Impact Of Mechanical Circulatory Support Research Articles

Monitoring a Mystery: The Unknown Right Ventricle during Left Ventricular Unloading with Impella in Patients with Cardiogenic Shock.

Background: Right ventricular (RV) dysfunction or failure occurs in more than 30% of patients in cardiogenic shock (CS). However, the importance of timely diagnosis of prognostically relevant impairment of RV function is often underestimated. Moreover, data regarding the impact of mechanical circulatory support like the Impella on RV function are rare. Here, we investigated the effects of the left ventricular (LV) Impella on RV function. Moreover, we aimed to identify the most optimal and the earliest applicable parameter for bedside monitoring of RV function by comparing the predictive abilities of three common RV function parameters: the pulmonary artery pulsatility index (PAPi), the ratio of right atrial pressure to pulmonary capillary wedge pressure (RA/PCWP), and the right ventricular stroke work index (RVSWI). Methods: The data of 50 patients with CS complicating myocardial infarction, supported with different flow levels of LV Impella, were retrospectively analyzed. Results: Enhancing Impella flow (1.5 to 2.5 L/min ± 0.4 L/min) did not lead to a significant variation in PAPi (p = 0.717), RA/PCWP (p = 0.601), or RVSWI (p = 0.608), indicating no additional burden for the RV. PAPi revealed the best ability to connect RV function with global hemodynamic parameters, i.e., cardiac index (CI; p < 0.001, 95% CI: 0.181-0.663), pulmonary capillary wedge pressure (PCWP; p = 0.005, 95% CI: -6.721--1.26), central venous pressure (CVP; p < 0.001, 95% CI: -7.89-5.575), and indicators of tissue perfusion (central venous oxygen saturation (SvO2); p = 0.008, 95% CI: 1.096-7.196). Conclusions: LV Impella does not impair RV function. Moreover, PAPi seems to be to the most effective and valid predictor for early bedside monitoring of RV function.

Evaluating The Impact Of Mechanical Circulatory Support On Short-term Outcomes Following Admission With Cardiogenic Shock: Insights From The National Readmissions Database

Evaluating The Impact Of Mechanical Circulatory Support On Short-term Outcomes Following Admission With Cardiogenic Shock: Insights From The National Readmissions Database

Abstract 18575: Impact of Mechanical Circulatory Support on In-Hospital Mortality in Ventricular Tachycardia Ablation: A United States Nationwide Analysis

Background: Mechanical circulatory support (MCS) devices have emerged as a valuable tool in ventricular tachycardia (VT) ablation procedures, offering potential benefits such as improved hemodynamic stability, preserved organ perfusion, and optimized coronary perfusion during prolonged VT induction and mapping. However, the impact of different MCS modalities on in-hospital mortality following VT ablation remains unclear. Objective: This study aimed to investigate the impact of various MCS modalities on in-hospital mortality in those undergoing VT ablation during hospitalization. Method: We analyzed data from the National Inpatient Sample to identify patients who underwent VT ablation and received transient mechanical cardiac support between 2019 and 2020. The primary endpoint was in-hospital mortality, stratified by different MCS modalities. Additionally, we explored independent predictors of in-hospital mortality. Result: A total of 850 patients underwent VT ablation and required MCS from January 2019 to December 2020. Among these patients, extracorporeal membrane oxygenation (ECMO), percutaneous left ventricular assist device (PLVAD), intra-aortic balloon pump (IABP), and a combination of more than one MCS modality were utilized in 5.8%, 64.7%, 18.8%, and 10.5% of cases, respectively. The in-hospital mortality rates for these groups were 40%, 16%, 22%, and 61%, respectively (p&lt;0.01). Notably, the use of multiple MCS modalities, female sex, other races, and self-payment were independent predictors of mortality, with adjusted odds ratios (aOR) of 21.9 (p=0.008; 95% confidence interval [CI]: 2.2-217.1), 9.27 (p=0.045; 95% CI: 1.1-82.1), 27 (p=0.038; 95% CI: 1.1-29.4), and 27.6 (p=0.041; 95% CI: 1.2-660.8), respectively. Conclusion: Our study highlights that the use of multiple MCS modalities, female sex, other races, and self-payment are independent predictors of in-hospital mortality, highlighting the need for careful consideration and selection of MCS for VT ablation patients.

