Introduction:Donation after circulatory death (DCD) has re-emerged as a means of expanding the donor heart pool. Current clinical practice relies mainly on direct procurement followed by normothermic machine perfusion or on thoraco-abdominal normothermic regional perfusion. This paper details the practical aspects with an alternative strategy: direct procurement followed by hypothermic oxygenated perfusion (HOPE). Methods:Key technical considerations include prevention of bubble formation in albumin-containing solutions and early machine priming to avoid ischemic delays. The final acceptance of grafts is based on a functional warm ischemic time <30 min, satisfactory cardioplegic flush and anatomy, and stable, uneventful machine perfusion. Conclusion:Though this approach does not permit functional assessment of the graft, early results suggest that when strict donor and procedural criteria are observed, outcomes are favorable. Direct procurement of the DCD heart with HOPE offers a simplified, logistically efficient preservation method that avoids donor blood recirculation. Further studies are warranted to refine candidate selection and assess long-term results.

How to diagnose and manage atrio-esophageal fistulas occurring after atrial fibrillation ablation procedures? An atrio-esophageal fistula (AEF) is a rare complication occurring after an ablation procedure for atrial fibrillation, associated with a high mortality. The aim of this study is to provide a practical flowchart for first-line healthcare professionals on the diagnostics and management of these patients. A literature search was performed, resulting in the inclusion of 100 AEF cases after atrial fibrillation ablation procedures (85 reports). The documentation on these 100 patients was analyzed to compose the flowchart. All patients presented within 2 months after the ablation procedure (23 ± 11 days). Neurologic symptoms (75%), fever (73%) and both symptoms (57%) occurred in the majority. A CT scan of the chest was performed in 78% of the cases. In 30% of the patients, an AEF was observed. In other patients, the diagnosis was suspected based on air in the left cardiac circulation or the mediastinum. An esophagogastroscopy resulted in an infaust deterioration in 14/26 of the cases. In total, 41 patients received esophageal surgery (76% survival) versus 9 with only stenting (22% survival). In 27 patients, the diagnosis or treatment was not obtained in time. An AEF should be suspected in patients presenting with fever or neurological symptoms after a recent ablation procedure. CT scans of the chest and head can support the diagnosis. Once diagnosed, one should proceed to emergency surgery to prevent further complications. An esophagogastroscopy should be avoided. The authors hope to provide a practical management guide, allowing an earlier diagnosis, a faster treatment and thus an improved survival in these patients.

Purpose: Cold static storage remains the worldwide gold standard for preserving donor hearts prior to transplantation. We evaluated if continuous, hypothermic, oxygenated perfusion of the donor heart with the XVIVO heart preservation technology, so called non-ischemic heart preservation (NIHP), is safe and superior compared to ischemic cold static storage.

Purpose: Donation after circulatory death (DCD) heart transplantation, with thoraco-abdominal normothermic regional perfusion (TA-NRP) or direct procurement with normothermic machine perfusion, has logistical, financial, and ethical limitations. A new strategy using direct procurement followed by hypothermic oxygenated perfusion (DP-HOPE) could be an effective alternative.

