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Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Background Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD. Methods We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression. Results PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD. Conclusions Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed.

Mitral valve repair is infrequently performed in patients undergoing corrective surgery for failed mitral transcatheter edge-to-edge repair in current United States practice. This article describes surgical techniques for reconstructive surgery after failed transcatheter edge-to-edge repair. Nine patients underwent robotic-assisted mitral surgery after failed transcatheter edge-to-edge repair between 2008 and 2020 at a single center. Repair was completed in 88.9% (n = 8) patients, and freedom from2+ mitral regurgitation was 87.5% (n = 7) at a median follow-up of 1.9 years.

In Barlow disease, increased repair complexity drives decreased repair rates. We evaluated outcomes of a simplified approach to robotic mitral repair in Barlow disease.A prospective institutional registry with vital-statistics, statewide admissions and echocardiographic follow-up was used to identify 924 consecutive patients undergoing robotic surgery for degenerative mitral regurgitation (MR) between 2005 and 2020, including 12% (n = 111) with Barlow disease. Freedom frommoderate (2+) MR was analyzed with death as a competing risk and predictors of failure were analyzed using multivariable Cox regression. Median follow-up was 5.5 years (range, 0-15 years).Patients with Barlow disease were younger (median, age 59 years; interquartile range [IQR], 51-67 vs 62; IQR, 54-70 years, P = .05) than patients without Barlow disease. Replacements were performed in 0.9% (n = 1) of patients with Barlow disease and 0.8% (n = 6) of patients without Barlow disease (P = 1). Repairs comprised simple leaflet resection and annuloplasty band in 73.9% (n = 546) of non-Barlow valves versus 12.7% (n = 14) of patients with Barlow disease who required neochordae (53.6%, n = 59), chordal transfer (20%, n = 22), and commissural sutures (37.3%, n = 41), with longer cardiopulmonary bypass time (median 133; IQR, 117-149 minutes vs 119; IQR, 106-142 minutes, P .01). Survival free from greater than moderate MR at 5 years was 92.0% (95% confidence interval [CI], 80.2%-98.1%) in patients with Barlow disease versus 96.0% (95% CI, 93.3%-98.0%) in patients without Barlow disease (P = .40). Predictors of late failure included Barlow disease (hazard ratio, 3.9; 95% CI, 1.7-9.0) and non-Barlow isolated anterior leaflet prolapse (hazard ratio, 5.6; 95% CI, 2.3-13.4).Barlow disease may be reliably and safely repaired with acceptable long-term durability by experienced robotic mitral surgery programs.

This study was designed to evaluate the association of surgical training on outcomes following orthotopic heart transplantation in all levels of cardiothoracic surgery fellows.A retrospective cohort analysis was performed on all heart transplants at a single institution from 2011 to 2020. Transplants performed using organ preservation systems (n = 10) or with significant missing data were excluded (n = 37), resulting in 154 transplants performed by faculty surgeons and 799 total transplants performed by first-year Accreditation Council for Graduate Medical Education fellows (n = 73), second-year Accreditation Council for Graduate Medical Education fellows (n = 124), or non-Accreditation Council for Graduate Medical Education fellows (n = 602) in a transplantation and mechanical circulatory support fellowship. Primary outcome was warm ischemic time analyzed by year of fellowship. Additional secondary outcomes included 30-day mortality, primary graft dysfunction, reoperation for bleeding, and 5-year survival. Median follow-up was 3 years (interquartile range [IQR], 1.0-5.5 years) and 100% complete.The median number of transplants performed was 30 (IQR, 19.5-51.8) during the study period performed by 22 trainees. Baseline transplant characteristics performed were similar amongst the trainee years, although the first-year Accreditation Council for Graduate Medical Education fellows approached significantly fewer re-do transplants (1.4% vs 8.1% and 4.3%; P = .07). Warm ischemic time was lower in the first-year fellows (49 minutes; IQR, 42-63 minutes) versus second-year fellows (56.5 minutes; IQR, 45.5-69 minutes) and mechanical circulatory support/transplant fellows (56 minutes; IQR, 46-67 minutes) (P = .028). Crossclamp time was also lower in the first-year fellows than in second-year and mechanical circulatory support/transplant fellows, respectively (79 minutes; IQR, 65-100 minutes vs 147 minutes; IQR, 125-176 minutes and 143 minutes; IQR, 119-175 minutes) (P = .008). Secondary outcomes, including 30-day mortality (4.1% [n = 3] vs 2.4% [n = 3] vs 2.7% [n = 16]; P = .76), primary graft dysfunction (5.5% [n = 4] vs 4.0% [n = 5] vs 4.3% [n = 26]; P = .88), reoperation for bleeding (2.7% [n = 2] vs 4.8% [n = 6] vs 4.2% [n = 25]; P = .78), and 5-year survival (82.2%; 95% CI, 66.7%-84.9% vs 77.3%; 95% CI, 66.7%-84.9% vs 79.3%; 95% CI, 74.9%-83.1%; P = .84) were comparable in all groups.This cohort of nearly 800 operations demonstrates that orthotopic heart transplantation may be performed by cardiac fellowship trainees all levels of training with acceptable short- and long-term outcomes.

