Cardiac Transplant Candidates Research Articles

Management of the high cardiac risk liver transplant candidate: multidisciplinary best practices and recommendations.

In a setting characterized by a growing prevalence of patients with alcohol- and metabolic dysfunction-associated steatotic liver diseases, coupled with an aging patient demographic, the incidence of cardiac comorbidities in liver transplant candidates is on the rise. These comorbidities not only pose barriers to transplant eligibility but also impact the intraoperative course and affect post-transplant outcomes. As such, there is a significant need to optimize the clinical management of these cardiac comorbidities. However, there is a scarcity of evidence regarding the best practices for managing cardiac comorbidities such as coronary and valvular heart diseases, arrhythmia and cardiomyopathy in this population, both before and during transplant surgery. These conditions necessitate a coordinated and multidisciplinary approach to care. In this manuscript, we conduct a comprehensive review of the most recent evidence pertaining to the pre- and intra-operative management of these cardiac comorbidities in liver transplant candidates. Our aim is to provide recommendations that improve and standardize their clinical care.

A - 95 State of the Science Systematic Review of the Neuropsychology of Solid Organ Transplantation.

Organ failure is associated with cognitive dysfunction; however, the acute and longitudinal effects of different types of organ failure and transplantation on cognition have yet to be fully elucidated. This systematic review aimed to identify evidence for key neurocognitive profiles by organ type among pre- and post-transplant patients and identify health and behavior factors that may influence cognition in transplant populations. PubMed, EMBASE, and PsychInfo database systemic searches were performed. The primary inclusion criteria were adult patients, peer-reviewed articles, full-organ transplant, and neuropsychological test results. Screening and data extraction were performed independently by two authors following PRISMA criteria. A total of 737 abstracts were screened, 237 full-text articles were reviewed for relevance in the second-level screening process, and a total of 125 articles were thoroughly reviewed and included. The number of studies by organ type included the following: liver (62), kidney (30), cardiac (17), lung (12), and multi-organ (4). Available research reported diffuse impairments in liver and cardiac transplant candidates, more circumscribed deficits (i.e., attention, executive functioning, and memory) in kidney transplant candidates, and few cognitive impairments among lung transplant candidates. Post-transplant research showed notable improvement across all organ recipients. Results appear to be impacted by disease severity and demographic variables, with older age more often associated with worse cognitive performance over time. Results highlight the several literature gaps that can be improved with further transplant neuropsychology research.

Extracorporeal cardiopulmonary resuscitation-based approach to refractory out-of-hospital cardiac arrest: A focus on organ donation, a secondary analysis of a Prague OHCA randomized study

BackgroundRefractory out-of-hospital cardiac arrest (OHCA) has a poor outcome. In patients, who cannot be rescued despite using advanced techniques like extracorporeal cardiopulmonary resuscitation (ECPR), organ donation may be considered. This study aims to evaluate, in refractory OHCA, how ECPR versus a standard-based approach allows organ donorship. MethodsThe Prague OHCA trial randomized adults with a witnessed refractory OHCA of presumed cardiac origin to either an ECPR-based or standard approach. Patients who died of brain death or those who died of primary circulatory reasons and were not candidates for cardiac transplantation or durable ventricle assist device were evaluated as potential organ donors by a transplant center. In this post-hoc analysis, the effect on organ donation rates and one-year organ survival in recipients was examined. ResultsOut of 256 enrolled patients, 75 (29%) died prehospitally or within 1 hour after admission and 107 (42%) during the hospital stay. From a total of 24 considered donors, 21 and 3 (p = 0.01) were recruited from the ECPR vs standard approach arm, respectively. Fifteen brain-dead and none cardiac-dead subjects were ultimately accepted, 13 from the ECPR and two from the standard strategy group. A total of 36 organs were harvested. The organs were successfully transplanted into 34 recipients. All transplanted organs were fully functional, and none of the recipients died due to graft failure within the one-year period post-transplant. ConclusionThe ECPR-based approach in the refractory OHCA trial is associated with increased organ donorship and an excellent outcome of transplanted organs.Trial registration: ClinicalTrials.gov Identifier: NCT 01511666. Registered January 19, 2012.

