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Heart failure-related cardiogenic shock (HF-CS) remains an understudied distinct clinical entity.The authors sought to profile a large cohort of patients with HF-CS focused on practical application of the Society of Cardiovascular AngiographyCardiovascular Interventions (SCAI) staging system to define baseline and maximal shock severity, in-hospital management with acute mechanical circulatory support (AMCS), and clinical outcomes.The Cardiogenic Shock Working Group registry includes patients with CS, regardless of etiology, from 17 clinical sites enrolled between 2016 and 2020. Patients with HF-CS (non-acute myocardial infarction) were analyzed and classified based on clinical presentation, outcomes at discharge, and shock severity defined by SCAI stages.A total of 1,767 patients with HF-CS were included, of whom 349 (19.8%) had de novo HF-CS (DNHF-CS). Patients were more likely to present in SCAI stage C or D and achieve maximum SCAI stage D. Patients with DNHF-CS were more likely to experience in-hospital death and in- and out-of-hospital cardiac arrest, and they escalated more rapidly to a maximum achieved SCAI stage, compared to patients with acute-on-chronic HF-CS. In-hospital cardiac arrest was associated with greater in-hospital death regardless of clinical presentation (de novo: 63% vs 21%; acute-on-chronic HF-CS: 65% vs 17%; both P 0.001). Forty-five percent of HF-CS patients were exposed to at least 1 AMCS device throughout hospitalization.In a large contemporary HF-CS cohort, we identified a greater incidence of in-hospital death and cardiac arrest as well as a more rapid escalation to maximum SCAI stage severity among DNHF-CS. AMCS use in HF-CS was common, with significant heterogeneity among device types. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483).

On June 3, 2021 Medtronic, Inc announced discontinuation of the HVAD left ventricular assist device. The purpose of this analysis was to provide summary data on surgical risks of HVAD to HeartMate 3 exchange and compare survival after HVAD to HeartMate 3 exchange to survival after primary HVAD implantation.Three cohorts within The Society of Thoracic Surgeons Intermacs database were identified: primary HVAD implant cohort (January 2017 to March 2021, n = 3797), HVAD to HeartMate 3 exchange cohort (December 2017 to March 2021, n = 45), and HVAD to HVAD exchange cohort (January 2017 to March 2021, n = 234). Mortality after HVAD to HeartMate 3 exchange was modeled and compared with the constant hazard phase for risk of mortality while on continued HVAD support. As a secondary analysis outcomes and survival were compared between patients who underwent HVAD to HeartMate 3 and HVAD to HVAD exchange.HVAD to HeartMate 3 exchange was associated with significantly reduced survival compared with survival while remaining on HVAD support (6 months after exchange, 73.8% [70% confidence interval, 68.6-77.8] vs 79.0% [70% confidence interval, 78.3-79] for continued HVAD support). Compared with HVAD to HVAD exchange, survival was higher after replacement with HeartMate 3 (1 year: 85.9% [70% confidence interval, 79.5-90.5] vs 66.6% [70% confidence interval, 63.0-70.0], P = .009).Compared with continued support on HVAD, an exchange to HeartMate 3 was found to be associated with a significant increase in mortality. For patients who required pump exchange on HVAD support, exchange to HeartMate 3 demonstrated superior survival. Currently there is insufficient evidence to support elective exchange from an HVAD to HeartMate 3.

BACKGROUND Measuring an accurate blood pressure (BP) in ambulatory patients is critical for therapeutic decisions. An accurate noninvasive device that measures BP continuously could provide a more comprehensive assessment of BP. The aim of this study was to determine whether the LiveOne device, a cuffless wristband that provides continuous BP measurements, is accurate in comparison to an invasive arterial line (A-line). METHODS We enrolled hospitalized patients and healthy volunteers in this multicenter study. All patients had an invasive A-line. Waveforms were simultaneously downloaded from the A-line and LiveOne device. The primary outcome was the correlation between the LiveOne device and the A-line for systolic BP (SBP) and diastolic BP (DBP). RESULTS Thirty-four patients with 233 measurement periods were included. Mean age was 60.7 ± 15.2 years, and 15 (44%) were female. The correlation for SBP was 0.91 and for DBP was 0.85. The mean band error was 0.0 ± 6.9 mm Hg for SBP and 1.2 ± 5.7 mm Hg for DBP. The mean absolute error was 8.2 ± 5.8 mm Hg for SBP and 6.4 ± 3.9 mm Hg for DBP. For SBP, 98% of LiveOne measurements were within 15 mm Hg and for DBP, 92% of LiveOne measurements were within 10 mm Hg. CONCLUSIONS The LiveOne device provides continuous, noninvasive BP measurements that are accurate in comparison to A-line measurements. The portability and unobtrusive nature of this device and the ability to provide continuous BP measurements may offer advantages over currently available BP monitors. CLINICAL TRIALS REGISTRATION Trial Number NCT03919136.

Despite increasing prevalence in critical care units, cardiogenic shock related to HF (HF-CS) is incompletely understood and distinct from acute myocardial infarction related CS. This review highlights the pathophysiology, evaluation, and contemporary management of HF-CS.

