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Objectives: Stroke is common following left ventricular assist device (LVAD) implantation, although comprehensive data on perioperative strokes in this uncommon population is lacking. The current study aim was to characterize the presentation, features, and outcomes of perioperative cerebrovascular ischemia post-LVAD implantation at the authors' institution., Design: Single-center retrospective cohort., Setting: St. Paul's Hospital, Vancouver, British Columbia, Canada., Participants: Adult patients who received an LVAD between January 1, 2008, and August 31, 2021, were included, and those who died intraoperatively or underwent a concurrent cardiac surgical procedure were excluded., Interventions: Data on demographics, comorbidities, stroke risk factors and characteristics, management, and outcomes (transplant, explant, death with LVAD in situ) were extracted., Measurements and Main Results: After exclusions, 172 adult patients who underwent LVAD implantation during the study period were included and analyzed. The rate of perioperative stroke was 12.8% (22/172). Of these, 72.7% (16/22) had a stroke occur within 7 days of surgery, and 86.4% (19/22) had a primarily ischemic (v hemorrhagic) event. A total of 68.2% (15/22) were intubated, sedated, or recently extubated at symptom onset, complicating diagnosis. All were managed supportively or palliated without specific stroke intervention. Patients who experienced a perioperative stroke had a significantly lower cumulative incidence of survival to cardiac transplantation and a significantly higher cumulative incidence of dying with their device in situ., Conclusions: LVAD patients carry a high risk of perioperative stroke. They experience delayed recognition and diagnosis, limited intervention, and poor outcomes. Frequent neurological assessment and a low threshold for neuroimaging are prudent., Competing Interests: Declaration of competing interest The authors declare the following financial interests and/or personal relationships that may be considered potential competing interests: Anson Cheung is a consultant and speaker for Medtronic and Abbott. Wynne Chiu has received a grant and speaker honoraria from Abbott Canada. Thalia Field has received consulting fees from HLS Therapeutics, Roche Canada, and AstraZeneca (and in-kind study medication from Bayer Canada); has served as an expert witness for the Canadian Medical Protective Association; and is a board member of DESTINE Health. Alana Flexman is supported by Michael Smith Research BC (Vancouver, BC, Canada) and receives consultant fees from UpToDate and research support from Eisai, Inc. She is an Editorial Board member of the Journal of Neurosurgical Anesthesiology. No other conflicts of interest among the authors exist that would influence the content of this manuscript., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Durable left ventricular assist device (LVAD) implantation is traditionally performed via median sternotomy (MS). Less-invasive implantation may lower the incidence of postimplant right ventricular failure (RVF). Our primary objective was to determine whether less-invasive implantation reduces the odds of severe RVF compared to MS., Design: Retrospective cohort study., Setting: St. Paul's Hospital, Vancouver, BC, Canada., Participants: One hundred ninety-eight adult patients between January 2008 and August 2021., Interventions: Isolated LVAD implantation either via median sternotomy or via a less-invasive surgical approach., Measurements and Main Results: Multivariable logistic regression was used to adjust for confounders. A sensitivity analysis using inverse probability of treatment weighting analysis based on propensity scores was conducted. One hundred seventy-two patients were analyzed; 54% (94/172) underwent LVAD implantation via MS, and 45% (78/172) via less-invasive approaches. Age, sex, and comorbidities were comparable, but the MS group tended to be more critically ill prior to surgery. After adjusting for confounders, less-invasive approaches did not show significant protection against severe postimplant RVF compared to MS (adjusted odds ratio 0.53; 95% confidence interval 0.20-1.44; p = 0.21). However, patients undergoing less-invasive techniques had reduced adjusted odds of 30-day mortality (odds ratio 0.29; 95% confidence interval 0.09-0.99); p = 0.049). There was no observed benefit of less-invasive approaches over MS for major bleeding, prevention of blood product transfusion, and listing for transplantation., Conclusions: There was no reduction in the odds of severe RVF following LVAD implantation using less-invasive approaches versus MS. However, we found improved odds of 30-day survival in the less-invasive group. The underlying mechanism requires further investigation., Competing Interests: Declaration of competing interest Wynne Chiu has received a grant and speaker honouraria from Abbott Canada. Alana Flexman has