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Gregory V, Okumura K, Isath A, Levine A, De La Pena C, Shimamura J, Spielvogel D, Kai M, Ohira S. Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy. J Am Heart Assoc 2024; 13:e033590. [PMID: 38742529 PMCID: PMC11179799 DOI: 10.1161/jaha.123.033590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/01/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The new heart allocation policy places veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA-ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA-ECMO remains unknown. METHODS AND RESULTS From October 18, 2018 to March 21, 2023, 624 patients on VA-ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA-ECMO alone (N=384) versus VA-ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra-aortic balloon pump (N=134). Recipient age was younger in the VA-ECMO alone group (48 versus 53 years, P=0.018), as was donor age (VA-ECMO alone, 29 years versus LV unloading, 32 years, P=0.041). One-year survival was comparable between groups (VA-ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P=0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P=0.70). Different LV unloading methods had similar 1-year survival (intra-aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P=0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). CONCLUSIONS Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA-ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA-ECMO, where routine LV unloading may not be universally necessary.
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Affiliation(s)
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Ameesh Isath
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Avi Levine
- New York Medical College Valhalla NY USA
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Junichi Shimamura
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - David Spielvogel
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Masashi Kai
- Division of Cardiac Surgery Beth Israel Deaconess Medical Center Boston MA USA
| | - Suguru Ohira
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
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Lerman JB, Patel CB, Casalinova S, Nicoara A, Holley CL, Leacche M, Silvestry S, Zuckermann A, D'Alessandro DA, Milano CA, Schroder JN, DeVore AD. Early Outcomes in Patients With LVAD Undergoing Heart Transplant via Use of the SherpaPak Cardiac Transport System. Circ Heart Fail 2024; 17:e010904. [PMID: 38602105 DOI: 10.1161/circheartfailure.123.010904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Heart transplant (HT) in recipients with left ventricular assist devices (LVADs) is associated with poor early post-HT outcomes, including primary graft dysfunction (PGD). As complicated heart explants in recipients with LVADs may produce longer ischemic times, innovations in donor heart preservation may yield improved post-HT outcomes. The SherpaPak Cardiac Transport System is an organ preservation technology that maintains donor heart temperatures between 4 °C and 8 °C, which may minimize ischemic and cold-induced graft injuries. This analysis sought to identify whether the use of SherpaPak versus traditional cold storage was associated with differential outcomes among patients with durable LVAD undergoing HT. METHODS Global Utilization and Registry Database for Improved Heart Preservation-Heart (NCT04141605) is a multicenter registry assessing post-HT outcomes comparing 2 methods of donor heart preservation: SherpaPak versus traditional cold storage. A retrospective review of all patients with durable LVAD who underwent HT was performed. Outcomes assessed included rates of PGD, post-HT mechanical circulatory support use, and 30-day and 1-year survival. RESULTS SherpaPak (n=149) and traditional cold storage (n=178) patients had similar baseline characteristics. SherpaPak use was associated with reduced PGD (adjusted odds ratio, 0.56 [95% CI, 0.32-0.99]; P=0.045) and severe PGD (adjusted odds ratio, 0.31 [95% CI, 0.13-0.75]; P=0.009), despite an increased total ischemic time in the SherpaPak group. Propensity matched analysis also noted a trend toward reduced intensive care unit (SherpaPak 7.5±6.4 days versus traditional cold storage 11.3±18.8 days; P=0.09) and hospital (SherpaPak 20.5±11.9 days versus traditional cold storage 28.7±37.0 days; P=0.06) lengths of stay. The 30-day and 1-year survival was similar between groups. CONCLUSIONS SherpaPak use was associated with improved early post-HT outcomes among patients with LVAD undergoing HT. This innovation in preservation technology may be an option for HT candidates at increased risk for PGD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04141605.
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Affiliation(s)
- Joseph B Lerman
- Department of Medicine, Division of Cardiology (J.B.L., C.B.P., S.C., C.L.H., A.D.D.), Duke University Hospital, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology (J.B.L., C.B.P., S.C., C.L.H., A.D.D.), Duke University Hospital, Durham, NC
| | - Sarah Casalinova
- Department of Medicine, Division of Cardiology (J.B.L., C.B.P., S.C., C.L.H., A.D.D.), Duke University Hospital, Durham, NC
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, (S.C., A.N., C.A.M., J.N.S.), Duke University Hospital, Durham, NC
| | - Alina Nicoara
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, (S.C., A.N., C.A.M., J.N.S.), Duke University Hospital, Durham, NC
| | - Christopher L Holley
- Department of Medicine, Division of Cardiology (J.B.L., C.B.P., S.C., C.L.H., A.D.D.), Duke University Hospital, Durham, NC
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, MI (M.L.)
| | - Scott Silvestry
- Department of Cardiothoracic Surgery, AdventHealth Transplant Institute, Orlando, FL (S.S.)
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Austria (A.Z.)
| | - David A D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston (D.A.D.)
| | - Carmelo A Milano
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, (S.C., A.N., C.A.M., J.N.S.), Duke University Hospital, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, (S.C., A.N., C.A.M., J.N.S.), Duke University Hospital, Durham, NC
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology (J.B.L., C.B.P., S.C., C.L.H., A.D.D.), Duke University Hospital, Durham, NC
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3
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Mazur M, Carmona Rubio A, Eisen HJ, Bhat G, Dowling R. Impact of the New Heart Allocation System on the Medium-Term Outcomes in Patients With Hypertrophic Cardiomyopathy. ASAIO J 2024:00002480-990000000-00471. [PMID: 38635492 DOI: 10.1097/mat.0000000000002216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
The introduction of the new heart allocation system in the United States in 2018 resulted in an increase in the number of heart transplants (HT) performed among patients with hypertrophic cardiomyopathy (HCM). However, whether that affected medium-term post-HT outcomes in this group of patients remains unknown. We conducted an analysis of the United Network for Organ Sharing Transplant Database, including adults with HCM who underwent heart transplantation between 2015 and 2021. Patients were divided into two equal-duration eras: Era 1 (October 17, 2015, to October 17, 2018) and Era 2 (October 18, 2018, to October 18, 2021). In the studied period, 444 patients with HCM underwent HT: 204 in Era 1 and 240 in Era 2. In Era 2, the waitlist time was shorter, transplant rates were higher, patients were less frequently supported with inotropes but more often with an IABP, ischemic time was longer, and donor-to-recipient distance larger. Pre- and post-transplant functional status was comparable across the two eras, while the pre-HT employment rate was higher in the new system. The 3 year survival was unchanged across eras. In the new allocation system, despite more frequent mechanical circulatory support (MCS) use and increased ischemic time, the medium-term outcomes of patients with HCM remained favorable.
