Orthotopic Heart Transplantation Patients Research Articles

CLINICAL OUTCOMES OF INFLAMMATORY BOWEL DISEASE AFTER ORTHOTOPIC HEART TRANSPLANT

Abstract BACKGROUND Limited data are available on outcomes of patients with pre-existing inflammatory bowel disease (IBD) who undergo orthotopic heart transplantation (OHT) or develop de novo IBD post-OHT. We aimed to assess the incidence and disease outcomes of pre-existing and de novo IBD in OHT patients while evaluating the effect of IBD on OHT outcomes. METHODS A retrospective review of records was performed from a tri-site tertiary care system between July 2000 and July 2022. A total of 83 OHT receipients were concomitantly diagnosed with colitis of infectious or inflammatory etiology. Only patients with a diagnosis of IBD were included. Sub-analyses of the outcomes and immunosuppressive regimens of OHT recepients were done relative to those with pre-existing or de novo IBD. RESULTS A total of 8 OHT patients with concomitant IBD were identified. The median patient age (IQR) was 54 (23) with OHT and IBD onset at 50 (21.2) and 32.5 (15.7), respectively. Six patients were diagnosed with ulcerative colitis (UC) and 2 were diagnosed with Crohn’s disease. Five of the patients were female. All patients developed IBD within 11.5 (8) years within OHT. Only 1 patient developed de novo IBD 15 years after the first OHT and 7 years prior to a second OHT. OHT immunosuppressive regimens included a combination of tacrolimus (TAC) and prednisone (n=2), TAC and mycophenolate mofetil (MMF) (n=2), TAC, MMF, and sirolimus (n=2), TAC and sirolimus (n=1), and MMF with sirolimus (n=1). Therapy for pre-existing IBD included maintenance of 5-aminosalicylic (5-ASA) (n=3), escalation to vedolizumab (VD) (n=2), and discontinuation of IBD therapy (5-ASA and azathioprine) (n=3). De novo IBD consistent with UC (15 years post-OHT) was managed with 5-ASA (n=1). Six patients (including de novo IBD case) maintained clinical and endoscopic remission of IBD with no flares post-OHT while 2 patients (1 UC and 1 CD) with active disease flares responded clinically and endoscopically to VD escalation from 5-ASA and azathioprine. Among two UC patients with ileal J-pouch pre-OHT, 1 developed refractory pouchitis requiring diverting ileostomy (while on TAC and prednisone) with no pouchitis in the other (maintained on TAC and MMF). Good graft tolerance limited to mild acute cellular rejection episodes was noted in 6 patients, while multiple or no rejection episodes were noted in the remaining two. None of the patients developed CMV or MMF-induced colitis. One patient died due to progressive functional decline unrelated to graft failure or IBD. DISCUSSION The clinical course and treatment of IBD preceding OHT or de novo (though rare) is not significantly worsened or altered post-OHT. The majority of patients achieve clinical and endoscopic remission while on heart transplant-related immunosuppression. Biologic therapy escalation to VD resulted in clinical remission with no effect on graft tolerance. Table 1 Clinical outcomes of OHT patients with concomitant IBD

Comparing 3-year survival and readmissions between HeartMate 3 and heart transplant as primary treatment for advanced heart failure

ObjectiveTo compare 3-year survival and readmissions of patients who received the HeartMate 3 (HM3) left ventricular assist device (LVAD) or underwent orthotopic heart transplantation (OHT) as primary treatment for advanced heart failure. MethodsWe retrospectively analyzed 381 adult patients who received an HM3 LVAD or were listed for OHT between January 2014 and March 2021 at our center. To minimize crossover bias, OHT recipients with a prior LVAD were excluded, and HM3 patients were censored at the time of transplant. Cohorts were propensity score–matched to reduce confounding variables. The primary outcome was 3-year survival, and the secondary outcome was mean cumulative all-cause unplanned readmission. ResultsThe study population comprised 185 HM3 patients (49%) and 196 OHT patients (51%), with 104 propensity score–matched patients in each group. After propensity score matching, there was no statistical difference in 3-year survival (83.7% for HM3 vs 87.0% for OHT; P = .91; relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.20). In the unmatched cohorts, patients age 18 to 49 years had comparable survival with HM3 and OHT (96.9% vs 95.9%; N = 91; P = 1.00; RR, 0.92; 95% CI, 0.09-9.78). Patients age 50+ years had slightly inferior survival with HM3 (75.0% vs 83.9%; N = 290; P = .60; RR, 1.51; 95% CI, 0.85-2.68). The mean number of readmissions at 3 years was higher in the HM3 group (3.89 vs 2.05; P < .001). ConclusionsThis exploratory analysis suggests that for similar patients, HM3 may provide comparable 3-year survival to OHT as a primary treatment for heart failure but may result in more readmissions.

