Patients Undergoing Heart Transplantation Research Articles

The impact of donor-recipient age difference on graft survival after heart transplant in adults with congenital heart disease

BackgroundThe impact of donor-recipient age difference in adult congenital heart disease (ACHD) patients undergoing heart transplant (HT) is unknown. MethodsACHD patients (≥18 years old) who underwent HT (2000-2020) were identified using the United Network for Organ Sharing database. Graft survival through 10 years based on donor-recipient age difference was evaluated by comparing outcomes of donors >5 years older than recipient (Older), donors within 5 years of recipient age (Equal Age), and donors >5 years younger than recipient (Younger, reference group). Cox multivariable analysis was performed to evaluate the effect of donor-recipient age difference on early and late graft survival. ResultsA total of 1,275 ACHD patients underwent HT (60% male, median 35 years-old (interquartile range 24-46) with median graft survival of 13.7 years (95% confidence interval [CI] 11.7-16.0). Compared to Younger donors (n=306 [24%]), graft survival was similar with Equal Age donors (n=698 [55%]; Log rank p=0.61), though significantly reduced with Older donors (n=271 [21%]; Log rank p=0.03). In multivariable analysis, late graft survival was similar with Equal Age donors but lower with Older donors (adjusted hazard ratio [aHR] 1.63, 95% CI 1.16-2.28, p=0.005), with a trend of reduced survival with Older donors in recipients <30 or ≥40 years-old. ConclusionsGraft survival in ACHD patients undergoing HT was similar for those with Younger and Equal Age donors. Recipients with Older donors had reduced 10-year survival, possibly related to increased risk in those <30 and ≥40 years-old. These data help inform optimal donor age for ACHD patients requiring HT.

Exploring suitability to electrical storm ablation in patients in waiting list for heart transplantation: A single center experience.

Electrical storm (ES) is among the most fearsome events in patients in waiting list for heart transplantation (HT) and catheter ablation (CA) demonstrated to be effective in reduce the arrhythmic burden. However, selection criteria for CA suitability in this specific population have never been addressed before. We retrospectively enrolled 36 patients (mean age 51±8 years; 83% men) waiting HT referred to our department for ES resistant to antiarrhythmic drugs and percutaneous stellate ganglion blockade. Twenty patients were judged suitable for VT ablation according to specific criteria including absence of increased arrhythmic burden secondary to volume overload and hemodynamic decompensation; expected CA outcome favorable due to etiology of the cardiomyopathy, no need for coronary revascularization and technical feasibility of the procedure. The pre-emptive use of mechanical circulatory supports (MCS) were discussed integrating the PAINESD score with additional clinical and hemodynamic parameters. Acute procedural success was accounted in 85% of cases with only two major complications. The CA group reported lower length of in-hospital stay after CA suitability evaluation (56±17vs. 131±64 days, p=.004). Furthermore, at a mean follow-up of 703±145 days, this group showed reduction of ventricular arrhythmia (VA) recurrence leading to implantable cardioverter defibrillator shock (4vs. 8, p=.051) and underwent HT with a lower level of urgency (0vs. 6 patients needed for UNOS1 status upgrade). Respectively, one patient of the CA group and two patients of the conservative group died (p=.839). At the end of follow-up, eight patients underwent heart transplantation (p=.964) while four patients underwent Left Ventricular Assist device (LVAD) implantation (p=.440). This pilot study should be a proof for further studies exploring CA of VAs as a possible bridge therapy to HT.

Initial Clinical Experience with Implantation of a New Left Ventricular Assist Device HeartCon