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Affiliation(s)
- Matylda Mazur
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Andres Carmona Rubio
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Howard J Eisen
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Geetha Bhat
- Cardiovascular Department, Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio
| | - Robert Dowling
- Cardiovascular Department, Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio
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Cevasco M, Shin M, Cohen W, Helmers MR, Weingarten N, Rekhtman D, Wald JW, Iyengar A. Impella 5.5 as a bridge to heart transplantation: Waitlist outcomes in the United States. Clin Transplant 2023; 37:e15066. [PMID: 37392194 DOI: 10.1111/ctr.15066] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/24/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES The 2018 United Network for Organ Sharing allocation policy change has led to a significant increase in the use of mechanical circulatory support devices in patients listed for orthotopic heart transplantation. However, there has been a paucity of data regarding the newest generation Impella 5.5, which received FDA approval in 2019. METHODS The United Network for Organ Sharing registry was queried for all adults awaiting orthotopic heart transplantation who received Impella 5.5 support during their listing period. Waitlist, device, and early post-transplant outcomes were assessed. RESULTS A total of 464 patients received Impella 5.5 support during their listing period with a median waitlist time of 19 days. Among them, 402 (87%) patients were ultimately transplanted, with 378 (81%) being directly bridged to transplant with the device. Waitlist death (7%) and clinical deterioration (5%) were the most common reasons for waitlist removal. Device complications and failure were uncommon (<5%). The most common post-transplant complication was acute kidney injury requiring dialysis (16%). Survival at 1-year post-transplant survival was 89.5%. CONCLUSION Since its approval, the Impella 5.5 has been increasingly used as a bridge to transplant. This analysis demonstrates robust waitlist and post-transplant outcomes with minimal device-related and postoperative complications.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce W Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Vaidya AS, Lee ES, Kawaguchi ES, DePasquale EC, Pandya KA, Fong MW, Nattiv J, Villalon S, Sertic A, Cochran A, Ackerman MA, Melendrez M, Cartus R, Johnston KA, Lee R, Wolfson AM. Effect of the UNOS policy change on rates of rejection, infection, and hospital readmission following heart transplantation. J Heart Lung Transplant 2023; 42:1415-1424. [PMID: 37211332 DOI: 10.1016/j.healun.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/04/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND The 2018 adult heart allocation policy sought to improve waitlist risk stratification, reduce waitlist mortality, and increase organ access. This system prioritized patients at greatest risk for waitlist mortality, especially individuals requiring temporary mechanical circulatory support (tMCS). Posttransplant complications are significantly higher in patients on tMCS before transplantation, and early posttransplant complications impact long-term mortality. We sought to determine if policy change affected early posttransplant complication rates of rejection, infection, and hospitalization. METHODS We included all adult, heart-only, single-organ heart transplant recipients from the UNOS registry with pre-policy (PRE) individuals transplanted between November 1, 2016, and October 31, 2017, and post-policy (POST) between November 1, 2018, and October 31, 2019. We used a multivariable logistic regression analysis to assess the effect of policy change on posttransplant rejection, infection, and hospitalization. Two COVID-19 eras (2019-2020, 2020-2021) were included in our analysis. RESULTS The majority of baseline characteristics were comparable between PRE and POST era recipients. The odds of treated rejection (p = 0.8), hospitalization (p = 0.69), and hospitalization due to rejection (p = 0.76) and infection (p = 0.66) were similar between PRE and POST eras; there was a trend towards reduced odds of rejection (p = 0.08). In both COVID eras, there was a clear reduction in rejection and treated rejection with no effect on hospitalization for rejection or infection. Odds of all-cause hospitalization was increased in both COVID eras. CONCLUSIONS The UNOS policy change improves access to heart transplantation for higher acuity patients without increasing early posttransplant rates of treated rejection or hospitalization for rejection or infection, factors which portend risk for long-term posttransplant mortality.
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Affiliation(s)
- Ajay S Vaidya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Emily S Lee
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Eric S Kawaguchi
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene C DePasquale
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kruti A Pandya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jonathan Nattiv
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sylvia Villalon
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Sertic
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Cochran
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Mary Alice Ackerman
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Marie Melendrez
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Rachel Cartus
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Kori Ann Johnston
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Raymond Lee
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Aaron M Wolfson
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
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6
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Prasad M, Mishaev R, Bhamidipati C, Aldweib N, Colaco N, Masha L. Biventricular Assist Devices as a Bridge to Heart Transplantation Under the New Donor Heart Allocation System in the United States. ASAIO J 2023; 69:902-906. [PMID: 37399274 DOI: 10.1097/mat.0000000000002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
Biventricular assist devices (BiVADs) for pre-heart transplant care is rare. The outcomes of pretransplant BiVAD support after the 2018 heart transplant allocation policy change are entirely unknown at this time. The United Network of Organ Sharing database was retrospectively queried from October 2018 to June 2022 to identify patients supported to transplant with BiVADs. They were compared to patients listed as Status 2 for heart transplantation with an isolated VAD (uni-VAD). The primary outcome of interest was 1 year survival. Secondary outcomes included length of stay, posttransplant stroke, dialysis, and pacemaker implantation. The frequency of BiVAD use for heart transplantation has remained unchanged after the 2018 allocation policy change, making up approximately 2% of transplant recipients annually. Patients supported with BiVADs appeared to be similar to patients supported with uni-VADs. One year survival was similar between the groups (88.57% vs. 87.90%). Length of stay was longer and there was a trend toward higher frequencies of posttransplant dialysis use. Patients supported to transplant with BiVADs appear to have posttransplant outcomes comparable to patients commonly listed as Status 2 with an isolated VAD. Compared to past analyses, there is a suggestion of improved survival with the 2018 allocation policy change.