Accuracy of free-breathing multi-parametric SASHA in identifying T1 and T2 elevations in pediatric orthotopic heart transplant patients.

T1/T2 parametric mapping may reveal patterns of elevation ("hotspots") in myocardial diseases, such as rejection in orthotopic heart transplant (OHT) patients. This study aimed to evaluate the diagnostic accuracy of free-breathing (FB) multi-parametric SAturation recovery single-SHot Acquisition (mSASHA) T1/T2 mapping in identifying hotspots present on conventional Breath-held Modified Look-Locker Inversion recovery (BH MOLLI) T1 and T2-prepared balanced steady-state free-precession (BH T2p-bSSFP) maps in pediatric OHT patients. Pediatric OHT patients underwent noncontrast 1.5T CMR with BH MOLLI T1 and T2p-bSSFP and prototype FB mSASHA T1/T2 mapping in 8 short-axis slices. FB and BH T1/T2 hotspots were segmented using semi-automated thresholding (ITK-SNAP) and their 3D coordinate locations were collected (3-Matic, Materialise, Leuven, Belgium). Receiver operator characteristic curve analysis and measures of central tendency were utilized. 40 imaging datasets from 23 pediatric OHT patients were obtained. FB mSASHA yielded a sensitivity of 82.8% for T1 and 80% for T2 maps when compared to the standard BH MOLLI, as well as 100% specificity for both T1 and T2 maps. When identified on both FB and BH maps, hotspots overlapped in all cases, with an average long axis offset between FB and BH hotspot centers of 5.8mm (IQR 3.5-8.2) on T1 and 5.9mm (IQR 3.5-8.2) on T2 maps. FB mSASHA T1/T2 maps can identify hotspots present on conventional BH T1/T2 maps in pediatric patients with OHT, with high sensitivity, specificity, and overlap in 3D space. Free-breathing mapping may improve patient comfort and facilitate OHT assessment in younger patient populations.

Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study

Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS. A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365. An academic tertiary referral center. A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS. The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p=0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365. In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

TAVI in a Heart Transplant Recipient-Rare Case Report and Review of the Literature.

The global demand for cardiac transplants continues to rise, even with advancements in assistive devices. Currently, the estimated annual mortality rate stands at 3-5%, and patients often face a waiting time of approximately four years on transplant waiting lists. Consequently, many transplant centers have started to consider heart transplants from donors who may be deemed "less than ideal" or marginal. However, the decision to accept such donors must be highly individualized, taking into consideration the risks associated with remaining on the waiting list versus those posed by the transplantation procedure itself. A potential solution lies in the creation of two distinct recipient lists, matched with donor criteria, allowing marginal donors to provide the lifeline that selected patients require. This paper follows a two-step approach. Firstly, it offers an overview of the current state of affairs regarding the topic of transcatheter aortic valve implantation (TAVI) in orthotopic heart transplant (OHT) patients. Secondly, it presents firsthand experience from our clinical center with a comprehensive case presentation of a patient in this unique medical context. The clinical case refers to a 62-year-old male patient, a smoker with a history of hypertension, dyslipidemia, and a prior OHT a decade earlier, who presented with fatigue during minimal physical exertion. The Heart Team carefully reviewed the case, considering the patient's immunosuppressed status and the heightened risk associated with a repeat intervention. In this instance, transcatheter aortic valve implantation (TAVI) was deemed the appropriate treatment. The TAVI procedure yielded successful results, leading to improved clinical status and enhanced cardiac function. The inclusion of marginal donors has introduced novel challenges related to the utilization of previously diseased marginal organs. TAVI has already demonstrated its efficacy and versatility in treating high-risk patients, including heart transplant recipients. Consequently, it emerges as a vital tool in addressing the unique challenges posed by the inclusion of marginal donors.

