Patients Receiving Heart Transplants Research Articles

Elevated serum albumin-to-creatinine ratio as a protective factor on outcomes after heart transplantation.

The purpose of this study was to investigate the prognostic significance of serum albumin to creatinine ratio (ACR) in patients receiving heart transplantation of end-stage heart failure. From January 2015 to December 2020, a total of 460 patients who underwent heart transplantation were included in this retrospective analysis. According to the maximum Youden index, the optimal cut-off value was identified. Kaplan-Meier methods were used to describe survival rates, and multivariable analyses were conducted with Cox proportional hazard models. Meanwhile, logistic regression analysis was applied to evaluate predictors for postoperative complications. The accuracy of risk prediction was evaluated by using the concordance index (C-index) and calibration plots. The optimal cut-off value was 37.54 for ACR. Univariable analysis indicated that recipient age, IABP, RAAS, BB, Hb, urea nitrogen, D-dimer, troponin, TG, and ACR were significant prognostic factors of overall survival (OS). Multivariate analysis showed that preoperative ACR (HR: 0.504, 95% = 0.352-0.722, P < 0.001) was still an independent prognostic factor of OS. The nomogram for predicting 1-year and 5-year OS in patients who underwent heart transplantation without ACR (C-index = 0.631) and with ACR (C-index = 0.671). Besides, preoperative ACR level was a significant independent predictor of postoperative respiratory complications, renal complications, liver injury, infection and in-hospital death. Moreover, the calibration plot showed good consistency between the predictions by the nomogram for OS and the actual outcomes. Our research showed that ACR is a favorable prognostic indicator in patients of heart transplantation.

1082-P: Safety of SGLT2 Inhibitors in Heart Transplant Recipients

Objective: The safety of SGLT2 inhibitor (SGLT2I) use in patients receiving heart transplants is unknown. We aimed to evaluate key measures of safety after initiation of SGLT2I in a cohort of heart transplant recipients. Methods: Patients in the University of Colorado Health system who received a heart transplant between 1991 and 2022 were included if an SGLT2I was prescribed post-transplant and continued for at least 1 month. Number of urinary tract infections (UTI), urogenital yeast infections (UGI), and ED visits and hospital admissions for skin and soft tissue infections (SSTI) and euglycemic DKA (eDKA) were collected by chart review for the duration of SGLT2I use. Vital signs and lab values were collected at baseline, 3 months, and 6 months after SGLT2I initiation. Least squared means and mean differences were extracted from a random intercept mixed model with an unstructured covariance matrix for each variable. Results: Forty-six (46) patients met criteria for analysis. Mean age was 56.1 years, 80.4% had DM, and 84.8% had CKD at the time of SGLT2I initiation. Mean time on SGLT2I was 15 months (range 1-91 months). Three patients (6.5%) developed UTI and one developed UGI. Three (6.5%) had ED visits and admissions for SSTI: 1 had a post-surgical scalp infection and 2 had lower extremity cellulitis (1 led to hallux gangrene and amputation). No patients developed eDKA. Seven patients (15.2%) discontinued their SGLT2I: 2 for UTI and 1 each for hypotension, cost, fatigue, dialysis, and unspecified. Thirty-six (36) patients with adequate data over time were included in the analysis to assess change in vital signs and labs. There were no statistically significant changes from baseline to 3 months or 6 months after SGTL2I initiation for weight, BMI, SBP, DBP, Cr, eGFR, serum Na or serum K. Conclusions: In this sample of heart transplant recipients on SGLT2I, there were few urogenital and SSTI infections, no eDKA, and no significant change in renal function or electrolytes, which adds support for the safety of SGLT2I in this population. Disclosure S.Zahalka: None. C.C.Low wang: Research Support; Dexcom, Inc., Virta Health Corp., CellResearch Corporation. P.Choksi: None. H.M.Lawler: None. L.Grau: None. T.Jensen: Other Relationship; Somalogic.

Effect of preoperative pulmonary artery pressure on the prognosis of end-stage heart failure patients after heart transplantation

ObjectiveTo evaluate the effect of preoperative pulmonary artery pressure on perioperative outcome of end-stage heart failure patients undergoing heart transplantation.MethodsRetrospective analysis was undertaken on the clinical data of patients receiving heart transplantation in the Department of Cardiovascular Surgery of our hospital from March 2017 to March 2022. A ROC curve analysis was developed between mean pulmonary artery pressure (mPAP) and postoperative mortality using mPAP as diagnostic criteria. Patients were divided into groups based on this threshold to determine the best mPAP threshold value for predicting postoperative nosocomial mortality, and the differences in preoperative and intraoperative data, postoperative complications, and clinical prognosis of patients in the two groups were compared. Patients were followed up to draw the survival curve of patients in the two groups.ResultsThe study enlisted the participation of 105 patients. ROC curve research revealed that preoperative pulmonary artery pressure was substantially linked with death following heart transplantation, with mPAP = 30.5mmHg being the best threshold. The group with mPAP ≥ 30.5mmHg had a greater incidence of postoperative ECMO support (28.2% vs. 10.6%, P = 0.021) and a higher incidence of in-hospital mortality (15.4% vs. 1.5%, P = 0.019) than the group with mPAP < 30.5mmHg. The postoperative survival rates of 105 patients were 91.3%, 88.7%, 81.6%, and 77.5% at 1, 2, 3, and 4 years, respectively, however, there was no significant difference between the two groups of patients in the postoperative intermediate-far survival rate (P = 0.431).ConclusionsPreoperative pulmonary artery pressure in patients with end-stage heart failure is intimately correlated with perioperative prognosis of heart transplant recipients. The optimal cut-off mPAP value in predicting perioperative prognosis of heart transplant recipients is 30.5mmHg. In the high mPAP group, perioperative ECMO support rate and perioperative mortality rate are high, which do not affect the medium and long-term prognosis of the recipients undergoing heart transplantation.

