Background Cardiologists performing endomyocardial biopsies (EMB) and right heart catheterizations (RHC) have high head-level radiation doses, which are comparable to doses received during coronary angiography. Yet, little is known about mitigating radiation doses during these procedures. Objective To evaluate head-level radiation doses while using suspended lead suits versus traditional lead aprons during EMB and RHC. Methods Physician radiation doses were prospectively collected by head-level, real-time dosimeters during EMB and RHC. Doses were compared between cases performed while using suspended lead aprons versus traditional lead aprons; the shielding utilized was at the physician’s discretion. Exploratory analyses in which physician radiation doses were normalized to dose area product (DAP) to account for between group differences in radiation usage were performed. Multivariate analysis was performed to determine patient and physician level variables associated with elevated radiation doses. Results Of the 141 EMB and RHC procedures, 72 (51%) were performed using a suspended lead suit and 69 (49%) with traditional lead aprons. Median radiation dose [IQR] while using traditional lead aprons was 2.2 µSv [0.8, 4.3], compared with 0.0 µSv [0.0, 0.0] while using a suspended lead suit (p <0.001). After normalizing to DAP, physician radiation doses remained lower with suspended lead suits compared to traditional lead aprons (0.0 [0.0, 0.0] µSv/Gy•cm2 vs 1.5 [0.5, 2.4] µSv/Gy•cm2, p<0.001). After accounting for patient and physician level variables, utilization of a suspended lead suit remained the strongest independent predictor of lower radiation doses (beta coefficient and 95% CI -3.28 [-4.26, -2.28], p<0.001). Conclusion Utilizing a suspended lead suit was associated with significantly lower head-level radiation doses among physicians performing EMB and RHC. This has important implications for occupational radiation protection during these procedures.

Introduction Right ventricular failure (RVF) remains a leading cause of mortality and morbidity in patients supported with left ventricular assist devices (LVAD). There is significant limitation in predicting early RVF post LVAD utilizing static parameters. Our objective was to evaluate the safety and feasibility of a dynamic evaluation of RV function (RV stress test) prior to HM3 LVAD implantation. Hypothesis Assessing dynamic hemodynamic and echocardiographic parameters during RV stress test is safe, and feasible to assess RV reserve prior to LVAD implantation. Methods Adult patients evaluated for LVAD implantation at our institution were consented for inclusion in the prospective RV stress test study. The RV stress test consisted of firstly, an infusion of epinephrine titrated to .03 mcg/kg/min (inotropic response). second, sodium nitroprusside titrated to 1.0 mcg/kg/min (vasodilators response). Lastly, a 500 cc bolus of normal saline (volume response). Repeat simultaneous invasive hemodynamics and echo parameters were collected at baseline and then each stage of the RV stress test. INTERMACS defined RV failure was the primary outcome, with adverse stress test outcomes, as secondary outcomes. Results A total of 11 patients enrolled in this pilot study. The median age was 58.4, 64% males, 45.5% Ischemic cardiomyopathy. Prior to LVAD implant the median LVEF and LVDD were 14.9% and 6.7cm respectively. The baseline hemodynamics are shown on Table 1. The change on baseline hemodynamics with each of the RV stress steps are shown on Figure 1. The nitroprusside intervention led to significant decreases in hemodynamic markers of preload and afterload, with no changes on hemodynamic markers of RV contractility. The epinephrine group had significant increase in pulmonary artery compliance. Both epinephrine and nitroprusside interventions achieved significant increases in total and Free wall RV strain. There were zero adverse events of hypotension, arrhythmias or pulmonary edema during the stress test. Conclusions Dynamic assessment of RV function using inotropes, vasodilators and fluid challenge is safe in end stage HF patients undergoing LVAD implantation. These steps were able to demonstrate variable degrees of RV reserve under different hemodynamic conditions. Further studies are needed to demonstrate the clinical utility of dynamic changes in RV function in prediction of RVF post LVAD implantation.