Acutely decompensated heart failure presents a complicated challenge. Established temporary support measures have significant adverse effects. A minimally invasive temporary left ventricular assist device (LVAD), the Impella 5.0 (Abiomed, Danvers, MA), has been developed to support these patients.Patients with acutely decompensated heart failure in whom medical management had failed and who required additional support using an Impella 5.0 device were evaluated from January 2014 to September 2018 at a single center in a retrospective manner using a prospectively maintained database. Patients were treated with the device as a bridge to recovery (BTR; n = 30), bridge to durable device (BTDD; n = 23), or bridge to transplantation (BTT; n = 47). All devices were placed using an axillary artery approach. Demographic features and outcomes were evaluated for each group and compared.A total of 100 patients underwent insertion of an axillary Impella 5.0 LVAD. Patients had an average age of 56.7 ± 13.2 years, were predominantly male (84%), and had a severely depressed left ventricular ejection fraction (average 16%), and most had an Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 (57%) or 2 (33%) score. When divided into groups, there was no difference in age or INTERMACS score, but a statistical difference was noted in baseline left ventricular ejection fraction (20%, 14%, 15%) and creatinine level (1.0, 2.0, 1.6), in the BTR, BTDD, or BTT group, respectively (all P.05). Survival was 64% overall, and it was 50%, 48%, and 81% for BTR, BTDD, and BTT, respectively (P = .007). Survival improved during this experience and was 90% overall in the most recent 30 patients.Use of this minimally invasive LVAD system is an attractive strategy to support patients with acute decompensated heart failure to recovery, durable LVAD, or heart transplantation.

National registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR.A prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk.Repair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P .05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P .01).A near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up.

Objective Up to 28% of patients may need mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). This study evaluates the outcomes of minimally invasive MV surgery after TEER. Methods: International multicenter registry of minimally invasive MV surgery after TEER between 2013 and 2020. Subgroups were stratified by the number of devices implanted (≤1 vs >1), as well as time interval from TEER to surgery (≤1 year vs >1 year). Results: A total of 56 patients across 13 centers were included with a mean age of 73 ± 11 years, and 50% were female. The median Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) score for MV replacement was 8% (Q1-Q3 = 5% to 11%) and the ratio of observed to expected mortality was 0.9. The etiology of mitral regurgitation (MR) prior to TEER was primary MR in 75% of patients and secondary MR in 25%. There were 30 patients (54%) who had >1 device implanted. The median time between TEER and surgery was 252 days (33 to 636 days). Hemodynamics, including MR severity, MV area, and mean gradient, significantly improved after minimally invasive surgery and sustained to 1-year follow-up. In-hospital and 30-day mortality was 7.1%, and 1-year actuarial survival was 85.6% ± 6%. Conclusions: Minimally invasive MV surgery after TEER may be achieved as predicted by the STS PROM. Most patients underwent MV replacement instead of repair. As TEER is applied more widely, patients should be informed about the potential need for surgical intervention over time after TEER. These discussions will allow better informed consent and post-procedure planning.

Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique.An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005 and 2020: 87% (n = 902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior or bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from greater than 2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years.Of patients with isolated posterior leaflet prolapse, 87% (n = 506) had standardized repairs and 13% (n = 76) had additional or nonresectional techniques vs 24% (n = 65) and 76% (n = 203), respectively, for anterior or bileaflet prolapse (P.001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n = 50) and commissural sutures (3.4%, n = 20). Overall, median clamp time was 80 (interquartile range, 68-98) minutes, 17 patients required intraoperative re-repair, and 6 required mitral replacement. Freedom from greater than 2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (vs 83% for anterior or bileaflet prolapse). Anterior or bileaflet prolapse was associated with late greater than 2+ regurgitation (hazard ratio, 3.0; 95% confidence interval, 1.3-7.0).Posterior leaflet prolapse may be repaired in greater than 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse preoperatively.

Background The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. Methods From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. Results Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis–patient mismatch (n = 260, 33%) had similar survival to patients without ( p > 0.9), as did patients undergoing less-invasive SAVR ( p = 0.3). Risk factors for death included cachexia ( p = 0.004), tricuspid regurgitation ( p = 0.01), coronary artery disease ( p = 0.02), preoperative atrial fibrillation ( p = 0.001), higher white blood cell count ( p p = 0.0002). Conclusions In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important.

