High-dose Inotropes Research Articles

Introduction of ex vivo perfusion of extended-criteria donor hearts in a single center in Asia.

The shortage of organs for heart transplantation has created a need to explore the use of extended-criteria organs. We report the preliminary use of normothermic TransMedics Organ Care System-an ex vivo approach to preserve extended-criteria brain-dead donor hearts. This System maintains a normal temperature, provides continuous perfusion and oxygenation, reduces ischemic time, and enables additional viability assessment options. In a retrospective single-centre study conducted from April 2020 to March 2023, four extended criteria brain-dead donor hearts were perfused and monitored using the Organ Care System. Suitability for transplantation was assessed based on stable or decreasing lactate levels, along with appropriate perfusion parameters. The Organ Care for use of the Organ Care System were coronary artery disease, left ventricular hypertrophy, high-dose inotrope use in the donor, a downtime exceeding 20min, and a left ventricular ejection fraction of 40-50%. Three out of the four donor hearts were transplanted, while one was discarded due to rising lactate concentration. The three recipients had a higher surgical risk profile for heart transplant. All showed normal cardiac function and no primary graft dysfunction postoperatively. At 2-3years post-transplant, all recipients have a ventricular function of > 60%, with only one showing evidence of mild rejection. The Organ Care System enables the successful transplantation of marginal donor organs in high-risk recipients, showcasing the feasibility of recruiting donors with extended criteria. This technique is safe and promising, expanding the donor pool and addressing the organ shortage in heart transplantation in Hong Kong.

(811) Incidence of Right Ventricular Dysfunction in Lvad Patients Bridged with High Dose Inotropes

(811) Incidence of Right Ventricular Dysfunction in Lvad Patients Bridged with High Dose Inotropes

Heart waitlist survival in adults with an intra-aortic balloon pump relative to other Status 2, Status 1, and inotrope Status 3 patients.

Intra-aortic balloon pump (IABP) utilization has significantly outpaced other Status 2 eligibility criteria for heart transplant. The risk of waitlist mortality of IABP-supported patients relative to other Status 2 listed patients has not been described. We performed a retrospective analysis of all adult patients listed Status 2 for heart transplantation under the current U.S. allocation policy, using data from the United Network for Organ Sharing. Patients listed status 1 and status 3 for high-dose inotropes were included for reference. Mortality and waitlist decompensation were modeled as a function of time-varying status in cause-specific Cox survival models. We identified 3638 Status 2 listings, of whom 1676 (46%) were Status 2 due to IABP. Relative to patients supported with IABP, status 2 patients with ventricular tachycardia/fibrillation [VT/VF] (HR 4.0, p < .001), right-or-biventricular assist device configurations (HR 2.3, p=.002), or temporary surgical left ventricular assist devices [LVAD] (HR 2.6, p=.003) had greater risk of waitlist mortality and decompensation. Other Status 2 subgroups had mortality comparable to IABP Status 2. Risk of waitlist mortality and decompensation for IABP Status 2 was similar to Status 3 patients listed for high-dose inotropes (HR 1.2, p=.27) and lower than Status 1 patients (HR 0.7, p=.002). Waitlist mortality varies significantly by Status 2 eligibility criteria and is highest among patients listed for VT/VF, right-or-biVAD configurations, or temporary surgical LVADs. IABP-supported patients were among those with the lowest Status 2 waitlist mortality risk and comparable to Status 3 inotrope-supported patients.

Transinnominate Impella 5.5 insertion as a bridge to transplantation in a pediatric patient in refractory cardiogenic shock.

Transinnominate Impella 5.5 insertion as a bridge to transplantation in a pediatric patient in refractory cardiogenic shock.

How High is Too High? Analysis of Donor Inotrope Support in Pediatric Heart Transplantation

