Advances In Mechanical Circulatory Support Research Articles

Unveiling the future of cardiac care: advances in mechanical circulatory support

Congestive heart failure (CHF) is a multifaceted clinical syndrome characterized by the inability of the heart to pump blood effectively, leading to inadequate oxygen and nutrient delivery to the body tissues. Despite advancements in treatment strategies, including guideline-directed medical treatment (GDMT), end-stage CHF remains a significant cause of morbidity and mortality worldwide. Heart transplantation is considered to be the gold standard treatment of end stage CHF but constrained by the lack of organ donors, lengthening waitlists, and the negative side effects of lifelong immunosuppressive medications. Mechanical circulatory support (MCS) has emerged as a pivotal intervention for patients with end-stage CHF, serving as a bridge to recovery, transplantation, or destination therapy. The aim of this narrative review is to highlight the historical development of MCS, to assess the recent status of MCS device technology and discuss current challenges associated with complications of MCS that need to be solved in the future by device development. The history of MCS dates back to pioneering efforts in the 1960s, with significant progress in device development and utilization over decades. MCS devices, including left ventricular assist devices (LVADs), extracorporeal membrane oxygenation (ECMO), and artificial hearts, play a crucial role in providing circulatory support to patients with end-stage CHF. Recent advancements in MCS technology aim to decrease the device size, enhance blood compatibility, reduce thrombo-embolic complications, and prolong device durability and battery life and improve physiological performance of MCS. Continued research and innovation are essential to address these challenges and improve outcomes in patients with end-stage CHF. Artificial intelligence (AI) has emerged as a valuable tool in cardiovascular medicine to facilitate risk prediction, patient selection, and treatment optimization for MCS and heart transplantation. Despite these advancements, challenges persist in MCS device selection, resource allocation, and integration of AI into clinical practice. Continued research and innovation are essential to address these challenges and improve outcomes in patients with advanced heart failure.

Predictors of Mortality in Acute Myocardial Infarction Complicated by Cardiogenic Shock despite Intra-Aortic Balloon Pump: Opportunities for Advanced Mechanical Circulatory Support in Asia.

Introduction: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) mortality remains high despite revascularization and the use of the intra-aortic balloon pump (IABP). Advanced mechanical circulatory support (MCS) devices, such as catheter-based ventricular assist devices (cVAD), may impact mortality. We aim to identify predictors of mortality in AMI-CS implanted with IABP and the proportion eligible for advanced MCS in an Asian population. Methods: We retrospectively analyzed a cohort of Society for Cardiovascular Angiography and Intervention (SCAI) stage C and above AMI-CS patients with IABP implanted from 2017-2019. We excluded patients who had IABP implanted for indications other than AMI-CS. Primary outcome was 30-day mortality. Binary logistic regression was used to calculate adjusted odds ratios (aOR) for patient characteristics. Results: Over the 3-year period, 242 patients (mean age 64.1 ± 12.4 years, 88% males) with AMI-CS had IABP implanted. 30-day mortality was 55%. On univariate analysis, cardiac arrest (p < 0.001), inotrope/vasopressor use prior to IABP (p = 0.004) was more common in non-survivors. Non-survivors were less likely to be smokers (p = 0.001), had lower ejection fraction, higher creatinine/ lactate and lower pH (all p < 0.001). On multi-variate analysis, predictors of mortality were cardiac arrest prior to IABP (aOR 4.00, CI 2.28-7.03), inotrope/vasopressor prior to IABP (aOR 2.41, CI 1.18-4.96), lower arterial pH (aOR 0.02, CI 0.00-0.31), higher lactate (aOR 2.42, CI 1.00-1.19), and lower hemoglobin (aOR 0.83, CI 0.71-0.98). Using institutional MCS criteria, 106 patients (44%) would have qualified for advanced MCS. Conclusions: Early mortality in AMI-CS remains high despite IABP. Many patients would have qualified for higher degrees of MCS.

