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Robot-assisted coronary artery bypass (RCAB) is typically not offered to higher risk patients with reduced cardiopulmonary function, critical coronary artery disease, and challenging chest wall anatomy. In this study, we report the novel use of nonemergency intraoperative peripheral extracorporeal membrane oxygenation as partial cardiopulmonary support during RCAB for patients who were considered high-risk candidates for conventional CAB and at the same time not eligible for RCAB without cardiopulmonary support.Forty-five high risk patients (mean age, 68 years; Society of Thoracic Surgeons score, 6.27%; ejection fraction, 45%) underwent RCAB with nonemergency peripheral extracorporeal membrane oxygenation support for the following indications: inability to tolerate single-lung ventilation (n = 17; 38%), low ejection fraction35% (n = 17; 38%), inadequate exposure of internal thoracic artery (n = 24; 53%), critical coronary artery disease (n = 16; 36%), and hemodynamic instability after anesthesia induction (n = 3; 7%). Following robotic internal thoracic artery takedown, all patients had beating heart minimally invasive direct CAB through a 2-inch minithoracotomy.Up to 30 days, there were no strokes (0%), myocardial infarctions (0%), or access vessel complications (0%). One noncardiac related mortality (2.2%) was related to hemodialysis access issues in a patient with preexisting end-stage renal disease. One redo-CAB (2.2%) patient required sternotomy to locate the target vessel. Thirty-four (75.6%) patients were extubated within 6 hours of surgery.Our results examine the feasibility of using peripheral extracorporeal membrane oxygenation during RCAB for high-risk patients who otherwise had limited options. The use of peripheral extracorporeal membrane oxygenation in RCAB can potentially expand the surgical treatment options in high-risk coronary artery disease patients.

To examine the efficacy of continuous unilateral erector spinae plane (ESP) blocks in minimally invasive cardiac surgery patients.A retrospective nonrandomized study.At a single-center, tertiary academic institution.The study comprised 129 adult patients undergoing minimally invasive cardiac surgery with cardiopulmonary bypass or extracorporeal membrane oxygenation.Patient data were retrospectively collected and compared. Group 1 patients received ultrasound-guided ESP blocks, and group 2 patients underwent conventional intraoperative management without ESP blocks. After intubation in the group 1 cohort, 20-to- 25 mL of 0.25% ropivacaine were deposited beneath the erector spinae plane, along with catheter placement for continuous postoperative infusion.Patient characteristics (ie, age, sex, and comorbidities) were well-matched between both cohorts. The total 48-hour opioid consumption, as measured in morphine equivalents (mg), was significantly decreased in patients receiving erector spinae plane blocks compared to patients receiving conventional therapy (30.24 mg ± 23.8 v 47.82 mg ± 53.6, p = 0.04). The length of stay in the intensive care unit (ICU) also was reduced in the treatment group in comparison to the control group (1.99 days ± 1.7 v 2.65 days ± 2.4, p = 0.03). Lastly, patients receiving the blocks benefitted from a decrease in overall hospital length of stay when compared to the control group (5.93 days ± 2.4 v 7.35 days ± 5.8, p = 0.04).Erector spinae plane catheter use may safely improve postoperative measures, including decreased opioid consumption and improved pain relief, as well as reductions in ICU and hospital lengths of stay in patients undergoing minimally invasive cardiac surgery.

Background As more left ventricular-assist devices (LVADs) are implanted, multidrug-resistant LVAD infections are becoming increasingly common, partly due to bacterial biofilm production. To aid in developing bacteriophage therapy for LVAD infections, we have identified the most common bacterial pathogens that cause LVAD driveline infections (DLIs) in our heart transplant referral center. Materials and methods We studied a retrospective cohort of patients who received LVADs from November 2003 to August 2017 to identify the common causative organisms of LVAD infection. We also studied a prospective cohort of patients diagnosed with DLIs from October 2018 to May 2019 to collect bacterial strains from DLIs for developing bacteriophages to lyse causative pathogens. LVAD infections were classified as DLI, bacteremia, and pump/device infections in the retrospective cohort. Results In the retrospective cohort of 582 patients, 186 (32.0%) developed an LVAD infection, with 372 microbial isolates identified. In the prospective cohort, 96 bacterial strains were isolated from 54 DLIs. The microorganisms causing DLIs were similar in the two cohorts; the most common isolate was Staphylococcus aureus. We identified 6 prospective S. aureus strains capable of biofilm formation. We developed 3 bacteriophages that were able to lyse 5 of 6 of the biofilm-forming S. aureus strains. Conclusions Similar pathogens caused LVAD DLIs in our retrospective and prospective cohorts, indicating our bacterial strain bank will be representative of future DLIs. Our banked bacterial strains will be useful in developing phage cocktails that can lyse ≥80% of the bacteria causing LVAD infections at our institution.

Left ventricular assist devices (LVADs) are increasingly used as destination therapy or as a bridge to future cardiac transplant in patients with end-stage heart failure. Extracorporeal membrane oxygenation (ECMO) can be used to bridge patients in cardiogenic shock or with decompensated heart failure to durable mechanical circulatory support. We assessed outcomes in patients in critical cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1) who underwent implantation of a continuous-flow (CF)-LVAD, with or without preoperative ECMO bridging. For this retrospective study, we selected INTERMACS profile 1 patients who underwent CF-LVAD implantation at our institution between Sep 1, 2004 and Nov 30, 2018. Of 768 patients identified, 133 (17.3%) were INTERMACS profile 1; 26 (19.5%) received preoperative ECMO support, and 107 (80.5%) did not. Postimplantation outcomes were compared between the ECMO and no-ECMO groups. No significant differences were found in 30-day mortality (15.4 vs. 15.9%, P = 0.95) or survival at 1 year (53.8 vs. 60.9%, P = 0.51). Three patients who received ECMO before CF-LVAD implantation subsequently underwent cardiac transplant. In the ECMO group, the lactate level 1 day after ECMO initiation was lower in survivors than nonsurvivors (2.7 ± 2.2 vs. 7.4 ± 4.2 mmol/L, P = 0.02; area under the curve = 0.85, P = 0.01) after CF-LVAD implantation. Bridging with ECMO to CF-LVAD implantation in carefully selected INTERMACS profile 1 patients (those who are at the highest risk for critical cardiogenic shock and for whom palliation may be the only other option) produced acceptable postoperative outcomes. Field of research: Artificial lung/ECMO.

Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p 0.001), reoperation for bleeding (34.3% vs 11.7%, p 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p 0.001). Patients requiring postoperative RRT also had poorer survival at 30 days (74.7% vs 98.8%), 6 months (48.2% vs 95.1%), and 12 months (45.3% vs 90.2%) (p 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate 45 mL/min/1.73 m

Early readmission (within 30 days) after left ventricular assist device (LVAD) implantation might be a marker for increased mortality. We retrospectively reviewed the records of 277 adults who underwent continuous-flow LVAD implantation from 2005 through 2015 at our institution. The baseline characteristics of patients who were (versus were not) readmitted within 30 days after LVAD implantation were compared. To assess the impact of 30 day readmission on long-term survival, we used multivariate Cox regression. We also compared the cardiac transplant rate between the two groups. Of the 277 patients, 217 (78.3%) underwent LVAD implantation as a bridge-to-transplant; 76 (27.4%) of the 277 were readmitted within 30 days. The most common reason for readmission was volume overload (23.6%), followed by gastrointestinal bleeding (15.8%). Male gender, previous smoking, a higher baseline creatinine level, higher Model for End Stage Liver Disease Excluding INR (MELD-XI) score, and postoperative gastrointestinal bleeding or stroke were each associated with 30 day readmission. In our final multivariate model, increased mortality was also associated with 30 day readmission (hazard ratio, 1.60; 95% confidence interval, 1.1-2.5). Among the 217 bridge-to-transplant patients, the cardiac transplant rate was similar between the two groups: 18.7 transplants per patient-year among those who were readmitted within 30 days versus 19.7 transplants per patient-year among those who were not (p = 0.26). Among our study patients, 30 day readmission after LVAD implantation was frequent and was associated with increased mortality. It is currently unclear whether the general health of those patients was a factor and whether efforts to reduce 30 day readmission would favorably affect longer-term patient outcomes.

Ionic–organic ratchets are three-terminal electronic devices with asymmetric conductivity of the active layer. These devices are capable of generating useful direct current electrical power by converting electromagnetic noise signals available in any environment. In this work, we demonstrate for the first time an n-type ionic–organic ratchet which can generate a current of up to 7.29 μA and power up to 12.5 μW that exceed the values reported for many of the presently state-of-the-art, p-type organic electronic ratchets. We show that n-type ratchets require elimination of electron traps at the SiO2 surface, which is not required in p-type devices. This can be achieved by using a trap-free passivation layer such as benzocyclobutene, where the traditional silane treatment is insufficient. Chemical doping is employed to further fill electron traps in the channel and increase carrier concentration and mobilities. Scanning Kelvin probe force microscopy studies provide evidence of a pn-like rectifying junction...

Compliance with the Renewable Fuel Standard (RFS) in the United States will require price incentives for a substantial number of motorists with flex‐fuel vehicles to switch to high ethanol‐gasoline blends. Existing estimates of motorists’ willingness to pay for high‐ethanol blends use data from Brazil, data generated when prices greatly favored low‐ethanol blends, or stated preference data collected from mail and online surveys. We conducted an intercept survey of flex motorists as they refueled in five U.S. states. We overcome the problem caused by sample prices favoring low‐ethanol blends by augmenting revealed preference data with stated preference data. A sample‐selection problem arises because motorists with high willingness to pay seek out the relatively few stations that sell high‐ethanol blends. We use responses from two questions to inform sample selection. We find the average U.S. motorist requires a substantial discount to switch to high ethanol blends beyond the price that equates the cost per mile of driving.

Purpose We explored if utilization of continuous flow (CF-LVADS) has increased amongst females in the age of new-generation devices, which are smaller and more durable. We also compared outcomes between female and male CF-LVAD recipients. Methods The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) was queried to identify 20,324 CF-LVAD recipients from June 2008 to December 2017, of which 4350 (21.4%) were female and 15,974 (78.6%) were male. Survival was compared after propensity matching for age ≥ 50 yr, heart failure etiology, body surface area, INTERMACS class, co-morbidities, device strategy as destination or bridge to transplant therapy, temporary mechanical circulatory support, and device type. Results In 2008, women made up 22.5% of CF-LVAD recipients but that decreased to 20.9% in 2016 (Figure 1a). After propensity matching, baseline characteristics were comparable between 2463 females and 3925 males with the exception of mean right atrial pressure / pulmonary capillary wedge pressure which was higher in women (0.50 vs 0.45, p Conclusion Women with heart failure are far less likely to receive CF-LVADs and despite propensity matching, women are more likely to present with right heart failure at time of implantation. The higher mortality risk may be due to women presenting with more advanced heart failure at time of referral for CF-LVAD.

Purpose Hyponatremia is a recognized risk factor for adverse outcomes in heart failure and after cardiac surgery. We hypothesized that hyponatremia would be associated with poorer short-term and longer-term survival in patients after continuous-flow left ventricular assist device (CF-LVAD) placement. Methods Patients who received a CF-LVAD between January 2012 and December 2017 were identified in a single-center database. Sodium values within 14 days of LVAD insertion were averaged; hyponatremia was defined as Na Results Out of 322 patients, 49.7% (n=160) were found to have hyponatremia prior to LVAD insertion. There were no significant differences in comorbidities between groups. Pre-operative hyponatremia was associated with increased length of post-operative stay (38 vs 30 days, p=0.02). Though there was no difference in short-term (90-day) mortality, hyponatremia was associated with increased long-term, five-year mortality (61% vs 44%, p=0.03) (Figure 1). On binary logistic regression analysis, hyponatremia (OR 1.88 95% CI [1.073-3.315], p=0.03), increased age (OR 1.03 95% CI [1.007-1.053], p=0.01), elevated neutrophil-lymphocyte ratio (OR 1.064 95% CI [1.004-1.128], p=0.037), decreased albumin (OR 0.94 95% CI [0.887-0.992], p=0.03), and elevated mean right atrial pressure/pulmonary capillary wedge pressure ratio (OR 4.69 95% CI [1.762-12.473], p=0.002) were independent risk factors of mortality. Conclusion Pre-operative hyponatremia is associated with increased mortality after LVAD implantation and can be used as a marker or added to existing risk scores to further risk stratify patients. Whether hyponatremia correction improves long-term survival should be investigated.

