Background Ascites commonly results from portal hypertension, malignancy, or cardiac disease. Systemic venous obstruction is an uncommon mechanism. Case Summary A 40-year-old woman with 2 prior kidney transplants, remote venous thromboembolism, and small bowel adenocarcinoma presented with recurrent ascites. Imaging revealed chronic superior vena cava (SVC) occlusion with collateralization to the inferior vena cava (IVC), IVC stenosis, and left iliac vein stenosis. Hemodynamics showed elevated SVC pressure, gradient from the left femoral vein to the IVC, and normal right atrial pressure. She underwent staged endovascular recanalization and stenting of the SVC, IVC, and left iliac vein, with repeated interventions for restenosis. Discussion Multilevel systemic venous obstruction can produce clinically significant ascites through venous hypertension. Symptom relief is possible, but may require technically complex recanalization and repeat interventions. Take-Home Messages Systemic venous obstruction should be considered in unexplained refractory ascites. Endovascular therapy can be effective, but often necessitates repeat procedures.

Cardiac allograft vasculopathy (CAV) is a leading cause of late graft failure with limited revascularization options and high rates of in-stent restenosis (ISR). This report details a 33-year-old heart transplant recipient with progressive CAV that underwent multiple prior revascularizations, including drug-eluting stents and coronary artery bypass grafting. He developed ISR of the right coronary artery stent, treated with paclitaxel drug-coated balloon (DCB) without further stenting. Follow-up at 3 and 9 months showed patent vessels without recurrent restenosis and preserved graft function. DCB may be a viable option for ISR in advanced CAV when additional stenting is undesirable. Larger studies are needed to define its long-term role.

Background:Patients with COVID-19 and ST-elevation myocardial infarction (STEMI) from the North American COVID-19 Myocardial Infarction (NACMI) registry had elevated in-hospital mortality compared with COVID-19-negative patients and historical controls. We examined 1-year mortality outcomes from the NACMI registry. Methods:This was a substudy of NACMI centers that participated in long-term follow-up. Patients in the NACMI registry were stratified into COVID-19-positive and COVID-19-negative groups. A historical 2018-2019 control group was derived from the Midwest STEMI Consortium registry. The primary outcome was 1-year mortality. Results:A total of 2358 STEMI patients (30% female) were included in this study, divided into 3 subgroups: COVID-19-positive (n = 623), COVID-19-negative (n = 694), and historical controls (n = 1041). One-year mortality in COVID-19-positive patients was 45% (HR, 4.88; 95% CI, 3.73-6.39; P < .001), compared with 27% (HR, 3.93; 95% CI, 2.92-5.29; P < .001) in COVID-19-negative patients and 11% in matched controls (P < .001). Most deaths (86%) occurred during the index hospitalization, with a median time to death of 27 days (IQR 6, 343) in the COVID-19-positive group. Among survivors of index hospitalization, 1-year mortality was 12% (COVID-19-positive; HR, 2.20; 95% CI, 1.26-3.85; P = .006), 9.6% (COVID-19-negative; HR, 2.31; 95% CI, 1.26-4.21; P = .007), and 5.3% (controls) (P < .001). Conclusions:This study describes long-term outcomes in patients with STEMI and COVID-19. We demonstrate that the excess mortality risk associated with COVID-19 STEMI extends beyond the index hospitalization and exhibits a clear risk gradient. The cause is likely multifactorial, including pandemic-era disruptions in care, longer time-to-treatment, and the unique pathophysiology of COVID-19 STEMI.