Impact of duration of mechanical support on heart transplantation: Hasty transplantation may not have a good long-term outcome.

Mechanical circulatory support (MCS) has been widely utilized in critically ill cardiac transplant candidates. Few studies have investigated the impact of duration of MCS before heart transplantation (HTx) on long-term patient survival. A retrospective HTx database was reviewed between 2009 and 2019. Patients who did not or did undergo MCS before HTx were categorized into two groups: (1) A (did not) and (2) B (did), respectively. A receiver operating characteristic (ROC) curve was plotted to assess the cutoff level of MCS duration before HTx in evaluating 5-year survival. A total of 270 HTx patients (group A: 120, group B: 150) were analyzed. Group B patients had a higher percentage of blood type O, a higher incidence of resuscitation, a shorter listing duration, and a higher likelihood of having United Network for Organ Sharing (UNOS) 1A status than group A. The ROC curve revealed 24 days as a good cut-off level for determining the best MCS before HTx timing. Group B was categorized into two subgroups: (1) B1 (MCS<24 days, n=65) and (2) B2 (MCS>24 days, n=85). B2 had a higher incidence of cardiopulmonary resuscitation (CPR), hemodialysis, longer waiting time after MCS, and better ventricular assist device implantation than B1. However, the survival curves showed that B1 outcomes were significantly worse than in groups A and B2. Groups A and B2 had similar survival curves without an increased incidence of infection. The preliminary data demonstrated that a longer duration of MCS may be associated with better outcomes than urgent HTx.

Heparin-Induced Fever in a Cardiac Transplant Candidate

AbstractPatient admitted to intensive care units frequently have fevers. A less common cause for fever is a drug-induced fever. For patients who are candidates for heart transplantation, persistent fevers can place a hold on their transplant candidacy until the etiology is found and the fevers resolve. We present a case of a patient with dilated cardiomyopathy who experienced fevers thought secondary to heparin that improved only with discontinuation of therapy and later underwent successful heart transplantation. Only three prior case reports of heparin-induced fevers are currently described in literature.

Association of ANK2 Mutation and Massive Myocardial Calcification: A Case Report

<h3>Introduction</h3> A 35-year-old man with no prior history of cardiovascular diseases was admitted with progressive exertional chest discomfort. Physical examination revealed irregular heart rhythm and an ejection murmur at the aortic area. EKG showed atrial fibrillation, and chest X-ray, calcification within the cardiac silhouette. Laboratory tests were all within normal ranges, including serological and inflammatory tests. <h3>Case Report</h3> An echocardiogram demonstrated diffuse myocardium calcification and intense mitral- aortic fibrocalcification, causing severe stenosis and moderate regurgitation, with a dilated left ventricle (LV) and moderate systolic dysfunction, akinesia of the inferolateral walls and hypokinesia of the anterior walls. A 128-row multidetector CT showed massive calcification affecting the aortic and mitral valves, the right ventricle, the left atrium wall and all the segments of the LV, preserving only the basal septum. Cardiovascular magnetic resonance imaging 1.5T revealed diffuse myocardial thickening, matching the areas seen on CT (figure). These areas were hypointense on the SSFP cine images and on T1- and T2-weighted images and had no late gadolinium enhancement (LGE). However, there was LGE in the underlying myocardium, in a non-ischemic distribution. Pericardium and coronary arteries were preserved. Genetic analysis identified a rare heterozygous variant of uncertain significance, c.10702C>T(p.Arg3568Trp), in ANK2 gene. <h3>Summary</h3> Ankyrin-B, also known as Ankyrin-2, is encoded by the ANK2 gene, which plays critical roles in the localization and stabilization of ion transporters and ion channels in cardiomyocytes. The Ankyrin-B syndrome has been associated to long QT syndrome and torsades depointes, but there are no reports of myocardial calcification. The patient was found to be a candidate for cardiac transplantation and is currently on the waiting list.

Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates.

BackgroundBecause of discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency.Methods and ResultsWe performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and posttransplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 versus 56 years) and more likely female (54.4% versus 23.8%) compared with the highest urgency patients, and these trends persisted in the new system (P<0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of cytomegalovirus, hepatitis C, or diabetes (P<0.01, all). The lowest urgency patients had longer waitlist times and under the new allocation system received organs from shorter distances with decreased ischemic times (178 miles versus 269 miles, 3.1 versus 3.5 hours; P<0.001, all). There was no difference in posttransplantation survival (P<0.01, all).ConclusionsPatients transplanted as lower urgency receive hearts from donors with additional comorbidities compared with higher urgency patients, but outcomes are similar at 1 year.

Reversal of pulmonary hypertension in paediatric patients with restrictive cardiomyopathy.

Left ventricular assist devices can reverse pulmonary hypertension in cardiac transplant candidates with heart failure with a reduced ejection fraction. Whether a similar approach is applicable in restrictive cardiomyopathy is uncertain. We report the successful implantation of a Medtronic HVAD left ventricular assist device in a bridge-to-candidacy concept in 2 paediatric patients with restrictive cardiomyopathy.

Liver Transplantation for Glycogen Storage Disease Type IV.

Glycogen storage disease type IV (GSD IV) is a rare autosomal recessive disorder caused by glycogen–branching enzyme (GBE) deficiency, leading to accumulation of amylopectin–like glycogen that may damage affected tissues. The clinical manifestations of GSD IV are heterogeneous; one of which is the classic manifestation of progressive hepatic fibrosis. There is no specific treatment available for GSD IV. Currently, liver transplantation is an option. It is crucial to evaluate long–term outcomes of liver transplantation. We reviewed the published literature for GSD IV patients undergoing liver transplantation. To date, some successful liver transplantations have increased the quantity and quality of life in patients. Although the extrahepatic manifestations of GSD IV may still progress after transplantation, especially cardiomyopathy. Patients with cardiac involvement are candidates for cardiac transplantation. Liver transplantation remains the only effective therapeutic option for treatment of GSD IV. However, liver transplantation may not alter the extrahepatic progression of GSD IV. Patients should be carefully assessed before liver transplantation.

569. A Multidisciplinary Approach to the Pre-evaluation Process of Pediatric Solid Organ Transplant Patients

BackgroundPediatric transplant recipients are at increased risk of infection-related morbidity and mortality, both from opportunistic infections and vaccine-preventable diseases. Since vaccine immunogenicity may wane with organ failure and immunosuppressive therapies, it is recommended that transplant candidates are immunized early in their disease course, prior to transplant. However, transplant candidates are often incompletely immunized due to factors including complexity of care and multiple providers. A multidisciplinary approach involving Infectious Diseases (ID) is crucial to ensure that vaccination status is optimized prior to transplant and to prevent and treat infectious complications.MethodsDuring the solid organ transplant evaluation process, liver, intestinal, and heart transplant candidates and their families meet with Infectious Diseases, Transplant Pharmacy, and Organ Procurement clinicians. The multidisciplinary team effort ensures that transplant candidates receive appropriate vaccines prior to transplant, based on immunization history and serology results. The team helps to manage infections diagnosed during the evaluation process (active or latent), identify risk factors for infection, optimize antimicrobial dosing based on comorbid conditions and concomitant medications, and follows patients post-transplant. Transplant candidates and their families are educated on how organ donation and organ allocation function in the US.ResultsSince launch of our multidisciplinary solid organ transplant team, we have completed pre-transplant ID evaluations on 64 patients [Table 1]. Nearly all (97%) of pre-transplant evaluated patients received vaccine optimization (booster/new vaccine doses) [Table 2]. Forty-five patients (70%) underwent organ transplant. Many intestinal (67%), cardiac (46%), and liver (27%) transplant candidates with pre-transplant evaluations required subsequent ID consultation.Table 1 Table 2 ConclusionMultidisciplinary ID pre-transplant evaluation leads to individualized vaccine optimization and infection management. Families benefit from education and counseling as well as familiarity with the Transplant ID consult service, involved in a large percentage of these patients in their peri- and post-transplant course.Disclosures All Authors: No reported disclosures

The effect of universal infant vaccination on the prevalence of hepatitis B immunity in adult solid organ transplant candidates.

