Purpose: The role and benefit of concomitant tricuspid valve repair (TVR) during ventricular assist device (VAD) implant remains unclear. Previously published data utilized historical VADs. Outcomes of TVR with contemporary LVAD implant remain unknown. We aimed to analyze our center's outcomes in a modern cohort with a focus on the role of TVR in mitigating RV dysfunction and improving LV unloading post LVAD.

Purpose: Optimal outcomes in left ventricular assist device (LVAD) therapy recipients require adequate right ventricular (RV) function. However, predicting RV failure remains challenging in many cases, and occasionally, the RV must be supported with mechanical support. RV assist device (RVAD) use adds excess morbidity and mortality. Therefore, strategies to avoid RVAD use in LVAD patients are necessary for optimal outcomes. We have focused on 1) reducing transfusions, 2) tricuspid valve repair, 3) keep mean arterial pressure > 70 mmHg, 4) optimizing pump speed to balance the ventricular septum, 5) inotrope use.

Purpose To assess the impact of insulin duration in insulin-dependent diabetic (IDDM) donors on long-term survival of heart transplant recipients. Methods Adult heart transplant recipients from an IDDM donor in UNOS between 5/1/2006-3/1/2021 were included. Patients were stratified based upon duration of donor insulin use: 0-5 years (Y), 6-10 Y, or >10 Y. Comparative statistics assessed differences in donor, recipient and transplant characteristics. Survival was estimated using Kaplan-Meier analysis. Results 426 IDDM donors were identified: 0-5 Y (n=173), 6-10 Y (n=74), or >10 Y (n=179). Increased duration of insulin use was associated with donors who were younger, more commonly male, had lower body mass index, and higher creatinine (p<0.05 for all). [Table 1] No significant recipient, center volume, or ischemic time differences existed based on duration of donor insulin use (p>0.05). Additionally, no significant differences were observed amongst groups with regards to length of stay, in hospital mortality, or acute rejection before discharge/in the 1st year. Both unadjusted (Kaplan-Meier analysis) and adjusted (Cox proportional hazard model) failed to reveal a significant association with donor insulin duration and survival. [Figure 1] Conclusion Despite differences in donor characteristics, donor duration of insulin use had no significant association with long term survival in heart transplant recipients. Within reason, programs should aggressively entertain offers from insulin dependent diabetics regardless of time on insulin.

Introduction Utilizing organs from hepatitis C virus nucleic acid amplification testing positive donors (HCV NAT+) is possible due to highly effective HCV treatment. We describe an HCV NAT+ donor in a recipient with human immunodeficiency virus (HIV). Case Report A 60-year-old male with well controlled HIV (CD4 >500, undetectable viral load, no opportunistic infection [OI]) was listed for heart transplantation. He previously had been successfully treated for HCV (sofosbuvir/velpatasvir). He also had prior coronary artery bypass grafting and a bridge to transplant left ventricular assist device at age 55 and 58 respectively. A suitable donor heart was identified that was HCV NAT+. The patient underwent methylprednisolone, mycophenolate mofetil (MMF) and anti-thymocyte globulin induction. He was prophylactically treated with sofosbuvir/velpatasvir (28 days, first dose pre-transplant). He had primary graft dysfunction temporarily requiring extracorporeal life support for 3 days, however this resolved and he was discharged with a normal graft at 18 days. HCV polymerase chain reaction (PCR) testing was positive immediately post-operatively, but negative thereafter. He is currently on tacrolimus (trough: 8-10 ng/mL) and MMF immunosuppression, trimethoprim- sulfamethoxazole prophylaxis, and continued on bictegravir/emtricitabine/tenofovir alafenamide for HIV suppression (CD4<200, no OI). Surveillance biopsies demonstrated episodes of mild rejection, which were treated once with pulse dose steroids. The patient is clinically doing well with good graft function 5 months post-transplant and EF of 50%. Summary We describe use of an HCV NAT+ donor heart in an HIV+ recipient with previously treated HCV. Despite concerns about OI and immunosuppression, we demonstrate that with prophylactic HCV treatment and standard immunosuppression, good outcomes without HCV viremia can be accomplished. Careful attention is necessary regarding HIV status as well as graft function as well.