Outcomes of continuous flow left ventricular assist device after surgical left ventricular restoration

ObjectivesThis study aimed to report the clinical outcomes of continuous flow left ventricular assist device implantation in end-stage chronic heart failure patients with a history of surgical left ventricular restoration.MethodsWe retrospectively identified 190 patients undergoing continuous flow left ventricular assist device implantation at our center from November 2007 to April 2020. In total, six patients underwent continuous flow left ventricular assist device implantation after various types of surgical left ventricular restoration procedures, including endoventricular circular patch plasty (n = 3), posterior restoration procedure (n = 2), and septal anterior ventricular exclusion (n = 1).ResultsContinuous flow left ventricular assist device (Jarvik 2000, n = 2; EVAHEART, n = 1; HeartMate II, n = 1; DuraHeart, n = 1; HVAD, n = 1) was successfully implanted in all patients. During a median follow-up of 48 months (interquartile range, 39–60 months; censoring heart transplantation), no death was documented, which means that overall survival after left ventricular assist device implantation was 100% at any time point. Finally, three patients received heart transplantation (waiting time: 39, 56, and 61 months, respectively) and the other three patients are still awaiting heart transplantation (waiting time: 12, 41, and 76 months, respectively).ConclusionsIn our series, continuous flow left ventricular assist device implantation after surgical left ventricular restoration was safe and feasible, even if an endoventricular patch was used, and effective for bridge to transplant strategy.

Hjartaígræðslur og hjartagjafir Íslendinga

INTRODUCTION: Information on the number, indications and outcome of cardiac transplantations in Icelandic patients is scarce, as is information on the number of hearts donated from Iceland for cardiac transplantation. MATERIAL AND METHODS: A retrospective study on patients receiving heart transplantation from the first procedure in 1988 until March 2019. Clinical information was gathered from Landspitali Transplantation Clinic, patient charts, and information on donated hearts from the Icelandic Donation Registry. Age-standardized incidence of the procedure was calculated, and overall survival (Kaplan-Meier) estimated. Mean follow-up was 10.3 years. RESULTS: Altogether 24 patients (19 males, median age 38 years, range: 4-65 years) underwent cardiac transplantation; that included one re-transplantation, three simultaneous heart- and lung transplants and two heart- and kidney transplants. The transplantations were performed in Gothenburg (n=20), London (n=3) and Copenhagen (n=2). Most common indications were dilated cardiomyopathy (n=10), congenital heart disease (n=4), and viral myocarditis (n=3). Five patients were bridged left ventricular-assist device preoperatively. Overall survival at 1 and 5 years was 91% and 86%, respectively; median survival being 24 years. The incidence of cardiac transplantation was 2.7 heart-TX pmp/year but increased to 4.6 heart-TX pmp/year after 2008 (p=0.01). During the same period 42 hearts were donated from Iceland for transplantation abroad, the first in 2002 and increasing from 0.8 to 3.0 hearts/year during the first and second half of the study-period, respectively. CONCLUSION: Survival of Icelandic cardiac transplant recipients is good and comparable to larger transplant centers overseas. Number of hearts donated from Iceland have increased and currently Iceland donates twice as many hearts at it receives.

Cardiac transplantation and donation in Icelandic patients - indications and outcome

Information on the number, indications and outcome of cardiac transplantations in Icelandic patients is scarce, as is information on the number of hearts donated from Iceland for cardiac transplantation. A retrospective study on patients receiving heart transplantation from the first procedure in 1988 until March 2019. Clinical information was gathered from Landspitali Transplantation Clinic, patient charts, and information on donated hearts from the Icelandic Donation Registry. Age-standardized incidence of the procedure was calculated, and overall survival (Kaplan-Meier) estimated. Mean follow-up was 10.3 years. Altogether 24 patients (19 males, median age 38 years, range: 4-65 years) underwent cardiac transplantation; that included one re-transplantation, three simultaneous heart- and lung transplants and two heart- and kidney transplants. The transplantations were performed in Gothenburg (n=20), London (n=3) and Copenhagen (n=2). Most common indications were dilated cardiomyopathy (n=10), congenital heart disease (n=4), and viral myocarditis (n=3). Five patients were bridged left ventricular-assist device preoperatively. Overall survival at 1 and 5 years was 91% and 86%, respectively; median survival being 24 years. The incidence of cardiac transplantation was 2.7 heart-TX pmp/year but increased to 4.6 heart-TX pmp/year after 2008 (p=0.01). During the same period 42 hearts were donated from Iceland for transplantation abroad, the first in 2002 and increasing from 0.8 to 3.0 hearts/year during the first and second half of the study-period, respectively. Survival of Icelandic cardiac transplant recipients is good and comparable to larger transplant centers overseas. Number of hearts donated from Iceland have increased and currently Iceland donates twice as many hearts at it receives.