The results of orthotopic heart transplantation using the bicaval technique

Circulatory failure, which develops in the final stages of the course of the most heart diseases, is a link in the progressive process. This process is accompanied by a significant decrease in the quality of life, as well as high disability and mortality.&#x0D; Heart transplantation increases the survival of patients with chronic heart failure, increases tolerance to physical exertion, improves the quality of life of patients and allows most of them to return to vigorous activity.&#x0D; Aim. The work is devoted to the analysis of the results of orthotopic heart transplantation in patients with a progressive course of chronic heart failure that cannot be treated conservatively.&#x0D; Materials and methods. We analyzed the clinical course of heart transplants in 55 patients. There were 46 (83.6 %) men and 9 (16.4 %) women among the recipients. The average age was 46.0 ± 10.0 years.&#x0D; Results. The result of the conducted retrospective study revealed that in-hospital (early) and one-year (longterm) survival among patients in our study was 92.7 % and 81.8 %, respectively.&#x0D; Conclusions. Heart transplantation is the most effective method of treatment for terminal heart failure. The quality of life of heart transplant patients improves significantly after surgery and is the main factor in the development of heart transplantation nowadays.&#x0D; The main causes of death were acute graft dysfunction, rejection reactions, and coronary heart disease of the transplanted heart. Problems related to cardiac graft dysfunction and rejection in the early and long-term period still need to be definitively resolved.

Cardiac magnetic resonance haemodynamics in paediatric heart transplant patients: fick oximetry versus cardiac magnetic resonance phase contrast.

Lifetime radiation exposure for paediatric orthotopic heart transplant (OHT) patients is significant with cardiac catheterisation as the dominant source. Interventional cardiac magnetic resonance is utilised to obtain simultaneous, radiation-free haemodynamics and flow/function measurements. We sought to compare invasive haemodynamic measurements and radiation exposure in traditional cardiac catheterisation, to comprehensive interventional cardiac magnetic resonance. Twenty-eight OHT patients who underwent 67 interventional cardiac magnetic resonance procedures at Children's National Hospital were identified. Both invasive oximetry with peripheral oxygen saturation (Fick) and cardiac magnetic resonance phase contrast measurements of pulmonary and systemic blood flow were performed. Systemic and pulmonary blood flow from the two modalities was compared using Bland-Altman, concordance analysis, and inter-reader correlation. A mixed model was implemented to account for confounding variables and repeat encounters. Radiation dosage data were collected for a contemporaneous cohort of orthotopic heart transplant patients undergoing standard, X-ray-guided catheterisation. Simultaneous cardiac magnetic resonance and Fick have poor agreement in our study based on Lin's correlation coefficient of 0.68 and 0.73 for pulmonary and systemic blood flow, respectively. Bland-Altman analysis demonstrated a consistent over estimation of cardiac magnetic resonance cardiac output by Fick. The average indexed dose area product for patients undergoing haemodynamics with endomyocardial biopsy was 0.73 (SD ±0.6) Gy*m2/kg. With coronary angiography added, the indexed dose area product was 14.6 (SD ± 7.8) Gy*m2/kg. Cardiac magnetic resonancemeasurements of cardiac output/index in paediatric orthotopic heart transplant patients have poor concordance with Fick estimates; however, cardiac magnetic resonance has good internal validity and inter-reader reliability. Radiation doses are small for haemodynamics with biopsy and increase exponentially with angiography, identifying a new target for cardiac magnetic resonance imaging.

Outcomes in orthotopic heart transplantation following pacemaker implantation.

