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Background: The United Kingdom (UK) was one of the first countries to pioneer heart transplantation from donation after circulatory death (DCD) donors. To facilitate equity of access to DCD hearts by all UK heart transplant centers and expand the retrieval zone nationwide, a Joint Innovation Fund (JIF) pilot was provided by NHS Blood and Transplant (NHSBT) and NHS England (NHSE). The activity and outcomes of this national DCD heart pilot program are reported., Methods: This is a national multi-center, retrospective cohort study examining early outcomes of DCD heart transplants performed across 7 heart transplant centers, adult and pediatric, throughout the UK. Hearts were retrieved using the direct procurement and perfusion (DPP) technique by 3 specialist retrieval teams trained in ex-situ normothermic machine perfusion. Outcomes were compared against DCD heart transplants before the national pilot era and against contemporaneous donation after brain death (DBD) heart transplants, and analyzed using Kaplan-Meier analysis, chi-square test, and Wilcoxon's rank-sum., Results: From September 7, 2020 to February 28, 2022, 215 potential DCD hearts were offered of which 98 (46%) were accepted and attended. There were 77 potential donors (36%) which proceeded to death within 2 hours, with 57 (27%) donor hearts successfully retrieved and perfused ex situ and 50 (23%) DCD hearts going on to be transplanted. During this same period, 179 DBD hearts were transplanted. Overall, there was no difference in the 30-day survival rate between DCD and DBD (94% vs 93%) or 90 day survival (90% vs 90%) respectively. There was a higher rate of ECMO use post-DCD heart transplants compared to DBD (40% vs 16%, p = 0.0006), and DCD hearts in the pre pilot era, (17%, p = 0.002). There was no difference in length of ICU stay (9 DCD vs 8 days DBD, p = 0.13) nor hospital stay (28 DCD vs 27 DBD days, p = 0.46)., Conclusion: During this pilot study, 3 specialist retrieval teams were able to retrieve DCD hearts nationally for all 7 UK heart transplant centers. DCD donors increased overall heart transplantation in the UK by 28% with equivalent early posttransplant survival compared with DBD donors., Competing Interests: Disclosure The authors have no conflicts of interest to declare. This research was funded by the National Health Service Blood and Transplant and National Health Service England., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Introduction and Objectives: Pump thrombosis is a serious left ventricular assist device complication, though there are no guidelines regarding its treatment. The main aim of this study was to describe a strategy of intravenous anticoagulation as the initial treatment in these patients and then to compare intravenous heparin with bivalirudin., Methods: All consecutive patients who received a HeartWare left ventricular assist device from July 2009 to March 2019 were retrospectively analysed. Patients developing a pump thrombosis were selected, and treatment, outcomes and complications were recorded., Results: During this period of time (116 months), 220 patients underwent HeartWare left ventricular assist device implantation and 57 developed pump thrombosis, with an incidence rate of first pump thrombosis of 0.17 events per patient-year of support (incidence rate of all episodes of pump thrombosis: 0.30 events per patient-year of support). All the patients were initially treated medically, predominantly with either intravenous heparin (n = 26) or bivalirudin (n = 16). Patients treated with bivalirudin during the first pump thrombosis episode had less subsequent re-thrombosis episodes (18.7% vs 57.7%, p < 0.05). In addition, percentage time in therapeutic range was greater for bivalirudin compared with heparin (68.5% ± 16.9% vs 37.4% ± 31.0%, p < 0.01). During the first pump thrombosis episode, 26.3% of the patients needed surgery (left ventricular assist device exchange (n = 8), transplant (n = 6) or decommissioning (n = 1)). The overall survival at 1 year was 61.4%, and there was no significant difference in survival., Conclusion: Left ventricular assist device thrombosis is a serious life-threatening complication; hence, we propose an initial conservative management of pump thrombosis with enhanced intravenous anticoagulation with either intravenous heparin or bivalirudin, with surgery reserved for refractory cases.