Complex Coronary artery to Pulmonary artery fistulas (CPFs) can be difficult to manage with embolization or ligation. An 88-year-old woman with exertional angina was found to have a complex precordial CPF, severe Mitral regurgitation, and Pulmonary Hypertension. CPF treatment was recommended prior to minimally invasive mitral valve replacement (to avoid postoperative myocardial ischemia from worsened steal). The CPF was supplied by multiple branches from the LAD and RCA, and formed a complex common varicosity with multiple drainage channels to the pulmonary artery. The CPF was treated by injecting a liquid embolic agent, Ethylene Vinyl Alcohol Copolymer (Onyx, Medtronic, MN), into two of the feeding arteries arising from the RCA through a Scepter C Dual lumen balloon micro catheter (Microvention, Aliso Viejo, CA. This resulted in complete obliteration of the fistula, and the patient subsequently underwent successful mitral valve replacement surgery.

Purpose Stroke is one of the leading complications during CF-LVAD support. The purpose of this observational study was to investigate the temporal relationship of circulating homocysteine (Hcy) and oxidative stress as potential markers to identify CF-LVAD patients at risk for developing postoperative strokes. Methods We analyzed available blood samples from 24 selected subjects including non-heart failure control group(n=6) and heart-failure patients undergoing CF-LVAD implant(n=18). The CF-LVAD patients were selected in stroke group(n=6) those who developed stroke within a month after implant and were compared to selected matched patients who did not develop stroke(n=12). Baseline Hcy, malondialdehyde(MDA) and antioxidant were compared between groups. Weekly blood samples at 1,2,3 and 4 weeks were analyzed in selected stroke and no-stroke groups. Results At baseline, CF-LVAD patients had higher plasma Hcy and MDA and lower antioxidant than the control group(Fig1A-C). There was a significant 1.8-fold increase in baseline Hcy in stroke group compared to no-stroke group though there were no differences in the levels of MDA and antioxidant between them(Fig1A-C). In stroke group, post-implant levels of Hcy and MDA increased temporally and remained elevated while these trends were not seen in the no-stroke group(Fig1D-F). There was also a significant depletion in antioxidant in stroke group at week 4 compared to no-stroke group(Fig1F). Conclusion A near 2-fold rise in baseline Hcy was seen in stroke group patients compared to no-stroke patients, suggesting its utility as a potential biomarker to predict stroke risk after CF-LVAD implant. Elevated Hcy, oxidative stress and depleted antioxidant may be important indicators of systemic response of the body to CF-LVAD in patients who have stroke. These findings also suggest that vascular endothelial dysfunction may plan an important role in the development of stroke in CF-LVAD recipients.

Introduction The SARS-CoV-2 virus is causing severe end-stage fibrosis and respiratory failure in otherwise healthy individuals. Lung transplant (LTX) has been performed internationally in select patients for this indication, but there is limited evidence on its role in COVID-19. We describe a patient who received a bilateral LTX 12 weeks after an initial diagnosis of COVID-19 pneumonia. Case Report A 51-year-old male with hypertension and presented to an outlying hospital with dyspnea, fever and exposure to SARS-CoV-2. He was hypoxic and a diagnosis of COVID-19 pneumonia was made by nasopharyngeal swab. He was treated with dexamethasone, remdesivir, and convalescent plasma, mechanical ventilation and eventually femoral VV-ECMO cannulation to maintain oxygenation. He was extubated and was transitioned to a left subclavian dual-limb 30 Fr VV-ECMO cannula for improved rehabilitation. He was then transferred to our center for LTX consideration given refractory ARDS. Evaluation for LTX revealed pulmonary hypertension, negative SARS-CoV-2 PCR and deconditioning but no absolute contraindications. He participated in intensive rehabilitation and progressed to assisted steps despite severe deconditioning and hypoxia. He was listed for a bilateral lung transplant with a lung allocation score of 90 and received a donor offer 7 days after listing and after 82 days on ECMO. He underwent bilateral LTX via clamshell exposure with central VA ECMO support. Intraoperatively, the lungs were densely consolidated with severe hilar adenopathy without peripheral adhesions. Post-operatively, he was transitioned back to his original VV ECMO circuit and then decannulated on post-op day 3. Standard induction with basiliximab and immunosuppression with IV methylprednisolone, mycophenolate and tacrolimus was administered. He had a transient elevation of liver enzymes on post-operative day 1 and an early planned tracheostomy was performed due to deconditioning. He has since, been progressing well on oxygen via tracheostomy collar and is able to speak with a one-way valve and participate in rehabilitation. Summary For patients with irreversible end-stage lung disease after COVID-19 pneumonia, LTX is a viable option. Timely transfer to a lung transplant center and intensive rehabilitation are essential. Standard established immunosuppression and post-transplant protocols should be followed.

Ascending thoracic aortic aneurysms (ATAAs) are anatomically complex in terms of architecture and geometry, and both complexities contribute to unpredictability of ATAA dissection and rupture in vivo. The goal of this work was to examine the mechanism of ATAA failure using a combination of detailed mechanical tests on human tissue and a multiscale computational model. We used (1) multiple, geometrically diverse, mechanical tests to characterize tissue properties; (2) a multiscale computational model to translate those results into a broadly usable form; and (3) a model-based computer simulation of the response of an ATAA to the stresses generated by the blood pressure. Mechanical tests were performed in uniaxial extension, biaxial extension, shear lap, and peel geometries. ATAA tissue was strongest in circumferential extension and weakest in shear, presumably because of the collagen and elastin in the arterial lamellae. A multiscale, fiber-based model using different fiber properties for collagen, elastin, and interlamellar connections was specified to match all of the experimental data with one parameter set. Finally, this model was used to simulate ATAA inflation using a realistic geometry. The predicted tissue failure occurred in regions of high stress, as expected; initial failure events involved almost entirely interlamellar connections, consistent with arterial dissection—the elastic lamellae remain intact, but the connections between them fail. The failure of the interlamellar connections, paired with the weakness of the tissue under shear loading, is suggestive that shear stress within the tissue may contribute to ATAA dissection.

