Patients Undergoing Heart Transplantation Research Articles

Abstract 9588: Intraplaque Myeloperoxidase Activity is a Hallmark of Vulnerable Atherosclerosis and Correlates With Clinical Outcomes

Introduction: There remains limited means by which to detect unstable atherosclerosis in patients at risk of myocardial infarction and stroke. Myeloperoxidase (MPO) is increased in unstable plaque and causally linked to plaque destabilization and rupture in pre-clinical models. We sought to assess whether MPO activity is greater in vulnerable human carotid and coronary atheroma, and how this relates to adverse cardiovascular events and non-invasive imaging parameters. Methods: Carotid endarterectomy specimens (CEA) were collected from 31 patients. Coronary trees were collected from 12 patients undergoing heart transplantation for ischemic cardiomyopathy. MPO activity was assessed through the conversion of hydroethidine added to tissue sections to the MPO-specific adduct 2-chloroethidium (2-Cl-E + ) and quantified by mass spectrometry. MPO activity was then compared with histologic determination of plaque phenotype and clinical outcomes. MPO activity was additionally assessed in high and low attenuation plaques derived by computed tomography, as well as perivascular adipose tissue (PVAT). Results: Unstable CEA had higher MPO activity when compared with stable CEA plaques (n = 26, 4.2 ± 3.1 vs. 0.2 ± 0.3 μmol/mgp; p < 0.0001). Similar results were seen in coronary segments with unstable compared to stable plaque (n = 17, 0.6 ± 0.5 vs. 0.0 ± 0.0 μmol/mgp; p = 0.0006). When comparing MPO activity in CEA to clinical outcomes, asymptomatic and stroke-free patients had lower MPO activity compared to those with symptoms or ipsilateral stroke on neuroimaging (n = 12, 3.7 ± 2.1 vs. 0.1 ± 0.2 μmol/mgp; p = 0.002). CT-determined plaque attenuation did not identify plaque MPO activity (n = 30, 0.1 ± 0.1 vs. 0.2 ± 0.3 μmol/mgp; p = 0.23) and enzymatically active MPO was not found in PVAT. Conclusion: MPO is active within unstable human carotid and coronary plaques and correlates with symptomatic carotid disease and stroke. In addition, current non-invasive imaging parameters do not selectively identify plaques enriched with active MPO. As intraplaque MPO appears to be a hallmark of unstable atherosclerosis and can potentially be imaged non-invasively, further investigation into its potential utility as a diagnostic tool for high-risk atherosclerosis is warranted.

Abstract 11945: Improved Outcomes in Severe Primary Graft Dysfunction Following Heart Transplantation With Donation After Circulatory Death Compared to Donation After Brain Death

Introduction: Primary graft dysfunction (PGD), the leading cause of early mortality after heart transplant, is more common following heart donation after circulatory death (DCD) than following donation after brain death (DBD). We conducted a single-center, retrospective cohort study to compare the incidence, severity, and outcomes of patients experiencing PGD after DCD compared to DBD heart transplant. Methods: We reviewed the medical records of all adult heart transplant recipients at our institution between March 2016 and December 2021. Patients undergoing multi-organ transplant were excluded. PGD was diagnosed within 24 hours after transplant according to modified ISHLT criteria and was classified by severity and ventricles involved. Results: A total of 459 qualifying patients underwent heart transplant during the study period, of whom 65 (14%) were DCD recipients and 394 (86%) were DBD recipients. The incidence of PGD in DCD and DBD recipients was 34% and 23%, respectively (p = 0.070). DCD recipients were more likely to experience severe, biventricular PGD than DBD recipients (19% vs. 7.3%, p = 0.004). Among patients with severe PGD, DCD recipients experienced shorter duration of mechanical circulatory support (ECMO, VAD, or balloon pump; mean 6.0 ± 2.5 vs. 12.1 ± 11.3 days, p = 0.039; Figure), shorter post-transplant hospital length of stay (32.4 ± 41.1 vs. 61.9 ± 47.7 days, p = 0.004), and a trend toward improved 60-day survival (100% vs. 80%, p = 0.170) and one-year survival (92% [95% CI: 76%-100%] vs. 69% [53%-84%]). Conclusions: DCD heart transplant recipients were more likely to experience severe, biventricular PGD than DBD recipients. Despite this, short- and medium-term outcomes among patients with severe PGD were improved in DCD compared to DBD recipients. These data suggest different mechanisms of graft dysfunction and recovery following DCD compared to DBD and support the expansion of the heart donor pool with DCD in most potential recipients.