Four decades of progress in heart-lung transplantation: Two hundred seventy-one cases at a single institution

ObjectiveThe objective of this study is to evaluate survival for combined heart-lung transplant (HLTx) recipients across 4 decades at a single institution. We aim to summarize our contemporary practice based on more than 271 HLTx procedures over 40 years. MethodsData were collected from a departmental database and the United Network for Organ Sharing. Recipients younger than age 18 years, those undergoing redo HLTx, or triple-organ system transplantation were excluded, leaving 271 patients for analysis. The pioneering era was defined by date of transplant between 1981 and 2000 (n = 155), and the modern era between 2001 and 2022 (n = 116). Survival analysis was performed using cardinality matching of populations based on donor and recipient age, donor and recipient sex, ischemic time, and sex matching. ResultsBetween 1981 and 2022, 271 HLTx were performed at a single institution. Recipients in the modern era were older (age 42 vs 34 y; P < .001) and had shorter waitlist times (78 vs 234 days; P < .001). Allografts from female donors were more common in the modern era (59% vs 39%; P = .002). In the matched survival analysis, 30-day survival (97% vs 84%; P = .005), 1-year survival (89% vs 77%; P = .041), and 10-year survival (53% vs 26%; P = .012) significantly improved in the modern era relative to the pioneering era, respectively. ConclusionsLong-term survival in HLTx is achievable with institutional experience and may continue to improve in the coming decades. Advances in mechanical circulatory support, improved maintenance immunosuppression, and early recognition and management of acute complications such as primary graft dysfunction and acute rejection have dramatically improved the prognosis for recipients of HLTx in our contemporary institutional experience.

Abstract 16293: Subsequent Pregnancies and Long-Term Cardiac Outcomes Among Patients With Prior Peripartum Cardiomyopathy in Kaiser Permanente Northern California

Introduction: Current recommendations for subsequent pregnancies after peripartum cardiomyopathy (PPCM) have been based on previously reported ~30% recurrence rates of PPCM, but evidence has evolved along with clinical practice. Research Questions: What is the incidence of repeat pregnancy in patients with PPCM, and what are cardiac outcomes during and after subsequent pregnancies? Methods: Retrospective study of subsequent pregnancies among 110 pregnant patients identified with a confirmed diagnosis of peripartum cardiomyopathy (PPCM) between 1995-2004 in a Kaiser Permanente Norther California (KPNC) cohort. Results: Among 110 women with a diagnosis of PPCM, there were 58 subsequent pregnancies, including 23 live births in 16 women (15%), and 35 therapeutic or spontaneous abortions in 24 women (21%) over a follow-up period of up to 26 years. The live births included one birth for 11 women, two births for 3 women, and three births for 2 women. Among the 32 women with subsequent pregnancies, there was no maternal mortality or need for advanced mechanical circulatory support. There was 1 woman with relapse of PPCM in subsequent pregnancy, with left ventricular ejection fraction (LVEF) improvement at the latest follow up. There was no significant differences in LVEF at the latest available echocardiogram among those women with and without subsequent live birth pregnancies (Table 1, X 2 -value 0.901, p=0.95). Only 2 women, both with no documented subsequent pregnancy, had persistent severe LV systolic dysfunction at the end of follow-up. Conclusions: In the KPNC cohort, most patients with PPCM recovered LV function and there were no significant differences in LVEF among those women with and without subsequent live birth pregnancy.

Clinical Outcomes and Predictors of All-Cause Mortality After Complex High-Risk and Indicated Revascularization Using Percutaneous Coronary Intervention.

