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Background With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. Case presentation A 65-year-old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function. Conclusion Potential fatal complications caused by catheter or wire entrapment in the right-sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH. more...

Evaluation of left ventricular devices is becoming increasingly important as the implantation of these devices increases. Cardiac computed tomography angiography (CCTA) has many potential advantages compared with plain radiographs and echocardiography to troubleshoot these devices and potentially help guide therapy. Heart failure (HF) remains a deadly, progressive disease with substantive and increasing morbidity, mortality, cost, and prevalence. Use of left ventricular assist devices (LVAD) as treatment for refractory HF has been steadily rising during the last decade. Seventy-four LVAD recipients who met an indication for CCTA were referred for scanning at our center for a total of 94 studies. All recipients had received a Heart Mate II (Thoratec, Pleasanton, CA) LVAD at a previous time. All patients underwent gated CCTA on a 320 row multidetector scanner (Aquilion ONE, Toshiba Medical Systems, Irvine, California, USA). Images were then reconstructed and analysis was performed using multiple oblique views. All 94 studies had technically good images. In survival analysis, 43 of the 74 LVAD patients had normal CCTA findings while 31 had abnormal CCTA results. The 6, 12, and 18 months survival was 93%, 79%, and 77% in those with normal results and 71%, 61%, and 61%, respectively, in the abnormal CCTA findings. Overall survival was statistically significant in when comparing the two groups (p = 0.003). Cardiac computed tomography angiography may be used as an aid for risk stratification and a potential indicator of short- and long-term prognosis in LVAD patients. more...

Purpose Dosing of Anti-thymocyte globulin therapy (ATG), used in the prevention and treatment of rejection, is optimally guided by CD3 levels. The purpose of this study was to establish the reliability of using Absolute Lymphocyte Count (ALC) as a substitute for CD3 given its ready availability and low cost. Methods A retrospective review was conducted of heart transplant recipients from 9/2014 to 2/2019 who received ATG and had a CD3 count with corresponding ALC. The Pearson correlation coefficient was used to examine the correlation between ALC and CD3. Validity tests and the Youden Index were performed to identify an appropriate range for an ALC cutoff that would provide the greatest degree of validity of ALC as an appropriate surrogate for a CD3 cutoff of 100 cells/mm3. Results 332 paired samples were collected. Analysis demonstrated correlation between ALC and CD3 count. The Pearson correlation coefficient was 0.45 (R-Square 0.23), p less than 0.0001. Validity testing of ALC of 200 cells/mm3 against CD3 counts 100 cells/mm3 showed sensitivity 0.635 (160/252), specificity 0.875 (70/80), positive predictive value (PV) 0.941 (160/170), and negative PV 0.432 (70/162). Based on the Youden index, the zone for the optimal cutoff points ranged from 100 to 200 cells (Figure 1). AUC for the ROC analysis was 0.81 (Figure 2). Conclusion This study suggests that ALC may have validity as a selective substitute for CD3 monitoring in patients receiving ATG. Further studies of this novel approach are warranted. more...

Solid organ transplantation is an effective treatment for patients with end-stage organ disease. The prevalence of cardiovascular diseases (CVD) has increased in recipients. CVD remains a leading cause of mortality among recipients with functioning grafts. The pathophysiology of CVD recipients is a complex interplay between preexisting risk factors, metabolic sequelae of immunosuppressive agents, infection, and rejection. Risk modification must be weighed against the risk of mortality owing to rejection or infection. Aggressive risk stratification and modification before and after transplantation and tailoring immunosuppressive regimens are essential to prevent complications and improve short-term and long-term mortality and graft survival. more...

