List For Heart Transplantation Research Articles

Hypertrophic Cardiomyopathy: From Medical Treatment to Advanced Heart Failure Therapies.

There has been much debate surrounding novel medical therapies and heart transplantation listing challenges in patients with hypertrophic cardiomyopathy (HCM). Recent clinical trials led to FDA approval of mavacamten (a cardiac myosin inhibitor), offering symptom relief and potentially delaying/avoiding invasive septal reduction therapies for some patients with HCM and left ventricular outflow obstruction (LVOTO). For those with refractory symptoms and end-stage heart failure, heart transplantation remains the gold standard. However, the concern for the organ allocation system failing to prioritize those individuals persists. HCM is a heterogeneous genetic condition with variable penetration and clinical presentation. Even though a large portion of patients remain asymptomatic, an important minority develops debilitating symptoms refractory to medical therapy. Post-HT short- and long-term outcomes are favorable. However, HT waitlist mortality remains high. For highly selected patients with HCM, a left ventricular assist device is a viable option.

Outcomes of pediatric heart transplantation in children with selected genetic syndromes

ObjectiveGenetic syndromes (GSs) are often linked to congenital heart disease (CHD) and cardiomyopathy (CM). The effect of GSs on survival following pediatric heart transplant (HT) has not been well described. We aimed to compare outcomes following HT between children with a GS and those without a GS. MethodsThe United Network for Organ Sharing (UNOS) transplantation database was merged with the Pediatric Health Information System (PHIS) administrative database to identify children with GS who underwent HT between 2009 and 2019. Characteristics and outcomes were compared between children with a GS (GS group) and those without a GS (no GS group). ResultsGSs were present in 225 of 2429 HT recipients (9%). The most common GSs were DiGeorge syndrome (n = 28), muscular dystrophy (n = 27), Down syndrome (n = 26), and Turner syndrome (n = 14). The incidence of CHD was higher in the GS group compared to the no GS group (54% vs 38%; P < .1); however, patient demographics, hemodynamics, renal and hepatic dysfunction, and requirements for dialysis, mechanical ventilation, extracorporeal membrane oxygenation, and mechanical circulatory support were not different between the 2 groups. Time on the waitlist was not significantly different between the GS and no GS groups (55 days vs 53 days; P = .4). There also was no between-group difference in the incidence of post-transplantation complications, including dialysis (8% vs 5%; P = .38), stroke (3% vs 4%; P = .34), primary graft dysfunction (2% vs 2%; P = .75), need for pacemaker (1% vs 1%; P = .84) and rejection (3.4% vs 3.4%; P = .96). Survival at 10 years post-HT was 75% for the no GS group and 72% for the GS group (P = .59). The survival curves also did not differ between patients with CM and those with CHD. ConclusionsChildren with certain GSs and end-stage heart failure can be expected to have similar post-transplantation outcomes to those without a GS. Although early and late post-transplantation care is individualized to each patient, the presence of a GS should not influence the decision to list for HT.

Management of incessant ventricular arrhythmias in a patient with left ventricular assist device: a case report

BackgroundThe implantation of left ventricular assist devices (LVADs) as a bridge to transplantation or as destination therapy in end-stage heart failure patients is frequently complicated by the emergence of ventricular arrhythmias (VAs). These arrhythmias have been implicated in precipitating deleterious clinical outcomes, increased mortality rates and augmented healthcare expenditures.Case PresentationWe present a challenging case of a 49-year-old male with a history of dilated cardiomyopathy who received an LVAD. Post-implantation, the patient suffered from intractable VAs, leading to multiple rehospitalizations and hemodynamic deterioration. Despite exhaustive medical management and electrical cardioversion attempts, the patient’s VAs persisted, ultimately necessitating prioritization for cardiac transplantation.DiscussionThis case highlights the challenges in managing VAs in LVAD patients and the importance of multidisciplinary collaboration. While pharmacological intervention is the initial strategy, catheter ablation may be considered in selected cases when medication is insufficient. In instances of intractable VAs, expeditious listing for heart transplantation as a high-priority candidate is advisable when feasible.