The concept of complex and high-risk indicated procedures using percutaneous coronary intervention (CHIP-PCI) has recently been defined. However, few studies have investigated the prognosis of patients after CHIP-PCI. We enrolled 322 consecutive patients who underwent CHIP-PCI. CHIP-PCI was defined as a procedure satisfying at least one criterion each for both patient and procedure characteristics, as follows: patient characteristics [age ≥ 75 years old, low left ventricular ejection fraction (LVEF), diabetes mellitus, acute coronary syndrome, previous coronary artery bypass surgery, peripheral arterial disease, severe chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and severe valvular disease] and procedure characteristics [unprotected left main disease, degenerated saphenous or radial artery grafts, severely calcified lesions, last patent conduit, chronic total occlusions, multivessel disease, and use of mechanical circulatory support]. On Kaplan-Meier analysis, 1-, 2-, and 3-year survival rates following CHIP-PCI was 93.8%, 89.2%, and 85.4%, respectively. Moreover, on Cox multivariate hazard analysis, age (≥ 75 years old) (hazard ratio: 4.01, 95% confidence interval: 1.92-8.38, P < 0.01), COPD (hazard ratio: 2.95, 95% confidence interval: 1.38-6.32, P < 0.01), low LVEF (hazard ratio: 3.35, 95% confidence interval: 1.55-7.22, P < 0.01), severe CKD (hazard ratio: 3.02, 95% confidence interval: 1.44-6.36, P < 0.01), and use of mechanical circulatory support (hazard ratio: 5.97, 95% confidence interval: 2.72-13.10, P < 0.01) remained significant predictors of mortality. In conclusion, we revealed the clinical outcomes after CHIP-PCI. The presence of advanced age, COPD, low LVEF, severe CKD, and mechanical circulatory support use might lead to worse clinical outcomes.

Editorial introductions.

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editor and Section Editors for this issue. SECTION EDITORS Ali J MarianAli J MarianDr Marian received his training in clinical cardiology and human molecular genetics at Baylor College of Medicine, Houston, USA. He was appointed as a faculty at the Section of Cardiology at Baylor College of Medicine, Houston, USA in 1992. He joined the Institute of Molecular Medicine in 2006 to lead the Center for Cardiovascular Genetics. Dr Marian is recognized for his research achievements in molecular genetics and clinical aspects of cardiomyopathies. He has published over 200 articles in peer-reviewed journals, which collectively have garnered over 12,000 citations and an H index of 60. He received the Young Investigator Award from the American College of Cardiology, the Established Investigator Award from the American Heart Association, the Clinician-Scientist Award in Translational Research from Burroughs Wellcome Fund, Distinguished Scientist Award from Baylor St Luke's Medical Center, and the Best Editor Award from the American Heart Association Circulation Research. Dr Marian is currently a Deputy Editor for Cardiovascular Research, Section Editor on Genetics for Current Opinion in Cardiology, and the Editor-in-Chief of The Journal of Cardiovascular Aging. He is a former Deputy Editor for Circulation Research, Associate Editor for Circulation and European Journal of Clinical Investigation. Dr Marian's research is supported by R01 grants from the NHLBI-NIH, Leducq Foundation Trans-Atlantic Network of Excellence, and local foundations. Gene KimGene KimDr Kim is a cardiologist with the Advanced heart failure, Cardiac transplant, and Mechanical Circulatory Support Program at the University of Chicago Medicine, USA. He is an Associate Professor of Medicine and the Advanced Heart Failure Fellowship Program Director. His medical school, residency, and fellowship training were completed at the University of Chicago, USA. Dr Kim also directs the Genetic Cardiomyopathy and Hypertrophic Cardiomyopathy Clinics at University of Chicago, USA. Dr Kim's research interests include the genetic and epigenetic regulation of heart failure and arrhythmogenesis with publications on the role of microRNAs in cardiomyopathy. His interests also include myocardial recovery, extracellular matrix in failing myocardium. He has published over 100 articles and book chapters and is an investigator in numerous clinical trials. Bhavadharini RamuBhavadharini RamuDr Bhavadharini (Dharini) Ramu is an Advanced Heart Failure & Transplant Cardiologist, Director of the Cardio-Obstetrics Program and an Associate Professor of Medicine at the University of Minnesota, USA. She completed her internal medicine residency and cardiology fellowship at the University of Connecticut, USA followed by Advanced Heart Failure Fellowship at the University of Minnesota, USA in 2016. She previously served on the faculty at the Medical University of South Carolina, USA from 2016 to 2023. Dr Ramu has been an invited faculty lecturer at scientific meetings of the American College of Cardiology (ACC), Heart Failure Society of America, American Society of Transplantation, and International Society of Heart & Lung Transplantation. She is a member of the ACC's Heart Failure & Transplant Section Leadership Council, the program planning committee for the ACC's Scientific Sessions, and serves on the leadership council of the Women in Heart Transplantation & MCS Network. Dr Ramu's research interests include increasing the understanding of and reducing the impact of health-related disparities in patients with advanced heart failure, with a goal of reducing health inequities and improving the health of disadvantaged and vulnerable populations. She has served as a peer reviewer for many journals and is an investigator in heart failure clinical trials.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

