcomes of stroke in a large cohort of patient who underwent clampless mini-MVS. Between January 2008 and June 2017, we performed 1247 mini-MVSs. The clinical, operative, and postoperative outcomes were analyzed. Univariable and multivariable regression analyses were used to identify predictors of postoperative stroke. The median follow-up was 5.2 years (interquartile range 2.6-7.5). The etiology of mitral valve (MV) disease was degenerative (60.4%, n = 753), functional (12.8%, n = 160), rheumatic (8.7%, n = 109), endocarditis (3.1%, n = 39), and reoperative MV surgery (14.9%, n = 186). The overall incidence of postoperative neurologic event was 2.5% (n = 31/1247). Univariable predictors of stroke were a higher Society of Thoracic Surgeons mortality risk (6.0 ± 11.8% vs 3.3 ± 5.2%, P0.001), advanced age, (69.6 ± 12.1 years vs 63.0 ± 13.6 years, P = 0.002), female gender (71.0% vs 46.3%, P = 0.007), and a history of a cerebrovascular accident (22.6% vs 8.7%, P = 0.008). Stroke patients had a higher 30-day mortality (22.6% vs 1.6%, P0.001) and a higher risk for long-term mortality (hazard ratio = 5.56, 95% confidence interval [CI] 3.2-9.6, P0.001). Advanced age (odds ratio [OR] 2.1; 95% CI 1.1-4.0; P = 0.02), female gender (OR 2.3; 95% CI 0.9-5.2; P = 0.05), and history of cerebrovascular accident (OR 3.1; 95% CI 0.98-10.1; P = 0.05) remained as independent predictors of stroke in the multivariable analysis. Our decade-long experience indicates that clampless mini-MVS is associated with a low incidence of postoperative stroke, and that the predictors of stroke are not specific to this approach.

Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, venovenous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure. (C) 2019 International Society for Heart and Lung Transplantation. All rights reserved.

Background Ischemia-reperfusion injury is characterized by an increase in oxidative stress and leads to significant morbidity and death. The tyrosine kinase c-Abl is activated by oxidative stress and mediates processes that affect endothelial barrier function. We hypothesized treatment with the c-Abl inhibitor imatinib would be protective against ischemia-reperfusion injury in our ex vivo rabbit model. Methods Heart-lung blocs were harvested from rabbits and stored in cold in Perfadex (Vitrolife, Englewood, CO) for 18 hours. Blocs were reperfused for 2 hours in an ex vivo circuit with donor rabbit blood alone (untreated group, n = 7) or donor rabbit blood and 4 mg imatinib (treatment group, n = 10). Serial clinical variables measured every 15 minutes (arterial oxygen and carbon dioxide tension and mean pulmonary artery pressures) and biochemistry of tissue samples before and after reperfusion were assessed. Results Compared with untreated lungs, imatinib treatment improved physiologic parameters, including oxygen, carbon dioxide, and pulmonary artery pressures. Imatinib-treated lungs had less vascular barrier dysfunction as quantified by wet-to-dry weight ratios and bronchoalveolar lavage protein concentrations. Treated lungs showed less inflammation as measured by bronchoalveolar lavage myeloperoxidase assay, less mitochondrial reactive oxygen species production, and increased antioxidant catalase levels. Finally, imatinib protected lungs from DNA damage and p53 upregulation. Conclusions Imatinib treatment significantly improved the physiologic performance of reperfused lungs and biochemical indicators associated with reperfusion injury in this ex vivo model. Further study is necessary to elucidate the mechanism of tyrosine kinase inhibition in lungs exposed to ischemia and reperfusion.