<h3>Purpose</h3> While the impact of donor inotrope use on post-transplant outcomes has been studied, a dose dependent relationship has not yet been established. We use donor Inotrope Score (dIS) to examine the impact of inotrope quantity on post-transplant outcomes in pediatric heart transplant recipients. <h3>Methods</h3> The United Network for Organ Sharing (UNOS) database was used to identify deceased donors <40 years between 2000-2019. Available dopamine, dobutamine, and epinephrine doses were used to calculate dIS. Donors were divided into two groups: Low dIS (score: ≤10), and High dIS (score: 10-30). Only 3% of dIS were above >30 and were excluded from the analysis. Post-transplant survival (PTS) and pediatric donor utilization (pDU) were compared. <h3>Results</h3> Of the total (n=4870), 28% (n=1373) recipients received an inotrope supported donor heart: Low dIS, n=1209 (88%); High dIS, n=164 (12%). High dIS patients were younger and lighter than Low dIS patients (p<0.01 for both). At transplant, high dIS recipients more often had renal dysfunction (eGFR) (40% vs 28%, p=0.003), required ECMO (11% vs 6%, p<0.01), and were on the ventilator (29% vs 18%, p<0.01). Donors did not differ in terms of Left Ventricular ejection fraction (LVEF) (63% vs 60%, p=0.50), ischemia time (3.8hours [2.3-4.3] vs 3.6 [3-4.4], p=0.26), or steroid use (69% vs 75%, p=0.10). Epinephrine use was more common in the high vs the low dIS group (29% vs 7%, p<0.01). PTS was worse in the high dIS vs low dIS group (1 year-83% vs 90%, p<0.05). On MV analysis, high dIS was a significant predictor of mortality (HR:1.4, CI:1.1-1.8). When broken down by age groups, high dIS was only significant for age <2 years (HR:1.8, CI:1.2-2.5). pDU was worse in dIS ≤10 compared to donors not on inotropes (66% vs 76%, p<0.01). <h3>Conclusion</h3> High dose inotrope use only impacts mortality in recipients <2 years of age. Although post-transplant mortality is not impacted by low dose inotrope use, heart utilization was worse in this group when compared to those not on inotropes. Acceptance of pediatric donors with low inotrope exposure could increase heart utilization, without negatively impacting survival.

Does Hemodynamic Response to Inotropes Predict Early Right Heart Failure After LVAD Implantation?

<h3>Purpose</h3> Right ventricular (RV) failure is a highly morbid clinical condition following left ventricular assist device (LVAD) implantation. We aimed to compare baseline and post-inotrope(s) hemodynamics as predictors of early right heart failure (RHF) after LVAD implantation. <h3>Methods</h3> We performed a single-center, retrospective analysis of all patients implanted with an LVAD between January 2018 and September 2020. We included patients with pre-implant baseline hemodynamics without augmentation by inotropic or mechanical circulatory support (MCS). This cohort was then placed on inotrope(s) with documented hemodynamics at 24 hours. We then utilized the Academic Research Consortium early RHF criteria to define severe-acute RHF (requirement of assist device or high dose inotropes with end-organ dysfunction). Stroke volume index (SVI) was identified as a surrogate of RV inotropic reserve. Comparisons between patients with and without early RHF were made using Fisher's Exact and Chi-Square tests, with probabilities determined by a binary logistical regression model. <h3>Results</h3> A total of 48 patients met study inclusion criteria. Early post-implant RHF was noted in 45.8% (n=22) of this population. There were no statistical differences among these groups when evaluated for type of inotrope utilized (p=0.2126), change in cardiac index (p=0.8924), or change in SVI (p=0.5659). There was, however, a nonsignificant trend towards decreased probability of development of early RHF, as evidenced by percent improvement in post-inotrope(s) SVI. This was most apparent in patients who received milrinone monotherapy (Figure). <h3>Conclusion</h3> We observed a nonsignificant trend of improved RV inotropic reserve represented by improvement in post-inotrope SVI, which numerically correlated with less early RHF.