Purpose Hypertension after heart transplantation (HTx) is noted in a majority of HTx patients due to the side effects of calcineurin inhibitors (CNI). The use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are effective anti-hypertensive agents and may have longer term clinical benefits. We assessed our patients on ACEI/ARBs versus others in the first year post-HTx and followed them for 5-year outcomes. Methods Between 2010 and 2015, we assessed 101 HTx patients who were on ACEI/ARBs only in the first year for more than 6 months. Those patients were then followed for 5 years. Likewise, a group of patients who were placed on non-ACEI/ARBs blood pressure medications, such as calcium channel-blockers, beta blockers, and diuretics, in the first year for more than 6 months were the control group. Outcomes included 5-year survival, 5-year freedom from non-fatal major adverse cardiac event (NF-MACE: MI, new CHF, PCI, ICD implant, stroke), freedom from cardiac allograft vasculopathy (CAV: angiographic stenosis >30%), freedom from left ventricular dysfunction (left ventricular ejection fraction ≤40%) and freedom from left ventricular hypertrophy (LVH), defined as intraventricular septum or posterior wall ≥1.3cm. Results The patients treated with ACEI/ARBs in the first year post-HTx compared to those without had significantly lower 5-year survival but a trend for greater 5-year freedom from CAV. There was no significant difference between the two study groups in 5-year freedom from NF-MACE, left ventricular dysfunction and LVH (see table). Baseline demographics between groups were similar for recipient age, % female, pre-transplant diabetes and renal dysfunction (creatinine >1.5mg/dl) (data not shown). Conclusion The use of ACEI/ARBs in the first year post-HTx is associated with lower survival but other factors may be involved. A possible lower development of CAV from ACEI/ARBs may be a benefit to be explored.

Purpose In the past, Hepatitis B donors have been declined in patients who have not been vaccinated by the Hepatitis B vaccine. There is concern that these donors would transmit Hepatitis B to the recipient if they are not vaccinated. There is treatment available for these Hepatitis B infections, however, it has not been established as to its efficacy in patients on immunosuppression. In addition, hepatitis viruses have been reported to affect the endothelium of vital organs. Hepatitis B may injure the endothelium of the coronary vascular tree and could potentially result in a greater development of cardiac allograft vasculopathy (CAV) after heart transplantation. Therefore, we sought to assess this possibility by examining our patients who received Hepatitis B donors. Methods Between 2010 and 2016 we assessed 24 heart transplant patients who received a Hepatitis B donor. All of the recipients had received a Hepatitis B vaccine prior to transplantation. Endpoints include 3-year survival, 3-year freedom from CAV, 3-year freedom from non-fatal major adverse cardiac events (NF-MACE), and freedom from first year rejection, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). These study patients were compared with 600 patients without Hepatitis B donors in a contemporaneous era. Results 3-year survival, freedom from NF-MACE, and freedom from first year rejection were similar between the Hepatitis B and control groups. There is numerically a lower incidence of freedom from CAV in the Hepatitis B group compared to the control, but this was not statistically significant. Conclusion Hepatitis B donors appear to have acceptable outcome compared to non-Hepatitis B donors after heart transplantation. Larger numbers of Hepatitis B donors will be needed to assess risk for increased CAV development.

Purpose Right ventricular failure occurs in a variety of clinical settings and is associated with worse survival. We describe our clinical experience with two temporary percutaneous right ventricular assist devices (RVADs): TandemLife Protek Duo (TPD) and Impella RP. Methods A prospectively maintained institutional registry was used to identify patients requiring TPD and Impella RP support. Baseline characteristics, etiology of heart failure, indication for RVAD support, timing of implantation in relation to the onset of right ventricular (RV) failure were characterized. Specific clinical outcomes, including overall survival, time on temporary percutaneous RV support, device explant and device exchange rates were analyzed. Outcomes were further analyzed among the cohort of explanted patients. Results Between January 2015 and December 2018, 19 TPD devices and 10 Impella RP devices were implanted. Indication for RV support included post-left ventricular assist device implantation RV failure, post-cardiotomy cardiogenic shock, and post-transplant RV failure. Mean (median) support duration for TPD was 16 (12) days, and 5 (4) days for Impella RP. Among TPD patients, 11 (57.9%) were explanted, 4 (21.0%) died, and there were no device exchanges. Among Impella RP patients, 5 (50.0%) were explanted, 3 (30.0%) died, and 1 (10.0%) required device exchange. Among TPD patients explanted, 7 (63.6%) recovered and were weaned, 3 (27.2%) died, and 1 (9.1%) required a durable RVAD. Among Impella RP patients explanted, 4 (80.0%) recovered and were weaned, and 1 (20.0%) required a durable RVAD. Conclusion RV failure is associated with reduced survival. Temporary percutaneous RVAD devices provide a suitable strategy for bridging patient to recovery.

Purpose Hemodynamic compromise rejection (HCR) is seen Methods Between 2010-15, among 589 heart transplants, we identified 15 HTx pts (2.5%) who developed HCR. At the time of presentation of HCR, results of EMB were reviewed. Outcomes of these pts included subsequent 1-year survival, freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), freedom from non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, defibrillator/pacemaker implant, stroke), and freedom from subsequent recurrence of rejection episodes, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). The HCR group was compared to a case-controlled group with similar age, sex, time from transplant (n=39). Results HCR did not consistently show rejection with 64% revealing neither ACR nor AMR on biopsy slides. 27% showed ACR, 9% showed AMR and the remainder showed no rejection. In the HCR group, subsequent 1-year survival and freedom from NF-MACE was significantly compromised compared to the control group. Subsequent 1-year freedom from CAV and recurrent rejections were not significantly different. (table) Conclusion In a majority of HCR cases, EMB findings reveal no rejection which may be due to an atypical immune process. In the current era, outcomes from HCR continue to be compromised which suggest the need for a more aggressive approach to immunosuppression and management.