Abstract Introduction Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is common and associated with adverse outcomes. Systematic monitoring of POAF beyond discharge is cumbersome. The emergence of photoplethysmography (PPG)-based rhythm monitoring with digital consumer devices could potentially mitigate these hurdles. Selected smartphone applications leveraging this technology have demonstrated excellent usability and accuracy for the detection of atrial fibrillation (AF). However, the impact of PPG-detected POAF on real-life clinical practice remains uncertain. Purpose To determine whether intermittent PPG-based smartphone rhythm monitoring, after being discharged home following cardiac surgery, impacts AF management. Methods The SURGICAL-AF 2 study is a pragmatic, investigator-initiated, open-label, multicenter, randomized clinical trial, conducted in three Belgian centers. The intervention group performed one-minute rhythm checks three times daily with a smartphone-based PPG application after hospitalization for cardiac surgery until the first follow-up visit with a cardiologist, scheduled at 21 – 91 days. Rhythm monitoring was not mandated in the usual care group. The primary endpoint was a composite of initiation of oral anticoagulation (OAC), cardioversion, up-titration or initiation of antiarrhythmic drugs (Vaughan-Williams class I or III) or implantation of a cardiac implantable electronic device (CIED). Secondary endpoints were incidence of POAF and actionable POAF, defined as a detection in patients with CHA2DS2-VASc score ≥2 for women or ≥1 for men who are not treated with OAC. Results Of the 450 patients randomized (238 patients in the intervention group and 212 patients in the usual care group; mean [SD] age, 64.1 [9.2] years; 96 women [21.3%]; 130 patients with AF before inclusion [28.9%]; 103 patients on OAC [22.9%], median [interquartile range] CHA2DS2-VASc score, 2 [1-3]), 98.7% completed the trial. In the intent-to-treat analysis, the primary end point occurred in 24 patients (10.3%) in the intervention group versus 5 patients (2.4%) in the usual care group (odds ratio (OR) 4.7, 95% CI, 1.8 - 12.6; P =.002). POAF was detected in 44 patients (18.8%) in the intervention group and was actionable in 25 patients (10.7%) versus 4 patients (1.9%) in the usual care group and actionable in 2 patients (0.9%). (POAF detection, OR 12.0, 95% CI, 4.2 - 34.5; P < .001; actionable POAF, OR 12.5, 95% CI, 2.9 - 52.6; P < .001) Conclusions In unselected patients discharged home following cardiac surgery, PPG-based smartphone monitoring revealed significantly more POAF which led to changes in AF management (OAC initiation, rhythm control therapy or CIED insertion). Longer follow-up is needed to determine whether these changes will lead to improved outcomes.

Abstract Introduction Postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with adverse outcomes. Systematic monitoring of POAF is cumbersome, specifically beyond discharge. Therefore, risk stratification may aid to identify patients at high risk of POAF and guide monitoring strategies alongside preventive measures. However, the performance of bedside risk stratification models reliant on clinical risk factors remained underwhelming, necessitating the exploration of more sophisticated models that maintain clinical applicability. Hence, artificial intelligence algorithms (AI) have been suggested to reinforce or replace clinical risk scores. As such, a deep neural network (DNN) algorithm was developed to identify patients with AF based on a 12-lead electrocardiogram (ECG) in sinus rhythm. Whether this algorithm can identify patients at high risk of POAF remains unknown. Purpose To evaluate the usability of an AI-enabled ECG algorithm, that was trained to predict AF in non-surgical conditions, for the prediction of POAF. Methods This study retrospectively analyzed data from the SURGICAL-AF trial that monitored patients after cardiac surgery. The inclusion criteria for this subanalysis comprised: (1) patients without a history of AF prior to cardiac surgery; (2) availability of the raw data of a pre-operative 12-lead ECG in sinus rhythm; and (3) patients with POAF (during hospitalization or up to 91 days after discharge) or patients having completed PPG-based rhythm monitoring per protocol. The AF-risk score was calculated by the DNN described elsewere.1 Results In total, 127 patients (mean [SD] age, 63.4 [8.4] years; 30 women [23.6%];, median [interquartile range] CHA2DS2-VASc score, 2 [1-3]) complied with the inclusion criteria, out of the 450 patients randomized in the SURGICAL-AF trial. Testing the DNN on the last ECG before cardiac surgery resulted in an area under the receiver operating curve (AUC) of 0.66 (95% CI, 0.56 - 0.77) and an area under the precision-recall curve of 0.57 (95% CI, 0.42 -0.72). The optimal cut of score resulted in a sensitivity of 64.3% (95% CI, 48.0%-78.4%), specificity of 64.7% (95% CI, 53.6%-74.8%), accuracy of 0.65 (95% CI, 0.56 - 0.73), F1-score of 54.5% (95% CI, 42.9% - 66.8%), positive predictive value of 47.4% (95% CI, 34.0%-61.0%), and negative predictive value of 78.6% (95% CI, 67.1%-87.5%). POAF occurred within three months after cardiac surgery in 23 patients out of 57 patients classified in the high-risk group (40.4%) versus 15 patients (21.4%) out of 70 patients classified in the low-risk group (hazard ratio, 2.2; 95% CI, 1.2 – 4.3; P-value = 0.020). Conclusions The AI-enabled ECG algorithm, trained to predict AF on a pre-operative sinus rhythm ECG, was able to identify POAF with an accuracy comparable to existing clinical risk scores. Further studies are needed to determine whether the DNN score can be used as an independent predictor and improve existing risk scores.