Outcomes Following Lvad Implantation In Covid-19 Patients

PurposeEnd-stage heart failure patients are at an increased risk of severe disease and complications from coronavirus disease-2019 (COVID-19). Additionally, the disease increases perioperative risks The purpose of this study was to describe the clinical course following left ventricular assist device (LVAD) implantation in patients with COVID-19.MethodsA single-center, retrospective review between March 2020 and March 2021 identified 6 patients with a history of COVID-19 who subsequently underwent LVAD implantation. Baseline characteristics, clinical course, and outcomes were examined.ResultsPatients were male (83%), Black (67%), and implanted with a Heartmate 3 for destination therapy. The time from COVID-19 diagnosis to LVAD surgery ranged from 3 days to 6 months (median 40 days, [IQR 12-114 days]). All patients were supported with an intra-aortic balloon pump (IABP) and high-dose inotropes prior to implant. The median age was 60 years (IQR 57-61 years) and body mass index 30 kg/m2 (IQR 24-31 kg/m2). Following implantation, 5 patients (83%) had respiratory failure greater than 7 days on ventilator support, 2 (33%) required tracheostomy, and 2 (33%) were reintubated before successful extubation. Two patients (33%) required temporary right ventricular assist device (RVAD) support, 4 patients (67%) needed continuous renal replacement therapy (CRRT), and 3 patients (50%) suffered ischemic strokes: two patients on postoperative day 1, and the other on postoperative day 5. The median length of hospital stay following surgery ranged from 16 to 73 days (median 53 days, [IQR 35-67 days]). Five patients (83%) were discharged from the hospital, 2 to acute inpatient rehab, 1 to a subacute rehabilitation facility, and 2 to home. Two patients (33%) were readmitted within 30 days for gastrointestinal bleeding and neuropathic pain. There was one (17%) 30-day hospital mortality due to multisystem organ failure following a stroke and the decision to withdraw care.

Early postoperative hemodynamic instability after heart transplantation \u2013 incidence and metabolic indicators

BackgroundPrimary graft dysfunction (PGD) is the main cause of death in the first 30 days after heart transplantation (HTX), accounting for approximately 40% of mortality. The study’s primary aim was to assess the incidence of PGD, following the International Society for Heart and Lung Transplantation consensus, and to compare it with the incidence of significant postoperative hypotension despite administration of high-dose inotropes and vasoconstrictors. The secondary aim of the study was to determine changes in biochemical markers that accompany the phenomenon.MethodsForty-five patients who underwent HTX between 2010 and 2015 were enrolled in this study, and detailed hemodynamic and metabolic data from the first 48 postoperative hours were collected and analyzed. Hemodynamic instability was defined as significant postoperative hypotension (mean arterial pressure (MAP) < 60 mmHg) combined with a high inotrope score (> 10). Data for long-term mortality were obtained from the population registration office.ResultsPGD incidence was relatively low (17.8%); however, hemodynamic instability was common (40%). Among unstable patients, MAP was insufficient for end-organ perfusion (51.4 ± 9.5 mmHg) but no decrease in left ventricular function was observed (cardiac index, 2.65 ± 0.6 l/min/m2; left ventricular ejection fraction, 52.9 ± 15.5%). Within this group, mean systemic vascular resistance index (961 ± 288 dyn*s*m2/cm5) was low despite receiving high doses of vasoactive agent (norepinephrine 0.21 (0.06-0.27) μg/kg/min during first 24 h postoperatively and 0.21 (0.01-0.27) μg/kg/min during next 24 h postoperatively). After HTX, serum lactate levels were initially significantly higher in patients with hemodynamic instability (p = 0.002); however, impaired lactate clearance was not observed (p = 0.366), and lactate levels normalized within the first 24 h postoperatively. Postoperative hemodynamic instability altered the long-term outcome and increased 5-year mortality after HTX (p = 0.034).ConclusionsHemodynamic instability is a more common phenomenon than PGD. Only early postoperative serum lactate levels correspond with hemodynamic instability following HTX. Postoperative hemodynamic instability is associated with poor long-term survival among HTX recipients.

Inotrope Use and Intensive Care Unit Mortality in Patients With Cardiogenic Shock: An Analysis of a Large Electronic Intensive Care Unit Database.

Purpose: To determine whether inotrope administration is associated with increased all-cause mortality in cardiogenic shock (CS) patients and to identify inotropes superior for improving mortality.Methods: This retrospective cohort study analyzed data retrieved from the Philips Electronic ICU (eICU) database, a clinical database of 200,859 patients from over 208 hospitals located throughout the United States. The database was searched for patients admitted with CS to the intensive care unit (ICU) between 2014 and 2015. We evaluated 34,381 CS patients. They were classified into the inotrope and non-inotrope groups based on whether inotropes were administered during hospitalization. The primary endpoint was all-cause hospital mortality.Findings: In total, 15,021 (43.69%) patients received inotropes during hospitalization. The in-hospital mortality rate was significantly higher in the inotrope group than in the non-inotrope group (2,999 [24.03%] vs. 1,547 [12.40%], adjusted hazard ratio: 2.24; 95% confidence interval [CI]: 2.09–2.39; p < 0.0001). After propensity score matching according to the cardiac index, 359 patients were included in each group. The risk of ICU (OR 5.65, 95% CI, 3.17–10.08, p < 0.001) and hospital (OR 2.63, 95% CI: 1.75–3.95, p < 0.001) mortality in the inotrope group was significantly higher. In the inotrope group, the administration of norepinephrine ≤0.1 μg/kg/min and dopamine ≤15 μg/kg/min did not increase the risk of hospital mortality, and milrinone administration was associated with a lower mortality risk (odds ratio: 0.559, 95% CI: 0.430–0.727, p < 0.001). Meanwhile, the administration of >0.1 μg/kg/min dobutamine, epinephrine, and norepinephrine and dopamine >15 μg/kg/min was associated with a higher risk of hospital mortality.Conclusions: Inotropes should be used cautiously because they may be associated with a higher risk of mortality in CS patients. Low-dose norepinephrine and milrinone may associated with lower risk of hospital mortality in these patients, and supportive therapies should be considered when high-dose inotropes are administered.