received a grant from Michael Smith Health Research British Columbia. Anson Cheung is a consultant and speaker for Medtronic and Abbott. No other conflicts of interest among the authors exist that would influence the content of this manuscript., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular assist device (LVAD) outflow graft obstruction can result in severe clinical deterioration. Underlying mechanisms may vary depending on the location. Outflow graft tamponade due to external compression can be under recognized. Management of this complication varies across institutions and a uniform approach has yet to be elucidated., Objectives: Report a single center experience with outflow graft tamponade in patients with LVAD with the purpose of developing an optimal algorithm for the diagnosis and treatment of LVAD-related outflow graft tamponade., Methods and Results: Retrospective chart review between July 2011 and July 2020. A total of 351 LVADs were implanted at our center, with outflow graft tamponade identified in 26 patients with LVAD. Fourteen (53.8%) had HeartMate II™, 8 (30.8%) had HeartMate3™ and 4 (15.4%) had HeartWare™. Individuals presented with heart failure symptoms, an audible precordial murmur and LVAD alarms after a median duration of 862 days of support (IQR 327 - 1455). Of the 26 patients, 15 (57.7%) underwent mini thoracotomy with outflow graft relief, 4 had percutaneous balloon dilatation and stenting, 2 were bridged directly to transplant and 1 had a pump exchange. No intervention was made on the remaining due to mild symptoms (n = 4)., Conclusions: Conclusions: Outflow graft tamponade is a form outflow graft obstruction with a variable presentation that can result in significant hemodynamic compromise. It is amenable to both surgical and percutaneous interventions that restore LVAD function., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Heart failure (HF) remains a public health concern affecting millions of individuals worldwide. Despite recent advances in device-related therapies, the prognosis for patients with chronic HF remains poor with significant long-term risk of morbidity and mortality. Left ventricular assist devices (LVADs) have transformed the landscape of advanced HF management, offering circulatory support as destination therapy or as a bridge for heart transplantation. Among the latest generation of LVADs, the HeartMate 3 has gained popularity due to improved clinical outcomes and lower risk of serious adverse events when compared with previous similar devices. The ELEVATE (Evaluating the HeartMate 3 with Full MagLev Technology in a Post-Market Approval Setting) Registry and the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial represent landmark investigations into the performance and comparative effectiveness of the HeartMate 3 LVAD. This review provides a comprehensive synthesis of the safety and efficacy of the 2-year and 5-year HeartMate LVAD outcomes, highlighting key findings, methodological considerations, implications for clinical practice, and future directions., Competing Interests: Declaration of competing interest Dr Ortoleva has received a one-time honorarium from La Jolla Pharmaceutical for a panel discussion on Angiotensin II. The remaining authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Multiple randomized clinical trials have demonstrated catheter ablation in heart failure with reduced ejection fraction reduces mortality and hospitalization as well as improves ventricular function, quality of life, and functional status. Catheter ablation has been shown to be superior to alternative rate and rhythm control strategies in these outcomes. Guidelines strongly support the use of catheter ablation to maintain sinus rhythm in patients with atrial fibrillation and heart failure., Competing Interests: Disclosures Dr E.P. Zeitler reports the following relevant disclosures: consulting fees from Biosense Webster, Boston Scientific, Medtronic, and Sanofi; travel and speaking for Abbott, Boston Scientific, and Medtronic; Non-financial research support from Biosense Webster, United States, Boston Scientific, United States, and Sanofi, United States; research support from the National Institutes of Health, United States/NIGMS. Dr A.Z. Spitz reports has no disclosures to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Atrioventricular nodal ablation (AVNA) represents a critical intervention in the management of refractory atrial fibrillation (AF) and heart failure (HF). When combined with biventricular pacing or conduction system pacing, particularly His bundle pacing and left bundle branch area pacing, this strategy offers distinct and complementary benefits. While each pacing modality presents unique advantages and potential limitations, their combination with AVNA offers a comprehensive and individualized treatment strategy for addressing associated HF. This integrated approach can enhance symptom control, improve hemodynamic performance, and