Purpose This study investigated the frequency and risk factors for delisting among bridge to transplant (BTT) patients and predictors of switching from a destination therapy (DT) strategy to listing for transplant. Methods Analysis included all patients > 18 years entered in The Society of Thoracic Surgery Intermacs database receiving a primary continuous-flow LVAD from 2012-2017 who were followed for 15 months. The primary outcome for BTT was delisting or death and for DT was listing for transplant. Proportional hazard regression model was used for the analysis. Predictors for each outcome event were identified using multivariable analysis with Cox proportional hazard models. Results Among BTT (n=3701), delisting or death occurred in 842 patients (22%). For DT (n=9434), transplant listing occurred in 1046 (11%) patients. Preimplant characteristics and post implant adverse events (AE) predicted changes in strategy for both BTT and DT patients. (see figure) Among BTT, the strongest predictors for de-listing included baseline INTERMACS profiles 1 -3 and adverse events occurring early after LVAD. Among DT, the predictors of listing or transplant included short duration of HF at implant and potentially reversible factors such as malnutrition. In addition, switch from DT to transplant strategy was less likely in patients with age > 65 and pre-implant frailty but more common with multiple GI bleeds post LVAD Conclusion Implant strategies remain dynamic over time. Pre-implant INTERMACS profiles and post implant AEs most strongly influenced delisting for those implanted as BTT. Patients implanted as DT with short duration of HF at implant and improvement in reversible concerns should be considered early for potential switch to a strategy of transplant.

Recent studies suggest that the use of preoperative β blockers in cardiac surgery may not provide improved mortality rates and may even contribute to negative clinical outcomes. We therefore assessed the role of β blockers on several outcomes after cardiac surgery (delirium, acute kidney injury [AKI], stroke, atrial fibrillation (AF), mortality, and hospital length of stay) in 4,076 patients who underwent elective coronary artery bypass grafting, coronary artery bypass grafting + valve, or valve cardiac surgery from November 1, 2009, to September 30, 2015, at Vanderbilt Medical Center. Clinical data from 2 prospectively collected datasets at our institution were reviewed: the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Preoperative β-blocker use was defined by Society of Thoracic Surgeons guidelines as patients receiving a β blocker within 24 hours preceding surgery. Of the included patients, 2,648 (65.0%) were administered a β blocker within 24 hours before surgery. Adjusting for possible confounders, preoperative β-blocker use was associated with increased odds of AKI stage 2 (odds ratio 1.96, 95% confidence interval 1.19 to 3.24, p

Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively ( p p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

Background The benefit of nanomedicine in mitigating acute lung injury (ALI) is currently unknown. Therefore, we introduced the generation IV polyamidoamine dendrimers with neutral surface property (dendrimer) into our established ex vivo animal model and sought to determine their biodistribution to define their cellular uptake profile and to evaluate their potential as a drug delivery candidate for the treatment of ischemia–reperfusion–induced ALI. Methods Eight rabbit heart–lung blocks were harvested and exposed to 18 h of cold ischemia. The heart–lung blocks were then reperfused with rabbit donor blood. Dendrimer was conjugated to fluorescein isothiocyanate (D-FITC) for localization and quantification studies. D-FITC (30 mg or 150 mg) was injected into the bypass circuit and baseline, 1- and 2-h tissue samples were obtained to determine percent uptake. Low (10×) and high (40×) magnification images were obtained using confocal microscopy to confirm the accumulation and to determine the cellular targets of the dendrimer. Results Four heart–lung blocks were exposed to 30 mg and four to 150 mg of D-FITC. After adjusting for dry weight, the mean uptake in the 30 and 150 mg samples after 2 h of reperfusion were 0.79 ± 0.16% and 0.39 ± 0.22% of perfused doses, respectively. Confocal imaging demonstrated dendrimer uptake in epithelial cells and macrophages. Conclusions Fluorescently tagged dendrimers demonstrated injury-dependent tissue accumulation in a variety of different cell types. This unique approach will allow conjugation to and delivery of multiple agents with the potential of mitigating ALI injury while avoiding systemic toxicity.

Background Angiogenesis is implicated in formation of gastrointestinal arteriovenous malformations (AVMs). Angiotensin II signaling is involved in angiogenesis through the vascular endothelial growth factor (VEGF) and angiopoietin-2 pathways. We hypothesized that angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) therapy would be associated with a reduced risk of all-cause gastrointestinal bleeding (GIB) and AVM-associated GIB in patients with left ventricular assist devices (LVADs). Methods We reviewed records of all adult patients receiving a continuous-flow LVAD (HeartMate II or HeartWare HVAD) at Johns Hopkins Hospital between January 2004 and December 2014. Of 192 patients, 131 were included for final analyses. Logistic regression analysis adjusting for demographic, cardiovascular, and laboratory variables was used to assess the association of ACEI or ARB therapy with GIB. Results Of 131 patients, 100 received ACEI or ARB therapy during LVAD support. Of the 31 patients who did not receive ACEI or ARB, 15 experienced GIB (48%), with 9 caused by AVMs (29%). Of 100 patients who received ACEI or ARB therapy, 24 experienced GIB (24%), with 9 caused by AVMs (9%). Logistic regression hazards model demonstrated that ACEI or ARB therapy was independently associated with a reduced risk for all-cause GIB (odds ratio 0.29, 95% confidence interval 0.12–0.72) and AVM-related GIB (odds ratio 0.23, 95% confidence interval 0.07–0.71). Conclusions Angiotensin II antagonism is associated with a reduced risk of AVM-related GIB in patients with LVADs. This association is independent of age, sex, blood pressure, renal function, international normalized ratio, LVAD type, and cardiomyopathy etiology.

