Introduction: The general reports of durable right-sided mechanical support describe poor outcomes. For biventricular support, contemporary data in the age of fully magnetically levitated ventricular assist devices is limited. We present a difficult case of biventricular failure in a patient with 2 mechanical prosthetic valves.

Objective “Fast-track” pathway has been successfully applied in low- and intermediate-risk patients during catheter ablation. Catheter ablation is one of the treatment for patients suffering sustained ventricular tachycardia (VT). Patients with reduced cardiac function and patient presented with VT storm may have life threatening reduction in cardiac output. Using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support during high-risk VT ablations can mitigate the risk of hemodynamic instability. The present study describes the application of “Fast-track” pathway in the high-risk patients underwent catheter VT ablation with and without ECMO support. Methods The study included patients undergoing catheter VT ablation between 2017 and 2022 at a high volume tertiary center in Israel. A prospective observational design was used. The patients were divided to two groups, Group I (non-ECMO group) and Group II (ECMO support group). In ECMO group cannulations was performed directly by the ECMO team, which include cardiac surgeon, perfusionist and operating nurse in the cardiac catheterization laboratory. Veno-arterial ECMO cannulations were inserted percutaneously using the Seldinger technique with ultrasound guidance. “Fast track” pathway defined as general Anesthesia or sedation using short-acting agent, early extubation, early decannulation (in ECMO group), early ICU discharge on Day 1 and early hospital discharge on Day 4. Results From the 87 procedures, Group I (non-ECMO) included 52 patients and Group II (ECMO support group) 35 patients.“Fast-track” pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analysis, VT storm and ASA class IV-V were independent risk factors for failed “Fast-track” Conclusions “Fast-track” pathway may be safely applied in selected high-risk patients underwent VT ablation. Using ECMO support during catheter VT ablation should not exclude otherwise qualified candidates from consideration for “Fast-track” pathway. “Fast-track” pathway has been successfully applied in low- and intermediate-risk patients during catheter ablation. Catheter ablation is one of the treatment for patients suffering sustained ventricular tachycardia (VT). Patients with reduced cardiac function and patient presented with VT storm may have life threatening reduction in cardiac output. Using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support during high-risk VT ablations can mitigate the risk of hemodynamic instability. The present study describes the application of “Fast-track” pathway in the high-risk patients underwent catheter VT ablation with and without ECMO support. The study included patients undergoing catheter VT ablation between 2017 and 2022 at a high volume tertiary center in Israel. A prospective observational design was used. The patients were divided to two groups, Group I (non-ECMO group) and Group II (ECMO support group). In ECMO group cannulations was performed directly by the ECMO team, which include cardiac surgeon, perfusionist and operating nurse in the cardiac catheterization laboratory. Veno-arterial ECMO cannulations were inserted percutaneously using the Seldinger technique with ultrasound guidance. “Fast track” pathway defined as general Anesthesia or sedation using short-acting agent, early extubation, early decannulation (in ECMO group), early ICU discharge on Day 1 and early hospital discharge on Day 4. From the 87 procedures, Group I (non-ECMO) included 52 patients and Group II (ECMO support group) 35 patients.“Fast-track” pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analysis, VT storm and ASA class IV-V were independent risk factors for failed “Fast-track” “Fast-track” pathway may be safely applied in selected high-risk patients underwent VT ablation. Using ECMO support during catheter VT ablation should not exclude otherwise qualified candidates from consideration for “Fast-track” pathway.