Can Malnutrition at the Time of Heart Transplantation Affect Early and Late Mortality?

<h3>Purpose</h3> To analyze early and late clinical outcomes of malnourished patients undergoing heart transplantation. <h3>Methods</h3> We retrospectively evaluated all patients ≥18 years of age, who received a heart transplant between January 2015 and July 2020 at our center. For each patient, we calculated the semi-quantitative Malnutrition Universal Screening Tool (MUST) score at the time of transplantation to assess the patient nutritional status. A Cox regression analysis was performed to assess follow-up mortality and postoperative complications risk. <h3>Results</h3> Data from 177 patients (median age 58, IQR 49-65; M 134, 76%) were collected. Median preoperative BMI was 24kg/mq (IQR 21-28). Preoperative MUST score was 0, 1, 2 or >2 in 100 (57%), 24 (14%), 40 (23%) and 12 (6%) patients, respectively. Median preoperative eGFR was 64 ml/min (IQR 49-83). An increase in MUST score (from 0 to 2) was not associated with higher in-hospital mortality (hazard ratio 0.99, 95% CI 2.06-0.45, p=0.99), and was only related to increased risk of postoperative acute kidney injury requiring renal replacement therapy (hazard ratio 2.04, 95% CI 1.06-3.95, p=0.033) or septicemia (hazard ratio 3.37, 95% CI 1.08-10.54, p=0.036) within 24 hours after transplantation. Postoperative data and associated hazard ratios are summarized in Table 1. Survival rates at 3 and 5 years were respectively 77% (95% CI 71-84, patients at risk n=83) and 73% (95 CI 66-82, patients at risk 28). An analogous increase in MUST score was associated with increased follow-up mortality risk (hazard ratio 1.67, 95% CI 1.07-2.61, p=0.025). <h3>Conclusion</h3> Severe malnutrition (evaluated with a multi-variable semi-quantitative parameter as MUST score) in patients receiving heart transplantation is a risk factor for late death. However, it is not associated with increased in-hospital mortality or major postoperative complications except for early septicemia or renal function.

8 versus 12 Week Complete Viral Suppression After Heart Transplantation from Hepatitis C Positive Donors in Hepatitis C Negative Recipients

<h3>Purpose</h3> Current research demonstrates acceptable rates of survival in patients receiving heart transplants from hepatitis c positive donors. The use of direct acting antiviral (DAA) therapy is effective in achieving sustained virologic response (SVR). It is unknown if shorter duration of therapy achieves complete viral suppression (CVS) and maintenance of this suppression until SVR is reached at 12 weeks. DAA's limit standard post-transplant use of HMG-Co-A reductase inhibitors, which are proven to improve survival after transplant. Given this impact on survival, we felt it prudent to evaluate time to complete viral suppression at 8 weeks. <h3>Methods</h3> We performed a retrospective review of all patients undergoing heart transplant between January 1, 2019 and June 1, 2021. Demographic and transplant related data were recorded for patients receiving organs from Hepatitis C positive and nucleic acid test positive donors at 8 and 12 weeks. <h3>Results</h3> 116 patients underwent heart transplant during our review period. Of these, a total of 14 (12%) patients received organs from Hepatitis C positive donors. 10 of these patients (79%) were nucleic acid test positive (NAT) at time of transplant, with three female (30%) and seven male (70%) recipients. The median age was 60 (IQR 57-67). Genotype distribution was as follows: 70% type 1 and 30% type 3. Six of the ten patients receiving DAA therapy achieved CVS at 8 weeks in our cohort. Median time from transplant to CVS was 55 days (IQR 50 - 86 days). Etiology was not significant with respect to CVS at 8 weeks (p=0.5). All patients achieved SVR at 12 weeks. Induction therapy with was not significantly associated with CVS at 8 (p=0.18) or 12 weeks(p=0.08). Age less than 50 at transplant was associated with CVS at 8 weeks (p=0.04). Peak viral load, but not initial viral load, was associated with CVS at 8 weeks (p=0.03). DAA (Epclusa or Mavyret) was not associated with CVS at 8 weeks (p=0.34). <h3>Conclusion</h3> Our data suggests potential benefit of shorter duration of therapy with direct acting antiviral therapy in specific patient populations receiving hepatitis c positive organs. Potential markers of response include peak viral load, age at transplant, but not induction immunotherapy or DAA type. Larger pooled studies should be performed to assess this trend and potentially change practice recommendations.