Purpose As donor criteria expand to meet increasing demand for transplantable hearts, increased focus has fallen on mitigating risk associated with extended criteria donors. It has been postulated that warm ischemic time may be as significant a factor as total ischemic time, and reduction is associated with better outcomes. This study investigates the impact of warm ischemic time on post-operative events and survival in orthotopic heart transplantation patients at a high-volume center. Methods From 2015 to 2020, patients who underwent heart transplantation were identified at a single institution in a prospectively maintained database with long-term clinical outcomes. After excluding heart-lung transplants and those with missing warm ischemic time, 388 patients were identified. Patients were classified in to three groups: Results Between warm ischemic time groups, there were significant differences in recipient sex, age, and body mass index (BMI), all p 0.05, as was 30-day freedom from PGD, 80.2% (85) vs 82.9% (141) vs 76.8% (86), 30-day survival, 98.1% (104) vs 98.2% (167) vs 97.3% (109), and one-year survival, 92.5% (98) vs 93.5% (159) vs 91.1% (102) (all p > 0.05). Warm ischemic time was not a predictor of one-year mortality, odds ratio (OR) 0.99 (95% CI, 0.97-1.02). In subgroup analysis with over 4 hours of total ischemic time, warm ischemic time was not a predictor of PGD, OR 0.94 (95% CI, 0.82-1.07), or one-year survival, OR 0.94 (95% CI, 0.82-1.07). Conclusion Although increased warm ischemic time did not predict increased adverse post-operative outcomes, continued emphasis on reducing total ischemic time is paramount.

Purpose Cyclosporine (CsA) became available in the US in 1983 and improved clinical outcomes. Another calcineurin inhibitor, tacrolimus (TAC), became available in the 1990s and demonstrated benefit in further reducing rejection. In most heart transplant (HTx) programs, TAC is currently the drug of choice for immunosuppression. However, a switch to CsA does occur due to adverse effects from TAC. It is not well-established that this switch to CSA results in subsequent non-inferior outcomes. Therefore, we reviewed our single center experience to assess for real world potential outcomes. Methods Between 2010 and 2017, we identified 58 HTx patients who were administered CsA in place of TAC mostly due to neurologic adverse effects from TAC. For comparison, a TAC group was matched based on age, sex, baseline renal function and time from transplant. The average time of this switch occurred at 6.6 ± 1.1 months post-transplant. Outcomes included subsequent 1-year freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR) and 3-year subsequent survival, freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), and freedom non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). Results The CsA/MMF group compared to the TAC/MMF group had significantly lower subsequent 3-year survival and worse renal function at 1-year (after the switch to CsA). There was similar subsequent 3-year freedom from CAV and NF-MACE and 1-year rejections between the two groups. (see table) Conclusion In the current era in a large, single center study there are indications that a switch to CsA from TAC may be inferior in heart transplant recipients. Further investigation with larger numbers is needed to confirm these findings.

Purpose The organ care system (OCS) has been found to have comparable 30-day mortality compared to standard of care (SOC) therapy for the donor heart. At our institution, we had previously shown comparable results on 1-year outcome in terms of rejection, antibody development and survival. In this current study, this cohort of patients were followed, and we evaluated long term results. Methods Between 2011 and 2013, we randomized 38 heart transplant (HTx) patients to either OCS or SOC. We assessed total ischemic time (TIT), cold ischemic time (CIT), development of de novo antibodies (abs) and donor specific antibodies (DSA) within 8 year post-HTx, 8-year survival, 8-year freedom from cardiac allograft vasculopathy (CAV), 8-year freedom from non-fatal major cardiac events (NF-MACE: Myocardial Infarction, Heart Failure, angioplasty, pacemaker/ICD, stroke), 8-year freedom from any-treated rejection (ATR), biopsy (bx) proven cellular rejection (ACR >2R), bx proven antibody-mediated rejection (AMR1, 2, or 3). Results OSC group had significant longer TIT but significantly shorter CIT compared to SOC. There was no statistically significant difference in 8-year freedom from CAV, NF-MACE, ATR, ACR and AMR. Moreover, 8-year survival was not statistically significant different between the two groups. There were total of 8 deaths in the OCS group and the cause of death included 3 immediate postoperative cases of hemorrhage and thrombotic event, two died of complications of malignancy, one due to multi-organ failure, one patient died due to complications of CMV infection and last patient died of unknown etiology. In the SOC group, there were 5 deaths. Causes of death included once case of rejection, one case of stroke, one patient died of CMV infection, one due to patient non-compliance, and one patient died of unknown cause at an outside hospital. Conclusion OCS appears to be a valid tool to extend total donor ischemic time without compromising long term outcomes.