Predictors, Outcomes and Impact of Mechanical Circulatory Support of Patients With Mechanical Complications After Acute Myocardial Infarction

BackgroundDespite early and currently effective epicardial coronary recanalization, the mortality rate after mechanical complication (MC) remains high, especially in cardiogenic shock. There is an increase in the use of mechanical circulatory support in patients with cardiogenic shock and MC, however, evidence is still scarce and most studies exclude patients with mechanical complications. MethodsUsing the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the predictors and outcomes of patients with MC, subtypes and the use of MCS. ResultsWe identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC and of them 1320 (56.3 %) received MCS. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture (FWR).Mortality was 12 times higher (OR: 11.663, CI: 10.582–12.855, p < 0.001) in patients with MC compared to patients without MC (49.7 % vs. 4.6 %, p < 0.001) and all subtypes of MC showed a significant increase in mortality. The use of MCS was associated with decreased mortality in PMR (46.2 % to 34.8 %, p = 0.009) and pseudoaneurysm (64.7 % to 42.1 %, p < 0.001), however, with higher mortality in VSR. ConclusionsThe incidence of MC after an AMI is very low, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and with fewer comorbidities. The subtype with the highest frequency and highest mortality was VSR. The use of mechanical circulatory support was associated with better survival in PMR and pseudoaneurysm, but not overall survival.

Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n=71] COVID-19+/MCS positive [MCS+] vs 12.4% [n=98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p=0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p=0.001) because of very high in-hospital mortality (59% vs 28%; p=0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

Abstract 12169: Re-Imagining Fontan Support: Novel Cavopulmonary Connection Can Accommodate Mechanical Circulatory Support, Augment Cardiac Output and Balance Hepatic Flow

Introduction: Improved Fontan survivorship requires novel treatments for late complications and inevitable failure. Typical total cavopulmonary connection (TCPC) shapes perform well in the short term yet competitive flows create challenges in providing mechanical circulatory support (MCS) due to two inflows/outflows. A novel, feasible Fontan shape, the Convergent Cavopulmonary Connection (CCPC), converges venous return to create a single inflow and outflow for easy institution of MCS, and maintains favorable hepatic flow distribution (HFD) and power loss. The impact of MCS on CCPC hemodynamic performance is still unknown. Hypothesis: In vitro implantation of a single MCS device into patient-specific CCPCs will be feasible and produce augmented cardiac output and acceptable HFD, compared to traditional TCPC. Methods: A benchtop mock circulatory flow loop using 60/40 glycerin equipped with inlet/outlet flow meters and outflow optical registers was used to analyze five 3D-printed TCPC and CCPC models derived from cardiac MRI images. Patient-specific flow conditions were applied to each model’s inlets/outlets. HFD was measured using an injection of blue tracer dye in the IVC and the optical concentration at the LPA and RPA outlets was compared. The CCPC models were also retrofitted to accommodate an Impella ventricular assist device (VAD) and PediPump VAD. HFD and cardiac index (CI) (IVC+SVC flow return) were compared with linear regression and paired t-test. Results: All CCPC HFD were within optimal range. Addition of either MCS device to the CCPC creates incremental increase of CI (p&lt;0.01) and significant improvement in HFD balance vs baseline TCPC (p=0.03), reflecting the dominance of the MCS mixing over anatomic influence on HFD. Conclusions: Patient-specific CCPC Fontan designs can successfully accommodate MCS implantation. Addition of MCS in benchtop testing shows improved CI and HFD, mitigating anatomic impact on HFD.

Impact of Mechanical Circulatory Support on Exercise Capacity in Patients With Advanced Heart Failure.

Approximately 6 million individuals have heart failure in the United States alone and 15 million in Europe. Left ventricular assist devices (LVAD) improve survival in these patients, but functional capacity may not fully improve. This article examines the hypothesis that patients supported by LVAD experience persistent reductions in functional capacity and explores mechanisms accounting for abnormalities in exercise tolerance.

Impact of mechanical circulatory support on post-transplant stroke risk.