Cardiothoracic transplantation research dates back to the late 1800s, yet the first human heart transplantation did not occur until 1967. Today, more and more centers worldwide are performing such procedures with increasing success, long-term survival rates, and, importantly, with an improved quality of life for recipients. Much work remains to increase the number of available hearts and lungs for these transplants, but progress is being made for many reasons that are discussed in this chapter. The use of ex vivo lung and heart perfusion technologies along with pharmacological advancements (e.g., preservation solutions) has expanded the time available between organ recovery and transplantation, allowing for enhanced functional assessment and providing a platform for therapeutic delivery. In this chapter, we provide a brief history of cardiothoracic transplantation, review the current state of transplantation procedures, and discuss future directions for research and technological advancements.

Purpose It is well established that “high volume” centers have better outcomes for complex surgical care including transplantation. However, few studies have used data-driven methodology to establish clinically meaningful volume thresholds predictive of improved outcomes for centers performing orthotopic heart transplantation (OHT). Methods All OHT cases performed between 2005 and 2015 (with follow-up through 2016) within the United Network for Organ Sharing (UNOS) database were reviewed for potential eligibility. All patients ≥18 years of age undergoing isolated OHT were included. Stratum-specific likelihood ratio analysis (SSLR) was used to establish volume thresholds predictive of the primary outcome of mortality at 1-year. Preoperative characteristics and postoperative outcomes were compared between volume strata using χ2 tests (categorical) or ANOVA (continuous). Results A total of 21,800 recipients (mean age 52.6 ± 12.8 years; 25.2% female) were included in the final cohort. Three distinct center volume strata were identified from the analysis: low ( Conclusion The results of our study demonstrate that higher volume centers perform better than their lower volume counterparts in terms of early mortality after OHT. Our study adds to the existing literature by providing specific, data-driven volume thresholds predictive of improved early outcomes in the contemporary transplant and circulatory support landscape.

Purpose Examine gender differences continuous-flow left ventricular assist device (CF-LVAD) recipients. Methods Retrospective review of 695 patients receiving a CF-LVAD from 11/2003 to 08/2017, of which 551 (79.3%) were male and 144 (20.7%) were female. Genders were compared after propensity score matching for age ≥50 yrs, diagnosis, body surface area, INTERMACS class, comorbidities, prior mechanical circulatory support, and prior sternotomy. Survival and outcomes were compared between 139 matched gender pairs. Results After matching, no difference was seen in baseline characteristics (Table 1). A competing risk analysis showed that women had a non-significant increase in mortality (p=0.065) (Figure 1). Women had higher rates of right ventricular assist device support (3.4% vs 0.8%, p=0.03) and there was a trend towards higher rates of stroke, LVAD exchange, and longer length of stay. Additionally, lower rates of drive line infection and transplantation in women were seen (Table 2). Conclusion Larger studies are needed to determine if these single center findings of increased probability of mortality amongst women are reproducible. Additionally, further study should be devoted to risk factors for postoperative right heart failure among women.

Purpose Advances in immunosuppression, bridging therapies, and ex vivo perfusion and ventilation have led to substantial advances in lung transplantation (LTx). Nevertheless, LTx is associated with substantial morbidity and mortality. Better outcomes have been demonstrated in “high volume” lung transplant centers, but the field lacks a definition of high volume. The present study aims to identify meaningful, data-driven volume thresholds predicting improved outcomes for LTx centers. Methods All single and double LTx cases performed on patients over the age of 18 between 2005 and 2015 in the United Network for Organ Sharing (UNOS) database were reviewed. Patients listed for other organs or transplants performed in centers that were active for less than three of the ten years of the study period were excluded. Under 1% of patients were excluded due to lack of follow-up data. Stratum-specific likelihood ratios (SSLR) were calculated to establish volume thresholds predictive of the primary outcome of 1 year mortality. Demographic and outcomes data were compared between volume strata. Results A total of 20,153 recipients were included in the final cohort. We identified two thresholds based on SSLR analysis at 12 and 28 LTx/year, which yielded three distinct volume strata: low (under 12), intermediate (12-27), and high volume (over 27). The majority of transplants are performed at high volume centers, which have shorter lengths of stay (24 days vs 29 for low-volume) and better 30-day and 1-year patient survival (96.7% and 86%, vs 94.2% and 80.3% for low-volume), despite older recipients, greater ischemic time, and increased use of extended-criteria donors. Conclusion The results of our study support that high volume centers outperform their low and intermediate volume counterparts and distinguish between the three volume levels. Our study adds to the existing literature by estimating targets for annual lung transplants at which centers may attain improvements in recipient outcomes.

This dissertation contains three studies that estimate the distribution of willingness to pay (WTP) for E85 as a substitute for E10 among flex motorists in the United States. The results are vital for estimating the demand for ethanol beyond the blend wall and for analysis of the Renewable Fuel Standard. The first study attempts to estimate the distribution of preference for E85 from data generated by a survey of E85 stations in Minnesota. The study uses an extensive sample of recent observations, but estimates of the WTP distribution vary substantially depending on model specification. The conclusion is that the data are not suitable to estimate the distribution of WTP for E85.The second and third studies collect primary data from E85 stations in different regions of the United States to more accurately estimate preferences for E85 and investigate locational differences. The studies obtain revealed-preference (RP) data from flex motorists refueling at E85 stations and stated-preference (SP) data from surveying the flex motorists and presenting hypothetical scenarios. The second study uses the RP data to estimate relative preferences for E85, and the third study incorporates the SP data to better capture the wide range of fuel-switching behavior.The estimation sample consists of about nine hundred flex motorists in six urban areas in the Midwest and California. The sample of flex motorists who refuel at E85 stations is endogenously stratified; the probability of a flex motorist appearing in the sample is correlated to the motorist's WTP for E85. The models apply corrective probability weights so estimates reflect the population and not the sample.The results show that a $0.10 increase in the E85-E10 price difference decreases the probability of motorists choosing E85 by about 2.5 percent, on average, and preferences are spread over a broad range of fuel prices. In general, motorists are willing to pay more for E85 in California than in the Midwest, and when E85 and E10 are priced equally on a cost-per-mile basis, about 25 percent of flex motorists choose E85 in the Midwest compared to 75 percent in California.