Absolute Lymphocyte Count as a Prognostic Factor for Cytomegalovirus Infection After Heart Transplantation

<h3>Purpose</h3> Previous studies have suggested a correlation between reduced absolute lymphocyte count (ALC) & cytomegalovirus (CMV) infection and have therefore highlighted the potential of ALC as a simple tool to predict CMV infection in transplant patients. This study aims to examine the prognostic value of ALC on CMV infection in heart transplant patients. <h3>Methods</h3> Clinical information and ALC data of all adult patients who received orthotopic heart transplantation between January 2004 and May 2019 were collected. We performed a multivariable Cox regression model that incorporates repeated measurements of ALC as a time-varying continuous prognostic factor in two ways, first as binary variable with a threshold of 610 cells/μL and secondly as a continuous variable. Furthermore, landmark analyses to evaluate the mean ALC level of the preceding month, at 1, 3 & 6 months were performed. <h3>Results</h3> 549 patients received heart transplantation during this study period. 407 patients met the inclusion criteria for the primary endpoint investigation. An ALC ≥610 cells/μL was associated with a significantly lower risk of CMV infection (HR 0.57; CI 0.40-0.83; p=0.003). The continuous approach showed similar results with a significantly reduced risk of infection in patients with higher ALC (HR[2-fold increase] 0.78; CI 0.66-0.91; p=0.002). Landmark analyses of mean ALC levels at month 1 & 3, respectively, after transplantation showed a significantly decreased risk of infection in patients with a higher mean ALC (HR[2-fold increase] 0.81; CI 0.65-0.99; p=0.043 & HR 0.46; CI 0.29-0.74; p=0.001). <h3>Conclusion</h3> Absolute lymphocyte count is strongly associated with CMV infection after heart transplantation. ALC value monitoring could serve as an additional tool to predict and minimize the risk of CMV infection.

Risk of Prolonged Intubation Post-Pediatric Heart Transplantation

<h3>Purpose</h3> Pediatric patients receiving heart transplantation are at increased risk of prolonged ventilation (PV). However, there is limited data on factors that predict PV post-heart transplant (HT). This study sought to determine the factors leading to PV post-HT as it could be an important outcome measure. <h3>Methods</h3> The United Network for Organ Sharing (UNOS) and the Pediatric Health Information System (PHIS) Registries were queried for pediatric patients who received HT in 2006-2020. Duration of post-HT ventilatory support was divided into those on "prolonged ventilation" (PV) (≥4 days) and those on "short-term ventilation" (SV) (<4 days). Binary logistic regression was used to identify independent predictors of PV and of reintubation. <h3>Results</h3> A total of 3092 patients were identified with a median duration of post-HT ventilation of 3 [2-8] days. 1565 (50.6%) patients were on SV and 1527 (49.4%) on PV. PV patients were younger (median 2 [0-11] years vs 9 [1-15] years, p<0.001) and more likely diagnosed with congenital heart disease (CHD) (62% vs 40%, p<0.001) compared to SV. At HT, PV patients had greater rates of ventilator (24% vs 5%, p<0.001) and extracorporeal mechanical oxygenation (ECMO) (6% vs 1%, p<0.001) requirement and more of their donors had a longer ischemic time (>4 hours) (40% vs 30%, p<0.001), and a higher ejection fraction% (EF) (65 vs 64, p=0.02). Independent predictors of PV were CHD [Odds ratio (OR)=2.5; 95% confidence interval (CI) 2.09-2.9], allograft ischemia time>4 hours [1.3; 1.1-1.6], ventilator [5; 3.8-6.8], ECMO [2.3; 1.3-3.9], VAD [1.4; 1.2-1.7] and donor EF<55% [1.5; 1.1-2] at HT. Older recipient age was associated with shorter duration [0.96; 0.95-0.97]. CHD [1.6; 1.4-1.9], ECMO [1.6; 1.1-2.4] and recipient age [1.01; 1-1.02] were associated with increased risk of reintubation. <h3>Conclusion</h3> Ischemic time and donor EF are associated with prolonged intubation, however, recipient's age, cardiopulmonary mechanical support at HT and CHD diagnosis increase the risk of prolonged ventilation and re-intubation, post-HT. Prolonged ventilation could potentially be used as an outcome measure.

Outcomes of hypertrophic cardiomyopathy in Japanese children: a retrospective cohort study.