The effect of type of mechanical circulatory support on stroke risk during the early post-transplant period remains undefined in patients bridged to transplant. This study assesses if the type of circulatory support device affects stroke risk in this population. The study cohort of 4257 adult patients bridged with mechanical support to cardiac transplant were derived from the UNOS transplant registry data. Risk factors assessed were age, gender, ischemic time, diabetes (recipient), durable mechanical support at listing and mechanical ventilation pre-transplant. Descriptive statistics were used to describe characteristics of the study cohort. Univariate logistic regression was used to test if there is a significant association between stroke event and all the potential risk factors. Multivariate logistic regression was used to test such associations while adjusting for all other risk factors. Odds ratios (ORs) and their 95% confidence intervals (CIs) in parenthesis, were calculated. p < 0.05 was considered significant. Patients on Extracorporeal membrane oxygenation (ECMO) had the highest risk of stroke immediately post-transplant prior to discharge (OR 3.03, {1.16, 7.95}) followed by Total Artificial Heart (TAH) (OR 2.03, {1.01, 4.07) as compared to those only on a Left Ventricular Assist Device (LVAD). Ischemic time (OR 1.3 {1.09, 1.45}) and diabetes (OR 1.8 {1.29, 2.51}) were significant risk factors. Patients on ECMO and TAH had a 203% and 103% increase respectively in the odds of having a stroke prior to discharge as compared to those only on LVADS.

Impact of mechanical circulatory support on donor heart allocation: past, present, and future.

The United Network for Organ Sharing (UNOS) recently revised its heart allocation policy to address numerous shortcomings of the previous system. Implemented in 2018, the changes sought to reduce waiting list mortality, clearly define urgency status based on objective physiologic variables, decrease exemption requests, and introduce geographic modifications to ensure organ distribution favors the highest urgency candidates. In large part, UNOS policy revisions were driven by the growing use of continuous flow left ventricular assist devices (CF-LVADs) and the relevant device complications that led to an unacceptably high number of status exemptions. The new 6-tiered system assigns a comparatively lower urgency status to patients supported on CF-LVADs and higher urgency to patients supported on short-term mechanical circulatory assist (MCA) such as extracorporeal membrane oxygenation (ECMO) and intraaortic balloon pump (IABP) counterpulsation. LVAD use as bridge to transplant (BTT) therapy increased steadily throughout the preceding decade due to technological improvements and increased physician familiarity, but the recent policy changes introduce incentives for physicians to withhold this life-saving therapy in order to achieve higher urgency status for their patients. This paper will explore the technological evolution of MCA and the pertinent clinical trials that have led to their FDA approval as BTT and destination therapy. A review of the inception and development of the donor allocation system will be provided before examining available post-policy outcome data. Finally, we will highlight successes and shortcomings of the implemented changes before commenting on areas to potentially expand upon the existing policy.

Abstract 15717: Impact of Mechanical Circulatory Support on Outcomes and In-hospital Mortality of Peripartum Cardiomyopathy Patients With Cardiogenic Shock: An Analysis of the Nis Database

Background: Peripartum cardiomyopathy (PPCM) is an uncommon form of cardiomyopathy that affects young women at the end of pregnancy or in the first few months following delivery, and is associated with increased morbidity and mortality. In selected patients with cardiogenic shock (CS), mechanical circulatory support (MCS) devices improve outcomes. However, data comparing outcomes of patients with PPCM who develop CS and receive mechanical circulatory support (MCS) vs. those treated medically remains limited. Methods: Using the National Inpatient Database (NIS) we identified patients with PPCM who were treated for CS from 2012 to 2017. Primary outcome was in-hospital mortality. Multivariate analysis models were adjusted for statistically significant differences in baseline characteristics between the groups. Results: A total of 4686 patients were admitted with a diagnosis of PPCM, of these 199 patients developed cardiogenic shock. Only 50 (25.1%) patients received MCS. Patients who received MCS were less likely to have a prior ICD in place (6% vs. 23%, p = 0.008), and were more likely to suffer from end-stage renal disease (6% vs. 0.67%, p = 0.020). There were no other major differences in baseline characteristics among the two groups. The incidence of ICD implant prior to discharge (4% vs. 7.4%, p = 0.243, OR 0.39) and cardiac arrest (16% vs. 7.4%, p = 0.173, OR 2.01) was not significantly different between the groups. There was no significant difference in in-hospital mortality between those who received MCS devices and those treated medically (22% vs 10.1%, p = 0.256, OR 1.73). LOS was longer for the MCS group (23.2% vs. 13.4 mean days, p = 0.001). Conclusions: The use of MCS in PPCM patients who developed cardiogenic shock appears to offer similar survival benefit compared to those treated medically, despite being associated with longer length of stay This finding may be related to the complexity and acuity level of patients receiving MCS compared to those treated medically.