Short Registry of Terminal Forms of Chronic Heart Failure in the Samara Region.

To study the clinical characteristics and prognosis of patients with functional class (FC) III-IV chronic heart failure (CHF) who meet the criteria for inclusion in the palliative care program. A short registry of severe CHF forms was conducted at 60 outpatient and inpatient clinics in the Samara region for one month (16.05.2022-15.06.2022). The registry included patients with FC III-IV CHF who sought medical help during that period. Lethal outcomes were assessed at 90 days after the inclusion in the registry using the Mortality Information and Analytics system. 591 patients (median age, 71.0 [64.0; 80.0] years were enrolled, including 339 (57.4%) men, of which 149 (24.1%) were of working age (under 65 years). The main cause of CHF was ischemic heart disease (64.5%). 229 (38.7%) patients had left ventricular ejection fraction &lt;40%. During the past year, 513 (86.8%) patients had at least one hospitalization for decompensated CHF. 45.7% of patients had hydrothorax, and 11.3% of patients had ascites. Low systolic blood pressure was observed in more than 25% of patients; 14.2% required in-hospital inotropic support; and 9.1% received it on the outpatient basis. 4.2% of patients received outpatient oxygen support and 0.8% required the administration of narcotic analgesics. 12 (1.9%) patients were on the waiting list for heart transplantation. In this study, there was an inconsistency in the number of patients with ventricular tachycardia and/or left bundle branch block (LBBB) who were implanted with cardiac resynchronization therapy devices (CRTD) or an implantable cardioverter defibrillator (ICD), a total of 19 patients (11 patients with CRTD and 8 patients with ICD), while 58 (9.8%) patients had indications for CRTD/ICD implantation. Within 90 days from inclusion in the registry, 59 (10.0%) patients died. According to binary logistic regression analysis, the presence of LBBB, hydrothorax, the requirement for outpatient oxygen support, and a history of cardiac surgery were associated with a high risk of death. Patients with severe forms of CHF require not only adequate drug therapy, but also dynamic clinical observation supplemented with palliative care aimed at improving the quality of life, including the ethical principles of shared decision-making and advance care planning to identify the priorities and goals of patients in relation to their care.

Predictors Associated With Prognosis of Patients on the Waiting List for Heart Transplantation.

Aim To identify predictors associated with the prognosis of patients on the heart transplant waiting list (HTWL) corresponding to UNOS class 2.Material and methods A HTWL database for 2010-2021 was retrospectively evaluated. The study included patients (n=162) who at the time of inclusion into the HTWL met UNOS class 2 and reached the endpoint of death, heart transplantation (HT), or exclusion from the HTWL due to an improvement of their condition. Mean age was 48±13 (from 11 to 67) years, 80% (n=130) were men, and body weight index was 24.9±4.4 kg/m2. Patients were divided into two groups: group 1 (n=131), patients who left the HTWL (improvement of CHF functional class) and patients who maintained the UNOS class 2 until HT; group 2 (n=31), patients who transferred from UNOS class 2 to UNOS class 1B/1A or died while on the HTWL.Results Patients of group 2 had lower systolic BP compared to patients of group 1 (100±17, mm Hg vs. 107±17 mm Hg, respectively, p=0.03). In group 1 compared to group 2, there was a higher proportion of patients with obesity, 29 (22%) vs. 1 (3%) (p=0.02). Laboratory blood tests: absolute lymphocyte count (2.0±0.7×109/L and 1.6±0.9×109/L, p=0.03), serum albumin (42±5 g/l and 40±6 g/l, p=0.03), red cell distribution width (RDW) (16±4% and 18±4%, p=0.01); sodium concentration (139±4 and 136±4 mmol/l, p=0.009). Patients from group 2 had a higher pulmonary vascular resistance (PVR) (4.0±2.4 Wood units vs. 3.2±1.4 Wood units, p=0.01) at baseline. A predictive model (p&lt;0.001) was developed to determine a probability of prognosis in HTWL. The model sensitivity was 75% and the specificity was 67%. High PVR was a predictor that worsened the prognosis in HTWL; higher serum concentrations of sodium and albumin increased the probability of a favorable outcome in HTWL.Conclusion During the period of waiting for HT, 19% of patients that met UNOS class 2 experienced deterioration of their condition (transitioned to UNOS 1) or died. The most important predictors for a better outcome in patients on HTWL who meet UNOS class 2 were higher serum levels of sodium and albumin and low pulmonary vascular resistance.

