Mechanical Support Devices Research Articles

Device-based therapy for decompensated heart failure: An updated review of devices in development based on the DRI2P2S classification.

Congestive heart failure (HF) is a devastating disease leading to prolonged hospitalization, high morbidity and mortality rates, and increased costs. Well-established treatments for decompensated or unstable patients include medications and mechanical cardiac support devices. For acute HF decompensation, new devices are being developed to help relieve symptoms and recover heart and renal function in these patients. A recent device-based classification scheme, collectively classified as DRI2P2S, has been proposed to better describe these new device-based therapies based on their mechanism: dilators (increase venous capacitance), removers (direct removal of sodium and water), inotropes (increase left ventricular contractility), interstitials (accelerate removal of lymph), pushers (increase renal arterial pressure), pullers (decrease renal venous pressure), and selective (selective intrarenal drug infusion). In this review, we describe the new class of medical devices with the most current results reported in preclinical models and clinical trials.

Pulmonary Artery Banding for Dilated Cardiomyopathy in Children: Returning to the Bench from Bedside.

Current treatment paradigms for end-stage dilated cardiomyopathy (DCM) in children include heart transplantation and mechanical support devices. However, waitlist mortality, shortage of smaller donors, time-limited durability of grafts, and thrombo-hemorrhagic events affect long-term outcomes. Moreover, both these options are noncurative and cannot preserve the native heart function. Pulmonary artery banding (PAB) has been reinvented as a possible “regenerative surgery” to retrain the decompensated left ventricle in children with DCM. The rationale is to promote positive ventricular–ventricular interactions that result in recovery of left ventricular function in one out of two children, allowing transplantation delisting. Although promising, global experience with this technique is still limited, and several surgical centers are reluctant to adopt PAB since its exact biological bases remain unknown. In the present review, we summarize the clinical, functional, and molecular known and supposed working mechanisms of PAB in children with DCM. From its proven efficacy in the clinical setting, we described the macroscopic geometrical and functional changes in biventricular performance promoted by PAB. We finally speculated on the possible underlying molecular pathways recruited by PAB. An evidence-based explanation of the working mechanisms of PAB is still awaited to support wider adoption of this surgical option for pediatric heart failure.

Transaortic Placement of Percutaneous Mechanical Support Device via Partial Sternotomy: Feasible Option for Unsuitable Axillary Artery Access.

Acute decompensated refractory cardiogenic shock is an emergency in which the prompt instauration of mechanical circulatory support improves outcomes. The typical, initial approach for device delivery is via femoral vessels due to easy access and safety. If longer support is needed, the femoral access will severely impair the patient's mobility and can also limit the amount of support given as the new-generation devices are too large for direct arterial insertion. Upper-body arterial conduits (UBACs) are used for the delivery of larger, percutaneous ventricular assist devices (pVADs). The Impella 5.5 (Abiomed, Danvers, MA, USA) is a pVAD that can be deployed through a UBAC by either axillary/subclavian access or a transaortic approach. The latter approach is typically used in cases of postcardiotomy shock, in which the ascending aorta is already exposed through a full sternotomy. However, in some cases, the axillary artery is not suitable due to size (<6 mm in diameter), and a smaller pVAD is delivered into the heart. To avoid providing suboptimal support, we present an alternative, minimally invasive approach in which the larger device is delivered through the ascending aorta. This article summarizes the details of this approach through a mini upper partial sternotomy and reviews the relevant technical considerations.

Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

Fontan failure: phenotypes, evaluation, management, and future directions.