Background Diastolic plateau is an invasive hemodynamic marker of impaired right ventricular (RV) diastolic filling. The purpose of the current analysis was to evaluate the prognostic importance of this sign in left ventricular assist device (LVAD) patients. Methods The analysis included all LVAD patients who received continuous-flow LVAD (HeartMate 3) at the Sheba medical center and underwent right heart catheterization (RHC) during follow up post-LVAD surgery. Patients were dichotomized into 2 mutually exclusive groups based on a plateau duration cutoff of 55% of diastole. The primary end point of the current analysis was the composite of death, heart transplantation, or increase in diuretic dosage in a 12-month follow-up period post-RHC. Results Study cohort included 59 LVAD patients with a mean age of 57 (IQR 54–66) of whom 48 (81%) were males. RHC was performed at 303 ± 36 days after LVAD surgery. Patients with and without diastolic plateau had similar clinical, echocardiographic, and hemodynamic parameters. Kaplan–Meier survival analysis showed that the cumulative probability of event at 1 year was 65 ± 49% vs. 21 ± 42% for primary outcomes among patients with and without diastolic plateau (p Log rank < 0.05 for both). A multivariate model with adjustment for age, INTERMACS score and ischemic cardiomyopathy consistently showed that patients with diastolic plateau were 4 times more likely to meet the study composite end point (HR = 4.35, 95% CI 1.75–10.83, p = 0.002). Conclusion Diastolic plateau during RHC is a marker of adverse outcome among LVAD patients.

Background: COVID-19 can cause severe respiratory failure and acute respiratory distress syndrome (ARDS). Lung transplantation is a potentially lifesaving treatment for patients with COVID-19–associated ARDS, but uncertainty still surrounds patient selection and timing of referral. Study objective: To identify factors associated with recovery (weaning from ECMO and intensive care unit discharge) versus death of patients with covid-19-associated ARDS on Extracorporeal Membrane Oxygenation (ECMO) listed for lung transplantation. Methods: Retrospective review of all consecutive cases referred to our center and listed for lung transplantation between January and December 2021. Factors associated with recovery versus death while on the waitlist were assessed. Results: Sixteen patients were included in the study: 2 underwent a lung transplant, 8 recovered, and 6 died. The median time on the transplant wait list was 20 days. Patients who recovered were significantly younger (47 vs. 58) with a trajectory towards decreased time on ECMO (71.5 vs. 83.5) and a longer time interval between hospital admission and initiation of mechanical ventilation (7 vs. 2.5 days), ECMO (9 vs. 4 days) or listing for transplant (75 vs. 56.5 days). Conclusions: Although the question regarding which of the patients on ECMO due to COVID-19 ARDS needs lung transplant remains unanswered, it appears that younger patients are more likely to recover without transplant even after a prolonged period on ECMO.

Harlequin Syndrome in A Young Adult with Multi-System Inflammatory Syndrome Post COVID-19 Lerner RK1,7*, Shilo N2,7, Lotan D3,6, Belinson V4, Kogan A5,7, Pessach IM1,7, Haviv Y6,7, Mayan H2,7# and Kassif Y5,7# 1Department of Pediatric intensive care, The Edmond and Lilly Children’s hospital, Sheba Medical Center, Tel Hashomer, Israel 2Department of Internal Medicine E, Sheba Medical Center, Tel-Hashomer, Israel 3Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel 4Department of Internal Medicine C, Sheba Medical Center, Tel-Hashomer, Israel 5Department of Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel 6Intensive Care Unit, Sheba Medical Center, Tel-Hashomer, Israel 7Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Combined procurement of heart and lungs is independently associated with an increased risk of PGD. Hemodynamic compromise and the lung preservation solution are potential contributing factors.

Spontaneous restoration of sinus after aortic unclamping at HT is associated with a reduced risk for PGD and early mortality, whereas pacing for AV block and DC are associated with an increased risk.

Phrenic nerve injury is a relatively common complication in HT recipients bridged with LVAD. However, the resulting diaphragm dysfunction is not associated with untoward early and late outcomes.

