Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Presentations
Objective:
Our project's primary goal was to develop an affordable yet highly realistic simulator for heart transplantation training. By offering a hands-on experience closely resembling the surgical procedure, we aimed to enhance surgical skills, improve patient outcomes, and reduce the learning curve associated with this complex operation.
Methods:
We initiated the project by acquiring high-resolution CT scan data of the presenting author's heart and posterior chest. Using specialized software, we meticulously converted this data into a file format suitable for 3D printing. The resulting digital models featured the heart's valves and chambers and were printed separately.
Results:
Through various material iterations, we identified a resin with the necessary elastic modulus and tensile strength to create a low-cost, high-fidelity, focused simulator. Our initial simulator weighed 150 grams and combined mitral, aortic, and vascular components. Encouraged by our success, we swiftly progressed to the heart transplant simulator system. The detailed 300-gram model provides a realistic tactile experience for suturing and other critical steps in heart transplantation.
Conclusions:
The concept of the **learning curve** is well-established in surgical practice. Surgeons often encounter challenges when adopting new techniques or procedures. Our simulator aims to flatten this learning curve by allowing surgeons, particularly those in training, to gain hands-on experience before operating on actual patients. Regular practice with the simulator can enhance surgical skills, boost confidence, and reduce the time required to achieve operative proficiency. In summary, our heart transplantation simulator project bridges theory and practice, empowering surgeons to navigate the complexities of heart transplantation with greater confidence and competence.
Authors
David Varghese (1), Myat Soe Thet (2), J.Florian Körwer (3), Prashant Mohite (1), ayush balaji (4), Yasser Hegazy (1), Karim Morcos (1), Sylvia Yew (5), Hari Doshi (1), Philip Curry (1)
Institutions
(1) Golden Jubilee National Hospital, Glasgow, United Kingdom, (2) St. Bartholomew’s Hospital, London, London, (3) Hochschule Niederrhein, Krefeld, Germany, (4) Hull York Medical School, United Kingdom, (5) University of Glasgow, Glasgow, United Kingdom
Abstract Presenter
David Varghese, The Golden Jubilee national Hospital
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Durham, NC
United States
Objective: As the use of ex vivo heart perfusion (EVHP) continues to expand clinically, there are limited studies assessing the impact of perfusate composition and strategies. This limitation is partly due to the lack of clinically relevant, easily reproducible, and cost-effective models to examine the impact of EVHP on post-transplantation outcomes. Here, we present a novel murine EVHP and transplantation model that allows for rapid prototyping and testing of EVHP strategies.
Methods: 10-12 week-old (20-30 grams) wild type mice underwent heart procurement. Hearts were then attached to a temperature- and pressure-controlled ex vivo perfusion system constructed from commercially available laboratory equipment. Hearts were perfused with acellular, unoxygenated Krebs-Henseleit (KH) buffer at 4⁰C for 90 minutes. Control hearts were maintained on ice under cold static preservation (CSP) conditions. After the preservation period, the donor grafts were transplanted onto the cervical vessels of a recipient mouse using a modified vascular cuff technique: the donor aorta was attached to the recipient carotid artery, and the donor pulmonary artery was attached to the recipient external jugular vein. Hearts were then allowed to re-perfuse for 120 minutes prior to echocardiographic assessment of function. As the left ventricle is unloaded in this model, fractional shortening and fractional area change were used to assess function.
Results: Overall graft survival at 120 minutes after cervical heart transplantation was similar between EVHP (n=18) and CSP (n=15) groups (72% vs. 67%, p=0.6 via Log-rank testing) (figure). Echocardiography demonstrated EVHP hearts had significantly improved graft function compared to CSP hearts: Short axis fractional shortening change 24.8% vs. 14.1%, p=0.005; short axis fractional area change 26.0% vs. 17.9%, p=0.03.
Conclusions: Our novel murine EVHP and heart transplantation model provides similar animal and graft post-transplantation survival compared to standard graft cold static preservation. Graft assessment with echocardiography demonstrated superior function of EVHP treated hearts compared to CSP controls. This model provides a new way to rapidly prototype various EVHP strategies, perfusate formulations, and techniques in a reproducible and cost-effective murine model. This approach can serve as a proof-of-concept testing platform before advancing to larger animal models. Cervical transplantation facilitates dynamic graft assessment via echocardiography in short-term survival models. Additionally, the success rate of the modified cervical cuff anastomosis technique allows for the consistent study of mechanisms of post-transplant graft failure, minimizing the potential technical limitations of the abdominal micro-vascular anastomosis, and potentially broadening the scope of research and facilitating skill acquisition.
Authors
Jack Zakrzewski (1), Li Lu (2), John Iguidbashian (2), Ludmila Khailova (2), Jesse Davidson (3), James Jaggers (3), Matthew Stone (3)
Institutions
(1) University of Colorado, Anschutz Medical Center, Aurora, CO, Denver, CO, (2) University of Colorado, Aurora, CO, (3) Children's Hospital Colorado, Aurora, CO
Abstract Presenter
Jack Zakrzewski, University of Colorado, Anschutz Medical Center, Aurora, CO
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Denver, CO
United States
Objective: It is estimated that one third of patients listed on the heart transplant waiting list in the UK do not receive a transplant. In recent years there has been an increase in the dependence of ventricular assisted devices to optimise patients on the waiting list pre-transplant. However, there has yet to be a single study formally analysing the outcomes of patients listed on the UK heart transplant waiting list.
Methods: A retrospective analysis of the NHS Blood & Transplant database that included all patients aged >15 listed on the heart transplant list between 1st January 2008 – 31st December 2022.
Results: In this time period only 65% of patients listed for heart transplantation in the UK go one to receive a heart. In patients who did not receive mechanical circulatory support before transplantation, 76% went onto receive a heart transplant. In patients who received long-term ventricular assist devices (LT-VAD) pre-transplant, significantly fewer received a transplant - only 35%. This group of patients also had significantly higher rates of removal from and death on the list. 28 % of patients with LT-VADs are removed from the list compared to only 14% of patients with no MCS pre-transplant. 22% of patients with LT-VADs die on the list, compared to 7% of patients not requiring MCS.
Secondary to this patients on LT-VADs pre-transplant had significantly worse survival post-transplant compared to those on short-term mechanical circulatory support (p=0.05) and not requiring mechanical circulatory support (p<0.005). Moreover, these patients had a higher dependence on mechanical circulatory support post-transplant (26.5% compared to 14.3% in those not requiring MCS post-transplant). Moreover, these differences persisted across different time periods (2008-2015 and 2016-2022).
Conclusions: Patients on LT-MCS are significantly less likely to receive a heart and significantly more likely to have worse outcomes post-transplant in the UK. This may be in part because these patients wait significantly longer before receiving a heart. There is a need to review the practice of VAD implantation in the UK to ensure that this group of patients have their outcomes optimised and understand how to improve outcomes for VAD patients in the UK currently. There is a need for further studies with greater granularity and a need to collect quality of life data for VAD patients in normal clinical practice.
Authors
John Louca (1), Marco Öchsner (2), Sai Bhagra (3), Alex Manara (4), Simon Messer (5), Sally Rushton (6), Aravinda Page (7), Nicole Asemota (3), Marius Berman (8), Stephen Large (3)
Institutions
(1) University of Cambridge, Northwood, United Kingdom, (2) University of Cambridge, Cambridge, NA, (3) Royal Papworth Hospital, Cambridge, NA, (4) Southmead Hospital, Bristol, NA, (5) Golden Jubilee Hospital, Glasgow, NA, (6) NHS Blood & Transplant, Bristol, NA, (7) Royal Papworth Hospital NHS Foundation Trust, Cambridge, NA, (8) Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
Abstract Presenter
John Louca, University of Cambridge
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Northwood
United Kingdom
Objective. The list of patients with end-stage lung disease who are waiting for the lung transplantation continues to grow. Despite maximum medical therapy and supplemental oxygen, some patients require ECMO as a bridge to lung transplantation. The purpose of this study is to present our clinical experience in patients who were supported with ECMO pre-operatively by describing pre-, peri-, and post-operative outcomes as well as assessing longitudinal survival.
Methods: We reviewed outcomes of all lung transplants between 2013-2023 at our institution. Patients were assigned to the following two groups: Group 1: patients supported with ECMO prior to transplantation and Group 2: patients with no mechanical circulatory support prior to transplantation. The primary outcome was mortality. Univariate comparisons of categorical and continuous variables were analyzed using a Chi-square test and Wilcoxon rank sum test after assessing normality. Kaplan-Meier (KM) methods and log-rank tests were used to assess group differences in long-term survival. T-tests using KM-estimated survival proportions and standard errors were used to compare post-transplant survival of groups at one, three, and five years. Continuous variables are represented as median [IQR] and categorical variables are represented as N(%).
Results: The entire cohort consisted of a total of 572 patients (n=65, supported with pretransplant ECMO; n=507 no pretransplant mechanical circulatory support). Patients supported with ECMO prior to lung transplantation were more likely to be older (62.5 years [53.9-67.9] vs 49.0 years [35-54.2], p = <0.001), have right ventricular dysfunction (n=43, 66.2% vs n=103, 20.3%; p <0.001) and have a history of renal failure (n=6, 9.2% vs n=11, 2.2%; p=0.006). Additionally, patients supported with ECMO pre transplant were more likely to have all-cause post-transplant complications (n=64, 98.5% vs n=394, 77.7%; p<0.001), including post-operative infection (n=43, 66.2% vs n=243, 47.9%; p=0.009) and bleeding (n=26, 40.0% vs n=53, 10.5%; p < 0.001). Patients supported with pretransplant ECMO additionally were more likely to have longer hospital length of stays (80 days [60.8-109.0] vs 28.0 days [17.5-57.5], p = <0.001), and be supported with post-transplant ECMO (n=57, 87.7% vs n=98, 19.3%; p<0.001). We observed no statistically significant difference in post operative stroke (n=2, 3.1% vs n=7 ,1.4%; p=0.62) and unplanned readmission within 30 days between groups (n=0, 0.0% vs n= 33, 6.5%; p=0.06). Upon survival analysis, longitudinal survival did not differ between groups at 1 (93.4% [95% CI:91.2-95.6%] vs 90.7% [95% CI:83.9-98.1%], log-rank = 0.655), 3 (79.9% [95% CI:76.2-83.8%] vs 77.4% [95% CI:65.6-91.2%], log-rank = 0.386), and 5 years post-transplant (61.9% [95% CI:56.3-68.1%] vs 42.0% [95% CI:20.8-84.8%], log-rank = 0.31.)(Figure 1).
Conclusions: Excellent post-transplant survival can be expected in patients with end-stage lung disease. Patients supported with ECMO as a bridge to lung transplantation tended to be sicker and had more immediate post-operative complications however, longitudinal survival did not differ between ECMO supported patients and those without mechanical circulatory support before transplant. Advances in the treatment of chronic lung allograft dysfunction will lead to improvements in long-term survival.
Authors
YURIY STUKOV (1), Ahmet Bilgili (2), Lindsey Brinkley (1), Liam Kugler (3), Amir Emtiazjoo (4), Marc Maybauer (5), Mindaugas Rackauskas (6)
Institutions
(1) The University of Florida, Gainesville, FL, (2) N/A, N/A, (3) Student, Gainesville, FL, (4) University of Florida, Gainesville, FL, (5) Division of Critical Care Medicine, Department of Anesthesiology, University of Florida, Gainesville, FL, (6) N/A, Gainesville, FL
Abstract Presenter
YURIY STUKOV, The University of Florida
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Gainesville, FL
United States
Purpose (50 words): Individuals with end-stage renal disease and contraindication to transplant are not considered for a left ventricular assist device (LVAD) as destination therapy due to high mortality rates. We report the course of the first 30 days of porcine renal xenograft perfusion and function in a human recipient with an LVAD.
Methods (150 words): The patient underwent a re-operative sternotomy with HeartMate III LVAD implantation. A week later after being maintained on CRRT, an alpha-gal knock-out porcine thymokidney was transplanted into the left iliac fossa. Hourly hemodynamic data and LVAD parameters were recorded. A complete metabolic panel was collected every 4 hours. Renal ultrasounds with color flow doppler and spectral analysis were performed weekly. Approval for this procedure was obtained from the FDA under a single patient expanded access Investigational New Drug application and the New York University Grossman School of Medicine Institutional Review Board.
Results (200 words): Renal xenograft dopplers demonstrated patent vasculature without stenosis or thrombosis throughout the duration of the study. Following transplant, main renal artery peak systolic velocity (MRA-PSV) was 53.4cm/s (normal: 60-100cm/s) with a resistive index (RI) of 0.7 (normal: 0.5-0.8). Spectral doppler showed a monophasic waveform with continuous antegrade flow. On post-operative day (POD) 2 creatinine clearance (CrCl) declined to 12mL/min from 75.8mL/min secondary to low effective circulating volume in setting of hypotension. Serum creatinine (Cr) peaked to 1.55mg/dL on POD4. Hemodynamic goals were broadened to prioritize a pulsatile flow with systolic blood pressure (SBP) of greater than 100mmHg per standard renal allotransplant protocols by a combination of inotropic and vasopressor support. When a SBP of >100mmHg and pulse pressure (PP) of >25mmHg was achieved, serum Cr and CrCl returned to baseline. Serum Cr reached a nadir of 0.48 mg/dL and CrCl increased to 72.9 mL/min on POD7. MRA-PSV and RI were normal at 88.4cm/s and 0.8, respectively. Renal artery doppler confirmed improved pulsatility with a sharp systolic upstroke. Between POD7 and POD30, serum Cr ranged from 0.49-1.11 mg/dL, and CrCl ranged from 35.9-72.9 mL/min. MRA-PSV and RI remained in reference range. LVAD flows were stable at 3.7L/min (range 3.1-4.4L/min).
Conclusions (50 words): Adequate xenograft perfusion was achieved in an LVAD recipient demonstrated by normal MRA-PSV and RI. Renal function normalized following an ischemic injury by maintaining a SBP of >100mmHg and PP of >25mmHg. Long-term impact of continuous flow on a transplanted kidney remains unclear, maintaining pulsatile flow seems beneficial.
Authors
Imad Aljabban (1), Ian Jaffe (2), Randal Goldberg (2), Alex Reyentovich (2)
Institutions
(1) NYU Langone, United States, (2) NYU Langone Health, New York, NY
Abstract Presenter
Imad Aljabban, NYU Langone hospital
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Ljubljana, ON
Slovenia
Objective: The Heart Allocation and Shared Core Policy in China have been implemented for more than three years. The aim of this study was to examine the impact of the heart allocation scheme in the China by analyzing and comparing the data from two eras and evaluating the post-transplant outcomes for patients in urgent and non-urgent status.
Methods: Data on all heart transplant recipients in the four years before (Era 1: January, 2015 to December, 2018) and after (Era 2: January, 2019 to December, 2021) the introduction of the policy were extracted from the China Heart Transplant Registry System and analyzed using Kaplan-Meier analysis and logistic regression analysis.
Results: There were 1583 heart transplantations in Era 1 and 1974 in Era 2. In Era 2, there were 1426 patients had been transplanted in non-urgent status (72.2%) and 548 HTx patients had been transplanted in urgent status (27.8%). As to the categories of urgent status in Era 2, the most common indication for urgent status was IABP (25.0%) and ECMO (24.5%), followed by MCS related complications (23.5%), pediatric urgent status (17.5%) and ventilator dependence (7.8%), and the least was LVAD (1.7%). The overall hospital mortality was not statistically different between two eras, with 8.4% in Era 1 and 9.6% in Era 2 (P=0.21). The overall hospital mortality was significantly higher in urgent status group, with 14.1% in urgent status and 7.9% in non-urgent status (P<0.01). The overall 1-year survival rate significantly decreased from 86.9% to 81.6% between Era 1 and Era 2 (P < 0.01). For urgent recipients during Era 2, 1-year survival was 77.4%, was significantly lower than that of non-urgent status (83.2%, P < 0.01). Factors independently associated with 1-year mortality in patients with urgent status were pre-HTx ECMO support, a lower baseline eGFR (<60 mL/min/1.73 m2), pretransplant CRRT support, donor age≥55 years.
Conclusions: The introduction of the heart allocation scheme in the China has increased the efficiency of donor heart allocation and the utilization rate of donor heart nationwide that has been a great improvement in the number of HTx in China after the heart allocation scheme. Considering the increasing complexity of recipients and donors, a 5% decrease in one-year post-transplant survival rate between the 2 eras is acceptable. The Heart Allocation and Shared Core Policy in China has been proved be feasible preliminarily.
Authors
Shan Zheng (1), Sheng Liu (2), Zhe Zheng (3)
Institutions
(1) Fuwai Hospital, Beijing, Beijing, (2) Fuwai Hospital, Beijing, NA, (3) Fuwai Hospital, Beijing, CA
Abstract Presenter
Sheng Liu, Fuwai Hospital
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Beijing, NA
China
Objective: In South Korea, the use of central extracorporeal membrane oxygenation (ECMO) is significantly less prevalent than peripheral ECMO, with substantial gaps in the literature regarding the primary indications and outcomes for central ECMO. The objective of this study was to analyze the outcomes of patients at our center who underwent treatment with central ECMO.