Managing patients of shock and acute kidney injury in tertiary care cardiac ICU: Experience with continuous renal replacement therapy

BackgroundClinical experience on details of CRRT initiation and outcomes in cardiac intensive care unit (CICU) patients is not available from developing countries like India. This study shares the 5-year clinical experience of managing CICU patients requiring CRRT in a tertiary care cardiac center of North India. Materials and methodsMedical records of all CICU patients with acute kidney injury (AKI) managed by CRRT from October 2011 to September 2016 at tertiary referral center in North India were retrospectively reviewed. Multiple logistic regression analysis was used to identify predictors of post-CRRT mortality. ResultsA total of 630 patients received CRRT during the study period. Most commonly AKI developed in patients with acute coronary syndrome (30.2 %) with cardiogenic shock. 55.9 % of the CRRT patients were >60 years of age, and/or on multiple supports in ICU including, mechanical ventilation, high doses of inotropes & vasopressors and other cardiovascular support. Of those on CRRT, 130 (20.6 %) patients had died, 215 (34.1 %) were discharged and 285 (45.2 %) could not complete the desired course. Multivariate regression analysis showed independent association of mortality with high vasoactive-inotropic score, single CRRT cycle and low mean arterial pressure in CRRT patients. ConclusionAbout 34.1 % of patients receiving CRRT were alive at discharge, emphasizing the feasibility and utility of CRRT as a promising modality in this population for improving outcomes.

Role of fast tract Extubation in Enhanced Recovery after Cardiac Surgery: Associated Factors and Outcomes

Objective: To assess the impact of fast track extubation versus late extubation in cardiac surgery patients being operated in Bahawal Victoria hospital, Bahawalpur, Pakistan.Methods: This analytical cross-sectional study was conducted in department of cardiac surgery, Bahawal Victoria Hospital, Bahawalpur, from March 2018 to March 2020. All patients who underwent cardiac surgical procedures were consecutively enrolled. Fast-track extubation (FTE) and delayed extubation (DE) in these patients were recorded. Moreover, information regarding baseline and clinical characteristics was collected and outcome like reintubations, hospital stay, and mortality were observed.Results: Of 86 patients, FTE was successful in 70 (80.14%) patients, while DE was observed in 16 (18.6%) patients. High dose inotropes 6 (37.50%) and increase drain output 5 (31.25%) were the most common cause of FTE failure among 16 patients. NYHA class was found to be significantly higher in DE group as compared to FTE group (pvalue 0.002). The mean ventilation time in FTE group was significantly higher as compared to DE group, i.e., 2.7±1.6 hours vs. 6.5±4.4 hours respectively (p-value 0.001). While, inotropic support (p-value 0.047), drain volume at 4 hours (p-value 0.039), and drain at the time of removal (p-value 0.002) were significantly lower in FTE group as compared to DE group. There was a single reintubation (1.16%) and mortality (1.16%).Conclusion: FTE is a safer technique in planned cardiac surgical procedures resulting in least morbidity and mortality.