There has been no multicenter study on the prognosis of pediatric hypertrophic cardiomyopathy (HCM) in Japan. Therefore, we conducted a retrospective multicenter observational study on the long-term survival rate in patients diagnosed with HCM under the age of 18 between 1990 and 2014. Twenty institutions participated. A total of 180 patients were identified. The median age at diagnosis was 5.8years old and median duration of observation was 8.3years. Although six patients (3%) deteriorated into the dilated phase of HCM, no patient received heart transplantation. Freedom from death at 1, 5, 10, and 20years were 97%, 92%, 84%, and 80%, respectively. There were 26 deaths. Among them, 11 patients died suddenly, presumably due to arrhythmia, and 15 patients died of heart failure. The presence of heart failure symptoms and a greater cardiothoracic ratio were significant risk factors for heart failure-related death. There were no significant risk factors identified for arrhythmia-related death. In conclusion, the prognosis of pediatric HCM in Japan is good and similar to those reported in population-based studies in the United States and Australia. Significant risk factors for heart failure-related death were identified in pediatric patients with HCM in Japan.

Outcome of patients with non‐ischaemic cardiogenic shock supported by percutaneous left ventricular assist device

AimsPercutaneous left ventricular assist devices (pVADs) are used to haemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI). One out of every two patients has a non‐ischaemic cause of CS, and these patients differ profoundly from patients with AMI‐related CS. We assessed the usefulness of pVAD support for patients with non‐ischaemic CS.Methods and resultsWe analysed 106 patients with CS and Impella® support between 2015 and 2018. CS was non‐ischaemic in 36 patients and AMI‐related in 70 patients. Compared with the AMI group, those in the non‐ischaemic group were significantly younger [median age 62 (50.8, 70.8) years vs. 68 (58.0, 75.5) years, P = 0.007] and had more patients with severely reduced left ventricular function (94% vs. 79%, P = 0.035) and worse glomerular filtration rate [45 (27, 57) mL/min vs. 60 (44, 78) mL/min]. Propensity score matching yielded 31 patients with non‐ischaemic CS and 31 patients with AMI‐related CS, without a difference in baseline laboratory values or comorbidities. In both groups, pVAD support was performed along with haemodynamic stabilization, reduction of catecholamines and normalization of lactate levels. In 7 days, systolic blood pressure increased from 91 (80, 101) mmHg at baseline to 100 (100, 120) mmHg in the non‐ischaemic CS group (P = 0.001) and 89 (80, 100) mmHg at baseline to 112 (100, 128) mmHg in the AMI‐related CS group (P = 0.001). Moreover, in 7 days, the need of catecholamines (calculated as vasoactive‐inotropic score) decreased from 32.0 (11.1, 47.0) at baseline to 5.3 (0, 16.1) in the non‐ischaemic group (P = 0.001) and from 35.2 (18.11, 67.0) to zero (0, 0) in the AMI‐related CS group (P = 0.001). Lactate level decreased from 3.8 (2.8, 5.9) mmol/L at baseline to 1.0 (0.8, 2.1) mmol/L (P = 0.001) in the non‐ischaemic CS group and from 3.8 (2.6, 6.5) mmol/L to 1.2 (1.0, 2.0) mmol/L in the AMI‐related group (P = 0.001).In the non‐ischaemic CS group, eight patients (25.8%) were upgraded to veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) or long‐term mechanical circulatory support. Two of these upgraded patients received heart transplantation. In the AMI group, eight patients (25.8%) were upgraded to VA‐ECMO or long‐term mechanical circulatory support. Ninety‐day survival did not significantly differ between the groups (non‐ischaemic CS group 48.4%, AMI‐related CS group 45.2%, P = 0.799).ConclusionspVAD support is useful for haemodynamic stabilization of patients with non‐ischaemic CS and is valuable as a bridge to patients' recovery or long‐term left ventricular support and heart transplantation.

Heart Failure Statistics in Korea, 2020: A Report from the Korean Society of Heart Failure.

Background and ObjectivesHeart failure (HF) is a disease with high morbidity and mortality. With ageing society and increasing prevalence of risk factors of HF, the prevalence of HF is expected to increase, as well. In this official report of the Korean Society of Heart Failure the epidemiology of HF in Korea is presented.MethodsThe data of Korean National Health Insurance big data, the Korean Heart Failure (KorHF) and the Korean Acute Heart Failure (KorAHF) registries have been used.ResultsIn 2018, the prevalence, incidence, mortality of HF patients, and mortality due to HF were 2,261, 579, 245, and 10.4 per 100.000 persons, respectively. Regarding the temporal trend, there was a continuous increase in HF prevalence (0.77% in 2002, 1.48% in 2013, and 2.24% in 2018) and HF related deaths. The most common etiology for HF was ischemic origin, and the dominant subtype was HF with reduced ejection fraction (EF), defined as EF ≤40%. Of these, 77.6%, 58.0%, and 55.1% received renin-angiotensin-system inhibitors (angiotensin-converting-enzyme inhibitors or angiotensin-receptor-blockers), beta-blockers, and aldosterone-antagonists, respectively. In 2018, 1,542 implantable cardiac defibrillators and 272 cardiac resynchronization therapy devices were implanted, and 176 patients received heart transplantation. With improvement of pharmacologic and non-pharmacological therapy, the survival time of HF has been improving in the last 2 decades; nonetheless, it is associated with enormous increase in medical costs.ConclusionsThe prevalence of HF has been increasing in Korea. With improvement of therapy, the prognosis of HF has been improving, too. Nonetheless, appropriate interventions are necessary to prevent HF.