Methods: Data were retrospectively collected and analyzed for patients who underwent central ECMO our center from 2017 to 2024. The collected data included baseline characteristics of the patients, intraoperative details, and outcomes.
Results: Of the 11 patients who received central ECMO, 7 (63.6%) were transitioned from peripheral to central ECMO, within 7.8 days on average. ECMO support was initiated for post-cardiotomy shock in six patients and for non-postcardiotomy shock in five. Most applications of central ECMO were primarily intended as a bridge to long-term support, which was more common than bridging to transplantation (7 (63.6%) versus 4 (36.4%)). Weaning from central ECMO was successful in five patients (45.5%), including two who were transitioned to transplantation, two to long-term support, and one weaned without additional mechanical circulatory support. The in-hospital mortality rae among these patients was 54.5%
Conclusions: The majority of patients received central ECMO as a bridge to long-term support. Among the survivors, individuals who underwent transplantation or left ventricular assist device implantation predominated over those weaned from ECMO without additional mechanical circulatory support. To enhance our understanding of the outcomes associated with central ECMO and to identify the determinants of these outcomes, additional multicenter studies are warranted.
Authors
Seunghwan Song (1), Ho Seong Cho (2), Soojin Lee (3)
Institutions
(1) Pusan National University Hospital, Busan, NA, Korea, Republic of, (2) Pusan National University Hospital, Seo-Gu, Busan, (3) Pusan National University Hospital, Busan, NA
Abstract Presenter
Seunghwan Song, Pusan National University Hospital
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Atlanta, GA
South Korea
Objective: The novel microaxial, surgically implanted heart pump (MSIHP) has become one of the most clinically utlized temporary left ventricular assist devices since its FDA approval in late 2019. It is critical to assess the hemocompatibility in pursuit of limiting thrombotic and hemorrhagic events. The safety of anticoagulation (AC) with direct thrombin inhibitors (DTI) during support has not been well described.
Methods: We retrospectively reviewed adult patients (≥18 years old) supported with MSIHP at our institution (May 2020–April 2023) used as bridge to durable support, and/or transplantation. Baseline demographics were collected on all patients. Number of blood products given during Impella support was recorded. Haptoglobin, plasma free hemoglobin, lactate dehydrogenase, and unconjugated bilirubin were collected, at several time points. Rates of in-hospital mortality, 30-day mortality, MSIHP-associated access site complications, and arterial thromboembolic events were recorded.
Results:
A total of 31 patients were supported with Impella 5.5 during the study period. There was no difference in baseline demographics. The duration of support was 28.06±32.56 days. The AC agent was heparin in 27 and DTI in 4 patients. Vascular access was axillary artery in 77% and direct aortic placement in 23%. There was no different in baseline characteristics between groups. In 19% of patients, there was concomitant veno-arterial ECMO support. In-hospital mortality was 33% for heparin and 25% for DTI patients (p=0.739). The mean number of blood products given during support was 7.71±11.76 units; however, 42% of the entire cohort and 75% of the DTI cohort required no transfusions. The heparin group required a greater mean number of transfusions 8.7 vs 1 units (p=0.133). Aggregate total blood products per day of MSIHP support was low at 0.28 units/day. DTI patients had lower rates of total product transfusions per day 0.03 vs 0.32, p-value=0.0329, lower pRBC 0.03 vs 0.22, p-value=0.0332, lower platelets 0.00 vs 0.07, p-value=0.0466 (Table 1). Hemolysis markers were not significantly different pre and post-implant or by AC strategy. Overall thromboembolic event rate was low at 3% and not different among AC strategy.
Conclusion: Support with MSIHP showed high rates of hemocompatibility with many patients requiring no transfusions during their support. In this limited cohort, we found anticoagulation with DTI to be associated with fewer transfusions than heparin.
Authors
Fabian Jimenez Contreras (1), Griffin Stinson (1), Carlos Valdes (1), Omar Sharaf (1), Alex Parker (1), Mohammad Al-Ani (1), Juan Vilaro (1), Mustafa Ahmed (1), Eric Jeng (1)
Institutions
(1) University of Florida, Gainesville, FL
Abstract Presenter
Fabian Jimenez Contreras
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Gainesville, FL
United States
Objective:
Despite the increasing use of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) as a bridge to heart transplantation, patient outcomes remain suboptimal. Waiting for transplantation in a state of peripheral cannulation is controversial, particularly due to the high risk of complications arising from immobilization.
Methods:
We retrospectively reviewed patients who received VA-ECMO as a bridge to heart transplantation at regional hub hospital between January 2018 and December 2023.
Results:
Of the 33 heart transplant recipients, 25 were bridged with ECMO. The median age of these patients was 61 years (range 31-74 years). The median duration from ECMO initiation to transplantation was 22 days (9-36 days). Sixteen patients (64%) survived and were discharged, with a median waiting time of 18 days. Fourteen were on peripheral cannulation. All surviving patients proceeded with transplantation in a non-intubated and awakening state. A median time to stand-up alone is 14 days (3-64 days).
Conclusions:
Most patients underwent transplantation in a non-intubated, awake state, with early mobilization contributing to positive outcomes. Despite the risks of immobilization, this approach led to a majority of patients being successfully transplanted and discharged. Further research is needed to confirm these preliminary findings.
Authors
Inseok Jeong (1)
Institutions
(1) Chonnam National University Hospital and Medical School, Gwangju, OH
Abstract Presenter
Inseok Jeong, Chonnam National University Hospital and Medical School
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Gwangju, KY
South Korea
Can Galectin-3 Predict Postoperative Adverse Outcomes After Cardiac Transplantation? A Systematic Review
Adham H. El-Sherbini2, Papus Keita1, MD, Yasi r Abu-Omar1, MD, PhD, Marc Pelletier, MD, Gabriel A. Rabinovich4, PhD, Mohammad El-Diasty1*, MD, PhD
1Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA. 2Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
3Queen's University School of Medicine, Kingston, ON, Canada. 3Division of Cardiology, Department of Medicine, Queen's University, Kingston, ON, Canada. 4Laboratorio de Glicomedicina, Instituto de Biología y Medicina Experimental, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
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Objective: To integrate biological and clinical data, particularly related to the role of galectin-3 in cardiac fibrosis, highlighting its potential role in predicting postoperative adverse outcomes in patients undergoing heart transplantation surgery.
Methods: We performed a literature review which was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, Embase, Cochrane, and Google Scholar databases were searched using a predetermined strategy.
Results: A total of 385 citations were found, of which 26 underwent full-text review, and 6 citations with independent samples (n=1056) met full inclusion/exclusion criteria. The reported outcomes included all-cause mortality, myocardial fibrosis, acute cellular rejection, antibody-mediated rejection, and chronic allograft vasculopathy. The relationship between pre- and post-operative galectin-3 levels was explored in three studies and demonstrated the potential utility of measuring galectin-3, both at pre-transplant and post-transplant settings, for all-cause survival prognosis and adverse outcomes.
Conclusion: Galectin-3 may have a role in predicting allograft dysfunction and mortality in patients after heart transplantation surgery; however, more robust evidence is required to justify its routine use in this group of patients.
Authors
M. Papus Keita (1)
Institutions
(1) Case Western Reserve University, Shaker Heights, OH
Abstract Presenter
M. Papus Keita, Case Western Reserve University
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Shaker Heights, OH
United States
OBJECTIVE: No prognostic indicators of myocardial recovery in patients requiring extra-corporeal membrane oxygenation (ECMO) support after cardiac surgery have been established. We evaluated whether cardiac markers (CK-MB and Troponin-I), indicators of myocardial recovery and blood lactate levels, an indicator of adequate tissue perfusion, can predict survival in patients undergoing ECMO after cardiac surgery.
METHODS: Patients who underwent venoarterial-ECMO (VA-ECMO) support for postcardiotomy cardiogenic shock (PCS) after major cardiac surgery from May 2005 to December 2021 were included. The primary outcome was ECMO weaning failure. The cardiac markers and blood lactate levels serially measured during ECMO (at pre-ECMO, 6, 12, 24, and 48 hours) were analyzed. To facilitate interpretation, optimal cutoff points for cardiac markers and blood lactate levels were determined based on the highest Youden index score, considering both sensitivity and specificity. Logistic regression analyses were conducted to assess whether cardiac markers and blood lactate levels could predict survival.
RESULTS: A total of 300 patients (mean age, 62.9 ± 13.4 years, 133 female patients) constituted the study cohort. 155 patients (51.7%) were successfully weaned from ECMO and 110 patients (36.7%) survived to discharge. Based on the highest Youden index score, the optimal cutoff points for CK-MB and blood lactate levels at 48 hours after ECMO initiation were 85.8 ng/mL (sensitivity 60.3%, specificity 71.7%) and 7.9 mmol/L (sensitivity 80.9%, specificity 91.2%), respectively. The area under the receiver operating characteristic curve (AUROC) for Troponin-I was less than 0.6, indicating that it was not useful as a predictor of weaning ECMO. CK-MB levels at 48 hours above the optimal cutoff point (OR, 4.47; 95% CI, 2.20-9.11) and blood lactate levels at 48 hours above the optimal cutoff point (OR, 15.89; 95% CI, 4.66-54.17) were associated with ECMO weaning failure.
CONCLUSIONS: CK-MB levels and blood lactate levels were significantly lower in survival patients. Each of them at 48 hours after the initiation ECMO can be the predictors of ECMO weaning failure.
Authors
Joon Young Kim (1), Pil-Je Kang (2), Ho Jin Kim (3), Jae Suk Yoo (4), Sung-Ho Jung (5), cheol hyun chung (6), Joon Bum Kim (2)
Institutions
(1) Asan Medical Center, Seoul, South Korea, (2) Asan Medical Center, Seoul, NA, (3) Asan Medical Center, Seoul, Korea, (4) Asan Medical Center, Bucheon-si, Seoul, (5) Asan Medical Center, Seoul, (6) N/A, Seoul, South Korea
Abstract Presenter
*Joon Bum Kim, Asan Medical Center
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Seoul, NA
South Korea
Introduction: Achieving optimal anticoagulation during coronary artery bypass graft
(CABG) surgery remains a challenge, with variations in heparin response attributed to
differences in demographic and clinical factors. Deviations from the target activated clotting
time (ACT) during CABG have been linked to adverse outcomes. This study aimed to assess
the impact of different intravenous heparin doses on ACT in patients undergoing on-pump
CABG.
Methods: A cross-sectional study was conducted on 54 patients scheduled for CABG surgery
with cardiopulmonary bypass in 2021. ACT measurements were taken 5 minutes after the
initial bolus dose of 200 IU/kg and a secondary dose of 100 IU/kg heparin. Demographic and
clinical data, including ACT measures, hemoglobin levels, bypass time, and mortality, were
collected.
Results: The study population predominantly comprised of male patients, with a mean age of
61.18 ± 8.81 years. The patients and received 4 (3-4) grafts over 75 (65-80) minutes. Baseline
ACT was 149.91±17.48 seconds, increasing to 410 (359-472) and 604 (542-679) seconds
after the initial and additional heparin, respectively. Only 22.2% of the study subjects
achieved target ACT>480 seconds with 200 IU/kg, and the remaining 77.8% required an
additional 100 IU/kg heparin to reach the target ACT. No cases of heparin resistance,
mortality, or dropouts were reported at the end of the study. Preoperative and postoperative
hemoglobin levels were positively correlated (r=0.59, p<0.0001).
Conclusion: A 300 IU/kg heparin dose appears safer than lower doses for initiating
cardiopulmonary bypass in on-pump CABG. Preoperative hemoglobin optimization may help
minimize perioperative hemoglobin drop. Further research is needed to refine dosing
strategies and personalize CABG management.
Authors
Bisma Zulfiqar (1), Hossein Hosseini (2), Bisma Zulfiqar (3), Ali Karami (4), Zeinabsadat Fattahi Saravi (5), Fatemeh Talebi (4)
Institutions
(1) Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran, (2) Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Fars, (3) olom pezeshkiye iran, Shiraz, Iran, (4) Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, (5) Anesthesiology and Critical Care Research Center, ShirazUniversity of Medical Sciences, Shiraz, Iran, Shiraz, Fars
Abstract Presenter
Hossein Hosseini, Student Research Committee, Shiraz University of Medical Sciences
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Shiraz, Fars
Iran, Islamic Republic of
Objective. Heart transplantation (HTx) in the setting of organ donation after circulatory death (DCD) is increasing worldwide with encouraging clinical results. However, heart grafts are exposed to a phase of warm ischemic time (WIT) that may produce a significant detrimental injury, especially in older donors. Aim of the present study is to evaluate the preliminary results of DCD HTx performed in our center with DCD donation on site and a WIT longer than 30 minutes.
Methods. Since the beginning of a DCD HTx protocol in July 2023, based on Thoraco-Abdominal Normothermic Regional Perfusion (NRP) and cold static storage (CS), seven heart donors (5 males/2 females, mean age 50.6±4.8 years) became available in our hospital after a mean ICU stay of 18±6 days. After the withdrawal of life sustaining therapies in the operative room, the agonal phase started after 4.1±2.1 min. Mean functional WIT (calculated from the falling of the systolic pressure below 50 mmHg and/or Oxygen Saturation below 70% till the start of NRP) and WIT were 39.4±4 min and 43.6±3.3 min, respectively. During the reperfusion time, blood test were conducted every hour to monitor trend of lactate, creatine phosphokinase-MB (CK-MB), troponin I, myoglobin. NRP was weaned after a mean time of 99.9±16.1 min and after a mean period (206.6±43.15 min) of beating heart ("DBD-like" situation), the grafts were preserved with CS under blood cardioplegic arrest. Figure 1 shows the timeline of the procedure.
Results. Seven recipients (7males, mean age 60±5.4 years) received the DCD heart grafts. One patient was on the status 1 on inotropes i.v. and intra-aortic balloon pump and 1 patient was supported with an LVAD at the time of transplant. Mean cold ischemic time of the grafts was 87.3±9.1 min with blood cardioplegia flushing every nearly 15 minutes. Two patients required post-Tx VA-ECMO that were both successfully weaned after four days. Mean time of mechanical ventilation and intensive care unit stay were 18±63 hours and 5.4±3.7 days, respectively. Post-operative period was uneventful in all cases except in one recipient who required temporary renal replacement therapy. All patients were discharged from hospital after 25.6±9.6 days. At a mean follow-up of 169.4±132 days, they are all in NYHA Class I with optimal graft function (mean Ejection Fraction 57±5.1 %, Cardiac Index 2.9±0.4 l/min/mq, wedge pressure 6.3±2.5 mmHg). Two patients suffered from a grade 2R cellular acute rejection, one responsive to steroids i.v. therapy and one resistant, successfully treated with thymoglobuline infusion.
Conclusions. Despite prolonged WIT, mainly related to a very long "stand off" period due to our legislation for the declaration of death, our preliminary results show encouraging short-term outcomes of DCD HTx, even using quite old donors. A longer follow-up and a larger cohort of patients are mandatory to better confirm these data.
Authors
Matteo Marro (1), Massimo Boffini (2), Erika Simonato (2), Marinella Zanierato (2), Rocco Gabriele Sorace (2), Antonio Loforte (2), Andrea Costamagna (2), Marco Ellena (2), Anna Chiara Trompeo (2), Mauro Rinaldi (2)
Institutions
(1) Torino University Hospital, Turin, Turin, (2) Torino University Hospital, Turin, NA
Abstract Presenter
Matteo Marro, AO Citta' della Salute e della Scienza di Torino
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Turin, Turin
Italy
Objective
Normothermic ex-situ heart preservation extends the viability of donor hearts by maintaining physiological temperatures and reducing ischemic damage. However, the optimal perfusion pressure remains unknown. This study aims to determine the best perfusion pressure in a rat model to improve heart preservation and expand the donor pool.
Materials
Twenty male Sprague-Dawley rats (400-500g) were used in this study. Donor hearts were subjected to normothermic preservation (NP) for 2 hours using a 12ml Langendorff priming circuit with a 2-3 ml/min perfusion rate. After 2 hours, hearts were harvested with HTK solution and weighed before and after ex-situ perfusion. Post-preservation, hearts underwent heterotopic abdominal transplantation. ECG recordings for 3 hours post-transplantation determined the success of preservation, with the presence of the QRS complex indicating success. Statistical analysis compared outcomes between the successful and unsuccessful groups. Histological analysis was performed after 4 hours of reperfusion to assess heart tissue.