High Pre-Donation Vasoactive Inotropic Score (VIS) May Be Associated with Increased Risk of Primary Graft Dysfunction in Cardiac Transplantation

Purpose Primary Graft Dysfunction (PGD) is one of the primary causes of 30 day mortality after heart transplantation. Optimal donor management is crucial to ensure effective organ procurement and favourable transplant outcomes. The prognostic impact of pre-donation inotropes use on PGD remains controversial, and its implication on organ preservation strategy and acceptance decision remains unclear. The purpose of this study is to investigate the relationship between donor heart inotrope dose and the incidence of PGD defined using the standard definition of PGD from the ISHLT consensus statement, and 30 day mortality post heart transplant. Methods Retrospective study of all patients who underwent isolated cardiac transplantation in a single centre between January 2017 and December 2019. Donor data was obtained de-identified from the Australian and New Zealand Cardiothoracic Organ transplant registry and electronic donor records (EDR). Inotropes were pooled into a vasoactive inotropic score (VIS). The primary outcome was a composite of PGD and 30 day mortality. Results There were 43 heart transplants and 40 were included for analysis. One patient was excluded as they underwent combined cardiac and kidney transplant, and there was incomplete donor data for 2 patients. 7 out of 40 patients (17.5%) developed primary graft dysfunction, and 4 patients (10%) died within 30 days of transplant. The primary composite endpoint occurred in 10 (25%) patients. Of the 7 patients that developed PGD, 1 died within 30 days. Patients were stratified into two groups according to their VIS (High versus Low). Multivariate logistic regression demonstrated that patients in the High VIS group (VIS> 26) had a higher incidence of the primary composite outcome occurring in 40% of patients when compared to the Low VIS group (VIS Conclusion Our single centre retrospective study demonstrated an increase risk of PGD and 30 day mortality associated with pre-donation high dose inotropes use. This preliminary finding suggests the potential utility of VIS to quantify pre-donation inotropes use and may inform donor organ management and acceptance decisions.

Abstract 13933: High Urgency Candidates for Heart Transplantation Does Not Correlate to the Development of Primary Graft Dysfunction

Introduction: Primary Graft Dysfunction (PGD) after Heart Transplantation (HTx) is seen in approximately 7-30% of heart transplant patients as described by the literature. Many of these patients have severe PGD which requires support with ECMO. It has been reported that patients who are severely ill on high dose inotropes or on assists devices have greater propensity to develop severe PGD. Many of these patients have borderline blood pressure due to poor cardiac function which may contribute to PGD with its associated vasoplegia. In order to asses risk for the development of PGD we evaluated our patients in terms of their status at the time of transplant to assess risk. Methods: Between 2010 and 2019 we assessed 44 Heart Transplant patients who developed severe PGD immediately after HTx. The UNOS Status at the time of Transplant was recorded along with the presence of a durable assist device, temporary assist device, or no Inotropes or assist device. 30 Day and 1 Year survival were assessed for all status groups including a control group (no PGD, n=799). Results: High urgency status at the time of transplant was not the overwhelming majority of patients that developed severe PGD. Approximately 32% of these patients were patients who were waiting for transplant at home, who were not on Intravenous Inotropes and not on assist devices. 1 Year survival was compromised in all patients who developed severe PGD with survival rates that were significantly lower than patients without PGD in our program (47.7% vs 93.6%, p&lt;0.001) (see Table). Conclusions: High urgency status is not solely associated with the development of severe PGD. Further assessment into these non-urgent patients who develop severe PGD is warranted and is under investigation. Inflammatory markers should be assessed in all patients who develop severe PGD.

Fetal aortic valvuloplasty: first report of two cases from Saudi Arabia

BackgroundFetal aortic stenosis may progress to hypoplastic left heart syndrome (HLHS), which carries a poor prognosis. We report two infants with fetal aortic stenosis successfully treated with fetal aortic valvuloplasty (FAV) using balloon dilatation.Case presentationOf five fetuses with aortic stenosis fulfilling the FAV criteria of severe aortic stenosis with a left ventricular length Z-score of ≥ − 2, retrograde flow in the transverse aortic arch, left-to-right flow across the foramen ovale, monophasic mitral inflow, and significant left ventricular dysfunction, we obtained permission for FAV in two fetuses. FAV was performed successfully under echocardiographic guidance using balloon dilatation. Both fetuses survived to birth. During FAV, mild pericardial effusion developed when introducing the stylet needle in the second fetus, and this resolved within 48 h. No intraprocedural complications occurred in the first patient, and no maternal complications occurred. The first infant underwent the Ross procedure after birth and is currently 7 years old and doing well. The second patient underwent aortic and mitral valve repair with endocardial fibroelastosis resection approximately 2 weeks after birth, which temporarily addressed the mitral valve stenosis; high doses of inotropes were subsequently required. The infant died of sepsis at 2 months of age.ConclusionFAV using balloon dilatation to treat fetal aortic stenosis was successful in our two patients, with subsequent neonatal biventricular repair resulting in long-term survival in one patient and death secondary to sepsis in the second patient.