Sex differences in patients undergoing heart transplantation and LVAD therapy

ABSTRACT Introduction Left ventricular assist device (LVAD) and heart transplantation (HT) are the two life-sustaining therapies that have revolutionized the management of end-stage heart failure (HF). Yet, significant sex differences exist with respect to their use and effects. Areas Covered This review summarizes sex differences in the utilization, outcomes, and complications of LVAD and HT. Particular emphasis is placed on leading clinical trials in the field, historical and recent large registries-based analyses, as well as contemporary technological and policy changes affecting these differences. Expert Opinion Women with advanced HF remain under-treated with guideline-directed medical therapy and are less likely to be referred for consideration for LVAD and HT. This remains true despite newer LVAD technology and the new heart transplant allocation system. Community outreach, education, as well as increased representation of women in clinical research may reduce inequities.

Reduction of Intra-Operative Nephrotoxic Antimicrobial Exposure Can Improve Renal Recovery in Patients Undergoing Heart Transplantation

Reduction of Intra-Operative Nephrotoxic Antimicrobial Exposure Can Improve Renal Recovery in Patients Undergoing Heart Transplantation

The effect of anticoagulation therapy on perioperative bleeding risk in patients undergoing heart transplantation

The effect of anticoagulation therapy on perioperative bleeding risk in patients undergoing heart transplantation

Cellular Landscapes of Nondiseased Human Cardiac Valves From End-Stage Heart Failure-Explanted Heart.

Exploring the mechanisms of valvular heart disease at the cellular level may be useful to identify new therapeutic targets; however, the comprehensive cellular landscape of nondiseased human cardiac valve leaflets remains unclear. The cellular landscapes of nondiseased human cardiac valve leaflets (5 aortic valves, 5 pulmonary valves, 5 tricuspid valves, and 3 mitral valves) from end-stage heart failure patients undergoing heart transplantation were explored using single-cell RNA sequencing. Bioinformatics was used to identify the cell types, describe the cell functions, and investigate cellular developmental trajectories and interactions. Differences among the 4 types of cardiac valves at the cellular level were summarized. Pathological staining was performed to validate the key findings of single-cell RNA sequencing. An integrative analysis of our single-cell data and published genome-wide association study-based and bulk RNA sequencing-based data provided insights into the cell-specific contributions to calcific aortic valve diseases. Six cell types were identified among 128 412 cells from nondiseased human cardiac valve leaflets. Valvular interstitial cells were the largest population, followed by myeloid cells, lymphocytes, valvular endothelial cells, mast cells, and myofibroblasts. The 4 types of cardiac valve had distinct cellular compositions. The intercellular communication analysis revealed that valvular interstitial cells were at the center of the communication network. The integrative analysis of our single-cell RNA sequencing data revealed key cellular subpopulations involved in the pathogenesis of calcific aortic valve diseases. The cellular landscape differed among the 4 types of nondiseased cardiac valve, which might explain their differences in susceptibility to pathological remodeling and valvular heart disease.

Heart transplantation for COVID-19 myopathy in the United States

Evidence on characteristics and outcomes of patients undergoing heart transplantation for coronavirus disease 2019 (COVID-19) associated cardiomyopathy is limited to case reports. Of all 6332 patients aged ≥18 years undergoing heart transplant from July 2020 through May 2022 in the United Network for Organ Sharing database, 12 (0.2%) patients had COVID-19 myocarditis and 98 (1.6%) patients with the same level of care had non-COVID-19 myocarditis. Their median age was 49 (range 19-74) years. All patients were hospitalized in the intensive care unit and 92.7% (n=102) were on life support prior to transplantation. No patients with COVID-19 myocarditis required ventilation whilst waitlisted. Survival free from graft failure was 100% among COVID-19 patients and 88.5% among non-COVID-19 patients at a median of 257 (range 0-427) days post-transplant. These findings indicate that transplantation is rarely performed for COVID-19 related cardiomyopathy in the United States, yet early outcomes appear favorable in select patients.