School age and adolescent heart failure following the Norwood procedure

Heart failure results in significant morbidity and mortality for young children with hypoplastic left heart syndrome (HLHS) following the Norwood procedure. The trajectory in later childhood is not well described. We studied the outcome into adolescence of participants enrolled in the Single Ventricle Reconstruction (SVR) trial who underwent the Fontan procedure or survived to 6 years without having undergone Fontan procedure. The primary outcome was heart failure events, defined as heart transplant listing or death attributable to heart failure. Symptomatic heart failure for participants surviving 10 or more years was also assessed utilizing the PedsQL. Of the 345 participants who underwent a Fontan operation or survived to 6 years without Fontan, 25 (7.2%) had a heart failure event before age 12 years. Among these, 21 were listed for heart transplant and 4 died from heart failure. Nineteen participants underwent heart transplant, all of whom survived to age 12 years. Factors associated with a heart failure event included longer Norwood hospital length of stay, aortic atresia and no Fontan operation by age 6 years. Assessment of heart failure symptoms at 12 years of age revealed that 24 (12.2%) of 196 PedsQL respondents "often" or "almost always" had difficulty walking more than one block. Heart failure events occur in over 5% of children with palliated HLHS between preschool age and adolescence. Outcomes for children listed for transplant are excellent. However, a substantial portion of palliated HLHS children have significant symptoms of heart failure at 12 years of age.

Cardiopulmonary Exercise Testing in Patients with Heart Failure: Impact of Gender in Predictive Value for Heart Transplantation Listing.

Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.

Supplemental nutrition, feeding disorders, and renourishment in pediatric heart failure through transplantation.

Tube feeds are used commonly in children listed for heart transplant; however, rates of renourishment and development of feeding disorders are not sufficiently characterized. Retrospective review of pediatric heart transplant recipients from January 1, 2014, to January 3, 2021. Demographics, anthropometric, and nutritional data were collected from heart transplant listing through 3 years post-transplant. Renourishment rates, presence of a feeding disorder, and need for a gastric feeding tube were analyzed. Multivariable analysis was conducted to identify risks for poor nutritional outcomes. Of 104 patients, 35 (34%) and 36 (35%) were malnourished at heart transplant listing and transplant, respectively, persisting in 21/91 (23%) 1 year postheart transplant. Forty (38%) received tube feeds at listing, 42 (40%) at heart transplant, and 18/90 (20%) 1 year post-transplant. Rates of feeding disorders fell from 23% at transplantation to 10% 1 year post-transplant. Feeding disorders were associated with younger age at heart transplant (p < .001) and congenital heart disease (p = .03). Forty-six percent of infants required a gastric feeding tube. Renourishment occurred in 20% during listing and was associated with ventricular assist device support (p = .03) and noncalorically dense feeds (p = .03). Malnutrition at transplant was associated with inferior post-transplant survival (6/36 (17%) vs. 2/68 (3%); p = .02). Malnourishment requiring tube feeds is common in pediatric heart transplant candidates; however, most patients who eventually survive to transplant remain malnourished at time of transplantation and 1 year later. While some children develop feeding disorders, they generally resolve by 1 year post-transplant.

