Axillary Intra-aortic Balloon Pump Research Articles

(478) - Optimized Procedural, Therapeutic, ICU and X-Ray Imaging to Reduce Adverse Events in Patients Bridged with Axillary Intraaortic Balloon Pump (OPTIX-IABP)

(478) - Optimized Procedural, Therapeutic, ICU and X-Ray Imaging to Reduce Adverse Events in Patients Bridged with Axillary Intraaortic Balloon Pump (OPTIX-IABP)

P56: The Impact of Ipsilateral Implantable Cardioverter Defibrillator in Axillary Intra-Aortic Balloon Pump Support as Bridge-to-Heart Transplantation

Background: The axillary artery (AX) access for intra-aortic balloon pump (IABP) as a bridge to heart transplant (HT) allows mobility while awaiting a suitable donor. As end-stage heart failure patients often have an implantable cardioverter defibrillator (ICD) on the left side, the left AX approach may be avoided due to the perception of difficult access and proximity of two devices. Purpose: We compare the outcomes of patients undergoing HT that were bridged with a left-sided AX IABP with or without ipsilateral ICDs. Methods: Patients who had undergone left AX IABP as a bridge to HT between January 2010 to February 2022 were retrospectively reviewed (N=31). All AX IABPs were surgically implanted via the left AX. ICD was present in a total of 17 (80.9%) on the left side (Group ICD) while 14 patients did not have ICD on the left side (Group No-ICD). The procedural time was defined as the time from skin incision to the beginning of anastomoses of a Dacron graft. Results: The median age of the recipients was 55.6±12.9 with 80.6% (N=25) males. The median duration of left AX IABP support was 14 (8,22) days. Technical success was 100%. The mean procedure time to expose the AX was comparable between the two groups (ICD, 12.5±6.2 min vs. No-ICD, 11.2±6.0 min, P=0.640), as was the incidence of bleeding/hematoma (ICD, 0% vs. No-ICD, 7.1%, P=0.202). There was no ischemic stroke in both group. The most common adverse event in the cohort was a malfunction in 4 patients (12.9%) and malposition requiring exchange in 2 patients (6.4%). There was AX hematoma in 1 patient requiring revision and 1 patient with a right-sided ICD who had peripheral vascular disease developed left-sided arm and lower limb ischemia. Neither group had no device-related infection, wound infection, or brachial plexus symptoms. Conclusion: The insertion of IABP via the left AX as a bridge to HT is feasible with a good safety profile. The left AX approach for patients with ipsilateral ICDs can also be performed safely without increasing procedure time and adverse events.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Ambulation of Patients With In Situ Femoral Intraaortic Balloon Pump While Awaiting Heart Transplantation.

Optimized Insertion And Management Approach To Bridging Axillary Intraaortic Balloon Pump Significantly Reduces Risk Of Complications

Optimized Insertion And Management Approach To Bridging Axillary Intraaortic Balloon Pump Significantly Reduces Risk Of Complications

Efficacy of Prolonged Impella 5.5 Support as Bridge to Heart Transplantation: Current Concepts and Future Direction.

To the Editor: Zaky et al.1 recently published an interesting article titled, “Impella 5.5 Support beyond 50 Days as Bridge to Heart Transplant in End-Stage Heart Failure Patients” that demonstrated efficacy of the Impella 5.5 regarding its ability to provide adequate prolonged hemodynamic support and maintain durability in four cases. The four patients presented in cardiogenic shock with a history of heart failure with or without chronic kidney disease. Due to contraindications to left ventricular assist device use, they received Impella 5.5 support for a mean duration of 70 days (range 54–83). All patients were able to ambulate by day 6, with the only device malfunction being loss of placement signal in one patient and the only complication being bilateral posterior cerebral artery infarcts of unknown cause in another patient. All four patients had devices with intact pump function on explantation and underwent successful heart transplantation. The authors note only one other report in the literature of prolonged Impella 5.5 support as bridge to heart transplantation and no reports in the existing literature of malfunctions or complications in patients with prolonged use (>50 days). Adding on to their discussion of the relevant literature, we wanted to note our published experience with a patient on prolonged Impella support beyond 50 days.2 The patient was a 51-year-old male with decompensated heart failure, chronic kidney disease, and cirrhosis who was sequentially supported with axillary intra-aortic balloon pump, Impella 5.5, and venoarterial extracorporeal membrane oxygenation (V-A ECMO) prior to triple organ, heart-liver-kidney transplantation. The patient was supported on Impella 5.5 for 79 days, comparable to the mean duration of support in the case series published by Zaky et al.1 Total length of temporary mechanical circulatory support (MCS) was 95 days prior to successful transplantation. During the period of Impella support in our patient, he had an episode of heparin-induced thrombocytopenia (HIT) at 30 days treated with argatroban and, subsequently, sepsis at 78 days, prompting Impella explant and initiation of V-A ECMO. Studies have evaluated the risk of these patterns of complications in patients supported with Impella and have shown an association between Impella support and HIT and sepsis.3–5 Our case report corroborates the findings of the reported case series.1 While our collective findings do demonstrate the efficacy of Impella 5.5 support for prolonged temporary MCS as a bridge to heart transplantation beyond the duration of less than or equal to 14 days as approved by the Food and Drug Administration, rates of complications during prolonged support have not been fully delineated. These potential complications do appear to be significant; however, they have not affected survival to transplantation based on our single-center experience. Multicenter, longitudinal studies are warranted to examine the risk and significance of complications of prolonged Impella support before prolonged use of this device becomes an established and widely applied bridging strategy.