BackgroundHepatitis B virus (HBV) immunity is recommended to optimize outcomes after solid organ transplantation (SOT). This study assessed the prevalence and predictors of HBV immunity at the time patients were placed on transplant waiting list over a period from 1997 to 2019 in a low HBV endemic region.MethodsData were obtained from the University Hospitals Leuven transplant database. Minors and patients with past/current HBV infection were excluded. From 1986, Belgian patients are covered by the universal infant vaccination; therefore, birth cohort was stratified in those born ≥1986 vs <1986.ResultsThe study population consisted of 3297 SOT candidates. HBV immunity rate was superior in renal transplant candidates (55.3%), and this number was 21.5%, 15.4% and 16.8% for liver, cardiac and pulmonary transplant candidates, respectively, P < .001. Among liver transplant candidates, HBV immunity rate was 14.8% in decompensated cirrhotic patients and 27.9% in those without advanced cirrhosis (P < .001). The overall immunity rate increased from 19.3% in period 1997‐2008 to 32.8% in 2009‐2019, P < .001. In multivariable analyses, younger age (odds ratio (OR) 95% confidence interval (CI): 0.97‐0.98, P < .001) and birth cohort ≥ 1986 (OR 95% CI: 1.18‐2.66, P = .006) were associated with increased HBV immunity.ConclusionAn increase in HBV immunity was observed over a 20‐year period related to the introduction of universal infant HBV vaccination. Nevertheless, this study highlights the low overall HBV immunity at the time of listing for organ transplantation and points out the need of an increased awareness and vaccination strategy at an early disease stage.

P1623MAJOR ADVERSE CARDIOVASCULAR EVENTS (MACE) AFTER KIDNEY TRANSPLANTATION: A POPULATION-COHORT ANALYSIS OF ENGLISH TRANSPLANT CENTRES

Abstract Background and Aims Due to a high burden of cardiovascular disease in end-stage kidney failure, candidates for kidney transplantation must undergo cardiac screening to determine their ‘cardiac fitness’ to proceed with surgery even when asymptomatic and in the absence of robust evidence. MACE rates within the first year after kidney transplantation in North American centres are reported at between 7.0% and 8.7% but data from an European cohort is lacking. Therefore, the aim of this population-cohort analysis was to determine the MACE rate within the first year after kidney transplantation for all kidney transplant recipients in England. Method We obtained data from every kidney transplant procedure performed in England between 1st April 2002 and 31st March 2018. Data was extracted from Hospital Episode Statistics using administrative ICD-10 and OPCS-4 codes, with linkage to the national death registry for mortality data (including causality). We excluded age ≤18, repeat transplant in same period, multi-organ transplant and residence outside England. MACE was defined as any hospital admissions with myocardial infarction, stroke, unstable angina, heart failure, any coronary revascularisation procedure and/or any cardiovascular-related death. Univariable and multivariable logistical regression analyses were conducted to investigate the odds for MACE after kidney transplantation. Results After exclusions, we had a cohort of 30,325 kidney transplant recipients for analysis. MACE events occurred in 781 kidney transplant recipients within the first-year post-transplantation (2.6% of all kidney transplant procedures). Of these 781 MACE events, 201 occurred during the index admission for kidney transplantation surgery (representing 25.7% of all first-year MACE events and 0.7% of all kidney transplant procedures). Predictors of long-term mortality on Cox regression include; age, non-White ethnicity, socio-economic deprivation, deceased donor, pre-existing diabetes, increased Charlson score, previous cardiac history and MACE within the first year (HR 2.59; 95% CI 2.34-2.88, p&amp;lt;0.001). Kidney transplant recipients who suffered a non-fatal MACE within the first year had 1-, 3-, 5- and 10-year patient survival of 80.5%, 70.2%, 54.5% and 38.6%, compared to 97.4%, 94.4%, 90.7% and 78.4% for kidney transplant recipients not developing MACE within the first year post-transplant (p&amp;lt;0.001). Kidney transplant recipients having MACE events during the index admission compared to subsequent admissions were differentiated by age, sex and previous cardiac history but had similar patient survival (p=0.283). Conclusion MACE events within the first year after kidney transplantation are associated with increased mortality risk in England but MACE rates are significantly lower at 2.6% than those reported in North America. This is despite similar cardiac screening strategies, which may reflect different patient demographics and kidney failure care. In the context of the increased debate concerning the utility of cardiac screening asymptomatic kidney transplant candidates, understanding baseline MACE rates can shape the design of clinical trials exploring non-inferiority of cardiac screening versus non-screening before joining the waiting list (which differs methodologically from the CARSK study). However, renal physicians and surgeons will need to determine the upper boundary of the 95% confidence interval for the hazard ratio of MACE risk in any future clinical trial.

