Underwent Heart Transplantation Research Articles

Trends in the Use of Recombinant Activated Factor VII and Prothrombin Complex Concentrate in Heart Transplant Patients in Virginia

To explore trends in intraoperative procoagulant factor concentrate use in patients undergoing heart transplantation (HTx) in Virginia. Secondarily, to evaluate their association with postoperative thrombosis. Patients who underwent HTx were identified using a statewide database. Trends in off-label recombinant activated factor VII (rFVIIa) use and on-label and off-label prothrombin complex concentrate (PCC) use were tested using the Mantel-Haenszel test. Multivariate logistic regression was used to test for an association between procoagulant factor concentrate administration and thrombosis. Virginia hospitals performing HTx. Adults undergoing HTx between 2012 and 2022. None. Among 899 patients who required HTx, 100 (11.1%) received off-label rFVIIa, 69 (7.7%) received on-label PCC, and 80 (8.9%) received off-label PCC. There was a downward trend in the use of rFVIIa over the 10-year period (p = 0.04). There was no trend in on-label PCC use (p = 0.12); however, there was an increase in off-label PCC use (p < 0.001). Patients who received rFVIIa were transfused more and had longer cardiopulmonary bypass time (p < 0.001). Receipt of rFVIIa was associated with increased thrombotic risk (odds ratio [OR] 1.92; 95% CI 1.12-3.29; p = 0.02), whereas on-label and off-label PCC use had no association with thrombosis (OR 0.98, 95% CI 0.49-1.96, p = 0.96 for on-label use; and OR 0.61, 95% CI 0.29-1.30, p = 0.20 for off-label use). Use of rFVIIa in HTx decreased over the past decade, whereas off-label PCC use increased. Receipt of rFVIIa was associated with thrombosis; however, patients who received rFVIIa were more severely ill, and risk adjustment may have been incomplete.

Plasma Levels of High-sensitivity Cardiac Troponin I and Histopathological Findings in Heart Transplant Patients: A Single-center Cross-sectional Study

Abstract Introduction: This study aimed to evaluate the association between plasma levels of high-sensitivity cardiac troponin I (cTnI) in heart transplant patients and the grading of graft rejection. Methods: In a cross-sectional study, 92 biopsy samples from the patients who had undergone heart transplantation during 2022, at Rajaie Cardiovascular Medical and Research Center, the largest referral center in Tehran, Iran, were evaluated for heart transplant rejection. Transplant rejection grades, high-sensitivity troponin I plasma levels, and the relationship between them were assessed statistically. Results: Forty-two patients (mean age 37 ± 9.6 years, 26 (62%) male) were assessed. The mean transplant age was 3 ± 1.8 years. In terms of graft rejection, 30 (33%) biopsies showed Grade 1R and 4 (4%) showed Grade 2R. Quilty effect was observed in 43 (47%). The median (Q1–Q3) of the cTnI was 0.02 (0.02–0.75) and 43 (47%) had high troponin level (&gt;0.03 ng/mL). A positive association was observed between high cTnI and rejection (P = 0.025). Conclusion: The association between the troponin level and rejection grade suggested the considerable myocardial injury during the rejection process.

Non-inferior outcomes in lower urgency patients transplanted with extended criteria donor hearts

Recent work has suggested that outcomes among heart transplant patients listed at the lower-urgency (United Network for Organ Sharing Status 4 or 6) status may not be significantly impacted by donor comorbidities. The purpose of this study was to investigate outcomes of extended criteria donors (ECD) in lower vs. higher urgency patients undergoing heart transplantation. The United Network for Organ Sharing (UNOS) database was queried for all adult patients undergoing heart transplantation from 10/18/2018 through 12/31/2021. Patients were stratified by degree of urgency (higher urgency: UNOS 1 or 2 vs. lower urgency: UNOS 4 or 6) and receipt of ECD hearts, as defined by donor hearts failing to meet established acceptable use criteria. Outcomes were compared using propensity score matched cohorts. Among 9,160 patients included, 2,320 (25.4%) were low urgency. ECD hearts were used in 35.5% of HU patients and 39.2% of LU patients. While ECD hearts had an impact on survival among high-urgency patients (p<0.01), there was no difference in 1- and 2-year survival (p>0.05) found among low urgency patients receiving ECD vs. standard hearts. Neither ECDs nor individual ECD criteria were independently associated with mortality in low urgency patients (p>0.05). Post-transplant outcomes among low urgency patients are not adversely affected by receipt of ECD vs. standard hearts. Expanding the available donor pool by optimizing use of ECDs in this population may increase transplant frequency, decrease waitlist morbidity, and improve postoperative outcomes for the transplant community at large.