A change of heart: Preliminary results of the US 2018 adult heart allocation revision.

In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1year before (pre: October 18, 2017-October 17, 2018) and following (post: October 18, 2018-October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre- to 3032 postimplementation. Seventy-eight percent of transplants in the post era were for the most medically urgent (statuses 1-3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4hours (all P<.001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient-years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.

Practice Changes at U.S. Transplant Centers After the New Adult Heart Allocation Policy

BackgroundIn October 2018, the U.S. heart allocation system expanded the number of priority “status” tiers from 3 to 6 and added cardiogenic shock requirements for some heart transplant candidates listed with specific types of treatments. ObjectivesThis study sought to determine the impact of the new policy on the treatment practices of transplant centers. MethodsInitial listing data on all adult heart candidates listed from December 1, 2017 to April 30, 2019 were collected from the Scientific Registry of Transplant Recipients. The status-qualifying treatments (or exception requests) and hemodynamic values at listing of a post-policy cohort (December 2018 to April 2019) were compared with a seasonally matched pre-policy cohort (December 2017 to April 2018). Candidates in the pre-policy cohort were reclassified into the new priority system statuses by using treatment, diagnosis, and hemodynamics. ResultsComparing the post-policy cohort (N = 1,567) with the pre-policy cohort (N = 1,606), there were significant increases in listings with extracorporeal membrane oxygenation (+1.2%), intra-aortic balloon pumps (+ 4 %), and exceptions (+ 12%). Listings with low-dose inotropes (−18%) and high-dose inotropes (−3%) significantly decreased. The new priority status distribution had more status 2 (+14%) candidates than expected and fewer status 3 (−5%), status 4 (− 4%) and status 6 (−8%) candidates than expected (p values <0.01 for all comparisons). ConclusionsAfter implementation of the new heart allocation policy, transplant centers listed more candidates with extracorporeal membrane oxygenation, intra-aortic balloon pumps, and exception requests and fewer candidates with inotrope therapy than expected, thus leading to significantly more high-priority status listings than anticipated. If these early trends persist, the new allocation system may not function as intended.

The Benefit of Heart Transplant Among Candidates Assigned Lower Priority in the New 6-Status US Heart Allocation System

Purpose In order to better rank-order candidates by medical urgency, the US has adopted a 6-status therapy-based system that reduces allocation priority for three groups that previously were Status 1A: candidates with 1) left ventricular assist devices (LVAD) listed with “elective” time, 2) LVAD complications and 3) intra-aortic balloon pump or high-dose inotrope treatment without cardiogenic shock. However, the potential impact of these priority reductions is unknown. Methods Using Scientific Registry of Transplant Recipients data on all US adult heart-alone transplant candidates from 2006-2015, We estimated the survival benefit of heart transplantation for each of the three targeted candidate groups using a mixed-effects proportional hazards model with transplantation as a time-dependent covariate, accounting for center-effects and adjusting for year of transplantation, donor quality and ischemic time Results A total of 29,095 adult candidates were listed at 113 centers during the study period and 19,507 (67%) received a heart transplant. Relative to remaining on the waitlist, Status 1A candidates in cardiogenic shock or respiratory failure had a dramatic survival benefit with transplantation, HR for death of 0.09 (95% CI 0.08-0.01). Compared to this group, all three targeted candidate groups had significantly lower benefit from heart transplantation, non-shock Status 1A candidates HR 0.20 (95% CI 0.17-0.24), LVAD complications HR 0.26 (95% CI 0.22-0.30), and LVAD elective 1A time HR 0.62 (95% CI 0.47-0.8) (Fig, p Conclusion All three of the targeted populations (LVAD elective time, LVAD complications, and non-shock 1A candidates) had lower estimated benefit of heart transplantation than Status 1A recipients in cardiogenic shock or respiratory failure, supporting the priority reductions implemented in the new 6-status system.