contribute to better long-term outcomes in patients with advanced HF and AF., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Catheter ablation (CA) for atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) addresses the significant overlap of these conditions, often found in patients with comorbidities such as obesity, diabetes, and hypertension. HFpEF is characterized by diastolic dysfunction, leading to high left atrial pressures and atrial remodeling, which promotes AF. While treatments for HFpEF are limited, recent studies suggest CA can reduce AF burden, improve quality-of-life, and lower hospitalization rates. Current and upcoming randomized trials aim to establish CA's role as a first-line therapy for AF in HFpEF, potentially transforming patient outcomes., Competing Interests: Disclosure Dr A. Natale is a consultant for Biosense Webster, Stereotaxis, and Abbott Medical, and has received speaker honoraria/travel from Medtronic, Atricure, Biotronik, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this article to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This article explores the existing knowledge regarding atrial fibrillation (AF) incidence, outcomes, and management in left ventricular assist device and orthotopic heart transplant patients as well as emerging technologies such as catheter ablation. It highlights the need for individualized care due to the varied pathophysiological mechanisms of AF in each group., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To determine if the intraoperative transfusion requirements differ based on the mechanical circulatory device used as a bridge to heart transplantation., Design: A single-center retrospective analysis of intraoperative transfusion requirements in all patients undergoing heart or heart/kidney transplantation between November 2018 and July 2021 who were bridged with a temporary (Impella 5.5) or durable left ventricular assist device (LVAD)., Setting: A tertiary care hospital., Participants: Forty-three adult patients bridged to heart or heart/kidney transplantation with a temporary or durable LVAD between 2018 and 2021 INTERVENTIONS: Recording of baseline characteristics and intraoperative transfusion requirements, including packed red blood cells, fresh frozen plasma, cryoprecipitate, autologous blood salvage, and platelets. The difference in cardiopulmonary bypass times, intensive care unit length of stay, and the vasoactive inotrope score following transplantation were also recorded., Measurements and Main Results: The primary outcome was the volume of blood products transfused intraoperatively. Patients who underwent bridge to transplantation using the Impella 5.5 had statistically significant lower median transfusions of cryoprecipitate (155 mL versus 200 mL, p = 0.015), autologous blood salvage (675 mL versus 1,125 mL, p ≤ 0.01), and platelets (412 mL versus 675 mL, p ≤ 0.01). Additionally, there was a trend toward lower transfusion of intraoperative packed red blood cells (4.5 units versus 6.5 units, p = 0.29) and fresh frozen plasma (675 mL versus 800 mL, p = 0.11), but these were not statistically significant., Conclusions: The results suggest a reduction in certain intraoperative transfusion requirements in patients undergoing heart transplantation bridged with the Impella 5.5 versus durable left ventricular assist device., Competing Interests: Declaration of competing interest Dr. Martin serves on the Scientific Advisory Board of Attgeno AB, with all compensation to Mayo Clinic. He also serves on the Data Safety Monitoring Board for the GLUSorb Trial (NCT05526950), with all compensation to Mayo Clinic. Dr. Goswami is a speaker for Abiomed., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of Competing Interest None.

The population of patients with advanced heart failure continues to increase steadily as does the need for mechanical circulatory support. Combination therapy with left ventricular assist devices (LVADs) and cardiovascular implantable electronic devices (CIEDs) is unavoidable. CIED complications in patients with LVADs are common and often necessitate device system revision and transvenous lead extraction. Despite this, management recommendations are limited, and guidelines are lacking., Competing Interests: Disclosure Dr M. Maytin has received research grants from and is a consultant for Medtronic., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Objectives: This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation., Design: Single-center retrospective observational cohort study., Setting: The University of Kansas Medical Center, a tertiary-care academic medical center., Participants: Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019., Interventions: All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion., Measurements and Main Results: Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found., Conclusions: The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest None.