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Affiliation(s)
- Mark Prasad
- From the Department of Internal Medicine, Oregon Health Science University, Portland, Oregon
| | - Raffael Mishaev
- From the Department of Internal Medicine, Oregon Health Science University, Portland, Oregon
| | | | - Nael Aldweib
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Nalini Colaco
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Luke Masha
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Volgmann C, Barten MJ, Al Assar Y, Grahn H, Metzner A, Söffker G, Schulte-Uentrop L, Magnussen C, Kirchhof P, Kluge S, Doll S, Doll N, Reichenspurner H, Bernhardt AM. Unloading, ablation, bridging and transplant: different indications and treatments using the Impella 5.5 as longer-term circulatory support in one patient-an interdisciplinary case report. Eur Heart J Case Rep 2023; 7:ytad293. [PMID: 37457054 PMCID: PMC10349291 DOI: 10.1093/ehjcr/ytad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
Background In patients with cardiogenic shock the clinical treatment often involves temporary mechanical circulatory support for initial haemodynamic stabilization to enable further assessment of therapeutic strategies. The surgically implanted Impella 5.5 can be used for several indications like ventricular unloading, haemodynamic support during high-risk interventions, and as a bridge-to-transplant strategy.We present an interdisciplinary managed case of using Impella 5.5 for multiple indications and treatment strategies in one patient. Case summary A 66-year-old patient with known dilated cardiomyopathy was admitted with non-ST-elevation myocardial infarction and underwent urgent coronary bypass grafting. His native heart function did not recover and he experienced recurrent episodes of sustained ventricular tachycardia (VT) and electrical storm. He was evaluated for heart transplantation (OHT) and received a VT-ablation. However, he suffered an in-hospital cardiac arrest (IHCA) with subsequent implantation of an extracorporeal life support system (ECLS). After surgical placement of an Impella 5.5 due to left ventricular distension and pulmonary congestion, the ECLS was successfully weaned. He showed good neurological outcomes and underwent another high-risk VT-ablation. The patient was further stabilized under Impella 5.5 support in a bridge-to-transplant strategy. After 34 days he underwent a successful OHT. Discussion In this interdisciplinary case report the surgically implanted Impella 5.5 as temporary mechanical circulatory support was used for multiple different indications and treatment strategies like ventricular unloading, haemodynamic support during high-risk interventions, and as bridge-to-transplant strategy in one patient.
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Affiliation(s)
- Constanze Volgmann
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg
| | - Yousuf Al Assar
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg
| | - Hanno Grahn
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Gerold Söffker
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | | | - Christina Magnussen
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Doll
- Department of Cardiovascular Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Nicolas Doll
- Department of Cardiovascular Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg
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8
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Cohen WG, Rekhtman D, Iyengar A, Shin M, Ibrahim M, Bermudez C, Cevasco M, Wald J. Extended Support With the Impella 5.5: Transplant, ECMO, and Complications. ASAIO J 2023; 69:642-648. [PMID: 37039780 DOI: 10.1097/mat.0000000000001931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
We report midterm results of Impella 5.5 use with focus placed on bridge-outcomes, venoarterial extracorporeal membrane oxygenation (VA-ECMO) transition, complications, and risk factors for mortality. A retrospective review of patients implanted with the Impella 5.5 at our medical center was conducted. Forty patients were included with varying bridge strategies. Sixteen (40%) patients were supported for <14 days, 13 (32.5%) for 14-30 days, and 11 (27.5%) for >30 days. Thirty day mortality was 22.5% (9/40). Twenty-five (62.5%) were successfully bridged to transplant or durable left ventricular assist device (LVAD), while four (10.0%) recovered without the need for any further cardiac support. Five of 11 (60%) patients initially supported with VA-ECMO were either transitioned to durable left ventricular assist device (dLVAD; n = 3, 27.3%), transplanted (n = 1, 9.1%), or recovered (n = 1, 9.1%). Of nine patients with >moderate right ventricle (RV) dysfunction, five (55.6%) were successfully bridged to transplant or LVAD. Five (12.5%) patients required interval cannulation to VA-ECMO, often in the setting of RV dysfunction, and all (100%) were successfully transplanted. Lower pulmonary artery (PA) systolic pressure ( P = 0.029), among other factors, was associated with mortality. In summary, the Impella 5.5 may be able to effectively stabilize patients in refractory left ventricular predominant cardiogenic shock for extended durations, allowing time for mechanical circulatory support (MCS) and transplant evaluations.
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Affiliation(s)
- William G Cohen
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Haddad O, Sareyyupoglu B, Goswami RM, Bitargil M, Patel PC, Jacob S, El-Sayed Ahmed MM, Leoni Moreno JC, Yip DS, Landolfo K, Pham SM. Short-term outcomes of heart transplant patients bridged with Impella 5.5 ventricular assist device. ESC Heart Fail 2023. [PMID: 37137732 PMCID: PMC10375168 DOI: 10.1002/ehf2.14391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 01/15/2023] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
AIMS We sought to investigate the outcomes of heart transplant patients supported with Impella 5.5 temporary mechanical circulatory support. METHODS AND RESULTS Patient demographics, perioperative data, hospital timeline, and haemodynamic parameters were followed during initial admission, Impella support, and post-transplant period. Vasoactive-inotropic score, primary graft failure, and complications were recorded. Between March 2020 and March 2021, 16 advanced heart failure patients underwent Impella 5.5 temporary left ventricular assist device support through axillary approach. Subsequently, all these patients had heart transplantation. All patients were either ambulatory or chair bound during their temporary mechanical circulatory support until heart transplantation. Patients were kept on Impella support median of 19 days (3-31) with the median lactate dehydrogenase level of 220 (149-430). All Impella devices were removed during heart transplantation. During Impella support, patients had improved renal function with median creatinine serum level of 1.55 mg/dL decreased to 1.25 (P = 0.007), pulmonary artery pulsatility index scores increased from 2.56 (0.86-10) to 4.2 (1.3-10) (P = 0.048), and right ventricular function improved (P = 0.003). Patients maintained improved renal function and favourable haemodynamics after their heart transplantation as well. All patients survived without any significant morbidity after their heart transplantation. CONCLUSIONS Impella 5.5 temporary left ventricular assist device optimizes care of heart transplant recipients providing superior haemodynamic support, mobility, improved renal function, pulmonary haemodynamics, and right ventricular function. Utilizing Impella 5.5 as a direct bridging strategy to heart transplantation resulted in excellent outcomes.