Results
In ECG monitoring, 8 out of 20 donor hearts showed the absence of the QRS complex, indicating unsuccessful NP preservation. Ischemic times were not significantly different between the two groups. At 120 minutes, serum lactate and potassium levels increased more in the unsuccessful group, although this was not statistically significant. Higher initial perfusion pressure (>65 mmHg) was associated with elevated lactate and potassium levels after 2 hours of NP preservation, indicating worse outcomes. Successfully preserved hearts maintained better structure in HE staining, while TUNEL staining revealed more DNA strand breaks in unsuccessfully preserved hearts. Heart weight increased significantly post-NP preservation, but this increase was statistically significant only in the unsuccessful group.
Conclusions
Higher initial perfusion pressures (>65 mmHg) were associated with worse outcomes, including elevated serum lactate and potassium levels, increased heart weight, and more significant DNA damage. These findings suggest that maintaining an optimal perfusion pressure is crucial for preserving heart structure and function.
Authors
Inseok Jeong (1), Ho Seong Cho (2), Mukhammad Kayumov (3), Hwa-Jin Cho (4), Do Wan Kim (1), Gyo Seon Lee (1), Seunghwan Song (5), Yang Hyun Cho (6)
Institutions
(1) Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea, (2) Pusan National University Hospital and School of Medicine, Biomedical Research Institute, Busan, Republic of Korea, (3) Brigham and Women's Hospital, Harvard Medical School, Boston, MA, (4) Chonnam National University Children’s Hospital and Medical School, Gwangju, Republic of Korea, (5) Pusan National University Hospital and School of Medicine, Busan, Republic of Korea, (6) Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
Abstract Presenter
Ho Seong Cho, Pusan National University Hospital
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Osaka, ON
Japan
Objective: Many DCD and DBD donor hearts are discarded over concerns of hemodynamic dysfunction following transplantation. Normothermic ex situ heart perfusion (NEHP) in full cardiac output (CO) mode provides a unique opportunity for hemodynamic assessment because loading conditions can be completely controlled. Over the last five years, we have developed NEHP protocols that routinely maintain normal heart functions for 24 hours or more. We have since developed system modifications enabling full-CO assessment with pressure-volume loop (PVL) derived measurements of hemodynamic performance. This proof-of-concept study aims to assess the accuracy and reproducibility of full-CO NEHP assessment as a surrogate for determining hemodynamic suitability for transplantation in donor hearts.
Methods: Three porcine hearts (342 ± 24.6 g) were procured and resuscitated using NEHP for 24 hours. Hearts were perfused in Langendorff mode at 0.5-0.6 cc/g of cardiac tissue/min with 22 kDa hemofiltration and electrolyte replacement. Hearts were randomized to one of three graded management protocols: minimal support (MS, no additional treatment), partial support (PS, vasoactive treatment), and full support (FS, vasoactive treatment with serum supplementation). At hours 1, 12, and 24, hearts were assessed utilizing full-CO NEHP with passive preload adjustable left atrial (LA) infusion and afterload adjustable aortic outflow (Ao). At each time point, hearts were exposed to three LA preload pressures (2-4 mmHg, 6-12 mmHg, and 12-22 mmHg) with afterload adjusted to replicate physiologic left ventricular (LV) conditions. Data collection during assessments included continuous flow monitoring (LA, Ao, coronary outflow), continuous chamber pressure monitoring (LA, LV, Ao), and echocardiography.
Results: At 24 h the MS heart displayed gross valvular incompetency with equalization of chamber pressures and converted to an irregular wide-complex arrythmia refractory to intervention. PS and FS hearts maintained functional viability. When compared to MS, there was a trend towards preserved cardiac index (CI) in the PS and FS hearts at hr12. At 24 h the FS heart demonstrated statistically significant improvement in CI in the FS group compared to MS heart at hour 24 (P=0.022) (Figure 1A). Preload recruitable stroke work (PRSW) displayed a trend towards improvement in PS and FS hearts compared to the MS heart (Figure 1B). There was no significant decline in dp/dt-max in any hearts from hour 1 to hour 12 and no significant change in the PS and FS hearts from hour 1 to hour 24 (Figure 1C). At hour 24, the FS heart displayed a statistically significant preservation in dp/dt-max compared to the PS heart at hour 24 (P=0.0413). No statistically significant changes in Tau were observed between groups; however, there was a trend towards improved diastolic preservation in the FS group (Figure 1D).
Conclusions: Donor heart function can be reproducibly stratified using full-CO NEHP. PRSW and Tau are load independent during NEHP and appear to be optimal for stratifying systolic and diastolic donor heart function. This is a proof-of-concept study and was not powered for statistical significance.
Authors
Wyeth Alexander (1), Daniel Drake (2), Alvaro Rojas-Pena (3), Robert Bartlett (2), Takahiro Nakashima (2), Kristopher Urrea (4), Vikramjit Chakrabortty (2), Sydney Maddox (5), Joe Niman (2)
Institutions
(1) University of Michigan Health System, Ann Arbor, MI, (2) University of Michigan, Department of Surgery, Ann Arbor, MI, (3) N/A, Ann Arbor, MI, (4) Michigan Medicine - University of Michigan, Saint Joseph, MI, (5) University of Michigan, Ann Arbor, MI
Abstract Presenter
Wyeth Alexander, University of Michigan Health System
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San Diego, CA
United States
Objective:
Remote ex vivo lung perfusion (EVLP) allows for evaluation of donor lungs that otherwise would have been discarded. After a clinical trial demonstrated the feasibility of remote EVLP, centralized evaluation facilities became operational. Real-world outcomes reports showed similar outcomes to the clinical trial for remote EVLP. The characteristics of the donor lungs referred to these facilities is not well known. We report the characteristics of lung grafts referred for evaluation to a centralized EVLP facility located in Jacksonville, FL. from December 2, 2020, to May 30, 2024.
Methods:
We performed a retrospective analysis of donor lungs referred to a centralized lung evaluation facility for remote EVLP between 12/2020 -05/2024. We report the donor characteristics of lungs accepted and rejected for transplantation. Chi-square test was used to compare categorical variables, continuous variables were compared using Mann-Whitney U test.
Results:
Two-hundred-seventy-two lungs were referred for remote EVLP. Thirteen lungs (6 DBDs, 7 DCDs) were not perfused due to poor graft quality and were excluded from the analysis. One-hundred-forty-three cases were referred by 12 transplant centers while the rest were referred by 31 distinct OPOs. Most lung grafts came from DBD donors (71% or 183 of 259). Overall, 144 of 259 perfused lungs were transplanted (utilization=55.6%). The utilization was 60% (109 out of 183) and 46% (35 out of 76) for DBD and DCD lungs, respectively. The utilization was 54% (75/139) for lungs referred by transplant centers and 57% (69/120) for lungs referred by OPOs (p=0.046). Lungs from female donors were accepted at a higher percentage than donors from male donors (p=0.03). Lungs from non-smokers were accepted at a higher percentage than smokers of 10 pack-years or more (p=0.040). Donor's age, chest x-ray (normal/abnormal), sputum culture results (positive/negative), bronchoscopy findings (normal /abnormal) and PaO2/FiO2 were similar between the lungs accepted for transplant and the lungs rejected for transplant after EVLP. The cold ischemia time between cross-clamp and initiation of EVLP was similar for both groups (Table 1).
Conclusions:
In the United States transplant centers and OPO's referred lung grafts for remote EVLP at a centralized facility. The utilization rate of lungs referred to a centralized EVLP facility located in Jacksonville Florida is similar to previous reports (56%). DBD lungs have a higher utilization rate than DCD lungs. Most donor characteristics and CIT-1 were similar between the lungs accepted for transplantation and the lungs that were not accepted for transplantation.
Authors
Jorge Mallea (1), Amaya Moats (1), Sebastian Vega-Rivera (1), Daphne Gomez Escudero (2)
Institutions
(1) Mayo Clinic Florida, Jacksonville, FL, (2) Lung Bioengineering, Jacksonville, FL
Abstract Presenter
Jorge Mallea, Mayo Clinic Florida
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Jacksonville, FL
United States
Doppler Red Blood Cell Backscatter Monitoring for Real-time Assessment of Adequacy of Anticoagulation in an Extracorporeal Circuit: In-Vitro Study
Objective: Red blood cells (RBCs) are primarily responsible for the ultrasound backscatter generated by blood. The ultrasound RBC backscatter is known to be related to the level of RBC aggregation. Increased RBC aggregation can be a precursor for intravascular thrombosis. This study investigates the association between blood ultrasound backscatter signal in an in-vitro extracorporeal membrane oxygenation circuit (ECMO) and the intensity of anticoagulation.
Methods: A mock pediatric extracorporeal membrane oxygenation circuit (ECMO) consisting of a 500 ml venous reservoir, 3/8-inch cardiopulmonary bypass (CPB) tubing, roller pump and an oxygenator was primed with fresh heparinized ovine blood. Activated clotting time (ACT) of >200 secs was achieved and flow of 400 ml/min was maintained. A pulse Doppler probe (GAMPT BCC 100) mounted on the circuit tubing (post-oxygenator) was used to measure the mean ultrasound backscatter signal (volts/second) in the circuit. Blood samples for baseline activated clotting time and complete blood count were drawn. At 60 minutes protamine reversal was given to normalize the ACT. The ultrasound backscatter was monitored in real-time and recorded for analysis.
Results: The anticoagulated (ACT>200 secs) mock ECMO circuits (n=3) produced constant baseline backscatter of 1.1 volts/sec; 1.5 volts/sec; 1.6 volts/1 sec at a hematocrit of 9.6%; 12.2% and 13% respectively. Protamine reversal (ACT <200 secs) led to a steady increase in the baseline ultrasound backscatter signal over 1-2 minutes followed by circuit thrombosis (Figure 1.)
Conclusions: Reversal of anticoagulation in an in-vitro ECMO circuit is associated with a sustained increase in the measured mean ultrasound backscatter signal followed by circuit thrombosis. Doppler RBC backscattering monitoring can potentially be used for the real-time assessment of adequacy of anticoagulation in an extracorporeal circuit.
Authors
Syed Peer (1), Teri Ulferts (2), Satoshi Miyairi (1), Pranava Sinha (1)
Institutions
(1) University of Minnesota, Masonic Children's Hospital, Minneapolis, MN, (2) Experimental Surgical Services, University of Minnesota, Minneapolis, MN
Abstract Presenter
Syed Peer, University of Minnesota
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Minneapolis, MN
United States
Objective: Donation after circulatory death (DCD) is a promising strategy to alleviate the shortage of hearts for transplantation. Ischemia-reperfusion injury (IRI) is inherent to the DCD process and is proportional to warm ischemia time (WIT). Therefore, donor hearts with WIT beyond 30 minutes are generally not accepted. A principal mediator of IRI is calpain-1 (CPN1), a cysteine protease found within the cytosol and mitochondria. CPN1 activation leads to degradation of cytosol and mitochondrial structural proteins, ultimately resulting in mitochondrial dysfunction and cell death. MDL-28170 (MDL) is a selective CPN1 inhibitor and has been shown to limit cardiac IRI in DCD hearts undergoing 25 minutes of ischemia; however, data beyond this ischemia time is unknown. Our aim was to assess infarct size and graft function of DCD rat hearts treated with MDL during reperfusion following 35 minutes of ischemia.
Methods: Male Sprague-Dawley rats were assigned to one of three groups: continuous beating-heart donors (CBD) (n=10), DCD donors with 35 minutes of ischemia without MDL treatment (n=7), and DCD donors with 35 minutes of ischemia with MDL treatment (n=8). All donor rats were anesthetized, intubated, and connected to a ventilator. Animals in the DCD protocol received vecuronium bromide (1.2 mg/kg) to paralyze the diaphragm. Ventilator support was then terminated, marking the start of the ischemia time. Following 35 minutes, hearts were procured and re-perfused ex-vivo with Krebs-Henseleit (KH) buffer on a Langendorff setup for 90 minutes. Treated hearts received 10 mM of MDL in KH buffer. CBD hearts procured without ischemia and immediately re-perfused using KH buffer served as controls. Cardiac function was assessed with a balloon-tipped catheter placed in left ventricle to record developed pressure (DP) and rate pressure product (RPP). Timed coronary effluent was collected to monitor coronary perfusion. Infarct size was measured using triphenyl-tetrazolium chloride (TTC) staining.
Results: Following 35 minutes of ischemia, rat hearts treated with MDL had significantly reduced infarct size compared to untreated hearts (33.26% ± 1.54 vs. 40.16% ± 1.53, respectively; p < 0.05). Both groups had significantly higher infarct size compared to CBD hearts (7.67% ± 1.12). Additionally, while CBD hearts demonstrated significantly higher DP, RPP and coronary effluent flow rate compared to DCD hearts, there were no significant differences between treated and untreated DCD hearts for DP (36.52 ± 2.77 mmHg vs. 24.73 ± 2.83 mmHg), RPP (8174 ± 821 mmHg*BPM vs. 6245 ± 739 mmHg*BPM) or coronary effluent flow rate (18.18 ± 0.648 mL/min vs. 13.23 ± 0.814 mL/min), respectively (Figure).
Conclusion: DCD hearts sustain large infarct with 35 minutes of ischemia. MDL treatment significantly decreased the infarct size in DCD hearts compared to untreated hearts. MDL can potentially be used to limit IRI in DCD hearts with longer ischemia times.
Authors
Zachary Kiernan (1), Gina Labate (1), Qun Chen (1), Mohammed Quader (1)
Institutions
(1) Virginia Commonwealth University, Richmond, VA
Abstract Presenter
Zachary Kiernan
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Richmond, VA
United States
Objective:
The objective of this single center study was to evaluate the impact of Impella 5.5 prolonged use on the access site vessel, to determine whether prolonged use is associated with dissection or thrombosis at the insertion site.
Methods:
This retrospective observational study included all patients who underwent Impella 5.5 support between February 2020 and March 2024. Data collection included baseline demographics, risk factors, procedural details, and clinical outcomes such as mortality, complications related to Impella use and ability to wean from mechanical circulatory support. Statistical analysis included descriptive statistics and appropriate inferential tests for comparison between groups.
Patients who underwent contrast enhanced CT scan during their mechanical circulatory support with Impella 5.5 were included in the review. The images were evaluated for presence of any dissection or thrombosis (partial or complete), or any other vascular complication related to the site of Impella device insertion.
Results:
A total of 145 patients (mean age 57.7, 88% male) were treated with Impella 5.5 during the study period. 29 (20%) had cross-sectional imaging performed in the time between device insertion and its removal. 7 of these scans were without contrast and therefore excluded from final review.
Of the 22 contrast-enhanced CT scans visualizing the area of interest 6 (27%) had evidence of partial thrombosis of the subclavian or axillary artery. Notably only one of these patients (4.5%) had clinical evidence of acute limb ischemia requiring revascularization procedure. More importantly 2 (33%) of the patients with imaging evidence of vessel thrombus developed an ischemic stroke while on mechanical circulatory support. Another 1 patient with evidence of thrombus burden developed ischemic strokes after MCS discontinuation 6 months later.
Of the original 29 patients with cross-sectional imaging performed in the time between device insertion and its removal, 17 of them also had additional contrast-enhanced CT scans after removal of the Impella 5.5. These scans ranged from 1 day post removal to 7 months post removal. 2 (11.7%) of these patients had new non-flow limiting dissections at the access site vessel that were not visualized on prior imaging. 6 (35%) of these patients had evidence of non-occlusive thrombus in the axillary or subclavian artery. 1 of these (16.7%) patients with new imaging evidence of vessel thrombus developed an ischemic stroke on post device removal day 4.
Conclusions:
Thrombosis at the site of Impella 5.5 insertion is a potentially under-diagnosed complication of this mechanical circulatory support device. Performing contrast-enhanced cross-sectional imaging on patients on prolonged support may help tailor anti-thrombotic therapy and prevent clinically significant complications.
Authors
Jacob Watson (1), Tommaso Cambiaghi (1), Fatima Qamar (1), Therese Hoof (2), Memhet Akay (2)
Institutions
(1) Houston Methodist Hospital, Houston, TX, (2) Houston Methodist, Houston, TX
Abstract Presenter
Tommaso Cambiaghi, Houston Methodist Hospital
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Houston, TX
United States
Objective:
To assess gender-based differences in hemodynamics and kidney outcomes at our center. Impella 5.5 devices are increasingly utilized in patients with cardiogenic shock (CS) to provide hemodynamic support, left ventricular unloading, and reduction in left ventricle end-diastolic pressure thereby lowering myocardial oxygen demand and improving end-organ perfusion.
Methods:
A retrospective cohort analysis of patients with CS at Mayo Clinic in Florida supported by Impella 5.5 between March 2019 and October 2021 was performed. Mann-Whitney U and paired t-test was performed with significance set at p < 0.05.
Results
The study investigated cardiovascular and renal parameters among a population of sixteen consecutive patients, equally stratified by gender. The mean age for females was 53 and 55 for males with BMI of 27.1 and 29.4 respectively. Females were found to have higher baseline MAP (86 vs. 74, p=0.007) and lower cardiac index of 1.65 L/min/m2 vs. 2.04 l/min/m2, p=.004. Post-device placement, PA pressures were markedly lower in females with PAs of 46 vs 53, p=.002 and Pad of 19 vs 24, p=.012. There was also a significant increase in post-Impella GFR in females compared to males, 79 vs 67, p=.004. All patients survived until heart transplantation while supported with the Impella 5.5 without the need for renal replacement therapies.