Purpose Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical worsening compared to those without CHD. Reviews and consensus statements have supported the use of harvesting donor pulmonary vasculature to assist in graft implantation which require a non-lung donor (NLD). However, the impact of this practice on waitlist times or mortality has yet to be evaluated. Methods We analyzed the United Network for Organ Sharing (UNOS) Registry to identify 1271 adults age ≥18 with CHD that underwent HT between January 1, 1987 and December 31, 2016. Baseline characteristics, mean waitlist time, 1-year survival, and overall survival by Cox proportional hazard models were compared between HT recipients receiving donor hearts from NLDs or donor hearts from concomitant lung donors. Results Over the study period, 32% of CHD recipients received HTs from concomitant lung donors; this practice increased from 6% between 1987-1991, to 45% between 2012-2016. Prior to HT, recipients from NLDs were significantly more likely to have undergone prior cardiac surgery, and less likely to be listed UNOS Status 1A, or require mechanical ventilation or intra-aortic balloon pump support. There was no difference in mean time on the waitlist (262 vs. 254 days, p=0.31), crude 1-year survival (82% vs. 80%, p=0.81), nor overall unadjusted risk of survival (hazard ratio 1.01, 95% confidence interval 0.83-1.24, p=0.86) (Figure 1) between CHD HT recipients from NLDs and concomitant lung donors. Results were unchanged after covariate adjustment. Conclusion Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HTs from NLDs. However, there is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLDs, longer wait times may result in worsening clinical status.

Purpose In October of 2018, the United Network for Organ Sharing (UNOS) instituted a revised allocation system (RAS) for heart transplantation (HT). We sought to explore how these changes impacted our own center's listing and bridging strategies and rates of adult HT. Methods We performed a retrospective review comparing adult patients transplanted at our center between October 1, 2017 and October 17, 2018 (prior to RAS, Cohort A) with those transplanted between October 18, 2018 and August 1, 2019 (following RAS, Cohort B). Among the characteristics we explored were patient blood type, status at time of listing and HT, status justification, and for patients listed by exception, reason for exception request Results Between October 1, 2017 and August 1, 2019, a total of 178 adults underwent HT at our institution, including 98 patients in Cohort A and 80 patients in Cohort B. Relative to patients in Cohort A, patients in Cohort B were more likely to be bridged to HT with temporary mechanical circulatory support (MCS) (9 (11%) vs 2 (2%), less likely to be bridged with durable LVAD (21 (26%) vs 39 (40%)) and equally likely to be listed by status exception request (23 (29%) vs 28 (29%)). Among 21 patients in Cohort B bridged with durable LVAD, only 4 (19%) underwent HT at status 4 whereas 17 (81%) required upgrade to status 3 using their ‘30-day time’ (n=15) or due to complications (n=2), in order to achieve HT. By comparison, among 39 patients in Cohort A bridged with durable LVAD, 18 (46%) underwent HT at Status 1B (equivalent to status 4 in the RAS). Nineteen (49%) transplanted LVADs in Cohort A had ABO O blood type, compared to only 6 (29%) in Cohort B. Conclusion While implementation of the RAS did not significantly impact our center's rate of HT, it influenced decision-making at time of HT listing in favor of temporary MCS when justified, and against durable MCS, especially in patients with O blood type. Moreover, despite RAS changes aimed at reducing status exception requests, requests made by our center remain equally likely now as they were prior to RAS implementation.

