Orthotropic Heart Transplantation Research Articles

Interventions on residual lesions in patients with heterotaxy syndrome following orthotropic heart transplantation: A single-center experience.

Heterotaxy syndrome (HS) is a defect in lateralization which often results in complex intra and extracardiac abnormalities. Orthotropic heart transplantation (OHT) in HS involves intricate and individualized modifications to surgical technique. Post-OHT outcomes are worse in patients with HS, however, the impact of post-OHT residual lesions has not yet been characterized. Patients with HS who underwent OHT at Ann & Robert H. Lurie Children's Hospital of Chicago between January 2012 and June 2023 were identified. Patients were excluded if follow-up data was not available due to follow up at a different institution of early mortality. Pre-OHT clinical data, surgical data, and post-OHT surgical and catheterization data were collected. Two early mortalities were excluded from analysis, leaving 15 patients in the study cohort. Median age at OHT was 3.7 years (range: 0.7-15.4). Nine out of 15 patients were diagnosed with residual lesions requiring intervention at a median of 188 days post transplantation. All interventions on residual lesions occurred via catheterization. Overall mortality rate was 27% (4/15) with all deaths occurring in patients with residual lesions (4/9 patients, 44%). 83% (10/12) of lesions were diagnosed via catheterization, and 83% (10/12) of lesions of occurred in the first year after transplant. Patients with HS are at high risk for residual lesions after OHT, which may contribute to increased mortality. Comprehensive invasive diagnostics were required to diagnose residual lesions, which were all addressed percutaneously.

Don't Break My Heart: A Case Report of Takotsubo Syndrome in a Transplanted Heart

Cardiogenic shock after heart transplant, could be due to acute rejection, cardiac allograft vasculopathy, or myocarditis. Stress cardiomyopathy (CM) in a denervated transplanted heart is unusual. A 56-year-old man with a history of ischemic heart disease and a seizure disorder underwent orthotropic heart transplant. He had breakthrough seizures posttransplant while on levetiracetam (Keppra) and was admitted for status epilepticus. A transthoracic echocardiogram (TTE) was done for hypotension (BP 90/60). TTE showed a severely reduced left ventricular ejection fraction (LVEF) of 15%, hyperkinetic base, and apical ballooning that are consistent with stress CM. Electrocardiogram with T wave inversion in precordial leads. Troponin was elevated to 1.77. The patient had cardiogenic shock and needed an intra-aortic balloon pump and multiple pressors. He was treated for status epilepticus and the LVEF completely recovered in 1 week. The patient had a normal TTE, coronary angiography, and biopsy with no rejection 8 days before admission. Stress CM was the diagnosis of exclusion, confirmed with a complete recovery of the LVEF. There are only 5 case reports of stress CM after heart transplant, with most presenting 9 to 10 years afterwards. We describe an unusual case of cardiogenic shock from stress CM triggered by status epilepticus in a denervated heart only 1 year posttransplant. The mechanism is elusive, and some hypotheses suggest exaggerated sensitivity to a plasma catecholamine surge from parasympathetic denervation. In a denervated heart, autonomic re-innervation can be seen as early as 1 year posttransplant.

HF-567-04 VENTRICULAR TACHYCARDIA PRIOR TO CFLVAD IMPLANTATION DOES NOT IMPACT SURVIVAL WHEN STRATIFIED BY VAD TYPE

Historically, the occurrence of ventricular tachycardia (VT) prior to implantation of continuous flow left ventricular assist device (CFLVAD) has been associated with worse long term survival. In the era of more modern CFLVADs, pre-implant VT may no longer significantly impact survival. To evaluate one-year transplant free survival by modern CFLVAD types based on the occurrence of pre-implant sustained VT. We retrospectively studied all patients who underwent both destination therapy and bridge to transplant initial CFLVAD implantation at our institution from 2017-2019. Patients who received a simultaneous RVAD or orthotropic heart transplant within one year after CFLVAD were excluded. We ascertained the occurrence of sustained VT in the year prior to implantation based on clinical documentation and available implantable cardioverter-defibrillator interrogation reports. Using independent sample t-tests with significance set to p<0.05, one-year transplant free survival was compared in those with and without pre-implant VT for CFLVADs including the Abbott Heartmate 3 (HM3), Abbott Heartmate 2 (HM2), and HeartWare HVAD (HW). There were 103 initial CFLVAD implants between 2017-2019, 38 HM3, 37 HM2, and 28 HW. Within the HM3 group, one-year TFS was 69% in those with pre-implant VT and 88% in those without pre-implant VT, p=0.1654. Within the HM2 group, one-year TFS was 68% in those with pre-implant VT and 61% in those without pre-implant VT, p=0.6526. Within the HW group, one-year TFS was 80% in those with pre-implant VT and 72% in those without pre-implant VT, p=0.6632. For all CFLVADs, one-year TFS was 71% in those with pre-implant VT and 75% in those without pre-implant VT, p=0.6555. Contrary to prior reports, sustained VT in the year prior to CFLVAD implantation did not reduce one-year transplant free survival in this cohort regardless of the type of CFLVAD implanted. In the modern era of CFLVAD implantation, pre-implant sustained VT may not necessarily be a contraindication. Further studies assessing sustained VT in the CFLVAD population are warranted.