Purpose Heart transplantation (HT) is uniquely associated with potential hormonal thyroid therapy implications, viz.: (1) Cardiac surgery is associated with a reduction in T3 levels (2) Administration of T3/T4 to the brain-dead organ donor is associated with increased recovery of transplantable hearts (3) Thyroid hormones directly influence myocardial function, having positive inotropic and chronotropic effects, which are modified in the transplanted heart. We aimed to study the effect of hormonal thyroid therapy to the donor on primary graft dysfunction (PGD). Methods The 209 HT patients assessed from 1992 to 2018 were divided into 2 groups, depending on whether their donors had received T4 (n = 33) or not (n = 176). The primary endpoint was PGD defined according to the ISHLT consensus statement. Results Group of recipients from T4 treated donors was characterized by lower pulmonary pressure (30±11 vs 36±14 mmHg, p = 0.03) lower ACEI therapy (48 vs 72%, p=0.018) and higher female gender (36 vs 14%, p=0.005). There were no other significant differences in donors clinical or echocardiographic parameters between the two groups. Incidence of PGD was significantly higher in recipients from donors who received T4 compared with recipients from donors who did not receive T4 (58 vs 35%, p=0.022). Severity of PGD was significantly higher in patients whose donors received T4 (43 vs 25% moderate/severe, p=0.007). Multivariate analysis showed that donor T4 therapy was independently associated with a significant >5-fold increased risk for PGD (OR=5.38, 95%CI 1.79-17.78; Fig). These results remained consistent after propensity score analysis. Conclusion Donor hormonal thyroid therapy is independently associated with increased risk of PGD. Hypothesizing a "withdrawal effect" as the cause, administration of thyroid hormonal therapy to the recipient at time of reperfusion may oppose this negative effect. Further prospective studies are needed to validate this hypothesis-generating study.

Hypomagnesemia is commonly observed in heart transplant (HT) recipients receiving calcineurin inhibitors. Since low serum magnesium (s-Mg) has been implicated in the progression of atherosclerosis, potentially leading to worsening coronary heart disease, arrhythmias and sudden death, we investigated the association between s-Mg and HT outcomes. Between 2002 and 2017, 150 HT patients assessed for s-Mg were divided into high (>= 1.7 mg/dL) and low s-Mg groups according to the median value of all s-Mg levels recorded during the first 3 months post-HT. Endpoints included survival, cardiac allograft vasculopathy (CAV), any-treated rejection (ATR) and NF-MACE. Kaplan-Meier analysis showed that at 15 years after HT, both survival (76 vs 33%, log-rank p = 0.007) and freedom from CAV (75 vs 48%, log-rank p = 0.01) were higher in the high versus low s-Mg group. There were no significant differences in freedom from NF-MACE or ATR. Multivariate analyses consistently demonstrated that low s-Mg was independently associated with a significant 2.6-fold increased risk of mortality and 4-fold increased risk of CAV (95 % CI 1.06 to 6.4, p = 0.04; 95 % CI 1.12 to 14.42, p = 0.01, respectively). In conclusion, low s-Mg is independently associated with increased mortality and CAV in HT patients. Larger multi-center prospective studies are needed to confirm these findings and to examine the effect of Mg supplementation. (C) 2020 Elsevier Inc. All rights reserved.