An Initial Experience from a Single Centre with Oral Milrinone in Patients Supported with a Left Ventricular Assist Device

Milrinone is a phosphodiesterase III inhibitor used as an inodilator in patients with right ventricular (RV) failure. Oral milrinone may offer an alternative to patients with refractory RV dysfunction supported with left ventricular assist devices (LVAD). We reviewed all patients supported on an LVAD commenced on oral milrinone for a refractory right ventricular failure who were maintained using therapeutic drug monitoring in the community (range 100-300 ng/ml). Available haemodynamic data and outcomes were assessed. Seven patients (Median Age 50 (IQR 48-54), Male 6/7) on chronic LVAD support with refractory RV failure, were commenced on oral Milrinone for persistently raised Pulmonary Vascular Resistance (PVR) or recurrent episodes of decompensated heart failure. The median duration of milrinone therapy was 117(IQR 59-221) days. Outpatient monitoring of milrinone levels was feasible and showed overall Median level was 175(111-256) ng/ml. There were no adverse events related to milrinone and in particular, there were no arrhythmias recorded. One patient died due to worsening heart failure; two patients were transplanted but one died during the post-op period. Of the surviving patients, matched right heart catheterisation data were available for 3 patients (see table) which showed some evidence of improved PVR and Cardiac Index (CI). In this limited cohort, oral milrinone appears to be tolerated, safe and feasible to maintain appropriate therapeutic levels in this population in the community. This therapy may offer additional cardiovascular support for patients deteriorating on maximal LVAD support who are not immediate candidates for cardiac transplantation.

Biventricular Support with Syncardia Total Artificial Heart: Long-Term Single-Center Experience