Long-term Survival And Factors Associated With Chronic Kidney Disease Requiring Dialysis Post Orthotopic Heart Transplantation.

Background Orthotropic Heart Transplantation (OHT) remains the definitive management for patients with end stage heart failure. Chronic kidney disease (CKD) is a common complication following OHT. In a non-transplant population, CKD that progresses to end stage renal failure requiring dialysis (CKD stage 5) is associated with increased morbidity and mortality. For non OHT recipients after one year on dialysis, mortality is 15-20%, and five-year survival is estimated at 50%. To date there are few large-scale studies that identify the prevalence, and risk factors associated with CKD stage 5 in patients following OHT. Methods This was an analysis of 53,566 OHT recipients captured in the United Network for Organ Sharing (UNOS) registry. Those included in the study were adult OHT recipients greater than 18 years of age from 1987 to 2019. Patients were categorized by long-term dialysis utilization (OHT-dialysis or OHT non-dialysis). Study objectives were to identify the prevalence of long-term dialysis use, long-term survival post OHT, and factors associated with long-term dialysis use. Associations were determined using Kaplan-Meier estimations. Confounding was addressed using multivariable Cox proportional hazards models. Results During the study period, the prevalence of long-term dialysis use in the study population was 13% (6902 OHT recipients). The mean age for the entire population was 55 years and was similar between the two groups. OHT dialysis patients were more likely to be male (79% vs 76%, p=<0.001), Black (20% vs 16%, p=<0.001), required pre-transplant dialysis (5% vs 2%, p=<0.001), and Hepatitis C positive (3% vs 2%, p=0.002). Factors associated with long-term dialysis use included Older age at time of OHT (OR 1.004, CI 1-1.09, p=0.032), Elevated BMI (OR 1.02, CI 1.012-1.031, P<0.0001), African American Race (OR 1.59, CI 1.43-1.78, p=0.0009), Cyclosporine use (OR 1.16, CI 1.016-1.331, p=0.028), HCV positivity (OR 1.87, CI 1.53-2.28, p=<0.0001), and dialysis prior to OHT (OR 2.03, CI 1.68-2.47, p=<0.0001). Long-term dialysis use post OHT was associated with worse long-term survival (Figure 1). Conclusion Post OHT CKD 5 is associated with worse long-term outcomes. Further studies into modifiable risk factors are needed. Orthotropic Heart Transplantation (OHT) remains the definitive management for patients with end stage heart failure. Chronic kidney disease (CKD) is a common complication following OHT. In a non-transplant population, CKD that progresses to end stage renal failure requiring dialysis (CKD stage 5) is associated with increased morbidity and mortality. For non OHT recipients after one year on dialysis, mortality is 15-20%, and five-year survival is estimated at 50%. To date there are few large-scale studies that identify the prevalence, and risk factors associated with CKD stage 5 in patients following OHT. This was an analysis of 53,566 OHT recipients captured in the United Network for Organ Sharing (UNOS) registry. Those included in the study were adult OHT recipients greater than 18 years of age from 1987 to 2019. Patients were categorized by long-term dialysis utilization (OHT-dialysis or OHT non-dialysis). Study objectives were to identify the prevalence of long-term dialysis use, long-term survival post OHT, and factors associated with long-term dialysis use. Associations were determined using Kaplan-Meier estimations. Confounding was addressed using multivariable Cox proportional hazards models. During the study period, the prevalence of long-term dialysis use in the study population was 13% (6902 OHT recipients). The mean age for the entire population was 55 years and was similar between the two groups. OHT dialysis patients were more likely to be male (79% vs 76%, p=<0.001), Black (20% vs 16%, p=<0.001), required pre-transplant dialysis (5% vs 2%, p=<0.001), and Hepatitis C positive (3% vs 2%, p=0.002). Factors associated with long-term dialysis use included Older age at time of OHT (OR 1.004, CI 1-1.09, p=0.032), Elevated BMI (OR 1.02, CI 1.012-1.031, P<0.0001), African American Race (OR 1.59, CI 1.43-1.78, p=0.0009), Cyclosporine use (OR 1.16, CI 1.016-1.331, p=0.028), HCV positivity (OR 1.87, CI 1.53-2.28, p=<0.0001), and dialysis prior to OHT (OR 2.03, CI 1.68-2.47, p=<0.0001). Long-term dialysis use post OHT was associated with worse long-term survival (Figure 1). Post OHT CKD 5 is associated with worse long-term outcomes. Further studies into modifiable risk factors are needed.