Levosimendán ambulatorio repetitivo como puente al trasplante cardiaco

Introduction and objectivesRepetitive ambulatory doses of levosimendan are an option as a bridge to heart transplantation (HT), but evidence regarding the safety and efficacy of this treatment is scarce. The objective of the LEVO-T Registry is to describe the profile of patients on the HT list receiving levosimendan, prescription patterns, and clinical outcomes compared with patients not on levosimendan. MethodsWe retrospectively reviewed all patients listed for elective HT from 2015 to 2020 from 14 centers in Spain. ResultsA total of 1015 consecutive patients were included, of whom 238 patients (23.4%) received levosimendan. Patients treated with levosimendan had more heart failure (HF) admissions in the previous year and a worse clinical profile. The most frequent prescription pattern were fixed doses triggered by the patients’ clinical needs. Nonfatal ventricular arrhythmias occurred in 2 patients (0.8%). No differences in HF hospitalizations were found between patients who started levosimendan in the first 30 days after listing and those who did not (33.6% vs 34.5%; P=.848). Among those who did not, 102 patients (32.9%) crossed over to levosimendan after an HF admission. These patients had a rate of 0.57 HF admissions per month before starting levosimendan and 0.21 afterwards. Propensity score matching analysis showed no differences in survival at 1 year after listing between patients receiving levosimendan and those who did not (HR, 1.03; 95%CI, 0.36-2.97; P=.958) or in survival after HT (HR, 0.97; 95%CI, 0.60-1.56; P=.958). ConclusionsRepetitive levosimendan in an ambulatory setting as a bridge to heart transplantation is commonly used, is safe, and may reduce HF hospitalizations.

Frailty Is Common in Heart Transplant Candidates But Is Not Associated With Clinical Events and Is Reversible After Heart Transplantation

Assessment of frailty before heart transplant (HT) is recommended but is not standard in most HT protocols. Our objective was to evaluate frailty at inclusion in HT list and during follow-up and to assess the influence of baseline frailty on prognosis. A prospective multicenter study in all adults included in the nonurgent HT waiting list. Frailty was defined as Fried's frailty phenotype score ≥3. Mean follow-up was 25.9±1.2months. Of 99 patients (mean age 54.8 [43.1 to 62.5]years, 70 men [70.7%]), 28 were frail (28.3%). A total of 85 patients received HT after 0.5±0.01years. Waiting time was shorter in frail patients (0.6years [0.3 to 0.8] vs 0.2years [0.1 to 0.4], p=0.001) because of an increase in priority. Baseline frailty was not associated with overall mortality, (hazard ratio 0.99 [95% confidence interval 0.41 to 2.37, p=0.98]). A total of 16 transplant recipients died (18.8%). Of the remaining 69 HT recipients, 65 underwent frailty evaluation during follow-up. Patients without baseline frailty (n=49) did not develop it after HT. Of 16 patients with baseline frailty, only 2 were still frail at the end of follow-up. Frailty is common in HT candidates but is reversible in most cases after HT and is not associated with post-transplant mortality. Our results suggest that frailty should not be considered an exclusion criterion for HT.

Dilemmas concerning heart procurement in controlled donation after circulatory death.

With an expanding population at risk for heart failure and the resulting increase in patients admitted to the waiting list for heart transplantation, the demand of viable organs exceeds the supply of suitable donor hearts. Use of hearts after circulatory death has reduced this deficit. Two primary techniques for heart procurement in circulatory death donors have been described: direct procurement and perfusion and thoraco-abdominal normothermic regional perfusion. While the former has been accepted as an option for heart procurement in circulatory death donors, the latter technique has raised some ethical questions in relation to the dead donor rule. In this paper we discuss the current dilemmas regarding these heart procurement protocols in circulatory death donors.