Background:The OPTN heart transplant allocation policy implemented in 2018 led to significant improvements in waitlist outcomes, but disparities persist. Our study evaluated the effect of the implementation of the new allocation on waitlist and post-transplantation outcomes in rural versus urban communities. Methods:Patients registered for HT in the OPTN database between January 1, 2014, and December 31, 2021, were included as rural or urban according to ZIP code. The cumulative incidence (CI) of death/delisting and transplantation in the different allocations were calculated. Post-transplant survival was calculated using Kaplan-Meier methodology. Results:26,450 patients were listed for transplant. Rural residents were more commonly white and had a higher incidence of ischemic cardiomyopathy. Both allocations saw a similar decrease in the CI of death/delisting from the wait list and an increase in the CI of HT in both rural and urban communities. In the prior allocation, no differences existed in the CI of death/delisting or transplantation between rural and urban residents. In the current allocation, rural residents had a higher frequency of death/delisting (p=0.01) after adjusting for risk factors. No differences existed in the CI of transplantation or post-transplant survival. Conslusions:Our findings suggest that despite an overall decrease in CI of death/delisting in both rural and urban communities, rural residence is associated with a disproportionately higher CI of death/delisting on the transplant list in the current allocation. We found no differences in the CI of transplantation or survival after transplant.

Purpose Implantable pulmonary artery pressure sensors (CardioMems) are being increasingly utilized for the management of heart failure (HF) patients who are at risk for hospitalization. Implantation of CardioMems requires the use of ionizing radiation. We have previously reported that the radiation utilized during CardioMems implantation is significantly higher than endomyocardial biopsies and similar to diagnostic coronary angiography (CA). Interventions to decrease physician radiation exposure during CardioMems implantations has not been described. Our objective was to describe the physician radiation exposure during implantation of CardioMems using standard radiation protection equipment and compare it with the suspended radiation protection system. Methods CardioMems implantation procedures performed between May 8,2023 and February 23, 2024 at our institution were included in the study. Physicians wore a real time RaySafe badge at the level of the neck. For the first phase of the study, physicians used standard radiation equipment (lead apron, thyroid collar, shield). For the second portion of the study, physicians utilized a suspended radiation protection system. Baseline patient clinical characteristics and radiation measures (fluoroscopy time (FT), air kerma (AK), dose area product(DAP), and physician radiation dose (µSv)) were obtained. Results A total of 24 patients underwent CardioMems implantation during the study period. Patient clinical characteristics, radiation utilization, and radiation exposure variables are shown in table 1. Clinical hemodynamic and echocardiographic characteristics were similar between the two groups. The radiation utilized for CardioMems implantation (AK, DAP, FT) was similar between both groups. The physician radiation exposure utilizing the standard protection equipment was 3.8 ± 3.8 µSv; this value is similar to that described for the exposure in CA. The physician radiation exposure with the utilization of suspended radiation protection equipment was 0.3 ± 0.3 µSv, which was significantly lower compared to radiation exposure with conventional protection methods (p = 0.005). Conclusion The physician radiation exposure during CardioMems implantation (via the femoral approach) is similar to coronary angiography, and is significantly reduced by the use of suspended radiation protection equipment.

Purpose Implantable pulmonary artery pressure sensors (CardioMEMS™) are being increasingly utilized for the management of heart failure (HF) patients who are at risk for hospitalization. CardioMEMS™ can be implanted via the femoral vein (FV) or the right internal jugular vein (RJV). Implantation using the RJV offers earlier ambulation and decreases the post-procedure observation period. We recently described that cardiologists performing endomyocardial biopsies using the RJV approach have increased radiation exposure. Currently, there is no information regarding the radiation exposure to physicians implanting CardioMEMS™ according to the FV or RJV approach. The objective of this study is to evaluate the physician radiation exposure during CardioMEMS™ implantation utilizing the femoral or right internal jugular vein. Methods Patients who underwent CardioMEMS™ implantation between January 6, 2015 and December 12, 2022 at our institution were included in the study. Baseline patient clinical characteristics and radiation measures (fluoroscopy time (FT), air kerma (AK), and dose area product (DAP) were obtained and compared between patients who underwent CardioMEMS™ implantation via the FV or the RJV approach. Results A total of 105 patients underwent CardioMEMS™ implantation during the study period. Of these, 95 (90.5%) patients underwent implantation via the FV and 10 (9.5%) via the RJV. The jugular vein approach was used much more frequently in females (80% vs 32.6%, p = 0.005). Larger patients were also more likely to undergo implantation via the RJV with the mean weight in this group being 136.5 kg vs 105.9 kg in the femoral group (p = 0.001). This data also correlated with BMI and BSA. Procedures that were performed from the RJV approach had significantly higher radiation measures, including, longer FT (24.9 ± 12.7 min vs 16.6 ± 9.7 min, p = 0.031), air kerma (570 ± 681 mGy vs 211 ± 326 mGy, p = 0.026) and dose area product (DAP, 64189 ± 70996 mGy-cm2 vs 25559 ± 38632 mGy-cm2, p = 0.01) (Table 1). Conclusion CardioMEMS™ implantation via the internal jugular vein is associated with significantly elevated radiation exposure. Implanting physicians utilizing this approach need to make maximal efforts to decrease radiation utilization and exposure.