Background Congestive Heart failure (CHF) is known to affect 2.6 million women and 3.4 million men in the United States. Sex based differences in the incidence, and types of heart failure, traditional risk factors, pathophysiology, and diagnosis affect the treatment and outcomes. Female-specific risk factors, hormonal changes, and gender stigma may play a role in the observed differences. Methods We analyzed National Readmission Database 2021 to identify all the discharges among patients aged ≥65 years with CHF using International Classification of Disease Tenth revision Clinical Modification system. All statistical analyses were performed using Stata MP/18. Results We identified 699,231 CHF patients with mean age of 78.78 years. 51.63% were females. A total of 12,078 females and 13,487 males died on index hospitalization. 27,159 females and 26,951 males were readmitted leading to a 30-day all-cause readmission rate of 7.79% in females and 8.29% in males. Independent predictors for readmissions were female sex, insurance, median income, hospital location, old myocardial infarction, prior coronary intervention, prior cardiac bypass, diabetes, smoking, acute or chronic kidney disease, atrial fibrillation, peripheral vascular disease, COPD. After adjusting for potential confounders, females had higher odds of readmissions at 30 days [unadjusted OR 0.93 (0.91-0.96), p<0.001; adjusted OR 1.04 (1.01-1.07), p<0.01] and lower odds of mortality on index hospitalization [unadjusted OR 0.83(0.80-0.86), p<0.001; adjusted OR 0.93 (0.89-0.97), p<0.01] compared to males. Conclusion We observed that older women with CHF hospitalization were less likely to die on hospitalization but more likely to be readmitted at 30-days.

Mechanical circulatory support (MCS) devices represent a major advance in the management of advanced heart failure and cardiogenic shock. Despite significant improvements in device technology and patient outcomes, infection remains the most common adverse event, affecting approximately 37% of patients and contributing substantially to morbidity and mortality. This state-of-the-art, multidisciplinary review comprehensively examines infections in patients who require durable or temporary mechanical circulatory support devices with contributions from experts in advanced heart failure, cardiovascular imaging, infectious diseases, cardiothoracic surgery, and pharmacology. We review the underlying pathophysiology of MCS-related infections, examine current preventative, diagnostic and management strategies, outline established best practices, discuss emerging technologies and therapies, and identify existing knowledge gaps and areas for future investigation.

Introduction The Heart Transplant (HT) allocation system prioritizes transplantation based on the likelihood of waitlist mortality (urgency) and doesn't incorporate post-transplant survival. Stable LVAD-supported patients have a low priority for HT. Currently, a new allocation system is being developed that would increase the chances of transplanting stable LVAD-supported patients. Our objective was to analyze the net benefit of receiving HT on LVAD patients according to their listing and transplant status. Methods Adult patients who were supported by durable LVAD at the time of listing and at the time of HT who were registered in the UNOS database between October 18, 2018, and June 30, 2022, were included in this study. Patients listed for dual organs or re-transplantation were excluded. One-year survival in the waitlist and after HT was calculated at each listing or transplant status. The net benefit within each status was calculated in days, by subtracting the survival after transplantation from the survival in the waitlist. Results A total of 2117 HM3 patients were listed for HT during the study period. Of these 899 were not transplanted within 1 year of listing. The survival at 1 year of these patients was 37.5%, 51.9%, 87.8%, and 94.5% for status 1, 2, 3, and 4 respectively. During the same study period, a total of 1440 HM3 patients received HT. The one-year survival after HT was 94%, 90.1%, 89.5%, and 88.9% for patients transplanted status 1,2,3, and 4 respectively. Patients transplanted as status 1, and 2 had a net positive survival benefit after transplantation of 168.7 and 135.3 days respectively (p<0.001). Patients transplanted as status 3 had a neutral benefit from transplantation, whereas patients who were transplanted as status 4 had a net negative survival benefit of 15.9 days (p <0.01)(Figure 1). Conclusion In terms of survival, transplanting stable HM3 LVAD patients listed as status 4 doesn't offer an advantage to patients. Informed shared decision-making is of critical importance when considering transplanting a stable HM3 patient.

Introduction:For individuals with both end-stage heart failure and end-stage kidney disease or persistent acute kidney injury (AKI), simultaneous heart-kidney transplantation (SHKT) emerges as a viable treatment option, potentially yielding superior survival rates compared with heart transplantation (HT) alone. Nevertheless, accurately forecasting kidney recovery following HT in patients with moderate kidney failure poses challenges, thereby complicating the decision-making process for SHKT. Methods:This study employed a random forest (RF) machine learning algorithm, using 15 variables with the highest feature importance scores in the Organ Procurement and Transplantation Network (OPTN) data in which we analyzed a retrospective cohort of adult HT recipients from October 18, 2018 to December 31, 2020 in the US, with a follow-up for at least 1 year. The algorithm's goal was to predict a composite binary outcome with a calculated probability. An adverse outcome included the need for SHKT or adverse kidney outcomes within the first-year posttransplant (defined as end-stage kidney disease requiring chronic dialysis, glomerular filtration rate (GFR) ≤ 20 ml/min per 1.73 m2 or listing for retransplant). The model underwent both internal and external validation. Results:Of the 6579 patients in the study cohort, 13.4% received SHKT or experienced adverse kidney outcomes within a year following HT (n = 880). The RF model demonstrated a high specificity (0.941-0.955) and negative predictive value (0.940-0.955). However, it exhibited a moderate level of sensitivity (0.605-0.694) and positive predictive value (0.604-0.680). The concordance (c)-statistics ranged between 0.849 and 0.899, indicating effective class differentiation. Conclusion:This tool supplements, not replace, clinical judgment in addressing the complexities of SHKT decision-making at the time of waitlisting.