"Beyond waking and walking. Intensive rehabilitation in patients requiring extended durations of advanced mechanical circulatory support: A case series".

Physical therapy (PT) utilization in patients requiring mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) has been reported; however, little is known about intensive rehabilitation and associated outcomes in patients requiring extended complex MCS and/or ECMO support. Authors sought to explore safety, feasibility and outcomes associated with active rehabilitation in patients requiring prolonged advanced MCS/ECMO support. Single-center retrospective series evaluated functional, clinical, and longitudinal outcomes of sample of eight critically ill, adult (≥18 years of age) patients who underwent a intensive rehabilitation while receiving prolonged MCS/ECMO through advanced configurations including: venovenous (VV-ECMO), venoarterial (VA-ECMO), oxygenator with right ventricular assist device (Oxy-RVAD) and right ventricular assist device (RVAD). 406 sessions were conducted; 246 during provision of advanced MCS/ECMO support. Incidence of major adverse events-accidental decannulation, migration of cannulas, circuit failure, hemorrhage, major flow limitations, and major hemodynamic instability-was 1.2 events per 100 sessions. None of reported major adverse events impeded longitudinal ability to participate in PT. Increased time to PT initiation was associated with a statistically significant increase in intensive care unit (ICU) length-of-stay (β1 1.93, CI 0.55–3.30) and reduced ambulatory distance during last session on MCS/ECMO (β1 -47.64, CI - 93.93, −1.66). All patients survived to hospital discharge and 12 months from sentinel hospitalization. Amongst those patients discharged to an inpatient rehabilitation center ( n = 4), all were discharged home within 3 months. Findings support the safety and feasibility of active rehabilitational PT in patients requiring extended durations of advanced MCS/ECMO support. Moreover, it highlights potentially associated benefits of this degree of intensive rehabilitation for these unique patients. Further investigation is needed to identify associations with longitudinal clinical outcomes, as well as predictors of success in this population.

Just Keep MOVEN: An Evidence-Based Approach to Improving Outcomes in Patients Receiving Mechanical Ventilation

Just Keep MOVEN: An Evidence-Based Approach to Improving Outcomes in Patients Receiving Mechanical Ventilation

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure.

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure.