Conclusions:
These findings highlight significant gender differences in the outcomes of patients with cardiogenic shock when managed with temporary mechanical circulatory support. Further assessment in larger data sets should be utilized to determine the appropriateness of standardized criteria for all patients requiring advanced therapies.
Authors
Shriya Sharma (1), Rohan Goswami (2), Jose Ruiz (2), Aarti Desai (2), Juan Leoni (2)
Institutions
(1) Mayo Clinic in Florida, Jacksonville, Fl, (2) Mayo Clinic in Florida, Jacksonville, FL
Abstract Presenter
Shriya Sharma, Mayo Clinic in Florida
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Vienna, ON
Austria
Heart Transplant from a Donor with Malignant Hyperthermia
Caleb Sokolowski M.D., Joshua Newman M.D., Zachary N. Kon M.D., Christina E. Saikus M.D. Ph.D.
Northwell Health/Zucker School of Medicine at Hofstra/Northwell
Objective: A male in his late 60's was listed for heart transplantation due to stage D non-ischemic cardiomyopathy requiring inotropic support. The patient's large size, blood group, and status made identifying a suitable donor challenging and the patient experienced prolonged waiting time during which he required hospitalization due to bacteremia and arrhythmia episodes. A suitable donor was identified but carried a history of malignant hyperthermia (MH). After thorough discussion with the patient, the organ was accepted.
Methods: Due to the donor's history of malignant hyperthermia, the donor recovery case was performed with MH precautions and the recipient case was completed using the guidelines for perioperative care of patients with malignant hyperthermia. The anesthetic workstation and machine were prepared to avoid exposure to residual volatile anesthetics. Anesthesia was commenced with the avoidance of all potential triggers (e.g. Desflurane, Sevoflurane, Isoflurane, Halothane, Methoxyflurane, and Succinylcholine). Total intravenous anesthesia (TIVA) was used with rocuronium for paralysis and a combination of propofol, dexmedetomidine, and sufentanil for sedation and analgesia. No volatile anesthetics were used in the cardiopulmonary bypass circuit.
Results: A cardiac donor with a history of MH poses potential ethical, clinical, and practical considerations to the heart failure team. It is plausible that the recipient may not be affected due to ryanodine receptors predominant concentration on skeletal muscle; however, a paucity of data renders it unknown what implications introducing a MH positive heart has on a transplant recipient. In this case, total intravenous anesthesia was used, and the recipient experienced no signs or symptoms of malignant hyperthermia. The patient had an uneventful postoperative course and was discharged home in stable condition.
Conclusion: We present a patient with limited compatible organ offers who underwent successful orthotopic heart transplant with a heart from a donor with a history of MH. With the appropriate donor and recipient considerations, this donor diagnosis may not preclude heart donation.
Authors
Caleb Sokolowski (1), Joshua Newman (2), Zachary Kon (3), Christina Saikus (4)
Institutions
(1) Northwell Health/Long Island Jewish Medical Center, Port Washington, NY, (2) North Shore University hospital, United States, (3) N/A, New York, NY, (4) N/A, Great Neck, NY
Abstract Presenter
Caleb Sokolowski, Northwell Health
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Port Washington, NY
United States
Objective. Durable Left Ventricular Assist Devices (LVADs) require a manually sutured apical cuff - left ventricular anastomosis. We developed an attachment device to automate this anastomosis for the most common durable LVAD. It is low profile to facilitate minimal exposure. The purpose of this study was to assess implant time, acute hemostasis, and chronic durability of apical cuff anastomosis using this device in acute and chronic (60 days) bovine calf models.
Methods. The device is comprised of 12 helical coil tissue anchors, 4 compression plates, and a delivery tool. Apical cuff anastomoses were performed in bovine calves. Implants were video recorded and photographed. Intravenous (IV) heparin was administered to Activated Clotting Time >300 seconds. Implant time was from first device epicardial contact to delivery tool release. The apex was cored, and the cuff site was occluded with a custom plug. Bleeding was assessed qualitatively by an experienced LVAD surgeon and characterized by Likert Scale (1=unacceptable, 2=poor, 3=acceptable, 4=good, 5 =excellent). ACUTE MODEL (n=6): Implants were by full median sternotomy. A proof-of-concept delivery tool requiring sequential tissue anchor deployment by hand-held driver was used in 3 cases. A fully automated synchronous anchor deployment tool was used in 3 cases. Caval inflow occlusion was used for coring and plugging. Animals were resuscitated to baseline blood pressure (BP). Bleeding was assessed at baseline and at supraphysiologic BP (norepinephrine). Implants and attachment components were examined after euthanasia. CHRONIC MODEL (n=3): The synchronous delivery tool was used via lower partial sternotomy. Coring and plugging were done on cardiopulmonary bypass (CPB-cervical cannulation). Acute hemostasis was assessed after CPB and after protamine. IV heparin was initiated at 12-24 hours and transitioned to warfarin (goal INR >2.5). Serial hematocrit, chest tube outputs, and INR were recorded. Necropsy was performed by a veterinary pathologist with extensive preclinical LVAD experience. Anchor position was compared by acute and necropsy photograph comparison. After gross inspection all hardware was removed and examined. Histopathologic heart and end organ examination was performed.
Results. Acute implant time ranges were: 77-93 (sequential), and 22-32 (synchronous) seconds. Hemostasis score was 3 (acceptable) in 1 and 4 or 5 (good-excellent) in 5 at baseline and induced supraphysiologic BP (range: 192-247 mm Hg). Chronic implant time range was 17-20 seconds. Intra-operative hemostasis score was 5 (excellent) in all cases. No animals were transfused. Twenty-four-hour hematocrit increased from intraoperative baseline by +2% to +5%. All chest tubes were removed within 48 hours. At necropsy (60±4 days) there were minimal pericardial and pleural adhesions, no pseudoaneurysms, or evidence of bleeding. All implants had stable anchor positions and a concentric ring of dense fibrous scar at the junction between the inner circumference of the apical cuff metal cylinder and the cored epicardial edge (see figure). Implant histopathology was similar to sutured apical cuff anastomoses observed in prior preclinical LVAD studies.
Conclusions. The device produced a hemostatic and durable apical cuff anastomosis. Advantages are rapid implant time, hemostasis, standardized technique, and low profile for limited exposure. The technology is adaptable for other intraventricular access requirements.
Authors
Max Mitchell (1), Jeremy Morgan (2), Daniel Sims (2), Jeffrey Steinmetz (2), Christopher Banas (2)
Institutions
(1) Children's Hospital Colorado, Aurora, CO, (2) ConneX Biomedical, Inc., Aurora, CO
Abstract Presenter
*Max Mitchell, University of Colorado Anschutz Medical Center
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Aurora, CO
United States
Objective: Organ recovery for heart transplantation (HT) has historically been performed by surgical fellows or attending cardiothoracic surgeons. In the era of machine perfusion, normothermic regional perfusion (NRP), and increasing utilization of expanded criteria and donation after cardiac death (DCD) donors, the need for highly skilled recovery surgeons has grown. Longer travel for heart recovery since the 2018 allocation change has increased strain on surgeons trying to balance clinical and other responsibilities, particularly at high volume centers. In an effort to alleviate this strain, our center incorporated an experienced and specially trained physician assistant (PA) as an integral lead surgeon for heart recoveries over the past two years. This strategy has mitigated the burden on cardiothoracic fellows and attendings while maintaining high quality allograft recovery. We sought to compare characteristics and outcomes of HT performed using this recovery strategy versus those in which heart recovery was performed only by physician surgeons.
Methods: We retrospectively reviewed all adult heart transplants between July 2022 and December 2023 at our institution. Patients undergoing multi-organ transplant and those with adult congenital heart disease were excluded. Patients were grouped based on the recovering team, either including a PA or exclusively faculty/fellow. We compared donor and recipient demographics, recovery characteristics such as procurement type (DBD, DCD), ischemic time, and recipient outcomes. Statistical comparisons were performed using Fisher's exact test for categorical variables and Wilcoxon signed-rank test for continuous variables.
Results: During the study period, 142 adult heart transplants met inclusion criteria. 92 recoveries (65%, 92/142) were performed by the PA and 50 recoveries (35%) were performed by surgical fellows/attendings. 63% (58/92) of the recoveries in the PA group were DCD compared to 24% (12/50) in the physician group (p<0.001). The average cold ischemic time was 210.5 ± 96.5 minutes in the PA group compared to 187.0 ± 66.8 minutes in the physician group (p=0.105). Among DCD-NRP recoveries, the rate of surgical complications resulting in organ turndown was lower in the PA group (0%, 0/58) compared to the physician group (16.6%, 2/12, p=0.027). All other donor characteristics and all recipient characteristics such as age, waitlist status, heart failure etiology, and lab values were similar between groups. Incidence of severe primary graft dysfunction (PGD) (8.7%, 8/92 v. 10.0%, 5/50, p>0.99) and one-year mortality were similar (2.2%, 2/92 v. 6.0%, 3/50, p=0.345) between groups.
Conclusions: In our experience, the utilization of an experienced surgical PA as opposed to cardiothoracic surgeons or fellows was associated with similar rates of severe PGD and 1-year survival among recipients, even in high-risk cases. As the number and complexity of heart recoveries increases, utilization of surgical PAs may afford cardiothoracic surgeons more bandwidth for other clinical and non-clinical responsibilities, while complementing the education of cardiothoracic surgical trainees.
Authors
Stephen DeVries (1), Swaroop Bommareddi (2), Mark Petrovic (2), Chen Chia Wang (2), Hasan Siddiqi (2), Kelly Schlendorf (2), Eric Quintana (2), Joseph Magliocca (2), Seth Karp (2), John Trahanas (2), Ashish Shah (2), Brian Lima (2)
Institutions
(1) Vanderbilt University Hospital, Nashville, TN, (2) Vanderbilt University Medical Center, Nashville, TN
Abstract Presenter
Stephen DeVries, Vanderbilt University Hospital
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Chicago, IL
United States
Objective: The objective of this study was to investigate the relationship between the duration of Impella 5.5 therapy and the risk of stroke in patients with severe heart failure requiring mechanical circulatory support.
Methods: A retrospective cohort study was conducted including all consecutive patients who received Impella 5.5 support between February 2020 and March 2024 at our institution. Data on patient demographics, duration of Impella therapy, incidence of stroke during or outside of mechanical circulatory support, and other relevant clinical variables were collected from electronic health records. The primary outcome was the incidence of stroke during Impella 5.5 therapy, with duration of therapy categorized into four groups for analysis.
Results: A total of 145 patients (mean age 57.7, 88% male) were included in the analysis. 25 patients (17.2%) experienced a stroke during the study period, 15 of which (10%) happened during Impella 5.5 support. The median duration of therapy was 24 days (IQR 12-51 days).
Incidence of stroke during Impella 5.5 therapy was 4.5% for group 1 (0-7 days), 4.2% for group 2 (8-14 days), 4.5% for group 3 (15-21 days) and 16% for group 4 (>21 days). The difference in stroke incidence between patients who received Impella support for less than 21 days and those who received it for longer than 21 days was statistically significant (p=0.05).
Conclusions: Prolonged therapy with the Impella 5.5 is associated with a higher risk of stroke in patients with severe heart failure. Clinicians should consider this risk when determining the duration of mechanical circulatory support with the Impella 5.5 and evaluating weaning strategies. Protocols to mitigate the risk of stroke, such as careful patient selection, monitoring, and potentially earlier device removal when feasible, should be explored in future studies to optimize outcomes for these critically ill patients.
Authors
Tommaso Cambiaghi (1), Therese Hoof (1), Fatima Qamar (1), Memhet Akay (1)
Institutions
(1) Houston Methodist, Houston, TX
Abstract Presenter
Therese Hoof, Houston Methodist
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Osaka, ON
Japan
Objective: Left ventricular assist device (LVAD) explant at the time of heart transplantation (HT) remains technically challenging and can be associated with perioperative hemorrhage. Techniques such as wrapping the outflow graft and/or chassis with polytetrafluoroethylene (PTFE) during implantation may facilitate hemostasis during redo sternotomy and adhesiolysis. However, these safeguards are not universally adopted or formally evaluated. In this study, we investigated the association between PTFE coverage of LVAD components and intraoperative and postoperative blood requirements during the subsequent LVAD explant-HT.
Methods: From November 2018 to December 2023, a total of 623 HTs were performed at a single institution. Of these, only patients with intrathoracic, fully magnetically levitated centrifugal-flow LVAD explants were included in our study. Patients were divided into four groups based on coverage during implantation: no PTFE coverage, chassis coverage only, outflow graft coverage only, and complete coverage. Intraoperative blood requirement was calculated as the sum of all intraoperative packed red blood cell (pRBC), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusions. Postoperative blood requirement was the sum of all pRBC, platelet, and FFP transfusions within 48 hours of HT. Multivariate linear regression models were used to control for other factors associated with blood product use, such as multi-organ transplant and history of multiple sternotomies. Other outcomes included cumulative 48-hour postoperative chest tube output, rates of reoperation for bleeding, extracorporeal membrane oxygenation (ECMO) requirement, and 30-day and one-year mortality.
Results: There were 104 qualifying VAD-explant HT during the study period, of which 18 had no PTFE coverage, 24 had only outflow graft coverage, 3 had only chassis coverage, and 59 had complete coverage. Donor and recipient demographics, cold ischemic time, and predicted heart mass ratio were similar between groups. Recipient baseline platelets, international normalized ratio, number of prior sternotomies, and rates of multi-organ transplant were also comparable. Patients with both outflow graft and chassis covering had significantly lower cumulative chest tube output (1838 vs 3191mL, p=0.037) compared to patients with no PTFE covering, but no significant difference compared to patients with only outflow graft (p=0.848) or chassis (p=0.948) covering. Linear regression adjusting for prior sternotomies and multi-organ transplants demonstrated that, relative to LVADs with both outflow graft and chassis covered, LVADs with no PTFE coverage had significantly higher intraoperative (estimate 2367 mL, SD 768, p=0.003) and postoperative transfusion requirements (estimate 2677 mL, SD 983, p=0.008). Rates of reoperation for bleeding, ECMO at 24 hours post HT, and mortality at 30 days and one year were comparable between the study groups.
Conclusions: LVAD implant techniques are currently heterogeneous in clinical practice, and difficult explants pose a major risk for hemorrhage during and after HT. This study demonstrated that PTFE coverage of the outflow graft and chassis during implant of the LVAD type examined is associated with substantially lower intraoperative and postoperative blood products utilization. Adopting this technique as standard of care during implants could greatly reduce the risk for patients requiring LVAD implant as a bridge to HT.
Authors
Chen Chia Wang (1), Mark Petrovic (1), John Trahanas (2), Jennifer Garcia (1), Emma Ye (1), Yuliya Tipograf (2), Alexandra Debose-Scarlett (2), Swaroop Bommareddi (2), Duc Nguyen (2), Hasan Siddiqi (2), Christina Jelly (2), Aditi Balakrishna (2), Kelly Schlendorf (2), Ashish Shah (2), Brian Lima (2)
Institutions
(1) Vanderbilt University School of Medicine, Nashville, TN, (2) Vanderbilt University Medical Center, Nashville, TN
Abstract Presenter
Chen Chia Wang
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Nashville, TN
United States
Objectives
Approximately 25-40% of simultaneous heart/kidney transplant (SHKT) recipients require renal replacement therapy (RRT) within 30 days of transplant. Our institution historically performed SHKT in separate operations with a period of resuscitation in the intensive care unit following heart transplantation (HT). In this case of a patient bridged to SHKT with an Impella 5.5, the device was preserved following HT to provide mechanical support and facilitate kidney transplantation in the same operative encounter with the goal of reducing delayed graft function of the kidney.
Methods
Our patient is a 60-year-old man, blood group O, ischemic cardiomyopathy (EF 20%), stage 3b chronic kidney disease due to diabetes, and listed status 5 for combined heart/kidney transplant. Due to worsening hemodynamics (cardiac index 1.7L/min/m2, mean PA pressures 37 mm Hg, and PCWP 28 mmHg) and rising creatinine (Cr 1.8-2.1 mg/dL, eGFR 30 ml/min/1.73 sqm) despite inotropes, a right axillary Impella 5.5 was inserted. After waiting 32 days as status 2, the patient underwent SHKT from a neurologically dead donor whose cause of death was blunt trauma. The donor had normal cardiac function, a KDPI of 9%, normal creatinine, and a small subcapsular hematoma of the kidney. Bicaval heart transplant was performed with a 226 minute ischemia time. The Impella driveline was cross-clamped with the aorta and preserved during cardiectomy. During the aortic anastomosis, the Impella was flushed with heparinized saline and then repositioned across the aortic valve. Following reperfusion, the recipient was able to be weaned from bypass without issue with a cardiac index of 2.5 L/min/m2. At the end of the HT, the patient was supported with the Impella on p7, flowing 4 liters, and 0.08 mcg/kg/min epinephrine primarily for right heart support. The kidney was transplanted in the iliac fossa with 10 hours cold ischemia and 32 minutes out of ice time and thymoglobulin induction immediately following chest closure.