The phenotypic and genetic features of arrhythmogenic cardiomyopathy in the pediatric population.

The present study aimed to describe the phenotypic features and genetic spectrum of arrhythmogenic cardiomyopathy (ACM) presented in childhood and test the validity of different diagnostic approaches using Task Force Criteria 2010 (TFC) and recently proposed Padua criteria. Thirteen patients (mean age at diagnosis 13.6 ± 3.7 years) were enrolled using "definite" or "borderline" diagnostic criteria of ACM according to the TFC 2010 and the Padua criteria in patients <18 years old. Clinical data, including family history, 12-lead electrocardiogram (ECG), signal-averaged ECG, 24-h Holter monitoring, imaging techniques, genetic testing, and other relevant information, were collected. All patients were classified into three variants: ACM of right ventricle (ACM-RV; n = 6, 46.1%), biventricular ACM (ACM-BV; n = 3, 23.1%), and ACM of left ventricle (ACM-LV; n = 4, 30.8%). The most common symptoms at presentations were syncope (n = 6; 46.1%) and palpitations (n = 5; 38.5%). All patients had more than 500 premature ventricular contractions per day. Ventricular tachycardia was reported in 10 patients (76.9%), and right ventricular dilatation was registered in 8 patients (61.5%). An implantable cardiac defibrillator was implanted in 61.5% of cases, and three patients with biventricular involvement underwent heart transplantation. Desmosomal mutations were identified in 8 children (53.8%), including four patients with PKP2 variants, two with DSP variants, one with DSG2 variant, and one with JUP. Four patients carried compound heterozygous variants in desmosomal genes associated with left ventricular involvement. Arrhythmias and structural heart disease, such as chamber dilatation, should raise suspicion of different ACM phenotypes. Diagnosis of ACM might be difficult in pediatric patients, especially for ACM-LV and ACM-BV forms. Our study confirmed that using "Padua criteria" in combination with genetic testing improves the diagnostic accuracy of ACM in children.

Osteoporosis and risk of fracture in heart transplant patients.

Significant bone loss occurs after heart transplantation, predominantly in the first year, with increased risk of incident fractures. The goal of this study was to evaluate the prevalence of fragility fractures in a population of heart transplantation patients and to identify the independent risk factors for fractures. This was a prospective monocentric study that included patients with heart transplantation occurring < 10 years who were undergoing heart transplantation monitoring. All patients underwent bone mineral density evaluation by dual-energy X-ray absorptiometry and radiographies to establish the presence of vertebral fractures. We included 79 patients (61 men); the mean age was 56.8 ± 10.8 years. The mean time between transplantation and inclusion was 32.3 ± 35.0 months. Incident fractures were diagnosed in 21 (27%) patients after heart transplantation. Vertebral fractures were the most frequent (30 vertebral fractures for 15 patients). Osteoporosis was confirmed in 22 (28%) patients. Mean bone mineral density at the femoral neck and total hip was lower with than without fracture (femoral neck: 0.777 ± 0.125 vs 0.892 ± 0.174 g/cm2, p<0.01; total hip: 0.892 ± 0.165 vs 0.748 ± 0.07 g/cm2, p<0.001), with a significant result on multivariate analysis. The mean time from transplantation to the first fracture was 8.0 ± 7.6 months. Our study confirmed a high vertebral fracture risk in heart transplant patients, especially during the first year after transplantation.

Decreased Heart Rate Variability in Children with Acute Decompensated Heart Failure is Associated with Poor Outcomes.