The prevalence of valvular heart disease in the United States has been estimated at 4.2-to-5.6 million, with mitral regurgitation (MR) being the most common lesion. Significant MR is associated with heart failure (HF) and death if left untreated. When HF is present, renal dysfunction (RD) is common and is associated with worse outcomes (ie, it is a marker of HF disease progression). Additionally, a complex interplay exists in patients with HF who also have MR, as this combination further impairs renal function, and the presence of RD further worsens prognosis and often limits guideline-directed management and therapy (GDMT). This has important implications in secondary MR because GDMT is the standard of care. However, with the development of minimally invasive transcatheter mitral valve repair, mitral transcatheter edge-to-edge repair (TEER) has become a new treatment option for secondary MR that is now incorporated into current guidelines published in 2020 that listed mitral TEER as a class 2a recommendation (moderate recommendation with benefit >> risk) as an addition to GDMT in a subset of patients with left ventricular ejection fraction <50%. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial, which demonstrated favorable outcomes in secondary MR by adding mitral TEER to GDMT versus GDMT alone, was the evidence base for these guidelines. Considering these guidelines and the understanding that concomitant RD often limits GDMT in secondary MR, there is emerging research studying the renal outcomes from the COAPT trial. This review analyzes this evidence, which could further influence current decision-making and future guidelines., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation., Design: This was a retrospective observational study between March 2013 and July 2019., Setting: The study was conducted at a single, quaternary-care academic center., Participants: Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD., Interventions: A left ventricular assist device was used for intervention., Measurements and Main Results: A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005)., Conclusions: The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation., Competing Interests: Conflict of Interest None., (Copyright © 2023. Published by Elsevier Inc.)

Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

We reviewed outcomes in 82 consecutive children supported with the Berlin Heart pulsatile ventricular assist device (VAD), comparing those with functionally univentricular circulation (n = 34) to those with biventricular circulation (n = 48). The primary outcome was mortality. Kaplan-Meier (KM) methods and log-rank tests were used to assess group differences in long-term survival. T-tests using KM-estimated survival proportions and standard errors were used to compare groups at specific time points. 48 biventricular patients were supported (Age: median = 1.4 years, range = 17 days-17.7 years; Weight [kilograms]: median = 9.4, range = 3.1-112), including 43 BiVAD, 4 LVAD only, and 1 LVAD converted to BiVAD. In biventricular patients, duration of VAD support [days]: median = 97, range = 4-315. Of 48 biventricular patients, 35 underwent heart transplantation, 7 died on VAD, 5 weaned off VAD (1 of whom underwent heart transplantation 334 days after weaning), and 1 is still on VAD. 34 univentricular patients were supported with single VAD (sVAD) (Age: median = 38.5 days, range = 4 days-13.3 years; Weight [kilograms]: median = 3.98, range = 2.4-32.6). In univentricular patients, duration of VAD support [days]: median = 138, range = 4-554. Of 34 univentricular patients, 22 underwent transplantation, 11 died on VAD, and 1 is still on VAD. One-year survival after VAD insertion was 82.7% (95% CI = 72.4-94.4%) in biventricular patients and 59.7% (95% CI = 44.9-79.5%) in univentricular patients, p = 0.026. Five-year survival after VAD insertion was 79.7% (95% CI = 68.6-92.6%) in biventricular patients and 50.5% (95% CI = 35.0-73.0%) in univentricular patients, p = 0.010. Pulsatile VAD facilitates bridge to transplantation in neonates, infants, and children with functionally univentricular circulation; however, survival is worse than in patients with biventricular circulation., (Copyright © 2022. Published by Elsevier Inc.)