PurposeIschemia occurring during donation after circulatory death (DCD) could trigger the release of both pro- and anti-inflammatory cytokines upon recirculation. As certain cytokines such as TNF-α and IL-1β have been shown to mediate cardiovascular dysfunction in reanimation settings, the presence of cytokines could compromise organ function prior to transplantation in TA-NRP. We aimed to characterize the profiles of cytokines during TA-NRP using a porcine model, and to evaluate whether a cytokine adsorption device could influence the plasma levels of the cytokines.MethodsHypoxic circulatory arrest and 15 min no touch followed by 60 minutes of TA-NRP was performed in 14 pigs. Seven had a cytokine adsorption device incorporated in the TA-NRP circuit. Plasma concentrations of 9 cytokines (IL-10, IL-6, IFN-α, IFN-γ, IL-1-β, IL-4, IL-8, TNF-α and IL-12p40) were assessed by enzyme-linked immunosorbent assay at baseline (before onset of hypoxia), and at 60 minutes after start of TA-NRP (T60). Data are expressed as mean [min-max].ResultsPlasma levels of IL-10, IL-6, IFN-α, IFN-γ, IL-1-β, IL-4, IL-8, TNF-α, IL-4 and IL-12p40 did not differ significantly at T60 between both groups. For IL-6, the levels increased significantly from baseline (6.3 pg/mL [1.5-16.9]) for both the group with adsorption device (17.9 pg/mL [10.3-20.7], p=0.04) as without adsorption device (16.1 pg/mL [11.5-24.3], p=0.04) (Fig 1 panel D).ConclusionIn our porcine DCD TA-NRP model, plasma levels at T60 of IL-10, IL-6, IL-4, IFN-α, IFN-γ, IL-1-β, IL-8, TNF-α and IL-12p40 did not differ significantly between the group with an adsorption advice and the group without an adsorption device. This could be due to insignificant time for cytokine production or filtration. Though the addition of a cytokine adsorption device did not influence plasma levels, further research is necessary to assess whether there is an influence of these cytokine levels on organ function. Ischemia occurring during donation after circulatory death (DCD) could trigger the release of both pro- and anti-inflammatory cytokines upon recirculation. As certain cytokines such as TNF-α and IL-1β have been shown to mediate cardiovascular dysfunction in reanimation settings, the presence of cytokines could compromise organ function prior to transplantation in TA-NRP. We aimed to characterize the profiles of cytokines during TA-NRP using a porcine model, and to evaluate whether a cytokine adsorption device could influence the plasma levels of the cytokines. Hypoxic circulatory arrest and 15 min no touch followed by 60 minutes of TA-NRP was performed in 14 pigs. Seven had a cytokine adsorption device incorporated in the TA-NRP circuit. Plasma concentrations of 9 cytokines (IL-10, IL-6, IFN-α, IFN-γ, IL-1-β, IL-4, IL-8, TNF-α and IL-12p40) were assessed by enzyme-linked immunosorbent assay at baseline (before onset of hypoxia), and at 60 minutes after start of TA-NRP (T60). Data are expressed as mean [min-max]. Plasma levels of IL-10, IL-6, IFN-α, IFN-γ, IL-1-β, IL-4, IL-8, TNF-α, IL-4 and IL-12p40 did not differ significantly at T60 between both groups. For IL-6, the levels increased significantly from baseline (6.3 pg/mL [1.5-16.9]) for both the group with adsorption device (17.9 pg/mL [10.3-20.7], p=0.04) as without adsorption device (16.1 pg/mL [11.5-24.3], p=0.04) (Fig 1 panel D). In our porcine DCD TA-NRP model, plasma levels at T60 of IL-10, IL-6, IL-4, IFN-α, IFN-γ, IL-1-β, IL-8, TNF-α and IL-12p40 did not differ significantly between the group with an adsorption advice and the group without an adsorption device. This could be due to insignificant time for cytokine production or filtration. Though the addition of a cytokine adsorption device did not influence plasma levels, further research is necessary to assess whether there is an influence of these cytokine levels on organ function.