Management of "failing" and "failed" Fontan circulation, particularly the indications, timing, and type of re-intervention, currently remains nebulous. Factors contributing to pathogenesis and mortality following Fontan procedure differ between children and adults. Since organ systems in individual patients are affected differently, we searched the extant literature for a "failing" and "failed" Fontan reviewing the clinical phenotypes, diagnostic modalities, pharmacological, non-pharmacological, and surgical techniques employed, and their outcomes. A total of 410 investigations were synthesised. Although proper candidate selection, thoughtful technical modifications, timely deployment of mechanical support devices, tissue-engineered conduits, and Fontan takedown have decreased the peri-operative mortality from 9 to 15% and 1 to 3% per cent in recent series, pernicious changes in organ function are causing long-term patient attrition. In the setting of a failed Fontan circulation, literature documents three surgical options: Fontan revision, Fontan conversion, or cardiac transplantation. The reported morbidity of 25% and mortality of 8-10% among Fontan conversion continue to improve in select institutions. While operative mortality following cardiac transplantation for Fontan failure is 30% higher than for other CHDs, there is no difference in long-term survival with actuarial 10-year survival of around 54%. Mechanical circulatory assistance, stem cells, and tissue-engineered Fontan conduit for destination therapy or as a bridge to transplantation are in infancy for failing Fontan circulation. An individualised management strategy according to clinical phenotypes may delay the organ damage in patients with a failing Fontan circulation. At present, cardiac transplantation remains the last stage of palliation with gradually improving outcomes.

Reperfusion therapy for ST-elevation myocardial infarction complicated by cardiogenic shock: the European Society of Cardiology EurObservational programme acute cardiovascular care-European association of PCI ST-elevation myocardial infarction registry.

To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in European Society of Cardiology (ESC) member and affiliated countries for patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). ESC EurObservational Research Programme prospective international cohort study of admissions with STEMI within 24 h of symptom onset (196 centres; 26 ESC member and 3 affiliated countries). Of 11 462 patients enrolled, 448 (3.9%) had CS. Patients with compared to patients without CS, less frequently received primary percutaneous coronary intervention (PCI) (65.5% vs. 72.2%) and fibrinolysis (15.9% vs. 19.0), and more often had no reperfusion therapy (19.0% vs. 8.5%). Mechanical support devices (intraaortic ballon pump 11.2%, extracoporeal membrane oxygenation 0.7%, other 1.1%) were used infrequently in CS. Bleeding definition academic research consortium 2-5 bleeding complications (10.1% vs. 3.0%, P < 0.01) and stroke (4.2% vs. 0.9%, P < 0.01) occurred more frequently in patients with CS. In-hospital mortality was 10-fold higher (35.5% vs. 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis, and no reperfusion therapy were 27.4%, 36.6%, and 62.4%, respectively. In this multi-national registry, patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore, strategies to improve clinical outcome in STEMI with CS are needed.

Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention

BackgroundSimultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required.Case presentationWe report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1–V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital.ConclusionsAcute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease.

Clinical profile and in-hospital outcome of patients supported by intra-aortic balloon pump in the clinical setting of cardiogenic shock

BackgroundDespite controversial evidences, intra-aortic balloon pump (IABP) is still the most widely used temporary mechanical support device in cardiogenic shock (CS), as a bridge to recovery or to more invasive mechanical supports/heart transplantation. MethodsWe analyzed retrospectively data of all patients receiving IABP for CS from 2009 to 2018 in a referral centre for advanced heart failure and heart transplantation; we included CS following acute coronary syndrome (ACS) and other CS etiologies different from ACS. We excluded patients in which IABP was implanted as a support following cardiac surgery, non-cardiac surgery in patients with severe chronic heart failure, or in elective high risk or complicated Cath Lab procedures.We focused on in-hospital outcomes (including death, recovery, heart transplantation, LVAD) and IABP complications. Results403 patients received IABP, 303 (75.2%) following ACS and 100 (24.8%) in non-ACS CS. Non-ACS patients were younger (59 ± 18.3 vs 73.1 ± 12.6 years, p < 0.001), had lower median left ventricular ejection fraction (LVEF) (25% [18–35] vs 38% [25–45], p < 0.001). In patients with non-ACS etiologies IABP was more frequently a bridge to heart transplantation [20% (n = 20) vs 0.3% (n = 1), P < 0.001] or LVAD [4% (n = 4) vs 0.6% (n = 2), P = 0.055], while ACS patients were more frequently discharged without transplantation/LVAD [65.7% (n = 199) vs 33% (n = 33), P < 0.001]. Non-ACS patients showed higher in-hospital mortality [46% (n = 46) vs 33.9% (n = 103), P = 0.042]. Post-transplant/LVAD outcome in non-ACS subgroup was favorable (21 out of 24 patients were discharged). Serious IABP-related adverse events occurred in 21 patients (5.2%). Ischemic/hemorrhagic complications, infections and thrombocytopenia were more frequent with longer IABP stay. ConclusionsDespite therapy including percutaneous circulatory support, mortality in CS is still high. In our experience, in the clinical setting of refractory CS an IABP support represents a relatively safe circulatory support, associated with a low rate of serious complications in complex clinical scenarios.