Introduction Patients with refractory cardiogenic shock have a mortality in excess of 80%. The use of percutaneous mechanical circulatory support devices to bridge patients with refractory cardiogenic shock to definitive therapy has steadily increased, although the benefit remains poorly defined. This study describes the Baylor St Luke's Medical Center - Texas Heart Institute institutional experience using the Impella 5.0 micro-axial flow device to treat patients with refractory cardiogenic shock. Methods A retrospective study of all consecutive Impella 5.0 devices implanted at our institution between 8/2013 - 12/2018. Results Sixty-eight patients with refractory cardiogenic shock received an Impella 5.0 as a bridge to decision or definitive therapy. The cohort mean age was 60.2±12.7 years, 85.3% were male, 51.5% were Caucasian and 50.0% had coronary artery disease. The etiology of cardiogenic shock was primarily acute on chronic decompensated systolic heart failure (89.7%). After a median of 10 days on support (range 1-83 days), thirty-five patients (51.5%) had significant improvement while on Impella 5.0 support and were successfully bridged; twenty-six patients received a durable left ventricular assist device, one received a heart transplantation and eight recovered. Thirty-three patients (48.5%) had failed to recover end-organ function and either expired or care was withdrawn. Conclusions In our single center experience, Impella 5.0 implantation allowed discrimination of a patient sub-population suitable for definitive long-term therapy and was associated with better than expected survival to hospital discharge in patients with refractory cardiogenic shock.

Background— Induced pluripotent stem cells (iPSCs) can be differentiated into potentially unlimited lineages of cell types for use in autologous cell therapy. However, the efficiency of the differentiation procedure and subsequent function of the iPSC-derived cells may be influenced by epigenetic factors that the iPSCs retain from their tissues of origin; thus, iPSC-derived cells may be more effective for treatment of myocardial injury if the iPSCs were engineered from cardiac-lineage cells, rather than dermal fibroblasts. Methods and Results— We show that human cardiac iPSCs (hciPSCs) can be generated from cardiac fibroblasts and subsequently differentiated into exceptionally pure (>92%) sheets of cardiomyocytes (CMs). The hciPSCs passed through all the normal stages of differentiation before assuming a CM identity. When using the fibrin gel–enhanced delivery of hciPSC-CM sheets at the site of injury in infarcted mouse hearts, the engraftment rate was 31.91%±5.75% at Day 28 post transplantation. The hciPSC-CM in the sheet also appeared to develop a more mature, structurally aligned phenotype 28 days after transplantation and was associated with significant improvements in cardiac function, vascularity, and reduction in apoptosis. Conclusions— These data strongly support the potential of hciPSC-CM sheet transplantation for the treatment of heart with acute myocardial infarction.

Radiation treatment of thoracic malignancies is linked with development of valvular disease years after exposure. Given the challenges to surgical treatment related to previous radiation exposure, TAVR has emerged as an alternative. However, outcomes data for patients with history of mediastinal

Introduction The Impella 5.0 micro-axial flow device has been increasingly used in refractory cardiogenic shock as a bridge to; long-term therapy or recovery. However, the durability of the device in this population has not been studied. Methods A retrospective study of all consecutive Impella 5.0 devices implanted at Baylor St Luke's Medical Center between 8/2013 - 12/2018. Results Sixty-eight patients received an Impella 5.0 for refractory cardiogenic shock at our institution. The cohort was divided, based on duration of support, into group 1 (≤ 1 week of support), group 2 (> 1 and ≤ 2 weeks of support), group 3 (> 2 and ≤ 3 weeks of support), and group 4 (> 3 weeks of support, up to 83 days). Group 1 (25 patients) had a 40% survival rate, of which 3 patients recovered and 7 patients were bridged to durable LVAD or transplant. Group 2 (17 patients) had 41% survival rate, of which 7 patients were bridged to durable LVAD or transplant. Group 3 (14 patients) had 64% survival rate, of which 2 patients recovered and 7 patients were bridged to durable LVAD or transplant. Group 4 (12 patients) had 58% survival rate, of which 1 patient recovered and 6 patients were bridged to durable LVAD/transplant. The survival difference was not statistically significant with a 2 tailed p-value of 0.39. Conclusion In our single-center experience, the Impella 5.0 device provided durable temporary mechanical circulatory support and was a reliable bridge to decision in patients with refractory cardiogenic shock.

Purpose The OCS Heart EXPAND Trial is a prospective, multi-center trial to evaluate the effectiveness of the OCS™ to resuscitate, preserve and assess donor hearts that may not meet current standard donor heart criteria for transplantation to potentially improve donor heart utilization for transplantation. Methods Donor hearts were eligible if they met any of the following characteristics: expected total ischemic time ≥ 4 hours or expected total ischemic time ≥ 2 hours plus at least one of the following risk factors: LVH, EF 40-50%, downtime ≥ 20 minutes, and age >55 yo. Hearts were perfused and assessed on OCS Heart System from donor to recipient. Hearts were eligible for transplantation if the following criteria were met: final OCS Heart arterial lactate Results 93 eligible donor hearts with a mean UNOS match run of 66 declines were assessed on OCS Heart. Donor categories were as follows: x-clamp time ≥ 4 hours 37%, LVH 23%, EF 40-50% were 23%, downtime ≥ 20 minutes 28%, older age 13% and 33% met multiple inclusion criteria. 75 of the 93 donor hearts were successfully transplanted resulting in a utilization rate of 81%. Mean OCS perfusion time was 6.35 hours. Incidence of severe LV or RV PGD at 24 hours was 10.7%. 30-day and 6-month survival were 94.7% and 88% respectively. Conclusion The use of OCS™ Heart System resulted in high utilization of ECD hearts with excellent short-term post-transplant outcomes, most notably a low rate of PGD. These results provide clinical evidence supporting its use in ECD heart preservation and assessment, and may significantly increase donor utilization for transplantation.

The role of mechanical circulatory support for cardiopulmonary failure is expanding. Anticoagulation in the setting of static blood, hypercoagulable states, extracorporeal circuits, and surgery presents an intricate and delicate balance. We present a patient with large, biventricular thrombi during and succeeding biventricular mechanical support. Management of the thrombi and device selection in this patient are discussed.