Abstract Background Recently, the European Heart Rhythm Association (EHRA) defined the phenotype of the arrhythmic mitral valve prolapse (AMVP) complex and proposed management approaches. Assessing the incidence of SCD in this small subset of patients is challenging due to the low event-rate and longitudinal real-world data remain scarce. Purpose To determine the predictors of AMVP and study the clinical outcome of patients stratified by ICD indication as proposed by the EHRA consensus statement. Methods All consecutive patients with MVP who underwent cardiac magnetic resonance imaging (CMR) were enrolled in a single-center retrospective registry. AMVP was defined as the presence of frequent or complex ventricular arrhythmias (>5% total PVC burden, non-sustained ventricular tachycardia (VT), VT or ventricular fibrillation) in a patient with MVP without alternative arrhythmic substrates. The medical records of these patients included a comprehensive clinical, rhythmic and echocardiographic characterization allowing to collect the key date of transition to AMVP. A forward conditional multivariable logistic regression was performed to identify clinical risk factors for AMVP reporting the odds ratio (OR) and corresponding 95% confidence interval (95% CI). Incidence rates were calculated for the composite endpoint of SCD, sustained VT, ICD shocks, and all-cause mortality. Results A total of 169 patients (52.1% male, median age 51.4 years) were included, of which 99 (58.6%) were classified as AMVP. Clinical characteristics are presented in Image 1. Patients with non-arrhythmic MVP and AMVP had comparable left ventricular function, mitral valve regurgitation grade and extent of MVP. Multivariable logistic regression identified the presence of late gadolinium enhancement (LGE, OR 2.82, 95%CI 1.45–5.50, p=0.002) and mitral annular disjunction (MAD, OR 1.98, 95%CI 1.02–3.86, p=0.045) on CMR as only predictors of AMVP. Cardiac CMR results are presented in Image 2. The median overall follow-up since first cardiac contact was 8.0 years (IQR 5.0–15.6), while this was 5.0 years (IQR 2.1–7.4 years) after transition to AMVP. The incidence for the composite endpoint in the overall population was 0.4%/year (95%CI 0.2 – 0.9). The 5-year cumulative event rate was 1.8%. According to the EHRA risk stratification the implantation of an ICD would have been reasonable in 69 patients (69.7%). In total, 5 patients were implanted with an ICD for secondary prevention, but all those patients did not classify as AMVP prior to the life threathening arrhythmic event. Conclusion CMR is an important tool in the challenging risk stratification of AMVP given that the presence of MAD and LGE enhancement are predictors of AMVP. There is a lack of longitudinal data to determine when patients transition from MVP to AMVP and how this modifies their outcome.Clinical characteristics and ECG resultsOverview of CMR measurements