Mechanical Circulatory Support for Right Ventricular Failure

Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.

Does Intra-Aortic Balloon pump (IABP) improve hemodynamics in Asian Indian patients with Acute Coronary Syndrome with cardiogenic Shock? (DIASTASIS study)

Introduction: Intra-aortic balloon pump (IABP) is widely used as a mechanical support device. Current evidence after the IABP-SHOCK II trial is ambiguous. We evaluated the impact of IABP on hemodynamic parameters (Cardiac Output (CO), Cardiac Power Output (CPO) and Systemic Vascular Resistance (SVR)) measured at 6 and 24 hours in patients presenting with cardiogenic shock (CS) with Acute Coronary Syndrome (ACS) amongst Asian Indians. Methods: The efficacy of IABP was evaluated in patients presenting with CS in open-label, prospective, randomized (for randomization every alternate patient presented to an emergency was given IABP support), consecutive 60 patients in ACS with CS with group A (N=30) comprising of those with IABP and Group B without IABP (n=30). Results: Both the groups were matched for baseline characteristics. The revascularization rate was 85% and only the culprit vessel was addressed during the study. Total 9 (15%) patients were managed medically and did not undergo revascularization. The mean changes in Systemic vascular resistance (SVR), cardiac output (CO) and cardiac power output (CPO) after 24 hours in patients with and without IABP showed no statistical difference except for the lower mean dose use of dobutamine in Group A (with IABP) vs Group B (without IABP) (4.08 (1.41) vs. 7.92 (2.52) mcg/kg/min, p&amp;lt;0.0001). Conclusion: The use of IABP in Asian Indians with CS in ACS did not provide any improvement in hemodynamic parameters.

Contemporary outcomes of cardiac surgery patients supported by the intra-aortic balloon pump.

OBJECTIVESAlthough the intra-aortic balloon pump (IABP) has been the most widely adopted temporary mechanical support device in cardiac surgical patients, its use has declined. The current study aimed to evaluate the occurrence and predictors of early mortality and complication rates in contemporary cardiac surgery patients supported by an IABP.METHODSA multicentre, retrospective analysis was performed of all consecutive cardiac surgical patients receiving perioperative balloon pump support in 8 centres between January 2010 to December 2019. The primary outcome was early mortality, and secondary outcomes were balloon-associated complications. A multivariable binary logistic regression model was applied to evaluate predictors of the primary outcome.RESULTSThe study cohort consisted of 2615 consecutive patients. The median age was 68 years [25th percentile 61, 75th percentile 75 years], with the majority being male (76.9%), and a mean calculated 30-day mortality risk of 10.0%. Early mortality was 12.7% (n = 333), due to cardiac causes (n = 266), neurological causes (=22), balloon-related causes (n = 5) and other causes (n = 40). A composite end point of all vascular complications occurred in 7.2% of patients, and leg ischaemia was observed in 1.3% of patients. The most important predictors of early mortality were peripheral vascular disease [odds ratio (OR) 1.63], postoperative dialysis requirement (OR 10.40) and vascular complications (OR 2.57).CONCLUSIONSThe use of the perioperative IABP proved to be safe and demonstrated relatively low complication rates, particularly for leg ischaemia. As such, we believe that specialists should not be held back to use this widely available treatment in high-risk cardiac surgical patients when indicated.