Objectives Continuous-flow left ventricular assist devices have become the standard of care for patients with heart failure requiring mechanical circulatory support as a bridge to transplant. However, data on long-term post-transplant survival for these patients are limited. We evaluated the effect of continuous-flow left ventricular assist devices on postcardiac transplant survival in the current era. Methods All patients who received a continuous-flow left ventricular assist device as a bridge to transplant at a single center from June 2005 to September 2011 were evaluated. Results Of the 167 patients who received a continuous-flow left ventricular assist device as a bridge to transplant, 77 (46%) underwent cardiac transplantation, 27 died before transplantation (16%), and 63 (38%) remain listed for transplantation and continued with left ventricular assist device support. The mean age of the transplanted patients was 54.5 ± 11.9 years, 57% had an ischemic etiology, and 20% were women. The overall mean duration of left ventricular assist device support before transplantation was 310 ± 227 days (range, 67-1230 days). The mean duration of left ventricular assist device support did not change in patients who had received a left ventricular assist device in the early period of the study (2005-2008, n = 62) compared with those who had received a left ventricular assist device later (2009-2011, n = 78, 373 vs 392 days, P = NS). In addition, no difference was seen in survival between those patients supported with a left ventricular assist device for fewer than 180 days or longer than 180 days before transplantation ( P = NS). The actuarial survival after transplantation at 30 days and 1, 3, and 5 years by Kaplan-Meier analysis was 98.7%, 93.0%, 91.1%, and 88.0%, respectively. Conclusions The short- and long-term post-transplant survival for patients bridged with a continuous-flow left ventricular assist device in the current era has been excellent. Furthermore, the duration of left ventricular assist device support did not affect post-transplant survival. The hemodynamic benefits of ventricular unloading with continuous-flow left ventricular assist devices, in addition to their durability and reduced patient morbidity, have contributed to improved post-transplant survival.

Background Liver dysfunction in left ventricular assist device (LVAD) recipients is common both before and after implantation. Postoperative liver dysfunction (PLD) develops in some LVAD recipients without preoperative liver dysfunction. The aim of this study was to assess clinical outcomes in such patients. Methods Records of all patients undergoing implantation of a HeartMate II (HM II, St. Jude Medical, Inc, Minneapolis, MN) LVAD at a single center at the University of Minnesota from January 2005 through June 2014 were analyzed. PLD was defined by hypertransaminasemia or hyperbilirubinemia, or both, during the hospitalization for LVAD implantation. Results During the study period, 284 patients underwent HM II implantation. Excluded from analysis were 14 recipients with preoperative liver dysfunction. In the final cohort (n = 270), there were no major difference in preoperative characteristics among those patients with versus without PLD. PLD developed in 129 (47.8%) recipients: 16 (12.4%) had isolated hypertransaminasemia (group I), 76 (58.9%) had isolated hyperbilirubinemia (group II), and 37 (28.7%) had combined hypertransaminasemia and hyperbilirubinemia (group III). Group III LVAD recipients had significantly greater rates of 30-day, 90-day, and 1-year mortality, along with significantly higher transfusion requirements and higher rates of renal replacement therapy, prolonged ventilation, and vasopressor use. Moreover, their mortality risk was significantly higher than that of PLD-free LVAD recipients (hazard ratio, 4.6; 95% confidence interval, 2.1 to 10.1; p Conclusions Isolated hyperbilirubinemia is common after LVAD implantation. In this study, it was not associated with an increase in early or midterm postoperative mortality. However, postoperative combined transaminasemia and hyperbilirubinemia was associated with a significant increase in early and midterm morbidity and mortality. Further research into the pathogenesis of post-LVAD PLD is necessary.

Temporary mechanical circulatory support (MCS) is a common supportive therapy in cardiogenic shock and high-risk coronary intervention. The proliferation of new percutaneous MCS devices allows support to be instituted rapidly without surgical cutdown. The recent literature exploring the indications, benefits, and risks of each is reviewed. Areas discussed: Current applications of percutaneous MCS devices, including intra-aortic balloon pumps (IAPB), Impella, TandemHeart, and VA ECMO are discussed. Studies investigating each were identified through a combination of online database queries and direct extraction of single studies cited in previously-identified papers. Information on unpublished trials and registries was found on ClinicalTrials.gov. Expert commentary: Direct VADs provide a higher level of hemodynamic support compared to IABP and their early use will continue to expand. The development of percutaneous RV support systems may allow more patients to receive such therapy faster. VA ECMO is being used increasingly in CPR and in outreach programs.

The use of continuous-flow left ventricular assist devices (CF-LVADs) has revolutionized the landscape of mechanical circulatory support for patients with heart failure. Clinical trials are already testing the next generation of CF-LVADs. In this study, our objective was to review our long-term experience with the current generation of CF-LVADs, specifically, the HeartMate (HM) II (Thoratec Corp, Pleasanton, CA). In this single-center retrospective analysis, we evaluated the records of 278 consecutive patients who underwent a total of 302 HM II placements from June 2005 through June 2014. We excluded 11 patients from our final study group, who had previously undergone placement of a HM XVE that failed. We divided the remaining 267 patients into 3 equal groups of 89 patients each, by time period: group 1, June 2005 through May 2009; group 2, June 2009 through January 2012; and group 3, February 2012 through June 2014. To examine differences in survival between our 3 groups, we used time-to-event analysis, including the Kaplan-Meier method. To examine secondary outcomes (including stroke, hemolysis, gastrointestinal bleeding, pump thrombus, and transplant), we used one-way analysis of variance. For our final study group of 267 patients, the total follow-up time was 479.01 patient-years (median, 469 days). The mean age of patients was 57 years; 81.4% were male. In all, 209 (78.9%) patients underwent HM II placement as a bridge to transplant; 58 (21.1%), as destination therapy (DT). The overall survival rate was 94% at 30 days, 77% at 1 year, 65% at 2 years, 60% at 3 years, 50% at 4 years, and 48% at 5 years. In bridge to transplant patients, the survival rate was 78% at 1 year and 66% at 2 years; in DT patients, 70% and 60%. In group 1 patients, the survival rate was 94% at 30 days, 64% at 1 year, and 48% at 2 years; in group 2, 93%, 88%, and 76%; and in group 3, 94%, 77%, and 73% (P = 0.003). In the later years of our study period, from June 2009 onwards (ie, in groups 2 and 3), we noted a statistically significant increase in HM II placement as DT, a reduction of driveline infections, increasing pump exchange, increasing hemolysis, a reduced frequency of transplants, and an improved survival rate (as compared with the earlier group 1). The HM II has favorably influenced the outcomes of patients with end-stage heart failure, yet major complications still limit their survival. Improving compatibility between the pump and the individual host patient, enhancing anticoagulation strategies, and developing a totally implantable pump might further reduce complications thereby improving survival times and allowing CF-LVAD placement to be a true long-term alternative to a heart transplant.