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

A Review of Cardiovascular Complications among Pregnant Patients with COVID-19

Cardiovascular complications of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection are well-described in the general population but remain limited among pregnant patients. This review summarizes data from case reports, case series, and observational studies of cardiovascular manifestations of corona virus disease 2019 (COVID-19) in pregnant patients and provides recommendations to the cardiovascular clinician regarding management considerations in this vulnerable population. Pregna is an immunocompromised state in which cardiovascular demands are increased. Cardiovascular complications of COVID-19 that have been described in pregnancy include myocardial injury, cardiomyopathy, thromboembolism, pre-eclampsia and arrhythmia. Physiologic and cardiovascular changes in pregnancy predispose pregnant patients with COVID-19 to more severe illness than the general population. Black or Hispanic race, obesity, diabetes, hypertension and lung disease are risk factors for more severe infection, maternal death and adverse perinatal outcomes. Pregnant patients with severe COVID-19 disease compared with non-pregnant age-matched women with COVID infection are more likely to be admitted to the intensive care unit (ICU), receive mechanical ventilation and require advanced mechanical circulatory support. Cardiovascular complications of COVID-19 in pregnant patients requires further attention, particularly given the anticipated increase in birth volume and ongoing nature of COVID-19 pandemic with novel variants. Clinicians should have a lower threshold for cardiac testing and multidisciplinary management in pregnant women with severe COVID-19 disease. Given the persistence of COVID-19 within our communities, diagnostic laboratory and imaging testing for high-risk pregnant patients hospitalized with COVID-19 infection should be routine. We strongly urge the implementation of a cardio-obstetric multidisciplinary team in individually managing these high-risk patients in an effort to improve maternal and fetal outcomes.

Abstract 12249: Optimal Timing of Extracorporeal Membrane Oxygenation (ECMO) Application for the Prognosis of Patients With Acute Coronary Syndrome (ACS) Accompanying Cardiogenic Shock

Introduction: Advances in mechanical circulatory support (MCS) devices and several studies showing that early application of MCS devices can improve survival rates in cardogenic shock (CS) patients are increasing interest in the usefulness of MCS devices in CS patients. However, studies on the optimal use and timing of application of MCS device in CS patients are still lacking. Methods: The RESCUE study is multicenter, retrospective, and prospective registry of patients that presented with CS. From January 2014 to December 2018, 1247 patients with CS were enrolled from 12 major centers in Korea. Among enrolled patients, ECMO was applied to 238 of 693 patients who performed percutaneous coronary intervention (PCI) with acute coronary syndrome. The primary endpoint was a composite of in-hospital, 30-day, 6-month and 12-month mortality according to ECMO application timing. Results: There was no difference in the 30-day mortality in ACS patients with CS according to ECMO application timing before and after PCI. However, when stratified by time from CS recognition to ECMO application (Shock to ECMO application time, ≤100 minute vs. &gt;100 minute), 30-day Kaplan-Meier survival curve showed differences according to ECMO application timing. When the time from CS to ECMO application less than 100 minutes, patients who applied ECMO during or after PCI had a 34% reduction in 30-mortality compared to patients who applied ECMO before PCI (HR = 0.64, 95% CI: 0.39-1.03; P = 0.07). And, when the time from CS to ECMO application exceeded 100 minute, patients who applied ECMO during or after PCI had an approximately twice the 30-day mortality compared to patients who applied ECMO before PCI (HR = 2.03, 95% CI: 1.07-3.85; P = 0.03). Conclusions: According to ECMO application timing, prognosis of ACS patients with cardiogenic shock was different. In case of exceed 100 minute, early initiation of ECMO application was associated with improved prognosis in 30-day mortality.

Abstract 14332: Syncope, Storm, and Shock: Fulminant Myocarditis

A 46-year-old female with prediabetes and recent hysterectomy three weeks prior presented to the hospital for syncope. Patient reported no chest pain or dyspnea but complained of intermittent palpitations. The patient developed runs of non-sustained ventricular tachycardia which quickly escalated into incessant ventricular tachycardia (VT). Unresponsive to maximal medical therapy, the patient was cardioverted, intubated and sedated. Electrocardiogram was obtained which showed ST segment elevation in V1 and V2 without reciprocal changes. Bedside point-of-care ultrasound was negative for wall motion abnormalities. Laboratory results were significant for normal electrolytes, elevated troponins peaking at 7.14 ng/mL the following morning, and lactic acid of 3.2 mmol/L. Patient was initiated on vasopressor and ionotropic support for suspected shock. Left heart catheterization was negative for obstructive coronary artery disease. Right heart catheterization revealed mild pulmonary hypertension and biventricular failure. Formal echocardiogram revealed mid-range ejection fraction with a small pericardial effusion. The patient’s clinical status was deteriorating and revealed multiorgan failure. In conjunction with advanced heart failure and mechanical circulatory support teams, veno-arterial extracorporeal membrane oxygenation was initiated with subsequent implantation of intra-aortic balloon pump. High-dose steroids were given while awaiting transfer to a quaternary center. The patient is currently being evaluated for endomyocardial biopsy and evaluation of left ventricular assist device or heart transplantation due to fulminant myocarditis (FM). FM requires early recognition, intensive support, and further investigation for optimal management.