Comparison of the Beacon and Quark indirect calorimetry devices to measure resting energy expenditure in ventilated ICU patients

Critically ill patients in the Intensive Care Unit (ICU) should receive nutritional support matched to their metabolic needs as both under- and overfeeding energy has been shown to increase mortality. Critical illness can significantly affect metabolism. Consequently, resting energy expenditure (REE) can vary markedly during critical illness. Therefore, indirect calorimetry to estimate REE is recommended to determine energy requirements in individual ICU patients and to guide optimal nutritional support. Currently, the Quark metabolic monitor is considered the gold standard in our ICU, but novel mechanical support devices are also equipped with indirect calorimetry functionalities. This study aimed to evaluate the performance of a currently unevaluated device. A cross-sectional analysis in mechanically ventilated patients was conducted in a mixed medical-surgical ICU. The primary outcome was a numerical and visual comparison of the performance of the Beacon indirect calorimeter to calculate REE compared to the Quark device using Bland Altman plots. Performance was evaluated using bias, precision, accuracy, and reliability. Secondary analysis included a comparison with REE estimated by predictive equations. Seventy-one measurements were obtained in 27 mechanically ventilated subjects. An underestimation by the Beacon device in calculated REE of-96.2kcal/day (4.5%) was found. There was a bias towards higher VCO2 and lower VO2 values with Beacon as compared to Quark. The reliability of the Beacon was good, with an absolute intraclass correlation coefficient of 0.897 (95%CI 0.751-0.955; p=0.000). There was a poor correlation (<0.40) between the separate indirect calorimetry devices and most predictive equations. Only the Faisy predictive equations had good reliability (ICC 0.687, p=0.002). Beacon indirect calorimetry accurately determined REE in mechanically ventilated critically ill patients compared to the gold standard in our ICU (Quark indirect calorimeter), although confidence intervals were wide. There was low bias and good reliability. On the other hand, predictive equations performed poorly compared to both devices, underestimating the true metabolic needs of mechanically ventilated ICU patients.

Improved Hemodynamic Response Following Intra-Aortic Balloon Pump Support in Patients with Heart Failure Related Cardiogenic Shock and Severe Right Ventricle Dysfunction

<h3>Purpose</h3> Intra-aortic balloon pump (IABP) support is a commonly used strategy in patients with heart failure related cardiogenic shock (HF-CS), however its efficacy in those with out-of-proportion right ventricular (RV) failure is unknown. We aim to assess the hemodynamic response of IABP support for HF-CS over a spectrum of RV function as defined by pulmonary artery pulsatility index (PAPi). <h3>Methods</h3> This is a single center, retrospective study assessing IABP support in consecutive HF-CS patients. We analyzed patients who underwent IABP support with or without baseline inotropic support and excluded patients with acute coronary syndromes or mechanical support devices. We stratified the cohort by PAPi ([pulmonary artery systolic pressure - pulmonary artery diastolic pressure] / central venous pressure) below or above 2. Hemodynamics were compared pre and 48 hours post IABP insertion. <h3>Results</h3> 46 patients were included with median age 61 yrs and left ventricular ejection fraction 19%, 32.6% women, and 91% on inotropes. 22 patients had PAPi > 2 and 24 had < 2. No significant differences in baseline characteristics were observed except for greater age in patients with PAPi > 2 (61 vs 51 yr). Within 48 hours of IABP insertion, patients with PAPi < 2 had significant improvement in central venous pressure, mean pulmonary artery pressure, and cardiac index (P < 0.05 for all, Figure). Although baseline hemodynamics were better optimized in patients with PAPi > 2, only CI improved significantly post IABP (Figure). No significant change in diuretic or inotrope dosing was observed in patients post-IABP irrespective of PAPi (P > 0.05). No significant change in 30-day survival was observed between patients with PAPi < 2 (n=3, 12.5%) versus PAPi > 2 (n=1, 4.5%; P=0.34). <h3>Conclusion</h3> In patients with HF-CS with baseline PAPi <2, we observed a positive hemodynamic response which may infer treatment benefit in patients with out-of-proportion RV dysfunction.