We report a case in which a recipient of a HeartWare® HVAD left ventricular assist device (HeartWare, Framingham, MA, USA) was unable to undergo standard outflow graft anastomosis to the ascending aorta due to severe aortic calcification. The outflow graft of the device was instead anastomosed to the descending aorta.

The discrepancy between the limited availability of donor hearts and the ever-increasing number of patients with heart failure has led to the increasing use of left ventricular assist devices (LVAD) as a bridge to transplant. One of the main complications inherent following institution of LVAD therapy is right ventricular (RV) failure, manifested by the need for inotropic and/or nitric oxide support >14 days after LVAD implant and/or the need for right-sided mechanical circulatory support. RV failure is a major contributor of significant morbidity and mortality after LVAD placement. The complex pathophysiology of RV failure, which could potentially be related to RV myocardial dysfunction, interventricular dependence, and RV afterload, has led to inconsistencies in predicting risk factors for RV dysfunction. Several strategies have evolved over the years of experience with mechanical circulatory support that have aimed to avoid as well as reduce the incidence of RV failure. It is imperative that patients who definitely need biventricular support are identified. Despite the numerous risk factors identified in many studies as well as the development of risk factor profile scores, this continues to be a challenging problem. However, the lower incidence of RV failure following LVAD in the current era is encouraging, suggesting a favorable relationship between RV unloading and function, and continuous-flow physiology.

ObjectivePulsatile left ventricular assist devices have been shown to effectively reduce pulmonary hypertension in patients with end-stage heart failure. However, it remains to be seen whether newer continuous-flow left ventricular assist devices have a similar effect on pulmonary hypertension. The objective of this study was to determine whether the HeartMate II (Thoratec Corp, Pleasanton, Calif), a continuous-flow left ventricular assist device, is effective in improving pulmonary hemodynamics in the period after left ventricular assist device support and posttransplant.MethodsFifty patients with end-stage heart failure underwent HeartMate II left ventricular assist device placement as a bridge to transplant. We evaluated their pulmonary hemodynamics with right-sided heart catheterization at baseline, after left ventricular assist device placement, and after heart transplant.ResultsThe mean age of patients was 53.7 ± 13.5 years. Ischemic etiology was present in 60% of the patients. After left ventricular assist device placement (mean duration, 135 ± 60 days), mean systolic and diastolic pulmonary artery pressures decreased significantly from a baseline of 55.2 ± 13.4 mm Hg and 27.3 ± 6.8 mm Hg, respectively, to 35.9 ± 10.8 mm Hg and 15.8 ± 6.5 mm Hg, respectively (P

University of Minnesota M.S. thesis. May 2010. Major: Cellular and Integrative physiology. Advisors: Paul A Iaizzo, PhD, Stephen A Katz, PhD. 1 computer file (PDF); v, 37 pages, appendix A. Ill. (some col.)

Heart transplantation has become the most effective therapy for end-stage congestive heart failure. Since the first human-to-human transplant in 1967, outcomes have changed from relatively poor to a mean survival of more than 11 years, according to data reported in 2012. These improved outcomes and increased numbers of patients receiving orthotopic heart transplants are due to multiple reasons, including changes in immunosuppressive drugs, better management of heart failure patients on the waiting list, increasing use of ventricular assist devices (VADs) as bridge support, improved VAD technology, and improved donor organ preservation. Much of this chapter focuses on details of the orthotopic transplantation procedure itself. Other sections describe the steps involved in accepting transplant recipients and potential contraindications and how patients are prepared for the transplant. Criteria for donor acceptance are also described, as is the critical nature of the target time frame from donor heart availability to transplant, how a donor heart is checked for viability, considerations of posttransplant care including management of immunosuppressive agents, and monitoring for various types of potential rejection and how to treat them.

Objective Pulsatile and nonpulsatile left ventricular assist devices are effective in managing congestive heart failure. Despite early evidence for clinical efficacy, the long-term impact of nonpulsatile flow on end-organ function remains to be determined. Our goal was to compare rates of gastrointestinal bleeding in nonpulsatile and pulsatile device recipients. Methods In a retrospective review of 101 left ventricular assist device recipients (55 nonpulsatile, 46 pulsatile) from October 31, 2003, to June 1, 2007, at a single center, gastrointestinal bleeding was defined as guaiac-positive stool with hemoglobin drop requiring transfusion of at least 2 units of packed red blood cells. To assess bleeding risk outside the initial postoperative course, any patients with a device in place for 15 days or less was excluded. Results Twelve nonpulsatile and 3 pulsatile left ventricular assist device recipients had gastrointestinal bleeding 16 days or longer after device implantation. The event rates were 63 events/100 patient-years for nonpulsatile devices and 6.8 events/100 patient-years for pulsatile devices (P = .0004). This difference persisted for bleeding occurring 31 days or longer after device implantation, with 46.5 events/100 patient-years for nonpulsatile devices versus 4.7 events/100 patient-years for pulsatile devices (P = .0028). Mortalities were similar between groups (15% nonpulsatile vs 17% pulsatile, P = .6965). Conclusion Patients with nonpulsatile left ventricular assist devices appear to have a higher rate of gastrointestinal bleeding events than do pulsatile left ventricular assist device recipients. Further prospective evaluation is needed to determine potential etiologies and strategies for reducing gastrointestinal bleeding in this population.

Objective Thromboembolic events can occur in up to 20% of patients with a left ventricular assist device. The aggressive use of anticoagulation with newer continuous-flow devices has potentially increased the risk of postoperative bleeding. The predecessor of the HeartMate II left ventricular assist device, the HeartMate XVE (Thoratec Corp, Pleasanton, Calif), was associated with an extremely low thromboembolic risk, even without anticoagulation, because of its unique textured surfaces. Even though several areas of the HeartMate II are textured, a protocol was adopted for this new axial flow pump requiring long-term anticoagulation with warfarin. In our study, we investigated whether the HeartMate II left ventricular assist device is associated with a similarly low thromboembolic risk as the HeartMate XVE. Methods At our institution, 45 patients (mean age, 57.24 ± 14.2 years) underwent implantation of the HeartMate II; 30 underwent bridge-to-transplantation therapy, 7 underwent destination therapy, and 8 underwent left ventricular assist device exchange for a failed XVE left ventricular assist device. Total duration of HeartMate II support was 352.13 patient-months (mean duration, 7.2 ± 5.2 months). All 45 patients were treated postoperatively with warfarin and aspirin. We recorded use of these 2 medications and monthly international normalized ratios. Prospectively, we also monitored patients for any clinical thromboembolic events and for pump thrombus. Results Of our 45 study patients, 41 had a mean international normalized ratio of less than 2.0; of those 41 patients, 21 had a mean international normalized ratio of less than 1.6. Because of recurrent gastrointestinal bleeding episodes, 7 patients discontinued warfarin for a total duration of 39.1 patient-months. During the entire period of HeartMate II support, we noted 1 thromboembolic event. In addition, another patient had a suspected left ventricular assist device pump thrombus that resolved with a high-intensity heparin anticoagulation protocol (international normalized ratio, 1.3). Conclusions Our preliminary single-center analysis suggests that the HeartMate II is associated with an extremely low thromboembolic risk and with less stringent requirements for anticoagulation. Selected patients at high risk for bleeding can be safely followed with either no or extremely low anticoagulation requirements for prolonged periods.