Repetitive ambulatory levosimendan as a bridge to heart transplantation

Introduction and objectivesRepetitive ambulatory doses of levosimendan are an option as a bridge to heart transplantation (HT), but evidence regarding the safety and efficacy of this treatment is scarce. The objective of the LEVO-T Registry is to describe the profile of patients on the HT list receiving levosimendan, prescription patterns, and clinical outcomes compared with patients not on levosimendan. MethodsWe retrospectively reviewed all patients listed for elective HT from 2015 to 2020 from 14 centers in Spain. ResultsA total of 1015 consecutive patients were included, of whom 238 patients (23.4%) received levosimendan. Patients treated with levosimendan had more heart failure (HF) admissions in the previous year and a worse clinical profile. The most frequent prescription pattern were fixed doses triggered by the patients’ clinical needs. Nonfatal ventricular arrhythmias occurred in 2 patients (0.8%). No differences in HF hospitalizations were found between patients who started levosimendan in the first 30 days after listing and those who did not (33.6% vs 34.5%; P=.848). Among those who did not, 102 patients (32.9%) crossed over to levosimendan after an HF admission. These patients had a rate of 0.57 HF admissions per month before starting levosimendan and 0.21 afterwards. Propensity score matching analysis showed no differences in survival at 1 year after listing between patients receiving levosimendan and those who did not (HR, 1.03; 95%CI, 0.36-2.97; P=.958) or in survival after HT (HR, 0.97; 95%CI, 0.60-1.56; P=.958). ConclusionsRepetitive levosimendan in an ambulatory setting as a bridge to heart transplantation is commonly used, is safe, and may reduce HF hospitalizations.

Single Ventricular Torsional Mechanics After Fontan Palliation and Their Impact on Outcomes

BackgroundAbnormal left ventricular (LV) rotational mechanics in biventricular hearts are associated with adverse outcomes; however, these are less well characterized for hearts with functionally single ventricles. ObjectivesThe purpose of this study was to characterize ventricular rotational mechanics in the Fontan circulation and their relationship to outcomes. MethodsSingle-center, retrospective analysis of magnetic resonance examinations for 329 Fontan patients (15 [IQR: 10-21] years) and 42 controls. The ventricular cine short-axis stack was analyzed to derive torsion metrics. Torsion calculated as the difference between apical and basal rotation normalized to ventricular length. ResultsFontan patients had higher indexed ventricular end-diastolic volume (97 mL/body surface area1.3 vs 72 mL/body surface area1.3), lower ejection fraction (53% vs 60%), and lower proportion of basal clockwise rotation (62% vs 93%), apical counterclockwise rotation (77% vs 95%), and positive torsion (82% vs 100%); P < 0.001 for all. A composite outcome of death or heart transplant-listing occurred in 31 (9%) patients at a median follow-up of 3.9 years. Torsion metrics were associated with the outcome; although, on multivariate analysis only right ventricular (RV) morphology and indexed ventricular end-diastolic volume were independently associated. LVs with negative torsion, and RVs regardless of torsional pattern, had worse outcomes compared to LVs with positive torsion (P = 0.020). ConclusionsSingle ventricles in a Fontan circulation exhibit abnormal torsional mechanics, which are more pronounced for RV morphology. Abnormal torsion is associated with death or need for heart transplantation. Fontan patients with LV morphology and preserved torsion exhibit the highest transplant-free survival and torsion may offer incremental prognostic data in this group of patients.

P284 POTENTIAL PROARRHYTHMIC SIDE EFFECT OF HIGH DOSE AND PROLONGED SODIUM NITROPRUSSIDE INFUSION THROUGH CALCIUM ION REDUCTION