Gender mismatch and outcomes following heart transplantation in the United States

Abstract Background Available literature indicates the possible detrimental effect of gender mismatching on mortality in patients undergoing heart transplantion. Our objective was to examine the role of gender mismatching on mortality and graft rejection in patients undergoing heart transplantation in the US. Methods Data on adult patients January who underwent heart transplantation between January 2015 and October 2021, was queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were all-cause mortality, 1-year all-cause mortality and treated acute rejection. Results A total of 19,805 adult patients underwent heart transplant during the study period. Approximately, one out of ten patients in the M-F group had a PHM mismatch<25%, while only four out of ten patients had such a mismatch in the F-M group. In both M-M and F-F groups, seven out of ten patients had a PHM mismatch<25% (p=0.122). Proportion of PHM mismatch was similar throughout the study period. Unadjusted analysis showed that M-F was associated with increased risk for all-cause mortality (HR: 1.13; 95% CI: 1.02, 1.27; p=0.026) and 1-year mortality (HR: 1.26; 95% CI: 1.09, 1.45; p=0.002) compared to M-M. Graft failure incidence was higher in the M-F group compared to M-M (HR: 1.12; 95% CI: 1.01, 1.25; p=0.041). Conclusions Gender mismatching is associated with post-transplant mortality with transplantation of female donor grafts to male recipients demonstrating worse outcomes. Further research is required to elucidate pathways involved and possible changes in clinical practice. Funding Acknowledgement Type of funding sources: None.

S1237 Association of Liver Biopsy Pathology on Outcome of Patients Undergoing Heart Transplantation

Introduction: Patients with advanced heart failure needing heart transplant (HT) commonly have some degree of liver dysfunction. Liver biopsies are the gold-standard for evaluating the severity of liver disease and are commonly performed prior to listing a patient for HT. However, there is limited data on the impact of liver fibrosis on outcomes for HT candidates. The objective of this study was to determine the relationship between liver fibrosis severity and mortality rates for patients on the HT waitlist and post-HT. Methods: A retrospective cohort study of adults listed for HT who underwent a liver biopsy for evaluation of liver fibrosis from 08/12/2004-02/16/2022 at a large heart transplant center was performed. Degree of fibrosis was categorized as either early (only fibrosis expansion of portal areas with or without short fibrous septa or no fibrosis) or advanced (evidence of portal-to-portal bridging or cirrhosis). Trend analysis was performed on clinical, laboratory and mortality data using Cox proportional hazard model, controlling for MELD-XI. At-risk period starts at the time of waitlist and extends into the post-transplant phase. The end of the follow-up period was defined as mortality on the waitlist, mortality post-HT, or administrative censoring at the end of the study period. Results: Of 42 patients with liver biopsies, 14 (33%) had advanced fibrosis, 28 (67%) had early fibrosis, and 2 (5%) patients had cirrhosis. There was no significant difference in the survival of patients with advanced fibrosis and early fibrosis over time (HR 1.37, CI 0.47- 3.98, p = 0.56). Fifteen waitlisted patients did not eventually receive transplants, and there was no significant difference in survival within group (HR 0.65, CI 0.18-2.32, p = 0.51); 9 of these 15 patients died on the waitlist. Twenty-seven patients did eventually receive transplants, and there was no significant difference in survival within this group (HR 1.00, CI 0.09-11.43, p = 1.00). (Figure) Conclusion: There was no significant difference in the survival rates between HT candidates with and without advanced fibrosis on the waitlist and post-HT, suggesting that patients on the transplant waitlist may not need liver biopsy for heart transplant workup. However, our sample population was derived from patients who were already on the transplant waitlist. Therefore, our results cannot be extrapolated to the general advanced heart failure population undergoing HT evaluation, many of whom are not waitlisted due to cirrhosis (Table). Table 1. - Predicted survival percentages for transplanted patients, non-transplanted patients, and both groups combined at 30 days, 1 year and 5 years with early liver fibrosis or advanced liver fibrosis from time of listing Transplanted Patients (% [CI]) Non-transplanted Patients (% [CI]) Transplanted and Non-transplanted Patients (% [CI]) Early Liver Fibrosis 30 Days 100 (0-100) 84.6 (66.0-100) 95.8 (90.0-100) 1 Year 96.2 (88.8-100) 53.5 (29.2-97.9) 84.5 (73.2-97.4) 5 Years 88.1 (74.6-100) 17.3 (3.6-84.0) 68.2 (52.4-88.9) Advanced Liver Fibrosis 30 Days 100 (0-100) 89.7 (75.7-100) 94.3 (86.1-100) 1 Year 96.2 (86.6-100) 66.6 (42.4-100) 79.3 (63.0-99.9) 5 Years 88.2 (67.4-100) 32.1 (9.8-100) 59.2 (37.6-93.1) CI = confidence interval. Figure 1.: (1) Survival curve of waitlisted patients with and without advanced liver fibrosis, including patients who received and did not receive transplants. Time 0 is the time of listing. Fibrosis score 0 = early liver fibrosis. Fibrosis score 1 = advanced liver fibrosis. (2). Survival curve of only those patients who did not receive transplants. Time 0 is the time of listing. Fibrosis score 0 = early liver fibrosis. Fibrosis score 1 = advanced liver fibrosis. (3) Survival curve of only those patients who received transplants. Time 0 is the time of listing. Fibrosis score 0 = early liver fibrosis. Fibrosis score 1 = advanced liver fibrosis.