Purpose Patients with advanced hypertrophic cardiomyopathy (HCM) have high waitlist (WL) mortality. The United Network of Organ Sharing (UNOS) heart allocation system from 10/18/2018 provides greater emphasis and clarity for status exceptions for HCM patients. We analyzed the effect of allocation policy change on the WL and post-transplant outcomes in HCM patients. Methods UNOS data from 06/1990 to 06/2020 was analyzed, HCM patients were divide into two cohorts: pre and post allocation change. WL status, selected baseline characteristics, waiting time, and WL mortality were summarized. Kaplan-Meier survival curves for all-cause mortality up to one year would also be examined. Results A total of 1,941 HCM patients were identified. Pre and post allocation change cohorts included 1,703 and 238 cases respectively. While the majority of pre-change patients were Status 2, most post-change patients were Adult Status 4 (Table 1). Post-change cohort had older recipient age, older donor age, longer ischemia time, and shorter waiting time but there were no significant differences in gender or IABP use (Table 2). The WL mortality was lower in the post-change group (33.6% vs 7.6%, p<0.0001). Additionally, there was no difference of Kaplan-Meier survival for all-cause mortality up to 1 year between the two groups (p=0.2671). Conclusion For HCM patients awaiting heart transplant, the new UNOS allocation system decreased the WL mortality and waiting time. There was no significant difference in post-transplant survival in HCM patients with the new allocation system.

Abstract Background Survival rates for out-of-hospital cardiac arrest (OOHCA) are extremely low and neurologic recovery is poor. Extracorporeal cardiopulmonary resuscitation (ECPR), which combines extracorporeal membrane oxygenation (ECMO) with cardiopulmonary resuscitation (CPR), has emerged as a viable strategy to improve outcomes in OOHCA. A collaborative ECPR program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire Emergency Medical Services (EMS). Purpose Outcomes for patients who present as an ECPR alert from the field, but did not meet predefined criteria for placement of extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL) is described. Methods Between September 15, 2017 and October 12, 2019, 50 subjects presented as an ECPR alert for OOHCA secondary to pulseless VT/VF refractory to defibrillation. All subjects were placed on an automated CPR device prior to transfer to the CCL. From these 50 individuals, 28 (56%) did not meet prespecified laboratory criteria (lactate ≤15 mg/dL, partial pressure of oxygen (PaO2) ≥50 mm Hg, end-tidal carbon dioxide (ETCO2) of ≥10) and did not have a shockable rhythm in the CCL, thus ECMO was not placed and usual care for cardiac arrest was administered. Results Nine (32%) of the 28 patients achieved return of spontaneous circulation (ROSC), while the remaining 19 (68%) where pronounced deceased in the CCL. All 9 patients who achieved ROSC underwent a coronary angiography with 4 (44%) requiring percutaneous coronary intervention and 4 (44%) requiring an acute mechanical circulatory support device (Impella with 1 change out to ECMO). Of the patients that achieved ROSC, 4 (44%) were discharged from the hospital with good neurologic recovery; the remaining 5 (56%) ultimately expired during the hospitalization. From the initial 28 patient cohort, there were 4 (14%) patients discharged alive. Patients who achieved ROSC as compared to no ROSC were found on presentation in the CCL to have a significantly lower lactate (12.3±4.3 vs 16.2±3.6, respectively; p=0.03) and greater PaO2 (145±125 vs 47±9, respectively; p=0.01); there was no significant differences between groups in ETCO2, age or emergency services dispatch to CCL arrival time. Conclusion This study demonstrates that an ECPR program for OOHCA due to refractory VT/VF may provide benefit to patients that do not meet the predefined criteria for ECMO. This may be due to minimizing no flow/low flow time by early recognition and ongoing CPR en route to the CCL by a skilled EMS team, high efficiency citywide expedited transport/triage, the provision of high quality uninterrupted chest compressions using the mechanical CPR device during transport, and the care provided by highly trained multidisciplinary team members in the CCL. Funding Acknowledgement Type of funding sources: None.