The SynCardia Total Artificial Heart (TAH) is a pneumatically driven assist system to provide mechanical circulatory support in patients with severe non-reversible biventricular failure, who otherwise have no mechanical support devices. The aim of our retrospective study is to assess the comorbidity and survival of patients awaiting cardiac transplant while circulatory support with TAH. We examined data related to survival, adverse events, and outcomes from patients undergoing TAH implantation between Januar 2001 and September 2019. For determination of the predictors for mortality we used multivariate analysis. Between February 2001 and September 2019, a total of 190 consecutive patients (88.9% men; mean age, 53±11.6 years,) underwent TAH implantation. Indications for TAH implantation were cardiomyopathy in 84 (44.2%), acute myocardial infarction in 50 (26.3%) and postcardiotomy biventricular heart failure in 29 (15.3%) and others (allograft rejection, myocarditis, endocarditis, congenital heart disease) in 27 patients (14.2%). The majority of patients (166/87.4%) were in INTERMACS profile 1, the remainder (24/12.7%) in INTERMACS profiles 2-3. Preoperative measures of the creatinine was 2.0±1.3 mg/dl and total bilirubin 3.0±3.8 mg/dl. The median support time was 169 days (range, 1 to 971 days). During TAH support, 32.1% of patients suffered from stroke, 30.5% from mesenteric ischemia and 24.2% from gastrointestinal bleeding. The median follow-up for survival of patients on support was 4.3 months. The 1-, 6- and 12-month survival was 71%, 42% and 35%, respectively. A total of 120 (63.2%) patients died during support. The most common causes of the death were multiorgan failure or/with sepsis. Multivariate analysis revealed that age p=0.003), underweight with BMI <18.5 kg/m² (p=0.001), higher total bilirubin (p=0.007) and preoperative IABP (p=0.013) were independent predictors for mortality during support. Sixty-nine (35.3%) were successfully bridged to transplantation after a mean support time of 311±205 days. 1-, 5- and 10-year survival was 64%, 58% and 51%, respectively. SynCardia TAH provides acceptable outcomes in critically sick patients with irreversible heart failure who are candidates for cardiac transplantation. More than one third of our TAH-patients were be successfully bridged to transplantation.

Management of pediatric cardiac transplantation candidates with pulmonary hypertension and high pulmonary vascular resistance.

Right ventricular failure is an important cause of mortality and morbidity after orthotopic heart transplantation (OHT). The right ventricle of the donor may fail to accommodate to the high pulmonary vascular resistance (PVR) of the recipient. Pulmonary hypertension (PH) due to chronic heart failure with PVRi > 4 Wood units.m2, transpulmonary gradient > 15 mmHg adversely affect the outcome of OHT. In this study we aimed to evaluate management strategies in our pediatric cardiac transplantation candidates with PH and high PVR prior to OHT. Twenty-six cardiac transplantation candidates (age: 10.2 ± 4.6, 1-17 years) underwent cardiac catheterization for the determination of PVR and pulmonary arterial pressure. They were admitted to the hospital and received 1-3 days of intravenous (IV) vasodilator therapy; 0.5-3 μg/kg/min nitroglyserin and/or 0.5-3 μg/kg/min nitroprusside, 5-15 μg/kg/min dobutamin and/or dopamin to keep systolic blood pressure above 80 mmHg. Thirteen patients had dilated cardiomyopathy (CMP), 11 had restrictive CMP, one had hypertrophic CMP and one had congenital heart disease (CHD). Nineteen of the 26 patients underwent OHT. Mean pulmonary arterial pressure of the patients ranged between 11 and 82 mmHg (30.4 ± 16 mmHg) and PVRi between 0.41-21.4 Wood units.m2 (5.3 ± 5.7). Nine patients had PVRi above 4 Wood units.m < sup > 2 < /sup > . Six of these patients had IV treatment for longer than three days and some received specific anti-PH treatment. Eventually they underwent a pulmonary vasoreactivity test with IV iloprost and six had PVRi < 4 Wood units.m < sup > 2 < /sup > . Five of them underwent OHT. Cardiac transplantation candidates with PH and high PVR should be evaluated after conditioning with vasodilator and inotropic treatment. Specific treatment for PH and vasoreactivity testing may help selected patients reenter the transplantation list.