Background Understanding the prognostic impact of right ventricular dysfunction (RVD) in cardiogenic shock (CS) is a key step toward rational diagnostic and treatment algorithms and improved outcomes. Using a large multicenter registry, we assessed (1) the association between hemodynamic markers of RVD and in-hospital mortality, (2) the predictive value of invasive hemodynamic assessment incorporating RV evaluation, and (3) the impact of RVD severity on survival in CS. Methods and Results Inpatients with CS owing to acute myocardial infarction (AMI) or heart failure (HF) between 2016 and 2019 were included. RV parameters (right atrial pressure, right atrial/pulmonary capillary wedge pressure [RA/PCWP], pulmonary artery pulsatility index [PAPI], and right ventricular stroke work index [RVSWI]) were assessed between survivors and nonsurvivors, and between etiology and SCAI stage subcohorts. Multivariable logistic regression analysis determined hemodynamic predictors of in-hospital mortality; the resulting models were compared with SCAI staging alone. Nonsurvivors had a significantly higher right atrial pressure and RA/PCWP and lower PAPI and RVSWI than survivors, consistent with more severe RVD. Compared with AMI, patients with HF had a significantly lower RA/PCWP (0.58 vs 0.66, P = .001) and a higher PAPI (2.71 vs 1.78, P Conclusions RVD is associated with poor outcomes in CS, with key differences across etiology and shock severity. Further studies are needed to assess the usefulness of RVD assessment in guiding therapy.

Intracranial hemorrhage (ICH) is a devastating complication for patients with ventricular assist devices (VADs). The safety of emergent anticoagulation reversal with four-factor prothrombin complex concentrate (PCC) and optimal timing of anticoagulation resumption are not clear. In addition, lactate dehydrogenase (LDH) is used as a biomarker for thromboembolic risk, but its utility in guiding anticoagulation management after reversal with PCC has not be described. We retrospectively reviewed a consecutive series of patients with VADs presenting with ICH between 2014 and 2020 who received four-factor PCC for rapid anticoagulation reversal. We collected the timing of PCC administration, timing of resumption of anticoagulation, survival, occurrence of thromboembolic events, and LDH levels throughout hospitalization. We identified 16 ICH events in 14 patients with VADs treated with rapid anticoagulation reversal using four-factor PCC (11 intraparenchymal, 4 subdural, 1 subarachnoid hemorrhage). PCC was administered at a mean of 3.3 ± 0.3 h after imaging diagnosis of ICH. Overall mortality was 63%. Survivors had higher presenting Glasgow Coma Scale (median 15, interquartile range [IQR] 15–15 versus 14, IQR 8–14.7, P = 0.041). In all six instances where the patient survived, anticoagulation was resumed on average 9.16 ± 1.62 days after reversal. There were no thromboembolic events prior to resumption of anticoagulation. Three events occurred after anticoagulation resumption and within 3 months of reversal: VAD thrombosis in a patient with thrombosis at the time of reversal, ischemic stroke, and readmission for elevated LDH in the setting of subtherapeutic international normalized ratio. Our limited series found no thromboembolic complications immediately following anticoagulation reversal with PCC prior to resumption of anticoagulation. LDH trends may be useful to monitor thromboembolic risk after reversal.

Aims Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described. Methods and results This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all‐cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow‐up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02–1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05–1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08–1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04–1.12). The most significant predictor of perioperative blood product exposure was a lower pre‐implant haemoglobin. Conclusions Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all‐cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre‐implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.

Standard evaluation and management of the patient with suspected or proven cardiovascular complications of coronavirus disease-2019 (COVID-19), the disease caused by severe acute respiratory syndrome related-coronavirus-2 (SARS-CoV-2), is challenging. Routine history, physical examination, laboratory testing, electrocardiography, and plain x-ray imaging may often suffice for such patients, but given overlap between COVID-19 and typical cardiovascular diagnoses such as heart failure and acute myocardial infarction, need frequently arises for advanced imaging techniques to assist in differential diagnosis and management. This document provides guidance in several common scenarios among patients with confirmed or suspected COVID-19 infection and possible cardiovascular involvement, including chest discomfort with electrocardiographic changes, acute hemodynamic instability, newly recognized left ventricular dysfunction, as well as imaging during the subacute/chronic phase of COVID-19. For each, the authors consider the role of biomarker testing to guide imaging decision-making, provide differential diagnostic considerations, and offer general suggestions regarding application of various advanced imaging techniques.

Despite increasing prevalence in critical care units, cardiogenic shock related to HF (HF-CS) is incompletely understood and distinct from acute myocardial infarction related CS. This review highlights the pathophysiology, evaluation, and contemporary management of HF-CS.

Background COVID-19 continues to inflict significant morbidity and mortality, particularly on patients with preexisting health conditions. The clinical course, outcomes, and significance of immunosuppression regimen in heart transplant recipients with COVID-19 remains unclear. Methods We included the first 99 heart transplant recipients at participating centers with COVID-19 and followed patients until resolution. We collected baseline information, symptoms, laboratory studies, vital signs, and outcomes for included patients. The association of immunosuppression regimens at baseline with severe disease were compared using logistic regression , adjusting for age and time since transplant. Results The median age was 60 years, 25% were female, and 44% were white. The median time post-transplant to infection was 5.6 years. Overall, 15% died, 64% required hospital admission, and 7% remained asymptomatic. During the course of illness, only 57% of patients had a fever, and gastrointestinal symptoms were common. Tachypnea , oxygen requirement, elevated creatinine and inflammatory markers were predictive of severe course. Age ≥ 60 was associated with higher risk of death and the use of the combination of calcineurin inhibitor , antimetabolite , and prednisone was associated with more severe disease compared to the combination of calcineurin inhibitor and antimetabolite alone (adjusted OR = 7.3, 95% CI 1.8-36.2). Among hospitalized patients, 30% were treated for secondary infection, acute kidney injury was common and 17% required new renal replacement therapy . Conclusions We present the largest study to date of heart transplant patients with COVID-19 showing common atypical presentations and a high case fatality rate of 24% among hospitalized patients and 16% among symptomatic patients.