Purpose Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality following heart transplantation (HT). Lower cardiovascular (CV) mortality and morbidity have been reported in non-HT patients treated with metformin. Given the high prevalence of diabetes mellitus (DM) in HT patients, we investigated the association between metformin therapy and CV outcomes after HT. Methods The study population comprised 103 DM patients who had undergone HT between 1994 and 2018 and were prospectively followed-up. Clinical data were recorded on prospectively designed forms. The primary outcomes included CAV and the combined end-point of CAV or CV mortality. Treatment with metformin and the development of CAV or the combined end-point of CAV or CV mortality were assessed as time-dependent factors in the analyses. Results Fifty-five HT patients (53%) were treated with metformin whereas 48 (47%) patients were not. Kaplan-Meier survival analysis showed that the CAV rate at 20 years of follow-up was lower in DM patients treated with metformin than in those who were not (30% vs. 65%; log-rank p=0.044; Figure); similarly, the combined risk of CAV or CV mortality was lower in the metformin-treated patients (32% vs. 68%; log rank p=0.01; Figure). Consistently, multivariate analysis adjusted for age and comorbidities showed that metformin therapy was independently associated with a significant 90% reduction (95% confidence interval 0.02-0.46, p=0.003) in the risk for the development of CAV, and a 91% reduction (95% confidence interval 0.02-0.42; p=0.003) in the risk for CAV or CV mortality. Conclusion In diabetic HT patients, metformin therapy is independently associated with a significant reduction in the long-term risk for CAV and the combined end-point of CAV or CV mortality after HT. Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality following heart transplantation (HT). Lower cardiovascular (CV) mortality and morbidity have been reported in non-HT patients treated with metformin. Given the high prevalence of diabetes mellitus (DM) in HT patients, we investigated the association between metformin therapy and CV outcomes after HT. The study population comprised 103 DM patients who had undergone HT between 1994 and 2018 and were prospectively followed-up. Clinical data were recorded on prospectively designed forms. The primary outcomes included CAV and the combined end-point of CAV or CV mortality. Treatment with metformin and the development of CAV or the combined end-point of CAV or CV mortality were assessed as time-dependent factors in the analyses. Fifty-five HT patients (53%) were treated with metformin whereas 48 (47%) patients were not. Kaplan-Meier survival analysis showed that the CAV rate at 20 years of follow-up was lower in DM patients treated with metformin than in those who were not (30% vs. 65%; log-rank p=0.044; Figure); similarly, the combined risk of CAV or CV mortality was lower in the metformin-treated patients (32% vs. 68%; log rank p=0.01; Figure). Consistently, multivariate analysis adjusted for age and comorbidities showed that metformin therapy was independently associated with a significant 90% reduction (95% confidence interval 0.02-0.46, p=0.003) in the risk for the development of CAV, and a 91% reduction (95% confidence interval 0.02-0.42; p=0.003) in the risk for CAV or CV mortality. In diabetic HT patients, metformin therapy is independently associated with a significant reduction in the long-term risk for CAV and the combined end-point of CAV or CV mortality after HT.

Purpose Primary graft dysfunction (PGD) is a leading cause of early morbidity and mortality after heart transplantation (HT) and is a significant predictor of adverse outcomes. We aimed to investigate the influence of pharmacologic therapies administered to the recipient before HT on PGD. Methods Between 1997-2017 we assessed 279 HT patients. Pharmacological therapies at the time of HT were reviewed, including a statin, spironolactone, amiodarone, beta-blockers (BBs) and ACE-inhibitors (ACEIs). Endpoints included PGD (defined according to the ISHLT consensus statement), in-hospital mortality, 1- and 5-yr survival. Results In the group of patients diagnosed with PGD (102; 36.5%) vs the non-PGD group, fewer had received pre-HT statins (35 vs 75%, p<0.001) or spironolactone (32 vs 81%, p<0.001), and more, amiodarone therapy (70 vs 29%, p<0.001). Donor characteristics were similar. Multivariate analysis consistently demonstrated that pre-HT treatment with a statin or spironolactone was independently associated with a significant 74% and 87% reduced risk for PGD, while pre-HT amiodarone therapy was independently associated with a significant >4-fold increased risk for PGD (Figure). Statin therapy was independently associated with a significant reduction in PGD severity (OR 0.26, 95% CI 0.03-0.74). In-hospital mortality was significantly lower for patients treated with a statin (9 vs 21%, p=0.006) or spironolactone (7 vs 27%, p<0.001) vs nontreated patients, with a corresponding significantly higher 1-yr (89 vs 73%, p=0.001; 91 vs 67% p<0.001) and 5-yr survival (86 vs 67%, p=0.002; 88 vs 60%, p<0.001, respectively). Conversely, 5-yr survival was significantly lower for patients treated with amiodarone (67 vs 82%, p=0.008). Pre-HT therapy with a BB or an ACEI was not associated with PGD. Conclusion Pre-HT statin or spironolactone therapies are independently associated with a reduced risk for PGD and mortality, whereas amiodarone therapy is associated with an increased risk.

Donor’s brain death (BD) is associated with impairment of myocardial function and hemodynamic performance. The impact of mode of BD on heart transplantation (HTx) outcomes has been poorly studied, with early results suggesting that it might impact survival and vasculopathy. We aimed to explore the impact of mode of donor’s BD on HTx outcomes.