Ventricular Tachycardia Cryoablation During HeartMate 3™ Implantation: A Case Series

Introduction Ventricular arrhythmias (VA) are common in ischemic cardiomyopathy (ICM) causing higher morbidity and mortality after left ventricular assist device (LVAD) implantation.1 While cardiac unloading can ameliorate ventricular tachycardia (VT), persistent post-implant VT results in RV failure and death. A 2013 study reported lower incidence of VA after cryoablation during HeartMate (HM) 2™ implantation, however the data for ablation with HM 3™ implants is slim.2 We present a single-center, 3-patient case series from 2019 to 2021 for concurrent VT cryoablation with HM 3™ implantation. Case Series Three patients with known ICM presented in VT storm and cardiogenic shock requiring inotropic support with or without temporary mechanical support (MCS) devices. Detailed patient characteristics and outcomes are shown in Table 1. Decision-making Given the low likelihood of recovery due to cardiogenic shock and refractory VT requiring temporary MCS and inotropes in transplant ineligible patients, the heart-team decided to pursue concurrent endocardial VT ablation with LVAD implantation. In all 3 cases, LV apical coring was undertaken followed by cryoablation of obvious endocardial scar and then epicardial ablation to isolate the LV apex. Intraoperative mapping was not performed. Outcomes All three patients underwent successful HM3™ implantation with surgical VT ablation. They continue to do well post-implant with no recurrence of VA and improvement in symptoms to NYHA functional class I or II. Conclusions Our case series demonstrates that concurrent VT ablation and HM 3™ LVAD implantation can be safely and effectively performed in end-stage ischemic cardiomyopathy patients with refractory VT. This strategy showed no further recurrence of arrhythmias postoperatively and drastic improvement in symptoms. Further large multicenter analysis should be conducted to explore this as a viable strategy for durable mechanical support.

Right Ventricular Dysfunction Is Associated With Increased Mortality In Patients Requiring Veno-venous Extracorporeal Membrane Oxygenation For The Management Of Severe Respiratory Failure In Covid-19 Infection

PurposeRefractory respiratory failure caused by the coronavirus SARS-CoV-2 is associated with a significant mortality rate. Patients unresponsive to conventional medical therapy may benefit from temporary veno-venous extracorporeal membrane oxygenation (VV-ECMO), which provides complete gas exchange while allowing the patient to recover. We sought to investigate the role of right ventricular failure in the outcomes of these patients since clinical and echocardiographic characteristics that predict survival are not yet defined in patients with respiratory failure caused by SARS-CoV-2.MethodsWe performed a single center retrospective cohort study enrolling consecutive patients that required VV-ECMO for the management of refractory respiratory failure between January and December 2020. Seventeen consecutive patients with COVID-19 infection were included in the reported cohort. Demographics, comorbidities, laboratory parameters and echocardiographic features of left and right ventricular (LV/RV) function were compared between patients who survived and those who could not be weaned from VV-ECMO and died.ResultsTen of the 17 patients failed to wean from VV-ECMO and died in the hospital on average 41.5 ± 10.9 days post admission. Seven were successfully decannulated and survived to hospital discharge on average 39.0 ± 19.8 days after admission. There were no significant differences in demographics, comorbidities, laboratory parameters between the groups. LV size and function were also similar. However, moderate to severe RV dysfunction was significantly more frequent in the group of patients who died (8/10, 80%) compared to the survivors (0/7, 0%) (p=0.0017).ConclusionSevere RV dysfunction is associated with increased mortality among patients with severe COVID-19 associated respiratory failure treated with VV-ECMO. Measures to support RV function, including temporary mechanical RV support devices, should be considered for these patients aiming to improve survival.