Recovery Of Allograft Right Ventricular Diastolic Dysfunction Post Heart Transplantation

Background Diastolic dysfunction after heart transplantation is a well-recognized phenomenon that is associated with high mortality. However, it is clinically well recognized that most allografts demonstrate stiffness in the early phase that recovers to a variable extent in most patients. The pattern of this recovery has not been well defined.ObjectivesWe aim to describe the natural course of allograft right ventricular (RV) diastolic function recovery in those without significant rejection or primary graft dysfunction events. Methods We retrospectively reviewed 22 patients who underwent orthotropic heart transplantation at UFhealth between September of 2015 and June of 2018. Exclusion criteria were significant acute cellular rejection (2R or more), primary graft dysfunction, and death due to any cause during the first year after transplantation. Invasive hemodynamics obtained during routine surveillance biopsies were recorded. We registered RV end diastolic and nadir pressures at 2 weeks, 1, 3, 6 and 12 months post-transplant. Results In our sample, the median age at transplant was 48 years, 63.6% were male, 4.6% were Hispanic, 72.3% were White, 22.7% were Black, 4.6% belonged to other racial groups. Looking at cardiovascular risk factors, 27.3% had diabetes, 90.9% had hypertension, and 18.2% had obesity with median BMI of 27. Figure 1 shows the trend of RV pressures overtime. Cold ischemic time was on average 211 min and did not correlate with RV end diastolic pressure (R = 0.49). Conclusions Early post transplantation period is associated with RV diastolic dysfunction that usually recovers by 12 weeks post operatively. Diastolic dysfunction after heart transplantation is a well-recognized phenomenon that is associated with high mortality. However, it is clinically well recognized that most allografts demonstrate stiffness in the early phase that recovers to a variable extent in most patients. The pattern of this recovery has not been well defined.ObjectivesWe aim to describe the natural course of allograft right ventricular (RV) diastolic function recovery in those without significant rejection or primary graft dysfunction events. We retrospectively reviewed 22 patients who underwent orthotropic heart transplantation at UFhealth between September of 2015 and June of 2018. Exclusion criteria were significant acute cellular rejection (2R or more), primary graft dysfunction, and death due to any cause during the first year after transplantation. Invasive hemodynamics obtained during routine surveillance biopsies were recorded. We registered RV end diastolic and nadir pressures at 2 weeks, 1, 3, 6 and 12 months post-transplant. In our sample, the median age at transplant was 48 years, 63.6% were male, 4.6% were Hispanic, 72.3% were White, 22.7% were Black, 4.6% belonged to other racial groups. Looking at cardiovascular risk factors, 27.3% had diabetes, 90.9% had hypertension, and 18.2% had obesity with median BMI of 27. Figure 1 shows the trend of RV pressures overtime. Cold ischemic time was on average 211 min and did not correlate with RV end diastolic pressure (R = 0.49). Early post transplantation period is associated with RV diastolic dysfunction that usually recovers by 12 weeks post operatively.

Neutrophile-to-Lymphocyte Ratio as a Predictor of Mortality and Response to Treatment in Invasive Aspergillosis among Heart Transplant Recipients-Exploratory Study.

Background and objective: Aspergillus pulmonary infections are potentially life-threatening complications that can occur after heart transplantation. The aim of the study was to find an easily available mortality predictor during Aspergillosis infection therapy following heart transplantation. Materials and methods: This study involved 15 heart recipients with the mean age of 55 ± 6 years who were diagnosed with invasive aspergillosis (IA) in a mean time of 80 ± 53 (19–209) days after orthotropic heart transplantation. Results: Out of fifteen patients diagnosed with IA, five died. The mean time from diagnosis to death in the deceased group was 28 ± 18 days. They were diagnosed with IA in a mean time of 80 ± 53 (19–209) days after orthotropic heart transplantation. During the initial seven days of therapy, the neutrophil to lymphocyte ratio (NLR) significantly differed between the two groups on day three and day seven, with median values of 10.8 [4.3–17.0] vs. 20.2 [17.4–116.8] (p = 0.0373) and 5.2 [3.2–8.1] vs. 32.2 [13.5–49.9] (p = 0.0101) in the survivor and the deceased group, respectively. The NLR was a significant predictor of death both on day three (cut-off point 17.2) and day seven (cut-off point 12.08) of therapy. Conclusions: Findings in our study indicate that NLR may be of predictive value in the estimation of mortality risk or response to treatment among patients with invasive aspergillosis following heart transplantation.