Abstract Patient presentation. A fifty y/o male patient with a history of congenital aortic stenosis surgically corrected previously and with chronic heart failure due to severe left ventricular dysfunction presented to our emergency department complaining dyspnea. Due to acute decompensated heart failure with ongoing cardiogenic shock, he was admitted to our intensive cardiology unit. Initial work up. The blood exams showed a normal renal and liver function, normal total and free calcium, 9.4 mg/dL and 1.16 mmol/L respectively, lactates were mildly increased. The chest x–ray showed pulmonary congestion. At the echocardiography we found severe biventricular dysfunction, moderate mitral regurgitation, severe pulmonary hypertension. Since the patient was unstable, adrenaline, high–dose sodium nitroprusside (SNP), and intra–aortic balloon pump were started. The right heart catheterization revealed combined pulmonary hypertension reversible with SNP and, therefore, the patient was inserted in the heart transplant list. Diagnosis and Management. One of the side effects of SNP is the thiocyanate toxicity. A high dose of SNP was necessary for this patient (2.2 mcg/kg/min). Thus, thiocyanate levels increased up to 10 mg/100 mL (NV&amp;lt;3). Importantly, the patient was asymptomatic despite these levels. However, the free calcium ion progressively decreased up to 0.94 mmol/L, despite normal total calcium and calcium supplementation iv and orally. Since arrhythmic burden markedly increased, we started lidocaine which was not effective. Follow–up. Since we suspected a possible causative role of thiocyanate, which might bond the double positive charged free calcium ion with its two negatively charged sulfur atoms, explaining the normal total calcium level and the low calcium ion, we carefully reduced SNP dose within days. This allowed us to reduce thiocyanate to 6 mg/100 mL, without compromising patient hemodynamics. Concomitantly, the free calcium ion tended to normalize, lowering the arrhythmic burden. Conclusions We describe for the first time a proarrhythmic side effect of prolonged SNP infusion, likely related to thiocyanate accumulation and free calcium ion binding, which, despite aggressive calcium supplementation, was normalized only after SNP down titration.

Pulmonary Artery Banding -Original, Current, and New Indications for Pulmonary Artery Banding-

First performed in the early 1950s in children with a large left-to-right shunt or single ventricle and excessive pulmonary blood flow, pulmonary artery banding (PAB) is a palliative surgery designed to relieve symptoms. After advances in cardiopulmonary bypass techniques in the 1980s allowed surgeons to perform corrective surgery even in infants, PAB has continued to play a palliative role in balancing the pulmonary to systemic blood flow ratio in critical situations. PAB is also used to retrain the left ventricle in patients with transposition of the great arteries to prepare them for the arterial switch procedure, either following late presentation or following prior atrial repair. Another role played by PAB is to train the left ventricle in patients with congenitally corrected transposition of the great arteries, not only for the purpose of retraining the sub-pulmonary left ventricle but also as an early prophylactic approach in newborns to avoid the severe tricuspid regurgitation sometimes associated with a morphologic right ventricle in the systemic position. Currently, PAB has two indications: 1. to reduce the pulmonary blood flow and relieve the symptoms of congestive heart failure, and 2. to train the sub-pulmonary ventricle for future corrective surgery. Recently, PAB has been successfully employed to treat children with dilated cardiomyopathy (DCM), a disease that has shown considerably increased morbidity and mortality rates and indications for heart transplantation; some of the patients thus treated have shown improved left ventricular function, allowing them to be taken off the waiting list for heart transplantation. In this paper, we review the original and current indications for PAB and explain the surgical technique and strategy. We also present a literature review of the new indications for PAB in patients with pediatric DCM, and compare outcomes in Japan with those in other countries.

(522) Impact of Blood Group on Status 2 vs Status 3 Heart Transplant Listing in the U.S

(522) Impact of Blood Group on Status 2 vs Status 3 Heart Transplant Listing in the U.S

Ventricular dyssynchrony late after the Fontan operation is associated with decreased survival