•Symptoms typically occur when endomyocardial fibrosis ensues.•Asymptomatic late-stage Loeffler’s endocarditis can rarely occur.•Multimodality imaging can aid in early recognition in asymptomatic patients.•CMR may be useful in monitoring treatment response in those with fibrosis and thrombus.

Purpose To compare the clinical, epidemiological characteristics, waitlist and post-transplant outcomes in patients that were listed at the lowest priority status, before (status 2) and after (status 6) the new UNOS heart transplant (HT) allocation system. Methods Adult patients listed for HT as status 2 in the old allocation system from October 18, 2016 to October 17, 2018 and as status 6 in the new allocation system from October 18, 2018 to October 17, 2019 were included in the study. Clinical characteristics at listing and at the time of transplant were compared between both groups. Competing outcomes in the waitlist (death/removal from the waitlist, transplantation, or alive) and post-transplant survival were compared between old and new systems. Results A total of 2825 patients were listed for HT. Of these, 1956 were listed as status 2 in the old system, and 869 were listed as status 6 in the new system. Patients listed in the new system were older and had a higher frequency of inotropic support at the time of listing. The cumulative incidence of transplantation was higher in patients listed in the new system (51% vs. 44%, p<0.001). Being listed in the new system was an independent factor associated with transplantation (HR: 1.33 (1.17-1.52). A total of 679 and 424 patients received HT in the old and new systems, respectively. The waitlist time was shorter, and the ischemic time was longer in the new allocation system. The 180 days post-transplant survival was similar between old and new systems (93.1% vs. 94.5%, p=0.369). Conclusion With the implementation of the new HT allocation system, patients listed at the lowest priority status have a shorter waitlist time and increased incidence of HT without differences in the post-transplant survival. To compare the clinical, epidemiological characteristics, waitlist and post-transplant outcomes in patients that were listed at the lowest priority status, before (status 2) and after (status 6) the new UNOS heart transplant (HT) allocation system. Adult patients listed for HT as status 2 in the old allocation system from October 18, 2016 to October 17, 2018 and as status 6 in the new allocation system from October 18, 2018 to October 17, 2019 were included in the study. Clinical characteristics at listing and at the time of transplant were compared between both groups. Competing outcomes in the waitlist (death/removal from the waitlist, transplantation, or alive) and post-transplant survival were compared between old and new systems. A total of 2825 patients were listed for HT. Of these, 1956 were listed as status 2 in the old system, and 869 were listed as status 6 in the new system. Patients listed in the new system were older and had a higher frequency of inotropic support at the time of listing. The cumulative incidence of transplantation was higher in patients listed in the new system (51% vs. 44%, p<0.001). Being listed in the new system was an independent factor associated with transplantation (HR: 1.33 (1.17-1.52). A total of 679 and 424 patients received HT in the old and new systems, respectively. The waitlist time was shorter, and the ischemic time was longer in the new allocation system. The 180 days post-transplant survival was similar between old and new systems (93.1% vs. 94.5%, p=0.369). With the implementation of the new HT allocation system, patients listed at the lowest priority status have a shorter waitlist time and increased incidence of HT without differences in the post-transplant survival.