Abstract 11693: When a Parachute Fails: A Rocky Landing to Heart Transplant

A 71 year-old man with heart failure, porcelain aorta, and mitral regurgitation presented for heart transplant evaluation. He was in cardiogenic shock requiring inotropic support. An echocardiogram showed a dilated left ventricle, severely reduced systolic function, restricted mitral valve leaflet motion, an elevated mean transmitral gradient, and severe mitral regurgitation. The differential of mixed stenotic and regurgitant mitral valve pathology included rheumatic heart disease and congenital mitral valve anomaly. Hemodynamic management of cardiogenic shock in the setting of mixed mitral valve disease presented unique challenges due to a narrow therapeutic window of optimal preload, afterload reduction, inotropic support, and chronotropic control. He was not a candidate for percutaneous mitral valve interventions or surgery. A porcelain aorta made him high risk for vascular complications with mechanical circulatory support. His course was complicated by worsening shock requiring escalation of inotropes, rapid atrial fibrillation, and recurrent episodes of acute pulmonary edema. Ultimately, he underwent an orthotropic heart transplant. A transesophageal echocardiogram at the time of transplant suggested a parachute mitral valve, where all chordae appeared be originating from one papillary muscle. However, additional views revealed the presence of two papillary muscles with asymmetric, shortened anterior chordae and a hypertrophied anterior papillary muscle. Findings were consistent with a rare parachute-like asymmetric mitral valve complicated by mild mitral stenosis and severe mitral regurgitation. Examination of the explanted native heart confirmed these findings.This case highlights: 1) complex management of mixed valvular disease in the setting of cardiogenic shock, 2) echocardiographic evaluation of mixed valvular heart disease, and 3) a rare congenital malformation of a parachute-like mitral valve presenting in adulthood.

Two Hearts, Believing in Just One Mind: What Is the Rhythm?

A 59-year-old patient who underwent orthotropic heart transplantation for end-stage nonischemic cardiomyopathy presented 2 months later with palpitations and fatigue. He had a history of hypertension, diabetes mellitus, and well-controlled HIV. Of note, pretransplant imaging had demonstrated a persistent left-sided superior vena cava draining into a large coronary sinus. Therefore, a biatrial anastomosis surgical technique (involving suturing the donor right atrium to a portion of the native right atrium with preservation of the native and donor coronary sinuses) was used at the time of transplantation.

Trends, risk factors and prognostic implications of postoperative stroke after heart transplantation: an analysis of the UNOS database

Abstract Background Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HT) are limited. Methods We conducted a retrospective analysis of the UNOS database from 2009 to 2020 to identify adults who developed stroke after orthotropic HT. HT recipients were divided according to the presence or absence of postoperative stroke. The primary endpoint was all-cause mortality after HT. Results A total of 25,015 HT recipients were analyzed, including 719 (2.9%) patients who suffered perioperative stroke. The rates of stroke increased from 2.1% in 2009 to 3.7% in 2019 and the risk of stroke was higher after the implantation of the new allocation system (odds ratio 1.29, 1.29, 95% Confidence Intervals [CI] 1.06–1.56, p=0.01). HT recipients with postoperative stroke were older (p=0.008), with higher rates of prior cerebrovascular accident (CVA) (p=0.004), prior cardiac surgery (p&amp;lt;0.001), longer waitlist time (p=0.04), higher rates of extracorporeal membrane oxygenation support (ECMO) (p&amp;lt;0.001), left ventricular assist devices (LVAD) (p&amp;lt;0.001), mechanical ventilation (p=0.003) and longer ischemic time (p&amp;lt;0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischemic time and mechanical ventilation at the time of HT were independent predictors of postoperative stroke. Stroke was associated with increased risk of 30-day and all-cause mortality after HT (hazard ratio [HR] 1.49, CI 1.12–1.99, p=0.007). Conclusion Perioperative stroke after HT is infrequent but associated with higher mortality. Redo sternotomy, LVAD and ECMO support at HT are among the risk factors identified. Funding Acknowledgement Type of funding sources: None. Risk factors for stroke

Outcomes of Cardiac Arrest and Cardiopulmonary Resuscitation in Patients With Left Ventricular Assist Device; an Insight From a National Inpatient Sample

Outcomes of patients with implanted left ventricular assist device (LVAD) implantation experiencing a cardiac arrest (CA) are not well reported. We aimed at defining the in-hospital outcomes of patients with implanted LVAD experiencing a CA. The national inpatient sample (NIS) was queried using ICD9/ICD10 codes for patients older than 18 years with implanted LVAD and CA between 2010-2018. We excluded patients with orthotropic heart transplantation, biventricular assist device (BiVAD) implantation and do not resuscitate (DNR) status. A total of 93,153 hospitalisations between 2010 and 2018 with implanted LVAD were identified. Only 578 of these hospitalisations had experienced CA and of those, 173 (33%) hospitalisations underwent cardiopulmonary resuscitation (CPR). The mean age of hospitalisations that experienced a CA was 60.61±14.85 for non-survivors and 56.23±17.33 for survivors (p=0.14). The in-hospital mortality was 60.8% in hospitalisations with CA and 74.33% in hospitalisations in whom CPR was performed. In an analysis comparing survivors with non-survivors, non-survivors had more diabetes mellitus (DM) (p=0.01), and ischaemic heart disease (IHD) (p=0.04). Age, female sex, peripheral vascular disease and history of coronary artery bypass graft (CABG) were independently associated with increased mortality in our cohort. Also, ventricular tachycardia (VT) and CPR were independently associated with in-hospital mortality. During the study period, there was a significantly decreasing trend in performing CPR in LVAD hospitalisations with CA. In conclusion, age, female sex, peripheral vascular disease, history of CABG, VT and CPR were independently associated with in-hospital mortality in LVAD hospitalisations who experienced CA.