Objectives: This study aimed to quantify the impact of donor variables on post-heart transplantation mortality and morbidity in recipients with and without a pretransplant left ventricular assist device (LVAD)., Methods: This is a prospective cohort study of the ISHLT Transplant Registry that includes all primary heart transplants in adult recipients (January 2005-June 2013, n = 15 532). All recipients were divided into patients with a durable continuous-flow LVAD (LVAD recipient, n = 3315) and without mechanical support (standard recipient, n = 12 217). Donors were classified as high risk (n = 3751) and low risk (n = 11 781). Transplants were categorized into low-risk donor/standard recipient (n = 9214), high-risk donor/standard recipient (n = 3003), low-risk donor/LVAD recipient (n = 2567) and high-risk donor/LVAD recipient (n = 748). Outcomes prior to discharge, survival at 5 years and freedom from complications were computed for each group., Results: LVAD recipients experienced more episodes of infection, stroke and acute rejection with both low- (P < 0.001, P < 0.001, P < 0.001) and high-risk donors (P < 0.001, P = 0.008, P = 0.028) prior to transplant discharge. Within standard recipients, a higher rate of primary graft failure (P = 0.035), infection (P = 0.001), dialysis (P = 0.012), acute rejection (P = 0.037) and less freedom from cardiac allograft vasculopathy (P < 0.001) and malignancy (P = 0.004) was observed with high-risk donors. Within LVAD recipients, no differences in complications prior to discharge or long-term morbidity were detected between low- and high-risk donors. When compared to standard recipient/low-risk donors, all the 3 remaining categories had an increased probability of death or graft failure within 90 days: LVAD recipient/low-risk donor [hazard ratio (HR) 1.26, confidence interval (CI) 1.05-1.51; P = 0.012], standard recipient/high-risk donor (HR 1.47, CI 1.27-1.71; P < 0.001) and LVAD recipient/high-risk donor (HR 1.72, CI 1.32-2.24; P < 0.001). Between 90 days and 5 years, only standard recipient/high-risk donor had an increased probability of death or graft failure (HR 1.140, CI 1.020-1.274; P = 0.021) when compared to standard recipient/low-risk donor., Conclusions: LVAD recipients, whether with high- or low-risk donors, have worse early (but not late) survival and more early complications than those of standard recipients. We found that adverse donor characteristics are less predictive for determining the outcome of LVAD-bridged recipients than standard recipients., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: This study examined whether aortic valve opening (AVO) and other echocardiographic parameters influence outcomes in patients on left ventricular (LV) assist device (LVAD) support. Pump thrombosis (PT) and ischemic stroke (IS) are known complications of LVAD, but mechanisms that could influence them are not completely understood., Methods: This was a retrospective analysis of 147 patients who received a HeartWare Ventricular Assist Device ( HeartWare International) as a bridge to transplant or to candidacy between July 2009 and August 2015, of whom 126 had at least 30 days of follow-up before the first event (30-days-out cohort). Outcomes included survival, PT, IS, and PT+IS (combined thrombotic event; CTE)., Results: Median time on support was 518 days. Of the 30-days-out cohort, 29% had a first PT and 19% a first IS. AVO was associated with longer survival on device (1,081 vs 723 days; p = 0.01) in the entire cohort. In the 30-days-out cohort, the aortic valve was more frequently closed in patients with lower ejection fractions on support (14% ± 6% vs 18% ± 9%; p = 0.009), more dilated pre-event echocardiogram (LV end-diastolic diameter, 66 ± 12 mm vs 62 ± 10 mm; p = 0.04), and pre-implant LV end-diastolic diameter (70 ± 10 mm vs 66 ± 9 mm; p = 0.06). CTE-free survival on the device was lower with a closed aortic valve (897 vs 1,314 days; p = 0.003) as was PT-free survival on the device (1,070 vs 1,457 days; p = 0.02). Cox regression analysis showed that AVO was an independent predictor of CTE (p = 0.03) CONCLUSIONS: Thrombotic events are relatively frequent in patients on long-term LVAD support. A closed aortic valve was associated with decreased overall survival, thrombosis-free survival, and poorer LV function on support. These are high-risk patients, so whether they require more intense anti-coagulation or prioritizing for transplantation requires further research., (Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)