Objective: Heart failure is a major health problem worldwide. We report the initial experience of a new left ventricular assist device (LVAD) Heartcon—a centrifugal pump of magnetic-fluid suspension rotor integrated with the pump and machine. From September 2020 to March 2023, HeartCon was implanted in a total of 78 cases throughout China, 27 were implanted in TEDA International Cardiovascular Hospital. Methods: The patient data collected from the medical record included patient demographics, surgical and cardiopulmonary bypass (CPB) data, doses of transfused red blood cells, mechanical ventilation time (h), intensive care unit (ICU) stay time (d), and cardiac function indices assessed by echocardiography, 6-minute walk tests, and N-terminal pro brain natriuretic peptide (NT proBNP) values. Results: All patients were in New York Heart Association (NYHA) grade IV before surgery and 21 had a dilated cardiomyopathy. All patients survived the surgery. One patient underwent heart transplantation 10 months after the implantation. Eight patients reported adverse event events. The duration of mechanical ventilation after operation was 37.8 ± 52.0 h. The incidence of hemorrhagic stroke was 7.4% and the incidence of mediastinal infection was 7.4%. At 90 day followup, 25 patients were in NYHA grade I and the other 2 patients were in grade II. Conclusion: We conclude that HeartCon implantation is a safe and useful LVAD for treatment of end-stage heart failure. It provides a shorter duration of mechanical ventilation time, and a lower incidence of hemorrhagic stroke and mediastinal infection.

Assessment of immunosuppression induction with basiliximab compared to antithymocyte-globulin in adult heart transplant patients.

Patients undergoing heart transplants are at risk of rejection which can have significant morbidity and mortality. Induction immunosuppression at the time of transplant reduces the early risk and has additional benefits. The induction agent of choice within our program was changed from rabbit antithymocyte-globulin (rATG) to basiliximab, so it was necessary to evaluate whether this had any impact on patient outcomes. Our primary objective was to describe rejection, infection, and other outcomes in adult heart transplant patients at the University of Alberta Hospital in Edmonton, Canada. This study was a nonrandomized, retrospective cohort study. Sixty-three patients were included with median ages 50 years versus 54 years. More female patients received rATG (20%vs. 42.4%). The most common indication for transplant in both cohorts was ICM (63.3%vs. 57.6%). Patients who received rATG had significantly higher PRA (0%vs. 43%, p<.001). Acute rejection episodes were similar between basiliximab and rATG at 3 months (16.7%vs. 15.1%; p=1.0) and 6-months (30.0%vs. 18.1%; p=.376). Infections were not statistically different with basiliximab compared to rATG at 3-months, 43.3%vs. 63.6% and at 6-months 60.0%vs. 66.7%). There were no fatalities in either group. Our study did not demonstrate differences in rejection with basiliximab compared to rATG. Mortality did not differ, but basiliximab-treated patients had fewer infections and infection-related hospitalizations than those treated with rATG. Larger studies with longer durations are needed to more completely describe the differences in rejection and infectious outcomes.

Diastolic Filling in Patients After Heart Transplantation Is Impaired Due to an Altered Geometrical Relationship Between the Left Atrium and Ventricle.

The geometrical relationship between atrial and ventricular short-axis cross-sectional area determines the hydraulic forces acting on intracardiac blood. This is important for diastolic filling. In patients undergoing heart transplantation (HTx), the left atrium is often enlarged as a result of the standard surgical technique. We hypothesized that diastolic filling in HTx patients is affected by the surgery altering the geometrical relationship between atrium and ventricle. This retrospective, cross-sectional study included 25 HTx patients (median age, 52 [range, 25-70] years), 15 patients with heart failure with reduced ejection fraction (median age, 63 [range, 52-75] years), 15 patients with heart failure with preserved ejection fraction (median age, 74 [range, 56-82] years), and 15 healthy controls (median age, 64 [range, 58-67] years) who underwent cardiac magnetic resonance imaging. Left ventricular, atrial, and total heart volumes (THV) were obtained. Atrioventricular area difference at end diastole and end systole was calculated as the largest ventricular short-axis area minus the largest atrial short-axis area. Left atrial minimum volume normalized for THV (LAmin/THV) was larger in HTx patients (median, 0.13 [range, 0.07-0.19]) compared with controls (median, 0.05 [range, 0.03-0.08], P <0.001), whereas left ventricular volume normalized for THV (left ventricular end-diastolic volume/THV) was similar between HTx and controls (median, 0.19 [range, 0.12-0.24] and median, 0.22 [range, 0.20-0.25], respectively). At end diastole, when atrioventricular area difference reached its largest positive value in controls, 11 HTx patients (44%) had a negative atrioventricular area difference, indicating impaired diastolic filling. Diastolic filling is impaired in HTx patients due to an altered geometrical relationship between the left atrium and ventricle. When performing cardiac transplantation, a surgical technique that creates a smaller left atrium may improve diastolic filling by aiding hydraulic forces.