An Abnormal Heart Lung Connection: A Case of Coronary Artery Fistula Formation Post Orthotropic Heart Transplantation

<h3>Introduction</h3> Coronary artery fistulas (CAF) are rare anomalies often congenital in origin, however, they have been seen after orthotropic heart transplantation (OHT). The mechanism of CAF formation is unclear, but it has been proposed that angiogenesis may occur in response to inflammation, surgical trauma, and hypoxia. Most are incidentally discovered on coronary angiography, and a majority of patients are asymptomatic. However, a potentially serious complication of CAF is ischemia due to coronary steal phenomenon. <h3>Case Report</h3> A 23-year-old male with a past medical history significant for nonischemic cardiomyopathy thought secondary to viral etiology who had OHT one year prior presented for post-transplant biopsy and angiography to evaluate for rejection. His post-transplant course was uncomplicated. Coronary angiography was notable for collaterals between diagonal branches of left anterior descending artery to pulmonary vasculature (Figure 1). To further evaluate, he had a gated cardiac computerized tomography scan which showed multiple small vessels from the left upper lobe that appeared to directly communicate with the pericardial surface at the left ventricular apex (Figure 2). After multidisciplinary discussion, decision was made to monitor patient with annual echocardiogram with strain imaging and coronary angiography. <h3>Summary</h3> Management of patients post OHT is a complex process. Surveillance and management of patients found to have CAF is not well established due to its rarity and unclear clinical significance. Additional research is necessary to better understand this phenomenon.

One Year Outcomes Following Orthotropic Heart Transplantation at a Tertiary Care Center in India

Purpose Cardiac transplantation remains the gold standard for end stage heart failure. Even after 25 years, the progress of heart transplants in India has not been as expected, especially in the public sector. Till recently, ours was the only government hospital in India with a successfully running heart transplant program. This study' s primary objective was to evaluate the 1- year survival of heart recipients in the last five years at our centre and risk factors associated with early mortality. Methods A retrospective analysis of records of 40 transplant patients, performed between 2014 2019 at our center was done to calculate one-year survival and evaluate risk factors for mortality. The following risk factors were analysed for a significant correlation with mortality- infections, primary graft dysfunction (PGD), allograft rejection, ischemia time and INTER-MACS (Interagency Registry for Mechanically Assisted Circulatory Support) score. Adults who are in current follow up (n= 21 ) were interviewed for evaluation of their per capita income and quality of life and a correlation was sought with quality of life. Results The mean age of patients was 31.2 ± 1 2.7 years. The 1- year survival of patients transplanted during 2014-15 and 2016-19 was 65% and 85%, respectively. None of the risk factors studied correlated with mortality. The most common cause of death in the first year following transplant was an infection. A total ischemia time of more than 240 minutes, higher preoperative PA pressures and INTER-MACS score Conclusion The 1- year survival of patients transplanted during 2014- 15 and 2016- 19 was 65% and 85%, respectively. There was no correlation between infections, primary graft dysfunction (PGD), allograft rejection, ischemia time, INTER-MACS score and mortality. The QOL of heart recipients, from economically weaker sections, is similar to that of India' s general population. There is no correlation between per capita income and quality of life after a heart transplant.

Features of Posterior Reversible Encephalopathy Syndrome 3 Days Following Tacrolimus Initiation in Heart Transplant Recipient

Introduction Neurotoxicity in the form of posterior reversible encephalopathy syndrome (PRES) secondary to tacrolimus has been well described, particularly in solid organ transplant recipients. PRES presents with rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbances. The time of onset of CNI-associated PRES varies, but according to published cased reports, typically occurs after greater than 7 days of initiating therapy, with few instances reported within the first few days post initiation. Our case highlights a case with features of PRES manifesting on pos- operative day 4 of orthotropic heart transplantation (OHT), 3 days after initiation of tacrolimus. Case Report A 24 year old male, with a past medical history of limb girdle muscular dystrophy complicated by non ischemic cardiomyopathy, underwent OHT. He had no history of seizure disorder prior to transplant. The patient was initiated on tacrolimus on post operative day 1. On post operative day 3, the patient experienced witnessed tonic-clonic seizure like activity. A CT head was obtained without evidence of hemorrhagic stroke. A brain MRI showed multiple hyper-intense lesions, with the distribution of lesions concerning for underlying PRES. At this point, the patient's tacrolimus was subtherapeutic following 5 consecutive doses. PRES secondary to tacrolimus was initially considered unlikely as the etiology of the patients seizures, given unusual time course, and tacrolimus was continued. Repeat MRI brain 3 days after the first showed residual vasogenic edema consistent with PRES. At this point, the patient's tacrolimus was discontinued and he was initiated on cyclosporine. No recurrent seizures occurred. Three weeks later, a surveillance MRI brain showed near complete interval resolution of previously seen signal abnormalities related to PRES. Summary Tacrolimus-associated PRES is an uncommon, but serious complication after solid organ transplantation. It is highly unusual to develop signs of PRES within 1 week of tacrolimus initiation, but as our case highlights, it is vital to maintain PRES in your differential when approaching acute neurological symptoms post-transplant. Of note, in our case, signs of PRES occurred despite low tacrolimus blood levels and resolved clinically and radiographically following discontinuation.