Results
After an uneventful operative course, the patient left the OR with 0.06 mcg/kg/min epinephrine, 0.04 mcg/kg/min norepinephrine, 0.04 units/kg/min vasopressin, and 5 mcg/kg/min dobutamine, along with Impella support. He was extubated and out of bed 18 hours after surgery, with a single agent inotrope (5 mcg/kg/min of dobutamine), and standard triple immunosuppression with tacrolimus, mycophenolate, and steroids. Heart and kidney function were excellent with immediate production of urine. The Impella was weaned and removed by postoperative day 4 and inotropes discontinued by postoperative day 7. He produced more than 2.5 liters of urine daily, with creatinine peaking at 2.39 mg/dL and ending at 0.9 mg/dL, without needing RRT. He was discharged on postoperative day 15 with an uneventful course and seen in outpatient follow-up with excellent heart and kidney graft function.
Conclusions
In our patient who was bridged to SHKT with an Impella 5.5, leaving the device for temporary mechanical support allowed for kidney transplant in the same operative encounter, early mobilization, reduction of vasoactive agents, and importantly, may have reduced the risk of delayed graft function and need for RRT. In select patients, this strategy may be considered to improve outcomes following SHKT.
Authors
Angela Kristo (1), Romulo Fajardo (2), John Harrison (3), Paul Tessman (4), Joshua Hermsen (5), Nikole Neidlinger (6), Yu Xia (7)
Institutions
(1) N/A, Madison, WI, (2) University of Wisconsin-Department of Cardiothoracic Surgery, Madison, WI, (3) University of Wisconsin Department of Anesthesiology, Madison, WI, (4) University of Wisconsin Department of Cardiothoracic Surgery, Madison, WI, (5) University of Wisconsin, Madison, Madison, WI, (6) University of Wisconsin Department of Transplant Surgery, Madison, WI, (7) Division of Cardiothoracic Surgery, University of Wisconsin Department of Surgery, Madison, Madison, WI
Abstract Presenter
Angela Kristo, University of Wisconsin
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Madison, WI
United States
Objective: Reoperation for durable left ventricular assist device (LVAD) insertion after coronary artery bypass grafting (CABG) is challenging due to potential injury to bypass grafts, great vessels, or the right ventricle (RV). We sought to analyze if less invasive LVAD implantation may improve outcome due to limited dissection around the heart which can reduce bleeding, graft injury, or RV failure.
Method: From Mar. 2012 to May. 2024, 29 patients with history of CABG received reoperative LVAD; 16 patients had redo full sternotomy (Group FS) and 13 patients had less invasive approach (Group LI). Since May 2019, LI approach has been used which includes: an inverted-T upper hemisternotomy at the level of the 2nd or 3rd intercostal space, dissection along the chest wall into the left pleural space, anastomosis of inflow cuff incorporating pericardium via a left thoracotomy in the 5th or 6th intercostal space, routing the outflow graft through the left pleural space, and outflow graft anastomosis to the ascending aorta. Either ascending aorta or axillary artery was used for arterial return and femoral vein was percutaneously cannulated.
Results:
The median age was 68 years in Group FS and 66 years in Group LI (P=0.81), respectively. The median duration from the last cardiac surgery was 118 [29, 192] months. Six patients had preoperative veno-arterial extracorporeal membrane oxygenation support (Group FS, 18.8% [N=3] vs. Group LI, 23.1% [N=3], P=0.56). Heartmate 2 was exclusively used in Group FS (Group FS, 56.3% [N=3] vs. Group LI, 0%), while HeartWare was predominantly used in group LI (FS, 31.3%, [N=5] vs. LI, 53.8% [N=7]. Heartmate3 was used in 6 patients. Left internal mammary artery graft was patent in 25 patients (86.0%). None of patients had injury of bypass graft. Concomitant procedure was performed in 5 patients in FS group (aortic valve, N=3, and tricuspid valve, N=2). In isolated LVAD implantation, cardiopulmonary bypass time was comparable between groups (FS, 92 [68, 96] min vs. LI, 82 [61, 96] min, P=0.33). The incidence of severe RV failure requiring mechanical support was less in LI groups (FS: 43.8% [N=7] vs. 0%, P=0.01), as was hospital mortality (FS: 31.3% [N=5] vs. LI, 9.1% [N=1], P=0.18). The rate of tracheostomy (FS: 62.5% [N=10] vs. 23.1 % [N=3], P=0.06) and hemodialysis (FS: 37.5% [N=6] vs. 7.7 % [N=1], P=0.18) were numerically higher in FS group. One-year estimated survival was not significantly different (FS: 68.8+\-11.6% vs. LI, 83.1 8+\-11.0 %, P=0.97).
Conclusions: Less invasive reoperative LVAD insertion may have a potential to reduce RV failure and hospital mortality in patients with history of CABG compared to FS approach, and can improve overall outcomes.
Authors
Junichi Shimamura (1), Sooyun Tavolacci (1), Elliot Levine (1), David Spielvogel (1), Masashi Kai (2), Suguru Ohira (1)
Institutions
(1) Westchester Medical Center, Valhalla, NY, (2) Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Abstract Presenter
Junichi Shimamura, Westchester Medical Center
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Valhalla, NY
United States
OBJECTIVE: Sepsis incidence in patients with left ventricular assist devices (LVADs) is known to be associated with worse clinical outcomes. The incidence and outcomes of sepsis during index implantation of LVADs, however, is lacking examination in literature. We sought to conduct a systematic review to assess the current known incidence of sepsis during index implantation and its outcomes.
METHODS: Using the PubMed, CINAHL, and Embase databases, we conducted a thorough search for studies that investigated infections and sepsis incidence in patients undergoing LVAD implantation from inception until March 2024. From these studies, we extracted the patient demographics, adverse outcomes of interest, and study characteristics. Our outcomes of interest included incidence of LVAD implantation complicated by sepsis, implant mortality related to sepsis, implant length of stay (iLOS), and 1-year survival.
RESULTS: From a retrieved total of 294 records, 9 studies met the final inclusion criteria to be included in the review, with a total of 24,795 patients. No studies reported on all 4 outcomes of interest. 89% of the studies reported the incidence of sepsis during index LVAD implantation hospitalization, with an incidence ranging from 3% - 60%. 22% studies commented on sepsis related mortality, with 1 reporting a 35.4% in-hospital mortality in those patients in whom LVAD implantation was complicated by sepsis. 1 study reported iLOS to be prolonged in those patients with sepsis versus those whose implant was not complicated by sepsis (43.8 vs 26.4 days). No studies commented on the relationship between sepsis and 1-year survival.
CONCLUSIONS: Outcomes of interest and its definitions varied widely between the studies, thus necessitating a narrative synthesis of the included studies. Narrative synthesis showed that sepsis incidence during index implantation is widely variable, more likely associated with higher rates of implant mortality and increased LOS. Due to the limited data currently available on index LVAD implantation related sepsis and its clinical outcomes, standardization of data collection and reporting metrics to guide additional research is needed to optimize outcomes.
Authors
Sarah Allbright (1), Parth Patel (2), Mustafa Ahmed (3)
Institutions
(1) University of Florida, Gainesville, FL, (2) University of Florida College of Medicine, Gainesville, FL, (3) University of Florida Health, Gainesville, FL
Abstract Presenter
Sarah Allbright, University of Florida
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Osaka, ON
Japan
Objective: The Impella 5.5 is a novel temporary mechanical circulatory support device used in the treatment of cardiogenic shock as a bridge to recovery or heart replacement therapy. We sought to assess the hemodynamic and clinical response to Impella 5.5 in patients with cardiogenic shock and identify predictors of response to this device.
Methods: We retrospectively reviewed 265 patients undergoing Impella 5.5 implantation from 2020-2024 at two institutions to identify patients in cardiogenic shock. Patients with preoperative extracorporeal life support (ECLS) were excluded. Clinical deterioration on Impella 5.5 was defined as failure to bridge to either recovery with discharge on medical therapy or to heart replacement therapy (HRT; durable left ventricular assist device or heart transplant) with Impella 5.5 alone.
Results: We identified 177 patients who met the criteria. Fifty patients (28%) deteriorated while on support and needed escalation to ECLS and/or died in-hospital, while 127 (72%) were successfully bridged to HRT or discharged without need for escalation of device support. Creatinine (1.54 vs. 1.27, p=0.041), lactate (1.4 vs. 1.0, p=0.001), white blood cell count (9.13 vs. 7.60, p=0.016), central venous pressure (CVP) (11 vs. 9, p= 0.029), and tricuspid regurgitation (TR) severity (moderate vs. mild, p=0.016) prior to implantation were all significantly higher in those that deteriorated, while pulmonary artery pulsatility index (PAPi) was lower (2.08 vs. 2.94, p=0.033). Rates of stroke (14% vs. 3% p= 0.019), AKI requiring CRRT (30% vs. 6%, p<0.001) and tracheostomy (14% vs. 3% p=0.019) were significantly higher in those who deteriorated. After adjusting for age, sex and CVP, TR was identified as a predictor of clinical deterioration on Impella 5.5 (OR 1.72, 95% CI 1.07-2.86, p=0.03). Similarly, PAPi <2.5 was significantly associated with clinical deterioration after adjusting for age and sex (OR 2.99, 95% CI 1.38 - 6.72; p= 0.006).
Conclusions: Overall outcomes with Impella 5.5 in cardiogenic shock patients are encouraging, and Impella 5.5 is a reasonable first-line device for stabilizing these patients. Baseline right ventricular function as measured by PAPi and TR severity were identified as predictors of worse outcomes with Impella 5.5 in this population.
Authors
Gabriel Dardik (1), John DePaolo (2), Marisa Cevasco (2), Yuji Kaku (1), Christine Yang (1), Mauer Biscotti (2), Joyce Wald (2), Nir Uriel (1), Gabriel Sayer (1), Koji Takeda (1), Justin Fried (1)
Institutions
(1) Columbia University Irving Medical Center, New York, NY, (2) Hospital of the University of Pennsylvania, Philadelphia, PA
Abstract Presenter
Gabriel Dardik, Columbia University Irving Medical Center
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LIVINGSTON, NJ
United States
Objective: In an effort to prioritize the most critically ill patients with heart failure and decrease overall waitlist mortality, the 2018 UNOS allocation policy change transitioned from a 3-tiered system, where Status 1A was composed of a heterogeneous group of qualifications, to a more stratified 6-tiered system. One concern was that overall transplant survival might decrease due to the increased acuity of the new Status 1 cohort, comprised primarily of those on ECMO support, who historically have experienced poor post-transplant survival. We aimed to evaluate our own institution's post-transplant survival in patients listed as Status 1 in the new era.
Methods: A single-center retrospective review of all adult heart transplant recipients with biventricular failure listed as Status 1 was conducted between 4/2019 and 4/2024. Patients who were listed as Status 1 by exception request for other causes were excluded. Demographic variables analyzed included age, gender, race, BMI, and etiology of heart failure. Waitlist variables included waitlist duration and mechanical circulatory support devices implanted during the waitlist period, including ECMO, Impella, IABP, RVAD, and durable LVAD. Intraoperative transplant variables analyzed included organs transplanted, cardiopulmonary bypass time, cold ischemia time, total operative time, and intraoperative blood products received. The primary outcome was 1-year mortality. Secondary outcomes focused on morbidity, and included prolonged intubation, tracheostomy, pneumonia, stroke, dialysis, reoperation for any cause, and ICU and postoperative lengths of stay.
Results: A total of 34 heart transplant recipients with biventricular failure who were listed as Status 1 were included over the study period. Median age of the cohort was 51 years, with a male predominance (82%). The majority of patients presented with non-ischemic cardiomyopathy (74%). All patients were bridged to transplant on mechanical circulatory support, half of whom required ECMO support (50%) for a median duration of 7 days. Those who were able to be weaned from ECMO support commonly required a combination of Impella and percutaneous RVAD support, with a median duration of 15 days. One patient was bridged to transplant with a total artificial heart that was implanted for 107 days prior to transplant. Median waitlist duration for the entire cohort was 9 days. While the majority of patients (62%) underwent isolated heart transplant, 21% received simultaneous heart/lung transplants, and 18% received heart/kidney transplants. Median cardiopulmonary bypass time was 139 minutes with a median cold ischemic time of 207 minutes. Total operative time ranged between 5 and 7 hours. Regarding the primary outcome, there were no 1-year mortalities at a mean follow up of 436 days. Postoperatively, 44% of patients experienced prolonged intubation. Nine patients underwent delayed chest closure, and seven patients required postoperative mechanical circulatory support. Median ICU length of stay was 9 days, with a median postoperative length of stay of 20 days.
Conclusions: The 2018 UNOS allocation policy change aimed to prioritize the highest acuity patients by awarding them Status 1 listing, raising concerns over post-transplant survival. We report our institutional experience with 34 patients with biventricular failure listed as Status 1 and successfully transplanted with no mortalities within 1 year.
Authors
Michael Dorsey (1), Jeffrey Park (1), Katherine Phillips (1), Alex Reyentovich (1), Randal Goldberg (1), Nader Moazami (1), Deane Smith (1)
Institutions
(1) NYU Langone Health, New York, NY
Abstract Presenter
Michael Dorsey, NYU Langone Health
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New York, NY
United States
Objective: To determine the association of prolonged normothermic regional perfusion (NRP) evaluation on the outcomes of lung transplant recipients.
Methods: The United Organ Sharing Database was queried from 1/1/2019 to 3/31/2024 for recipients who received lungs from donation after circulatory death (DCD) donors who were evaluated for heart transplantation using NRP. NRP donation was determined if a donor heart was evaluated for transplantation and had a circulatory standstill to aortic cross-clamp time (warm ischemic time [WIT]) > 40 minutes). Recipients were then stratified into short evaluation (SE, 40-90 minutes) or long evaluation (LE, >90 minutes). The groups were then analyzed with comparative statistics, and Kaplan-Meier method for survival. Next, a 1:1 nearest neighbor propensity match (caliper 0.2, all standard mean differences [SMD]<0.1) based on select donor and recipient characteristics was performed to further compare SE and LE. The matched groups analyzed with comparative statistics and survival was assessed with the Kaplan-Meier method.
Results: 76 patients were stratified into the LE group, and 151 patients stratified into the SE group. The median WIT for the LE group was 125.5 minutes and 57 minutes for the SE group. In terms of recipient characteristics, significantly fewer patients in the LE group were placed on pre-operative ECMO (0% [0/76] vs 7.9% [12/151], p=0.027). Regarding donor characteristics, there were no significant differences in smoking history (LE 6.7% [5/75] vs SE 8.2% [12/146], p=0.89) and BMI (LE M:26.4 vs SE M:25.9, p=0.94). Conversely, the donors in SE group were significantly older (median [M]: 39 vs M: 33, p=0.003) and had a significantly higher PaO2:FiO2 (PF) ratio (M:439 vs M:407, p=0.038). Post-operatively the SE group had significantly longer ischemic time (M:8.4 hours vs M:6.6 hours, p=0.034) and length of stay (LOS) (M:28 days vs M:20 days, p=0.017). Though not significant, the SE group had a higher incidence of dialysis (14.2% [20/141] vs 5.7% [4/70], p=0.11), primary graft dysfunction grade 3 (PGD3) (23.2% [35/151] vs 15.8% [12/76], p=0.26). In-hospital mortality (LE 4.5% [3/67] vs SE 9.2% [12/130], p=0.36) and short-term survival for the unadjusted groups were not significantly different (p=0.065, Figure A). Following matching, two well matched groups (SMD<0.1) of 44 patients in each group were formed. Post-operatively, the SE group had significantly longer ischemic time (M: 8.5 hours vs 6.1 hours, p=0.003). Additionally, though not significant, the SE group had longer LOS (M:26 days vs M:19 days, p=0.25) and increased incidences of PGD3 (22.7% [10/44] vs 15.9% [7/44], p=0.59). In-hospital mortality (LE 4.8% [2/42] vs SE 9.1% [4/43], p=0.69) nor short-term survival was significantly different between the matched groups (p=0.23, Figure B).
Conclusions: Though there were few statistically significant differences between the LE and SE groups (in both matched and unmatched analysis), those in the SE group had increased rates of peri-operative morbidity as compared to the LE group. Additionally, the LE group had about ~4% lower in-hospital mortality as well ~12-14% lower short-term mortality. Further research is needed to clarify NRP evaluation times prior to lung transplant, given the association with reduced survival and shorter evaluation.