Bringing The Swan Back: Improving Cardiogenic Shock Mortality

<h3>Background</h3> Mortality in cardiogenic shock is historically high, with advances in devices and mechanical cardio-circulatory support treatment is improving. Institutional recognition and implementation is of utmost importance. <h3>Objective</h3> To create early multidisciplinary activation of hemodynamic-guided management which includes early shock identification and implementation of mechanical circulatory support to improve the outcomes of cardiogenic shock patients at a non-tertiary care hospital. <h3>Methods</h3> A single-center, retrospective study was performed on patients who presented with cardiogenic shock secondary to acute decompensated heart failure or acute myocardial infarction between 2016-2020. Use of mechanical support including Impella and intra-aortic balloon pump as well as the use of Swan-Ganz catheters were examined. Endpoints of survival to discharge were also examined. <h3>Results</h3> A total of 209 patients presented with cardiogenic shock over a 5 year period. Data analysis showed that compared to baseline 2016 survival data of 37% (10/27), survival rates increased every year to 43%(12/28) in 2017, 54%(14/26) in 2018, 70 %(40/57) in 2019, and 71% (51/72) in 2020 (p= 0.001; OR 25.22; CI 3.55 to 179.23), facilitated by the implementation of a multidisciplinary cardiogenic shock team in 2018. In addition, the use of Swan-Ganz catheters substantially increased from 0% in 2016 to 100% in 2019. Specifically between 2018 and 2019, Swan-Ganz catheter usage increased from 43% in 2018 to 100% in 2019 as did survival percentage (54% to 71%) (p=0.06). The use of mechanical support increased from 9 patients in 2016 to 35 patients in 2020. The survival to discharge of patients requiring Impella support increased from 17% in 2018 to 67% in 2020. <h3>Conclusions</h3> The results of this study demonstrate that a multidisciplinary team approach to the treatment of cardiogenic shock resulted in better clinical outcomes. Survival to discharge improved substantially from 2016 to 2020. These improved outcomes were driven by a combination of a multidisciplinary team approach, utilization of Swan-Ganz catheters, and effective use of mechanical support devices.

The New UNOS Heart Transplant Statuses: Upgrades, Transplant Rate and Survival

<h3>Purpose</h3> The UNOS heart transplant policy was changed in October 2018 giving priority to temporary mechanical support devices (tMCS). The primary aim of the study was to evaluate the distribution of patients listed and transplanted based on new priority status and their waitlist and post-transplant outcome. <h3>Methods</h3> The UNOS thoracic transplant data was queried after October 2018 to identify adult patients listed for heart transplant (n=10957) based on their UNOS priority status. The 30-day transplant rate based on listing status was evaluated. Kaplan Meier curves were used for post-transplant survival stratified by the transplant UNOS status (1, 2, 3, 4). <h3>Results</h3> The initial listing status 1, 2, 3, 4, 5 and 6 was in 511 (6%), 2296 (21%), 1242 (11%), 4098 (37%), 316 (3%) and 2352 (22%) patients respectively. 142 (1%) patients at listing and 1359 (12%) after listing became inactive. Of all transplants (n=7025), 50% (n=3505) had end priority status 2, half (48%) of which were upgraded from lower statuses (Status 4=21%). Over 75% Status 1 and 2 patients are transplanted in 30 days of listing (Figure 1). 33% in status 4 and 47% status 6 are upgraded to prior to transplant. Status 1 patients had worst port transplant survival at 1 year (82% v. 91% v. 87% v. 90%, p<.01) compared to statuses 2, 3, 4 (Figure 2). <h3>Conclusion</h3> Over 60% of patients listed for heart transplant under new UNOS policy are Status 4, 5 or 6 whereas more than 50% of patients transplanted are Status 1 and 2. Over 33% patients from status 4 and 6 are upgraded to higher statuses before transplant. Status 1 and 2 patients have higher rate of transplant within 30 days of listing. Status 1 patients have worst post-transplant survival.

Outcomes of a multidisciplinary shock team utilizing an integrated medical/surgical strategy: The Penn Medicine Shock Model