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Affiliation(s)
- Osama Haddad
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Rohan M Goswami
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Macit Bitargil
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Parag C Patel
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Magdy M El-Sayed Ahmed
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | | | - Daniel S Yip
- Department of Transplantation, Mayo Clinic Hospital, Jacksonville, FL, USA
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
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Impact of Temporary Preoperative Mechanical Support on Heart Transplant Outcomes. ASAIO J 2023; 69:290-298. [PMID: 35609176 DOI: 10.1097/mat.0000000000001772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We sought to assess the impact of temporary preoperative mechanical circulatory support (TPMCS) on heart transplantation outcomes. A total of 4,060 adult heart transplants from June 1, 2006, to December 31, 2019, were identified in the Scientific Registry of Transplant Recipients database as having TPMCS. Recipients were divided into groups based on their type of TPMCS: intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), biventricular assist device (BIVAD), and extracorporeal membrane oxygenation (ECMO). Perioperative outcomes and survival were compared among groups. Recipients with IABP were associated with older age, a smoking history, and a significantly shorter wait list time ( p < 0.01). Recipients with ECMO had a significantly increased in-hospital mortality as well as an increased incidence of dialysis ( p < 0.01). Kaplan-Meier analysis revealed worse 1 and 5 year survival for recipients with ECMO. Cox model demonstrated a significantly increased risk of mortality with BIVAD (hazard ratio [HR], 1.33; 95% CI, 1.12-1.57; p < 0.01) and ECMO (HR, 1.64; 95% CI, 1.33-2.03; p < 0.01). While patients with IABP have a survival comparable to patients without TPMCS or durable left VAD, outcomes for BIVADs and ECMO are not as favorable. Transplantation centers must continue to make careful choices about the type of TPMCS utilized before heart transplant.
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11
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Varshney AS, Berg DD, Zhou G, Sinnenberg L, Hirji S, DeFilippis EM, Mallidi HR, Morrow DA, Rinewalt D, Givertz MM. Bridging strategies and cardiac replacement outcomes in patients with acute decompensated heart failure-related cardiogenic shock. Eur J Heart Fail 2023; 25:425-435. [PMID: 36597721 PMCID: PMC10065926 DOI: 10.1002/ejhf.2762] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 12/20/2022] [Accepted: 12/24/2022] [Indexed: 01/05/2023] Open
Abstract
AIMS To describe outcomes associated with bridging strategies in patients with acute decompensated heart failure-related cardiogenic shock (ADHF-CS) bridged to durable left ventricular assist device (LVAD) or heart transplantation (HTx). METHODS AND RESULTS Durable LVAD or HTx recipients from 2014 to 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by bridging strategy. The primary outcome was operative or 30-day post-operative mortality. Secondary outcomes included post-operative major bleeding. Exploratory comparisons between bridging strategies and outcomes were performed using overlap weighting with and without covariate adjustment. Among 9783 patients with pre-operative CS, 8777 (89.7%) had ADHF-CS. Medical therapy (n = 5013) was the most common bridging strategy, followed by intra-aortic balloon pump (IABP; n = 2816), catheter-based temporary mechanical circulatory support (TMCS; n = 417), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO; n = 465). Mortality was highest in patients bridged with VA-ECMO (22%), followed by catheter-based TMCS (10%), IABP (9%), and medical therapy (7%). Adverse post-operative outcomes were more frequent in LVAD recipients compared with HTx recipients. CONCLUSION Among patients with ADHF-CS bridged to HTx or durable LVAD, the highest rates of death and adverse events during index hospitalization were observed in those bridged with VA-ECMO, followed by catheter-based TMCS, IABP, and medical therapy. Patients who received durable LVAD had higher rates of post-operative complications compared with HTx recipients. Prospective trials are needed to define optimal bridging strategies in patients with ADHF-CS.
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Affiliation(s)
- Anubodh S. Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, CA
| | - David D. Berg
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Levine Cardiac Intensive Care Unit and Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA
| | - Guohai Zhou
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, MA
| | - Lauren Sinnenberg
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sameer Hirji
- Division of Cardiothoracic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Hari R. Mallidi
- Division of Cardiothoracic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Levine Cardiac Intensive Care Unit and Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA
| | - Daniel Rinewalt
- Cardiovascular and Thoracic Surgery, AdventHealth, Orlando, FL
| | - Michael M. Givertz
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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12
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Maitra NS, Dugger SJ, Balachandran IC, Civitello AB, Khazanie P, Rogers JG. Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes. JACC. HEART FAILURE 2023; 11:491-503. [PMID: 36892486 DOI: 10.1016/j.jchf.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 03/05/2023]
Abstract
In 2018, the United Network for Organ Sharing implemented a 6-tier allocation policy to replace the prior 3-tier system. Given increasing listings of critically ill candidates for heart transplantation and lengthening waitlist times, the new policy aimed to better stratify candidates by waitlist mortality, shorten waiting times for high priority candidates, add objective criteria for common cardiac conditions, and further broaden sharing of donor hearts. There have been significant shifts in cardiac transplantation practices and patient outcomes following the implementation of the new policy, including changes in listing practices, waitlist time and mortality, transplant donor characteristics, post-transplantation outcomes, and mechanical circulatory support use. This review aims to highlight emerging trends in United States heart transplantation practice and outcomes following the implementation of the 2018 United Network for Organ Sharing heart allocation policy and to address areas for future modification.
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Affiliation(s)
- Neil S Maitra
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Samuel J Dugger
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Isabel C Balachandran
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA
| | - Andrew B Civitello
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA
| | - Prateeti Khazanie
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joseph G Rogers
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA.
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13
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Ganapathi AM, Lampert BC, Mokadam NA, Emani S, Hasan AK, Tamer R, Whitson BA. Allocation changes in heart transplantation: What has really changed? J Thorac Cardiovasc Surg 2023; 165:724-733.e7. [PMID: 33875259 DOI: 10.1016/j.jtcvs.2021.03.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 02/27/2021] [Accepted: 03/04/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE In 2018, the heart allocation system changed status classifications and broadened geographic distribution. We examined this change at a national level based on the immediate pre- and postchange periods. METHODS Using the Scientific Registry of Transplant Recipients database, we identified all adult primary, isolated heart transplants from October 18, 2017, to October 17, 2019. Two time periods were compared: (1) October 18, 2017, to October 17, 2018 (pre); and (2) October 18, 2018, to October 17, 2019 (post). Comparisons were made between groups, and a multivariable logistic regression model was created to identify factors associated with pretransplant temporary mechanical circulatory support. Volume analysis at the regional, state, and center level was also conducted as the primary focus. RESULTS A total of 5381 independent heart transplants were identified within the time frame. On unadjusted analysis, there was a significant increase in temporary mechanical circulatory support (pre, 11.1%; post, 36.2%, P < .01) and decrease in waitlist days (pre, 93 days; post, 41 days; P < .01). Distance traveled (nautical miles) (pre, 83; post, 225; P < .01) and ischemic time (hours) (pre, 3.0; post, 3.4; P < .01) were significantly increased. On multivariable analysis, the postallocation time period was independently associated with temporary MCS (odds ratio, 4.463; 95% confidence interval, 3.844-5.183; P < .001). Transplant volumes did not significantly change after the allocation change at a regional, state, and center level. CONCLUSIONS Since the planned alteration to the allocation system, there have been changes in the use of temporary mechanical circulatory support as well as distance and ischemic time associated with transplant, but no significant volume changes were observed. Continued observation of outcomes and volume under the new allocation system will be necessary in the upcoming years.