Authors
Martin Walsh (1), Vivienne Pham (2), Ervin Cui (3), Divyaam Satija (4), Matthew Henn (5), Kukbin Choi (6), Nahush Mokadam (6), Asvin Ganapathi (5), Doug Gouchoe (7), Bryan Whitson (4)
Institutions
(1) Ohio State Wexner Medical Center, Burr Ridge, IL, (2) The Ohio State University College of Medicine, Columbus, OH, (3) The Ohio State Wexner Medical Center, Columbus, OH, (4) Ohio State University, Columbus, OH, (5) Ohio State University Wexner Medical Center, Columbus, OH, (6) The Ohio State University Wexner Medical Center, Columbus, OH, (7) The Ohio State Medical center and Nationwide Childrens Hospital, Columbus, OH
Abstract Presenter
Martin Walsh, Ohio State Wexner Medical Center
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Columbus, OH
United States
Objective: To compare outcomes for patients with post-infarction ventricular septal defect (VSD) with and without Impella 5.5 bridging.
Methods: We retrospectively reviewed 34 patients who were admitted to our institution with post-infarction VSD from January 2018 to June 2024. Patients who had a history of previous or recent cardiac surgery or chronic VSD were excluded (n=4). One patient was excluded for receiving axillary Impella CP support due to a small axillary artery. Axillary artery Impella 5.5 was first used as bridge therapy for post-infarction VSD at our institution in May 2022, and employed thereafter for this indication based on surgeon preference. We compared patients with post-infarct VSD who received Impella 5.5 as a bridge to VSD closure or palliation to those who did not. Primary outcomes were survival at 30-days and hospital discharge. Categorical variables were compared using Fisher's exact test and continuous variables were compared using Mann Whitney U test.
Results: Of the 29 patients included, 10 received Impella 5.5 support and 19 did not receive Impella 5.5 support. Baseline characteristics were similar between groups. Of the Impella 5.5 group, prior to receiving Impella 5.5 support, 1 patient received venoarterial (VA) ECMO, 3 patients received Impella CP, and 2 patients received IABP support. Among the patients who did not receive Impella 5.5 support, prior to VSD closure, 3 patients received VA ECMO, 3 patients received Impella CP, and 12 patients received IABP support. Three patients had failure of percutaneous VSD closure, then underwent subsequent surgical VSD closure. One patient in the Impella 5.5 group received concomitant Heartmate 3 left ventricular assist device support along with surgical VSD closure. Among the patients bridged to surgical repair with Impella 5.5, 4 out of 5 underwent Impella 5.5 removal at the time of surgical repair. Among patients who underwent surgical VSD closure, patients in the Impella 5.5 group had significantly shorter cardiopulmonary bypass times (109 vs. 183 min, P=0.05). Of patients who survived to surgical VSD closure, 100% survived to hospital discharge with preoperative Impella 5.5 support while 54.5% survived without preoperative Impella 5.5 support.
Conclusions:
Impella 5.5 bridging to surgical VSD closure could be a viable strategy and may improve postoperative survival. It may reduce cardiopulmonary bypass time and need for postoperative VA ECMO. Limitations of this study include small sample size and potential selection bias of patients.
Authors
Sarah Madira (1), Sophia Roberts (2), Aaron Guo (3), Takuya Wada (4), Kunal Kotkar (5), Muhammad Masood (6), Ralph Damiano (7), Tsuyoshi Kaneko (8), John Lasala (9), Amit Pawale (10)
Institutions
(1) N/A, St Louis, MO, (2) Barnes Jewish Hospital, St. Louis, MO, (3) Washington University School of Medicine in St. Louis, St. Louis, MO, (4) Akita University Hospital, Akita, Akita, (5) Barnes Jewish hospital, St. Louis, MO, (6) Barnes Jewish Hospital, Saint Louis, MO, (7) Washington University - St. Louis, St. Louis, MO, (8) Washington University, St. Louis, MO, (9) Washington University in St Louis School of Medicine, St Louis, MO, (10) Washington University in St Louis, St Louis, MO
Abstract Presenter
Sarah Madira
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St Louis, MO
United States
Objectives: Historically, older recipients have been considered to have poorer-post-transplant outcomes; however, the relationship between organ preservation quality and outcomes in older recipients has not been well-studied. Use of a controlled, moderate hypothermic cardiac transport system (CTS) is an organ preservation technology designed to maintain donor heart temperatures continuously between 4°C - 8°C, potentially mitigating tissue damage due to freezing temperatures in organs transported using traditional ice cooler methods, in addition to minimizing mechanical insult through a hermetically sealed chamber. We seek to investigate whether improved preservation of the donor heart prior to transplantation has an impact on post-transplant outcomes in older heart transplant recipients. This is especially important to European transplant programs, who typically have an older recipient population.
Methods: The GUARDIAN Heart Registry is an international, multicenter real-world registry comparing post heart transplant outcomes using CTS and traditional ice cooler methods for organ preservation and transport. Review of global data from the subset of recipients over 55 years old (N=347 Ice cooler, N=447 CTS) were evaluated and compared using summary statistics. Propensity-matching was also performed using criteria of donor age, recipient age, total ischemic time, site, recipient durable left ventricular assist device (LVAD) bridge, and transplant era (referencing the pre- and post-October 2018 UNOS organ allocation changes.
Results: Despite significantly longer average ischemic time by 24 minutes, there was a significant 32% reduction (p=0.01) in the rate of any primary graft dysfunction (PGD) and a 51% reduction (p=0.004) in the overall subset of patients >55 years old who received a heart preserved using the CTS compared to ice coolers (see Table). A significantly greater proportion of recipients in the CTS cohort also exhibited normal right ventricular (RV) function post-transplant, as well as a trending reduction in total hospital length of stay (p=0.08). Following propensity matching, the baseline variables were similar, and there remained significant reductions of 49% in PGD, 74% in severe PGD, as well as a 39% reduction in moderate to severe RV dysfunction (RVD) along with a trending reduction in RV-PGD (p=0.06) in those receiving hearts preserved using the CTS. Survival was statistically similar between cohorts in both analyses.
Conclusions: Use of controlled moderate hypothermic organ preservation was associated with meaningful improvements in post-transplant outcomes in older recipients, despite significantly longer ischemic times. Propensity matching of the data resulted in maintenance of these advantages, including significant improvements in PGD, severe PGD, moderate to severe RVD, and shorter time to weaning. These data add to the growing evidence supporting use of the moderate hypothermic CTS to optimize post-transplant outcomes, including in the subgroup of older recipients.
Authors
Mary Jacoski (1), Dan Meyer (2), Andreas Zuckermann (3), Jacob Schroder (4), Andrea Eixeres Esteve (5), Rajamiyer Venkateswaran (6), Heinrich Maechler (7), Yasuhiro Shudo (8), Juan bustamante-Munguira (9), Koji Takeda (10), David D'Alessandro (11)
Institutions
(1) Paragonix Technology, Inc., Waltham, MA, (2) Baylor Scott and White Health, Dallas, TX, (3) Department of Cardiac Surgery, Medical University of Vienna, Vienna, Vienna, (4) Duke University Medical Center, Durham, NC, (5) N/A, N/A, (6) Department of cardiothoracic surgery, Manchester University NHS Foundation Trust, Manchester, UK, Manchester, Manchester, (7) Medical University of Graz, Graz, NA, (8) Stanford University, Stanford, CA, (9) Hospital Clínico Universitario, Valladolid, Spain, (10) Columbia University, New York, NY, (11) Harvard University Medical School, Weston, MA
Abstract Presenter
*Dan Meyer, Baylor Scott & White Health
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Dallas, TX
United States
Objective: UNOS status 4 represents a heterogeneous mix of pathologies including patients with inotrope dependence and durable LVADs. For better understanding during advanced heart failure discussions, we compared outcomes of status 4 patients by indication in a nationwide analysis.
Methods: We included all adults (age≥18) in the UNOS STAR file who were listed for heart transplant from 10/18/2018-3/30/2024 with any time as status 4 with the primary focus on patients initially listed as status 4. Primary endpoints were percent of patients and transplants, time to transplant, and survival on the waitlist stratified by indication. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test.
Results: A total of 11,966 unique patients were listed as status 4 with 66.7% (7,983/11,966) as initial status 4. Most (96.3%, 7,687/7,983) initial status 4 patients had no change in the indication for status 4 while listed. Overall, 65.5% (5,232/7,983) of patients were transplanted with a median 70 days (IQR: 24-194) to transplant. For initial status 4 patients, 19.9% were transplanted at 1 month, 38.1% at 3 months, 50.1% at 6 months, 61.8% at 12 months, 67.5% at 18 months, 71.1% at 24 months, 75.0% at 36 months, 77.3% at 48 months, and 77.9% at 60 months (Figure). Percent of total patients, percent of total transplants, and median days to transplant by indication were: 38.8% (3,098/7,983), 33.3% (1,741/5,232), and 135 for LVAD; 20.0% (1,598), 23.4% (1,223), and 31 for IV inotropes; 15.3% (1,218), 16.4% (860), and 60 for exceptions; 10.5% (837), 12.1% (635), and 57 for cardiomyopathy; 8.0% (636), 7.3% (381), and 105 for congenital heart disease; 5.4% (435), 5.4% (283), and 70 for re-transplant; and 2.0% (161), 2.1% (109), and 46 for ischemic heart disease, respectively. Median survival on the waitlist was: 48 months for LVAD, 47 for congenital heart disease, 40 for cardiomyopathy, 38 for ischemic heart disease, 33 for re-transplant, 31 for exceptions, and 24 for IV inotropes. At 5 years, waitlist survival was highest with LVAD indications, and lowest with re-transplant and inotrope dependent indications (p<0.0001).
Conclusions: For status 4 patients, half will be transplanted within 6 months and two-thirds will be transplanted within 18 months of initial status 4 listing. Waitlist survival for status 4 patients is heterogeneous with patients on LVADS having twice the median survival compared to patients on IV inotropes. These results should be considered in advanced heart failure shared decision making.
Figure Legend: Alluvial plot of 7,983 initial status 4 patients showing status changes, deaths on the waiting list, delistings, and transplants at specific time points. Flows of less than 20 patients are not shown for clarity. Dec denotes deceased; Del, delisted; and Tra, transplanted.
Authors
Craig Jarrett (1), Kelsey Gray (1), Yakov Elgudin (1), Chantal ElAmm (1), Marc Pelletier (1), Yasir Abu-Omar (1)
Institutions
(1) University Hospitals, Cleveland, OH
Abstract Presenter
Craig Jarrett, University Hospitals of Cleveland
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Cleveland, OH
United States
Objectives
The combination of Impella devices (Abiomed, Inc., Danvers, MA) and ECMO support has been suggested to counteract the LV afterload seen with ECMO, prevent complications during VA ECMO, and facilitate weaning from VA-ECMO. While this technique has been successfully utilized in adults, efficacy data in patients under 18 are limited.
Methods
Eight pediatric patients, aged 13 to 18 years and weighing 40 to 59 kg, underwent VA-ECMO support with Impella 2.5 or 3.5 implantation at our institution between July 2016 and April 2024. All patients were hemodynamically unstable at the presentation time (INTERMACS 1). Our policy is to wean the patient off ECMO first while ensuring support in the early stages of ECMO removal (~ 2 days) with the Impella device still in place for those achieving myocardial recovery.
Results
Indications for implantation were heart failure secondary to myocarditis (4), rejection of prior orthotopic heart transplant (1), heart failure after transposition of the great arteries repair (1), metabolic cardiomyopathy (1), and arrhythmia-induced cardiomyopathy (1). VA-ECMO cannulation was performed first via neck vessels in six patients and groin vessels in two. Impella device was implanted in femoral vessels in seven patients and the carotid artery (through a chimney graft) in one. The median duration of Impella support was eight days (range, 2-20 days). The median duration of ECMO support was 11 days (4-14 days). One patient was bridged to transplant; one patient received a HeartMate3; five patients recovered myocardial function and were weaned off mechanical support; and one patient died on support. Impella removal was performed by compression of the arterial femoral access.
Conclusions
Given the high rate of ventricular recovery in pediatric acute heart failure, the ideal support strategy would be temporary and with a favorable risk profile. A short ECMO run in combination with LV unloading provided by the Impella device seems the treatment of choice. Impella percutaneous pump support should be considered in adolescents supported with peripheral VA-ECMO as a means of left heart decompression and a strategy to come off ECMO to achieve endpoints of myocardial recovery, transition to a durable ventricular assist device, or transplantation.
Authors
Matteo Trezzi (1), Gianluca Brancaccio (2), micol rebonato (3), Silvia Teresa Scalera (4), francesco lodoli (5), Gianluigi Perri (6), Sergio Filippelli (2), Rachele Adorisio (7), Lorenzo Galletti (8), Antonio Amodeo (9)
Institutions
(1) Bambino Gesù Children's Hospital, Rome, Rome, (2) Bambino Gesù Children's Hospital, Rome, NA, (3) Bambino Gesù Children's Hospital, roma, Italy, (4) Bambino Gesù Childrens' Hospital, Roma, NA, (5) Bambino Gesù Childrens' Hospital, ROMA, NA, (6) N/A, Rome, Italy, (7) Bambino Gesu' Childrens' Hospital, rome, NA, (8) Hospital Bambino Gesù, Roma, Italy, (9) Bambino Gesù Children's Hospital, Roma, Italy
Abstract Presenter
Gianluca Brancaccio, Bambino Gesù Children's Hospital
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Rome, Rome
Italy
Objective: The International Society for Heart and Lung Transplantation (ISHLT) Consensus Statement on Donor Heart and Lung Procurement recommends static lung inflation to 12-15 cm H2O prior to explant to protect from barotrauma. This is particularly important during fixed wing air transport as there are inevitable atmospheric pressure drops even in pressurized cabins. We report a case of cabin depressurization with no affect on allograft pressure due to organ preservation using the BAROguard™ device (Paragonix Technologies, Inc., Waltham, MA), designed to maintain stable pressure and temperature during donor organ transportation.
Methods: Donor lungs were procured from a 55-year-old brain dead female with a history of coronary artery disease status post myocardial infarction, diabetes mellitus and hypertension, and a limited smoking history. Perfadex® (XVIVO, Molndal, Sweden) was used for perfusion without ex vivo lung perfusion, and lungs were placed into a BAROguard device with a goal pressure of 12-15 cmH2O, and goal temperature of 4-8oC. Upon reaching 18,000 feet, a sudden loss of cabin pressure occurred due to a door seal malfunction. The aircraft consequently made an emergency landing and an alternate charter flight was arranged and were safely delivered to the recipient center 1,069 miles away.
Results: The lungs were implanted off-pump into a 54-year-old Caucasian female with idiopathic pulmonary fibrosis, with a left lung total ischemic time of 8:42 hours and right lung total ischemic time of 10:15 hours. At 72 hours the patient was extubated with grade 1 primary graft dysfunction, and ultimately discharged home on room air on post-operative day 12.
A review of the pressure log within the transport system revealed that the lungs remained in the recommended intermediate pressure zone, never exceeding 16.1 cm H2O nor dropping below 12.8 cm H2O (Figure 1).
Conclusions: Active pressure control during allograft transport not only avoids over- or under-inflation of donor lungs, but can also compensate during a rare but possible in-flight depressurization emergency. Despite a long ischemic time and potential allograft atelectasis from depressurization, graft function remained excellent resulting in a successful patient outcome.
Authors
John Eisenga (1), Magdy El-Sayed Ahmed (2), Sigrid Ringenberg (3), Shair Ahmed (4), Gary Schwartz (1)
Institutions
(1) Baylor University Medical Center, Dallas, TX, (2) N/A, Jacksonville, FL, (3) Baylor University Medical Center, part of Baylor Scott & White Health, Dallas, TX, (4) Emory University School of Medicine, Atlanta, GA
Abstract Presenter
John Eisenga, Baylor University Medical Center
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Dallas, TX
United States
Objective: To evaluate the predictive ability of pre-operative hemodynamic parameters on postoperative right ventricular failure (RVF), long-term survival and readmissions for heart failure (HF) after implantation of continuous-flow left ventricular assist devices (LVAD).
Methods: Retrospective review of 399 consecutive patients who underwent primary continuous flow LVAD implantation at our institution between 2007 and 2023. Pre-operative hemodynamics were used to estimate the relative contributions of the right heart to the cardiac index via its passive and active components. Pre-operative passive cardiac index (PasCI) was calculated by dividing right atrial pressure (RAP) by mean pulmonary artery pressure (mPAP), multiplied by total cardiac index. The active cardiac index (ActCI) was calculated by subtracting the RAP from the mPAP, divided by the mPAP, and multiplying by the total cardiac index. To assess the impact of PasCI and ActCI on outcomes, separate unadjusted logistic regression models were fitted for early postoperative RVF and multivariable Cox regression models were fitted for long-term outcomes of all-cause mortality and readmission for heart failure. The model for readmission for HF used the Andersen-Gill formulation to allow for multiple events. Partial effects plots were derived from these models to display the risk relationships (Figure 1).