Purpose Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. We investigated whether blood urea nitrogen to creatinine ratio (BCR) at time of HT listing among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) is associated with higher risk of post-HT death or dialysis. Methods We identified 159 patients who underwent HT alone at our institution between 1/2009 and 2/2018. Univariate and multivariate Cox-proportional regression analyses were used to investigate the association between BCR and composite risk of post-HT death or dialysis at 1 year. Results At listing, average age was 55±10 years (74% male and 28% African American) and eGFR was 47 ± 8. Mean eGFR did not differ between those with the composite outcome (46 ± 8) and those without (47 ± 8; p = 0.60). Overall, 14 patients (9%) died and 25 (16%) needed dialysis by 1 year post-HT. The univariate and multivariate adjusted hazard ratios for continuous variable BCR as a predictor of the composite outcome were 1.05 [95% confidence interval (CI): 1.02, 1.09; p Conclusion Heart transplant candidates with stage 3 CKD and elevated BCR at time of listing are at increased risk of post-HT mortality or dialysis. Further investigation of HKT outcomes among those with stage 3 CKD and elevated BCR at listing is warranted.

Purpose Optimal size-matching metrics for prediction of outcomes after combined heart-kidney transplantation (HKT) are unknown. Methods Combined HKTs performed between January 2000 and April 2019 were analyzed using United Network of Organ Sharing registry. Size metrics (weight, height, body mass index (BMI) and predicted heart mass (PHM)) were divided into seven equally sized groups using donor-to-recipient ratio. Kaplan-Meier survival and Cox proportional hazard analyses were performed to assess composite risk of mortality or re-transplantation at 1-year. Results A total of 1,290 recipients were analyzed; 155 events occurred (n=153 deaths; n=4 re-transplants). Compared to a well-matched cohort, severe under-sizing by either PHM (0.56 to 0.85; hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.02-3.08, p=0.042) or weight (0.50 to 0.80; HR 2.00, 95% CI 1.14-3.52, p=0.015), but not BMI and height, was associated with an increased risk of events. Upon categorizing recipients into 4 groups based on presence or absence of severe under-sizing by either PHM or weight ratio, those whose donors were severely undersized for both were at significantly higher risk of poor outcomes (HR 2.74, 95% CI 1.78-4.19, p Conclusion Recipients of combined HKT whose donors were severely undersized based on both weight ratio and PHM had significantly worse outcomes compared to those whose donors were severely undersized by either parameter alone or not at all.

Background Delirium is a common complication after cardiac surgical procedures and is associated with increased morbidity and mortality. However, whether rigorously assessed postoperative delirium is associated with an increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. Methods Patients (n = 66) undergoing coronary artery bypass or valve operations, or both, were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record, and hospital charges were obtained from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. Results Patients who developed delirium (56%) versus no delirium (43%) had increased median LOS-ICU (75.6 hours [interquartile range (IQR): 43.6 to 136.8] vs. 29.7 hours [IQR: 21.7 to 46.0]; p = 0.002), increased median LOS (9 days [IQR: 6 to 16] vs. 7 days [IQR: 5 to 8]; p = 0.006), and increased median hospital charges ($51,805 [IQR: $44,041 to $80,238] vs. $41,576 [IQR: $35,748 to $43,660]; p = 0.002). In propensity score models adjusted for patient-related and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated on the basis of the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and increased charges in a dose-response manner. Conclusions Delirium after cardiac surgical procedures is independently associated with both increased LOS-ICU and higher hospital charges. Because delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement.

Objectives The aim of this study was to develop a risk index specific to patients on mechanical circulatory support that accurately predicts 1-year mortality after orthotopic heart transplantation using the United Network for Organ Sharing database. Background Few clinical tools are available to aid in the decision between continuing long-term device support and performing transplantation in patients bridging with mechanical circulatory support. Methods Using a prospectively collected, open cohort, 6,036 patients receiving mechanical circulatory support who underwent orthotopic heart transplantation between 2000 and 2013 were evaluated and randomly separated into derivation (80%) and validation (20%) groups. Multivariate logistic regression models were constructed using variables that improved the explanatory power of the model, which was determined using multiple methods. Points for a simple additive risk index were apportioned on the basis of relative effect on odds of 1-year mortality. Results A 75-point scoring system was created from 9 recipient and 4 donor variables. The average score in the validation cohort was 14.4 ± 7.7, and scores ranged from 0 to 57; these values were similar to those in the derivation cohort. Each 1-point increase predicted an 8.3% increase in the odds of 1-year mortality (odds ratio: 1.08; 95% confidence interval: 1.06 to 1.11). Low (0 to 10), intermediate (11 to 20), and high (>20) risk score cohorts were created, with predicted average 1-year mortalities of 8.6%, 12.8%, and 31%, respectively, in the validation cohort. Conclusions The investigators present a novel, internally cross-validated risk index that accurately predicts mortality in bridge-to-transplantation patients.