Bradyarrhythmias including sinus node dysfunction (SND) and atrioventricular block (AVB) can necessitate pacemaker (PPM) implantation in orthotopic heart transplant (OHT) recipients. Prior studies have shown conflicting findings regarding the effect of PPM implantation on survival. We evaluated the effect of PPM indication on long-term re-transplant-free survival in OHT patients. We conducted a retrospective cohort study of OHT patients at UCLA Medical Center from 1985 to 2018. Indication for PPM (SND, AVB) was identified. Cox proportional hazards model with pacemaker implantation as a time-varying covariate was used to evaluate its effect on the primary endpoint of retransplant or death. We included 1609 OHTs in 1511 adult patients with median follow-up of 12 years. At transplant, patients were aged 53±13 years and 1125 (74.5%) were male. Pacemakers were implanted in 109 (7.2%) patients; 65 for SND (4.3%) and 43 for AVB (2.8%). Repeat OHT was performed in 103 (6.4%) cases and 798 (52.8%) patients died during the follow-up period. The risk of the primary endpoint was significantly higher in patients requiring PPM for AVB (HR 3.0, 95% CI 2.1-4.2, p<.01) after controlling for age at OHT, gender, hypertension, diabetes, renal disease, history of repeat OHT, acute rejection, transplant coronary vasculopathy, and atrial fibrillation, but not PPM for SND (HR 1.0, 95% CI 0.70-1.4, p=1.0). Patients who required PPM for AVB, but not SND, were at significantly higher risk of death or retransplant compared to patients who did not require PPM.

One-year survival in recipients older than 50 bridged to heart transplant with Impella 5.5 via axillary approach.

Optimizing patients with advanced heart failure before orthotopic heart transplantation (OHT), especially in patients greater than 50 years old, is imperative to achieving successful post-transplant outcomes. Complications are well-described for patients bridged to transplant (BTT) with durable left ventricular assist device (LVAD) support. Given the lack of data available in older recipients after the recent increase in mechanical support use, we felt it crucial to report our center's one-year outcomes in older recipients after heart transplantation with percutaneously placed Impella 5.5 as a BTT. Forty-nine OHT patients were supported with the Impella 5.5 intended as a bridge between December 2019 and October 2022 at Mayo Clinic in Florida. Data were extracted from the electronic health record at baseline and during their transplant episode of care after Institutional Review Boards approval as exempt for retrospective data collection. Thirty-eight patients aged 50 or older were supported with Impella 5.5 as BTT. Ten patients underwent heart and kidney transplantation within this cohort. The median age at OHT was 63 (58-68) years, with 32 male (84%) and six female patients (16%). Etiology was divided into ischemic (63%) and non-ischemic cardiomyopathy (37%). The baseline median ejection fraction was 19% (15-24). Most patients were in blood group O (60%), and 50% were diabetic. The average duration of support was 27 days (range 6-94). The median duration of follow-up is 488 days (185-693). For patients that have reached the 1-year follow-up timeframe (22 of 38, 58%), the 1-year post-transplant survival is 95%. Our single-center data provides awareness for using the Impella 5.5 percutaneously placed axillary support device in older heart failure patients in cardiogenic shock as a bridge to transplantation. One-year survival outcomes after heart transplantation are excellent despite the older recipient's age and prolonged pre-transplant support.

Epidemiology, management, and clinical outcomes of extrapulmonary Mycobacterium abscessus complex infections in heart transplant and ventricular assist device recipients