Abstract 15874: An Ischaemia Time of Greater Than 6 Hours is Associated With Deleterious Outcomes in Pediatric Heart Transplantation

Introduction: The shortage of available donor organs means we must re-consider our current policies on donor selection. There is a broad variation in practice between centers as to the acceptable limit to ischaemia time (IT) in pediatric cardiac transplantation, with no recommendations in international guidelines. Hypothesis: We hypothesised that a prolonged ischaemia time was not associated with impaired post-transplant outcomes. Methods: Data from the Pediatric Heart Transplantation Society was analysed for all pediatric patients receiving heart transplants (Jan 1993 - June 2019). Transplants were separated into 5 categories depending on the IT (hours): &lt; 2.4, 2.5-3.4, 3.5-4.4, 4.5-6.0, &gt;6. Risk-adjusted outcomes were assessed by multivariable analysis, adjusting for donor, recipient, and peri-operative characteristics. Results: Data for 6,903 transplants were assessed (IT &lt; 2.4 in 980, 2.5-3.4 in 2032, 3.5-4.4 in 2310, 4.5-6.0 in 1162, &gt;6 in 281). In univariate analysis, increasing IT was associated with reduced 1-year survival (90.1%, 87.7% and 84.6%; p&lt;0.001) for the 3.5-4.4, 4.5-6.0 and &gt;6 groups, respectively. Similar findings, of a deleterious association with prolonged IT, were observed for freedom from infection (73.0%, 66.8% and 56.4%; p&lt;0.001), freedom from first rejection (67.4%, 62.6% and 61.0%; p = 0.01) and freedom from haemodynamically compromising rejection (89.1%, 85.4% and 85.3%; p=0.004) at 1-year. No significant differences in the risk of malignancy (p=0.2) and time to first CAV (p=0.08) between the IT groups were noted. We separately analysed the risk of graft failure by multiphase hazards modelling. In adjusted analysis, increasing IT was found to be a risk factor for graft failure (HR: 1.08, 95% CI: 1.00-1.16, p=0.04). Within this model, primary diagnosis was a predictor of the outcome (p&lt;0.001). Exploring this association, an IT of &gt; 6 hours was associated with graft failure in cardiomyopathy (HR: 2.87, 95% CI: 1.34 - 6.15, p=0.007), but not congenital heart disease patients. Conclusions: In this large multi-centre cohort study, we found a deleterious association between prolonged IT and post-transplant outcomes. We recommend that an IT greater than 6 hours should be avoided in pediatric cardiac transplantation.

Impella 5.0 Reduces Vasoactive Agents In Cardiogenic Shock

Introduction Mortality remains high in cardiogenic shock (CS) despite recent emphasis on multidisciplinary approach with early identification and initiation of mechanical circulatory support (MCS). The microaxial ventricular assist device (VAD), Impella 5.0® (Abiomed, Danvers, MA), is an acute MCS device effective in unloading the left ventricle and providing circulatory support to facilitate cardiac recovery or bridge to durable therapies. Escalation in pharmacologic support of CS with vasopressors and inotropes have been associated with increased mortality. We evaluated the impact of the early use of Impella 5.0 in CS with respect to vasoactive agent requirements and clinical outcomes. Methods Retrospective analysis was performed on 14 consecutive patients in CS admitted to the University of Pittsburgh Medical Center between Jan. 2019 - March 2020 implanted with Impella 5.0. Hemodynamic data was collected pre-implantation and up to 72 hours post-implantation. The Vasoactive-Inotropic Score (VIS) and an adjusted Catecholamine Equivalent (CE) score were used to quantify vasopressor and inotrope use for cardiovascular support. Results Most patients were male (86%) with a mean age of 55 ± 11.0 years. Etiologies of CS were acute myocardial infarction (29%) and decompensated heart failure (71%). Use of Impella 5.0 was associated with a reduction in RAP, mPAP, and PCWP that was apparent after 4 hours and continued up to 72 hours post-implantation (RAP: 18 [12, 23], 9 [7, 14], 12 [7, 15]; mPAP: 40 [37, 48], 29 [26, 34], 30 [25, 31]; PCWP: 32 [28, 37], 23 [15, 26], 21 [18, 23] at pre-implantation, 4, and 72 hours after implantation respectively). An immediate and sustained increase in CI, CPO, and PAPi was also demonstrated up to 72 hours (CI: 1.79 [1.38, 2.09], 2.31 [1.93, 2.83], 2.5 [2.04, 2.75]; CPO: 0.54 [0.44, 0.81], 0.8 [0.66, 1.08], 0.80 [0.69, 0.92]; PAPi: 1.26 [0.90, 1.73], 2.145 [1.32, 2.81], 2.0 [1.23, 2.57] at pre-implantation, 4, and 72 hours after implantation respectively). The mean number of vasopressor and inotropes at 72 hours were reduced from 1.92 to 1, along with a sustained reduction in the VIS and CE scores up to 72 hours (Figure 1). The burden of ventricular arrhythmias also decreased post-implantation. Survival occurred in 11 patients (78.6%), with all being discharged from the hospital. Two patients received heart transplants, six received durable LVADs, and three recovered. Conclusions Early initiation of acute MCS with Impella 5.0 in CS is associated with an improvement in hemodynamic parameters and a reduction in vasoactive agents as demonstrated by the VIS and CE score, with favorable clinical outcomes.