Tacrolimus Induced Severe Cerebral and Coronary Vasospasm after Heart Transplantation

IntroductionTacrolimus has several cardiovascular adverse events. We report case of tacrolimus-induced severe cerebral and coronary vasospasm after heart transplantation.Case ReportA 62-year-old female underwent orthotropic heart transplantation due to dialted cardiomyopathy. Her postoperative course was benign. At 2 months, she complained of severe pulsatile headache. CTA of the brain showed diffuse cerebral artery constriction with multifocal beaded features at nearly all distal cranial arteries and scant SAH in the right parietal area (Figure 1). We diagnosed reversible cerebral vasospasm syndrome (RCVS) induced by tacrolimus and planned to switch tacrolimus to sirolimus using the vasodilator. She inevitably maintained a low level of tacrolimus due to sirolimus induced diarrhea. Using nimodipine, her symptoms disappeared, and follow-up CTA of the brain showed relieved cerebral vasoconstriction and absorption of hemorrhage (Figure 1). At 5 months after surgery, she was admitted from acute rejection. After 2 weeks of treatment, she was stabilized with biopsy improvement. We maintained a triple regimen. She soon complained of chest pain. Telemetry revealed transient ST segment elevation (Figure 2). We assumed that this event was associated with elevated tacrolimus levels; thus, tacrolimus was reduced, and oral diltiazem was administered. Using a vasodilator, a coronary vasospasm provocation test was performed. During the test, severe coronary spasm was noted. Intracoronary and intravascular nitroglycerin was administered aggressively. The study was completed after confirming a normalized coronary artery(Figure 3). Twenty minutes later, she collapsed with squeezing chest pain. On-site CPR and ECMO insertion were performed. Two days later, she died of cardiogenic shock even with ECMO support.SummaryEarly detection of disease and withholding tacrolimus are important strategies. Tacrolimus has several cardiovascular adverse events. We report case of tacrolimus-induced severe cerebral and coronary vasospasm after heart transplantation. A 62-year-old female underwent orthotropic heart transplantation due to dialted cardiomyopathy. Her postoperative course was benign. At 2 months, she complained of severe pulsatile headache. CTA of the brain showed diffuse cerebral artery constriction with multifocal beaded features at nearly all distal cranial arteries and scant SAH in the right parietal area (Figure 1). We diagnosed reversible cerebral vasospasm syndrome (RCVS) induced by tacrolimus and planned to switch tacrolimus to sirolimus using the vasodilator. She inevitably maintained a low level of tacrolimus due to sirolimus induced diarrhea. Using nimodipine, her symptoms disappeared, and follow-up CTA of the brain showed relieved cerebral vasoconstriction and absorption of hemorrhage (Figure 1). At 5 months after surgery, she was admitted from acute rejection. After 2 weeks of treatment, she was stabilized with biopsy improvement. We maintained a triple regimen. She soon complained of chest pain. Telemetry revealed transient ST segment elevation (Figure 2). We assumed that this event was associated with elevated tacrolimus levels; thus, tacrolimus was reduced, and oral diltiazem was administered. Using a vasodilator, a coronary vasospasm provocation test was performed. During the test, severe coronary spasm was noted. Intracoronary and intravascular nitroglycerin was administered aggressively. The study was completed after confirming a normalized coronary artery(Figure 3). Twenty minutes later, she collapsed with squeezing chest pain. On-site CPR and ECMO insertion were performed. Two days later, she died of cardiogenic shock even with ECMO support. Early detection of disease and withholding tacrolimus are important strategies.

Management of Arrhythmias After Heart Transplant: Current State and Considerations for Future Research.

Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.

Abstract 12812: The Use of Hemodynamics Does Not Aide in Correctly Identifying the Etiology of Cardiomyopathy in Patients Receiving Advanced Therapy

Introduction: There is limited evidence demonstrating the benefit of hemodynamics in diagnosing the etiology of cardiomyopathy in patients referred for advanced therapies such as left ventricular assist device (LVAD) or orthotropic heart transplantation (OHT). Hypothesis: In patients with end stage heart failure, invasive hemodynamic measures differ between patients with different etiologies of cardiomyopathy. Methods: Hemodynamic and echocardiography data from 119 patients undergoing LVAD (n=85, Male 76%, Age 63 ± 12 years) or OHT (n=34, Male 70%, Age 60 ± 11 years) at a single center was reviewed. The follow invasive hemodynamic measurements were recorded and compared (central venous pressure (CVP), Pulmonary Artery Pulsatility Index (PAPI), peripheral vascular resistance (PVR), transpulmonary gradient, mean pulmonary artery pressure, cardiac index, and pulmonary diastolic pressure decoupling) were compared between groups. Results: Between patients with dilated cardiomyopathy (DCM), ischemic cardiomyopathy (ICM), and those with missed diagnosis, there were no significant differences between CVP, PAPI, PVR, transpulmonary gradient, mean PA pressure, cardiac index, or decoupling (Table 1). Left ventricular end diastolic diameter (LVEDD) on echocardiography was significantly larger in patients with DCM when compared to those with ischemic cardiomyopathy as well as infiltrative cardiomyopathies (6.65±1.04mm, 6.24±0.77mm, and 5.14±1.25mm, respectively p&lt;0.0001). Conclusions: Hemodynamic measures in patients with stage D cardiomyopathy did not differ according to the etiology of the underlying cardiomyopathy. . The similarity in hemodynamic profiles amongst different cardiomyopathy subtypes likely reflects end stage disease. LVEDD performed better than hemodynamics to help differentiate cardiomyopathy etiologies, and in addition were helpful in identifying cases where the diagnosis was incorrect.