Some patients with functionally univentricular circulation develop cardiac failure refractory to maximal management and are supported with a ventricular assist device (VAD). The purpose of this manuscript is to summarize our previous publications related to single ventricle-ventricular assist device (sVAD) support in patients with functionally univentricular circulation and to describe our current institutional approach at University of Florida to sVAD support in neonates, infants, and children prior to Fontan. Our programmatic philosophy at University of Florida is to strive to identify the minority of neonates with functionally univentricular circulation who are extremely high-risk prior to initiating staged palliation and to stabilize these neonates with primary preemptive sVAD in preparation for cardiac transplantation; our rationale for this approach is related to the challenges associated with failed staged palliation and subsequent bail-out sVAD support and transplantation. A subset of extremely high-risk neonates and infants with functionally univentricular ductal-dependent circulation undergo primary preemptive sVAD insertion and subsequent cardiac transplantation. Support with VAD clearly facilitates survival on the waiting list during prolonged wait times and optimizes outcomes after Norwood (Stage 1) by providing an alternative pathway for extremely high-risk patients. Therefore, the selective utilization of sVAD in extremely high-risk neonates facilitates improved outcomes for all patients with functionally univentricular ductal-dependent circulation. At University of Florida, our programmatic approach to utilizing sVAD support as a bridge to transplantation in the minority of neonates with functionally univentricular circulation who are extremely high-risk for staged palliation is associated with Operative Mortality after Norwood (Stage 1) Operation of 2.9% (2/68) and a one-year survival of 91.1% (82/90) for all neonates presenting with hypoplastic left heart syndrome (HLHS) or HLHS-related malformation with functionally univentricular ductal-dependent systemic circulation. Meanwhile, at University of Florida, for all 82 consecutive neonates, infants, and children supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 73.3% (95% confidence interval [CI] = 64.1-83.8%), and Kaplan-Meier survival estimated five years after VAD insertion = 68.3% (95% CI = 58.4-79.8%). For all 48 consecutive neonates, infants, and children at University of Florida with biventricular circulation supported with pulsatile paracorporeal VAD: Kaplan-Meier survival estimated one year after VAD insertion = 82.7% (95% CI = 72.4-94.4%), and Kaplan-Meier survival estimated five years after VAD insertion = 79.7% (95% CI = 68.6-92.6%). For all 34 consecutive neonates, infants, and children at University of Florida with functionally univentricular circulation supported with pulsatile paracorporeal sVAD: Kaplan-Meier survival estimated one year after VAD insertion = 59.7% (95% CI = 44.9-79.5%), and Kaplan-Meier survival estimated five years after VAD insertion = 50.5% (95% CI = 35.0-73.0%). These Kaplan-Meier survival estimates for patients supported with pulsatile paracorporeal VAD are better in patients with biventricular circulation in comparison to patients with functionally univentricular circulation both one year after VAD insertion (P=0.026) and five years after VAD insertion (P=0.010). Although outcomes after VAD support in functionally univentricular patients are worse than in patients with biventricular circulation, sVAD provides a reasonable chance for survival. Ongoing research is necessary to improve the outcomes of these challenging patients, with the goal of developing strategies where outcomes after sVAD support in functionally univentricular patients are equivalent to the outcomes achieved after VAD support in patients with biventricular circulation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest None.

Objective: To address the current lack of specified data existing regarding the perioperative characteristics and outcomes in a novel patient population, which may bridge the current understanding of how patient characteristics and perioperative management may influence the postoperative hospital course before cardiac transplantation., Design: A retrospective electronic chart review included all patients with failing single- ventricle (SV) physiology receiving ventricular assist device (VAD) support at a high-volume pediatric VAD center between April 5, 2010, and December 1, 2020, using institution-based electronic medical records for retrospective analysis., Setting: At a single pediatric hospital., Participants: Fourteen pediatric patients with failing SV physiology receiving ventricular assist device therapy (SVAD)., Interventions: None., Measurements and Main Results: Preoperative, intraoperative, and postoperative patient demographic and medical data were obtained from prior inpatient progress notes, laboratory values, anesthetic records, cardiac catheterization reports, echocardiography reports, and postoperative surgical notes entered during inpatient encounters at the time of SVAD placement. Between April 5, 2010, and December 1, 2020, 16 VAD device implants supported 14 pediatric patients with failing SV physiology. Most patients presented with a preoperative diagnosis of hypoplastic left heart syndrome (N = 9, 64.3%). A total of 6 patients expired on VAD therapy (43%), 7 (50%) survived to receive a cardiac transplant, and 1 patient currently remains on device therapy., Conclusion: Although our institutional approach represents a single