Nontuberculous mycobacteria are emerging pathogens, yet data on the epidemiology and management of extrapulmonary nontuberculous mycobacteria infections in orthotopic heart transplantation (OHT) and ventricular assist device (VAD) recipients are scarce. We retrospectively reviewed records of OHT and VAD recipients who underwent cardiac surgery at our hospital and developed Mycobacterium abscessus complex (MABC) infection from 2013 to 2016 during a hospital outbreak of MABC linked to heater-cooler units. We analyzed patient characteristics, medical and surgical management, and long-term outcomes. Ten OHT patients and 7 patients with VAD developed extrapulmonary M. abscessus subspecies abscessus infection. The median time from presumed inoculation during cardiac surgery to the first positive culture was 106 days in OHT and 29 days in VAD recipients. The most common sites of positive cultures were blood (n = 12), sternum/mediastinum (n = 8), and the VAD driveline exit site (n = 7). The 14 patients diagnosed when alive received combination antimicrobial therapy for a median of 21 weeks, developed 28 antibiotic-related adverse events, and underwent 27 surgeries. Only 8 (47%) patients survived longer than 12 weeks after diagnosis, including 2 patients with VAD who experienced long-term survival after an explantation of infected VADs and OHT. Despite aggressive medical and surgical management, OHT and VAD patients with MABC infection experienced substantial morbidity and mortality.

(1283) Covid-19 Associated Development of Antibody Mediated Rejection in Orthotopic Heart Transplantation Patients

(1283) Covid-19 Associated Development of Antibody Mediated Rejection in Orthotopic Heart Transplantation Patients

Abstract 15126: Hybrid Supervised and Unsupervised Machine Learning Model Improves Prediction of New-Onset Dialysis in Orthotopic Heart Transplant Patients

Introduction: Machine learning (ML) approaches to clinical risk prediction have demonstrated improved performance over traditional statistical approaches. New-onset dialysis following isolated orthotopic heart transplantation (OHT) is an important contributor to mortality risk and quality of life in recipients, yet traditional approaches to predicting its occurrence have performed only modestly. This study sought to develop and evaluate a hybrid supervised and unsupervised ML approach to estimating the risk of new-onset dialysis following OHT. Methods: This was a retrospective study of patients (n = 26,505) with no history of dialysis undergoing primary, isolated OHT between 2000 and 2022 as identified in the United Network for Organ Sharing (UNOS) database. The study cohort was split randomly into training (80%) and validation sets (20%) and under-sampling using K-Nearest Neighbors clustering was used to account for class imbalance. ML models, including a Multilayer Perceptron Classifier, a Support Vector Classifier, and a Logistic Regression Model were developed and compared. Sensitivity, accuracy, precision, and F 1 score were measured, and discriminatory performance was assessed using the area under the receiver-operating-characteristic curve (AUC). Results: The rate of new dialysis was 11.3% following OHT with comparable rates in the training and validation cohorts. In the validation cohort, the support vector classifier had the highest AUC Score (0.774 (95% CI, 0.748 - 0.800), sensitivity (0.74), F 1 Score (0.72), accuracy (0.70), and precision (0.70). All other models yielded poorer performance by every metric. Predictive risk factors that were common across models included congenital heart disease, pre-transplant glomerular filtration rate, and human leukocyte antigen mismatch. Conclusions: This study demonstrates that an ML approach using a support vector model was associated with improved model performance metrics including discriminatory capability compared to other modeling approaches in predicting new-onset dialysis risk after OHT. The use of ML models in OHT may have utility in patient selection, modification of risk factors, and programmatic evaluation.

Clinicopathological correlations in heart transplantation recipients complicated by death or re-transplantation.