Trends and Impact of the Use of Mechanical Circulatory Support for Cardiogenic Shock Secondary to Takotsubo Cardiomyopathy

Data on the trend and impact of mechanical circulatory support (MCS) in patients with Takotsubo cardiomyopathy (TC) are scarce. We evaluated the incidence and outcomes of cardiogenic shock (CS) in TC patients and the trend in use of MCS over time. The National Inpatient Sample from 2005 to 2014 was used to identify patients admitted with TC and those receiving MCS. Multivariate logistic regression was performed to identify predictors of mortality. The Cochran-Armitage test was used for the trend analysis across the years. Admissions for TC showed a linear increase for the study period. From 2005 to 2014 the proportion of TC managed with MCS remained stable, with some yearly fluctuations. Crude in-hospital mortality rate was 2.5% in the patients admitted with TC but was significantly higher in those with CS (15.81% vs 1.68%, p < 0.001). There was no difference in mortality in TC patients with CS, both with and without the use of MCS. However, patients managed with MCS were more likely to be discharged to a skilled nursing facility (31% vs 25.55, p = 0.015) compared with TC patients with CS who were medically managed. The cost of care for patients with TC and CS, managed with MCS was significantly higher than those managed medically ($171K vs $128K, p <0.001). In patients managed with MCS, only sepsis was associated with a higher likelihood of death using multivariate analysis (Odds Ratio 2.538, Confidence Interval 1.245 to 5.172; p = 0.011). In conclusion, the incidence of TC has increased over the years, but the proportion of patients requiring MCS has declined. Crude mortality rate for TC was 2.5%, but was 15.8% in the TC patients with CS. The use of MCS did not lead to improved mortality but was associated with higher cost and increased likelihood of skilled nursing facility discharge.

Impact of mechanical circulatory support on pediatric heart transplant candidates with elevated pulmonary vascular resistance.

With the new era of increasing use of mechanical circulatory support (MCS) in children, seemingly more patients with elevated pulmonary vascular resistance (PVR) are having positive outcomes. The purpose of this study was to define the effect of MCS on pediatric patients listed for heart transplant with an elevated PVR. The United Network for Organ Sharing (UNOS) database was used to identify patients aged 0-18 at the time of listing for heart transplant between 2010 and 2019 who had PVR documented (n = 2081). Patients were divided into MCS (LVAD, RVAD, BiVAD, and TAH) and No MCS groups, then divided by PVR (PVR) at the time of listing: <3, 3-6, and >6 Wood units (WU). MCS was used in 20% overall (n = 426); 57% of those with PVR <3, 27% with PVR 3-6, and 16% with PVR >6. MCS, PVR <3 patients had a higher chance of positive waitlist outcome than all No MCS groups (vs. PVR <3, P = .049; vs. PVR 3-6, P = .004; vs. PVR >6, P < .001). MCS, PVR 3-6 patients had a higher chance of positive waitlist outcome than all No MCS groups (vs. PVR <3, P = .048; vs. PVR 3-6, P = .009; vs. PVR >6, P < .001). MCS, PVR >6 patients had a higher chance of positive waitlist outcome than No MCS, PVR >6 patients (P = .012). Within the No MCS group, patients with a PVR >6 had a higher incidence of negative waitlist outcome compared to PVR <3 (17% vs. 10%, P = .002); this was not the case in the MCS group (5% vs. 6%, P = .693). More patients in the MCS group were ventilator dependent (15% vs. 9%, P < .001) at the time of listing and less likely to have a functional status >50% (43% vs. 73%, P < .001). No significant differences in post-transplant survival were found in pairwise comparisons of MCS and No MCS PVR subgroups. Patients supported with MCS had a significantly higher chance of a positive waitlist outcome than those without such support regardless of PVR status. This was most pronounced with a PVR greater than 6 WU. MCS compared to No MCS patients had better waitlist survival and equivalent post-transplant survival. MCS patients, despite being more ill, had better overall survival regardless of PVR.