P175 Cardiac device infection: to extract or not to extract, that is the question

Abstract Introduction The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients. Case report We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock. Conclusion Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

The Approach to the Psychosocial Evaluation of Cardiac Transplant and Mechanical Circulatory Support Candidates

We update evidence underlying the recommendations of a 2018 multi-society consensus report regarding the psychosocial evaluation of individuals for cardiothoracic transplantation and mechanical circulatory support (MCS). In the present review, we focus on heart transplantation and MCS. Expert opinion and new evidence support the inclusion of ten core content areas in the psychosocial evaluation. Prospective data indicate that psychosocial factors can predict post-transplantation/post-implantation outcomes. Such factors include treatment adherence history, mental health and substance use history, cognitive impairment, knowledge about treatment options, and social factors such as socioeconomic status. For other factors (e.g., coping, social support), new evidence is weaker because it derives largely from cross-sectional studies. Concerning evaluation process issues, expert opinion remains consistent with consensus recommendations, but there is a dearth of empirical evidence. The psychosocial evaluation can identify factors relevant for candidacy for heart transplantation and MCS implantation. It enables the provision of interventions to improve patients' viability as candidates, and facilitates care planning.

Case report and review of the literature: the utilisation of a ventricular assist device as bridge to recovery for anthracycline-induced ventricular dysfunction - CORRIGENDUM.

Ventricular assist devices are used in children with heart failure as a bridge to myocardial recovery or cardiac transplantation. Anthracyclines cause cardiac toxicity and may result in acute or long-term cardiac failure. We describe the use of a ventricular assist device as a bridge to recovery in a child with severe acute anthracycline-induced cardiomyopathy, and we review the associated literature. A 6-year-old girl was treated for acute myeloblastic leukaemia with daunorubicin and mitoxantrone. After 2 weeks her final dose of chemotherapy, her Left Ventricular Ejection Fraction decreased to 21%. Despite initiation of medical therapy, she had continued deterioration of left ventricular function and developed evidence of poor end-organ perfusion. She was not a candidate for cardiac transplantation, as the post-transplant immune suppression therapy would put her at risk for recurrence of her malignancy. We placed her on a short-term ventricular assist device as a bridge to ultimately placing her on a long-term ventricular assist device versus continuing medical therapy. Her left ventricular ejection fraction improved to 55% 24 days after ventricular assist device insertion. She was separated from the ventricular assist device 26 days after its insertion. She was discharged home 29 days later and is now 28 months after ventricular assist device implantation with stable ventricular function, as documented by a left ventricular ejection fraction of 55%, and normal end organ function. This case is one of the only reports known describing successful use of a short-term ventricular assist device as a bridge to recovery in a child with severe acute anthracycline-induced cardiotoxicity.

P075 Comparative efficacy of bortezomib and carfilzomib desensitization protocols in highly sensitized cardiac transplant candidates

P075 Comparative efficacy of bortezomib and carfilzomib desensitization protocols in highly sensitized cardiac transplant candidates

Time for evidence-based, standardized donor size matching for pediatric heart transplantation

BackgroundAccurately predicting cardiac size by other body parameters has long been problematic to determine whether a donor heart will serve a given waitlist candidate, yet hundreds of heart donors are turned down annually for size mismatch. ObjectivesWe sought to describe how donor body weight parameters are currently utilized in cardiac transplantation and its influence on waitlist outcomes. MethodsFrom the United Network for Organ Sharing database, pediatric (age <18 years) heart transplant candidates were divided into lower quartile, interquartile, and upper quartile categories based on final maximum acceptable donor–candidate weight ratio (DCW), expressed as percentage. Baseline characteristics and waitlist outcomes, including monthly offers/candidate and survival were compared. ResultsOverall median DCW was 200% (range, 159%-241%). Patients with congenital heart disease had higher DCW than those with cardiomyopathy (223% vs 203%; P < .001). Number of monthly offers/candidate (5.0, 5.6, and 7.2, respectively; P < .001) increased with quartile of DCW. Posttransplant survival was similar amongst the groups (log-rank P > .05). Subgroup analysis of critically ill children showed a waitlist survival advantage in those listed with a DCW ≥200% (P < .001). ConclusionsDespite substantial practice variation in acceptable donor weight in pediatric heart transplantation, patients listed with variable DCW had similar posttransplant survival. However, in critically ill patients, higher DCW was associated with greater waitlist survival. Better understanding of the importance of donor weight could reduce practice variability and improve organ use and waitlist outcomes for pediatric cardiac transplant candidates.