Sex mismatch following heart transplantation in the United States: Characteristics and impact on outcomes.

Available literature indicates the possible detrimental effect of sex mismatching on mortality in patients undergoing heart transplantation. Our objective was to examine the role of sex and heart mass (predicted heart mass [PHM]) mismatch on mortality and graft rejection in patients undergoing heart transplantation in the US. Data on adult patients who underwent heart transplantation between January 2015 and October 2021 were queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were all-cause mortality, 1-year all-cause mortality and treated acute rejection. A total of 19805 adult patients underwent heart transplant during the study period. 92.2% of the patients in the female graft to male group had a PHM mismatch <25%, while only 38.5% had such a mismatch in the male graft to female group. In male to male and female to female groups, 79% and 76% of the patients had a PHM mismatch <25% (p=.122). Proportion of PHM mismatch was similar throughout the study period. Unadjusted analysis showed that male recipients of female grafts had increased risk for all-cause mortality (hazard ratio [HR]: 1.13; 95% confidence intervals [CI]: 1.02, 1.27; p=.026) and 1-year mortality (HR: 1.26; 95% CI: 1.09, 1.45; p=.002) compared to male recipients of male grafts. Graft failure incidence was also higher (HR: 1.12; 95% CI: 1.01, 1.25; p=.041). However, all these associations were non- significant after risk factor adjustment. Sex mismatching is associated with post-transplant mortality with transplantation of female donor grafts to male recipients demonstrating worse outcomes, although this association disappears after risk factor adjustment. Further research is required to elucidate the need for potential changes in clinical practice.

Heart transplantation after total artificial heart bridging-Outcomes over 15 years.

Data are limited on outcomes after heart transplantation in patients bridged-to-transplantation (BTT) with a total artificial heart (TAH-t). The UNOS database was used to identify 392 adult patients undergoing heart transplantation after TAH-t BTT between 2005 and 2020. They were compared with 11014 durable left ventricular assist device (LVAD) BTT patients and 22348 de novo heart transplants (without any durable VAD or TAH-t BTT) during the same period. TAH-t BTT patients had increased dialysis dependence compared to LVAD BTT and de novo transplants (24.7%vs. 2.7%vs. 3.8%) and higher levels of baseline creatinine and total bilirubin (all p<.001). After transplantation, TAH-t BTT patients were more likely to die from multiorgan failure in the first year (25.0%vs. 16.1%vs. 16.1%, p=.04). Ten-year survival was inferior in TAH-t BTT patients (TAH-t BTT 53.1%, LVAD BTT 61.8%, De Novo 62.6%, p<.001), while 10-year survival conditional on 1-year survival was similar (TAH-t BTT 66.8%, LVAD BTT 68.7%, De Novo 69.0%, all p>.20). Among TAH-t BTT patients, predictors of 1-year mortality included higher baseline creatinine and total bilirubin, mechanical ventilation, and cumulative center volume <20 cases of heart transplantation involving TAH-t BTT (all p<.05). Survival after TAH-t BTT is acceptable, and patients who survive the early postoperative phase experience similar hazards of mortality over time compared to de novo transplant patients and durable LVAD BTT patients.