Purpose The criteria for combined heart-liver transplant (HLiTx) has not been well established. Liver cirrhosis in a heart failure patient would require consideration for HLiTx. Investigators have used non-invasive testing (NIT) such as abdominal ultrasound and CT scans to assess for liver surface nodularity which suggests cirrhosis. Biopsies are then performed to assess for liver disease. However, pathology findings can be heterogeneous and, therefore, the biopsy may not be reliable to exclude cirrhosis due to sampling error. It is not known whether abnormal NIT suggesting cirrhosis alone renders poor outcome if heart alone transplant (HATx) proceeds. Methods Between 2012 and 2017, we identified 24 patients with an abnormal NIT demonstrating liver surface nodularity suggestive of cirrhosis but with liver biopsies showing no cirrhosis by pathology. Of these 24 patients, most patients had mild-moderate fibrosis with 3 patients who had severe 3-4+ fibrosis. Study endpoints included 3-year survival, freedom from non-fatal major adverse cardiac events (NF-MACE: MI, CHF, PCI, ICD implant, stroke), and freedom from cardiac allograft vasculopathy (CAV, defined by stenosis ≥30%). Freedom from 1-year rejection [acute cellular rejection (ACR), antibody-mediated rejection (AMR)] was also recorded. We compared these 24 patients to patients who underwent HATx without liver disease (n=523) during this same time period. Results Patients who had liver nodularity with HTx had similar 3-year survival, freedom from NF-MACE, and freedom from CAV compared to control patients who had HATx without liver disease. Furthermore, 1-year freedom from rejection was similar between study groups (see table). The 3 patients with 3-4+ fibrosis on liver biopsy had similar outcomes to the rest of the study group. Conclusion In our single center experience, surface nodularity suggesting cirrhosis by NIT but with no evidence of biopsy-proven cirrhosis does not appear to be a contraindication to proceed with HATx.

The most recent American College of Cardiology/American Heart Association heart valve guidelines recommend that prompt surgical correction of severe degenerative mitral valve regurgitation, ideally mitral valve repair, should be performed to decrease the risks of long-term mortality and heart failure risks associated with this condition. Mitral valve repair performed using a minimally invasive robotic approach can now be successfully carried out in nearly all cases of degenerative disease with very low risks of stroke or death. Experienced groups have further shown specific advantages of robotic mitral valve repair compared with conventional approaches, including reduced blood loss, lower risks of infection and atrial fibrillation, shorter hospital length of stay, quicker return to normal activities, and a superior cosmetic result. Herein, we discuss the current status of robotic mitral valve repair including indications, technical advances, safety, effectiveness, and durability.

Purpose Diabetes is common in heart failure patients and almost a quarter of heart transplant (HTx) recipients are diabetic at 1-year post transplant. The effect of diabetes on transplant outcomes is conflicting. The goal of this study was to examine the impact of diabetes on post-transplant outcomes at a large single center. Methods We divided 952 patients at our center transplanted from 2010 to 2018 into those with (n = 274) and without pre-transplant diabetes (n = 578). The diabetic patients were further divided: tight glucose control (HbA1c 7.0; n = 23) Demographic data and outcomes were compared between groups. Results There was no significant difference between groups in 1-year survival, freedom from cardiac allograft vasculopathy, non-fatal major cardiac events, rejection, new-onset dialysis, or infection. There was a trend towards worse 1-year survival in the relaxed glucose control group compared with the tight control group (82.6 v 94.1%; p=0.35). There was no difference in other outcomes between groups. Conclusion While pre-transplant diabetes is often considered an important factor in selecting appropriate heart transplant candidates, this large single-center analysis does not demonstrate an association between pre-transplant diabetes and post-transplant outcomes, regardless of the adequacy of glucose control.

Purpose Severe primary graft dysfunction (PGD) is seen in approximately 5% of all heart transplant recipients per the International Society for Heart and Lung Transplantation (ISHLT) PGD grading scale. These patients suffer endothelial cell damage and are known to have increased risk of early mortality. It is not known whether the survivors of severe PGD develop more donor specific antibody (DSA), have more treated rejections, have increased risk of the development of cardiac allograft vasculopathy (CAV), and have increased mortality at 3 years post transplantation. We sought to assess this potential association. Methods Between 2010-2016 we assessed 24 heart transplant patients who developed severe PGD per the ISHLT PGD grading scale. These patients who developed severe PGD were compared to those without severe PGD in a contemporaneous era. Patients were then followed for 3 years and assessed for the following endpoints: 3-year survival, 3-year freedom from CAV, 3-year freedom from non-fatal major adverse cardiac events (NF-MACE, defined as myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and 1-year freedom from rejection, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Results Patients with severe PGD had decreased 3-year survival, 1-year freedom from any treated rejection, and 3-year freedom from NF-MACE compared to those patients who did not have severe PGD. There were no significant differences between the two groups in terms of 3-year freedom from CAV and freedom from DSA. Conclusion Severe PGD appears to have increased mortality and morbidity with more rejection and more NF-MACE. More intense therapies to offset the inflammatory response from severe PGD should be pursued.