Heart rate variability (HRV) is a noninvasive indicator of the health of neurocardiac interactions of the autonomic nervous system. In adults, decreased HRV correlates with increased cardiovascular mortality. However, the relationship between HRV and outcomes in children with acute decompensated heart failure (ADHF) has not been described. Patients < 21years old hospitalized with ADHF from 2013 to 2019 were included (N = 79). Primary outcome was defined as death, heart transplant, or mechanical circulatory support (MCS). The median standard deviation of the R-to-R interval in 5-min intervals (SDNN) was calculated from telemetry data obtained across the first 24h of admission. Patients who met the primary outcome had significantly lower median SDNN (13.8 [7.8, 29.1]) compared to those who did not (24.6 [15.3, 84.4]; p = 0.004). A median SDNN of 20ms resulted in a sensitivity of 68% and specificity of 69%. Median SDNN < 20ms represented decreased freedom from primary outcome (p = 0.043) and a hazard ratio of 2.2 in multivariate analysis (p = 0.016). Pediatric patients with ADHF who died, underwent heart transplant, or required MCS had significantly decreased HRV at presentation compared to those that did not. This supports HRV as a noninvasive tool to improve prognostication in children in ADHF.

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.

Systemic and local vascular inflammation and arterial reactive oxygen species generation in patients with advanced cardiovascular diseases.

Systemic inflammation may cause endothelial activation, mediate local inflammation, and accelerate progression of atherosclerosis. We examined whether the levels of circulating inflammatory cytokines reflect local vascular inflammation and oxidative stress in two types of human arteries. Human internal mammary artery (IMA) was obtained in 69 patients undergoing coronary artery bypass graft (CABG) surgery and left anterior descending (LAD) artery was obtained in 17 patients undergoing heart transplantation (HTx). Plasma levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) were measured using ELISA, high-sensitivity C-reactive protein (hs-CRP) was measured using Luminex, and mRNA expression of proinflammatory cytokines in the vascular tissues was assessed. Furthermore, formation of superoxide anion was measured in segments of IMA using 5 uM lucigenin-dependent chemiluminescence. Vascular reactivity was measured using tissue organ bath system. TNF-α, IL-6 and IL-1β mRNAs were expressed in all studied IMA and LAD segments. Plasma levels of inflammatory cytokines did not correlate with vascular cytokine mRNA expression neither in IMA nor in LAD. Plasma TNF-α and IL-6 correlated with hs-CRP level in CABG group. Hs-CRP also correlated with TNF-α in HTx group. Neither vascular TNF-α, IL-6 and IL-1β mRNA expression, nor systemic levels of either TNF-α, IL-6 and IL-1β were correlated with superoxide generation in IMAs. Interestingly, circulating IL-1β negatively correlated with maximal relaxation of the internal mammary artery (r = -0.37, p = 0.004). At the same time the mRNA expression of studied inflammatory cytokines were positively associated with each other in both IMA and LAD. The positive correlations were observed between circulating levels of IL-6 and TNF-α in CABG cohort and IL-6 and IL-1β in HTx cohort. This study shows that peripheral inflammatory cytokine measurements may not reflect local vascular inflammation or oxidative stress in patients with advanced cardiovascular disease (CVD). Circulating pro-inflammatory cytokines generally correlated positively with each other, similarly their mRNA correlated in the arterial wall, however, these levels were not correlated between the studied compartments.

Survival After Cardiac Transplantation in Adults With Single-Ventricle Congenital Heart Disease