119 Axillary Intra-Aortic Balloon Pump, Biventricular Assist Device Implantation and Subsequent Orthotopic Heart Transplantation in a Patient with Sickle Cell Trait

Abstract A 38-year-old Caucasian male presented to a local hospital with breathlessness. After thorough investigation, transthoracic echocardiography demonstrated dilated cardiomyopathy. He continued to deteriorate and developed florid pulmonary oedema, necessitating transfer to our centre. Routine work-up for cardiac transplantation found him to be a carrier of the HbS sickle cell trait, with an HbS concentration of 34.4%. Due to uncertainty of candidacy and further deterioration, axillary-IABP supported his bridge-to-decision. An IABP was inserted under fluoroscopic guidance via the right axillary artery using Seldinger technique. He continued to deteriorate requiring implantation of a BiVAD. He developed cardiac tamponade 23 days after BiVAD implantation demanding surgical evacuation. His condition improved with recovery of renal and liver function and resolution of pulmonary oedema. As there was no evidence of myocardial recovery, he was placed on the super-urgent heart transplant (HTX) list. After 45 days of BiVAD support, he underwent orthotopic HTX. The donor heart was from a 31-year-old male transported on cold storage. The patient remained normothermic throughout and diastolic arrest was achieved with cold blood cardioplegia delivered via the aortic root. Upon completion of anastomoses, bleeding from the posterior aortic wall occurred, requiring further aortic cross-clamping, cold-blood cardioplegia and administration of multiple blood products. Subsequently, the right ventricle distended, and the septum became dyskinetic. Central veno-arterial extracorporeal membrane oxygenation was initiated uneventfully. VA-ECMO was weaned on the 5th-postoperative day, and he was discharged from the CTCCU six days later, he returned home 28 days after HTX. He maintained recovery and remains alive and well 34 months after discharge.

Clinical outcomes of grafted vs. percutaneous axillary intra-aortic balloon pump support as a bridge to transplantation: a propensity score-matched analysis

The purpose of this study is to investigate the early and late outcomes of axillary intra-aortic balloon pump (IABP) implantation as a bridge to heart transplantation, comparing the grafted technique with the percutaneous technique. Between July 2009 and January 2020, 163 patients underwent an axillary IABP insertion as a bridge to heart transplantation. Among them, 97 patients underwent axillary IABP implantation through a graft sutured onto the axillary artery (Group A) and 66 patients underwent percutaneously (Group B). Propensity matching identified 53 matched pairs for analysis (C-statistics 0.741). The primary outcomes of interest includedIABP-related complications, success rate of a bridge to transplantation, in-hospital mortality, and late survival. In the propensity-score matched cohort, there were no significant differences in the baseline characteristics between the two groups. The operation time was significantly longer in Group A than in Group B (141.5 ± 38.3min vs 42.7 ± 19.3min, p < 0.01). The complication rates including stroke, re-exploration for bleeding, and aortic event were not significantly different between Group A and B. However, Group A required more transfusion and re-exploration for bleeding. The success rate of a bridge to transplantation was similar between Group A (47/53, 88.7%) and Group B (47/53, 88.7%). There were no significant differencesinin-hospital mortality and late survival between two groups. In the propensity score matching analysis, there were not any significant differences between the two groups in IABP-related complications, in-hospital mortality, and late survival. The percutaneous technique provided a shorter operation time and less requirement of transfusion and re-exploration for bleeding compared to the grafted technique. The percutaneous technique might be favorable when feasible.

Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure.

Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure.

Contemporary Single-Center Experience with Axillary Intra-Aortic Balloon Pumps

<h3>Purpose</h3> Intra-aortic balloon pumps (IABP) are increasingly being utilized to augment hemodynamic support in patients awaiting heart transplantation. In this subset of patients, the use of axillary IABP has the benefits of allowing increased mobility and decreased risk of infection when compared to the femoral approach for IABP. To further gain insight into the risks and benefits of this approach, we performed a retrospective review of our center's experience with axillary IABP. <h3>Methods</h3> We conducted a retrospective review of adult patients undergoing axillary IABP placement from July 2017 to April 2021. Variables collected included general patients' characteristics such as gender, age and comorbidities, indication for axillary IABP placement, hemodynamic parameters before and after IABP, days on axillary IABP, days from initial axillary IABP to transplant, postoperative and device complications. <h3>Results</h3> A total of 42 adults underwent open axillary IABP placement during the study period. Mean age was 52 years and most of the patients were male. The most common etiology was non-ischemic with an indication of bridge to transplantation (BTT) (<b>Table</b>). Successful orthotopic heart transplantation was performed in 40 of these patients. Mean duration of axillary IABP support was 19 days and mean duration from initial axillary IABP insertion to transplant was 27 days. Cardiac output and cardiac index significantly increased after IABP placement (p<0.001). Ten patients required one balloon exchange and two required two exchanges. Device malfunction was the most common IABP complication and acute kidney injury was the most common patient complication. There were no mortalities related to IABP placement. <h3>Conclusion</h3> Axillary intra-aortic balloon pump use has risen over the past years. The most common indication for axillary IABP at our institution was BTT with a success rate of 97.5%. The most common balloon complication was malfunction requiring an exchange, and the most common patient complication was acute kidney injury.

Acute Left Subclavian Artery - Aortic Arch Approach Angle Increases the Risk of Axillary Intra-Aortic Balloon Pump Complication: A Word of Caution

<h3>Introduction</h3> The axillary intra-aortic balloon pump (ax-IABP) is frequently used as a bridge to transplantation (BTT) as it allows for rehabilitation. However, it is associated with 40% rate of device failure, without data to guide patient selection. We contrast two patients' outcomes with ax-IABP to highlight the potential role of CT-guided risk stratification for ax-IABP malfunction. <h3>Case Report</h3> Two patients with dilated cardiomyopathy had ax-IABP placed as BTT. Patient A, a 32-year-old male, and patient B, a 63-year-old female. Patient A was successfully supported for 15 days, reconditioned physically, and transplanted without complications. Patient B had recurrent ax-IABP malfunction. Four days after placement, the ax- IABP had migrated into the ascending aorta and required replacement. On Day 12, the ax- IABP device again prolapsed into the ascending aorta and ruptured. The sharp edge of the IABP kink caused a proximal descending aorta pseudo-aneurysm that required endovascular repair. The main anatomic difference between patient A and B was the angle between the left subclavian artery and the aorta, the path taken by the ax-IABP (Figure 1) <h3>Summary</h3> Many centers observed recurrent device malfunction in certain patients while others tolerate ax-IABP well, indicating inherent patient susceptibility. The IABP device was designed for femoral access, which does not entail acute angels. Measuring the angle of the projected path taken by the ax-IABP, between the subclavian artery towards the descending aorta, may help prevent this severe complication. A CT scan of the chest is routinely performed for surgical planning of transplant and allows for accurate measurement of the described angle in the oblique sagittal "candy-cane" plane. Until a new IABP device developed for axillary approach is released, device failure will remain a challenge. We plan to publish our local data to provide an evidence-based cut-off angel that can be clinically referenced.