perspective, we anticipate that our experience institutional experience may prove helpful to others caring for peditric patients with single ventricle physiology undergoing ventricular assist device placement and promote collaborative efforts to improve their care., Competing Interests: Conflict of Interest None., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy, and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their posttransplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates to be transplant-ready when donor hearts are available., Competing Interests: Conflict of Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: The prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implantation remains a challenge. Recently, risk scores were derived from analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data, the EUROMACS-RHF, and the modified postoperative EUROMACS-RHF. The authors assessed the performance characteristics of these 2 risk score formulations in a continuous-flow LVAD cohort at their institution., Design: A retrospective, observational study., Setting: At a tertiary-care academic medical center., Participants: Adult patients who underwent durable LVAD implantation between 2015 and 2018., Interventions: None MEASUREMENTS AND MAIN RESULTS: Early post-LVAD RHF was defined as follows: (1) need for right ventricular assist device, or (2) inotropic or inhaled pulmonary vasodilator support for ≥14 postoperative days. The authors used logistic regression and examined receiver operating characteristic (ROC) curves to evaluate the ability of the 2 risk scores to distinguish between outcome groups. A total of 207 patients met the inclusion criteria. Of the patients, 16% developed RHF (33/207). The EUROMACS-RHF score was not predictive of RHF in the authors' cohort (odds ratio [OR] 1.25; 95% CI [0.99-1.60]; p = 0.06), but the postoperative EUROMACS-RHF CPB score was significantly associated (OR 1.38; 95% CI [1.03-1.89]; p = 0.03). The scores had similar ROC curves, with weak discriminatory performance: 0.601 (95% CI [0.509-0.692]) and 0.599 (95% CI [0.505-0.693]) for EUROMACS-RHF and postoperative EUROMACS-RHF, respectively., Conclusions: In the authors' single-center retrospective analysis, the EUROMACS-RHF risk score did not predict early RHF. An optimized risk score for the prediction of RHF after LVAD implantation remains an urgent unmet need., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Heart failure affects 6.2 million adults in the United States (US), resulting in a decrease in quality of life. Limited options exist for the treatment of end-stage heart failure. Mechanical circulatory support and transplantation are considered when no further optimization can be obtained with medical management. Heart transplant is regarded as superior to mechanical assist devices due to a lower incidence of multiorgan dysfunction. However, transplants are limited by the availability of donor organs. Heart transplants using organs from donation after circulatory death (DCD) have blossomed globally since 2014; whereas, in the US, this method has had a slower implementation. Today, the realization of the need to increase the number of donor hearts has reinvigorated the interest in heart transplantation using DCD organs. The authors review the process and discuss the unique opportunities anesthesiologists have to impact the future success of DCD heart transplantation as it continues to expand., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Adult congenital heart disease (ACHD) is a rising concern for the current healthcare system, with a prevalence that is anticipated to steadily increase through the year 2050. It is estimated that there are >1.4 million adults in the United States living with a congenital heart defect. Despite significant advances in medical and surgical therapy, most of these patients progress to advanced heart failure due to the unique anatomic, physiological, and hemodynamic abnormalities associated with the disease. Patient awareness of the disease coupled with advances in the diagnosis and treatment has led to a significant increase in the surgical treatment of CHD in adults. The authors aim to summarize and critically appraise the current literature on the morbidity, mortality, and risk scores associated with ACHD., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest None.

Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device., Competing Interests: Declaration of Competing Interest No financial or other conflicts of interest relevant to this paper. The use of brand names for the devices is essential as part of the description., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The authors developed and utilized an anesthetic protocol for the management of an off-pump approach for minimally invasive Heartmate III (HM3) implantation. Their goal was to determine if this method was safe and feasible for patients with in-situ mechanical support., Design: The authors performed a retrospective study of consecutive patients undergoing off-pump HM3 implantation via bilateral minithoracotomies., Setting: This was a single-institution study at the University of Rochester Medical Center, using the same cardiac anesthesiologist and cardiac surgeon pair., Participants: The authors studied 8 consecutive patients undergoing off-pump HM3 implantation from June 2019 to July 2020., Interventions: The authors developed an anesthetic management protocol for off-pump HM3 implantation via bilateral minithoracotomies., Measurements and Main Results: As a result, the authors evaluated 88% of men with a mean age