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Affiliation(s)
- Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Brent C Lampert
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sitaramesh Emani
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ayesha K Hasan
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert Tamer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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14
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Cleveland JC. Commentary: This heart will travel. J Thorac Cardiovasc Surg 2023; 165:735-736. [PMID: 33867128 DOI: 10.1016/j.jtcvs.2021.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colo.
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15
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Shin M, Han JJ, Cohen WG, Iyengar A, Helmers MR, Kelly JJ, Patrick WL, Wang X, Cevasco M. Higher Rates of Dialysis and Subsequent Mortality in the New Allocation Era for Heart Transplants. Ann Thorac Surg 2023; 115:502-509. [PMID: 35926639 DOI: 10.1016/j.athoracsur.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation. METHODS Dialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score-matched cohorts. Survival was compared by Kaplan-Meier analysis. RESULTS A total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P < .01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P < .01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1. CONCLUSIONS Patients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Biostatistics Analysis Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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16
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Orozco-Hernandez E, DeLay TK, Gongora E, Bellot C, Rusanov V, Wille K, Tallaj J, Pamboukian S, Kaleekal T, Mcelwee S, Hoopes C. State of the art - Extracorporeal membrane oxygenation as a bridge to thoracic transplantation. Clin Transplant 2023; 37:e14875. [PMID: 36465026 DOI: 10.1111/ctr.14875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has revolutionized the treatment of refractory cardiac and respiratory failure, and its use continues to increase, particularly in adults. However, ECMO-related morbidity and mortality remain high. MAIN TEXT In this review, we investigate and expand upon the current state of the art in thoracic transplant and extracorporeal life support (ELS). In particular, we examine recent increase in incidence of heart transplant in patients supported by ECMO; the potential changes in patient care and selection for transplant in the years prior to updated United Network for Organ Sharing (UNOS) organ allocation guidelines versus those in the years following, particularly where these guidelines pertain to ECMO; and the newly revived practice of heart-lung block transplants (HLT) and the prevalence and utility of ECMO support in patients listed for HLT. CONCLUSIONS Our findings highlight encouraging outcomes in patients bridged to transplant with ECMO, considerable changes in treatment surrounding the updated UNOS guidelines, and complex, diverse outcomes among different centers in their care for increasingly ill patients listed for thoracic transplant.
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Affiliation(s)
- Erik Orozco-Hernandez
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Kurt DeLay
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Enrique Gongora
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chris Bellot
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Victoria Rusanov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keith Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Salpy Pamboukian
- Division of Cardiology, University of Washington, Birmingham, Alabama, USA
| | - Thomas Kaleekal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sam Mcelwee
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Hoopes
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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17
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Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2023; 165:711-720. [PMID: 34167814 DOI: 10.1016/j.jtcvs.2021.05.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/03/2021] [Accepted: 05/17/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is used to support patients in severe cardiogenic shock. In the absence of recovery, these patients may need to be listed for heart transplant (HT), which offers the best long-term prognosis. However, posttransplantation mortality is significantly elevated in patients who receive ECMO. The objective of the present study was to describe and risk-stratify different profiles of patients listed for HT supported by ECMO. METHODS Patients listed for HT in the United Network for Organ Sharing database were analyzed. The primary outcome was 1-year survival and was assessed in patients bridged to transplant with ECMO (ECMOBTT) and patients who were previously supported on ECMO but had it removed before HT (ECMOREMOVED). RESULTS Among 65,636 adult candidates listed for HT (between 2001 and 2017), 712 were supported on ECMO, 292 of whom (41%) underwent HT (ECMOBTT, n = 202; ECMOREMOVED, n = 90). Most of the patients with ECMOREMOVED were transplanted with a ventricular assist device. In ECMOBTT, recipient age (each 10-year increase), time on the waitlist (both defined as minor risk factors), need for dialysis, and need for mechanical ventilation (both defined as major risk factors) were independent predictors of mortality. ECMOREMOVED and ECMOBTT with no risk factors showed 1-year survival comparable to that in patients who were never supported on ECMO. Compared with patients who were never on ECMO, patients in ECMOBTT group with minor risk factors, 1 major risk factor, and 2 major risk factors had ~2-, ~5-, and >10-fold greater 1-year mortality, respectively (P < .05). CONCLUSIONS The HT recipients in the ECMOREMOVED and ECMOBTT groups with no risk factors showed similar survival as the HT recipients who were never supported on ECMO. In the ECMOBTT group, posttransplantation mortality increased significantly with increasing risk factors.
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18
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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19
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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20
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Hill MA, Kwon JH, Shorbaji K, Kilic A. Waitlist and transplant outcomes for patients bridged to heart transplantation with Impella 5.0 and 5.5 devices. J Card Surg 2022; 37:5081-5089. [PMID: 36378877 DOI: 10.1111/jocs.17209] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/16/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Impella devices are increasingly utilized as a bridge to heart transplantation (BTT) and are now prioritized as Status 2 under the current heart allocation policy. This study evaluated waitlist and post-transplant outcomes of patients supported with Impella 5.0/5.5 devices. METHODS The United Network of Organ Sharing registry was used to identify adults waitlisted or transplanted with Impella 5.0 or 5.5 devices from 2010 to 2021. Separate analyses were performed for waitlist and transplantation outcomes for patients supported by Impella 5.0/5.5 devices. Competing outcomes for the waitlist analysis included rates of transplantation, recovery, and death or clinical deterioration. Among patients undergoing transplantation, the primary outcome was 1-year survival. Secondary outcomes included rates of rejection, new postoperative dialysis, stroke, and pacemaker implantation after transplantation. RESULTS There were 344 patients waitlisted and 394 patients transplanted with an Impella 5.0 (n = 212 and 251) or 5.5 (n = 132 and 143) device. Competing risk regression demonstrated similar likelihood of transplant (subhazard ratio [SHR], 1.33 (0.98-1.81, p = 0.067)) and similar likelihood of death or clinical deterioration (SHR, 0.67 [0.27-1.69, p = 0.400]) for Impella 5.5 patients. In the transplanted cohort, unadjusted 1-year post-transplant survival was comparable at 91.3% versus 94.6% (log-rank p = 0.661) for patients supported by Impella 5.0 or 5.5 device, respectively, a finding that persisted after risk-adjustment (HR 1.22, p = 0.699). Post-transplant complication rates were also comparable between 5.0 and 5.5 patients. CONCLUSIONS Impella devices can be used as a BTT with excellent survival and minimal post-transplant morbidity. Outcomes were comparable for Impella 5.0 and 5.5 devices.