Hypoplastic Left Heart Syndrome Palliation: Technical Aspects and Common Pitfalls of the Hybrid Approach.

The Giessen hybrid strategy is used for initial palliation of HLHS and variants when the intent is to pursue further staged palliative reconstruction toward Fontan circulation. It is also used for initial palliation of HLHC and other anomalies with potential for eventual biventricular repair. From June 1998 - October 2021, 197 patients with HLHS and related variants underwent hybrid stage 1. Follow-up is complete (median 8.3 [range 0-23.3] years). Operative mortality for hybrid stage I was 3.6% (7/197); reduced to 2.8% since 2010 (4/141). Interstage mortality was 4.1% (8/197). Operative mortality for comprehensive stage II was 5.8% (10/172), and since 2010 was 1.8% (2/113 patients). Fontan completion has been accomplished in 117 patients, and 33 are still awaiting stage III. Twelve patients underwent heart transplantation. Over 23 years, overall survival is 77.7% and transplant-free survival is 73.6%.

A Case Report on Application of Multimodal Imaging to an Alcoholic Cardiomyopathic Patient Undergoing Heart Transplantation

Alcoholic cardiomyopathy (ACM) is a dilated cardiomyopathy induced by excessive alcohol consumption that causes progressive cardiac dysfunction and chamber dilatation, leading to arrhythmias, heart failure, and death. Cardiac transplantation is the final measure for end-stage ACM. In this case, we used multimodal imaging for ACM diagnosis in a patient with refractory heart failure. The patient received a heart transplant with a good prognosis, and his pathological results after the transplant confirmed our suspected diagnosis. End-stage ACM may lead to refractory heart failure and multimodal imaging may play an important role in the diagnosis, prognosis prediction, and follow-up study of suspected ACM.

1035 Gender Equality in Heart Transplantation: A Single Centre Study

Abstract Background International Society for Heart and Lung Transplantation catergoirises female gender in donor/recipient, as a significant risk factor for mortality after heart transplantation. Further, donor-recipient gender mismatch is also reported to be a determinant of post-transplant morbidity/mortality. To examine the effect of gender in survival outcomes, we conducted a retrospective study. Method Population comprised of 298 patients undergoing heart transplantation from 2001 to 2021, divided into four groups on the basis of donor and recipient matching. Group A consisted of men who received male donor-hearts, group B of women who received female donor-hearts, group C of women who received male donor-hearts, and group D of men who received female donor-hearts. Standard heart transplantation protocols were applied to all patient groups for graft preservation, surgical technique, donor-recipient size matching, induction &amp; immunosuppressive therapy. Results The study groups were found to be homogeneous to the major preoperative- risk- factors (aetiology, transplantation status, donor-recipient-age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery, and primary graft dysfunction post-surgery. Conclusions Even though previous reports suggest that gender negatively affects survival, this proved to have no influence on the outcomes in our study. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients’ tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.

1036 Gender Equality in Heart Transplantation: A Single Centre Study

Abstract Background International Society for Heart and Lung Transplantation categorises female gender in donor/recipient, as a significant risk factor for mortality after heart transplantation. Further, donor-recipient gender mismatch is also reported to be a determinant of post-transplant morbidity/mortality. To examine the effect of gender in survival outcomes, we conducted a retrospective study. Method Population comprised of 298 patients undergoing heart transplantation from 2001 to 2021, divided into four groups on the basis of donor and recipient matching. Group A consisted of men who received male donor-hearts, group B of women who received female donor-hearts, group C of women who received male donor-hearts, and group D of men who received female donor-hearts. Standard heart transplantation protocols were applied to all patient groups for graft preservation, surgical technique, donor-recipient size matching, induction &amp; immunosuppressive-therapy. Results The study groups were found to be homogeneous to the major preoperative- risk- factors (aetiology, transplantation status, donor-recipient-age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery, and primary graft dysfunction post-surgery. Conclusions Even though previous reports suggest that gender negatively affects survival, this proved to have no influence on the outcomes in our study. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients’ tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.