BackgroundVentricular dyssynchrony and its relationship to clinical outcomes is not well characterized in patients following Fontan palliation. MethodsSingle-center retrospective analysis of cardiac magnetic resonance (CMR) imaging of patients with a Fontan circulation and an age-matched healthy comparison cohort as controls. Feature tracking was performed on all slices of a ventricular short-axis cine stack. Circumferential and radial strain, strain rate, and displacement were measured; and multiple dyssynchrony metrics were calculated based on timing of these measurements (including standard deviation of time-to-peak, maximum opposing wall delay, and maximum base-to-apex delay). Primary endpoint was a composite measure including time to death, heart transplant or heart transplant listing (D/HTx). ResultsA total of 503 cases (15 y; IQR 10, 21) and 42 controls (16 y; IQR 11, 20) were analyzed. Compared to controls, Fontan patients had increased dyssynchrony metrics, longer QRS duration, larger ventricular volumes, and worse systolic function. Dyssynchrony metrics were higher in patients with right ventricular (RV) or mixed morphology compared to those with LV morphology. At median follow-up of 4.3 years, 11% had D/HTx. Multiple risk factors for D/HTx were identified, including RV morphology, ventricular dilation, dysfunction, QRS prolongation, and dyssynchrony. Ventricular dilation and RV morphology were independently associated with D/HTx. ConclusionsCompared to control LVs, single right and mixed morphology ventricles in the Fontan circulation exhibit a higher degree of mechanical dyssynchrony as evaluated by CMR-FT. Dyssynchrony indices correlate with ventricular size and function and are associated with death or need for heart transplantation. These data add to the growing understanding regarding factors that can be used to risk-stratify patients with the Fontan circulation.

Izazovi terapije srčane insuficijencije kod gojaznih pacijenata

Obesity is one of the most significant independent risk factor for developing heart failure (HF) through direct and indirect mechanisms. Excessive secretion of aldosterone and activation of the renin-angiotensin system (RAAS) in obese patients leads to sodium retention and an increase in extracellular volume, which contributes to the development of heart failure and increased cardiovascular risk. Abdominal visceral obesity is associated not only with an increased risk for the development of heart failure with preserved ejection fraction (HFpEF), but also with a high risk for the development of diabetes mellitus and hypertension in both sexes, but more dominantly in women, with an increase in incidence with menopause. Multiple studies and meta-analyses have confirmed that obese patients with heart failure regardless of ejection fraction (HFpEF and HFrEF) have better survival compared to those of normal or underweight, a phenomenon known as the obesity paradox. The HF-ACTION trial showed that even small improvements in cardiorespiratory fitness could lead to significant improvements in cardiovascular outcomes, reducing the impact of the obesity paradox on the clinical outcome of heart failure. The ESC recommendations for heart failure advise weight loss in order to prevent cardiovascular disease in obese and overweight patients, and gradual weight loss should be considered in patients with heart failure and BMI &gt; 35 kg/m2 , while in patients with heart failure and BMI&lt;35 kg/m2 , weight loss is not recommended. The goal of bariatric procedures is to prevent or delay the onset of heart failure, not only by reducing body weight but also by reducing risk factors. The randomized DAPA-HF trial showed that the use of dapagliflozin proved to reduce the composite outcome of worsening heart failure or cardiovascular death in heart failure patients with BMI&gt;30 kg/m2 and in HF patients with BMI&lt;30 kg/m2 . The EMPEROR-preserved and DELIVER trials showed that therapy with SGLT2 inhibitors in patients with HFpEF and BMI&gt;30kg/m2 reduces the risk of hospitalization and cardiovascular death. It is recommended that patients in the terminal stage of heart failure in the pre-transplantation period and placed on the list for heart transplantation achieve target values of BMI&lt;30 kg/m2 in order to achieve a better clinical outcome and reduce mortality after transplantation.

Efficacy of controlvit as a complementary strategy in reducing hospitalizations in patients with heart failure. Randomized clinical trial