This study aimed to identify and correlate pathological findings with clinical outcomes in patients after orthotopic heart transplantation (OHT) who either died or underwent a re-transplantation. Single-center retrospective analysis of primary OHT patients who died or were re-transplanted between October 2012 and July 2021. Clinical data were matched with corresponding pathological findings from endomyocardial biopsies on antibody-mediated rejection, cellular rejection, and cardiac allograft vasculopathy. Re-assessment of available tissue samples was performed to investigate acute myocardial injury (AMI) as a distinct phenomenon. These were correlated with clinical outcomes, which included severe primary graft dysfunction. Patients were grouped according to the presence of AMI and compared. We identified 47 patients with truncated outcomes after the first OHT. The median age was 59 years, 36 patients (76%) were male, 25 patients (53%) had a prior history of cardiac operation, and 21 patients (45%) were supported with a durable assist device before OHT. Of those, AMI was identified in 22 (47%) patients (AMI group), and 25 patients had no AMI (non-AMI group). Groups were comparable in baseline and perioperative data. Histopathological observations in AMI group included a non-significant higher incidence of antibody-mediated rejection Grade 1 or higher (pAMR ≥ 1) (32% vs. 12%, P = 0.154), and non-significant lower incidence of severe acute cellular rejection (ACR ≥ 2R) (32% vs. 40%, P = 0.762). Clinical observations in the AMI group found a significantly higher occurrence of severe primary graft dysfunction (68% vs. 20%, P = 0.001) and a highly significant shorter duration from transplantation to death or re-transplantation (42 days [IQR 26, 120] vs. 1,133 days [711-1,664], P < 0.0001). Those patients had a significantly higher occurrence of cardiac-related deaths (64% vs. 24%, P = 0.020). No difference was observed in other outcomes. In heart transplant recipients with a truncated postoperative course leading to either death or re-transplantation, AMI in endomyocardial biopsies was a common pathological phenomenon, which correlated with the clinical occurrence of severe primary graft dysfunction. Those patients had significantly shorter survival times and higher cardiac-related deaths. The presence of AMI suggests a truncated course after OHT.

The HeartMate 3 left ventricular assist device as a strategy to bridge to transplant.

Recent changes in the market for left ventricular assist devices have resulted in the HeartMate 3 (HM3) being the only commercially-available device. This study evaluates the outcomes of patients with a HM3 waitlisted for and undergoing orthotopic heart transplantation (OHT). Patients waitlisted for isolated OHT with a HM3 or undergoing OHT after bridge-to-transplant (BTT) with a HM3 between 2015 and 2021 were identified from the UNOS registry and included in this study. Propensity matching was used to compare outcomes of BTT-HM3 versus primary OHT. A total of 1321 patients supported with a HM3 underwent OHT during our study period. Unadjusted 30-day, 90-day, and 1-year survival following OHT in the BTT-HM3 cohort was 96.5%, 94.4%, and 90.7%, respectively. In propensity-matched analysis, 1103 BTT-HM3 patients were compared with 1103 primary OHT patients. Rates of post-OHT stroke were higher in the BTT-HM3 group (4.4% vs. 2.0%, p = .001). The BTT-HM3 group had lower 30-day survival (96.2% vs. 97.4%, p = .033) although 90-day (94.2% vs. 95.3%, p = .103) and 1-year survival (90.4% vs. 91.7%, p = .216) were comparable. A total of 1251 patients were supported with a HM3 at the time of OHT listing during the study period. At the time of this analysis, 60 (4.5%) remained on the waitlist, 991 (75.0%) underwent OHT, and 119 (9.0%) died or clinically deteriorated with waitlist removal. The HM3 is a viable method for BTT with acceptable waitlist outcomes. Although 1-year survival is comparable to primary OHT, early outcomes are worse, suggesting that refinement of patient selection and perioperative management is prudent to optimizing outcomes.

Outcomes among heart transplant recipients following acute coronary syndrome: A nationwide population based study

BackgroundFor patients with refractory heart failure despite optimal medical therapy, orthotopic heart transplantation (OHT) remains the treatment of choice. Since transplanted hearts have variable cardiac denervation and acute coronary syndrome often presents as a silent myocardial infarction or with atypical symptoms, the true impact of ACS on outcomes within this population needs more study. The aim of this study is to evaluate in-hospital mortality in post-transplant patients with ACS. MethodsUtilizing data from the 2002–15 Nationwide Inpatient Sample database, patients with a primary diagnosis of acute coronary syndrome among those with prior heart transplantation were included. A risk adjusted regression analysis was performed to assess if ACS post-OHT had an independent impact on the risk of in-hospital mortality. A 2:1 propensity matching was used to match ACS patients with and without OHT, respectively to assess differences in mortality. ResultsA total of 3,224,073 patients with a primary diagnosis of acute coronary syndrome were included, of which 842 (0.03%) were heart-transplant recipients. The type of ACS: NSTEMI (76.0% vs 74.5%; p = 0.32) and STEMI (24.8% vs 26.7%; p = 0.21) between heart transplant and non-heart transplant patients was similar in both groups. Following ACS, patients with heart transplant were more likely to have accompanying shock of any etiology (15.6% vs 3.8%; p < 0.001) and cardiogenic shock (11.2% vs 2.6%; p < 0.001) compared to those with native hearts. OHT patients also had significantly higher in-hospital mortality (14.3% vs. 3.7%; p < 0.001) that remain significant following regression analysis (aOR 3.6, 95% CI 2.8–4.5; p < 0.001) irrespective of the presence of cardiogenic shock compared to native hearts. This relationship remained consistent following propensity matching where patients with OHT had significantly higher in-hospital mortality (13.5% vs. 7%; p < 0.001). ConclusionsACS following OHT was more likely to have accompanying cardiogenic shock. ACS in the setting of prior OHT remained a strong independent predictor of higher mortality as compared to native hearts.