Changes in nutritional status and the development of obesity and metabolic syndrome following pediatric heart transplantation.

Nutritional status in pediatric patients undergoing heart transplantation (HT) is frequently a focus of clinical management and requires high resource utilization. Pre-operative nutrition status has been shown to affect post-operative mortality but no studies have been performed to assess how nutritional status may change and the risk of developing nutritional comorbidities long-term in the post-transplant period. A single-center retrospective chart review of patients ≥2 years of age who underwent heart transplantation between 1/1/2005 and 4/30/2020 was performed. Patient data were collected at listing, time of transplant, 1-year, and 3-year follow-up post-transplant. Nutrition status was classified based on body mass index (BMI) percentile in the primary analysis. Alternative nutritional indices, namely the nutrition risk index (NRI), prognostic nutrition index (PNI), and BMI z-score, were utilized in secondary analyses. Of the 63 patients included, the proportion of patients with overweight/obese status increased from 21% at listing to 41% at 3-year follow-up. No underweight patients at listing became overweight/obese at follow-up. Of patients who were overweight/obese at listing, 88% maintained that status at 3-year follow-up. Overweight/obese status at listing, 1-year, and 3-year post-transplantation were significantly associated with developing metabolic syndrome. In comparison to the alternative nutritional indices, BMI percentile best predicted post-transplant metabolic syndrome. The results suggest that pediatric patients who undergo heart transplantation are at risk of developing overweight/obesity and related nutritional sequelae (ie, metabolic syndrome). Improved surveillance and interventions targeted toward overweight/obese HT patients should be investigated to reduce the burden of associated comorbidities.

Co-localization of the sodium-glucose co-transporter-2 channel (SGLT-2) with endothelin ETA and ETB receptors in human cardiorenal tissue.

Immunocytochemistry localised SGLT-2, ETA and ETB receptors in sections of histologically normal kidney, left ventricle from patients undergoing heart transplantation or controls. Primary antisera were visualised using fluorescent microscopy. Image analysis was used to measure intensity compared with background in adjacent control sections. As expected, SGLT-2 localised to epithelial cells of the proximal convoluted tubules, and co-localised with both ET receptor sub-types. Similarly, ETA receptors predominated in cardiomyocytes; low (compared with kidney but above background) positive staining was also detected for SGLT-2. Whether low levels of SGLT-2 have a (patho)physiological role in cardiomyocytes is not known but results suggest the effect of direct blockade of sodium (and glucose) influx via SGLT-2 inhibition in cardiomyocytes should be explored, with potential for additive effects with ETA antagonists.

Comparison of Intraoperative Blood Product Use During Heart Transplantation in Patients Bridged with Impella 5.5 versus Durable Left Ventricular Assist Devices

To determine if the intraoperative transfusion requirements differ based on the mechanical circulatory device used as a bridge to heart transplantation. A single-center retrospective analysis of intraoperative transfusion requirements in all patients undergoing heart or heart/kidney transplantation between November 2018 and July 2021 who were bridged with a temporary (Impella 5.5) or durable left ventricular assist device (LVAD). A tertiary care hospital. Forty-three adult patients bridged to heart or heart/kidney transplantation with a temporary or durable LVAD between 2018 and 2021 INTERVENTIONS: Recording of baseline characteristics and intraoperative transfusion requirements, including packed red blood cells, fresh frozen plasma, cryoprecipitate, autologous blood salvage, and platelets. The difference in cardiopulmonary bypass times, intensive care unit length of stay, and the vasoactive inotrope score following transplantation were also recorded. The primary outcome was the volume of blood products transfused intraoperatively. Patients who underwent bridge to transplantation using the Impella 5.5 had statistically significant lower median transfusions of cryoprecipitate (155 mL versus 200 mL, p = 0.015), autologous blood salvage (675 mL versus 1,125 mL, p ≤ 0.01), and platelets (412 mL versus 675 mL, p ≤ 0.01). Additionally, there was a trend toward lower transfusion of intraoperative packed red blood cells (4.5 units versus 6.5 units, p = 0.29) and fresh frozen plasma (675 mL versus 800 mL, p = 0.11), but these were not statistically significant. The results suggest a reduction in certain intraoperative transfusion requirements in patients undergoing heart transplantation bridged with the Impella 5.5 versus durable left ventricular assist device.