Purpose For patients in cardiogenic shock, temporary mechanical circulatory support (MCS) with impella 5.0 as a bridge to decision, durable MCS, or transplantation, is associated with acceptable clinical outcomes. In October 2018, UNOS heart allocation criteria were reclassified, and we sought to determine the impact of bridging with impella 5.0 post-reclassification. Methods A prospectively collected institutional heart failure device registry was mined for clinical data related to the impella 5.0 before and after UNOS re-classification. Basic demographic characteristics, surgical access site, and duration of support (total and after listing) were queried pre and post-reclassification. The proportion of patients who died, received device exchange, were explanted, bridged to durable MCS or transplant were queried. Survival to hospital discharge, and 3 and 6-month survival post-transplant were analyzed. Results Under old and new criteria respectively, 105/24 patients received an impella 5.0, 8(7.6%)/2(8.3%) had device exchange, 23(21.9%)/2(8.3%) expired, 28(26.7%)/4(16.6%) were explanted, 13(12.4%)/2(8.3%) received durable MCS, and 33(31.4%)/14(58.3%) were transplanted. Among those transplanted, duration of support after listing was 14.6(12.1) v 7.1(7.5), p=0.038. There was no significant difference in the proportion of patients supported ≤14d v >14d under old and new criteria (p=0.421). Among transplanted patients, there were no significant demographic differences (gender, age, blood type, length of support). 100% of transplanted patients were alive at discharge under old allocation criteria, whereas only 91.7% of patients were alive at discharge under new criteria, although this was not significant (p=0.094). 3 and 6-month survival were 100% under old allocation criteria, and 88.9% under new criteria (p=0.055). Conclusion A greater proportion of patients supported with impella 5.0 were transplanted under the new allocation criteria, with shorter support duration and no significant difference in mortality. Impella bridging to transplant is associated with excellent survival. Further investigation is required to delineate the relationships between allocation tier and clinical outcomes.

Purpose Patients with muscular dystrophy may have an associated cardiomyopathy, resulting in advanced heart failure requiring transplantation. However, the skeletal muscle dysfunction can result in respiratory impairment, dysphagia, and inability to participate in rehabilitation after heart transplantation. The purpose of this study was to describe the characteristics and outcomes of muscular dystrophy patients undergoing heart transplantation at our center. Methods We reviewed patients at our center status post heart transplantation between 2010 and 2017. Of the 646 patients, we identified 10 with muscular dystrophy. The demographics, clinical characteristics, and outcomes of these 10 patients with muscular dystrophy were compared to the 646patients without muscular dystrophy transplanted during this time period. Results The muscular dystrophy patients were all deemed acceptable to proceed by a neurologist with expertise in muscular dystrophy. They were younger (45 years vs 56 years; p = 0.006); had younger donors (27 years vs 35 years, p = 0.05); had lower creatinine (0.95 mg/dL vs 1.15 mg/dL; P = 0.01); and less pre-transplant diabetes (13% vs 52%; p = 0.03). There was no difference in sensitization, CMV IgG mismatch status, or Status 1A listing. The muscular dystrophy patients had 100% 1- and 5-year survival (Figure) and there was no difference in the incidence of cellular rejection, antibody-mediated rejection, or allograft vasculopathy between groups. Conclusion Patients with muscular dystrophy-associated cardiomyopathy may require heart transplantation. This analysis indicates that carefully selected patients can have excellent outcomes and therefore should be considered candidates for advanced heart failure therapies.

Background Vasoplegia is characterized as a severe vasodilatory shock after cardiac surgery, and can be associated with substantial morbidity. Increased systemic inflammation and endothelial dysfunction, often related to prolonged cardiopulmonary bypass times, anesthesia, or mechanical circulatory support have been shown to be associated with the development of vasoplegia. We sought to identify risk factors and the impact of various degrees of vasoplegia after heart transplantation. Methods A retrospective review was conducted of 244 consecutive patients who underwent heart transplantation over a 3-year period. Patients were divided into three groups: no vasoplegia, mild vasoplegia (requiring one vasopressor), and moderate/severe vasoplegia (more than two vasopressors). One-year survival, freedom from rejection, and postoperative complication rates were assessed. Risk factors for vasoplegia subgroups were retrospectively identified. Results Vasoplegia syndrome was observed in 34.3% of patients after heart transplantation (mild, 74.1%; moderate/severe, 25.9%). Cardiopulmonary bypass time was significantly longer and pretransplant creatinine was significantly higher in the moderate/severe vasoplegia group. There was a strong trend toward greater use of mechanical circulatory support among moderate/severe vasoplegia patients compared with mild and no vasoplegia patients. After heart transplantation, 1-year survival, freedom from rejection, and need for hemodialysis were not significantly different between groups. Conclusions Vasoplegia syndrome is common after heart transplantation. Risk factors for increased severity include longer cardiopulmonary bypass times and elevated preoperative creatinine. Although higher rates of mortality or graft rejection were not detected, vasoplegia was associated with prolonged intubation, greater blood product usage, and lengthened hospital stay. Further studies involving larger cohorts are warranted.