Background: Impella-supported high-risk percutaneous coronary intervention (HRPCI) is an alternative for patients ineligible for coronary artery bypass grafting (CABG). However, limited data exist on patient characteristics, reasons for surgical turndown, and patient outcomes. This study aimed to characterize the baseline characteristics and short-term and intermediate-term outcomes of patients evaluated for CABG in the PROTECT III study. Methods: Patients enrolled in the PROTECT III study (NCT04136392), who underwent Impella-supported HRPCI, with an evaluable chart who were assessed by a cardiothoracic surgeon (CTS) for CABG were studied. Reasons for surgical turndown were derived from medical records. Baseline characteristics and major adverse cardiovascular and cerebrovascular events (composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 30 and 90 days and all-cause mortality at 1 year were assessed. Observed to expected 30-day mortality ratios were calculated using the Society of Thoracic Surgeons (STS) risk score. Results: Of 791 patients evaluated for CABG, 680 (86.0%) were turned down by a CTS, and 111 (14.0%) declined surgery. The most common reasons for surgical turndown were comorbidities (40%) and anatomical factors (25%). Compared with patients who declined surgery, patients turned down (deemed ineligible) by CTS had higher rates of major adverse cardiovascular and cerebrovascular event at 30 days (9.2% vs 4.6%; P = .12) and 90 days (14.1% vs 4.6%; P = .02). The observed to expected mortality ratio, based on the STS risk score, was 1.43 (95% CI, 1.08-1.83). Conclusions: Impella-supported HRPCI is a viable alternative for high-risk patients deemed ineligible for CABG. Patients turned down by a CTS had worse clinical outcomes than those who declined surgery. The underestimation of 30-day mortality by the STS risk score suggests the need for improved risk prediction models in this high-risk cohort.

Introduction The implementation of the current Heart Transplant (HT) allocation system in 2018 led to a significant change in practices in the management of waitlisted patients. The regional impact of the current system has not been evaluated. Our objective was to evaluate the changes in outcomes in the waitlist and after HT with the implementation of the current allocation system according to transplant regions. Methods Adult patients who were registered in the UNOS database for heart transplantation between Jan 1, 2014, and Dec 31, were included in the study. Patients listed for re-transplantation or multiorgan transplant were excluded. Patients were classified in the current or prior allocation system using Oct 18, 2018, as a cutoff. The one-year, cumulative incidence (CI) of transplantation, death or delisting due to worsening clinical status, and the post-transplant survival were calculated for each transplant region and compared using Fine-Gray analysis (competing risks) and Kaplan-Meier (post-transplant survival). Results A total of 26450 patients were listed for HT during the study period. Of these 15761 and 10689 patients were listed in the prior and current allocation system, respectively. A total of 17796 patients received HT, 9424 in the prior and 8372 in the current allocation system. There were significant variations in the outcomes in the waitlist and post transplantation according to transplant regions and the effect of the implementation of the current (Table 1). In the prior system, regions 3 and 11 had the highest CI of death or delisting (12.5% and 12%) and regions 4 and region 9 had the lowest (8.7% and 8.5%) (p<0.001). In the new system region 3 had the highest CI of death or delisting (9.5%) whereas region 9 had the lowest 4.5%). Region 1 had the lowest cumulative incidence of transplantation in the prior system (46.6%), whereas region 5 had the highest (63.7%) (p<0.001), In the current allocation system Region 10 had the lowest cumulative incidence of transplantation (57%), whereas region 5 had the highest (78.7%), (p<0.001). In the prior system, regions 5 and 6 had the highest 1-year post-transplant survival (93.3% and 93.4%) and region 4 had the lowest (90.9%) (p<0.001). In the current system region 3 had the lowest survival (89.3%) and regions 5 and 6 the highest (94.2% and 94.1%). Conclusion There are significant regional variations in the outcomes in the waitlist and after heart transplantation in the United States. The implementation of the current allocation system has shifted the disparities but not resolved them. These disparities will require careful monitoring if a new continuous allocation system is implemented.