Significant vascular complications in percutaneous axillary intra-aortic balloon pump

ObjectiveAxillary Intra-aortic balloon pump (IABP) has been increasingly utilized for hemodynamic support in heart failure patients. Vascular complications associated with axillary IABP such as dissection or rupture are relatively rare but not negligible that could negatively affect clinical outcomes. We summarized our experiences. MethodsThis is a retrospective study reviewing of all patients receiving an axillary IABP between June 2016 and November 2020. A total of 199 patients underwent percutaneous axillary IABP placement. 6 patients (6/199, 3.0%) were complicated with arterial/aortic dissection or rupture during the procedures or the course of treatment. We described their clinical presentations and outcomes. ResultsVascular complications included acute type A aortic dissection in 2 patients, descending aortic rupture in 1 patient, abdominal aortic rupture along with type B aortic dissection in 1 patient, and the localized left subclavian artery dissection in 2 patient. 2 type A aortic dissection cases were surgically treated: 1 with emergent left ventricle assist device and ascending aorta replacement, the other with emergent left ventricle assist device. Emergent endovascular treatment was successfully performed in 2 aortic rupture cases. The left subclavian artery dissection cases were managed medically. The postoperative/treatment course was uneventful in all patients. ConclusionPercutaneous axillary IABP therapy can cause significant vascular complications. Early diagnosis and prompt treatment would be the key to improve the clinical outcomesv.

Ten-year, single center experience of ambulatory axillary intra-aortic balloon pump support for heart failure

BackgroundThe axillary intra-aortic balloon pump has an advantage over the femoral intra-aortic balloon pump in terms of mobility. While axillary intra-aortic balloon pump has been widely used recently as a mode of mechanical circulatory support, the number of reported cases is limited. The purpose of this study is to summarize our experience and to evaluate the safety and efficacy of axillary intra-aortic balloon pump support. MethodsBetween July 2009 and July 2019, 241 patients underwent axillary intra-aortic balloon pump support for heart failure. The intended therapeutic goals were bridge to heart transplantation (n=146), left ventricular assist device (n=66), and recovery (n=29). Intra-aortic balloon pumps were inserted through a graft sutured onto the axillary artery in 142 patients (58.9%) and percutaneously in 99 patients (41.1%). It was placed from the right axillary artery in 147 patients (61.0%) and left in 94 patients (39.0%). Primary outcome measures of interest included achievement of intended therapeutic goal, hemodynamic data, ambulatory data, intra-aortic balloon pump-related death, and complications. ResultsAmbulation was possible in 217 patients (90.0%) during support. Hemodynamic parameters improved significantly after axillary intra-aortic balloon pump support. In total, 13 patients (5.4%) died and 10 patients (4.1%) required escalation of mechanical support. There were no deaths directly attributable to intra-aortic balloon pumps. Intra-aortic balloon pump-related stroke occurred in 6 patients (2.5%). Overall, 86.7% were successfully bridged to intended therapy (transplantation 90.4%, left ventricular assist device 90.9%, and recovery 58.6%). ConclusionsAxillary intra-aortic balloon pumps allow most patients to ambulate during support, improve hemodynamics, and lead to the intended goals successfully.

Endovascular repair of aortic perforation and type B aortic dissection after axillary intra-aortic balloon pump insertion

We present the successful endovascular repair of an iatrogenic aortic dissection in a 57-year-old woman with decompensated heart failure. An intra-aortic balloon pump was inserted in the patient via a percutaneous axillary approach for circulatory support. Six days later, she developed symptoms of abdominal pain and lower extremity malperfusion. Computed tomography angiography demonstrated a type B aortic dissection with associated retroperitoneal hematoma secondary to aortic perforation. The patient underwent emergent endovascular aortic repair and intra-aortic balloon pump removal with return of lower extremity perfusion. She recovered well and underwent heart and kidney transplant less than 2 months postoperatively.

Migration of Left Axillary Intra-Aortic Balloon Pump to the Right Common Carotid Artery.

Migration of Left Axillary Intra-Aortic Balloon Pump to the Right Common Carotid Artery.

Bridge to Transplant Outcomes with Axillary Intra-Aortic Balloon Pump versus Durable Left Ventricular Assist Device in the Current UNOS Heart Allocation System