Geographic Variation in the Treatment of U.S. Adult Heart Transplant Candidates

BackgroundThe current U.S. priority ranking for heart candidates is based on treatment intensity, not objective markers of severity of illness. This system may encourage centers to overtreat candidates. ObjectivesThis study sought to describe national variation in the intensity of treatment of adult heart transplantation candidates and identify center-level predictors of potential overtreatment. MethodsThe registrations of all U.S. adult heart transplantation candidates from 2010 to 2015 were collected from the SRTR (Scientific Registry of Transplant Recipients). “Potential overtreatment” was defined as treatment of a candidate who did not meet American Heart Association cardiogenic shock criteria with either high-dose inotropes or an intra-aortic balloon pump. Multilevel logistic regression and propensity score models were used to adjust for candidate variability at each center. Center-level variables associated with potential overtreatment were identified. ResultsFrom 2010 to 2015, 108 centers listed 12,762 adult candidates who were not in cardiogenic shock for heart transplantation. Of these, 1,471 (11.6%) were potentially overtreated with high-dose inotropes or intra-aortic balloon pumps. In the bottom quartile of centers, only 2.1% of candidates were potentially overtreated compared with 27.6% at top quartile centers, an interquartile difference of 25.5% (95% confidence interval: 21% to 30%). Adjusting for candidate differences did not significantly alter the interquartile difference. Local competition with 2 or more centers increased the odds of potential overtreatment by 50% (adjusted odds ratio: 1.50; 95% confidence interval: 1.07 to 2.11). ConclusionsThere is wide variation in the treatment practices of adult heart transplantation centers. Competition for transplantable donor hearts is associated with the potential overtreatment of hemodynamically stable candidates. Overtreatment may compromise the fair and efficient allocation of scarce deceased donor hearts.

O18-2 - Inflammatory Cardiomyopathy Associated with Rheumatoid Arthritis Treated with Left Ventricular Assist Device

Cardiovascular involvement is common in patients with rheumatoid arthritis (RA), however, advanced heart failure is rare. We report a case of severe heart failure who required the placement of left ventricular assist device (LVAD). A 34-year old woman, who had been diagnosed as RA 8 years before and treated with predonisolone and methotrexate, was admitted to the local hospital due to short of breath. She had severe left ventricular (LV) dysfunction with an ejection fraction (EF) of 15%. Twenty days after the recovery by intensive treatment, she was re-hospitalized due to cardiogenic shock requiring intravenous administration of inotropes and intraaortic balloon pump (IABP). She was referred to our institution as a candidate of heart transplantation because she required the continuous infusions of high-dose inotropes. Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) revealed increased uptake in LV. Histologic examination from right ventricle showed infiltration of CD3-T lymphocytes and diffuse interstitial or replacement myocardial fibrosis. Based on these finding, she was diagnosed as chronic inflammatory cardiomyopathy with little chance of LV recovery. On the other hand, RA was in a state of remission. She was judged as an indication for heart transplantation and underwent a successful placement of LVAD.

Deceased Organ Donation From Pediatric Donors: Does the Literature Really Help Us? Implication for More Powerful Guidelines

BackgroundBrain-dead pediatric donors have always been the focus of attention because of the higher quality, utility, and possibility of their organ donation. However, donors under the age of 5 years always necessitate making more challenging management efforts, which are not clearly implied in most parts of the guidelines. MethodsThe data obtained from 79 brain-dead pediatric donors of the Organ Procurement Unit of Masih Daneshvari Hospital, Tehran, Iran, were assessed. The donors were divided into 2 groups, including donors under 5 years of age (group A) and those between 5 and 12 years of age (group B). Metabolic, hemodynamic, hematologic, and electrolyte status as well as the suitability for donation were compared in the study groups. ResultsOf 1252 donors, 6.3% were under 12 years of age. Trauma and drug toxicity were the two primary causes of brain death in group A. In comparison, trauma and brain tumor were the leading causes of brain death in group B. The prevalence of both hyperglycemia and respiratory acidosis was significantly higher in group A (P < .05). However, severe anemia and coagulopathy were more prevalent in group B (P < .05). The high-dose inotropic administration was used for 42.4% of the donors in group A, whereas only 26% of the donors in group B needed a high dose of inotropes (P < .05). The mean quantity of organ harvested per donor was 2.1 and 2.25 in groups A and B, respectively. Furthermore, donor loss was not significantly different in both groups. ConclusionsThe occurrence of different complications in donors under the age of 5 years requires special treatment considerations that should be the center of attention in the related guidelines. Organ donation per donor indicates that donors under the age of 5 years are a valuable resource for organ procurement.