Outcomes of Heart Transplantation in Cardiac Amyloidosis Patients: A Single Center Experience

BackgroundIndications for heart transplantation are expanding to include amyloid light chain (AL) and transthyretin-related (TTR) amyloidosis. Previously, AL amyloid had been a contraindication to heart transplantation given inferior outcomes. These patients typically have biventricular failure requiring mechanical circulatory support (MCS). We report the outcomes of patients with end-stage cardiac amyloidosis who underwent cardiac transplantation, including some who were bridged to transplantation with a durable biventricular MCS MethodsThe records for patients with cardiac amyloidosis who underwent cardiac transplant between 2010 and 2018 were reviewed. Primary endpoint was post-transplant 1-year survival. Secondary endpoints included 1-year freedom from cardiac allograft vasculopathy (as defined by stenosis ≥ 30% by angiography), nonfatal major adverse cardiac events (myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and any rejection. ResultsA total of 46 patients received heart transplantation with a diagnosis of either AL or TTR amyloidosis. Of these, 7 patients were bridged to transplantation with a durable biventricular MCS device (6 AL, 1 TTR) and 39 patients were transplanted without MCS bridging. The MCS group consisted of 5 total artificial hearts and 2 biventricular assist devices. The 1-year survival was 91% for the entire cohort, 83% for those with AL amyloidosis, 94% for those with TTR amyloidosis, and 86% for those who received MCS bridging. ConclusionsCardiac transplantation can be safely performed in selected amyloidosis patients with reasonable short-term outcomes. Those bridged to transplantation with biventricular MCS appear to have short-term outcomes similar to those transplanted without MCS. Larger numbers and longer observation are required to confirm these findings.

Long-term follow-up of patients supported with the HeartWare left ventricular assist system.

The aim of the present study is to report our long-term experience with the HeartWare Ventricular Assist System (HVAD). Between July 2009 and February 2018, a total of 103 patients (mean age 50.0±14.4, range 28-74years; 22 females) received HVAD implantation in a single center institution. A total of 26 (25.4%) patients were in cardiogenic shock preoperatively and received extracorporeal life support (ECLS) prior to HVAD implantation. The aim of left ventricular assist device (LVAD)implantation was bridge to transplantation (BT) in 59 (57.3%), destination therapy (DT) in 28 (27.2%), and bridge to decision in16 (15.5%). There were 211.1 total patient years of support. Mean survival was 2.05±2.14years. Kaplan-Meier analysis showed an overall survival rate of 69.7%, 56.7%, 46.0%, and 25.0% at 1, 2, 4, and 8years, respectively. A total of 23 patients (22.3%) died during the hospital stay. Of them 65.2% (15 patients) were preoperatively in cardiogenic shock (INTERMACS 1). Sub-analysis of the BT patients showed a mean survival of 2.45±2.29years with a survival rate of 85.1%, 75.1%, 67.2%, and 44.8% at 1, 2, 4, and 8years, respectively. Among them, 20 patients received heart transplantation on follow-up. Mean survival of DT patients was 2.18±1.91years with a survival rate of 67.9%, 49.0%, and 25.1% at 1, 2, and 4years, respectively. At latest follow-up in September 2018, 26 patients (25.24%) were still on LVAD. A total of five patients completed 6years on LVAD, of them two were supported over 8years. The most common adverse event reported was gastrointestinal bleeding requiring rehospitalization (0.161 EPPY). A total of 19 patients reported disabling stroke. Pump thrombosis was diagnosed in six patients (5.8%) (0.02 EPPY), of them four patients underwent pump exchange. To the best of our knowledge, this is the longest experience with HVAD reported so far. Patients supported with an HVAD show a satisfactory long-term survival. Further multicenter evaluations are needed to confirm these single-center results.