COVID-19 Infection in Heart Transplant Recipients: Results of a Six-Month Prospective Survey-Based Study

Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P&lt;0.001). A later six months follow-up showed that two out of 12 (16.6%) COVID-19 positive OHT patients died. There was no statistically significant difference between the prevalence of COVID-19 in our patients compared to Iran’s general population (P=0.152). Non-compliance with personal protective protocols and a history of contact with COVID-19 cases were the most risk factors for COVID-19 infection in OHT patients.

Implantable cardioverter defibrillators in patients with orthotopic heart transplant: A multicenter case series.

Sudden cardiac death (SCD) is common after orthotopic heart transplant (OHT). No clear guidelines for implantable cardioverter defibrillator (ICD) implantation in OHT patients at high risk for SCD currently exist. To assess the safety, efficacy, and benefit of ICDs and resynchronization therapy post-OHT. We also provide a systematic review of previous reports. A retrospective multicenter cohort study within the United States. Patients with ICD post-OHT between 2000 and 2020 were identified. We analyzed 16 patients from 4 centers. The mean standard-deviation (SD) age was 43 (18) years at OHT and 51 (20) years at ICD implantation. The mean (SD) duration from OHT to ICD implantation was 9 (5) years. The mean (SD) left ventricular ejection fraction (LVEF) was 35% (17%). There were 2 (13%) postprocedural complications: 1 hematoma and 1 death. Mean (SD) follow-up was 24 (23) months. Survival rate was 63% (10/16) at 1 year and 56% (9/16) at 2 years, with 6/7 of those who died having LVEF < 35% at the time of the ICD implantation. Patients were more likely to receive appropriate therapy if their ICD was implanted for secondary (5/8) rather than primary (0/8) prevention (p = .007). Of those who did, 4 patients survived to 30 days post-ICD therapy. Severe CAV was not associated with the rate of appropriate therapy. Beneficial outcomes were observed when ICDs were implanted for secondary prevention only, and in patients with higher baseline LVEF. We also observed benefits with resynchronization therapy.

Emergency department use and hospital admissions among adult orthotopic heart transplant patients.

ObjectiveTo study the demographics, clinical presentations, and outcomes of emergency department (ED) visits of patients with heart transplantation (HT) in the United States.MethodsWe performed a secondary analysis of the National Emergency Department Sample database from 2016 to 2018. All ED visits of patients with HT aged ≥ 18 years were identified using International Classification of Diseases, Tenth Revision codes.ResultsOut of a total 308,182,495 national ED visits, 55,583 were HT‐related visits. The median age was 61.07 years (interquartile range [IQR]: 46.91–69.38) and 69.44% were males. The hospital admission rate was 54.3% and median inpatient length of stay was 3.19 days (IQR: 1.63–5.92). The mortality rate during inpatient stay was 1.16%. Median inpatient and ED charges among admitted patients were $37,911 (IQR: $21,487–$71,262). The most common primary diagnosis of HT‐related ED visits was sepsis (4.3%) followed by acute kidney injury (3.57%) and chest pain (3%).ConclusionMore than half of total ED visits among HT patients resulted in hospital admission. The most common cause for ED visit in these patients was sepsis followed by acute kidney injury and chest pain.