Purpose Since the 2018 UNOS Allocation system for heart transplantation change there has been concern for increased wait times for patients with durable left ventricular assist devices (LVAD) as bridge to transplantation (BTT). Furthermore, there are increasing trends to utilize axillary intra-aortic balloon pumps (Ax-IABP) to optimize cardiac unloading while maintaining ambulatory status in listed hospitalized patients. BTT outcomes data for Ax-IABP patients is limited. Understanding risks vs benefits of prolonged support with Ax-IABP vs LVAD in the current UNOS allocation environment is imperative. Methods We performed a single center retrospective review from October 18, 2017 to October 18, 2019 for all patients who underwent heart transplant. Waitlist times based on device (Ax-IABP or LVAD) to transplant were assessed in addition to time from transplant to discharge. Intraoperative cardiopulmonary bypass time, transfusion requirements and post-operative vasoactive support was also compared. Results 59 heart transplants occurred during our review period. 8 bridged with Ax-IABP (13%) and 22 with LVAD (37%). Average age in both groups was 53 with 75% and 68% males in the IABP and LVAD groups respectively. More LVAD as BTT were transplanted prior to the UNOS change (13 vs. 9). All Ax-IABP patients were transplanted after the UNOS change. Waitlist time for LVAD was higher than Ax-IABP patients (109d vs. 575d, p=0.0003). Waitlist time before and after UNOS change was not statistically different among LVAD patients, but did increase (497d vs 688d, p=0.176). Cardiopulmonary bypass time was longer in LVAD patients, but not significant, despite similar UNOS Status at transplant. More PRBC transfusions in the LVAD group (7.5u, IQR 0u - 24u) compared to the Ax-IABP group (2.6u, IQR 0u - 6u, p=0.0012). Time from transplant to discharge was 25 days for LVAD group and 13 for Ax-IABP group (p=0.075). Conclusion Waitlist time and transfusion requirements are statistically increased in LVAD as compared to Ax-IABP as BTT. In the current listing schema for heart transplant, risk vs. benefit of increased waiting time, perioperative hemodynamic compromise and increased transfusions in the LVAD population pose significant concerns. Further prospective studies with larger cohorts may be needed to better evaluate this trend.

“Clots and Failures” A Case of COVID-19 Causing STEMI and Persistent Cardiogenic Shock Ultimately Requiring LVAD

IntroductionWe present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation.Case Report57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20th . She failed an extubation trial and underwent tracheostomy on July 23rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1.SummaryHypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

Successful Heart Transplantation in a Pan-Inflammatory Patient with Interstitial Lung Disease

Introduction We present a case with multiple comorbidities posing a dilemma regarding the need for multi-organ transplant or not being a candidate for any transplant. Case Report 58 year old Hispanic female was referred with decompensated heart failure (CHF), in cardiogenic shock. She had a history of nonischemic cardiomyopathy on home milrinone therapy. She had interstitial lung disease (ILD) on chronic therapy with high-dose hydroxychloroquine (HCQ), mycophenolate (MMF) and prednisone. She had an overlap syndrome consisting of inflammatory arthritis, ILD and myositis for four years, with a history of recurrent myositis flares treated with intravenous immunoglobulin. Presenting creatinine was impaired at 1.9mg/dL. Catheterization on milrinone 0.375mcg/kg/min showed RA 27, PA 60/41 (44), PCWP 33 with a Fick cardiac index 1.7, PAPi of 0.7 and SVR 23WU. Her initial response to diuresis was poor with worsening creatinine so she received an axillary intra-aortic balloon pump (IABP). Positive serologies included highly elevated Jo-1 antibody (185 AU/mL, reference 1000 U/L but repeat levels were normal. Endomyocardial biopsy showed inflammatory lymphocyte and macrophage infiltration. Following aggressive diuresis, HRCT chest showed persistent bilateral ground-glass opacities with interlobular thickening and lower lobe bronchiectasis consistent with ILD without honeycombing. Repeat PFT showed stable FVC of 41% predicted. After multidisciplinary discussion, she was listed status 2 for heart transplant only. Given the relative stability of her restrictive lung disease, concomitant lung transplant was not pursued. HCQ was stopped. She received a heart transplant the next day with basiliximab induction. She was extubated post-operative day 1 and on day 10 she is off inotropes and on tacrolimus, MMF and steroid taper, with no ongoing acute issues. Summary The patient's presentation was dramatic with cardiogenic shock and the decision was time-sensitive given the dependence on IABP. She was not an LVAD candidate given the RV failure (low PAPi). The transplant workup was done methodically yet urgently, with excellent multidisciplinary response, resulting in a successful heart transplant.