Comparison of Four Machine Learning Techniques for Prediction of Intensive Care Unit Length of Stay in Heart Transplantation Patients.

BackgroundPost-operative heart transplantation patients often require admission to an intensive care unit (ICU). Early prediction of the ICU length of stay (ICU-LOS) of these patients is of great significance and can guide treatment while reducing the mortality rate among patients. However, conventional linear models have tended to perform worse than non-linear models.Materials and MethodsWe collected the clinical data of 365 patients from Wuhan Union Hospital who underwent heart transplantation surgery between April 2017 and August 2020. The patients were randomly divided into training data (N = 256) and test data (N = 109) groups. 84 clinical features were collected for each patient. Features were validated using the Least Absolute Shrinkage and Selection Operator (LASSO) regression’s fivefold cross-validation method. We obtained Shapley Additive explanations (SHAP) values by executing package “shap” to interpret model predictions. Four machine learning models and logistic regression algorithms were developed. The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the prediction performance of different models. Finally, for the convenience of clinicians, an online web-server was established and can be freely accessed via the website https://wuhanunion.shinyapps.io/PredictICUStay/.ResultsIn this study, 365 consecutive patients undergoing heart transplantation surgery for moderate (NYHA grade 3) or severe (NYHA grade 4) heart failure were collected in Wuhan Union Hospital from 2017 to 2020. The median age of the recipient patients was 47.2 years, while the median age of the donors was 35.58 years. 330 (90.4%) of the donor patients were men, and the average surgery duration was 260.06 min. Among this cohort, 47 (12.9%) had renal complications, 25 (6.8%) had hepatic complications, 11 (3%) had undergone chest re-exploration and 19 (5.2%) had undergone extracorporeal membrane oxygenation (ECMO). The following six important clinical features were selected using LASSO regression, and according to the result of SHAP, the rank of importance was (1) the use of extracorporeal membrane oxygenation (ECMO); (2) donor age; (3) the use of an intra-aortic balloon pump (IABP); (4) length of surgery; (5) high creatinine (Cr); and (6) the use of continuous renal replacement therapy (CRRT). The eXtreme Gradient Boosting (XGBoost) algorithm presented significantly better predictive performance (AUC-ROC = 0.88) than other models [Accuracy: 0.87; sensitivity: 0.98; specificity: 0.51; positive predictive value (PPV): 0.86; negative predictive value (NPV): 0.93].ConclusionUsing the XGBoost classifier with heart transplantation patients can provide an accurate prediction of ICU-LOS, which will not only improve the accuracy of clinical decision-making but also contribute to the allocation and management of medical resources; it is also a real-world example of precision medicine in hospitals.

Long-Term Benefit of Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with a Left Ventricular Assist Device: A Single-Center Retrospective Study

Left ventricular assist devices (LVADs) are an epoch-making treatment option for patients with severe heart failure; however, the patients occasionally experience severe acute ischemic strokes (AISs). Although mechanical thrombectomy is considered as an effective treatment for severe AIS in patients with LVADs, there remains a paucity of data on the long-term outcomes. This study aimed to investigate the acute-phase efficacy and long-term outcomes of mechanical thrombectomy for AIS patients with LVADs. We retrospectively reviewed 9 cases in 8 patients with LVADs who developed AIS and underwent mechanical thrombectomy from July 2014 to November 2021 at our hospital. Clinical information, including the National Institutes of Health Stroke Scale score and modified Rankin Scale score before and after thrombectomy, the details of procedures, and the long-term outcomes after thrombectomy, was retrospectively reviewed and statistically analyzed. Effective recanalization was achieved in 89% of the 9 cases. The median National Institutes of Health Stroke Scale score improved from 12 (range, 8-29) to 5 (range, 0-29) after mechanical thrombectomy. The median total follow-up duration was 1327 (range, 78-2659) days. Of the 8 patients, 3 patients underwent heart transplantation, and the LVAD was removed after recovery of the patient's heart function. One patient awaited heart transplantation. This study revealed the long-term benefit of mechanical thrombectomy for AIS in patients with LVADs, eventually achieving 50% of independence from LVADs.