BackgroundWithout large-scale analyses of adults with single-ventricle congenital heart disease (CHD) undergoing heart transplantation, little evidence exists to guide listing practices and patient counseling. ObjectivesThis study aims to evaluate survival after heart transplantation in adults with single and biventricular CHD and compare it to that of non-CHD transplant recipients. MethodsIn this 15-year (2005-2020) retrospective analysis, outcome-blinded investigators used probability-linkage to merge the National (Nationwide) Inpatient Sample and Organ Procurement and Transplantation Network data sets. ResultsOf 382 adult (≥18 years of age) heart transplant recipients with CHD, 185 (48%) had single-ventricle physiology. Compared to biventricular CHD, single-ventricle patients showed significantly reduced survival at 1 (80% vs 91%; HR: 2.50; 95% CI: 1.40-4.49; P = 0.002) and 10 years (54% vs 71%; HR: 2.10; 95% CI: 1.38-3.18; P < 0.001). Among patients who survived the first post-transplantation year, biventricular CHD patients exhibited similar 10-year survival as single-ventricle patients, except for those with hypoplastic left heart syndrome (79% vs 71%; HR: 1.58; 95% CI: 0.85-2.92; P = 0.15). Additionally, biventricular CHD transplant recipients showed significantly better 10-year conditional survival compared to their non-CHD counterparts (79% vs 68%; HR: 0.73; 95% CI: 0.59-0.90; P = 0.003). ConclusionsAmong adult CHD transplant recipients, single-ventricle physiology correlated with higher short-term mortality. However, 10-year conditional survival was similar for biventricular and most single-ventricle CHD patients, and notably better for biventricular CHD patients compared to non-CHD heart transplant recipients. These findings have significant implications towards patient selection and listing strategies, easing concerns related to heart transplantation in adults with CHD and destigmatizing most subtypes of single-ventricle CHD.

Abstract P187: Comparative Analysis Of Covid-19 Vaccine Efficacy In Heart Transplant Recipients On Standardized Immunotherapy Regimens

Background: International data on COVID-19 infection in immunosuppressed populations is limited. Heart transplant (OHT) recipients requiring immunotherapy are at risk for potentially increased complications with COVID-19 infection, including long-covid and oxidative stress during initial infection. The availability of vaccination and temporal trends in this population has not been well described. We report outcomes in immunosuppressed patients during the initial years of the COVID pandemic. Methods: All patients who underwent heart transplantation at Mayo Clinic in Florida were reviewed from March 2019 to October 2021. Patients were divided into two groups: those diagnosed with COVID-19 (based on a positive SARS-CoV-2 RT-PCR) and those not. A p value of 0.05 was considered significant using the Chi-squared test. Results: A total of 98 patients were reviewed. Of these, 49 were COVID-19-positive (CP), and 49 were negative (CN). The cohort was well matched, with a median age of 58 years (49 - 65) in both groups. 20 females in the CP group and 9 in the CN group. Diabetic status (p = .07), history of hypertension (p=.5), BMI (p=.41), GFR (p=.19), and ejection fraction (p=.29) were not significantly different between the two groups. Immunosuppression was not significantly different for CP or CN patients, with a median trough tacrolimus level of 7.68 vs. 8.70 (p = .26). The median time from transplant to CP was 384 days (237 - 677). The CN group’s median follow-up after transplant was 947 days (737 - 1191). CP hospitalization rate was 24% (5 Pfizer, 3 unvaccinated, 4 Moderna) with only 1 death. Hospitalized patients’ markers of inflammation were: IL6 19.2 (12-48), D-dimer 1408 (763 - 2227), and CRP 54 (20 - 90). The CP group was more vaccinated than the CN group (92% vs. 78%, p = .025). More CP patients received the Pfizer vaccine compared to Moderna (p = .018). Conclusion: We found that patients after OHT on similar immunotherapy regimens did not carry the same risk of contracting Covid-19 despite being vaccinated. CP patients were generally infected in the first 1.5 years after OHT. This may indicate an increased infection rate due to a weakened immune system or lack of bivalent boosters before 2022. Vaccine efficacy in this population should be evaluated in larger studies.

Relation Between Preoperative Hypoxia and Postoperative Oxygen Saturation in Patients Post-Fontan Palliation Who Undergo Heart Transplant

Relation Between Preoperative Hypoxia and Postoperative Oxygen Saturation in Patients Post-Fontan Palliation Who Undergo Heart Transplant

Predicted Heart Mass: A Tale of 2 Ventricles.