Long-Term Triple Temporary Mechanical Circulatory Support as a Bridge to Triple Organ Transplant

Introduction Temporary mechanical circulatory support (MCS) systems such as the intra-aortic balloon pump (IABP), Impella, and extracorporeal membrane oxygenation (ECMO) are used to stabilize decompensating patients with cardiogenic shock with the strategy of either durable MCS and/or transplantation. We present the use of all three temporary MCS platforms in a single patient as a bridge to triple organ—heart-liver-kidney transplantation. Case Report The patient is a 51-year-old gentleman with history of atrioventricular canal repair, inotrope-dependent heart failure, non-sustained ventricular tachycardia, chronic kidney disease stage III, and cirrhosis who failed outpatient inotrope therapy. His tachyarrhythmias, and liver and renal disease made him a poor candidate for durable MCS. He underwent initiation of axillary IABP and was listed as UNOS Status 2 for a heart-liver-kidney transplant. This platform supported the patient for 13 days, however, due to persistently elevated pulmonary artery pressures and poor left ventricular unloading we upgraded our support platform to the axillary Impella 5.5 (achieving >4.5lpm for 78 days). During this time frame, he was transitioned to UNOS Status 7 twice, once for heparin-induced thrombocytopenia where we were required to modify our anticoagulation to include Argatroban, and then separately when he became septic and the Impella was explanted. Still requiring circulatory support, we advanced to femoral cannulation VA ECMO. After four days on VA ECMO support as a UNOS Status 1, the patient received an en-bloc heart and liver, which was followed by a kidney implant the next day. Myocardial biopsies have consistently showed ISHLT Grade 0 R rejection, and hemodynamics showed cardiac index of 2.7 L/min/m2 and normal biventricular pressures. His postoperative stay was uncomplicated, and he was discharged to inpatient rehab after 38 days post-transplantation. Summary Temporary MCS platforms can provide varying levels of support, and implementation should be balanced by their inherent risks. This case displayed the utilization of three temporary MCS platforms in a single patient, and to our knowledge is the longest documented support for an Impella 5.5 (78 days Impella, 95 days total MCS support) to successfully bridge to heart-liver-kidney transplantation.

Abstract 13753: Early and Late Outcomes of Ambulatory Counter Pulsation Device: Novel Intravascular Ventricular Assist Device vs Conventional Axillary Intra-aortic Balloon Pump

Introduction: Intravascular ventricular assist device (iVAS; NuPulse CV, North Carolina, USA) is a newly developed ambulatory and portable counter pulsation heart assist system. Hypothesis: Early and late clinical outcomes of iVAS is comparable to those of conventional axillary intra-aortic balloon pump (IABP) as a bridge to heart transplantation(BTT). Methods: Between April 2016 and January 2020, 33 patients underwent iVAS implantation (Group A) and 69 patients underwent axillary IABP (Group B) as a BTT. We reviewed perioperative data and late clinical outcomes including survival. Long-term survival was assessed with the Kaplan-Meier analysis. Results: The patients in Group A was significantly older than Group B (A: 58.8±8.1 vs B: 53.3±14.7 p=0.048). The use of inotropes at the time of device implantation was similar between two groups (A:22/33(66.7%) vs B: 47/69(68.1%), p=0.88). Almost all patients were able to ambulate and participate in physical therapy (A:100% vs B:97.1%, p=0.21). The duration of device support in Group A was significantly longer than Group B (A:83.3±93.7 vs B:19.0±13.3 days, p &amp;lt;0.01). After a FDA approval, eleven patients (44%) in Group A was able to be discharged with an iVAS. While waiting for transplantation, 3 patients expired in Group A and none in Group B. Two patients in Group A required an escalation of support (ECMO N=1, LVAD N=1) and 1 patients in Group B (percutaneous LVAD N=1). Balloon exchange due to device related complications was required less frequently in Group A compared to Group B (A: 2/33, 6.1% vs B: 20/69, 29.0% p &amp;lt;0.01). Adverse events during balloon exchange included aortic rupture (N=1) and type A aortic dissection (N=1) (all in Group B). The success rate of BTT was not significantly different between groups (A:27/32(84.4%), B: 64/68(94.1%),p=0.13). The long-term survival after heart transplantation did not differ between the groups (A: 78.1% at 3 years vs B: 83.8% at 3 years, log-rank=0.07). Conclusions: Both iVAS and conventional axillary IABP showed comparable long-term survival and decent success rates of BTT. The iVAS featured with the portable mechanism might be a promising option as a BTT.

Positively Double Jeopardy - Dual Organ Transplantation in an HIV+ Patient

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