Impact of Mechanical Circulatory Support on Pediatric Heart Transplant Candidates with Elevated Pulmonary Vascular Resistance

With the new era of more effective medicines and increasing use of mechanical circulatory support (MCS) in children, seemingly more patients with elevated pulmonary vascular resistance (PVR) are having positive outcomes. The purpose of this study is to define the effect of MCS on pediatric patients listed for heart transplant with an elevated PVR. The United Network for Organ Sharing (UNOS) database was used to identify patients ages 0-18 at time of listing for heart transplant between 2010 and 2019 who had PVR documented. Patients were divided into MCS (LVAD, RVAD, BiVAD, and TAH) and No-MCS groups, then divided by indexed PVR (PVRi) at time of listing: <3, 3-6, and >6 Wood units. Positive waitlist outcome was defined as reaching transplant or delisted because of clinical improvement. Negative waitlist outcome was defined as death or delisted because too sick to transplant. 2081 pediatric patients were listed for heart transplant between 2010 and 2019. MCS was used in 20% overall (n=426); 57% of those with PVRi <3, 27% with PVRi 3-6, and 16% with PVRi >6. Median MCS duration was 68 days (IQR 30-142). In all three PVRi groups, MCS patients had a significantly higher incidence of positive waitlist outcome compared to No-MCS patients (Table 1). Within the No-MCS group, patients with a PVRi >6 had a higher incidence of negative waitlist outcome compared to PVRi <3 (17 vs 10%, p=0.002). This was not true in the MCS group (5 vs 6%, p=0.693). No significant differences in post-transplant survival were found between the subgroups. Patients supported with MCS had a significantly higher chance of a positive waitlist outcome than those without such support regardless of PVR status. With better waitlist survival and equivalent post-transplant survival compared to No-MCS patients, MCS patients had better overall survival from listing regardless of PVR.

Impact of mechanical circulatory support on survival in pediatric heart transplantation.

Evidence on the impact of MCS on pediatric heart transplant survival is still scarce related to congenital heart disease patients including univentricular physiology as well as the risk factors for complications. We performed a retrospective review of all urgent pediatric (aged ≤16years) HT from 2004 to 2014 in the Spanish Pediatric Heart Transplant Registry Group. Patients were stratified into two groups: urgent 0 (MCS at HT) and urgent 1 (non-MCS at HT). The primary outcome measure was post-transplant survival; secondary outcome measures were complications and absence of infections and rejection during the first post-transplant year. One hundred twenty-one pediatric patients underwent urgent HT, 58 (47.9%) urgent 0 and 63 (52%) urgent 1. There were 30 (24.8%) deaths: 12 in the urgent 0 group and 18 in the urgent 1 group, P=n.s. Regarding the type of MCS, patients on ECMO had the highest rate of complications (80%) and mortality (40%). Patients in the urgent 1 group showed a higher risk of hospital re-admission for infection during the first year after transplantation (OR 2.31 [1.1-4.82]), P=.025. We did not identify a risk factor for mortality. MCS does not impact negatively on survival after HT. However, there is a significant increase in 30-day and 1-year mortality and complications in ECMO patients compared with VAD patients. Infants, congenital heart disease, and PediMACS were not found to be risk factors for mortality.

Impact of Mechanical Circulatory Support on Posttransplant Outcomes

Mechanical circulatory support (MCS) has markedly improved the likelihood of transplant among patients with advanced heart failure. Transplant survival following MCS is similar for supported and unsupported recipients. Transplant survival is only reduced following left ventricle assist device (LVAD) support complicated by infection, total artificial heart support, and extracorporeal life support. Despite allosensitization and a higher incidence of vasoplegia syndrome, posttransplant survival for durable LVADs is similar to patients with inotropes alone at the time of transplant. MCS as a bridge to transplant offers significant benefits over waiting without support.

Heart transplant program at IRCCS-ISMETT: Impact of mechanical circulatory support on pre- and post -transplant survival

BackgroundHeart transplantation (HTx) improves the quality of life and survival in patients affected by end-stage heart failure. The purpose of the current study is to present the patients' clinical data and results of HTx in a single Center of Sicily. Focus on survival after pre and post HTx mechanical circulatory support use will be performed. Methods. 133 HTx were done from 2004 to the end of 2015.The average donor age was 34±13.5years and the proportion of male donors was 67%. Percentage of use of mechanical circulatory support to bridge patients to HTx was 18%. Results. Overall pre-transplant mechanical circulatory support was not correlated to worse post-transplant prognosis, p=0.757. Severe primary early graft failure requiring extra corporeal membrane oxygenator support strongly impact the early mortality after heart transplantation (p<0.001). Conclusions. The results of HTx at ISMETT are comparable to those reported in high volume Italian transplant centers as well as in the ISHLT registry. The favorable outcome can be related to focus on multidisciplinary approach, strict recipients' selection and young donor population. Post HTx mechanical circulatory support use in general remains associated with worse post-transplant outcomes. This does not apply to pre-op mechanical circulatory support population.