Results: Majority of patients were male (79%), and the median age was 63 (IQR: 55, 69) years. LVAD was used as destination therapy in 136 (65%), bridge to transplant in 136 (34%), and bridge to decision in 2 (0.5%). Etiology of HF was ischemic cardiomyopathy in 189 (47%). Median RAP was 13 (IQR: 9, 18) mmHg and median mPAP was 35 (IQR: 30, 42) mmHg; median PasCI was 0.64 (IQR: 0.45, 0.89) L/min/m2 and median ActCI was 1.11 (IQR: 0.78, 1.45) L/min/m2. Operative mortality occurred in 34 (9%) patients, and postoperative RVF in 28 (7%). On unadjusted analysis, lower ActCI was found to be associated with early postoperative RVF (p=0.021, Figure 1B). On multivariable analysis, higher PasCI scores were associated with worse long-term survival (p=0.004, Figure 1C) and with borderline increased risk of readmissions for HF (p=0.052, Figure 1E).
Conclusions: In patients who underwent LVAD implantation, indices derived from the preoperative hemodynamics to assess the relative contributions of the right heart to the cardiac index showed some association with early postoperative RVF, long-term survival, and readmissions for HF. This study serves as a platform for future development of risk score calculators and inform therapeutic decision-making.
Authors
Rolando Calderon (1), John Stulak (2), Mauricio Villavicencio (3), Richard Daly (4), Philip Spencer (5), Andrew Rosenbaum (2), Sina Danesh (2), Hossam Elbenawi (2), Brian D. Lahr (2), Alexander Lee (2), Paul Tang (6)
Institutions
(1) N/A, Rochester, MN, (2) Mayo Clinic, Rochester, MN, (3) Department of Cardiovascular Surgery, Mayo Clinic, Boston, MA, (4) Mayo Clinic College of Medicine and Science, Rochester, MN, (5) Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, (6) Mayo Clinic (Rochester, MN), Rochester, MN
Abstract Presenter
Rolando Calderon
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Rochester, MN
United States
Objective: Right heart failure after durable left ventricular assist device (LVAD) implantation has been associated with increased mortality. While sternal-sparing surgical techniques that do not open the pericardium overlying the right ventricle have been associated in some studies with lower rates of early right heart failure (RHF), associations between implantation technique and late RHF have not been well characterized. Here we report a large series of 334 patients undergoing less invasive (LIS) HeartMate3 (HM3; Abbott Laboratories) implantation via bilateral thoracotomies (BT) or left thoracotomy with upper hemi-sternotomy (UH). We describe early and late RHF events in this cohort, as well as their association with overall survival.
Methods: All patients at our institution undergoing HM3 implantation via BT or UH between February 28, 2017 and April 17, 2024 were included for analysis. Early right heart failure events, including RVAD placement, were identified by chart review of all included patients. Late RHF events were identified by query of our institutional Intermacs database according to definitions in the STS Intermacs User's Guide Version 6.1 and adjudicated by a cardiac surgeon as true late RHF through targeted chart review. Baseline characteristics and outcomes of patients supported on HM3 including age, BMI, comorbidities, prior sternotomy, year of implant, use of cardiopulmonary bypass, RVAD support, return to the operating room for bleeding, and late right heart failure were analyzed. Unadjusted survival of patients grouped by RVAD use were compared using Log Rank comparisons. Cox proportional hazards models were built using SPSS software.
Results: A total of 334 patients met criteria and were included for analysis, including 290 BT and 44 UH patients. Among this pooled cohort, median and maximum follow-up was 33.4 and 76.4 months, respectively. Overall survival at 60 months is 69.7%. (See Figure 1A). Early RHF occurred in 9.4% of patients, and 5.0% of patients required RVAD placement. When stratified by RVAD placement, survival for those not requiring RVAD was significantly better by Log Rank comparison (p = 0.032; see Figure 1B). Late RHF in this pooled cohort was also low overall with 34 events occurring in 27 unique patients, for a total of 8.0% of patients experiencing late RHF events.
Conclusions: This large, single-institution cohort of patients undergoing HM3 implantation via LIS approach demonstrates this strategy has excellent long-term survival results, with five-year overall survival of 69.7%. Early right heart failure (9.4%), RVAD use (5.0%), and late RHF (8.0%) is low in this series, and use of RVAD was associated with worse survival compared to no RVAD (p = 0.032) when compared by Log Rank comparison. Taken together, these data suggest that low incidence of early RHF, especially severe RHF requiring RVAD use, may contribute to the excellent long-term survival seen amongst HM3 patients implanted via LIS. Late RHF remains a significant problem amongst LVAD patients, and the effect of surgical implantation strategy on late right heart outcomes warrants further investigation. Future work should also include comparisons to patients with HM3 implanted via full sternotomy for further investigation into the effect of surgical approach on RHF and survival.
Authors
Madeline Fryer (1), Andrew Jones (1), Igor Gosev (1), Katherine Wood (1)
Institutions
(1) University of Rochester Medical Center, Rochester, NY
Abstract Presenter
Madeline Fryer
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Paris, IL
France
Objective: Orthotopic heart transplantation (OHT) remains the gold standard for patients with end-stage heart failure. Significant lactic acidosis following heart transplantation has been a widely observed phenomenon amongst surgeons. Despite this, the mechanism and overall significance are not well understood. Kedziora and colleagues reported a median peak lactic acid of seven mmol/L amongst nearly 50 heart transplant recipients.1 Several studies demonstrate an association between high post-operative lactate levels in those with left ventricular assist devices (LVAD), long cardiopulmonary bypass runs, and higher inotropic support.2,3 The objective of this study is to identify the risks associated with a high lactic acidosis immediately following transplantation (POLA), including its association with primary graft dysfunction (PGD), use of post-operative mechanical circulatory support, and over-all mortality.
Methods: We conducted a single-institution retrospective analysis. Patients included had undergone OHT between January 2022 and May 2023. The EMR was used to interrogate individual patient charts. Data was collected on patient demographics, indications for transplant, donor type, post-operative echo, and both pressor and mechanical-assist device requirements.
Results: Our sample included 33% (16/49) women with a mean age of 47 (17-70) years. The majority underwent OHT alone (83%, 41/49), 7 underwent combined heart/kidney transplant, and 1 heart/lung transplant. Of the donors, 92% were brain dead donors (45/49). POLA was separated into a high and low groups based on the median distribution (>6 mmol/L). An elevated POLA was correlated with being male (48%, 16/33 vs 25%, 4/16 p =0.1) and pre-operative LVAD placement (88%, 7/8 vs 32%, 13/41 p=0.03). There was a trend towards higher POLA after brain dead donation (DBD) as compared to cardiac death donation (DCD) (41%, 19/46 vs 0%, 0/3 p=0.17). In the immediate post-operative period depressed cardiac function on TEE (57%, 8/14 vs 30%, 10/33 p=0.03), at least three pressor requirement (82%, 9/11 vs 48%, 11/23 p=0.01), PGD, defined as the requirement of a cardiac mechanical support device for more than 24 hours (16%, 5/30 vs 1%, 1/29 p=0.02) and all-cause mortality (2%, 4/20 vs 0%, 0/29 p=0.01) were associated with POLA. In the adjusted outcomes, these factors remained associated with an elevated POLA.
Conclusion: Our study significantly expands upon existing literature. We demonstrate an association between a spike in lactate levels and, pre-operatively, those with LVADs and, post-operatively, those who develop PGD, require an increase in ionotropic support, and with all-cause mortality. There were trends towards both donor and recipient factors including male sex and DBD status that may increase the risk of POLA. Further exploration of both donor and recipient factors may elucidate the drivers behind lactic acidosis in the immediate post-operative period.
Authors
Phoebe Miller (1), Andrew Akcelik (1), Alison Baskin (1), Mohammad Arammash (1), Alexander Merriman (1), Jason Smith (1), Amy Fiedler (1)
Institutions
(1) University of California San Francisco, San Francisco, CA
Abstract Presenter
Phoebe Miller, University of California San Francisco
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San Francisco, CA
United States
Objective: To show the degree of renal recovery after second generation surgically implanted ventricular assist device based on changes in creatine, blood urea nitrogen (BUN), and urine output before and after implantation.
Methods: This is a single-center retrospective cohort analysis of hospitalized adult patients. Over the period from April 2021 to June 2023, 113 patients received a second generation surgically implanted ventricular assist device via the right or left axillary artery. Both pre-implantation and post-implantation analysis was performed examining relevant laboratory values, the cause of heart failure, indication for mechanical support, 30-day outcome, The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) classification, The Society for Cardiovascular Angiography and Interventions (SCAI) stage, as well as basic demographic data.
Results: The median age of the patients was 58 years (range, 19 to 82 years), 84.1% were male (95 out of 113). The median duration of support was 16 days (range, 0 to 92 days). The device was utilized in 57 patients with non-ischemic cardiomyopathy (50.4%), 40 with ischemic cardiomyopathy (35.4%), 6 with post-cardiotomy shock (5.3%), 3 for planned post-cardiotomy (2.7%), and in 1 patient with congenital heart disease (0.9%). It was utilized in 54 patients as a bridge to decision (47.8%), 28 patients as bridge to transplant (24.8%), and 19 as bridge to recovery (16.8%). In this cohort 42 received an orthotropic heart transplant (37.2%) and 20 received a permanent durable left ventricular assist device (17.7%). The majority of the patients were INTERMACS class 2 (68), while the next most common classification was class 1 (38). The 30-day survival through device explant was 85.8% (97 out of 113). Patients' median creatinine, BUN, and urine output values before compared to after implantation, measured over a period of 3 days prior to and 3 days post-implantation, were 1.34 mg/dL vs 1.24 mg/dL (p = 0.02), 27mg/dL vs 26mg/dL (p=0.115), and 2427cc and 2850c (p<0.0001), respectively.
Conclusions: In this single-center retrospective cohort analysis of 113 hospitalized adult patients who underwent a second generation surgically implanted ventricular assist device, the 30-day survival through device explant was 85.8% (97/113). There was statistically significant renal recovery in the form of reduced creatinine (p = 0.02) and increased urine output (p <0.0001).
Authors
Andrew Acker (1), Mickel Attia (1), Jenelle Safadi (1), Joyce Wald (1), Aditya Parikh (1), Christian Bermudez (1), Marisa Cevasco (1)
Institutions
(1) Hospital of the University of Pennsylvania, Philadelphia, PA
Abstract Presenter
Andrew Acker, Penn Medicine, Department of Surgery
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Philadelphia, PA
United States
Objective:
The objective of this single center study was to evaluate the clinical efficacy and safety of the use of Impella 5.5 in patients in cardiogenic shock or end-stage cardiomyopathy as bridge to destination therapy, focusing on peri-procedural outcomes and short-term clinical endpoints.
Methods:
This retrospective observational study included all patients who underwent Impella 5.5 support between February 2020 and March 2024. Data collection included baseline demographics, risk factors, procedural details, and clinical outcomes such as mortality, complications related to Impella use and ability to wean from mechanical circulatory support or effectively bridge to transplant or implantable left ventricular assist device (LVAD). Statistical analysis included descriptive statistics and appropriate inferential tests for comparison between groups.
Results:
A total of 145 patients (mean age 57.7, 88% male) were included in the analysis. The primary indication for mechanical circulatory support was acute cardiogenic shock in 59% of patients, cardiomyopathy in 33%, acute coronary syndrome in 7%, and post-cardiotomy shock in 1%. Median Impella support duration was 24 days (IQR 12-51 days)
65% of patients were successfully weaned off Impella mechanical circulatory support, 14% of them to medical therapy alone, 16% were bridged to LVAD implant, and 35% to heart transplant. Of note 3 of the patients bridged to LVAD therapy eventually received a heart transplant within the short follow-up period.
In-hospital mortality and 30-day mortality were 25% and 23% respectively. New strokes during Impella therapy occurred in 10% of patients, bleeding at insertion site in 7% of patients and access-related limb ischemia in 3%.
Conclusions:
In conclusion, our study demonstrates that Impella provides effective hemodynamic support in high-risk patients with cardiogenic shock or end-stage cardiomyopathy, significantly improving their outcomes and chances to reach destination therapy.
Authors
Tommaso Cambiaghi (1), Fatima Qamar (1), Therese Hoof (1), Memhet Akay (1)
Institutions
(1) Houston Methodist, Houston, TX
Abstract Presenter
Fatima Qamar, Houston Methodist Hospital
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Houston, TX
United States
Objective:
Temporary circulatory support (TCS) devices are being used more frequently as bridge to heart transplant (BTT) following the 2018 UNOS allocation change. We aim to describe and compare the adverse event profile and outcomes associated with TCS as a BTT.
Methods:
A retrospective analysis of our institutional database was performed on all adult patients (≥18 years old) who were listed for cardiac transplantation from October 1st, 2018, until June 30th, 2024. Patients implanted with an intraaortic balloon pump (IABP) or a microaxial left ventricular assist device (mLVAD) capable of at least 5 liters of support were identified and included in our cohort. Demographics and preoperative characteristics were identified. Device related adverse events as reported in the medical record and defined by laboratory values were included. Patient outcomes were defined by transplantation, delisting, continued support, durable LVAD implantation, or death.
Results:
A total of 64 patients were included of which 49 (76.6%) received an IABP, 8 (12.5%) were implanted with a mLVAD, and 7 (10.9%) were implanted with both. Median age of the entire cohort was 57 years with 48 (75%) males. Nearly half of the patients had a prior history of arrhythmia (37, 58%), HTN (35, 55%), CKD (28, 44%), DM (29, 45%), and were former smokers (32, 50%). Cohorts for mLVAD and IABP were similar in comorbidities except for prior history of dialysis use (IABP 4, 8.2%; mLVAD 4, 50.0%; p < 0.01). The most common device related complication was hemolysis in 20 (31.3%) patients, more commonly in the mLVAD cohort (6, 75%) compared to the IABP group (8, 16.3%), p < 0.01. Bleeding (13, 20.3%) and infection (10, 15.6%) were less common with no significant difference between to the two groups. Stroke (2, 3%) and limb ischemia (1, 2%) were rare events overall. Twenty-seven patients (55.1%) in the IABP and one (12.5%) in the mLVAD cohort were free from complication, death, or emergent LVAD. Most patients were successfully bridged to transplant occurring in 57 (89%) patients, while 1 (2%) is currently waitlisted, and 6 (9%) were removed from the waitlist. Three patients expired while on device support and 4 required urgent implantation of a durable LVAD.
Conclusion:
TCS is a successful strategy to bridge patients to cardiac transplantation, but the burden of device related complications in this setting has not been well described. Our data demonstrates a significant risk of hemolysis, bleeding, and infection when using TCS as a bridge to transplant. While an overwhelming majority of patients are successfully transplanted, there are many that are either delisted or expire while on support, and even fewer who can be salvaged with a durable, implantable device. Consideration for organ allocation distribution to include temporary device adverse events in patients without a durable option as salvage therapy may be prudent to minimize waitlist death and removal.
Authors
Rithva Ramesh (1), Brandon Ferrell (2), Daniel Goldstein (2), Stephen Forest (2)
Institutions
(1) Albert Einstein College of Medicine, Bronx, NY, (2) Montefiore Medical Center, Bronx, NY
Abstract Presenter
Rithva Ramesh, Albert Einstein College of Medicine
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Washington, DC
United States
Objective: An evolving strategy and trend in heart transplantation is the utilization of temporary mechanical circulatory support in the pre-operative period. Axial flow pump devices, such as the Impella 5.5, have increasingly been used in the setting of cardiogenic shock as a bridge to transplantation. Although the device was initially approved for a period of 14 days, little has been reported regarding the safety of prolonged use and its impact on post-transplant outcomes. The current study aims to compare post-transplantation mortality based on duration of support with the Impella 5.5.
Methods: Adult patients listed for first-time isolated heart transplantation between October 18, 2018 and January 1, 2023 were identified in the United Network for Organ Sharing database. Those that had been supported by the Impella 5.5 and subsequently transplanted were included in this study. Patients who were on multiple forms of temporary mechanical circulatory support were excluded. A histogram of support duration was developed to determine an appropriate cut-off in cohort development (Figure 1a). Based on the distribution of the data, as well as the current FDA policy, patients were stratified based on duration of Impella 5.5 support with a cut-off of 14 days. Baseline characteristics and post-transplant outcomes were compared utilizing the Kruskal-Wallis rank test and chi-squared analysis for continuous and categorical variables, respectively. Further, Kaplan-Meier estimates as well as univariable and multivariable Cox proportional hazards were used to assess 1-year mortality.