Purpose Certain donor characteristics after heart transplantation (HTx) may have less optimal outcome post-HTx. One factors leading to worse outcome is female donors to male recipient possibly due to size (height and weight) mismatch relative to male donors. We try to compensate for this size mismatch by using obese female donors into male recipients. However, there have been recent concerns with obese donors, in the sense that there are commonly large fat deposits on the donor heart. It is not known whether short and obese female donors (weight oversizing) results in acceptable outcome after HTx. We sought to assess for this possibility in our large single center. Methods Between 2010 and 2017 we assessed 799 HTx patients and divided them into those male recipients who received female donors (n=246) that were short (≤ 66 inches) and obese (BMI≥30) (n=61) and short and non-obese (BMI major adverse cardiac events (NF-MACE: myocardial infarction , new congestive heart failure , percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and freedom from any-treated rejection, acute cellular rejection , and antibody-mediated rejection . Results There is no significant difference in 1-year outcomes between short and obese female donors, short and non-obese female donors, and male donors of similar heights and weights (see tables). Conclusion Short and stout female donors appear to be acceptable for HTx which increases the donor pool.

Purpose Approximately 30% of patients undergoing heart transplantation (HTx) may have diabetes mellitus type 2 (DM2). More importantly, DM2 may become more prevalent after HTx because of high corticosteroid use. Metformin - an oral anti-hypoglycemic drug for DM2- has also been demonstrated to have immunomodulatory effects. It has been reported that metformin may decrease acute and chronic rejection as well as the development of cardiac allograft vasculopathy (CAV). Therefore, we reviewed our HTx patients placed on metformin pre-HTx and post-HTx to assess potential outcomes and benefits. Methods Between 2010 and 2017, we assessed 229 heart transplant patients with DM2. We divided these diabetic patients in those on metformin post-HTx (n=32) and those not on metformin (n=176). Metformin was continued for at least one-year post-transplant. Endpoints included 1-year survival, 1-year freedom from CAV (as defined by >30% stenosis via angiography), 1-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and 1-year freedom from any-treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Results There was no significant difference in 1-year survival in DM2 patients on metformin and DM2 patients not on metformin. There was no significant difference in 1-year freedom from CAV, NF-MACE or rejection between the groups (see table). Conclusion The use of metformin does not appear to demonstrate an immunomodulatory benefit. A larger cohort of patients are needed to confirm these findings.

Reports of cardiac surgery in the elderly have focused primarily on septuagenarians and octogenarians. There are very limited data regarding risk-adjusted models in nonagenarians.From 1983 to 2011, patients with age 90 years or greater at the time of coronary artery bypass grafting (CABG) or valve surgery (aortic or mitral) were retrieved from a prospective institutional database. A Cox proportional hazard model was used to determine significant predictors of 5-year survival. In addition, a 12-month assessment of quality of life was conducted.The CABG-only (n = 46), valve-only (n = 55), or CABG-valve (n = 53) surgery was conducted in 154 patients. Demographic characteristics were similar in all groups except for congestive heart failure, which was more prominent in the valve-only or CABG-valve groups (p0.0001). The 30-day mortality was 8.8%, 12.8%, and 18.9% in the CABG-only, valve-only, and CABG-valve groups, respectively, without significant difference among groups (p = 0.35). At 5-years follow-up, the Kaplan-Meier survival curves do not show a difference among groups (p = 0.62). Cox proportional hazard model for 5-year survival identified age (hazard ratio [HR] = 1.25, confidence interval [CI] 1.09 to 1.43, p = 0.001, for 1-year increase), prior surgery (HR = 2.23, CI 1.23 to 4.64, p = 0.007), and prior stroke (HR = 2.39, CI 1.25 to 3.98, p = 0.01), as significant predictors of mortality. The 12-month quality of life questionnaire revealed an improvement in 83% of the patients, whereas only 4% reported a decline in cardiac status.Survival in nonagenarians is comparable after CABG or valve surgery. Redo surgery, stroke, and increasing age are significant hazards for mortality. Nonagenarians can undergo cardiac surgery with acceptable mortality and quality of life.

OBJECTIVES Vasoplegia syndrome is a potentially life-threatening condition that can occur following cardiopulmonary bypass. Heart transplantation is a recognized risk factor for developing this vasodilatory state. The objective of this study was to determine the effects of vasoplegia syndrome on 1-year heart transplant outcomes. METHODS A retrospective review of orthotopic heart transplants at a single institution between November 2010 and December 2014 was performed. Of the 347 consecutive adult patients, 107 patients (30.8%) met criteria for vasoplegia syndrome. Preoperative factors and intraoperative variables were collected and compared between vasoplegia and non-vasoplegia cohorts. The incidence of postoperative complications, transplant rejection and patient survival within 1 year were evaluated. RESULTS Demographics and preoperative medication profiles were similar in both groups, while mechanical circulatory support device use was associated with vasoplegia syndrome (30.8% vs 20.0%; P = 0.039). Perioperative characteristics such as longer cardiopulmonary bypass [165.0 (interquartile range [IQR] 74) min vs 140.0 (IQR 42.7) min; P