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Affiliation(s)
- Morgan A Hill
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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21
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Cohen WG, Han J, Shin M, Iyengar A, Wang X, Helmers MR, Cevasco M. Lack of volume-outcome association in ECMO bridge to heart transplantation. J Card Surg 2022; 37:4883-4890. [PMID: 36352776 DOI: 10.1111/jocs.17157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes. METHODS Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%). RESULTS In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103 [19%] vs. 32 [11.6%], p = .008) and inotropes (267 [49.2%] vs. 106 [38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6 [4-9] days, compared to 8 [4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2 [1-5] vs. 3 [1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4-8] vs. 6 [4-10], p = .187), or time from registration to transplant (5 [2-20] vs. 7 [3-22] days, p = .560). Posttransplant survival did not vary (p = .293). CONCLUSIONS LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.
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Affiliation(s)
- William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xingmei Wang
- Perelman School of Medicine at the University of Pennsylvania, Biostatistics Analysis Center, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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TEMPORAL TRENDS IN THE USE AND OUTCOMES OF TEMPORARY MECHANICAL CIRCULATORY SUPPORT AS A BRIDGE TO CARDIAC TRANSPLANTATION IN SPAIN. FINAL REPORT OF THE ASIS-TC STUDY. J Heart Lung Transplant 2022; 42:488-502. [PMID: 36470772 DOI: 10.1016/j.healun.2022.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/12/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We aimed to describe recent trends in the use and outcomes of temporary mechanical circulatory support (MCS) as a bridge to heart transplantation (HTx) in Spain. METHODS Retrospective case-by-case analysis of 1,036 patients listed for emergency HTx while on temporary MCS in 16 Spanish institutions from January 1st, 2010 to December 31st, 2020. Patients were classified in 3 eras according to changes in donor allocation criteria (Era 1: January 2010/May 2014; Era 2: June 2014/May 2017; Era 3: June 2017/December 2020). RESULTS Over time, the proportion of candidates listed with intra-aortic balloon pumps decreased (Era 1 = 55.9%, Era 2 = 32%, Era 3 = 0.9%; p < 0.001), while the proportion of candidates listed with surgical continuous-flow temporary VADs (Era 1 = 10.6%, Era 2 = 32%, Era 3 = 49.1%; p < 0.001) and percutaneous VADs (Era 1 = 0.3%, Era 2 = 6.3%; Era 3 = 17.2%; p < 0.001) increased. Rates of HTx increased from Era 1 (79.4%) to Era 2 (87.8%), and Era 3 (87%) (p = 0.004), while rates of death before HTx decreased (Era 1 = 17.7%; Era 2 = 11%, Era 3 = 12.4%; p = 0.037) Median time from listing to HTx increased in patients supported with intra-aortic balloon pumps (Era 1 = 8 days, Era 2 = 15 days; p < 0.001) but remained stable in other candidates (Era 1 = 6 days; Era 2 = 5 days; Era 3 = 6 days; p = 0.134). One-year post-transplant survival was 71.4% in Era 1, 79.3% in Era 2, and 76.5% in Era 3 (p = 0.112). Preoperative bridging with ECMO was associated with increased 1-year post-transplant mortality (adjusted HR=1.71; 95% CI 1.15-2.53; p = 0.008). CONCLUSIONS During the period 2010 to 2020, successive changes in the Spanish organ allocation protocol were followed by a significant increase of the rate of HTx and a significant reduction of waiting list mortality in candidates supported with temporary MCS. One-year post-transplant survival rates remained acceptable.
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Mehra MR, Nayak A, Morris AA, Lanfear DE, Nemeh H, Desai S, Bansal A, Guerrero-Miranda C, Hall S, Cleveland JC, Goldstein DJ, Uriel N, Chen L, Bailey S, Anyanwu A, Heatley G, Chuang J, Estep JD. Prediction of Survival After Implantation of a Fully Magnetically Levitated Left Ventricular Assist Device. JACC: HEART FAILURE 2022; 10:948-959. [DOI: 10.1016/j.jchf.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
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Pre-operative Machine Learning for Heart Transplant Patients Bridged with Temporary Mechanical Circulatory Support. J Cardiovasc Dev Dis 2022; 9:jcdd9090311. [PMID: 36135456 PMCID: PMC9500687 DOI: 10.3390/jcdd9090311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Existing prediction models for post-transplant mortality in patients bridged to heart transplantation with temporary mechanical circulatory support (tMCS) perform poorly. A more reliable model would allow clinicians to provide better pre-operative risk assessment and develop more targeted therapies for high-risk patients. Methods: We identified adult patients in the United Network for Organ Sharing database undergoing isolated heart transplantation between 01/2009 and 12/2017 who were supported with tMCS at the time of transplant. We constructed a machine learning model using extreme gradient boosting (XGBoost) with a 70:30 train:test split to predict 1-year post-operative mortality. All pre-transplant variables available in the UNOS database were included to train the model. Shapley Additive Explanations was used to identify and interpret the most important features for XGBoost predictions. Results: A total of 1584 patients were included, with a median age of 56 (interquartile range: 46-62) and 74% male. Actual 1-year mortality was 12.1%. Out of 498 available variables, 43 were selected for the final model. The area under the receiver operator characteristics curve (AUC) for the XGBoost model was 0.71 (95% CI: 0.62-0.78). The most important variables predictive of 1-year mortality included recipient functional status, age, pulmonary capillary wedge pressure (PCWP), cardiac output, ECMO usage, and serum creatinine. Conclusions: An interpretable machine learning model trained on a large clinical database demonstrated good performance in predicting 1-year mortality for patients bridged to heart transplantation with tMCS. Machine learning may be used to enhance clinician judgement in the care of markedly high-risk transplant recipients.