Results: Of the 865 patients included in this study, 331 (38%) were supported for less than 14 days while the remaining 534 (62%) required more than 14 days of Impella 5.5 support. Cohorts were similar with regard to age, sex, insurance status, body mass index, ABO blood group, underlying cardiomyopathy etiology, and listing status (all p>0.05). Notably, patients with shorter Impella 5.5 support duration had lower cardiac output (3.8 vs. 4.1 L/min, p=0.005) and more ventilator requirements (3% vs. 1%, p=0.044). These patients were also less likely to be on Impella 5.5 support at time of listing (57% vs. 66%, p=0.014). Although donor hearts were procured from further distances for patients on shorter support (287 vs. 236 miles, p=0.018), post-transplant outcomes including dialysis, graft rejection, pacemaker requiring, stroke, and death at time of last follow-up were not different (all p>0.05). Similarly, no difference in 1-year mortality was found between the two cohorts (Figure 1b, log-rank test p=0.252). On univariable and multivariable Cox regression models, prolonged Impella 5.5 support was not predictive of 1-year mortality (HR 0.71 [0.39-1.29]; HR 0.86 [0.43-1.72]).
Conclusions: Prolonged Impella 5.5 support for patients awaiting heart transplantation is not associated with a difference in post-transplant outcomes or 1-year mortality. As patients on the heart transplantation waiting list await a donor heart, prolonged axial-flow pump support may be a reasonable bridging strategy as experience in managing these critically ill patients grows.
Authors
David Rekhtman (1), Amit Iyengar (2), Cindy Song (1), Michaela Asher (1), Noah Weingarten (2), Max Shin (2), Samuel Kim (2), John DePaolo (2), Mauer Biscotti (2), Marisa Cevasco (2)
Institutions
(1) Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, (2) Division of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
Abstract Presenter
David Rekhtman, Perelman School of Medicine, University of Pennsylvania
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Bethesda, MD
United States
Objective: Left ventricular assist device (LVAD) implantation and orthotopic heart transplantation (OHT) are standard therapies for the treatment of end-stage heart failure. While OHT and LVADs improve survival and quality of life, both have a unique adverse event profile limiting their success. Although the effect of socioeconomic status (SES) on these interventions individually has been previously published, comparing the impact of SES on the long-term outcomes and unique complications after each intervention has not been well reported. We aimed to compare the impact of SES on one-year postoperative outcomes of OHT versus LVAD pts.
Methods: All pts undergoing HeartMate 3 (HM3) implantation or OHT at a quaternary care hospital between August 2017 – December 2021 were eligible for inclusion of this retrospective cohort study. Distressed Community Index (DCI) is a model of social vulnerability that assigns a score from 0 (not distressed) to 100 (severely distressed) to a zip code based on several SES determinants. Pts were stratified as being distressed (DS), DCI >60, or not distressed (ND), DCI <60. Living well was defined as freedom from rehospitalization or complication.
Results: A total of 257 pts met criteria for inclusion, 147 (57%) DS and 110 (43%) ND pts. Baseline characteristics in each cohort were largely similar.
In the DS cohort, there were 76 (52%) OHT and 71 (48%) LVAD recipients. There was no difference in post-operative ICU length of stay (OHT 10 days, LVAD 9 days, p=0.30), though the length of hospital stay was longer in LVAD recipients (22 vs 17 days, p<0.0001). 30-day (OHT 73 (96%), LVAD 63 (89%), p=0.09) and 1-year (OHT 66 (87%), LVAD 59 (83%), p=0.14) survival were similar between each respective intervention. Within the first year of initial discharge, there was not a significant difference in pts readmitted (OHT 50 (66%) vs LVAD 42 (59%), p=0.67). Common indications for readmission were infection or rejection (37, 49%) in OHT pts and bleeding or thrombotic complications (18, 25%) and infection (20, 28%) in LVAD recipients. In total, OHT recipients had a higher median time spent alive outside the hospital in the first year after initial discharge (353 vs 314 days, p=0.001).
In the ND cohort, there were 78 (71%) OHT and 32 (29%) LVAD recipients. Like the DS cohort, there was no difference in post-operative ICU length of stay (8 vs 8 days, p = 0.63) in the ND arm, and the length of hospital stay was longer in LVAD recipients (21 vs 15 days, p=0.002). 30-day (OHT 77 (99%), LVAD 30 (94%), p=0.15) survival was similar between recipients, as was 1-year survival (OHT 73 (94%) vs LVAD 27 (84%), p=0.07). There were significantly more OHT recipients that were readmitted in the first year (54 (69%) vs 12 (38%), p = 0.008) despite no difference in median number of days alive outside the hospital (OHT 359 vs LVAD 346 days, p=0.06). Similar to the DS cohort, common indications for readmission were infection or rejection (39, 50%) in OHT pts and bleeding or thrombotic complications (3, 9%) and infection (4, 13%) in LVAD recipients.
Conclusion: Based on one's SES status, OHT and LVAD recipients have similar 30-day and 1-year survival. OHT pts are more likely to be readmitted than LVAD recipients from ND communities, while OHT recipients from DS communities spend more days alive outside the hospital in the first year in comparison to LVAD pts. LVAD and OHT can safety be performed in pts regardless of SES.
Authors
Brandon Ferrell (1), Albert Dweck (2), Roger Zhu (1), Joseph Khory (2), Justin Olivera (2), Korri Hershenhouse (1), Snehal Patel (1), Daniel Goldstein (1), Stephen Forest (1)
Institutions
(1) Montefiore Medical Center, Bronx, NY, (2) Albert Einstein College of Medicine, Bronx, NY
Abstract Presenter
Brandon Ferrell
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Bronx, NY
United States
Objective: To investigate post-operative outcomes and survival after the change in allocation policies from the lung allocation score (LAS) compared to composite allocation score (CAS).
Methods: The United Organ Sharing Database was queried from 03/08/2022 to 03/09/2024 for lung transplant recipients. Recipients were excluded if: <18 years old, re-transplants, multi-organ transplants, or had incomplete data. Recipients were then stratified into LAS (03/08/2022-03/08/2023) or CAS (03/09/2023-03/09/2024) based on date of transplant. The groups were then analyzed with comparative statistics, and Kaplan-Meier method for survival. Finally, a multivariable logistic regression using select donor and recipient characteristics was created to determine if the LAS or CAS era was independently associated with 90-day survival.
Results: There were 2925 patients stratified into the CAS group and 2648 patients stratified into the LAS group. CAS recipients were more often hospitalized prior to transplant (15% [395/2629] vs 11.9% [315/2648], p=0.001), while LAS recipients had a higher incidence of pre-operative ventilator use (5% [132/2648] vs 3.2% [93/2925], p=0.001) and ECMO use (7.3% [193/2648] vs 5.1% [148/2925], p=0.001). CAS recipients had significantly fewer days on the waitlist (median [M]: 29 days) than LAS recipients (M: 33 days) (p<0.001). CAS donors had a significantly higher incidence of smoking history (10% [282/2832] vs 7.9% [203/2555], p=0.011), higher BMI (M: 26.3 vs M: 25.9, p=0.028), and higher incidence of donation after circulatory death (DCD) donors (12.2% [356/2925] vs 7.6%, [202/2648], p<0.001) and ex vivo lung perfusion (EVLP) (8.3% [216/2606] vs 6.3% [167/2648], p=0.007). Prior to transplantation, the CAS group had a significantly longer distance traveled from donor to recipient hospital (M:382 nautical miles vs M:192 nautical miles, p<0.001) and ischemic time (M:6.8 hours vs M:5.9 hours, p<0.001). Post-operatively, the CAS group had a significantly shorter length of stay (LOS) (M:19 days vs M:20 days, p=0.002), and significantly lower incidence of primary graft dysfunction grade 3 (PGD3) (16.8% [490/2923] vs 20.7% [547/2646], p<0.001) and prolonged ventilation (5+ days) (24.1% [623/2586] vs 26.1% [685/2624], p=0.009). Additionally, the CAS group had a lower incidence of post-operative dialysis (7.9% [205/2591] vs 9.4% [250/2648], p=0.06). Neither in-hospital mortality (CAS: 4% [94/2341] vs LAS: 4.8% [125/2614], p=0.21) nor 90-day survival (CAS: 94.5% [95% confidence interval (CI), 93.5%-95.6%], LAS: 95.6% [95% CI, 94.8%-96.4%], p=0.14) was significantly different. Finally, on multivariable regression the CAS era was independently associated with decreased 90-day survival (Hazard Ratio: 0.52, 95% CI: 0.30-0.90, p=0.019).
Conclusions: In the first year following the implementation of the CAS system, CAS recipients had significantly shorter days on waitlist, and significantly lower incidence of post-operative morbidity. However, the change in the allocation system was also met with increased travel distances and ischemia time. Multivariable logistic regression found that the CAS era was independently associated with decreased 90-day survival. While the CAS change favored shorter waitlist duration, additional studies are needed to clarify the associated of the new allocation system on decreased 90-day survival.
Authors
Martin Walsh (1), Divyaam Satija* (2), Vivienne Pham (2), Ervin Cui (1), Matthew Henn (1), Kukbin Choi (1), Nahush Mokadam (1), Asvin Ganapathi (1), Doug Gouchoe (1), Bryan Whitson (1)
Institutions
(1) The Ohio State University Wexner Medical Center, Columbus, OH, (2) The Ohio State University College of Medicine, Columbus, OH
Abstract Presenter
Divyaam Satija*, Ohio State University
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Columbus, OH
United States
Objectives: Dual lumen cannulation for extracorporeal support is increasingly utilized, with proposed benefits of increased mobility, decreased insertion site infections, ease of nursing care, and patient comfort. The right internal jugular vein is the predominant approach for such cannulation, however the left subclavian vein has several potential advantages including cannula stability, ease of nursing care, and decreased bloodstream infections. Experience with this location – including technical aspects, procedural and long-term complications, and outcomes – are under-reported.
Methods: A retrospective review was performed for a single high volume ECMO center. All patients who were cannulated using the left subclavian venous approach were included. Primary end points were cannulation-related complications and survival. Secondary end points included patient demographics, indication(s), type of cannula, time on ECMO, and anticoagulation regimen.
Results: From 2012 to 2024 a total of 1385 patients were supported on ECMO. Of these, 24 were cannulated via the left subclavian vein: 22 were venovenous utilizing the Crescent™ (Medtronic, Minneapolis, MN) cannula for respiratory failure with preserved right ventricular function and 2 were venopulmonary for right ventricular failure using the ProtekDuo™ (LivaNova, London, UK) and Quantum (Spectrum Medical, Gloucester, UK) cannulas. Five were primary cannulations and 19 were revisions from another configuration due to blood stream infections (5); transition from a venoarterial configuration (2), or to promote reconditioning during long runs (12). There were no cannulation associated complications. There were no cannulation site infections or significant bleeding, although 2 patients developed left upper extremity deep venous thrombosis. 10/24 (41%) patients survived to discharge neurologically intact. Demographics are listed in Table 1, with several patients having multiple indications for extracorporeal support and profoundly long ECMO runs.
Discussion: The left subclavian is an underutilized access point for dual lumen venovenous and venopulmonary extracorporeal support. It is particularly useful for revision from femoral/jugular configurations when indicated. Deep venous thrombosis may be more frequent than other sites, necessitating therapeutic anticoagulation if not already employed. Technical considerations include more inferolateral cutaneous access than with small bore subclavian access, a stiffer guidewire, and mandatory fluoroscopic guidance.
Authors
John Eisenga (1), Kara Monday (1), Britton Blough (1), Michael Foreman (1), Kaitlyn Lingle (1), Dan Meyer (2), Gary Schwartz (1)
Institutions
(1) Baylor University Medical Center, Dallas, TX, (2) Baylor Scott & White Health, Dallas, TX
Abstract Presenter
John Eisenga, Baylor University Medical Center
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Dallas, TX
United States
OBJECTIVE: The specific effects of exercise on pulmonary hypertension-right ventricular failure (PH-RVF) patients remain poorly understood, especially severe PH. Our group has previously established a large animal model of pulmonary hypertension-right ventricular failure (PH-RVF). We combined this model with an exercise platform to improve our understanding of exercise on PH-RVF and the impact of mechanical circulatory support (MCS) on exercise tolerance.
METHODS: A 67-kg healthy sheep was acclimated to a livestock treadmill. Following our previously published protocol for a sheep PH-RVF model, we ligated the left pulmonary artery, placed an inflatable adjustable silicone band on the main PA, and inserted an indwelling catheter in the RV outflow tract. The pressure in the adjustable silicone band was increased weekly an average of 100-150 mmHg to create a progressive model of PH-RVF over the course of 8 weeks. During this period, the sheep completed a weekly exercise routine on the treadmill at speeds ranging from 0-1.1 m/s. Mixed venous oxygenation (SvO2) and RV systolic pressure [(RVSP), mmHg)] were measured during each treadmill session. Following the 8-week period of progressive cuff inflation and exercise regimen, a re-operative thoracotomy was performed, and the sheep was placed on a right atrial to left atrial (RA-LA) ECMO circuit at a blood flow ranging from 2 L/min to 3.5L/min. The sheep completed the full exercise routine 3 days post op. The same parameters including SVO2 and RVSP were measured during this exercise routine with the MCS circuit.
RESULTS: As the PH-RVF model progressed, the sheep experienced more difficulty completing the exercise routine as evidenced by clinical appearance (gait ataxia, increased respiratory rate, pallor) and decreasing SVO2. At rest, the week 1 SVO2 and RVSP were 84.2% and 80mmHg respectively, compared to week 8 resting SVO2 and RVSP of 73.4% and 59mmHg. By week 8, the sheep was unable to complete the exercise routine. The sheep was able to complete the entire routine after the attachment of the extracorporeal circuit. MCS support resulted in a 18.8%% increase in SVO2 at the same speed, from 52.1% to 70.9%. RVSP during exercise while on MCS support ranged from 45 to 83 mmHg with a mean of 60. Total distance traveled during exercise was 1197 meters at week 8 of the model without MCS versus 3600 meters with MCS implant, a 117% increase.
CONCLUSION: Intervention with RA-LA MCS during exercise is feasible in a large animal model of PH-RVF and improves physiologic performance of a protocolized exercise routine.
Authors
Victoria Simon (1), Michael Cortelli (2), Carl Johnson (3), Kaitlyn Tracy (2), Timothy Harris (3), William Tucker (2), TiOluwanimi Adesanya (2), Avery Fortier (2), Elizabeth Simonds (1), Mark Petrovic (2), Briana Bernicker (4), Gabriella Glomp (4), David J. Skoog (5), Keith Cook (6), Eric Austin (2), Erika Rosenzweig (7), Garrett Coyan (8), Ashish Shah (4), Caitlin Demarest (1), Matthew Bacchetta (2), Rei Ukita (9)
Institutions
(1) Vanderbilt University Hospital, Nashville, TN, (2) Vanderbilt University Medical Center, Nashville, TN, (3) N/A, N/A, (4) Vanderbilt University, Nashville, TN, (5) 3. Advanced Respiratory Technologies, Inc., Pittsburgh, PA, Pittsburgh, PA, (6) Carnegie Mellon University, N/A, (7) Columbia University Irving Medical Center – New York Presbyterian, New York, NY, (8) University of Pittsburgh Medical Center, Pittsburgh, PA, (9) N/A, Nashville, TN
Abstract Presenter
Victoria Simon, Vanderbilt University Hospital
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Nashville, TN
United States
Objective: Extracorporeal membrane oxygenation (ECMO) has been used as a bridge to lung transplantation in patients with end stage lung disease. Venovenous (VV) ECMO is the most commonly used mode of support in pre-lung transplant recipients. In certain patients who experience right ventricular dysfunction, venopulmonary ECMO is an excellent option to preserve RV function.
Methods: We retrospectively reviewed patients who were supported with venopulmonary ECMO using the ProtekDuo cannula in our institution (May 1, 2021, to March 14, 2024). Descriptive analysis, patient characteristics, ECMO outcomes, and survival were assessed. The primary outcome was mortality.
Results: 2 patients required ECMO due to COVID-19 fibrosis, 1 post bleomycin toxicity and 1 for interstitial lung disease with pulmonary hypertension. Mean age was 45.5 + 15.63, mean ECMO hours 1391.75 + 1239.01, mean hospital length of stay was 107.5 + 54.29 All 4 patients had right ventricular dysfunction. 3 (75%) patients were supported with venovenous ECMO before conversion to venopulmonary mode with mean of 17 + 13.2 days before development of the ventricular dysfunction. All patients received bilateral orthotopic lung transplant. One-year survival was 100% for all patients.
Conclusions: Venopulmonary extracorporeal membrane oxygenation can be safely used to bridge patients with end-stage lung disease to lung transplantation. Potential etiologies for right ventricular dysfunction include pulmonary hypertension and volume overload from return cannula during venovenous ECMO.
Authors
YURIY STUKOV (1), Mindaugas Rackauskas (2), Yuriy Stukov (3), Amir Emtiazjoo (4), Marc Maybauer (5)
Institutions
(1) The University of Florida, Gainesville, FL, (2) N/A, Gainesville, FL, (3) N/A, N/A, (4) University of Florida, Gainesville, FL, (5) Division of Critical Care Medicine, Department of Anesthesiology, University of Florida, Gainesville, FL
Abstract Presenter
Mindaugas Rackauskas
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Gainesville, FL
United States