Where do we stand with acute myocardial infarction patients with severely reduced left ventricular ejection fraction? insights from AMIS Plus Registry

Abstract Background Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-word experiences focused on AMI patients with severely reduced LVEF (i.e. &amp;lt;30%) are lacking. Purpose The present study aims at providing a comprehensive picture on temporal trends in AMI patients with severely reduced LVEF, with a particular focus on prevalence, in-hospital management/prognosis and pharmacological therapy at discharge. These data could shed light on the implementation in the clinical arena of guideline-directed therapies in this fragile subgroup of patients and on their effect on real-word short-term prognosis. Methods On a total of 48,543 screened AMI patients included in AMIS Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as AMI patients with or without severely reduced LVEF (i.e. patients with LVEF &amp;lt;30% and ≤30%, respectively). Results Overall, 1657 AMI patients (7%) presented with severely reduced LVEF. Prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p&amp;lt;0.001; Figure 1). In the subgroup of patients with severely reduced LVEF a significant increase in revascularisation (percutaneous and/or surgical) rate was observed (from 61% to 84%, p&amp;lt;0.001); in-hospital access to advanced short-term mechanical circulatory support (both ECMO and/or Impella) significantly increased from 0% in 2011 to 17% (p=0.05). Rate of cardiogenic shock developed during hospitalization remained stable over time (from 21% to 16%, p=0.7); in-hospital mortality did not significantly decrease and remained well above 20% all over the study period (from 23% to 26%, p=0.65; Figure 2). At discharge, prescription of optimal anti-ischaemic therapy (defined as an association of dual antiplatelet therapy and statine) significantly increased (from 47% to 75%, p&amp;lt;0.001), mainly driven by an increase in dual antiplatelet therapy prescription; however, prescription of optimal cardio-protective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, beta-blocker and mineralcorticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p=0.96). Conclusion AMI patients with severely reduced ejection fraction still remain a fragile subgroup of patients; in-hospital mortality did not significantly decrease and remained exceedingly high and well above 20% all over the study period; efforts are, therefore, urgently needed to develop therapeutic strategies focused on this subgroup of patients and aiming at improving short-term prognosis. Moreover, access at discharge to optimal cardio-protective therapy remains suboptimal; efforts are needed to improve access to guidelines-directed therapy both at discharge and follow-up in this fragile population. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Swiss Heart Fundation

Editorial introductions.