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25
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Zhou AL, Etchill EW, Shou BL, Whitbread JJ, Barbur I, Giuliano KA, Kilic A. Outcomes after heart transplantation in patients who have undergone a bridge-to-bridge strategy. JTCVS OPEN 2022; 12:255-268. [PMID: 36590736 PMCID: PMC9801290 DOI: 10.1016/j.xjon.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/13/2022] [Accepted: 08/29/2022] [Indexed: 01/04/2023]
Abstract
Objectives We compared posttransplant outcomes between patients bridged from temporary mechanical circulatory support to durable left ventricular assist device before transplant (bridge-to-bridge [BTB] strategy) and patients bridged from temporary mechanical circulatory support directly to transplant (bridge-to-transplant [BTT] strategy). Methods We identified adult heart transplant recipients in the Organ Procurement and Transplantation Network database between 2005 and 2020 who were supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device as a BTB or BTT strategy. Kaplan-Meier survival analysis and Cox regressions were used to assess 1-year, 5-year, and 10-year survival. Posttransplant length of stay and complications were compared as secondary outcomes. Results In total, 201 extracorporeal membrane oxygenation (61 BTB, 140 BTT), 1385 intra-aortic balloon pump (460 BTB, 925 BTT), and 234 temporary ventricular assist device (75 BTB, 159 BTT) patients were identified. For patients supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device, there were no differences in survival between BTB and BTT at 1 and 5 years posttransplant, as well as 10 years posttransplant even after adjusting for baseline characteristics. The extracorporeal membrane oxygenation BTB group had greater rates of acute rejection (32.8% vs 13.6%; P = .002) and lower rates of dialysis (1.6% vs 21.4%; P < .001). For intra-aortic balloon pump and temporary ventricular assist device patients, there were no differences in posttransplant length of stay, acute rejection, airway compromise, stroke, dialysis, or pacemaker insertion between BTB and BTT recipients. Conclusions BTB patients have similar short- and midterm posttransplant survival as BTT patients. Future studies should continue to investigate the tradeoff between prolonged temporary mechanical circulatory support versus transitioning to durable mechanical circulatory support.
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Key Words
- BTB, bridge-to-bridge
- BTT, bridge-to-transplant
- CO, cardiac output
- ECMO, extracorporeal membrane oxygenation
- IABP, intra-aortic balloon pump
- LVAD, left ventricular assist device
- MCS, mechanical circulatory support
- OPTN, Organ Procurement and Transplantation Network
- PA, pulmonary artery
- PCWP, pulmonary capillary wedge pressure
- TAH, total artificial heart
- UNOS, United Network for Organ Sharing
- extracorporeal membrane oxygenation
- heart transplant
- intra-aortic balloon pump
- mPAP, mean pulmonary arterial pressure
- mechanical circulatory support
- tVAD, temporary ventricular assist device
- transplant outcomes
- ventricular assist devices
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Affiliation(s)
- Alice L. Zhou
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Eric W. Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | | | - Iulia Barbur
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Katherine A. Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
- Address for reprints: Ahmet Kilic, MD, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Suite 7107, 1800 Orleans St, Baltimore, MD 21287.
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26
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Ortiz-Bautista C, Muñiz J, Almenar-Bonet L, Crespo-Leiro MG, Sobrino-Márquez JM, Farrero-Torres M, García-Cosio MD, Díaz-Molina B, Zegrí-Reiriz I, González-Vilchez F, Blázquez-Bermejo Z, López Granados A, Gómez-Bueno M, de la Fuente-Galán L, Blasco-Peiró T, Garrido-Bravo IP, García-Romero E, Rábago Juan-Aracil G, García-Guereta L, Delgado-Jiménez JF. Utility of the IMPACT score for predicting heart transplant mortality. Analysis on a contemporary cohort of the Spanish Heart Transplant Registry. Clin Transplant 2022; 36:e14774. [PMID: 35829691 DOI: 10.1111/ctr.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort. METHODS Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N = 2,810). RESULTS Median value of the IMPACT score was 5 points (IQR: 3, 8). Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥ 15) were 84.4%, 81.5%, 79.3%, 77.3% and 58.5% respectively (Log-Rank test: p<0.001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for one year was 7.56; p = 0.47) and poor discrimination ability (AUC-ROC 0.59) of the IMPACT score as a predictive model. CONCLUSIONS In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Universidade da Coruña, Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica (INIBIC), A Coruña, Spain
| | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María G Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade da Coruña (UDC), A Coruña, Spain
| | - José M Sobrino-Márquez
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Marta Farrero-Torres
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Clínic, Barcelona, Spain
| | - María D García-Cosio
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Beatriz Díaz-Molina
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Isabel Zegrí-Reiriz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco González-Vilchez
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Zorba Blázquez-Bermejo
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Manuel Gómez-Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia cardiaca avanzada y Trasplante, Servicio de Cardiología, Hospital Universitario Puerta de Hierro de Majadahonda, Madrid, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Elena García-Romero
- Servicio de Cardiología, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases group, Cardiovascular, Respiratory and Systemic Diseases and cellular aging program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Juan F Delgado-Jiménez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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Jaiswal A, Gadela NV, Baran DA, Dasgupta O, Gluck J, Radojevic J, Arora S, Scatola A, Ali A, Hammond J, Jennings DL, Baker WL. Post Heart Transplantation Outcomes of Patients Supported on Biventricular Mechanical Support. ASAIO J 2022; 68:914-919. [PMID: 34619695 DOI: 10.1097/mat.0000000000001588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
With the implementation of the new heart transplant (HT) allocation system, patients requiring biventricular support systems have the highest priority, a shorter waitlist time, and a higher frequency of HT. However, the short-term and long-term outcomes of such patients are often disputed. Hence, we examined the outcomes of these patients who underwent HT before change in allocation scheme. Additionally, we compared post-HT outcomes of extracorporeal membrane oxygenation (ECMO) with other nondischargeable biventricular (BiVAD) supported patients. We identified adult ECMO or BiVAD supported HT recipients between 2000 and 2018 in the Scientific Registry of Transplant Recipients database. We compared survival with the Kaplan-Meier method. Using overlap propensity score weighting, we constructed Cox proportional hazards regression models to determine the risk-adjusted influence of BiVAD versus ECMO on survival. Of the 730 patients HT recipients; 528 (72.3%) and 202 (27.7%) were bridged with BiVAD and ECMO, respectively. For BiVAD versus ECMO patients, the 30-day, 1-year, 3-year, and 5-year mortality rates were 8.0% versus 14.4%, 16.3% versus 21.3%, 22.4% versus 25.3%, and 26.3% versus 25.7%, respectively. Risk-adjusted post-HT survival of BiVAD and ECMO patients at 30-day (HR 1.24 [95% CI, 0.68-2.27]; P = 0.4863), 1-year (HR 1.29 [95% CI, 0.80-2.09]; P = 0.3009), 3-year (HR 1.27 [95% CI, 0.83-1.94]; P = 0.2801), and 5-year (HR 1.35, 95% CI, 0.90-2.05; P = 0.1501) were similar. Around three-fourth of the ECMO or BiVAD supported patients were alive at 5-years post-HT. The short-term and long-term post-HT survivals of groups were comparable.
