Introduction Mitral regurgitation (MR) often co-exists with severe left ventricular (LV) systolic dysfunction and there is controversy regarding the need for corrective surgery at the time of left ventricular assist device (LVAD) implantation as it often improves with mechanical LV unloading. We describe three patients with significant MR after LVAD implant in which transcatheter mitral valve repair (TMVR) [MitraClip] was utilized. To our knowledge, this is the largest case series of TMVR post-LVAD implant reported. Case Report Patient #1 is a 40-year-old male with severe LV dysfunction due to a non-ischemic cardiomyopathy (CM) who presented in cardiogenic shock (CS) and underwent centrifugal-flow LVAD [Heartmate 3]. MR was severe due to bileaflet tethering at time of implant and improved to mild to moderate immediately after. With medical and device optimization, EF improved to 35-40% however he had right ventricular (RV) dysfunction with recurrence of severe MR secondary to bileaflet prolapse. Given NYHA III symptoms, he underwent TMVR with improvement in MR to mild to moderate and improvement in his symptoms to NYHA class II. Patient #2 is a 27-year-old female who presented with acute severe LV dysfunction with moderate to severe functional MR due to viral myocarditis. She required extracorporeal membrane oxygenation and initially improved but decompensated after removal of support and subsequently underwent implantation of Heartmate 3. Her LV function recovered and she was scheduled for LVAD explantation but pre-operative tranesophageal echocardiogram revealed moderate to severe MR secondary to bileaflet prolapse so the procedure was deferred. She successfully underwent TMVR with improvement to mild to moderate MR and is planned for LVAD explant in the future. She had unchanged NYHA I symptoms before and after TMVR. Patient #3 is a 76-year-old male who underwent an axial-flow LVAD [Heartmate 2] seven years prior for ischemic CM. He reported worsening dyspnea despite device and medication optimization and was found to have moderate to severe MR (secondary to leaflet tethering). He underwent a successful TMVR with reduction in MR to mild to moderate, as well as improvement of NYHA class III to II. Summary Persistence of MR after LVAD implantation can be associated with worse outcomes. We describe three patients who underwent successful TMVR to reduce morbidity.

SA significantly underestimates frailty as compared to mFFI. Both frailty scores and MIF improved after LVAD, suggesting reversibility of the frailty syndrome. Understanding frailty will be key to improving outcomes in advanced HF.

Purpose With increased use of venoarterial extracorporeal membrane oxygenation (VA ECMO) to support patients in cardiogenic shock (CS), protocols for weaning and assessment of recovery are required. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA ECMO. Methods All patients on VA ECMO for CS were considered for the Northwell Weaning Protocol (NWP). 24 hours before NWP, pulmonary toilet and fluid balance were optimized. Full ventilator support and dobutamine 3-5µg/kg/min were initiated prior to the protocol. Patients had invasive hemodynamic monitoring (arterial, Swan-Ganz), echocardiography, cerebral oxygenation and blood gas analysis. aPTT was maintained > 50s prior to NWP and ACT maintained > 200s when ECMO flow was reduced < 3 LPM. Flow was decreased in 1 LPM intervals and data acquired after 5 min at each stage. At ECMO 2 LPM, Impella/IABP support was minimized. After 1 LPM, the inflow line was clamped (15s flush every 5 min) for 30 min and final measures taken. Durable recovery (DR) was defined as being free of pharmacologic and mechanical support at 30 days post explant. Results Over 8 months, 25 patients had VA ECMO for CS. Eleven patients underwent NWP at 4-12 days (14 not stable for NWP). Eight of 11 tolerated flow reduction and were successfully decannulated for recovery. Of these, 5 had DR and 3 did not (2 durable LVAD, 1 died). Patients with DR had significantly higher EF and smaller LV size, and tended to have higher cardiac index and mean arterial pressure at lowest flow during NWP (Table 1). Patients with DR also tended to have shorter durations of ECMO support. No adverse events occurred during NWP. Conclusion We describe a safe, stepwise weaning protocol to assess recovery during ECMO support. In this cohort of patients, 20% demonstrated DR. Echocardiographic and hemodynamic measures at lowest flow identified patients who went on to demonstrate DR. Formal weaning studies can help guide decision making in this challenging patient population.