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Ali J. MarianAli J. MarianDr Ali J. Marian joined the faculty at the Department of Medicine (Cardiology) at Baylor College of Medicine, USA, in 1992 and was recruited to The Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases at UTHealth, USA, in 2006. His colleagues nationally and internationally recognize him for his research achievements and expertise in genetics of cardiomyopathies. He received the Young Investigator Award from the American College of Cardiology, the Junior Faculty Award for research from the American Federation of Medical Research, the Award for Excellence in Research at Baylor College of Medicine, the Established Investigator Award by the American Heart Association, the Clinician-Scientist Award in Translational Research from Burroughs Wellcome Fund and the Best Editor Award from the American Heart Association. Dr Marian is an Associate Editor of Cardiovascular Research and Section Editor on Genetics for Current Opinion in Cardiology and Current Atherosclerosis Reports. He was a Deputy Editor of Circulation Research, Associate Editor for Circulation and an Associate Editor for European Journal of Clinical Investigation. He received the Best Editor Award from the American Heart Association for his work for Circulation Research. Dr Marian has co-authored ∼ 200 manuscripts in peer-reviewed journals. He has served as a reviewer for > 100 National Institute of Health, American Heart Association and other organizations study sections. Dr Marian's research is supported by grants from NHLBI-NIH, Leducq Foundation Trans-Atlantic Network of Excellence and local foundations. Rebecca CogswellRebecca CogswellDr Cogswell completed internal medicine residency, chief residency, and cardiology fellowship at the University of California, San Francisco, USA. While at UCSF, she also completed a year of advanced clinical research training. She then went on to complete Advanced Heart Failure fellowship at the University of Minnesota, USA. She has been on faculty at the University of Minnesota since 2013 and is presently the Medical Director of Mechanical Circulatory Support Program. Dr Cogswell's research focus is the skeletal muscle changes that occur in end stage heart failure. Specifically, she is interested in what these changes can reveal about optimal timing of advanced heart failure therapies and using these measures to predict outcomes after mechanical circulatory support. She has built a left ventricular assist device database at the University of Minnesota and is collaborating with other centers towards answering several clinical questions in the contemporary continuous flow LVAD population. She is presently the Advanced Heart Failure fellowship director and is an active reviewer for Journal of Heart Lung Transplant and Circulation Heart Failure. She is a principle investigator for several heart failure and LVAD related clinical trials. In 2017, she was appointed to the Medtronic Heart Failure Advisory Board. In addition, she developed and directs to the Infiltrative Cardiomyopathies Clinic at the University of Minnesota. Gene KimGene KimDr Kim is a cardiologist with the Advanced heart failure, Cardiac transplant, and Mechanical Circulatory Support Program at the University of Chicago Medicine, USA. He is an Assistant Professor of Medicine and the Advanced Heart Failure Fellowship Program Director. His medical school, residency, and fellowship training were completed at the University of Chicago. Dr Kim's research interests include the genetic and epigenetic regulation of heart failure and arrhythmogenesis with publications on the role of microRNAs in cardiomyopathy. His interests also include myocardial recovery, extracellular matrix in failing myocardium, and the role of inflammation and angiogenesis in LVAD patients. He has published over 80 articles and book chapters and is an investigator in numerous clinical trials.

Increased Opportunities for Transplantation for Women in the New Heart Allocation System

BackgroundHistorically, women have had less access to advanced heart failure therapies, including temporary and permanent mechanical circulatory support and heart transplantation (HT), with worse waitlist and post-transplant survival compared with men. This study evaluated for improvement in sex differences across all phases of HT in the 2018 allocation system. Methods and ResultsThe United Network for Organ Sharing registry was queried to identify adult patients (≥18 years) listed for HT from October 18, 2016, to October 17, 2018 (old allocation), and from October 18, 2018, to October 18, 2020 (new allocation). The outcomes of interest included waitlist survival, pretransplant use of temporary and durable mechanical circulatory support, rates of HT, and post-transplant survival. There were 15,629 patients who were listed for HT and included in this analysis; 7745 (2039 women, 26.3%) in the new and 7875 patients (2074 women, 26.3%) in the old allocation system. When compared with men in the new allocation system, women were more likely to have lower priority United Network for Organ Sharing status at time of transplant, and less likely to be supported by an intra-aortic balloon pump (27.1% vs 32.2%, P < .001), with no difference in the use of venoarterial extracorporeal membrane oxygenation (5.5% vs 6.3%, P = .28). Despite these findings, when transplantation was viewed in the context of risk for death or delisting, the cumulative incidence of transplant within 6 months of listing was higher in women than men in the new allocation system (62.4% vs 54.9%, P < .001) with no differences in post-transplant survival. When comparing women in the old with the new allocation system, the distance traveled for organ procurement was 187.5 ± 207.0 miles vs 272.8 ± 233.7 miles (P < .001). ConclusionsAlthough the use of temporary mechanical circulatory support in women remains lower than in men in the new allocation system, more women are being transplanted with comparable waitlist and post-transplant outcomes as men. Broader sharing may be making its greatest impact on improving transplant opportunities for women.