Intraoperative Use of Intra-Aortic Balloon Pump to Generate Pulsatile Flow During Heart Transplantation: A Single-Center Experience.

The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. Using an intra-aortic balloon pump (IABP) to maintain PF during CPB for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for postoperative outcomes. A single-center retrospective study of 76 patients bridged to HT with IABP was conducted between January 2018 and December 2022. Beginning in May 2022, patients received IABP-generated PF during CPB at an internal rate of 80 beats/minute. Fifty-eight patients underwent HT with the IABP turned off (IABP-Off), whereas 18 patients underwent HT with IABP-generated PF (IABP-On). The unmatched IABP-On group experienced shorter organ ischemia times (180 vs . 203 minutes, p = 0.015) and CPB times (104 vs . 116 minutes, p = 0.022). The cohort was propensity matched according to age, organ ischemia time, and CPB time. Elevations in postoperative lactates in the immediate (2.8 vs . 1.5, p = 0.062) and 24 hour (4.7 vs . 2.4, p = 0.084) postoperative periods trended toward significance in the matched IABP-Off group. There was no difference in postoperative vasoactive inotropic score (VIS), postoperative creatinine, or length of stay. This limited preliminary data suggest that maintaining counterpulsation to generate PF during CPB may improve end-organ perfusion in this patient population as suggested by lower postoperative lactate levels.

Changes in heart transplant outcomes of elderly patients in the new allocation era

ObjectiveStudies demonstrate that heart transplantation can be performed safely in septuagenarians. We evaluate the outcomes of septuagenarians undergoing heart transplantation after the US heart allocation change in 2018. MethodsThe United Network for Organ Sharing registry was used to identify heart transplant recipients aged 70 years or more between 2010 and 2021. Primary outcomes were 90-day and 1-year mortality. Kaplan–Meier, multivariable Cox proportional hazards, and accelerated failure time models were used for unadjusted and risk-adjusted analyses. ResultsA total of 27,403 patients underwent heart transplantation, with 1059 (3.9%) aged 70 years or more. Patients aged 70 years or more increased from 3.7% before 2018 to 4.5% after 2018 (P = .003). Patients aged 70 years or more before 2018 had comparable 90-day and 1-year survivals relative to patients aged less than 70 years (90 days: 93.8% vs 94.2%, log-rank P = .650; 1 year: 89.4% vs 91.1%, log-rank P = .130). After 2018, septuagenarians had lower 90-day and 1-year survivals (90 days: 91.4% vs 95.0%, log-rank P = .021; 1 year: 86.5% vs 90.9%, log-rank P = .018). Risk-adjusted analysis showed comparable 90-day mortality (hazard ratio, 1.29; 0.94-1.76, P = .110) but worse 1-year mortality (hazard ratio, 1.32; 1.03-1.68, P = .028) before policy change. After policy change, both 90-day and 1-year mortalities were higher (90 days: HR, 1.99; 1.23-3.22, P = .005; 1 year: hazard ratio, 1.71; 1.14-2.56, P = .010). An accelerated failure time model showed comparable 90-day (0.42; 0.16-1.44; P = .088) and 1-year (0.48; 0.18-1.26; P = .133) survival postallocation change. ConclusionsSeptuagenarians comprise a greater proportion of heart transplant recipients after the allocation change, and their post-transplant outcomes relative to younger recipients have worsened.

Long-Term Survival After Single-Ventricle Palliation: A Swedish Nationwide Cohort Study.