Background: Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. Methods: Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. Results: Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups ( P 1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA= Conclusions: Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.

Background: Advanced age is associated with poor outcomes in cardiovascular emergencies. We sought to determine the association of age, use of support devices and shock severity on mortality in cardiogenic shock (CS).Methods: Characteristics and outcomes in CS patients included in the Cardiogenic Shock Work Group (CSWG) registry from 8 US sites between 2016 and 2019 were retrospectively reviewed. Patients were subdivided by age into quintiles and Society for Cardiovascular Angiography & Interventions (SCAI) shock severity.Results: We reviewed 1,412 CS patients with a mean age of 59.9 ± 14.8 years, including 273 patients > 73 years of age. Older patients had significantly higher comorbidity burden including diabetes, hypertension and coronary artery disease. Veno-arterial extracorporeal membrane oxygenation was used in 332 (23%) patients, Impella in 410 (29%) and intra-aortic balloon pump in 770 (54%) patients. Overall in-hospital survival was 69%, which incrementally decreased with advancing age (p < 0.001). Higher age was associated with higher mortality across all SCAI stages (p = 0.003 for SCAI stage C; p < 0.001 for SCAI stage D; p = 0.005 for SCAI stage E), regardless of etiology (p < 0.001).Conclusion: Increasing age is associated with higher in-hospital mortality in CS across all stages of shock severity. Hence, in addition to other comorbidities, increasing age should be prioritized during patient selection for device support in CS.

Standard evaluation and management of the patient with suspected or proven cardiovascular complications of COVID-19, the disease caused by severe acute respiratory syndrome–related coronavirus-2 (SARS-CoV-2), is challenging. Routine history, physical examination, laboratory testing, electrocardiography and plain x-ray imaging may often suffice for such patients but given overlap between COVID-19 and typical cardiovascular diagnoses such as heart failure and acute myocardial infarction, need frequently arises for advanced imaging techniques to assist in differential diagnosis and management. This document provides guidance in several common scenarios among patients with confirmed or suspected COVID-19 infection and possible cardiovascular involvement, including chest discomfort with electrocardiographic changes, acute hemodynamic instability, newly-recognized left ventricular dysfunction, as well as imaging during the sub-acute/chronic phase of COVID-19. For each, we consider the role of biomarker testing to guide imaging decision-making, provide differential diagnostic considerations, and offer general suggestions regarding application of various advanced imaging techniques. Condensed Abstract Standard evaluation and management of the patient with suspected or proven cardiovascular complications due to COVID-19 infection often requires advanced imaging techniques to assist in differential diagnosis and management. This document provides guidance in several common scenarios among patients with COVID-19 infection and for each provides advice regarding the role of biomarker testing to guide imaging decision-making, provides differential diagnostic considerations, and offers general suggestions regarding application of various advanced imaging techniques.

Cardiovascular magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) has recently been examined in patients after orthotopic heart transplantation (OHT); however, the data is limited to relatively small cohorts [(1–3)][1]. The objective of this study was to examine natural

Purpose The purpose of this study is to compare short term results of patients undergoing a third generation (HVAD™or HeartMate™ 3) Left Ventricular Assist Device (LVAD) implantation through either minimally-invasive, thoracotomy approach or standard median sternotomy. Methods We prospectively collected data on all patients at our institution that received an LVAD from September 2008 to February 2020. Surgical approach was decided by the implanting surgeon. We used 1:1 propensity score (PS) matching to compare the sternotomy versus thoracotomy groups. A logistic regression model based on 19 explanatory variables was used to estimate the propensity score. Overall survival post-implantation was summarized using Kaplan-Meier curves and compared using the log-rank test. Results A total of 272 patients were included, of whom 194 had sternotomy and 78 had either left thoracotomy and hemi-sternotomy or bilateral thoracotomies. Using PS matching, 128 (64/64) patients were selected. Demographics and operative characteristics were well balanced between groups. Overall, there was a trend towards better survival in thoracotomy group (33.1% vs 66.4%, p=0.06) at 5 years, but higher stroke rate (11% in sternotomy group vs 21% in thoracotomy group, p = 0.035). Following PS-matching, however, there was no difference in early or late mortality (Graph 1) but there was a higher rate of pump exchange in the thoracotomy group (2% vs 9%, p = 0.052). There was no difference in perioperative stroke rates (sternotomy 6% vs thoracotomy 9%), extubation time (2.5 days vs 2.5 days), right ventricular failure (13% vs 14%), renal failure (8% vs 5%) or hospital readmissions (81% vs 88%). Conclusion Minimally invasive LVAD implantation is feasible and safe in the current LVAD era. In a PS matched analysis, patients in the minimally invasive group displayed lower overall mortality, but without reaching statistical significance. Adverse events were similar in both groups.