Total predicted heart mass (PHM) is the recommended metric to assess donor-recipient size matching in patients undergoing heart transplantation. Separately measuring right ventricular (RV) and left ventricular (LV) PHM may improve risk prediction of 1-year graft failure. Adult heart transplant recipients from the UNOS database from 2000 to 2018 were included in the study. LV and RV PHM were modeled as restricted cubic splines. The association with 1-year graft failure was determined using adjusted Cox regression. The risk reclassification of using both LV and RV PHM versus total PHM was assessed using the net reclassification index. A total of 34 976 recipients were included. We observed a U-shaped association between total PHM and 1-year graft failure, such that risk increased for hearts undersized by >15% and those oversized by more than 27%. Graft failure incrementally increased when LV PHM was undersized by more than 5% and when RV was oversized by >20%. There was 1.5-fold greater risk of graft failure for an LV undersized by >26% or an RV oversized by more than 40%. Using LV and RV PHM risk-assessment separately led to a net reclassification index=8.5% ([95% CI, 5.3%-11.7%], nonevent net reclassification index=9.1%, event net reclassification index=-0.6%). The association between donor-recipient PHM match and the risk of graft failure after heart transplantation can be further understood as risk attributable to LV undersizing and RV oversizing. Assessing LV and RV PHM separately instead of total PHM could further refine the methods used to match donors and recipients for heart transplantation, minimize the risk of 1-year graft failure, and increase the use of donor organs.

Cost-Effectiveness of Tacrolimus Compared With Cyclosporine for Immunosuppression Therapy in Patients Who Underwent Heart Transplant in Colombia

ObjectivesTo evaluate the cost-effectiveness of pharmacological treatment in maintenance therapy for adult heart transplant recipients from the Colombian health system perspective. MethodsWe constructed a decision tree model with a 1-year time horizon. A review of the clinical literature was performed to extract probabilities of health events and acute rejections avoided were used as the health outcome. Costs were calculated from the base-case approximation and were obtained from administrative databases in Colombia (Sistema de Información de Precios de Medicamentos 2020 and Suficiencia 2012-2019), and the prices were adjusted to US dollar 2021. ResultsTwo evaluation results were presented. The first evaluates the tacrolimus + azathioprine + corticosteroid (TAC) scheme compared with cyclosporine + azathioprine + corticosteroid (CAC), in which the incremental cost-effectiveness ratio indicates that 1 additional rejection avoided has a cost of US dollar $5461.09 which, compared with the cost-effectiveness threshold in the base case, indicates that the TAC scheme is not a cost-effective (CE) strategy with respect to the CAC scheme. The second result shows the comparison of tacrolimus + mycophenolate mofetil + corticosteroid (TMC) with cyclosporine + mycophenolate mofetil + corticosteroid (CMC) in which TMC was found to be a dominant alternative to CMC. ConclusionsThe tacrolimus-based immunosuppression scheme is not CE in its TAC scheme, versus CAC, and is dominant in its TMC scheme, versus CMC, sensitivity analyses show that tacrolimus could become a CE alternative in any scheme used against higher cost-effectiveness threshold.

Phenotypic variability of filamin C–related cardiomyopathy: Insights from a novel Dutch founder variant

Dilated cardiomyopathy (DCM) can be caused by truncating variants in the filamin C gene (FLNC). A new pathogenic FLNC variant, c.6864_6867dup, p.(Val2290Argfs*23), was recently identified in Dutch DCM patients. The report aimed to evaluate the phenotype of FLNC variant carriers and to determine whether this variant is a founder variant. Clinical and genetic data were retrospectively collected from variant carriers. Cardiovascular magnetic resonance (CMR) studies were reassessed. Haplotypes were reconstructed to determine a founder effect. The geographical distribution and age of the variant were determined. Thirty-three individuals (70% female) from nine families were identified. Sudden cardiac death was the first presentation in a carrier at 28 years of age. Median age at diagnosis was 41 years (range 19-67). The phenotype was heterogeneous. DCM with left ventricular (LV) dilation and reduced ejection fraction (<45%) was present in eleven individuals (33%), three (9%) of whom underwent heart transplantation. CMR showed late gadolinium enhancement (LGE) in 65% of the assessed individuals, primarily in a ring-like distribution. Non-sustained ventricular arrhythmias were detected in six (18%), and five (15%) individuals received an implantable cardioverter defibrillator. A shared haplotype spanning 2.1 Mb was found in all haplotyped individuals. The variant originated between 275-650 years ago. The pathogenic FLNC variant c.6864_6867dup, p.(Val2290Argfs*23) is a founder variant originating from the south of the Netherlands. Carriers are susceptible to developing heart failure and ventricular arrhythmias. The cardiac phenotype is characterized by ring-like LGE, even in individuals without significantly reduced LV function.

Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation.

Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p=.79 and adj B-coeff 2.40, (-.21)-(5.02), p=.07) and mortality (aOR 1.02, .61-1.70, p=.94 and aOR 1.08, .72-1.62, p=.73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.

Utilization and outcomes of V-AV ECMO: A systematic review and meta-analysis.

Veno-arterial-venous extracorporeal membrane oxygenation (V-AV ECMO) is a less commonly used configuration of ECMO. We sought to understand the indications, utilization patterns, and outcomes of V-AV ECMO by quantitatively pooling the existing evidence from the literature. Electronic search was performed to identify all relevant studies reporting V-AV ECMO usage. Five studies comprising 77 patients were selected and cohort-level data were extracted for further analysis. Mean patient age was 61 (95% CI: 55.2, 66.5) years and 30% (23/77) were female. The majority of cases [91% (70/77)] were transitioned to V-AV ECMO from another pre-existing ECMO configuration: V-A ECMO in 55% (42/77) vs. V-V ECMO in 36% (28/77), p = 0.04. Only 9% (7/77) of cases were directly placed on V-AV ECMO. The mean duration of hospital stay was 42.3 (95% CI: 10.5, 74.2) days, while ICU mortality was 46% (29, 64). Transition to durable left ventricular assist device was performed in 3% (2/64) of patients, while 3% (2/64) underwent heart transplantation. V-AV ECMO was successfully weaned to explantation in 33% (21/64) of patients. V-AV ECMO is a viable option for optimizing cardiopulmonary support in selected patients. Survival to weaning or bridging therapy appears comparable to more common ECMO configurations.

Topical skin adhesive PRINEO as the ideal wound closure system in cardiac surgery to limit surgical site infection.

Surgical site infections (SSIs) are a major source of morbidity after cardiac surgery, involving prolonged hospitalisation. Among the numerous techniques of skin closure and dressings available, the optimal method remains undetermined. The DERMABOND-PRINEO (PRINEO) (PRINEO, Ethicon, J&J) is the only skin closure system which combines a topical skin adhesive with a mesh. Other surgical disciplines have highlighted remarkable results with PRINEO. The aim of this study was to evaluate the effects of PRINEO, used as the final layer in sternotomy closure, in the incidence of postoperative SSIs. This was a retrospective single-centre cohort study including adult patients who underwent cardiac surgery between January 2015 and December 2018. Patients who had undergone heart transplantation or ventricular assist surgery were excluded. Included patients were divided into two groups depending on the type of post-operative wound care technique used. Group 1 consisted of patients who had their sternotomy closed with a standard dressing and group 2 consisted of patients who were treated with PRINEO. The primary endpoint of our study was the occurrence of SSIs and secondary outcomes were the length of hospitalisation and mortality. A total of 1603 patients were reviewed with the occurrence of 44 SSIs. Both groups were homogeneous in terms of risk factors. The incidence of SSIs was significantly lower in group 2 (PRINEO) than in group 1 (standard dressing) (n=29, 3.8% vs n=15, 1.8%, respectively; p=0.042). However, there was no significant difference in the duration of hospitalisation and mortality. In our practice, PRINEO has proven to be a safe wound closure system after sternotomy, with a reduced SSI rate compared to conventional wound care techniques.

Amyloid myopathy: expanding the clinical spectrum of transthyretin amyloidosis—case report and literature review