(401) - Impact of Mechanical Circulatory Support Before Cardiac Transplantation on Early and Late Rejection, Allograft Vasculopathy and Survival: Analysis of the ISHLT Adult Heart Transplant Registry

(401) - Impact of Mechanical Circulatory Support Before Cardiac Transplantation on Early and Late Rejection, Allograft Vasculopathy and Survival: Analysis of the ISHLT Adult Heart Transplant Registry

(603) - Outcome of Pediatric Heart Transplantation Has Continued to Improve Over the Last Three Decades: Impact of Mechanical Circulatory Support

(603) - Outcome of Pediatric Heart Transplantation Has Continued to Improve Over the Last Three Decades: Impact of Mechanical Circulatory Support

The impact of mechanical circulatory support on outcomes in paediatric heart transplantation†

Internationally, the number of donors for cardiac transplantation has remained static, while the number of patients requiring transplantation for congenital heart disease (CHD) has increased. Although the availability of mechanical circulatory support (MCS) may increase the number of transplants performed by reducing deaths while waiting, it may also lead to increased morbidity post-transplantation. We sought to assess the impact of mechanical support on post-transplant outcomes in a single centre. We assessed the outcomes of paediatric (age ≤16 years) heart transplantation in a single unit in the era of mechanical support (1998-2012) by retrospective cohort study. Outcomes before (1998-2005) and after (2005-2012) the routine use of the Berlin Heart EXCOR device were contrasted. A total of 167 patients underwent heart transplantation during this period. The diagnosis was dilated cardiomyopathy in 61.7%, two-ventricle CHD in 11.4%, single ventricle CHD in 16.8% and miscellaneous in 10.1%. Sixty-nine (41%) were bridged to transplant by mechanical support; with extracorporeal membrane oxygenation in 19 (28%), ventricular assist device in 40 (58%) and a combination in 10 (14.0%). Post-transplant mortality at 30 days was significantly greater in those supported by MCS than without (7 vs 1%, P < 0.05), and a greater proportion of patients had neurological (23 vs 8%, P < 0.01) and major respiratory sequelae (20 vs 4%, P < 0.001). There was no significant increase in the need for post-transplant mechanical support (10 vs 6%, P = 0.3) in those supported prior to transplant. The number of transplants performed increased from 67 in 1998-2005 to 100 in the most recent era (2005-2012), and an increased proportion of these patients have been supported mechanically prior to transplantation (51 vs 27%, P < 0.01). Along with strategies to increase donor utilization, MCS has allowed an increase in cardiac transplant activity at the expense of a higher early mortality and morbidity.

Health-Related Quality of Life among Patients with Mechanical Circulatory Assistance: Clinician Perspectives

Purpose There is a lack of validated outcome measures that assess health-related quality of life (HRQOL) among patients with mechanical circulatory support (MCS). The purpose of this qualitative study was to obtain health care clinicians’ perspectives on factors that influence HRQOL, both positively and negatively, among advanced heart failure patients with MCS. Methods and Materials We conducted semi-structured qualitative interviews with 15 clinicians who provide care to MCS patients (including 3 cardiac surgeons, 3 cardiologists, 2 palliative care physicians, 3 ventricular assist device coordinators, 2 social workers, and 2 psychologists). Interviews lasted 30-60 minutes, were audio-recorded, and transcribed verbatim. Data were analyzed using a 2-phase strategy of descriptive and thematic coding. Results Clinicians described a wide range of issues that impact on HRQOL of patients with MCS. Clinicians identified positive outcomes: improved physical function, decreased symptom burden, and increased life expectancy, often described as “the gift of time.” Importantly, clinicians identified negative outcomes related to the emotional impact of MCS: loss of independence and autonomy, uncertainty about the future, and concerns about being a burden to loved ones. Disturbed role performance and anxiety about device management were identified as problems in the early post-implant phase but tended to resolve over time. Finally, clinicians indicated that a small subset of patients, typically those with device-related complications, expressed regret over their decision to receive a device. Conclusions HRQOL among patients with MCS is a multi-dimensional construct that includes symptom burden, physical function and role performance, and emotional and relational impact. Clinicians indicated that MCS can have both a positive and negative impact on HRQOL. These findings indicate the necessity of developing a measure of HRQOL for patients with MCS. This will be done by triangulating clinician interviews with patient and caregiver interviews.