Purpose Advanced age is associated with poor outcomes in cardiovascular emergencies. We sought to determine the association of age, use of temporary mechanical circulatory support (t-MCS) devices and shock severity on inpatient mortality in cardiogenic shock (CS). Methods Outcomes in CS patients included in Cardiogenic Shock Work Group (CSWG) registry from 8 US sites between 2016 - 2019 were retrospectively reviewed. Patients were subdivided by age into quintiles as well as by Society for Cardiovascular Angiography & Interventions (SCAI) shock severity. Etiology of CS, comorbidities, t-MCS use, labs and hemodynamics were reviewed across the quintiles in each SCAI stage. Results We reviewed 1,412 CS patients with a mean age of 59.9±14.8 years, including 27.5% females and 273 patients > 73 years of age. Acute MI was the etiology of CS in nearly 40% of patients. Older patients had significantly higher comorbidity burden including diabetes, hypertension and coronary artery disease. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was used in 332 (23%) patients, Impella in 410 (29%) and intra-aortic balloon pump (IABP) in 770 (54%) patients. Overall in-hospital survival was 69%, which incrementally decreased with advancing age (p Conclusion Increasing age is associated with higher in-hospital mortality in cardiogenic shock across all stages of shock severity. Patient selection for use of t-MCS should focus on multiple factors, with prioritization of advanced age and early establishment of goals of care.

Purpose Characteristics and outcomes of heart transplant (HT) recipients who contract coronavirus (SARS-CoV-2) have been poorly described. The current study was undertaken to better understand the risk obesity may pose in this patient population Methods A prospectively-maintained Trans-CoV-VAD Registry containing HT recipients at 11 participating institutions who presented with SARS-CoV-2 were reviewed. Presenting characteristics, hospitalization rates, ventilator & intensive care unit usage, and mortality were queried. Patients were grouped by body mass index (BMI) into obese (BMI≥30 k/m2) and non-obese cohorts (BMI0.10) Conclusion Acute presentations of SARS-CoV-2 amongst HT recipients carry significantly higher mortality over the general population. Obesity appears to impact presenting symptoms and secondary infections, but does not strongly impact ICU requirements or mortality

Background Right ventricular (RV) adaptation to afterload is crucial for patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. We hypothesized that stratifying patients by RV pulsatile load, using pulmonary arterial compliance (PAC), and RV response to load, using the ratio of central venous to pulmonary capillary wedge pressure (CVP:PCWP), would identify patients at high risk for early right heart failure (RHF) and 6-month mortality after cf-LVAD. Methods During the period from January 2008 to June 2014, we identified 151 patients at our center with complete hemodynamics prior to cf-LVAD. Pulsatile load was estimated using PAC indexed to body surface area (BSA), according to the formula: indexed PAC (PACi) = [SV / (PA systolic – PA diastolic )] / BSA, where SV is stroke volume and PA is pulmonary artery. Patients were divided into 4 hemodynamic groups by PACi and CVP:PCWP. RHF was defined as the need for unplanned RVAD, inotropic support ≥14 days or death due to RHF within 14 days. Risk factors for RHF and 6-month mortality were examined using logistic regression and Cox proportional hazards modeling. Results Sixty-one patients (40.4%) developed RHF and 34 patients (22.5%) died within 6 months. Patients with RHF had lower PACi (0.92 vs 1.17 ml/mm Hg/m 2 , p=0.008) and higher CVP:PCWP (0.48 vs 0.37, p=0.001). Higher PACi was associated with reduced risk of RHF (adjusted odds ratio [adj-OR] 0.61, 95% confidence interval [CI] 0.39 to 0.94, p=0.025) and low PACi with increased risk of 6-month mortality (adjusted hazard ratio [adj-HR] 3.18, 95% CI 1.40 to 7.25, p=0.006). Compared to patients with low load (high PACi) and adequate right heart response to load (low CVP:PCWP), patients with low PACi and high CVP:PCWP had an increased risk of RHF (OR 4.74, 95% CI 1.23 to 18.24, p=0.02) and 6-month mortality (HR 8.68, 95% CI 2.79 to 26.99, p Conclusions A hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.

Purpose Heart transplantation candidates are often bridged to transplantation with medical therapy (MT) or mechanical circulatory support (MCS). Recent changes were made in the UNOS adult heart allocation system, partly based on bridging strategy, and potential effects remain uncertain. We compared outcomes of patients bridged to OHT with durable VAD (dVAD), intra-aortic balloon pump (IABP), and MT prior to the new allocation system. Methods A retrospective review was performed on 513 consecutive patients listed for OHT between April 2004 and December 2018. Patients were excluded if bridged with extracorporeal ventricular assist devices or multiple concomitant MCS devices. Pre-, intra-, and post-operative characteristics were compared between the BTT strategies. Continuous variables are expressed as mean ± standard deviation or median (Q1-Q3) while categorical variables are expressed as number (%). Results A total of 501 patients were included (age 54.5(42.5-62.0) years, 104(30%) female). Of these, 348(69.5%) were transplanted (dVAD 175(50.3%), IABP 69(19.8%), and 104(29.9%) MT). Overall, 30-day mortality was 4% and 2-year mortality was 11%. dVAD had longer CPB minutes (dVAD 155.9±42.9, IABP 145.3±65.7, MT 139.7±52.6, p=0.031), but donor ischemic minutes were similar (dVAD 179.9±44.4, IABP 188.2±49.1, MT 179.9±53.7, p=0.44). IABP patients had longer overall LOS (IABP 55.0(31.0-90.0) days, dVAD 16.0(11.0-26.0) days, MT 40.0(20.5-75.0) days, p Conclusion In this study, OHT outcomes were similar between the three bridging strategies, but overall LOS was higher in the IABP group. Further study is needed to determine the long-term effects of the new UNOS allocation system in regards to waiting-time, death on waiting list, transplant survival and cost-effectiveness of these bridging strategies.