Objectives The authors sought to determine whether an institutional transition from intermittent to continuous dosing of intraoperative antibiotics in cardiac surgery affected surgical site infection (SSI) outcomes. Design A retrospective chart review utilizing propensity matching. Setting A single academic, tertiary care hospital. Participants One thousand one hundred seventy-nine patients undergoing coronary artery bypass grafting (CABG) and/or cardiac valvular surgery between April 2013 and November 2014 who received perioperative cefazolin. Interventions By method of cefazolin administration, patients were divided into an “intermittent-dosing” (ID) group and a “continuous-infusion” (CI) group. Measurements and Main Results Of the 1,179 patients who underwent cardiac surgery during the study period, 1:1 propensity score matching yielded 399 patients in each group. Rates of diabetes (33.6% ID v 33.8% CI, p = 0.94), coronary artery bypass (62.3% v 61.4%, p = 0.66), and bilateral internal mammary artery harvesting (6.0% v 8.3%, p = 0.22) were similar between groups. SSIs occurred in more ID patients than CI patients (2.3% v 0.5%, p = 0.03). This difference was driven by decreases in extremity and conduit harvest site SSIs (1.8% v 0.3%, p = 0.03), as there were no episodes of mediastinitis, and superficial sternal SSI rates did not differ (0.5% v 0.3%, p = 0.56). There also were significantly fewer episodes of pneumonia in the CI group (6.0% v 2.3%, p = 0.008). Intensive care unit and total lengths of stay did not differ. Thirty-day mortality was 2.8% in both groups (p = 1.00). Conclusions As compared to ID regimens, CI cefazolin infusion may reduce post-cardiac surgery infectious complications. Further study in larger patient populations is needed.

Purpose Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. The Model for End-Stage Liver Disease Excluding INR (MELD-XI) score at the time of HT has been shown to predict early post-HT mortality. We investigated whether trends in the MELD-XI score between listing and transplant among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or dialysis. Methods We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. The following groups were created: Group 1 - MELD-XI ≤ 16 at listing and HT, Group 2 - MELD-XI ≤ 16 at listing and > 16 at HT, Group 3 - MELD-XI > 16 at listing and ≤ 16 at HT, Group 4 - MELD-XI > 16 at listing and HT. A cutoff of 16 was chosen based on the 75th percentile in a normal distribution among those without a composite outcome of post-HT death or dialysis at 1 year. Cox-proportional regression and survival analyses were performed to assess risk of this outcome. Results Average MELD-XI at listing was 14.0 ± 4.9 and at HT was 12.8 ± 4.5 (p 16 was present in 51 (32.1%) at listing and 38 (23.9%) at HT. Group 4 incurred highest risk of composite outcome relative to Group 1 (adjusted hazard ratio 3.67 (95% confidence interval: 1.38-9.76, p Conclusion Changes in MELD-XI between listing and transplantation offer additional risk stratification beyond absolute MELD-XI at time of transplant for death or dialysis at 1 year in patients with stage 3 CKD.