PREDICTORS OF IN-HOSPITAL MORTALITY IN PATIENTS WITH SARCOIDOSIS WITH CARDIOMYOPATHY

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: We sought to determine the predictors of in-hospital mortality using charlson co-morbidity variables among patients with sarcoidosis with cardiomyopathy (SCM) METHODS: The Nationwide Inpatient Sample was queried from 2010 to 2014 using ICD-9 diagnosis code (135) for sarcoidosis among patients >18 years. We combined it with code 425.8 for cardiomyopathy in other diseases including sarcoid and sarcoid heart muscle disease. We excluded patients with a history of prior myocardial infarction, percutaneous coronary intervention and coronary artery bypass graft. RESULTS: From 2010 to 2014, we identified 9,063 patients with SCM (Mean age = 53.11 ± 11.28 years; men 51.8% and black 52.5%). The overall in-hospital mortality rate was 2.5%. Various arrhythmias include atrial fibrillation (AF) 18.4%, ventricular fibrillation (VF) 2.5%, ventricular tachycardia (VT) 24.7%, complete heart block (CHB) 1.5% and second degree Mobitz type II 0.5%. Rates of implantable cardiac devices included implantable cardioverter-defibrillator (ICD) 9.7%, Cardiac Resynchronization Therapy Defibrillator (CRT-D) 3.6%, permanent pacemaker (PPM) 1.9%. Rate of endomyocardial biopsy (EMB) was found to be 2.8%. Rates of heart failure, cardiogenic shock, orthotropic heart transplantation (OHT), and catheter ablation were 100%, 2.6%, 1.4%, and 4.4%, respectively. Overall rate of sudden cardiac arrest (SCA) was found to be 1.8%. Based on a multivariate analysis, significant predictors of in-hospital mortality were age (AOR = 1.047, 95% CI [1.033, 1.061]), peripheral vascular disease (AOR = 0.297, 95% CI [0.173, 0.509]), COPD (AOR = 0.568, 95% CI [0.419, 0.771]), mild liver disease (AOR = 0.242, 95% CI [0.160, 0.367]), hemiplegia or paraplegia (AOR = 12.223, 95% CI [5.637, 26.506]), renal disease (AOR = 0.451, 95% CI [0.328, 0.619]), AF (AOR = 2.686, 95% CI [1.963, 3.675]), VF (AOR = 0.453, 95% CI [0.250, 0.821]), and SCA (AOR = 0.023, 95% CI [0.015, 0.036]). CONCLUSIONS: Patients with co-morbidities such as peripheral vascular disease, COPD, mild liver disease, hemiplegia or paraplegia, and renal disease were associated with higher in-hospital mortality. Among complications AF, VF, and SCA were predictors of in-hospital mortality. CLINICAL IMPLICATIONS: This study sheds light on clinical factors that could play a role in predicting mortality in patients with SCM. Possible identification and appropriate management of these factors may improve outcomes. DISCLOSURES: No relevant relationships by Abhijit Bhattaru, source=Web Response No relevant relationships by Akhil Gade, source=Web Response No relevant relationships by Karthik Gonuguntla, source=Web Response No relevant relationships by Pranav Karambelkar, source=Web Response No relevant relationships by Shivaraj Patil, source=Web Response No relevant relationships by Chaitanya Rojulpote, source=Web Response