We identified two patients with transthyretin (ATTR) amyloid myopathy (one ATTR variant amyloidosis, ATTRv; one wild-type ATTR amyloidosis, ATTRwt). Myopathy was the initial manifestation in ATTRwt, whereas it followed neuropathy and cardiomyopathy in ATTRv. The ATTRwt patient showed muscular tracer uptake on 99mTc-DPD planar scintigraphy at the time of initial diagnosis, consistent with ATTR amyloid myopathy. The ATTRv patient underwent heart transplantation because of progressive heart failure. Within the next two years, progressive myopathic symptoms and extracardiac tracer uptake on 99mTc-DPD planar scintigraphy were documented, attributable to ATTR amyloid myopathy. Interstitial amyloid deposits were confirmed by muscle biopsy in both patients, with a particularly high amyloid burden in the adipose tissue. This case report highlights the frequent concomitant presence of cardiac ATTR amyloidosis and ATTR amyloid myopathy. ATTR amyloid myopathy may precede cardiac manifestation in ATTRwt or occur after heart transplantation in ATTRv. Due to the high diagnostic accuracy of 99mTc-DPD scintigraphy for detecting ATTR amyloid myopathy and the emergence of novel therapeutics, it is important to increase the awareness of its presence.

Long-term medical treatment and adherence in patients with left ventricular assist devices: a Danish nationwide cohort study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Grant from Karen Elise Jensen Foundation and Helse Foundation. Introduction An increasing number of patients with advanced heart failure (HF) live with a left ventricular assist device (LVAD). Data regarding medical treatment after LVAD implantation is sparse, including the impact of socioeconomic factors and multimorbidity. Purpose To describe medication use and assess the influence of socioeconomic factors and multimorbidity on medication use in the first two years following LVAD implant. Methods We conducted a nationwide cohort study based on data from the Danish clinical LVAD databases, the Scandiatransplant Database, and Danish nationwide administrative and medical registries. We identified patients with LVAD implantation between January 1, 2008, and December 31, 2018, who were discharged with LVAD therapy. Patients were followed until heart transplantation, LVAD explant, death, or December 31, 2018. Medication use was defined as a redeemed prescription from the Danish National Prescription Registry using ATC codes. Socioeconomic factors included cohabitation status, highest education attained, employment status, and personal income. Multimorbidity was defined as two or more chronic conditions. Medical treatment 90 days before LVAD implant and 720 days post-LVAD were assessed using descriptive statistics in 90 days intervals. Results We identified 119 patients; 88.2% were male, and the mean age (standard deviation) was 52.6 (14.5) years. The median (IQR) follow-up time was 0.8 years (0.4;1.8 years). 44.5% of patients underwent heart transplantation, and 4.2% had the LVAD explanted during follow-up. 27.7% of the patients were living alone, 27.7% had a low educational level, 37.8% were unemployed, 15.1% were in the lowest income (25 percentile), and 16.8% were categorized with multimorbidity (without cardiovascular disease group). The proportion of medication users of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (88.7%), beta-blocker (67%), mineralocorticoid receptor antagonists (62.9%), warfarin (87.6%), and aspirin (55.7%) within 90 days post-LVAD were substantially higher than pre-LVAD and were stable during the follow-up (Figure 1). In contrast, the proportion of diuretic users was lower post-LVAD implant than pre-LVAD, decreased further, and plateaued up to 180 days after hospital discharge. Stratified analyses according to socioeconomic factors and multimorbidity showed no differences in medication use (Figure 2). Conclusions Guideline-derived medical therapies for HF increased after LVAD implantation and were stable during long-term follow-up. As expected, the proportion of warfarin users increased substantially after LVAD implantation. Surprisingly, the percentage of aspirin users was not at the same level as for warfarin users. Socioeconomic factors and comorbidity burden did not influence long-term medication use of guideline-derived HF therapies, warfarin and aspirin in LVAD recipients.

The Use of Impella 5.5 for Donor-Heart Hemodynamic Support in Heart Transplantation.

Primary graft dysfunction is a feared complication and cause of mortality post-heart transplant. Primary graft dysfunction may require mechanical circulatory support, such as venoarterial extracorporeal membrane oxygenation, which carries its own risk for complications. We developed a new mechanical circulatory support method for patients who underwent heart transplant bridged with Impella 5.5, which was then placed into the donor heart. Among 12 heart transplants, four required Impella 5.5 support. The average age was 55.8 years. The mean duration for postoperative mechanical circulatory support was 3.8 days, ranging from 2 to 5 days. No patients developed severe right ventricular dysfunction. In our limited study, complications and mortality associated with the replanted Impella 5.5 were both 0%.