The purpose of this study was to examine prognostic value of T1- and T2-mapping techniques in heart transplant patients.Myocardial characterization using T2 mapping (evaluation of edema/inflammation) and pre- and post-gadolinium contrast T1 mapping (calculation of extracellular volume fraction [ECV] for assessment of interstitial expansion/fibrosis) are emerging modalities that have been investigated in various cardiomyopathies.A total of 99 heart transplant patients underwent the magnetic resonance imaging (MRI) scans including T1- (n = 90) and T2-mapping (n = 79) techniques. Relevant clinical characteristics, MRI parameters including late gadolinium enhancement (LGE), and invasive hemodynamics were collected. Median clinical follow-up duration after the baseline scan was 2.4 to 3.5 years. Clinical outcomes include cardiac events (cardiac death, myocardial infarction, coronary revascularization, and heart failure hospitalization), noncardiac death and noncardiac hospitalization.Overall, the global native T1, postcontrast T1, ECV, and T2 were 1,030 ± 56 ms, 458 ± 84 ms, 27 ± 4% and 50 ± 4 ms, respectively. Top-tercile-range ECV (ECV29%) independently predicted adverse clinical outcomes compared with bottom-tercile-range ECV (ECV 25%) (hazard ratio [HR]: 2.87; 95% confidence interval [CI]: 1.07 to 7.68; p = 0.04) in a multivariable model with left ventricular end-systolic volume and LGE. Higher T2 (T2 ≥50.2 ms) independently predicted adverse clinical outcomes (HR: 3.01; 95% CI: 1.39 to 6.54; p = 0.005) after adjustment for left ventricular ejection fraction, left ventricular end-systolic volume, and LGE. Additionally, higher T2 (T2 ≥50.2 ms) also independently predicted cardiac events (HR: 4.92; CI: 1.60 to 15.14; p = 0.005) in a multivariable model with left ventricular ejection fraction.MRI-derived myocardial ECV and T2 mapping in heart transplant patients were independently associated with cardiac and noncardiac outcomes. Our findings highlight the need for larger prospective studies.

Background: Hemodynamic ramp (HR) tests can guide the optimization of left ventricular assist device (LVAD) speed and direct medical therapy. We investigated the effects of HR-guided LVAD management. Methods and Results: This prospective, multicenter, randomized, pilot study compared outcomes in LVAD patients using an HR-guided (HR group) versus a standard transthoracic echocardiography-guided (control group) management strategy. Patients were enrolled and randomized 1 to 3 months post-HVAD implantation and followed for 6 months. Twenty-two patients (57±10 years, 73% male) were randomized to the HR group and 19 patients (51±13 years, 63% male) to the control group. HR group patients had double the number of LVAD speed changes (1.68 versus 0.84 changes/patient, P =0.09 with an incidence rate ratio 2.0, 95% CI, 0.9–4.7) with twice the magnitude of rotations per minute changes (130 versus 60 rotations per minute/patient, P =0.004) during the study. The HR group also had 2-fold greater heart failure medication changes (4.32 versus 2.53 changes/patient, P =0.072, incidence rate ratio 1.7 with 95% CI, 0.8–3.5) predominantly because of changes in diuretic dose (40 versus 0 mg/patient, P P =0.087; hazard ratio, 0.46 with 95% CI, 0.2–1.2), with numerically but not statistically lower events per patient-year ( P =0.084). There were no significant differences in the 6-minute walk or Kansas City Cardiomyopathy Questionnaire tests at 6 months. Conclusions: In this randomized pilot study of LVAD patient management we demonstrated the feasibility of standardized HR testing at multiple institutions and that a strategy guided by hemodynamics was associated with more LVAD speed and medication adjustments and a nonsignificant reduction in adverse events. A pivotal study to demonstrate the clinical benefit of HR testing is warranted. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03021239.

Purpose Cardiogenic shock (CS) is a heterogeneous syndrome that represents an acute and fulminant form of heart failure (HF). We (1) employed machine learning (ML) to identify distinct CS phenotypes which could help define treatment algorithms based on individual risk and (2) tested the correlation of the SCAI staging system. Methods We included data from 1957 CS patients from 2 cohorts: CSWG Registry, further grouped for myocardial infarction (CSWG-MI, n=408) and acute on chronic HF (CSWG-HF, n=480); and the Danish Retroshock Registry containing MI patients (DRR, n=1069). Independent consensus k means clustering derived phenotypes at admission in the CSWG-MI cohort that were then validated in the CSWG-HF and DRR cohorts. Patients were also categorized by the most severe SCAI stage reached during the hospitalization. Results The ML algorithms revealed 3 distinct clusters that we designated: ‘non-congested (I)’, ‘cardio-renal (II)’ and ‘cardio-metabolic (III)’. In-hospital mortality was 21% vs 29% vs 10%, 42% vs 46% vs 32%, and 55% vs 57% vs 54% among the CSWG-MI vs DDR vs CSWG-HF for Clusters I, II and III, respectively. Despite baseline differences among the overall cohorts, clusters presented similarly across the 3 cohorts. The risk of escalating to stage D or E shock was lowest in Cluster I and highest in Cluster III for both CS-MI and CS-HF patients. Within each phenotype, the SCAI staging (C-E) further stratified mortality (fig). Conclusion Using ML, we derived and externally validated 3 distinct CS phenotypes. SCAI stages and CSWG CS phenotypes identify patients at risk for in-hospital mortality.