S1638 An Unexpected Cause of Colitis in a Cardiac Transplant Patient

INTRODUCTION: Mycophenolate induced colitis is an unexpected complication of the immunosuppression medication. CASE DESCRIPTION/METHODS: A 36 year-old-female with a history of Epstein’s anomaly underwent repeat orthotropic heart transplant in 2020 due to primary graft failure of the first transplant in 2019. Mycophenolate had been changed to Myfortic for abdominal complaints prior to retransplant. She had early mild allograft dysfunction despite unremarkable prospective crossmatch and first surveillance right ventricular biopsy (RVB). She was empirically treated with rituximab, high dose intravenous steroids, serial plasmapheresis, and IVIG. Despite improving cardiac function, she developed acute hypoxic respiratory failure, acute on subacute renal failure, and worsening anemia. Repeat RVB revealed acute antibody and T-cell mediated rejection; the Myfortic dose was increased. Two weeks later the patient developed abdominal pain and loose maroon-colored bloody stool. Lab data showed a white blood cell count of 3.61k/ul and hemoglobin of 9.1g/dl. Elevated liver tests: Alk Phos 143U/L and ALT 111U/L. The CRP was normal however the fecal calprotectin was greater than 1250 ug/g. The SARS-CoV-2 and stool studies including clostridioides difficile, serum CMV IgG yielded negative results. A CT scan showed distension of the colon with an average amount of retained stool and gas. No bowel inflammation was noted. Colonoscopy showed diffuse edematous folds, loss of vascularity, and friable mucosa with dispersed aphthous ulcers and erosions from cecum to the sigmoid colon (Figure 1a, 1b, and 1c). The mucosa was biopsied with concern for inflammatory bowel disease, viral etiology, or undiagnosed inflammatory bowel disease. On histology, the colon mucosa was noted to have interstitial edema, abortive mitosis, eosinophilia, and scattered dilated irregular shaped crypts, most consistent with Mycophenolate related colitis (Figure 2). There was no evidence of viral inclusion bodies. Myfortic was replaced with renal dosing of Azathioprine. There was a dramatic improvement in appetite, nausea, energy, and renal function with no subsequent bloody stools or abdominal pain. DISCUSSION: There are very few reported cases of Mycophenolate induced colitis. Our patient developed bloody stools, acute kidney injury and abdominal pain as was the case in other reports. An elevated fecal calprotectin and the above biopsy findings helped clinch the diagnosis. New-onset colitis can be noted even if the patient was previously on Mycophenolate.Figure 1.: Colonoscopy images.Figure 2.: Histopathological features.

Impact of Therapy with Anti-Thymocyte Globulin in Heart Transplant Recipients on Acute Cellular Rejection and Readmission for Infection - A Single Center Retrospective Study

Background Approximately 20% of all orthotropic heart transplant (OHT) recipients in the US receive anti-thymocyte globulin (ATG) post-transplant to prevent acute rejection, however use varies between centers. There is lack of prospective multi center clinical trials assessing long-term survival benefit of early ATG treatment including readmission for infections compared with no induction in OHT patients. We aim to review the role of ATG use during the index hospitalization for OHT to prevent acute cellular rejection (ACR) and evaluate the impact of ATG in readmission rates for infection at our center. Hypothesis We hypothesize that therapy with ATG improves freedom from ACR but may result in higher readmission rates for infection. Methods We performed a retrospective cohort study of 98 adults who underwent OHT at a single center from January 2014 to December 2019. Patients without one year follow up and those who underwent heart-kidney transplant were excluded. We compared baseline characteristics and analyzed outcomes between patients with and without ATG administration using standard statistical methods. Unadjusted Kaplan-Meier curves were used to study differences in ACR and hospitalization for infection between patients with and without ATG administration. Results 53 OHT patients received ATG and 45 patients did not. There was no significant difference in death at one year (p=1.0), ACR (p=0.17) or readmission for infection (p=0.35) between the two groups. Patients receiving ATG had delayed date to first ACR (p=0.038), with a median time of first ACR of 100 days versus 26 days post-OHT in the non-ATG group. Conclusion Treatment with ATG during the index hospitalization for OHT delayed the time of first ACR but not the overall burden of rejection in the first year. The rate of freedom from infection was similar in both groups along with overall mortality. As this is a retrospective observation we will analyze the use of ATG in selected patients at high risk for rejection or for renal sparing.

Pulmonary Hypertension and its Association with Cardiac Transplant Outcomes: Does PA Systolic Matter?

Background Pulmonary hypertension (PH) is a common in patients with chronic heart failure (HF). For patients who progress to end stage HF and require orthotropic heart transplant (OHT), irreversible PH is a relative contraindication as it may lead to post-operative right HF. The International Society of Heart and Lung Transplant (ISHLT) recommends that transplantation be pursued in patients with a pulmonary vascular resistance (PVR) Methods This was an analysis of OHT recipients captured in the United Network for Organ Sharing (UNOS) transplant registry. We included OHT recipients with a PVR ≤ 3 Woods Units for analysis. The cohort was further categorized by PASP (PASP > 50 mmHg and PASP ≤ 50 mmHg). Primary outcome was survival. We classified survival as short term (0-5 years), Intermediate (6-10 years) and long-term (>15 years). Secondary outcome was graft failure. Baseline characteristics were compared between the two groups using the chi-squared analysis. Unadjusted associations between PASP and patient survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. Results Our study included 62,793 OHT recipients (7,187 PASP>50 mmHg, 55,606 PASP ≤50 mmHg) from 1999-2019. The PASP >50 mmHg group had a mean PASP of 60 ±8 mmHg, were older (50.9 vs 44.9 years, p= Conclusions In this large multicenter study of OHT recipients, patients with PASP>50 mmHg have similar outcomes to patients with lower PASP. OHT should be considered an option for patients with this hemodynamic derangement. Studies into factors that affect long-term outcomes is warranted.