Amyloid-Targeted Immunosuppression After Orthotopic Heart Transplantation

<h3>Purpose</h3> The optimal immunosuppressive therapy (IST) for patients with AL amyloid undergoing orthotopic heart transplantation (OHT) is not well defined. Our study aims to present the IST and outcomes after OHT in patients with cardiac amyloidosis at a large quaternary university hospital. <h3>Methods</h3> In a retrospective chart review, we performed a case series of all patients with AL amyloid who underwent OHT from Jan 2017 to Oct 2020. We assessed their IST and outcomes of survival, infection and rejection. <h3>Results</h3> We identified 7 patients with AL amyloidosis who underwent OHT. Three patients (43%) had Mayo Stage 3, and 4 (57%) patients had stage 4. Autologous stem cell transplant (ASCT) was performed in 4 patients with a median time from OHT to ASCT of 429 days. In patients who had bone marrow biopsy, amyloid was present in 21% and the mean plasma cells visualized by immunohistochemistry was 4.41%. IST after OHT consisted of a calcineurin inhibitor, antimetabolite and steroids initially. Some required treatment with bortezomib/daratumumab for sub-optimal duration or hematologic response to AL amyloid therapies prior to OHT at which time antimetabolite was stopped. Median time to antimetabolite withdrawal was 317 days. Median times to introduction of daratumumab and bortezomib after OHT were 283 and 388 days, respectively. Figure 1 displays the time series of IST. Renal involvement was the more prevalent extracardiac organ (57%), followed by gastrointestinal (43%), carpal tunnel (29%), and peripheral neuropathy (29%). We did not observe any mortality, graft failure, episodes of acute cellular or antibody-mediated rejection. One patient had clostridium difficile infection who was admitted for monitoring. <h3>Conclusion</h3> In those that require ongoing AL amyloid therapies following OHT, it may be safe to discontinue antimetabolite in efforts to minimize complications from over-immunosupression without compromising risk of rejection. Personalized IST in this traditionally high-risk population should be considered.

Characteristics and Outcomes of Patients with Cardiac Amyloidosis Requiring Orthotopic Heart Transplantation

<h3>Purpose</h3> It has been suggested that patients with cardiac amyloidosis can have similar outcomes post orthotopic heart transplantation (OHT) compared to non-amyloid cardiomyopathies. Our aim is to report characteristics and outcomes after OHT in patients with cardiac amyloidosis in a large single-center quaternary university hospital. <h3>Methods</h3> We performed a retrospective chart review of all patients with AL amyloid who underwent OHT from January 2017 to October 2021. Kaplan-Meier method was used to assess time to death compared to non-amyloid cardiomyopathies. <h3>Results</h3> Analytic sample was 280 patients, with a median follow up of 1.86 years. We had 16 patients with amyloid, aTTR amyloid was the more prevalent (50%), followed by AL (44%) and one case of ApoA1. Our cohort had a male predominance (75%), with a mean age of 61.7 years. Carpal tunnel was the most prevalent extracardiac involvement (56%), followed by renal (31%), peripheral neuropathy (31%), autonomic neuropathy (19%) and gastrointestinal (19%). Mean Vo2 max was of 14ml/min/kg; the median time on the waiting list was 35 days. The pathological light chain was Lambda in 86% of those with AL with a median difference in free light chains of 280 mg/dL. In patients with ATTR, wild type was the most prevalent (63%) compared to 38% with the V122I mutation. We did not observe mortality, graft failure or episode of antibody-mediated rejection. There was no statistical difference in survival at 3-years between amyloid (100%) and non-amyloid (93.4%) patients, Wilcoxon p-value = 0.32. Acute cellular rejection requiring treatment was observed in 2 patients, with a mean time to rejection of 100 days. Multifactorial progression of nephropathy was seen in 31% of patients. Progression of neuropathy was seen in 25% of patients and only one patient reported GI symptom progression. <h3>Conclusion</h3> Patients with cardiac amyloid undergoing OHT with limited extracardiac involvement had comparable survival to patients with non-amyloid cardiomyopathies.