Ischemic Versus Nonischemic Recipient Indication Does Not Impact Outcome After Heart Transplantation.

Heart transplant is the treatment of choice for patients with end-stage heart failure who remain symptomatic despite optimal medical therapy. The primary indications for heart transplant worldwide have been nonischemic cardiomyopathy and ischemic cardiomyopathy. For the 2 indications, patients differ in underlying pathomechanisms leading to their disease and consecutively in relevant comorbidities. However, the influence of an indication of ischemic or nonischemic cardiomyopathy for heart transplant on recipient outcomes posttransplant remains controversial. Here, we investigated whether ischemic or nonischemic cardiomyopathy indication were associated with patient morbidity and mortality after heart transplant. We included all patients undergoing heart transplant in our center between September 2010 and June 2021 (n = 218). Recipients were divided into 2 groups related to their indication: ischemic (n = 92; 42%) and nonischemic cardiomyopathy (n = 126; 58%). Recipient and donor variables were reviewed and compared, including peri- and postoperative characteristics and recipient survival up to 5 years posttransplant. Although patients with nonischemic cardiomyopathy were significantly younger (51.7 vs 59.1 years; P < .001), had fewer previous cardiac surgeries (56% vs 75%; P = .01), and less frequent severe infections or sepsis (19% vs 32%; P = .03), other outcome-related parameters such as need for extracorporeal life support posttransplant (26% vs 33%), rejection within index stay (7% vs 8%), and survival after 30 days (88% vs 92%), 90 days (85% vs 88%) or 1 year (76% vs 77%) were different. In this retrospective analysis, although barring different baseline characteristics, ischemic versus nonischemic recipient diagnosis was not associated with outcome or survival after heart transplant.

Clinical characteristics and survival of children with hypertrophic cardiomyopathy in China: A multicentre retrospective cohort study.

SummaryBackgroundFew data on paediatric hypertrophic cardiomyopathy (HCM) are available in developing countries. A multicentre, retrospective, cohort study was conducted to profile the clinical characteristics and survival of children with HCM in China.MethodsWe collected longitudinal data on children with HCM aged 0–18 years at three participating institutions between January 1, 2010 and December 31, 2019. Patients were identified by searching for the diagnosis using ICD-10 codes from the electronic medical records database. HCM was diagnosed morphologically with echocardiography or cardiovascular magnetic resonance imaging. The exclusion criteria were secondary aetiologies of myocardial hypertrophy. The primary outcomes were all-cause death or heart transplantation. The Kaplan–Meier method was used to estimate the survival rate of different groups.FindingsA total of 564 children were recruited, with a median age at diagnosis of 1.0 year (interquartile range, IQR: 0.4–8.0 years), followed for a median of 2.6 years (1977 patient-years, IQR:0.5, 5.9 years). The underlying aetiology was sarcomeric (382, 67.7%), inborn errors of metabolism (IEMs) (108, 19.2%), and RASopathies (74, 13.1%). A total of 149 patients (26.4%) died and no patients underwent heart transplantation during follow-up. The survival probability was 71.1% (95% confidence interval [CI], 66.3%–75.3%) at 5 years. Patients with IEMs or those diagnosed during infancy had the poorest outcomes, with an estimated 5-year survival rate of 16.9% (95% CI, 7.7%–29.1%) and 56.0% (95% CI, 48.8%–62.5%), respectively. Heart failure was the leading cause of death in the cohort (90/149, 60.4%), while sudden cardiac death was the leading cause in patients with sarcomeric HCM (32/66, 48.5%).InterpretationThere is a high proportion of patients with IEM and a low proportion of patients with neuromuscular disease in children with HCM in China. Overall, mortality remains high in China, especially in patients with IEMs and those diagnosed during infancy.FundingNational Natural Science Fund of China (81770380, 81974029), China Project of Shanghai Municipal Science and Technology Commission (20MC1920400, 21Y31900301).

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study.

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.