Long-term survival after single-ventricle palliation and the effect of dominant ventricle morphology in large, unselected series of patients are scarcely reported. This nationwide cohort study included all children undergoing operation with single-ventricle palliation during their first year of life in Sweden between January 1994 and December 2019. Data were obtained from institutional records and assessment of underlying cardiac anomaly and dominant ventricular morphology was based on complete review of medical records, surgical reports, and echocardiographic examinations. Data on vital status and date of death were retrieved from the Swedish Cause of Death Register, allowing for complete data on survival. Among 766 included patients, 333 patients (43.5%) were classified as having left or biventricular dominance, and 432 patients (56.4%) as having right ventricular (RV) dominance (of whom 231 patients had hypoplastic left heart syndrome). Follow-up was 98.7% complete (10 patients emigrated). Mean follow-up was 11.3 years (maximum, 26.7 years). Long-term survival was significantly higher in patients with left ventricular compared with RV dominance (10-year survival: 91.0% [95% CI, 87.3%-93.6%] versus 71.1% [95% CI, 66.4%-75.2%]). RV dominance had a significant impact on outcomes after first-stage palliation but was also associated with impaired survival after completed total cavopulmonary connection. In total, 34 (4.4%) patients underwent heart transplantation. Of these 34 patients, 25 (73.5%) had predominant RV morphology. This study provides clinically relevant knowledge about the long-term prognosis in patients with different underlying cardiac anomalies undergoing single-ventricle palliation. RV dominance had a significant impact on outcomes after initial surgical treatment but was also associated with impaired survival after completed Fontan circulation. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356574.

Impact of new allocation policy on waitlist and transplant outcomes of adult congenital heart patients supported with ECMO.

The use of ECMO as a bridge to heart transplantation has been growing rapidly in all heart transplant recipients since the implementation of the new UNOS allocation policy; however, the impact on adult congenital heart disease (ACHD) patients is not known. We analyzed the UNOS data (2015-2021) for ACHD patients supported with extracorporeal membrane oxygenation (ECMO) during the waitlist, before and after October 2018, to assess the impact on the waitlist and posttransplant outcomes. We compared the characteristics and outcomes of ACHD patients with or without ECMO use during the waitlist and pre- and postpolicy changes. A total of 23 821 patients underwent heart transplantation, and only 918 (4%) had ACHD. Out of all ACHD patients undergoing heart transplants, 6% of patients in the prepolicy era and 7.6% in the postpolicy era were on ECMO at the time of listing. Those on ECMO were younger and sicker compared to the rest of the ACHD cohort. Those on ECMO had similar profiles pre- and postpolicy change; however, there was a very significant decrease in the waitlist time [136 days (IQR 29-384) vs. 38 days (IQR 11-108), p = 0.01]. There was no difference in waitlist mortality; however, competing risk analyses showed a higher likelihood of transplantation (51% vs. 29%) and a lower likelihood of death or deterioration (31% vs. 42%) postpolicy change. Long-term outcomes posttransplant for those supported with ECMO compared to the non-ECMO cohort are similar for ACHD patients, although there was higher attrition in the first year for the ECMO cohort. The new allocation policy has resulted in shorter waitlist times and a higher likelihood of transplantation for ACHD patients supported by ECMO. However, the appropriate use of ECMO and the underuse of durable circulatory support devices in this population need further exploration.

Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death

The use of ex vivo normothermic organ perfusion has enabled the use of deceased after circulatory death (DCD) donors for heart transplants. However, compared with conventional brain death donation, DCD heart transplantation performed with ex vivo organ perfusion involves an additional period of warm and cold ischemia, exposing the allograft to multiple bouts of ischemia reperfusion injury and may contribute to the high rates of extracorporeal membrane oxygenation usage after DCD heart transplantation. To assess whether the beating heart method of DCD heart transplantation is safe and whether it has an acceptable rate of extracorporeal membrane oxygenation use postoperatively. This case series includes 10 patients with end-stage heart failure undergoing DCD heart transplantation at a single academic medical center from October 1, 2022, to August 3, 2023. Data were analyzed from October 2022 to August 2023. Using a beating heart method of implantation of the donor allograft. The main outcome was primary graft dysfunction necessitating postoperative initiation of mechanical circulatory support. Survival and initiation of mechanical circulatory support were secondary outcomes. In this case series, 10 consecutive patients underwent DCD heart transplantation via the beating heart method. Ten of 10 recipients were male (100%), the mean (SD) age was 51.2 (13.8) years, and 7 (70%) had idiopathic dilated cardiomyopathy. Ten patients (100%) survived, and 0 patients had initiation of extracorporeal membrane oxygenation postoperatively. No other mechanical circulatory support, including intra-aortic balloon pump, was initiated postoperatively. Graft survival was 100% (10 of 10 patients), and, at the time of publication, no patients have been listed for retransplantation. In this study of 10 patients undergoing heart transplantation, the beating heart implantation method for DCD heart transplantation was safe and may mitigate ischemia reperfusion injury, which may lead to lower rates of primary graft dysfunction necessitating extracorporeal membrane oxygenation. These results are relevant to institutions using DCD donors for heart transplantation.