ObjectiveThe Endovascular Valve Edge-to-Edge Repair Study (EVEREST II) is a prospective, multicenter, randomized controlled trial comparing percutaneous repair with the MitraClip device to mitral valve (MV) surgery in the treatment of mitral regurgitation. The present study analyzed the patient characteristics and treatment effects on mitral repair versus replacement.MethodsOf 279 patients enrolled, 80 surgical patients underwent 82 MV operations and 178 underwent an initial MitraClip procedure, of whom 37 underwent a subsequent MV operation within 1 year of their index the MitraClip procedure. A logistic regression model was used to predict MV replacement according to valve pathology, etiology of mitral regurgitation, age, previous cardiac surgery, and treatment group.ResultsThe rate of percutaneous or surgical MV repair at 1 year was 89% (158/178) in patients initially receiving the MitraClip device versus 84% (67/80) in the surgical patients (P = .36). Surgical repair was performed after the MitraClip procedure in 20 (54%) of 37patients (P < .001 vs surgery). In both the MitraClip device and surgery groups, MV replacement was significantly associated with anterior leaflet pathology (P = .035). Logistic regression analysis showed that anterior leaflet pathology predicted MV replacement. In 5 (13.5%) of 37 patients undergoing surgery after MitraClip therapy, replacement was performed in part because of MV injury associated with the MitraClip procedure.ConclusionsThese data suggest that anterior leaflet pathology is strongly associated with MV replacement in patients undergoing either de novo MV surgery or surgery after MitraClip therapy. MitraClip therapy has a repair rate similar to surgery through 1 year but also imparts a risk of replacement of a potentially repairable valve.

Background Heart transplantation for sensitized patients has been a significant challenge. In this study, outcome of heart transplantation in sensitized patients with virtual cross match was compared with prospective cross match. Methods Prior to July 2007, prospective cross match was used and afterward, virtual cross match with Luminex (One Lambda, Inc, Canoga Park, CA) based antibody analysis was used for potential heart transplant recipients. Prospectively collected data for the 3 years before and after July 2007, in sensitized (panel reactive antibody greater than 10%) and nonsensitized heart transplant recipients were reviewed. Results One hundred sixty-eight patients met inclusion criteria for analysis (78 patients for prospective cross match and 90 patients for virtual cross match). Multiple parameters were compared for the prospective cross match and virtual cross match eras. Three-year survivals in nonsensitized patients were 84.6% and 77.2% and in sensitized patients were 76.9% and 77.4% (p = 0.49) for prospective cross match and virtual cross match eras, respectively. Freedom from 3A (2R) cellular rejection in nonsensitized patients was 96.9% and 95.3%, and in sensitized patients was 90.9% and 100% (p = 0.83). Freedom from antibody-mediated rejection in nonsensitized patients was 95.3% and 96.8%, and in sensitized patients was 90.9% and 90.5% (p = 0.65). Mean waiting time was 129 ± 246 days (mean ± SD) for the period before virtual cross match and 59 ± 78 days with virtual cross match (p = 0.018). Donor geographic area was similar for prospective and virtual cross match. Conclusions In sensitized heart transplant candidates, virtual cross match may shorten waiting time to heart transplantation without increasing subsequent occurrence of cellular rejection, antibody mediated rejection, and mortality after heart transplantation.

We aimed to determine the risk factors associated with mortality in patients with congenitally bicuspid aortic valve disease and dilation (5 cm) of the ascending aorta after aortic valve replacement.We reviewed 252 patients with bicuspid aortic valve undergoing aortic valve replacement at our institution from 1971 through 2000. Patients undergoing concomitant replacement of the ascending aorta were excluded.The average patient age was 61 +/- 15 years; 66.3% were male, and 40.5% of patients had coronary artery disease. The ascending aorta was normal (4.0 cm) in 60.3%, mildly dilated (4.0 to 4.4 cm) in 24.2%, and moderately dilated (4.5 to 4.9 cm) in 15.5% of patients. Patients with moderate aortic dilatation had significantly lower prevalence of coronary artery disease compared with patients with normal ascending aortas (20.5% and 45.4%; p = 0.006). Mean follow-up was 8.9 +/- 6.3 years. Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group; 88%, 77%, and 46%, respectively, in the mild aortic dilation group; and 92%, 83%, and 70%, respectively, in the moderate aortic dilation group. No significant difference in cardiac death was found among the groups (p = 0.08). The significant predictors of survival using the Cox regression model were coronary artery disease, age, decade of surgery, and ejection fraction. Aortic dilation was not significant after adjusting for these other variables. At follow-up, 18 patients required reoperation, 17 for aortic valve prosthesis failure and 1 for ascending aorta aneurysm.The present study highlights the important adverse effect of concomitant coronary artery disease, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after aortic valve replacement for bicuspid aortic valve in patients with no or mild and moderate (5 cm) dilation of the ascending aorta.

In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair.We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group.No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (or = 30 days) by Cox analysis were longer pump time (p0.001) and older age (p0.02). Predictive of late mortality (30 days) were older age (p0.001), fewer bypass grafts (p0.01), and lower ejection fraction (p0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure.In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.

Combined heart and kidney transplantation is increasing in frequency but there are no guidelines to establish the indications, contraindications and sequence for this surgical procedure. We report our single-centre experience on 30 consecutive patients who underwent combined heart and kidney transplant in comparison with heart transplant alone. Patients had similar preoperative characteristics in both groups. Combined heart and kidney transplant is associated with the same long-term survival rate, low cellular rejection and antibody-mediated rejection rates when compared with heart transplant alone. We did not observe any difference in the outcomes related to preoperative patient characteristics. We suggest the staged surgical approach as the preferred method for transplant.