Purpose In 2017, 2817 heart transplants (HT) were performed in the United States, up from 1882 10 years prior. With competing therapies now available, a thorough understanding of the distribution of and resources required for HT is required. Utilizing the National Inpatient Sample (NIS), we examined temporal trends and determinants of short-term outcomes of HT. Methods A retrospective analysis of the NIS from 2001-2011 was performed using SPSS, encompassing N=17426 HT from 2001-2011. Both patient specific and center specific characteristics were characterized with t-test and chi-squared where appropriate. Hospitalizations were grouped according to occurrence before or after the 2006 UNOS allocation policy change. Risk factors were identified using univariate and multivariate analyses. Results Of the N= 17426 HTs included in the analysis, N=6924 and N=10502 occurred 2001-2005 and 2006-2011, respectively. Of these, 76% were male, and 70% were Caucasian, which decreased from 2001 to 2011 (81% v 63%, p<0.0001) demonstrating increased diversity of recipients. Primary insurance was Medicare or Medicaid in 45% and private in 51% of cases. Patients with greater risk underwent HT in 2011 than 2001, having an increased number of comorbidities (3.2±1.7 v 1.0±1.0, p<0.001) and diagnoses (18.4±6.9 v 9.2±3.0, p<0.001). Although longer LoS is correlated with more diagnoses, LoS overall decreased from 2001-2011 (41d v 37d, p=0.0124). Large institutions performed the most HTs (95.8%) with a 9 day shorter LoS than medium sized hospitals (36d v 45d, p=0.001). In-hospital mortality rates decreased from 7% to 5.5% (p=0.077), with the most prominent discharge location being home discharge (53%) followed by home with home healthcare (23%) and skilled nursing facility (8%). Conclusion HT is being performed more frequently in recent years than has occurred previously. Although patients are sicker with additional medical comorbidities and active diagnoses in 2011 than 2001, the average LoS and in-hospital mortality rates are decreasing, likely demonstrating improvement in patient-donor matching and management of HT patients. Elective transplant, hospital region, and teaching status play significant roles in short-term outcomes. In 2017, 2817 heart transplants (HT) were performed in the United States, up from 1882 10 years prior. With competing therapies now available, a thorough understanding of the distribution of and resources required for HT is required. Utilizing the National Inpatient Sample (NIS), we examined temporal trends and determinants of short-term outcomes of HT. A retrospective analysis of the NIS from 2001-2011 was performed using SPSS, encompassing N=17426 HT from 2001-2011. Both patient specific and center specific characteristics were characterized with t-test and chi-squared where appropriate. Hospitalizations were grouped according to occurrence before or after the 2006 UNOS allocation policy change. Risk factors were identified using univariate and multivariate analyses. Of the N= 17426 HTs included in the analysis, N=6924 and N=10502 occurred 2001-2005 and 2006-2011, respectively. Of these, 76% were male, and 70% were Caucasian, which decreased from 2001 to 2011 (81% v 63%, p<0.0001) demonstrating increased diversity of recipients. Primary insurance was Medicare or Medicaid in 45% and private in 51% of cases. Patients with greater risk underwent HT in 2011 than 2001, having an increased number of comorbidities (3.2±1.7 v 1.0±1.0, p<0.001) and diagnoses (18.4±6.9 v 9.2±3.0, p<0.001). Although longer LoS is correlated with more diagnoses, LoS overall decreased from 2001-2011 (41d v 37d, p=0.0124). Large institutions performed the most HTs (95.8%) with a 9 day shorter LoS than medium sized hospitals (36d v 45d, p=0.001). In-hospital mortality rates decreased from 7% to 5.5% (p=0.077), with the most prominent discharge location being home discharge (53%) followed by home with home healthcare (23%) and skilled nursing facility (8%). HT is being performed more frequently in recent years than has occurred previously. Although patients are sicker with additional medical comorbidities and active diagnoses in 2011 than 2001, the average LoS and in-hospital mortality rates are decreasing, likely demonstrating improvement in patient-donor matching and management of HT patients. Elective transplant, hospital region, and teaching status play significant roles in short-term outcomes.

Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or “eye-ball” test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02–0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs. 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.