THE USE PICCO TECHNOLOGY FOR ASSESSMENT THE FUNCTIONAL STATE OF THE HEART AND SYSTEMIC GEODYNAMICS DURING ORTHOTOPIC HEART TRANSPLANTATION

Summary. Approximately 5000 heart transplants are performed annually in the world. According to the American College of Cardiology/American Heart Association/ Heart Failure Society of America (ACC/AHA/HFSA) and the European Society of Cardiology (ESC), there are currently more people on the waiting list for heart transplants than there are donor organs available. The Ukrainian National Waiting List of the Unified State Transplantation Information System contains more than 2,000 patients, of whom about 500 need a heart transplant. Objective. The aim was to evaluate the effectiveness of haemodynamic monitoring using a continuous analysis system for measuring pulse waveform and transpulmonary thermodilution and its impact on orthotopic heart transplantation. Materials and methods. The work is based on the results of 30 recipients diagnosed with dilated cardiomyopathy who underwent orthotopic heart transplantation. The average age of the recipients was 41.4±3.2 years. There were 90 % of male recipients and 10 % of female recipients. All recipients were diagnosed with dilated cardiomyopathy with reduced ejection fraction with an average of 18 ± 4.4 %. All patients underwent heart transplantation using PiCCO hemodynamic monitoring, which assessed the optimality of fluid, inotropic and vasopressor therapy with analysis of changes in the functional state of systemic hemodynamic (blood pressure, heart rate, central venous pressure, cardiac index, cardiac output, global end-diastolic volume index, extravascular lung water index, systemic vascular resistance and global ejection fraction) at the time of donor heart inclusion in the recipient’s circulation Results. It was found that all patients had a reduced ejection fraction. In 100% of patients undergoing orthotopic heart transplantation, PiCCO monitoring was used, which showed cardiac dysfunction with a reduced cardiac index of 1.90 ± 0.24 l/min/m on average, global end-diastolic blood volume index was 571 ± 163.7 ml/m2 and was reduced, reflecting a decrease in preload. While the extravascular water index in the lungs averaged 9.2 ± 1.41 ml/kg of body weight and was increased, indicating possible pulmonary oedema at the beginning of surgery. Conclusions. PiCCO monitoring allows real-time diagnosis of functional changes in the myocardium, differentiation of major circulatory disorders in patients with involvement of vital organs and systems, including breathing (gas exchange), classification of haemodynamic disorders and timely correction. During the study, PiCCO monitoring revealed an improvement in extravascular lung water in 95 % of patients by the end of CPR, which made it possible to adequately treat these disorders and prevent pulmonary oedema, provide adequate correction with inotropic support and balance postload with the systemic vascular resistance index and improve the cardiac index by 99.1 %.

Severe Acute Kidney Injury Postheart Transplantation: Analysis of Risk Factors.

Acute kidney injury (AKI) is a common complication postheart transplantation and is associated with significant morbidity and increased mortality. We conducted a single-center, retrospective, observational cohort study of 109 consecutive patients undergoing heart transplantation between September 2019 and September 2021 to determine major risk factors for, and the incidence of, severe postoperative AKI as defined by Kidney Disease Improving Global Outcomes criteria in the first 48-h posttransplantation and the impact that this has on mortality and dialysis dependence. One hundred nine patients were included in our study, 83 of 109 (78%) patients developed AKI, 42 (39%) developed severe AKI, and 37 (35%) required renal replacement therapy in the first-week posttransplantation. We found preoperative estimated glomerular filtration rate (eGFR), postoperative noradrenaline dose, and the need for postoperative mechanical circulatory support to be independent risk factors for the development of severe AKI. Patients who developed severe AKI had a 19% 12-mo mortality compared with 1% for those without. Of those who survived to hospital discharge, 20% of patients in the severe AKI group required dialysis at time of hospital discharge compared with 3% in those without severe AKI. Severe AKI is common after heart transplantation. Preoperative kidney function, postoperative vasoplegia with high requirements for vasoactive drugs, and graft dysfunction with the need for mechanical circulatory supports were independently associated with the development of severe AKI in the first-week following heart transplantation. Severe AKI is associated with a significantly increased mortality and dialysis dependence at time of hospital discharge.