BACKGROUND:The 2018 revision of the adult Heart Allocation Policy (aHAP) led to a notable increase in the rate of simultaneous heart-kidney transplants (SHKT) in the United States. However, this policy has faced criticism for its inability to enhance post-transplant survival rates or decrease mortality among SHKT recipients on the waitlist, although high-quality kidneys are used. METHODS:We analyzed data from the Organ Procurement and Transplantation Network, covering 1549 SHKT cases from 2015 to 2021. The study assessed 1-y post-transplant outcomes, including all-cause heart and kidney graft failures and adverse kidney outcomes such as end-stage kidney disease, significantly reduced kidney function or the need for retransplantation. Using a propensity score-matching approach, we compared 2 cohorts: patients treated before and after the policy implementation in October 2018. RESULTS:The multivariable Cox proportional hazard models indicated a significant increase in mortality (hazard ratio [HR] 1.62; 95% confidence interval [CI], 1.10-2.37) and all-cause graft failures for both heart (HR 1.59; 95% CI, 1.08-2.33) and kidney (HR 1.39; 95% CI, 1.03-1.85) during the period after the new aHAP implementation. One year post-transplant, the incidence of adverse kidney outcomes was 6.8% under the new aHAP compared with 5.3% in the previous period among survivors ( P = 0.33). CONCLUSIONS:The suboptimal outcomes of SHKT under the new aHAP, alongside its potential impacts on kidney-alone transplant candidates, suggest a need for regular monitoring of SHKT policies. This is crucial to ensure that the intentions of the Final Rule regarding equity and utility are effectively met.

BACKGROUND:To date, there has been no independent core lab angiographic analysis of patients with COVID-19 and STEMI. The study characterized the angiographic parameters of patients with COVID-19 and STEMI. METHODS:Angiograms of patients with COVID-19 and STEMI from the North American COVID-19 Myocardial Infarction (NACMI) Registry were sent to a Core Laboratory in Vancouver, Canada. Culprit lesion(s), Thrombolysis In Myocardial Infarction (TIMI) flow, Thrombus Grade Burden (TGB), and percutaneous coronary intervention (PCI) outcome were assessed. RESULTS:From 234 patients, 74% had one culprit lesion, 14% had multiple culprits and 12% had no culprit identified. Multivessel thrombotic disease and multivessel CAD were found in 27% and 53% of patients, respectively. Stent thrombosis accounted for 12% of the presentations and occurred in 55% of patients with previous coronary stents. Of the 182 who underwent PCI, 60 (33%) had unsuccessful PCI due to post-PCI TIMI flow <3 (43/60), residual high thrombus burden (41/60) and/or thrombus related complications (27/60). In-hospital mortality for successful, partially successful, and unsuccessful PCI was 14%, 13%, and 27%, respectively. Unsuccessful PCI was associated with increased risk of in-hospital mortality (risk ratio [RR] 1.96; 95% CI: 1.05-3.66, P = .03); in the adjusted model this estimate was attenuated (RR: 1.24; 95% CI: 0.65-2.34, P = .51). CONCLUSION:In patients with COVID-19 and STEMI, thrombus burden was pervasive with notable rates of multivessel thrombotic disease and stent thrombosis. Post-PCI, persistent thrombus and sub-optimal TIMI 3 flow rates led to one-third of the PCI's being unsuccessful, which decreased over time but remained an important predictor of in-hospital mortality.