Background Cardiogenic shock (CS) is associated with poor prognosis, with mortality rates in excess of 40-50%. Multidisciplinary shock teams have been created to facilitate early diagnosis and appropriate escalation of support. However, there are varying approaches to implementation, resulting in variable outcomes. We describe our team's approach and outcomes over 18 months. Shock team Approach : The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019 and consists of physicians from Interventional Cardiology, Electrophysiology, Cardiac Surgery, and Intensive Care. The team is led by an Advanced Heart Failure Cardiologist and Cardiothoracic Surgeon, who activate other members of the team by phone for expedited decision-making. The multidisciplinary team evaluates referred patients for a potentially treatable insult and/or an appropriate exit strategy to avoid futile device placement. Accepted patients are then categorized for treatment/escalation of support according to three pathways: 1) acute myocardial infarction (AMI) shock, 2) hemodynamic (non-AMI) shock, 3) post-cardiotomy shock. All PMCST calls are maintained in a data registry. Results Between November 2019 and April 2021, the team received a total of 197 shock calls. Majority of the calls (93%) came from 20 local referring centers and 139 patients (70%) were accepted. Approximately half (53%) were admitted to the Cardiothoracic Intensive Care Unit. Temporary mechanical support devices were used in 84 patients (61%). Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) were the most frequently used single platforms (IABP 29%, ECMO 23%), but the majority of patients (36%) received multiple devices. Escalation of mechanical support was required in 32 patients (38%). Combined Impella and ECMO was the most commonly implemented escalation platform (25%). In total, 39 patients (46%) were evaluated for advanced therapies, with 6 patients (7%) proceeding to durable VAD or transplant. Overall survival rate was 68%. Discussion The PMCST multidisciplinary approach utilizes an integrated medical/surgical team strategy with leadership by Advanced Heart Failure and Cardiothoracic Surgery. This approach prioritizes ongoing community partnership for early recognition and appropriate utilization of therapy, and represents a successful strategy towards implementation of timely, but not futile, mechanical support and advanced therapies. Cardiogenic shock (CS) is associated with poor prognosis, with mortality rates in excess of 40-50%. Multidisciplinary shock teams have been created to facilitate early diagnosis and appropriate escalation of support. However, there are varying approaches to implementation, resulting in variable outcomes. We describe our team's approach and outcomes over 18 months. : The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019 and consists of physicians from Interventional Cardiology, Electrophysiology, Cardiac Surgery, and Intensive Care. The team is led by an Advanced Heart Failure Cardiologist and Cardiothoracic Surgeon, who activate other members of the team by phone for expedited decision-making. The multidisciplinary team evaluates referred patients for a potentially treatable insult and/or an appropriate exit strategy to avoid futile device placement. Accepted patients are then categorized for treatment/escalation of support according to three pathways: 1) acute myocardial infarction (AMI) shock, 2) hemodynamic (non-AMI) shock, 3) post-cardiotomy shock. All PMCST calls are maintained in a data registry. Between November 2019 and April 2021, the team received a total of 197 shock calls. Majority of the calls (93%) came from 20 local referring centers and 139 patients (70%) were accepted. Approximately half (53%) were admitted to the Cardiothoracic Intensive Care Unit. Temporary mechanical support devices were used in 84 patients (61%). Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) were the most frequently used single platforms (IABP 29%, ECMO 23%), but the majority of patients (36%) received multiple devices. Escalation of mechanical support was required in 32 patients (38%). Combined Impella and ECMO was the most commonly implemented escalation platform (25%). In total, 39 patients (46%) were evaluated for advanced therapies, with 6 patients (7%) proceeding to durable VAD or transplant. Overall survival rate was 68%. The PMCST multidisciplinary approach utilizes an integrated medical/surgical team strategy with leadership by Advanced Heart Failure and Cardiothoracic Surgery. This approach prioritizes ongoing community partnership for early recognition and appropriate utilization of therapy, and represents a successful strategy towards implementation of timely, but not futile, mechanical support and advanced therapies.

Mechanical Circulatory Support in COVID-19.

Despite aggressive care, patients with cardiopulmonary failure and COVID-19 experience unacceptably high mortality rates. The use of mechanical circulatory support devices in this population offers potential benefits but confers significant morbidity and novel challenges for the clinician. Thoughtful application of this complex technology is of the utmost importance and should be done in a multidisciplinary fashion by teams familiar with mechanical support devices and aware of the particular challenges provided by this complex patient population.

NOVEL OPERATIVE TECHNIQUE FOR FULLY IMPLANTABLE TOTAL ARTIFICIAL HEARTS WITH NORMAL CARDIAC ANATOMY- CADAVERIC EVALUATION

23 million people are affected by heart failure in the world. Even with the best promotional methods there is a shortage of donor hearts globally. Advances in technology with development of fully implantable, durable, devices for mechanical support have strengthened the necessity of use of these devices for destination therapy. As better and novel prototypes emerge, the requirement of surgical innovations is a necessity for quick and safe implantation and explantation procedures in emergency. Use of augmented and virtual reality platforms for device patient match as well as surgical training is being looked into a serious option for such procedures in future.