Advocacy and Legislation for Regionalization Practices in the Treatment of Cardiogenic Shock: The Time Is Now

Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.

Abstract 9559: Clinical Outcomes and Predictors of All-Cause Mortality After Complex High-risk and Indicated Revascularization Using Percutaneous Coronary Intervention

Introduction: The concept of complex and high-risk indicated procedures using percutaneous coronary intervention (CHIP-PCI) has recently been defined. However, few studies have investigated the prognosis of patients after CHIP-PCI. Methods: CHIP-PCI was defined as a procedure satisfying at least one criterion each for both patient and procedure characteristics, as follows: patient characteristics [age (≥ 75 years old), low left ventricular ejection fraction (LVEF), diabetes mellitus, acute coronary syndrome, previous coronary artery bypass surgery, peripheral arterial disease, severe chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and severe valvular disease] and procedure characteristics [unprotected left main disease, degenerated saphenous or radial artery grafts, severely calcified lesions, last patent conduit, chronic total occlusions, multivessel disease, and use of mechanical circulatory support]. Between January 2017 and December 2018, we performed PCI for 695 consecutive patients in our hospital. Of these patients, CHIP-PCI was performed for 322 consecutive patients. Results: The survival rate was significantly lower in CHIP-PCI group than non-CHIP-PCI group (log-rank P &lt; 0.01, Figure). Moreover, on Cox multivariate hazard analysis, age (≥ 75 years old) (hazard ratio: 4.01, 95% confidence interval: 1.92-8.38, p &lt; 0.01), COPD (hazard ratio: 2.95, 95% confidence interval: 1.38-6.32, p &lt; 0.01), low LVEF (hazard ratio: 3.35, 95% confidence interval: 1.55-7.22, p &lt; 0.01), severe CKD (hazard ratio: 3.02, 95% confidence interval: 1.44-6.36, p &lt; 0.01), and use of mechanical circulatory support (hazard ratio: 5.97, 95% confidence interval: 2.72-13.10, p &lt; 0.01) remained significant predictors of mortality after CHIP-PCI.. Conclusions: The presence of advanced age, COPD, low LVEF, severe CKD, and mechanical circulatory support use might lead to worse clinical outcomes after CHIP-PCI.

The influence of surface roughness on the damage of von Willebrand Factor under shear flow condition.

Despite technological advances in mechanical circulatory support devices to treat end-stage heart failure, blood damage induced by non-physiological shear stress in operation often triggered clinical hemocompatibility complications. The loss of high molecular weight von Willebrand Factor (HMW-VWF) has been considered as an essential cause of gastrointestinal bleeding. In addition to the mechanics factors, interface factors may also affect blood damage, especially the surface characteristics. In this study, the effect of surface roughness on VWF damage under flow condition was investigated. A roller pump circulation experimental platform with a roughness embedded sample chamber was constructed to provide blood shearing flow condition. VWF molecular weight analysis, VWF antigen (VWF-Ag) concentration assay, and VWF ristocetin cofactor activity (VWF-Rico) assay were performed on the sheared blood samples. These variables are the main functional indicators of VWF. It was found that the surface roughness induced VWF damage is mainly caused by the loss of HMW-VWF rather than reducing the total amount of VWF. The threshold value of surface roughness for a rapid increase in the degradation of HMW-VWF under low flow rate was obtained between Ra 0.4 and 0.6 μm, which was smaller than the threshold for hemolysis. Our findings indicated that VWF is more sensitive to the interface factor of surface roughness than red blood cells, thus has a higher requirement for blood pump design. It could provide reference for the material design and processing in developing mechanical circulatory support devices.