Purpose Infection with the Coronavirus (SARS-CoV-2) is particularly dangerous for patients with left ventricular assist devices (LVAD). Obesity is associated with worse outcomes among both LVAD and SARS-CoV-2 patients. This study evaluated the risk of obesity among LVAD patients who contracted SARS-CoV-2. Methods A prospectively maintained Trans-CoV-VAD Registry of LVAD patients from 11 institutions who presented with SARS-CoV-2 was analyzed. Two cohorts, 1) non-obese and 2) obese, were formed utilizing a body mass index (BMI) cutoff of 30 k/m2. Presenting characteristics, hospitalization rates, ventilator & intensive care unit usage, and mortality were compared. Chi-squared, Fisher's exact test, Mann-Whitney U-tests and multivariable logistic regression models were utilized. Results Across all centers, 46 LVAD patients contracted SARS-CoV-2 during the study period of whom 19 (41%) were obese. Time from LVAD implantation to infection was 2.4±2.5 years. Age and gender profiles were similar. Non-obese and obese patients had similar presenting symptoms, most commonly cough (52% vs 47%), fever (48% vs 37%), dyspnea (41% vs 47%) and fatigue (41% vs 37%). No difference in rates of hospital (70% vs 63%, p 0.8) and ICU admissions (26% vs 37%, p 0.3) was observed. Hospital (20.0±23.2 vs 17.1±14.2) and ICU length of stay were similar (16.2±26.1 vs. 13.9±13.1 days). Obese patients were more likely to require mechanical ventilation than non-obese patients (7% vs 26%, p0.10). Conclusion Among LVAD patients who contract SARS-CoV-2, obese patients appear to have higher risk of intubation, but did not experience increased ICU requirements or mortality.

Introduction The management of patients with heart failure who contract COVID-19 and those who develop heart failure as a consequence of the disease is challenging. The use of advanced therapies in the form of durable left ventricular assist device or heart transplant in this patient population remains a data free zone. We present, to our knowledge, the first case of durable LVAD implantation in a recovered COVID-19 patient. Case Report A 63-year old, previously healthy, male was admitted to OSH with COVID-19 pneumonia and acute respiratory distress syndrome requiring prolonged mechanical ventilation. This hospitalization was complicated by anterior STEMI, cardiomyopathy with severe LV dysfunction and cardiogenic shock. Due to widespread COVID-19 pandemic, invasive evaluation was deferred and the patient was medically managed. He was then transferred to our institution after re-admission for recurrent cardiogenic shock. Echocardiogram revealed dilated LV cavity (6.3 cm), LVEF 10% and large apical aneurysm. Chest CT showed sequelae of prior COVID-19 with changes suggestive of fibrosis. CMR which showed LV dilatation, severe LV systolic dysfunction, LVEF 7% and large apical aneurysm with evidence of thrombus. A large transmural infarct in the LAD territory without viability was confirmed. Cardiogenic shock was managed with Dobutamine and attempts to wean inotrope resulted in worsening hemodynamic and clinical profile. Axillary IABP was placed to facilitate physical and respiratory rehabilitation. The patient underwent placement of HeartMate™ 3 device as DT and LV aneurysm repair. Post-operative course was uneventful and he was ultimately discharged to acute rehabilitation in stable condition. Summary As the global case rate continues to climb and the threat of an exponential surge of long-term cardiac complications looms in the not so distant future, the use of durable MCS in recovered COVID-19 patients may evolve. This case highlights LVAD as a feasible option in end-stage HF and emphasizes the importance of a multidisciplinary approach in assessing candidacy for advanced HF therapies in post-COVID-19 patients. Continued international collaboration and further study regarding use of MCS will be paramount in optimizing care and outcomes in this growing patient population.

Introduction Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD), however predicting RVF remains challenging. Hypothesis We hypothesized that an analysis of late gadolinium enhancement (LGE) patterns on pre-operative cardiac MRI (cMRI) could identify patients at risk for RVF after LVAD. Methods We analyzed reports for cMRIs performed on patients within one year prior to LVAD at our institution and abstracted LGE patterns using the 17-segment model. Patients were then grouped into clusters by similarities in LGE patterns using an unsupervised machine learning (ML) algorithm of hierarchical agglomerative clustering. Statistical comparison of the resulting clusters was then performed. Results Patients (N=31) were grouped into 3 clusters (Figure) with varying patterns of LGE. Cluster 1 patients (n=16) had no LGE or atypical LGE patterns and were significantly younger (age 42 ± 18) than other clusters (p=0.029). Cluster 2 patients (n=11) had extensive transmural LGE patterns and were more likely to have hypertension (p=0.006) and dyslipidemia (p=0.002) than other groups. Cluster 3 patients (n=4) had some degree of subendocardial LGE but no extensive transmural LGE patterns. No patients in cluster 2 developed RVF after LVAD, while 4 patients (25%) in cluster 1 and 2 patients in cluster 3 (50%) had RVF after LVAD, though the difference between groups did not reach statistical significance due to small number of patients in the cohort overall (p=0.058). Importantly, traditional factors associated with RVF including hemodynamics and echocardiographic/MRI parameters of LV and RV function were not significantly different between clusters. Further, LGE enhancement of the RV myocardium or RV insertion points were not associated with RVF after LVAD. Conclusions Unsupervised ML of LGE patterns on cMRI can identify clusters of patients at risk for RVF. LGE patterns on cMRI may identify patients with non-ischemic (cluster 1) and mixed (cluster 3) etiologies of their heart failure who are at higher risk for developing RVF due to global biventricular myocardial involvement than patients with a truly ischemic etiology of their heart failure (cluster 2). Future research in a larger cohort is needed to confirm this hypothesis. Figure: Dendrogram produced from agglomerative hierarchal clustering of LGE analysis of cardiac MRIs using standardized myocardial segmentation