Purpose Use of extracorporeal life support (ECLS) in lung transplantation (LTx) is center dependent. Peri-operative use of ECLS in sequential single LTx (SSLTx) in our department is conservative to avoid specific ECLS-related complications. In this study we describe the incidence and nature of ECLS-related complications in our LTx experience. Methods All transplantations with peri-operative use of ECLS (2010-2020) were retrospectively analyzed. The demographics, the type of ECLS and its indication were described. All complications were divided within prior specified groups (Fig 1, B). Results Overall the use of ECLS was 22% (156/703 patients) in our patients (mean age of 52 (36-59)). In 84% (131/156) of the patients an arterial cannula was inserted. In 16% (25/156) only venous cannulation was performed. In 7% (11/156) cardiopulmonary bypass (CPB) was applied intra-operatively. Most common indications for LTx (Fig 1, A, C) was pulmonary fibrosis in 38% (60/156). Main indication for ECLS was intra-operative hemodynamic instability in 52% (81/156) (Fig 1, A, D). 16% (25/156) of patients were bridged to LTx on ECLS and 13% (20/156) required prolonged ECLS post-operatively. Thirty day mortality was 6% (9/156). The use of ECLS did not change over time, the overall incidence of patients with at least one complication was 67% (104/156), over the past years it increased from 56% to 78% (Fig 1, A, B). Most common complications were revision for hemothorax in 25% (39/156) and need for continuous renal replacement therapy (CRRT) in 19% (Fig 1, A, E). Conclusion In our center, we only use ECLS in 22% of our SSLTx population. However, when ECLS is applied, we report a relatively high number of post-operative complications. Based on our results, we need to focus our attention on kidney failure and strategies to manage coagulation. Center experiences are important but larger databases will be necessary to develop uniform approaches and reports on ECLS in LTx. Use of extracorporeal life support (ECLS) in lung transplantation (LTx) is center dependent. Peri-operative use of ECLS in sequential single LTx (SSLTx) in our department is conservative to avoid specific ECLS-related complications. In this study we describe the incidence and nature of ECLS-related complications in our LTx experience. All transplantations with peri-operative use of ECLS (2010-2020) were retrospectively analyzed. The demographics, the type of ECLS and its indication were described. All complications were divided within prior specified groups (Fig 1, B). Overall the use of ECLS was 22% (156/703 patients) in our patients (mean age of 52 (36-59)). In 84% (131/156) of the patients an arterial cannula was inserted. In 16% (25/156) only venous cannulation was performed. In 7% (11/156) cardiopulmonary bypass (CPB) was applied intra-operatively. Most common indications for LTx (Fig 1, A, C) was pulmonary fibrosis in 38% (60/156). Main indication for ECLS was intra-operative hemodynamic instability in 52% (81/156) (Fig 1, A, D). 16% (25/156) of patients were bridged to LTx on ECLS and 13% (20/156) required prolonged ECLS post-operatively. Thirty day mortality was 6% (9/156). The use of ECLS did not change over time, the overall incidence of patients with at least one complication was 67% (104/156), over the past years it increased from 56% to 78% (Fig 1, A, B). Most common complications were revision for hemothorax in 25% (39/156) and need for continuous renal replacement therapy (CRRT) in 19% (Fig 1, A, E). In our center, we only use ECLS in 22% of our SSLTx population. However, when ECLS is applied, we report a relatively high number of post-operative complications. Based on our results, we need to focus our attention on kidney failure and strategies to manage coagulation. Center experiences are important but larger databases will be necessary to develop uniform approaches and reports on ECLS in LTx.

Purpose To analyze our institutional outcomes in heart-lung transplantation (HLTx). Methods We performed a single-center retrospective analysis of all patients who underwent HLTx at the University Hospitals Leuven (UZL) from 1991 to 2018 and compared our results to ISHLT registry data. Results 50 patients underwent HLTx in UZL. In-hospital mortality was 24% vs 72% in the ISHLT database (p<1.10-5). On average baseline characteristics of donors and receptors were comparable between UZL and ISHLT. Kaplan-Meier survival curves for both are depicted in figure 1. When considering the eras 1991-2003 and 2004-2018, 1-, 5, and 10-year survival rates of UZL were more favorable for the latter era; 15-year survival was significantly better for era 2004-2018, as depicted in figure 2. Over time, we observed an increase in cardiac-related indications with Eisenmenger syndrome being the most important (56% vs 25% in the ISHLT registry, p<1.10-5). Other forms of pulmonary arterial hypertension (PAH) were an important indication to perform HLTx (24% in both groups). The major cause of late mortality in our population was rejection (41.4%), more specifically chronic lung allograft dysfunction. Conclusion Between 1991 and 2018, we performed 50 HLTx's. The most frequent indication was Eisenmenger syndrome, but with a twofold higher proportion in our population compared to the ISHLT registry. The proportion of other forms of PAH was comparable. While over time the indications shifted from pulmonary to cardiac conditions, our survival continues to improve.