PurposeIn 2018, United Network of Organ Sharing (UNOS) changed the heart allocation system to better stratify higher acuity patients and provide more equitable geographic distribution. However, they did not prioritize recipient allosensitization which can be a barrier to organ access. We analyzed outcomes based on sensitization in the modern era and the impact of the new allocation system on sensitized patients.MethodsUNOS data from 3/31/2015-6/12/2020 was analyzed. Multi-organ transplants were excluded. Recipient, donor, and transplant characteristics were analyzed. Patients were stratified by cPRA level 0, 1-49, 50-79, and ≥ 80. Waitlist days prior to transplant, survival, and treated rejection pre and post allocation system change were analyzed. Survival was estimated using Kaplan-Meier methods and the log-rank test.ResultsTotal of 10598 patients were included and evaluated by cPRA (Table). Patients with higher cPRA were more likely to be younger, African American, and female. Higher cPRA patients weighed less and were more likely to have non-ischemic cardiomyopathy, congenital disease, or be a retransplant. Waitlist days were significantly lower in the new allocation system for cPRA groups 0, 1-49, and 50-79 (p<0.0001) and there was a trend toward fewer waitlist days for cPRA ≥ 80 (p=0.062). Treated rejection during the transplant hospitalization and in the first year was significantly higher as cPRA increased (p<0.0001). However, when compared pre- and post-allocation change, there was no significant difference in long term survival across cPRA groups (p=0.531).ConclusionThe new heart allocation system did not discriminate against sensitization, but rather facilitated a reduction in wait time for all but the most highly sensitized recipients. This may relate to increased access to appropriately matched donor organs through broader geographic sharing, but further investigation is needed. In 2018, United Network of Organ Sharing (UNOS) changed the heart allocation system to better stratify higher acuity patients and provide more equitable geographic distribution. However, they did not prioritize recipient allosensitization which can be a barrier to organ access. We analyzed outcomes based on sensitization in the modern era and the impact of the new allocation system on sensitized patients. UNOS data from 3/31/2015-6/12/2020 was analyzed. Multi-organ transplants were excluded. Recipient, donor, and transplant characteristics were analyzed. Patients were stratified by cPRA level 0, 1-49, 50-79, and ≥ 80. Waitlist days prior to transplant, survival, and treated rejection pre and post allocation system change were analyzed. Survival was estimated using Kaplan-Meier methods and the log-rank test. Total of 10598 patients were included and evaluated by cPRA (Table). Patients with higher cPRA were more likely to be younger, African American, and female. Higher cPRA patients weighed less and were more likely to have non-ischemic cardiomyopathy, congenital disease, or be a retransplant. Waitlist days were significantly lower in the new allocation system for cPRA groups 0, 1-49, and 50-79 (p<0.0001) and there was a trend toward fewer waitlist days for cPRA ≥ 80 (p=0.062). Treated rejection during the transplant hospitalization and in the first year was significantly higher as cPRA increased (p<0.0001). However, when compared pre- and post-allocation change, there was no significant difference in long term survival across cPRA groups (p=0.531). The new heart allocation system did not discriminate against sensitization, but rather facilitated a reduction in wait time for all but the most highly sensitized recipients. This may relate to increased access to appropriately matched donor organs through broader geographic sharing, but further investigation is needed.

In conclusion, permanent pacemaker implantation has no influence on survival. However, additional analysis of the surgical technique used in transplantation, types of conduction abnormalities and other factors which can influence outcomes need to be evaluated further.

Burden of heart failure is higher in SUS and resources are needed to improve HF management of, improved access to HF therapies including HTX and strategies to improve HTX outcomes in AA.

PRFT has a positive impact on both short-term and long-term post-transplant survival. With many patients being predisposed to a spectrum of metabolic disorders, it is apparent that PRFT is an integral part of evaluation and prediction of survival following HTX. The patho-physiological synergy between the cardiac and renal systems evidently justifies that pre-transplant optimization of renal function leads to an increased short-term and long-term post-transplant survival.

With recent allocation system changes and use of more PMCS, better understanding of the impact of these therapies on transplant candidates is essential. Based on the finding that pretransplant ECMO is associated with significantly worse outcomes, it may be beneficial to avoid ECMO when clinically feasible.

We evaluated the United Network for Organ Sharing (UNOS) registry for all adult heart transplant recipients (HTR) from 1999 to 2018. Recipients were grouped based upon their education level. We had two groups in our analysis: group 1 = education level > high school and group 2 = education level < high school. Kaplan-Meier survival analysis and Cox regression modelling were used in our analysis for confounding variables like age, gender, status of HF, ethnicity, etc. RESULTS: 30,999 heart transplant recipients (HTR) in our analysis, 29,877 in group 1 and 1,122 in group 2. Kaplan-Meier survival analysis of the patient survival time showed a higher survival in HTRs with education level above high school (Figure). Group 2 had 17% increased risk of death (p=0.0024). On adjusting for confounding variables including age, gender, status of HF, ethnicity, etc., education level continued to have a positive impact on survival. Lower episodes of rejection and better follow-up were also seen in HTR with an education level higher than high school. (data not shown) CONCLUSION: Higher level of education has a positive impact on survival. This relationship can be explained by the notion that HTRs with higher education status may be better informed, more adherent to medication, and more likely to follow-up. All of these factors contribute to earlier identification of complications and fewer rejection episodes, ultimately leading to greater outcomes of survival. Further studies are required to further understand this complex relationship.

Donors with more risk factors were associated with slightly worse outcomes following heart transplant. While differences were statistically significant, careful selection of both recipients and donors with risk factors at appropriate centers may increase utilization of donor hearts.