BACKGROUND:Severe lung injury with the development of acute respiratory distress syndrome (ARDS) is a serious complication of cardiac surgery. The aim of this study was to determine the incidence, risk factors, and mortality of ARDS following cardiac surgery.METHODS:We retrospectively analyze data in the period between January 2005 and March 2013.RESULTS:Of 6069 patients who underwent cardiac surgery during the study period, 37 patients developed ARDS during the postoperative period. The incidence of ARDS was 0.61%, with a mortality of 40.5% (15 patients). Multivariate regression analysis identified previous cardiac surgery, complex cardiac surgery, and more than three transfusions with packed red blood cells (PRBC) were independent predictors for developing ARDS.CONCLUSIONS:ARDS remains a serious, but very rare complication associated with significant mortality. In our study, previous cardiac surgery, complex cardiac surgery, and more than three transfusions of PRBC were independent predictors for the development of ARDS.

BACKGROUND:Postoperative mortality after coronary artery bypass grafting (CABG) surgery is traditionally considered to be influenced by gender. However, the data are conflicting and it is not clear whether gender is a true independent risk factor for death in this setting. We analyzed our database to determine whether gender is an independent risk factor for death after CABG. PATIENTS AND DESIGN:A retrospective analysis of 1 758 isolated first-time coronary artery bypass graft patients treated between 2003 and 2005 was conducted in the Department of Cardiothoracic Surgery of Rabin Medical Center, a major tertiary facility in Israel. RESULTS:The female patients had a distinctly different pre- and intraoperative profile compared with the male patients, and significantly higher postoperative mortality (p < 0.05). On a propensity scoring of 359 matched pairs, the risk factors for death were found to be severe left ventricular dysfunction, chronic obstructive pulmonary disease, and use of an intra-aortic balloon pump (p < 0.05). The addition of intraoperative data to the model yielded only cardiopulmonary bypass time and use of an intra-aortic balloon pump as risk factors for death (p < 0.05). Validation with the bootstrap technique revealed that strong predictors of death (> 50 % of the sample) were cardiopulmonary bypass time, use of an intra-aortic balloon pump, and, to a lesser extent, chronic obstructive pulmonary disease. Female gender was not found to be an independent risk factor for death after coronary artery bypass graft. CONCLUSIONS:Female gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

OBJECTIVE:Open-heart surgery carries a high risk for hemodialysis patients. This study focuses on the short and long-term outcomes of hemodialysis patients undergoing heart surgery.DESIGN:The study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital.PATIENTS:115 hemodialysis patients underwent cardiac surgery in our department between 1 July 1996 and 31 July 2006. 67.5 % (77 patients) underwent isolated coronary artery bypass grafting (CABG), 13.2 % (15 patients) underwent isolated aortic valve replacement (AVR) and 20.2 % (23 patients) underwent mitral valve surgery or combined valve and coronary artery bypass grafting or multiple valve surgery.METHODS:The relationship between several variables (age, sex, hypertension, diabetes, and previous myocardial infarction, type of disease, preoperative ejection fraction, and congestive heart failure) and operative (30 days) mortality and late survival was analyzed.RESULTS:The overall 30-day mortality was 18.3 % (21 patients). It was 13 % (10/77 patients) for the isolated CABG group and 13.3 % (2/15) for the isolated AVR group. Patients undergoing combined valve and coronary surgery or multiple valve surgery had a higher perioperative mortality of 39.1 % (9/23) compared to the isolated CABG and isolated AVR patients. Perioperative death was also higher in patients with moderate and severe LV dysfunction, and in patients with diabetes. The duration of dialysis periods was not related to perioperative death. Mean follow-up was 26.4 +/- 29.7 months (0.1 to 104 months). Actuarial survival at 1 year and 5 years was 76 % and 55 % for isolated CABG, 59 % and 21 % for isolated AVR, and 44 % and 33 % for all other cases, respectively (log rank P = 0.001).CONCLUSION:Patients on dialysis have a high risk of perioperative mortality and poor long-term survival rates. Mortality is higher and survival is worse after combined CABG and valve-related procedures or multiple valve surgery than after isolated CABG and AVR.