Background Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation is an important source of morbidity and mortality but is difficult to predict. Right atrial (RA) strain by echocardiography is a novel hemodynamic parameter likely indicative of atrial functional capacity and RV diastolic function. Previous studies have suggested that pre-LVAD RV strain may be a predictor of RVF, but no studies have systematically evaluated the association of RA strain with outcomes after LVAD. We hypothesized that pre-LVAD RA strain may improve the ability to predict RVF after LVAD. Methods We evaluated 31 adults who received continuous flow LVAD between 2008-2018. Peak RA and RV strain values were measured by two-dimensional speckle-tracking echocardiography. RA strain was measured during three phases: reservoir phase (end-diastole to onset of ventricular filling), conduit phase (onset of ventricular filling to onset of atrial contraction), and contractile phase (onset of atrial contraction to end-diastole). RVF was defined as need for inotropic support longer than 14 days, inhaled nitric oxide for longer than 48 hours, or unplanned RVAD. Pearson correlation was used to compare RA and RV strain parameters. Logistic regression was performed for the outcome of RVF. Cox-proportional hazards modelling was performed for the outcome of survival free from transplant or device explant/exchange and hazard ratios were calculated per standard deviation change in regressors. Results Four patients (13%) developed RVF. Median time from echo to LVAD was 31 days. Correlation between RV free wall longitudinal strain (FWLS) and RA reservoir (R=-0.45, p=0.01), conduit (R=-0.30, p=0.10), and contractile strain (R=-0.27, p=0.15) was modest at best. None of the RA strain parameters were associated with RVF. Lower RA reservoir strain (HR 2.26, p=0.003) and RA conduit strain (HR 3.63, p=0.004) were associated with decreased survival free from transplant or device explant/exchange, while RA contractile strain was not. Conclusions In this small cohort, RA strain parameters were not associated with early RVF following LVAD implant. However, RA reservoir strain and RA conduit strain were strongly associated with post LVAD long term survival. RA strain parameters may represent a form of RV diastolic dysfunction that impacts long term outcomes more so than early post operative events. The utility of RA strain parameters for predicting outcomes following LVAD implant deserves further investigation and validation in a larger cohort.

Intro : Solid organ transplantation (SOT) is uncommon in persons living with HIV infection (PLWHIV), as historically, HIV infection was a contraindication to transplantation. However, advancements in antiretroviral therapy (ART) and immunosuppression has led to successful organ transplantation, including heart, in PLWHIV. Here, we present a case of dual-organ transplant in a PLWHIV. Case Report : A 46 yo African American man with Stage D heart failure due to dilated cardiomyopathy, end-stage renal disease (ESRD) on peritoneal dialysis (PD), and longstanding HIV infection (CD4 726 cells/µl, HIV RNA less than 20 copies/mL) presented in cardiogenic shock. On hospital day 5, an axillary intra-aortic balloon pump (IABP) was placed, and the patient was upgraded to a status 2 on the UNOS waitlist for heart-kidney transplantation. On hospital day 33, he received a heart transplant, followed the next day with a deceased donor renal transplant from the same donor. He underwent induction with basiliximab 20 mg, on POD#0 and #4, followed by immunosuppression with mycophenolate mofetil 1g BID, tacrolimus 3mg BID, and prednisone 10mg BID. The pre-transplant ART with dolutegravir/rilpivirine was resumed and he was initiated on standard anti-infective prophylaxis with valganciclovir, atovaquone, and clotrimazole. Hospital course was complicated by hospital-acquired pneumonia and delayed kidney graft function with acute tubular necrosis, initially requiring hemodialysis. There was no evidence of antibody mediated or acute cellular rejection on endomyocardial biopsies. Two months after transplant, the patient was found to have BK viremia, initiated on cidofovir. Four months post-transplant, he was no longer requiring dialysis, had preserved graft function on echocardiogram, and transitioned from atovaquone to sulfamethoxazole-trimethoprim for a lifelong course. Most recent labs notable for sCr 1.66 mg/dL, eGFR 54 mL/min/1.73m2, CD4 890 cells/µl, HIV RNA less than 20 copies/mL, BK virus quantitative PCR 23,875 copies/mL. His current immunosuppressive regimen includes mycophenolate mofetil 250mg BID and tacrolimus 2mg BID. Summary Patients with advanced heart failure who are concomitantly HIV+ are a unique and growing population. Multi-organ transplantation involving heart and kidney in this patient population has not been reported in the literature. As demonstrated in this case, with special considerations to patient selection, immunosuppression, and anti-infective regimens, and collaboration of a multidisciplinary team of heart and kidney transplant physicians and surgeons, along with infectious disease specialists, a successful multi-organ heart-kidney transplant in PLWHIV is feasible with excellent outcomes early after transplant.