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure

Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF. Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied. The LSG and non-LSG cohorts had comparable ages (P=.088) and starting BMI score (P=.918), and a proportion of patients had a ventricular assist device (P=.191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9kg/m2 (SD, ±6.13) and 1.1kg/m2 (SD, ±4.10), respectively (P=.040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P=.884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P=.525). LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

Association between early postoperative hypoalbuminaemia and outcome after orthotopic heart transplantation.

In patients undergoing heart transplantation (HTX), preoperative liver impairment and consecutive hypoalbuminaemia are associated with increased mortality. The role of early postoperative hypoalbuminaemia after HTX is unclear. This study investigated the association between early postoperative hypoalbuminaemia and 1-year mortality as well as 'days alive and out of hospital' (DAOH) after HTX. This retrospective cohort study included patients who underwent HTX at the University Hospital Duesseldorf, Germany, between 2010 and 2022. The main exposure was serum albumin concentration at intensive care unit (ICU) arrival. The primary endpoints were mortality and DAOH within 1 year after surgery. Receiver operating characteristic (ROC) curve analysis was performed and logistic and quantile regression models with adjustment for 13 a priori defined clinical risk factors were conducted. Out of 241 patients screened, 229 were included in the analysis (mean age 55 ± 11 years, 73% male). ROC analysis showed moderate discrimination for 1-year mortality by postoperative serum albumin after HTX [AUC = 0.74; 95% confidence interval (CI): 0.66-0.83]. The cutoff for serum albumin at ICU arrival was 3.0 g/dl. According to multivariate logistic and quantile regression, there were independent associations between hypoalbuminaemia and mortality/DAOH [odds ratio of 4.76 (95% CI: 1.94-11.67) and regression coefficient of -46.97 (95% CI: -83.81 to -10.13)]. Postoperative hypoalbuminaemia <3.0 g/dl is associated with 1-year mortality and reduced DAOH after HTX and therefore might be used for early postoperative risk re-assessment in clinical practice.

Long-term outcomes and reverse remodelling in recently diagnosed unexplained left ventricular systolic dysfunction.

In patients with recently diagnosed non-ischaemic LV systolic dysfunction, left ventricular reverse remodelling (LVRR) and favourable prognosis has been documented in studies with short-term follow-up. The aim of our study was to assess the long-term clinical course and stability of LVRR in these patients. We prospectively studied 133 patients (37 women; 55 [interquartile range 46, 61] years) with recently diagnosed unexplained LV systolic dysfunction, with heart failure symptoms lasting <6months and LV ejection fraction <40% persisting after at least 1week of therapy. All patients underwent endomyocardial biopsy (EMB) at the time of diagnosis and serial echocardiographic and clinical follow-up over 5years. LVRR was defined as the combined presence of (1) LVEF≥50% or increase in LVEF≥10% points and (2) decrease in LV end-diastolic diameter index (LVEDDi)≥10% or (3) LVEDDi≤33mm/m2. LVRR was observed in 46% patients at 1year, in 60% at 2years and 50% at 5years. Additionally, 2% of patients underwent heart transplantation and 12% experienced heart failure hospitalization. During 5-year follow-up, 23 (17%) of the study cohort died. In multivariate analysis, independent predictors of mortality were baseline right atrial size (OR 1.097, CI 1.007-1.196), logBNP level (OR 2.02, CI 1.14-3.56), and PR interval (OR 1.02, CI 1.006-1.035) (P<0.05 for all). The number of macrophages on EMB was associated with overall survival in univariate analysis only. LVRR at 1year of follow-up was associated with a lower rate of mortality and heart failure hospitalization (P=0.025). In multivariate analysis, independent predictors of LVRR were left ventricular end-diastolic volume index (OR 0.97, CI 0.946-0.988), LVEF (OR 0.89, CI 0.83-0.96), and diastolic blood pressure (OR 1.04, CI 1.01-1.08) (P<0.05 for all). LVRR occurs in over half of patients with recent onset unexplained LV systolic dysfunction during first 2years of optimally guided heart failure therapy and then remains relatively stable during 5-year follow-up. Normalization of adverse LV remodelling corresponds to a low rate of mortality and heart failure hospitalizations during long-term follow-up.