Abstract Introduction In patients with heart failure, the main cause of hospital admissions is due to episodes of decompensation, which are associated with an increase in the costs and resources needed for care; they have a negative impact on the quality of life and prognosis of the disease. Therefore, it is necessary to design, evaluate and implement alternatives to achieve efficient follow-up and monitoring, improving adherence to treatment and helping identify decompensation episodes that facilitate their early treatment, so new hospital admissions can be avoided. For this reason, the use of information and communication technologies (apps) is emerging as an excellent strategy for the possibility of improving coverage, real-time monitoring and timeliness of care. ControlVit® is an electronic application that allows permanent, real-time monitoring of biomedical measurements for early detection of complications. Objective To determine the efficacy of ControlVit® as a complementary strategy in reducing hospital admissions in patients in a heart failure program. Methodology A randomized, placebo-controlled, open-label clinical trial was conducted, (n=140), included patients with heart failure under controlled clinical follow-up in a structured heart failure program, into NYHA FC II–IV, capable of handling smartphones and with permanent internet connectivity. All patients were provided with educational elements, a scale and a blood pressure monitor to enter clinical data and a symptom questionnaire necessary for follow-up. The patients were randomized to 2 groups: intervention: use of ControlVit® vs. placebo, with a 6-month follow-up. The primary outcome was the difference in readmissions for heart failure between the 2 groups. Patients on the waiting list for heart transplantation or use of ventricular assist devices were excluded. All participants signed informed consent and the protocol was approved by the institutional ethics committee. Results A total of 140 patients were included in the study (intervention = 71, placebo = 69), with an average age of 66 years, 71% were men, the main etiology of heart failure was ischemic (60%), the main comorbidities were arterial hypertension (44%), dyslipidemia (42%), hypothyroidism (38%), chronic kidney disease (38%), and diabetes mellitus (27%). During follow-up, there were 6 deaths (3 in each group) and 17 readmissions (3 in the intervention group and 14 in the control group). After adjustment for comorbidities, HR 0.72 CI95 (0.52; 0.92), p=0.0325 was found. Conclusion In patients with heart failure, ControlVit® is a useful and complementary tool for follow-up, which reduces hospital admissions due to episodes of decompensation. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): German Saldarriega award.Javeriana University

Prognostic implications of inactive status in highest urgency categories among heart transplantation recipients in the new donor heart allocation system.

Patients on the waiting list for heart transplantation (HT) can become inactive or made status seven because of medical reasons, such adverse events, complications, or psychosocial circumstances. If the condition that caused the inactivation is resolved, patients are re- activated. Information about the prognostic implications of Status 7 in the new donor heart allocation system has not been described. To bridge this knowledge gap, we performed an analysis of the United Network of Organ Sharing (UNOS) registry. Data on adult patients who underwent HT between October 18th, 2018 and October 2021, were queried from the UNOS registry. The main outcomes were post- transplant all-cause mortality, 1-year all-cause mortality and treated acute rejection. Since re-transplantation is a competing event for all-cause mortality, we performed competing risk survival analysis and reported sub distribution hazard ratios (SHR) from the Fine and Gray model to examine the relationship between inactive status and all-cause mortality. A total of 5267 adult patients underwent HT and were previously listed as Status 1 or Status 2 in the new allocation system. We identified 946 HT recipients temporarily inactivated while on HT list (18%). The number of temporarily inactive patients remained stable since the implementation of the new donor allocation system (p=.37). Approximately, two-thirds of temporarily inactive patients (65.9%) were inactivated for being too sick, whereas other frequent justifications for inactivity included left ventricular assist device implantation (7.8%) and insurance related issues (4.8%). Temporarily inactive HT recipients were more likely to be African Americans, males, have a higher body mass index (BMI) and significantly longer waiting time (391.6±600vs. 72.3±223 days, p<.001) compared with never inactivated patients. In the unadjusted analyses 30-day mortality did not differ between groups, but both 1-year and overall all-cause mortality was significantly higher in temporarily inactive patients (1-year: SHR: 1.3; 95% confidence intervals [CI]: 1.03, 1.64; p=.028, overall mortality SHR: 1.31; 95% CI: 1.06, 1.64; p=.014). After adjustment for donor and recipient characteristics, a trend towards higher 1-year and overall mortality remained (1-year: SHR 1.32; 95% CI .99, 1.76, p=.006, overall mortality SHR: 1.29; 95% CI: .98-1.68, p=.065). No differences in treated acute allograft rejection at 1 year were found between groups. Temporary inactive status while waiting for HT occurs in approximately one in five HT recipients listed in higher urgency categories after the implementation of the new allocation system. A signal of adverse long-term outcomes was found, and this could be explained by differences in recipient characteristics. Further research is required to elucidate pathways involved and possible implications for clinical practice.