of 55.0 ±13.0 years. The median time to extubation was 19.7 hours, with a median intensive care unit length of stay of 6.5 days. Fifty percent of patients required blood transfusions during the first 24 hours after surgery (postoperative), and 63% of patients were free from all postoperative complications. No patients required a right ventricular assist device. The mean hospital stay was 26.3 ± 11.3 days, with an 88% survival to discharge., Conclusion: In this single-center study, the authors have described the anesthetic consideration for the implantation of the HM3 left ventricular assist device using a complete sternal-sparing technique without the use of cardiopulmonary bypass. Their results have shown, in a case series of 8 patients, that this is a safe and feasible alternative to traditional techniques in patients with existing mechanical support., Competing Interests: Conflict of Interest Wendy K. Bernstein, MD, MBA, and Igor Gosev, MD, PhD, are both associated with the Speakers Bureau with Abbott Laboratories., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To determine if venoarterial extracorporeal membrane oxygenation (VA ECMO) as a bridge to left ventricular assist device (LVAD) in heart transplant (HT) candidates (ie, double bridge to HT) was associated with increased morbidity and mortality when compared to LVAD bridging to HT (ie, single bridge to HT)., Design: A retrospective analysis of patients undergoing LVAD support from 2011 to 2020. A Kaplan-Meier survival curve and Cox-Mantel hazard ratios (HR) were calculated during LVAD support and after HT. Postoperative complications were collected., Setting: University Hospital Erasme., Participants: HT candidates requiring LVAD., Interventions: VA ECMO bridging to LVAD (ECMO-LVAD group [n = 24]) versus LVAD (LVAD group [n = 64])., Measurements and Main Results: Eighty-eight patients underwent HeartWare LVAD (HVAD, Medtronic) placement. Survival to hospital discharge and during the entire study period were lower in the ECMO-LVAD group (66.7% v 92.2%; p = 0.0027, and 37.5% v 62.5%; p = 0.035, respectively). Overall HR of death was 2.46 (95% confidence interval [CI]: 1.13-5.37; p = 0.005) in the ECMO-LVAD group and remained elevated throughout their time on LVAD support (HR 3.24 [95% CI: 1.15-9.14]; p = 0.0036). However, in patients who underwent HT (n = 50), mortality was similar between groups (HR 1.33 [95% CI: 0.33-5.31]; p = 0.66). Postoperative complications were more frequent in the ECMO-LVAD group (infection = 83.3% v 51.6%, p = 0.007; renal replacement therapy = 45.8% v 9.4%, p = 0.0001; post-LVAD ECMO = 25.0% v 1.6%; p = 0.0003)., Conclusions: VA ECMO as a bridge to LVAD support before HT was associated with increased morbidity and mortality during LVAD support. However, in patients who underwent HT, outcomes were similar regardless of VA ECMO bridging., Competing Interests: Declaration of Competing Interest Sean Coeckelenbergh received honoraria from Medtronic, outside the submitted context of the work. Fabio Taccone received honoraria from Eurosets, outside the submitted context of the submitted work. The other authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Advances in surgical techniques and outpatient cardiac care have led to a growing population of pediatric patients surviving well into adulthood with previous single-ventricle palliation. Continued improvement in survival has resulted in subsequent increases in the number of patients with single-ventricle physiology listed for heart transplantations. Some of these patients require mechanical circulatory support as a bridge to transplantation, although establishing successful mechanical circulatory support in these complex patients remains challenging. Only limited published data exist describing the perioperative anesthetic management and key considerations dedicated to patients with failing single-ventricle physiology presenting for ventricular assist devices. This clinical review aims to provide a focused evaluation of the vital perioperative considerations encountered in this novel population., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Right ventricular heart failure (RVHF) is a critical complication in patients with respiratory failure, particularly among those who transitioned to lung transplantation using venovenous (VV) extracorporeal membrane oxygenation (ECMO). In these patients, both cardiac and respiratory functions are supported using venoarterial or venoarterial-venous ECMO. However, these modalities increase the risk of device-related complications, such as thromboembolism, bleeding, and limb ischemia, and they may disturb early rehabilitation. Due to these limitations, a right ventricular assist device with an oxygenator (Oxy-RVAD) using ECMO may be considered for patients with RVHF with VV ECMO., Design: A retrospective case series and literature review., Setting: A single tertiary care university hospital., Participants: The study comprised lung transplantation candidates on ECMO bridging who developed right-sided heart failure., Interventions: An RVAD with ECMO., Measurements and Main Results: Of eight patients who underwent the study protocol, seven were bridged successfully to lung transplantation (BTT), and all patients with BTT were discharged, with a 30-day survival rate of 100% (7/7 patients). The 180-day survival rate was 85% (6/7 patients)., Conclusions: The study suggested that Oxy-RVAD using ECMO may be a viable option for bridging patients with RVHF to lung transplantation., Trial Registration: Retrospectively registered., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)