Background The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems. Methods Adult HT candidates in the United Network for Organ Sharing database from 2014 through 2021 were included. Old or new system classification was according to listing before or after October 18, 2018. SES was stratified by patient ZIP code and median household income via U.S. Census Bureau and classified into terciles. Competing waitlist outcomes and post-transplantation survival were compared between systems. Results In total, 26,450 patients were included. Waitlisted candidates with low SES were more frequently younger, female, African American, and with higher body mass index. Reduced cumulative incidence (CI) of HT in the old system occurred in low SES (53.5%) compared to middle (55.7%, p = 0.046), and high (57.9%, p < 0.001). In the new system, the CI of HT was 65.3% in the low SES vs middle (67.6%, p = 0.002) and high (70.2%, p < 0.001), and SES remained significant in the adjusted analysis. In the old system, CI of death/delisting was similar across SES. In the new system, low SES had increased CI of death/delisting (7.4%) vs middle (6%, p = 0.012) and high (5.4%, p = 0.002). The old system showed similar 1-year survival across SES. In the new system, recipients with low SES had decreased 1-year survival (p = 0.041). Conclusions SES affects waitlist and post-transplant outcomes. In the new system, all SES had increased access to HT; however, low SES had increased death/delisting due to worsening clinical status and decreased post-transplant survival.

Cardiogenic shock is the most common cause of mortality in patients with acute myocardial infarction with an increase in incidence over the last 15-years. Recent classification systems of cardiogenic shock (CS) have improved categorization of patients into subsets of acuity and begun to integrate phenotypes and etiologies in addition to risk modifiers. Early revascularization with PCI or CABG has been the most important advance in the management of AMI-CS patients with improvements in survival. Despite this initial progress, mortality remains high at approximately 40%, with a significant proportion of patients dying of neurological causes, especially in the cohort with cardiac arrest and multi-organ dysfunction despite cardiac recovery. Mechanical circulatory support devices are an attractive strategy to ameliorate the cardio-metabolic spiral but have thus far failed to show survival benefits in randomized trials during revascularization of AMI-CS patients with IABP and ECMO use, although many aspects of their use have yet to be studied, including their role as part of an escalation or bridging strategy along the continuum of CS care. Randomized trials in Impella percutaneous LVAD use are pending. Cardiac arrest patients represent an important cohort with specific challenges of care and familiarity with management including the use of mechanical CPR devices, temperature optimization, MCS use and pharmacotherapy issues are critical to successful outcomes.

Cardiac Allograft vasculopathy (CAV) is a major barrier to improving outcomes after heart transplantation. Coronary angiography has very low sensitivity to detect early CAV and intravascular ultrasound (IVUS) only improves it to some extent. In this article, we detail the current evidence surrounding use of Optical Coherence tomography (OCT) in patients with CAV. OCT has the ability to recognize CAV at earlier stages with intimal thickness < 150 μm, can characterize CAV in almost pathologic / microscopic detail – plaque characteristics are better visualized and novel early features such as layered fibrotic plaques and microchannels have been identified. Progression of CAV can be monitored also, with promise shown in automated serial measurements also. OCT has significantly advanced our understanding of the pathophysiology—as well as permits precise monitoring and surveillance of the disease. Potential treatment options could also be evaluated using OCT.

The “International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates—2024” updates and replaces the “Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006” and the “2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update.” The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

The United Network for Organ Sharing (UNOS) heart transplant allocation policy was changed in 2018. This study examines the impact of the change in UNOS heart transplant allocation policy on the use of temporary mechanical circulatory support (MCS) devices and post-transplant survival.The analysis included a total of 26,481 patients listed and transplanted between January 2013 and June 2022. The results showed a decrease in waiting time for transplant after the policy change, indicating a successful reduction in waitlist time for high-priority status patients. However, the length of hospital stays from transplant to discharge increased following the policy change. The study also found an increase in the frequency of ECMO and IABP use both at the time of listing and at the time of transplant following the policy change.Cumulative patient and graft survival at 1000 days decreased following the policy change (86.1 per cent versus 83.7 per cent at 1000 days, p = 0.002). However, the survival curves showed similar survival trends in the first 2 years, with late divergence in survival occurring after 2 years.In conclusion the latest UNOS heart transplant allocation policy change led to a decrease in waiting times and an increase in the use of temporary MCS devices. There was a decrease in cummulative survival at 1000 days following the policy change.