Duration of Bridge-to-Transplant Extracorporeal Membrane Oxygenation and Heart Transplant Survival

Background. The 2018 Organ Procurement and Transplantation Network (OPTN) heart allocation policy change prioritizes patients bridged to transplant with mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO). As a result, the use of ECMO has significantly increased. Methods. We reviewed the OPTN database for adult patients undergoing heart transplant after bridge with ECMO between January 1st 2000 and October 18th 2018. We excluded patients with ≥180 days of ECMO duration, prior transplants, and those using additional MCS devices. Survival and morbidity outcomes of patients with ≥7 days of pre-transplant ECMO were compared to those of patients with &lt;7 days. Results. Of 362 eligible transplant recipients, 163 (45%) utilized &lt;7 days of pre-transplant ECMO and 199 (55%) utilized ≥7 days. Those with ≥7 days were younger (median age: 43 [28–54] vs. 50 [36–57] years, p=0.006) and more likely to have temporary waitlist inactivity (18% vs. 7%, p=0.003) with significantly longer duration of ECMO use (median: 14 [9–24] vs. 4 [2–5] days, p &lt; 0.001). Patients with ≥7 days of ECMO had comparable survival to those with &lt;7 days at one year (81.1% vs. 79.4%, p=0.64) and five years (61.1% vs. 49.3%, p=0.27). After adjustment for clinically relevant variables, duration of ECMO ≥7 days did not increase mortality at five years (HR = 0.90, p=0.59). Conclusions. Longer duration of ECMO (≥7 days vs. &lt;7 days) among patients successfully bridged to transplant is not associated with increased mortality or selected adverse outcome, including graft failure or rejection, at up to five years.

Left ventricular fibrosis as a main determinant of filling pressures and left atrial function in advanced heart failure.

Advanced heart failure (AdHF) is characterized by variable degrees of left ventricular (LV) dysfunction, myocardial fibrosis, and raised filling pressures which lead to left atrial (LA) dilatation and cavity dysfunction. This study investigated the relationship between LA peak atrial longitudinal strain (PALS), assessed by speckle-tracking echocardiography (STE), and invasive measures of LV filling pressures and fibrosis in a group of AdHF patients undergoing heart transplantation (HTX). We consecutively enrolled patients with AdHF who underwent HTX at our Department. Demographic and basic echocardiographic data were registered, then invasive intracardiac pressures were obtained from right heart catheterization, and STE was also performed. After HTX, biopsy specimens from explanted hearts were collected to quantify the degree of LV myocardial fibrosis. Sixty-four patients were included in the study (mean age 62.5 ± 11 years, 42% female). The mean LV ejection fraction (LVEF) was 26.7 ± 6.1%, global PALS was 9.65 ± 4.5%, and mean pulmonary capillary wedge pressure (PCWP) was 18.8 ± 4.8 mmHg. Seventy-three % of patients proved to have severe LV fibrosis. Global PALS was inversely correlated with PCWP (R = -0.83; P < 0.0001) and with LV fibrosis severity (R = -0.78; P < 0.0001) but did not correlate with LVEF (R = 0.15; P = 0.2). Among echocardiographic indices of LV filling pressures, global PALS proved the strongest [area under the curve 0.955 (95% confidence interval 0.87-0.99)] predictor of raised (>18 mmHg) PCWP. In patients with AdHF, reduced global PALS strongly correlated with the invasively assessed LV filling pressure and degree of LV fibrosis. Such relationship could be used as non-invasive indicator for optimum patient stratification for therapeutic strategies.