Purpose Access to heart transplantation (HTX) within the Veteran Affairs Health Administration (VA) is an area of concern. In our study we examined the outcomes of veterans, often traveling great distances, undergoing HTX at Vanderbilt (VUMC) compared to non-veteran patients at the highest volume HTX VA-civilian partnership. Methods Statistical analysis was performed on data gathered retrospectively from the EMR of 287 adult patients (VA=51, VUMC=236) who underwent isolated heart transplant at VUMC between January 2015 and December 2018 (Table 1) Multiple ordinal or binary logistic regressions for hospital length of stay, intensive care length of stay, and primary graft dysfunction were performed while adjusting for patients’ age, preoperative VAD, PVR, donor ischemic times, and bypass time. Kaplan-Meier and Cox regression were used to evaluate the differences in the hazard of mortality between the groups at 1 year. Results A total of 312 patients underwent heart transplant; 3 were combined heart/liver (1VA and 2 VUMC), 21 were combined heart/kidney (1VA and 20 VUMC), and 287 were isolated heart transplants. VA patients from 14 states traveled significantly greater distances than non-VA patients (Table 1a)[p=0.001]. Multiple logistic regression model did not demonstrate statistically significant differences in ICU LOS (OR=0.95, CI=0.55-1.66, p=0.87), LOS (OR=1.02, 95%CI=0.59-1.77, p=0.94) or PGD (OR=0.92, 95%CI=0.42-2.04, p=0.84) (Table 1c). Kaplan-Meier plot showed no significant survival difference between VA and VUMC. On Cox regression analysis, the HR (risk of death) for site (VUMC vs. VA) was 2.0 (95% CI=0.25-15.9; p=0.51). Conclusion Regionalization of care for cardiac transplantation within the VA system provides veterans with access to quality, specialized heart failure care that is comparable to the civilian population. Further analysis needs to be performed to determine if follow up patterns and long term survival differences exist between the two groups.

Purpose Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in refractory cardiogenic shock. However, the retrograde arterial perfusion can result in left ventricular (LV) distention and overloading, which leads to pulmonary edema and failure of LV recovery. Various LV unloading strategies have been utilized, including creation of an LV vent, use of temporary percutaneous left ventricular assist devices, and balloon atrial septostomy (BAS). Of these, BAS is a less common strategy. We sought to assess outcomes of LV unloading with BAS at our center. Methods Thirty-seven patients undergoing VA-ECMO for cardiogenic shock between July 2018 and September 2019 were included in the study. Of these, 7 patients underwent BAS. Three of them had concurrent intra-aortic balloon pump (IABP). These patients all had the IABP inserted prior to VA-ECMO initiation and BAS. Thirty patients underwent either no unloading or unloading with LV venting, the Impella device, or IABP. The causes of cardiogenic shock and pre- and post-BAS left atrial pressures were evaluated, along with outcomes. Results The causes of cardiogenic shock are listed in the corresponding figure. Of the seven patients who were unloaded with the BAS strategy, three patients recovered, two died, one received an LVAD, and one underwent heart transplant. The patient who underwent LVAD implantation passed away due to post-operative RV failure. One patient in this study was converted from peripheral VA-ECMO to central VA-ECMO. Of the 7 patients, 4 of them had pre- and post-BAS left atrial pressure measured. There was a mean decrease of 5.75 mmHg. Of the patients who underwent other unloading strategies or no venting, thirteen recovered, thirteen died, and four underwent transplant or LVAD implantation. Conclusion This small, single-center experience suggests that BAS could be a viable strategy of LV unloading. Further investigation needs to be undertaken to better understand patient selection.

Purpose Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at higher risk of mortality and poor renal outcomes compared to those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT. We investigated whether interval changes in blood urea nitrogen to creatinine ratio (BCR) between listing and transplant in those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) 30 - 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or worsening renal function (WRF). Methods We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. Absolute changes in BCR between listing and transplant were categorized as improved (BCR decreased) or worsened (BCR increased). Next, the following groups were created: Group 1 - improved BCR and BCR ≤ 21 at HT, Group 2 - worsened BCR but remained ≤21 at HT, Group 3 - worsened BCR and BCR >21 at HT, and Group 4 - improved BCR but remained >21 at HT. WRF was defined as a decrease in eGFR by >25% or need for dialysis between HT and 1-year follow up. One-year composite risk of death or dialysis was our primary outcome of interest; WRF in survivors was our secondary outcome of interest. Results By 1 year, a total of 14 patients died and 43 had WRF, including 15 who needed dialysis. The BCR improved in 98 patients (62%) and worsened in 61 (38%); BCR was >21 at HT in 25 patients (16%). Group 4 incurred highest risk of both the primary and secondary outcomes (see figure) with adjusted hazard ratio of 3.81 (95% confidence interval (CI): 1.45-10.00; p Conclusion High BCR at listing that remained >21 at HT despite interval improvement was associated with increased risk of death or dialysis and WRF. These findings warrant further pathophysiologic explanation.

Right Ventricular failure (RVF) contributes significantly to early mortality after Left Ventricular Assisting Device (LVAD) implantation. At present, there is no good predictor of post-LVAD RV function. Echocardiographic (echo) RV dP/dt is a non-invasive parameter measuring the rate of rise in the