Purpose With the shortage of donor hearts, older donors are being increasingly evaluated for potential recipients. Currently it is unknown if the younger recipients is affected by donor age. We sought to evaluate the outcomes in younger heart transplant recipients from younger and older donors and conversely, the older heart transplant recipients from younger and older donors. Methods We analyzed The United Network for Organ Sharing data registry for all adult heart transplant recipients (HTR) from 2008 to 2017. HTR with right or bi-ventricular support or TAH were excluded. Patients were stratified based on recipient age (R) 18-29, 20-39, 40-49 and >50 years old and donor age (D) 18-29, 20-39, 40-49 and >50 years old. Kaplan-Meier estimates were used to evaluate overall survival. Potential confounders were adjusted for, using a Cox proportional hazards model. Results 19,514 HTR were included in the analysis. In the overall cohort of HTR, 6.22% (n=1213) were 18-29, 8.48% (n=28670 were 30-39, 15.42% (n=5877), and 69.88%were >50 years old. In the DN category 45.10% (n=8801) were 18-29, 25.90% (n=5054) were 30-39, 19.59% (n=3822) were 40-49 and 9.41% (n=1837) were >50 years old. Adjusting for other variables, the age of donor was not associated with decreased survival in R18-39. R40-49 receiving a HTX from D40-49 and D>50 had a 43% and 75 % decreased survival at 10 years, when compared to receiving from D 18-29. Similarly, R>50 receiving a HTX from D30-39, D40-49, D>50 had a 14%, 27%, and 47% decreased survival at 10 years. Cox proportional regression analysis also indicates that African American recipients, female donor to male recipient, higher BMI and previous LVAD support decrease survival. Conclusion In a population based analysis, donor age does not appear to impact survival in younger recipients. Recipient related factors (including other co-morbidities) might potentially contribute to decreased survival in older recipients. This information can be potentially used to expand the donor organ pool.

Right ventricular failure (RVF) after LVAD implant is a common post-operative complication. Data are mixed regarding the early utilization of beta-blocker (BB) therapy in LVAD patients as there is some concern this is associated with RVF. We set out to evaluate if early BB utilization was associated with RVF and increased mortality at one year.

BACKGROUND: Heart failure education programs are not standardized. The best form of education is unclear. We evaluated whether addition of a novel tablet application to nurse practitioner (NP) education was superior to NP education alone in reducing 30-day readmission after heart failure hospitalization. METHODS: From February 2015-March 2016. patients admitted to a quaternary academic center with primary diagnosis of heart failure were randomized to 1) treatment - NP education plus tablet application (interactive conditional logic program that flags patient questions to medical staff), or 2) control - NP education. The primary outcome was reduction in 30-day readmission rate. Secondary outcomes included satisfaction and education assessed via survey. RESULTS: Randomization included 60 patients to treatment and 66 to control. A total of 13 patients withdrew prior to intervention (treatment n = 4, control n = 1) or were lost to follow-up (treatment n = 3, control n = 5). The 30-day readmission rate trended lower for treatment compared with control, but results were not statistically significant (13.2% [7/53]. 26.7% [16/60]. respectively, P = .08). Similarly, satisfaction trended higher with treatment than control (P = .08). Treatment patients rated explanations from their physicians higher than control (Always: 83.7%. 55.8%, respectively, P = .01). CONCLUSIONS: NP education plus tablet use was not associated with significantly lower 30-day readmission rates in comparison with NP alone, but a positive trend was seen. Patient satisfaction trended higher and heart failure explanations were better with NP education plus tablet. A larger study is needed to determine if NP education plus tablet reduces readmission rates following heart failure admission. (C) 2018 Elsevier Inc. All rights reserved.

To investigate the impact of body mass index (BMI) on mortality, rates of device-related infections and stroke/ transient ischemic attack (TIA) after left ventricular assist device (LVAD) placement.

Current knowledge on serum lactate dehydrogenase (LDH) and its relationship to HeartMate II (HMII) pump thrombosis (PT) are mainly based on single center, retrospective analyses. The PREVENT study is a prospective, multicenter trial designed to determine the risk factors for PT in patients with HMII. Our aim was to evaluate the trends in serum LDH levels and its relation to clinical outcomes in the PREVENT study and assess treatment strategy for elevated LDH.

There is considerable practice variation in LVAD care and it is unknown how much this variation influences patient outcomes. The PREVENtion of HeartMate II pump Thrombosis through clinical management (PREVENT) study was a multicenter, prospective trial designed to evaluate rates of pump thrombosis (PT) following adoption of a uniform set of surgical and medical recommendations.