Intermediate Survival Outcomes after Heart Transplantation Using Donor HCV NAT Positive Hearts

The availability of hepatitis C (HCV) antiviral therapy has made transplantation of HCV NAT+ donor hearts a new reality, expanding the pool of donor organs. We report the utilization and outcomes of transplantation of HCV NAT positive (HCV NAT+) hearts recorded in the United Network for Organ Sharing (UNOS) database. 11,252 heart transplant (HT) patients with HCV NAT status were reported by UNOS (2010-2019), of which 274 received an HCV NAT+ donor organ. Survival was evaluated at 24 months post HT. Demographics, comorbidities, hemodynamics were compared using standard statistical methods. Multivariate Cox-proportional hazard regression analysis (adjusted for age, sex, diabetes, ethnicity, ischemic time, dialysis, life support and HLA mismatch) was also performed for survival analysis. 274 patients received heart transplantation from HCV NAT+ donors. No significant difference in survival was identified at 24 months post-transplant (NAT + vs. -: 16.7% vs. 9.3%, p=0.70) despite longer allograft ischemic times in the HCV NAT+ group. HCV NAT+ recipients were older (Mean 53.6 ± 12.7 vs. 55.4 ±11.7 years, p=0.01) and also had older donors (Mean 32.1 ± 11.1 vs. 33.6 ± 8.1 years, p=0.02). Additionally, HCV NAT+ recipients had shorter median waitlist times (Median [inter-quartile range], 86.5 [18.0, 254.0] vs. 100.0 [29.0, 301.0], p=0.002). Multivariate analysis yielded a hazard ratio of 0.87 (CI 0.51-1.48) comparing NAT + to NAT - recipients. Intermediate survival post-transplantation is similar between HCV NAT+ and HCV NAT- recipients. Expansion of the donor pool via the inclusion of HCV NAT+ donors may shorten waitlist times and may extend donor organ availability.

Cardiac Transplantation for Cancer Involving the Heart: Results from 35 Years of Transplants from the ISHLT Registry

Cancer of the heart is rare but lethal. For those few patients with primary or metastatic cardiac malignancy, options for treatment are limited. Heart transplantation as a treatment for cardiac malignancy has been suggested by several small case series but outcomes data are scarce. We present a series of 104 heart transplants performed for any cancer involving the heart from 1982 to 2017 from the International Society of Heart and Lung Transplant (ISHLT) Thoracic Organ Transplant Registry. 104 heart recipients were identified with cancer as the indication for transplant. We performed Kaplan-Meier survival analyses matching the 104 cancer patients with 104 patients receiving heart transplants for hypertrophic cardiomyopathy (HCM) because both cohorts are young with few co-morbidities. Matching was based on age, gender and transplant year. Median survival in the cancer cohort was 3.6 years (95% Confidence Interval (CI) = 1.2,7.2) compared to 17.5 (CI 16.6, 19.0) years in the matched HCM group (Table). Mortality was not significantly different at 30 days, but at the end of 5 years, more than half of the cancer patients were dead (Figure). 27 of these deaths were due to cancer. In the Cox-proportional hazards model, transplant for cardiac malignancy correlated with mortality (HR=1.8 (CI=1.1-3.1), p=0.02). This study presents the largest retrospective series to date of heart transplantations performed for cancer. These patients had significantly increased mortality due to tumor recurrence. This raises a concern about allocating donor hearts for malignancy.

Outcomes of Heart Transplantation from Hepatitis C Seropositive Donors: An Updated Analysis of the United Network for Organ Sharing Registry

Hepatitis C (HCV) has become readily treatable in the modern era. The use of HCV+ organs for transplant has shown promising results and increases donor availability. This study is an updated analysis of outcomes after HCV+ heart transplantation in the United States. The United Network for Organ Sharing registry was queried for adult patients who received heart transplants from 2015-2018. Excluded multiorgan transplants, incomplete HCV data, and loss to follow-up. HCV status was classified by serology (Ab+ vs Ab-). Median follow-up was 24 months. During the study period, 7529 patients received heart transplants: 136 from HCV Ab+ donors and 7393 from HCV Ab- donors. Seven recipients (5.1%) of HCV Ab+ hearts had HCV+ serology prior to transplant, compared to 129 recipients (1.7%) of HCV Ab- organs (p=0.018). There was no difference in donor age (p=0.489), ejection fraction (p=0.221), gender mismatch (p=0.341), or ABO compatibility (p=0.707). HCV Ab+ transplants involved further travel (mean: 323 vs 149 miles, p<0.001) with longer ischemic times (mean: 3.55 vs 3.03 hours, p<0.001) due to regional variation in use of HCV+ organs. Kaplan Meier analysis showed no effect of HCV status on overall survival (p=0.960), and no difference in graft failure (p=0.700). On multivariate Cox regression, HCV status was not a significant predictor of mortality (HR 0.85, 95% CI 0.47-1.56, p=0.601), while overall mortality was affected by HLA mismatch (HR 1.07, 95% CI 1.00-1.14, p= 0.037), donor age (HR 1.01, 95% CI 1.00-1.02, p=0.002), recipient creatinine (HR 1.07, 95% CI 1.04-1.12, p<0.001), and use of ECMO (HR 3.27, 95% CI 2.08-5.12, p<0.001) or a ventricular assist device (HR 1.23, 95% 1.08-1.41, p=0.003) at the time of transplant. Transplantation of HCV+ donor hearts has demonstrated promising outcomes thus far, with comparable overall survival and graft outcomes. Ongoing investigation is warranted to observe long-term outcomes.