Objective Patients with refractory acute cardiogenic shock and multisystem organ failure have a poor outcome with implantation of permanent ventricular assist devices. We review our experience with the use of the CentriMag (Levitronix LLC, Waltham, Mass) circulatory support system in such patients whose neurologic status was uncertain. Methods From January 2004 to June 2006, 30 patients underwent CentriMag circulatory support system placement at the University of Minnesota. Of these patients, 12 were transferred from an outside hospital with refractory acute cardiogenic shock requiring biventricular support; they are the focus of this study. Results Of our 12 study patients, 8 underwent successful bridging to the HeartMate XVE (Thoratec Corp, Pleasanton, Calif) ventricular assist device after biventricular support (mean support time of 9.4 days, range: 5–22 days). Another 2 patients underwent successful explantation (after 8 and 9 days); the remaining 2 patients died (after 4 days). Thus, the survival on CentriMag support, to either bridge or recovery, was 83% (10/12). Of the 8 patients who subsequently underwent HeartMate implantation, 5 also underwent a heart transplant within 6.9 months (range, 4.5-10 months), another 2 are still awaiting a transplant, and 1 died of sepsis and right ventricular failure 3 days after HeartMate implantation. Thus, for our 12 study patients, long-term survival was 75% at 1 month and 62.5% at 1 year. Conclusions Our aggressive strategy in this group of patients involved early operative intervention and implantation of biventricular support. By using this strategy, we avoided the urgent placement of expensive long-term ventricular assist devices in hemodynamically unstable patients with multisystem organ failure whose neurologic status was uncertain until end-organ recovery and excellent hemodynamic stability were achieved with the relatively inexpensive short-term CentriMag circulatory support system. The excellent midterm outcomes in this group of patients whose original prognosis was poor justify this therapeutic strategy.

A patient with multisystem organ failure and refractory cardiopulmonary shock stemming from Aspergillus pneumonia was treated with 2 Levitronix ventricular assist devices as a bridge-to-recovery. After ventricular assist device placement, the patient recovered myocardial function. The ventricular assist devices were removed on post-implant Day 7, and the patient made a full long-term recovery. Ventricular assist devices should be strongly considered, as bridges to recovery, to support patients with acute myocardial dysfunction associated with sepsis while the underlying infection is treated.

Gastrointestinal bleeding (GIB) remains a significant problem after continuous-flow left ventricular assist device (CF-LVAD) implantation. We hypothesized that the subsequent need for blood transfusions in patients with GIB may reduce rates of cardiac transplantation. We performed a retrospective review of 232 patients implanted with the HeartMate II (HM II) CF-LVAD from June 2005 through May 2013 at our center to determine risk factors for GIB and assess its effect on cardiac transplantation. Over a total LVAD follow-up time of 364 person-years, 62 GIB episodes occurred in 49 patients (27%), for an event rate of 0.45 gastrointestinal bleeds/patient-year of LVAD support. Women made up 15% of our cohort, yet contributed 29% of the GIB (p = 0.06). Survival at 6 month, 1 year, and 2 years was not statistically different in patients who developed GIB and those who did not (77% vs 78%, 74% vs 71%, and 61% vs 54%, respectively). In transplant-eligible patients, GIB was associated with a 27% lower rate of cardiac transplantation (rate ratio 0.73, p < 0.05). Although the mechanism behind this finding is unclear, GIB appears to be linked to higher transfusion rates, which may cause the development of subsequent allosensitization.

Our patient suffered a single stab wound to the heart that resulted in a coronary artery to ventricle fistula, a ventricular septal defect, mitral regurgitation from chordal transection, and a delayed left ventricular aneurysm. We used transesophageal echocardiography to characterize these multiple defects to help guide successful surgical repair. The patient recovered uneventfully.

Primary cardiac tumors are far rarer than tumors metastatic to the heart. Angiosarcoma is the primary cardiac neoplasm most frequently detected; lymphomas constitute only 1% of primary cardiac tumors. We present the case of a 55-year-old woman with a recently diagnosed intracardiac mass who was referred to our institution for consideration of urgent orthotopic heart transplantation. Initial images suggested an angiosarcoma; however, a biopsy specimen of the mass was diagnostic for diffuse large B-cell lymphoma. The patient underwent chemotherapy rather than surgery, and she was asymptomatic 34 months later. We use our patient's case to discuss the benefits and limitations of multiple imaging methods in the evaluation of cardiac masses. Certain features revealed by computed tomography, cardiac magnetic resonance, and positron emission tomography can suggest a diagnosis of angiosarcoma rather than lymphoma. Cardiac magnetic resonance and positron emission tomography enable reliable distinction between benign and malignant tumors; however, the characteristics of different malignant tumors can overlap. Despite the great usefulness of multiple imaging methods for timely diagnosis, defining the extent of spread and the hemodynamic impact, and monitoring responses to treatment, we think that biopsy analysis is still warranted in order to obtain a correct histologic diagnosis in cases of suspected malignant cardiac tumors.

Congestive heart failure (CHF) is a major cause of morbidity and mortality within the adult population. If these patients progress to the end stages of this disease, then heart transplantation or ventricular support devices are required. However, due to a shortage of donor hearts, the use of ventricular assist devices (VADs) as either a bridge to transplant or destination support has grown dramatically as a therapy. Furthermore, with the increased use of these devices, there have been major efforts to develop these technologies as well.