Introduction Right heart function impacts outcomes in left ventricular assist devices (LVADs) but a comprehensive exploration of changes in right heart function over time and its effects on outcomes has not been fully elucidated. We sought to characterize changes in right heart function according to hemodynamic, imaging, and laboratory data at multiple time points and evaluate how pre-implant function compares to postoperative function in predicting heart failure (HF) outcomes. We hypothesized that postoperative (pre-discharge) right ventricular (RV) systolic function would be more predictive of HF readmissions compared to preoperative RV function. Methods In this single-center study, we included consecutive patients (n=298) who received primary LVADs between May 2008 and December 2018. Invasive hemodynamics, echocardiography (ECHO), and laboratory data were collected preoperatively, postoperatively, and at 3, 6, and 12 months following LVAD implantation. Post-implant readmission data were also collected up to 12 months post hospital discharge. Results Compared to pre-implant values, significant and persistent improvements in right atrial pressure (RAP), pulmonary artery (PA) pressures, pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistance (PVR), and RAP/PCWP occurred at 3, 6, and 12 months post-implant respectively (figure 1a). On the other hand, PA pulsatility index (PAPi) fluctuated over time and RV stroke work index (RVSWI) decreased over time (figure 1a). In addition, the proportion of patients with moderate-severe/severe RV dilation, tricuspid regurgitation (TR), and RV systolic function reduction eventually decreased on average by 12 months post-implant (figure 1b). Significant improvements in BNP and bilirubin levels occurred (figure 1c). Finally, we found that postoperative (pre-discharge) RV systolic function by ECHO was significantly predictive of readmissions due to HF (p=.03) whereas preoperative RV systolic function was not (p=0.81). Conclusions Right heart function metrics generally improve and persist at various time points post-implant compared to preoperative values. However, normalization of right heart function is rarely achieved, highlighting the need to redefine “normal” in LVAD patients. Additionally, the superior predictive value of postoperative RV function on HF readmissions underscores the importance of re-assessing right heart function post-implant for improved risk stratification.

Background Transposition of the great arteries (TGA) is a common congenital anomaly in which the aorta arises from the morphological systemic right ventricle (SRV), and the pulmonary artery arises from the morphologic left ventricle. With surgical and medical advancements, TGA patients are living longer and as a result failure of the SRV is a common cause of morbidity and mortality. Orthotopic heart transplantation (OHT) has been shown to be a successful strategy for TGA patients that progress to end stage heart failure. Candidacy for OHT is often jeopardized due to allosensitization, pulmonary hypertension, or hemodynamic instability. Little is known about long term outcomes of Left Ventricular Assist Devices (LVAD) in patients with TGA. In this study we present long term outcomes of TGA patients with LVADs. Methods This was a single center retrospective analysis of 309 consecutive patients who underwent LVAD placement from May 2008 to February 2020. Our primary outcome of interest was Post LVAD survival. Secondary outcomes of interest were hospitalizations for gastrointestinal (GI) bleeds, driveline infections (DLI), pump thromboses, acute heart failure, and right ventricular (RV) failure were outcomes of interest. The Cox proportional hazard model was used to estimate the association of TGA and AE-related hospital admissions. The cumulative incidence competing risk method was used for survival analysis. Results From May 2008 - February 2020, 10 patients with TGA underwent LVAD placement. Mean follow up was 1.3 years. TGA patients were younger, Caucasian and more likely to be male. TGA patients had similar likelihood of LVAD mortality (HR 1.35, CI 0.70-2.61, p= 0.37), RV failure (1.8, CI 0.35-10.16, p= 0.46), GI bleeding (OR 1.76, CI .33-9.47, p= 0.51), Heart failure hospitalizations (OR 1.12, CI 0.13-9.84, p= 0.55), DLI (OR 0.63, CI 0.07-5.40, p=0.64) and VAD thrombosis (OR 1.23, CI 0.28-6.68, p=0.69) as non TGA patients. Conclusions In this analysis of TGA patients with end stage heart failure, we report that TGA patients have similar outcomes to non-TGA patients post LVAD. LVAD should be considered a durable option for TGA patients who progress to end stage HF. Further studies with a larger population is warranted to further assess LVAD associated adverse events in this patient population.

Purpose Acute kidney injury (AKI) and chronic kidney disease (CKD) cause morbidity and mortality following heart transplantation (HT). Left ventricular assist devices (LVAD) are often used as a bridge to HT. We sought to determine the incidence and risk factors for developing AKI and CKD following HT in LVAD patients. Methods We examined the ISHLT Transplant Registry for heart alone transplant patients between 2000-15. We compared patients bridged with durable continuous-flow LVAD to those without LVAD bridging. Primary outcomes were AKI (defined as post-HT dialysis prior to discharge) and CKD (defined as creatinine >2.5 mg/dL, chronic dialysis, or renal transplant) within 3 years. Chi-squared and Gray's tests compared incidence rates while accounting for competing risk of death. Multivariable logistic and Cox regression analyses were used. Results There were 21,432 total patients, with 5,038 having LVAD support. LVAD patients had a higher incidence of AKI and CKD at 1 year, but a similar incidence of CKD at 3 years (Table). Multivariable regression analysis showed that non-LVAD patients had OR 0.74 (95% CI 0.63-0.86; p=0.0001) for AKI at discharge and HR 0.90 (95% CI 0.80-1.01; p=0.0635) for CKD at 3 years. Among LVAD patients, certain characteristics were significantly associated with development of AKI and CKD (Fig). Conclusion LVAD patients had higher incidence of AKI at hospital discharge and CKD at 1 year after HT compared to patients without LVAD bridging, but development of CKD was similar by 3 years. Baseline renal function, BMI, ischemic time, and diabetes can identify LVAD patients at risk for post-HT AKI or CKD.

Intracardiac and pulmonary artery (PA) pressures are currently assessed by cardiac catheterization (CC). Tissue phase mapping (TPM) is a cardiac magnetic resonance (CMR) 2D phase contrast technique for 3-directional myocardial velocity calculation. This study aims to verify correlations between LV/

Cellular rejection (CR) causes mortality during the first year post-heart transplantation (HTx). Endomyocardial biopsy is the current diagnostic gold standard. Currently only ≥2R grade episodes are treated. Cardiac magnetic resonance imaging (CMR) has been explored as a diagnostic adjunct.