Purpose Use of left ventricular assist device (LVAD) therapy is proven to be effective for the treatment of advanced heart failure. Heart transplant is not an option for patients with advanced age, frequently defined as age 70 or greater. The purpose of this study was to compare the survival rate post LVAD implantation for between patients who were less than 70 years or 70 years or older. Methods A retrospective review of patients implanted with an LVAD between March 2008 and February 2019 was conducted. 413 patients who received a continuous flow LVAD were included in the study. Patients were stratified by ≥70 years of age (n= 60) and Results Table 1 contains baseline demographics and survival. There was no statistically significant survival difference between the two groups. Survival in the 18-69 group vs the ≥70 group at 6 months was 87.8% vs 83.3% (p 0.302). 1 year survival was 81.6% and 83.3% (p 0.793), and 2 year survival was 70.3% and 71.7% (p 0.629), respectively. Figure 1 shows the Kaplan-Meier curves for each group. Conclusion LVAD recipients who were ≥70 years of age did not experience increased mortality compared to LVAD recipients who were 18-69 years of age. Patients should not be declined for LVAD therapy based on chronological age alone. more...

Purpose Right ventricular (RV) failure is associated with poor outcomes after left ventricular assist device (LVAD) placement. This can be treated with a temporary right ventricular assist device (RVAD), which ideally should be placed before the development of multisystem organ failure. The purpose of this study was to determine if there is any outcome difference in patients who underwent early or concurrent RVAD as compared to delayed RVAD implantation. Methods Via retrospective chart review, 32 patients who received temporary RVAD (30 CentriMag and 2 Protek Duo) were identified between 1/2013 and 7/2018. Subjects were divided into two groups as concurrent RVAD placement (defined as RVAD at the time of LVAD implantation) versus delayed RVAD placement (defined as an RVAD placed at any time after leaving the operating room for the LVAD implant). Survival, ICU and total length of stay (LOS), and total number of days on RVAD were compared utilizing Chi-square and two tailed t-test. Results Patients in the concurrent RVAD group had higher preoperative central venous pressure (p = 0.037). Survival rate at three months (χ² = 6.647, p 0.010) and one year (χ² = 3.983, p 0.046) was statistically significantly better among patients who received concurrent LVAD. ICU LOS, total hospital LOS, and number of days on RVAD were not statistically significant between the two groups. Conclusion Concurrent placement of a temporary RVAD for patients with RV failure at the time of LVAD implantation improves short- and long-term survival post LVAD implantation as compared to a delayed RVAD approach. more...

Purpose Strokes and infection are two potential complications in patients with left ventricular assist devices (LVADs). The combination of infection and stroke is particularly concerning for LVAD recipients and may be interrelated. We evaluated the impact of concomitant bacteremia in LVAD patients who suffered a stroke. Methods All patients implanted with a continuous flow LVAD at our center from 2009 to 2019 who experienced a stroke post LVAD implantation were included. Stroke was defined by clinical signs of stroke and confirmed by neuroimaging. We then assessed the number of hemorrhagic (HCVA) and ischemic (ICVA) strokes. All patients with bacteremia prior to stroke were included in the analysis. Kaplan Meier survival curves were used to evaluate survival. Results A total of 117 LVAD patients with strokes were included, of those 62 had ICVA (53%) and 55 had HCVA (47%). Forty-three of these patients (37.6%) had an episode of bacteremia prior to their stroke, of whom 14 were in the ICVA group and 29 in the HCVA group. Figure 1 demonstrates that patients with strokes and concomitant bacteremia carry significantly increased risk of mortality over two years (p=0.046) compared to patients with strokes without bacteremia. Of the observed deaths, 8 out of 14 (57%) in the ICVA group died, while 19 of the 29 (66%) in HCVA died within a 2 year period. Conclusion LVAD patients with bacteremia who have a stroke carry significantly worse 2 year survival when compared to those who do not have bacteremia at the time of their stroke. Patients with bacteremia and concomitant stroke may benefit from further investigation to create strategies to reduce the probability of subsequent mortality. more...

Purpose Left Ventricular Assist Devices (LVADs) have successfully been established as a treatment for advanced heart failure. However, many areas of the country do not have direct availability to LVAD programs. Therefore, building patient care networks is essential to successful outcomes for patients living in rural areas. The goal of this study is to analyze the effect of distance from an LVAD implanting center on patient survival. Methods We retrospectively analyzed all patients at our center who received HeartMate II LVADs as both “bridge-to transplant” and “destination therapy” from 2008 to 2016, 185 patients were included. Patients were excluded if they: (1) received a transplant, (2) had their LVAD explanted, (3) were transferred to another hospital for care, or (4) failed to reach outpatient status. Patients were then divided into 3 groups based on distance (miles) from their home to the implanting center. Group 1: less than 29, Group 2: between 30 and 120, and Group 3: greater than 120 miles from our implanting center. We then compared survival outcomes at 3, 6, 12, 18, and 24 months on LVAD support. Logistic regression analysis was used to determine statistical significance, p valve Results See Table Conclusion Residential distance from implanting LVAD medical center did not have an adverse effect on the survival outcomes. This supports the notion that a well designed patient care network can provide effective care for patient living remotely from the implanting center. more...

Purpose There is limited data in the literature defining criteria for bridging advanced cardiogenic shock (ACS) patients supported by veno-arterial (VA) ECMO to durable Mechanical Circulatory Support (MCS). We evaluated our screening process on outcomes for all patients at our center bridged from VA ECMO to durable MCS. Methods From September 2014 to October 2018, 153 patients received VA ECMO for treatment of ACS greater than 24 hours. Care was withdrawn from 64 (42%) patients, 68 (44%) were successfully weaned from VA ECMO, 4 (3%) were bridged to extracorporeal biventricular assist device, and 14 (9%) were bridged to durable MCS, which were included in this retrospective analysis. All 14 patients accepted for durable support implantation underwent a multidisciplinary screening process. Criteria for candidacy included 1) acceptable end organ function, 2) extubation, 3) negative infection surveillance, and 4) neurologically intact. To compare clinical status pre VA ECMO and pre MCS, end organ function was assessed by Sequential Organ Failure Assessment (SOFA) score, lactic acid, renal, and hepatic markers. Outcomes assessed included survival and post durable MCS implant hospital length of stay (HLOS). Results As of October 2018, 11 of the 14 patients bridged to durable MCS are still alive (79%). Mean duration of support on VA ECMO before transition was 11 days ± 5 (4-22), and a mean of 343 days ± 312 (28-1041) on durable MCS. The mean post MCS HLOS was 29 days ± 20 (9-90). Of the 14 patients, 11 were transitioned to LVAD. One patient was explanted due to cardiac recovery, 1 received a heart transplant, 1 deceased, and 8 are still on LVAD support. In 2 patients, temporary RVAD support was required post LVAD. Three of the 14 were bridged to Total Artificial Heart, of which 2 have died. Conclusion Applying a thorough screening process to INTERMACS level 1 patients bridged with VA ECMO to durable MCS is a highly successful strategy and yields excellent long-term survival. Our screening process might be a useful guide to bridge select VA ECMO patients to cardiac transplantation. more...

Heart transplant remains the gold standard therapy for patients with end stage heart disease and offers improved survival and quality of life. Significant progress has been achieved in improving one year mortality after heart transplantation. Nonetheless, long-term graft survival has not changed significantly over the past few decades. Long term survival of heart transplant recipients is limited by chronic rejection, cardiac allograft vasculopathy (CAV), and malignancy. CAV is a major contributor for graft failure and mortality after the first year of in heart transplant recipients. CAV is a proliferative vasculopathy characterized by diffuse myointimal hyperplasia and progressive narrowing of the graft vessels. Both immune dependent and independent factors have been shown to contribute to the pathogenesis of CAV. Understanding these risk factors is essential in developing preventative and therapeutic strategies. Angiography with Intravascular ultrasound (IVUS) has become the key diagnostic tool in the early detection of CAV as well as prognostication. Echocardiographic assessment of allograft function in conjunction with coronary angiographic findings are used in assessing the severity of CAV. Adjustment of immunosuppression and statins remain the initial steps in the management of CAV. Retransplantation is the definitive treatment for severe CAV, however, the paucity of organs along with increased mortality associated with retransplantation makes it a less desirable option. Although significant progress has been achieved in the understanding of pathogenesis, risk factors for CAV and plaque morphology, knowledge gaps still persists and further research is warranted. Progress is still needed in developing diagnostic modalities that could detect early CAV, as well as preventative and therapeutic strategies that will facilitate graft tolerance and immune modulation. This review focuses on summarizing the pathogenesis and risk factors for CAV. more...