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Affiliation(s)
- Abhishek Jaiswal
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | | | - David A Baran
- Advanced Heart Failure and Transplant, Sentara Heart Hospital, Advanced Heart Failure Center and Eastern Virginia Medical School, Norfolk, Virginia
| | - Oisharya Dasgupta
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Jason Gluck
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Joseph Radojevic
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Sabeena Arora
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Andrew Scatola
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Ayyaz Ali
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Jonathan Hammond
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Douglas L Jennings
- Department of Pharmacy Practice, Long Island University, New York, New York
- Department of Pharmacy Practice, New York-Presbyterian Hospital Columbia University Irving Medical Center, New York, New York
| | - William L Baker
- From the Advanced Heart Failure and Transplant, Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut
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28
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Hansen B, Singer Englar T, Cole R, Catarino P, Chang D, Czer L, Emerson D, Geft D, Kobashigawa J, Megna D, Ramzy D, Moriguchi J, Esmailian F, Kittleson M. Extracorporeal membrane oxygenation as a bridge to durable mechanical circulatory support or heart transplantation. Int J Artif Organs 2022; 45:604-614. [PMID: 35658592 DOI: 10.1177/03913988221103284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with cardiogenic shock may require extracorporeal membrane oxygenation (ECMO) prior to durable mechanical circulatory support (dMCS) or heart transplantation (HTx). METHODS We investigated the clinical characteristics and outcomes of adult patients with ECMO support as bridge to dMCS or HTx between 1/1/13 and 12/31/20. RESULTS Of 57 patients who underwent bridging ECMO, 41 (72%) received dMCS (approximately half with biventricular support) and 16 (28%) underwent HTx, 13 (81%) after the 2018 UNOS allocation system change. ECMO → HTx patients had shorter ventilatory time (3.5 vs 7.5 days; p = 0.018), ICU stay (6 vs 18 days; p = 0.001), and less need for inpatient rehabilitation (18.8% vs 57.5%; p = 0.016). The 1-year survival post HTx was 81.3% in the ECMO → HTx group and 86.4% in the ECMO → dMCS group (p = 0.11). For those patients in the ECMO → dMCS group who did not undergo HTx, 1-year survival was significantly lower, 31.6% (p = 0.001). CONCLUSION Patients on ECMO who undergo HTx, with or without dMCS bridge, have acceptable post-HTx survival. These findings suggest that HTx from ECMO is a viable option for carefully selected patients deemed acceptable to proceed with definitive advanced therapies, especially in the era of the new UNOS allocation system.
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Affiliation(s)
| | | | - Robert Cole
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | - David Chang
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Dael Geft
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | - Danny Ramzy
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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Pahwa S, Dunbar-Matos C, Slaughter MS, Trivedi JR. Use of Impella in Patients Listed for Heart Transplantation. ASAIO J 2022; 68:786-790. [PMID: 35184091 DOI: 10.1097/mat.0000000000001679] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.
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Affiliation(s)
- Siddharth Pahwa
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | | | - Mark S Slaughter
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Jaimin R Trivedi
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
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30
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A New Dawn for Transvalvular Pumps for Ventricular Unloading as a Bridge to Heart Transplantation. ASAIO J 2022; 68:760-762. [PMID: 35649223 DOI: 10.1097/mat.0000000000001778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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31
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Zheng S, Tang H, Zheng Z, Song Y, Huang J, Liao Z, Liu S. Validation of existing risk scores for mortality prediction after a heart transplant in a Chinese population. Interact Cardiovasc Thorac Surg 2022; 34:909-918. [PMID: 35018445 PMCID: PMC9070526 DOI: 10.1093/icvts/ivab380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/04/2021] [Accepted: 11/23/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES The objectives of this study were to validate 3 existing heart transplant risk scores with a single-centre cohort in China and evaluate the efficacy of the 3 systems in predicting mortality. METHODS We retrospectively studied 428 patients from a single centre who underwent heart transplants from January 2015 to December 2019. All patients were scored using the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) and the United Network for Organ Sharing (UNOS) and risk stratification scores (RSSs). We assessed the efficacy of the risk scores by comparing the observed and the predicted 1-year mortality. Binary logistic regression was used to evaluate the predictive accuracy of the 3 risk scores. Model discrimination was assessed by measuring the area under the receiver operating curves. Kaplan-Meier survival analyses were performed after the patients were divided into different risk groups. RESULTS Based on our cohort, the observed mortality was 6.54%, whereas the predicted mortality of the IMPACT and UNOS scores and the RSSs was 10.59%, 10.74% and 12.89%, respectively. Logistic regression analysis showed that the IMPACT [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.15-1.36; P < 0.001], UNOS (OR, 1.68; 95% CI, 1.37-2.07; P < 0.001) and risk stratification (OR, 1.61; 95% CI, 1.30-2.00; P < 0.001) scores were predictive of 1-year mortality. The discriminative power was numerically higher for the IMPACT score [area under the curve (AUC) of 0.691)] than for the UNOS score (AUC 0.685) and the RSS (AUC 0.648). CONCLUSIONS We validated the IMPACT and UNOS scores and the RSSs as predictors of 1-year mortality after a heart transplant, but all 3 risk scores had unsatisfactory discriminative powers that overestimated the observed mortality for the Chinese cohort.
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Affiliation(s)
- Shanshan Zheng
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hanwei Tang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Zhe Zheng
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yunhu Song
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jie Huang
- Department of Heart Failure and Heart Transplant, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Zhongkai Liao
- Department of Heart Failure and Heart Transplant, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Sheng Liu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
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Tang PC, Wu X, Zhang M, Likosky D, Haft JW, Lei I, Abou El Ela A, Si MS, Aaronson KD, Pagani FD. Determining optimal donor heart ischemic times in adult cardiac transplantation. J Card Surg 2022; 37:2042-2050. [PMID: 35488767 PMCID: PMC9325483 DOI: 10.1111/jocs.16558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Objectives Unsupervised statistical determination of optimal allograft ischemic time (IT) on heart transplant outcomes among ABO donor heart types. Methods We identified 36,145 heart transplants (2000–2018) from the United Network for Organ Sharing database. Continuous and categorical variables were analyzed with parametric and nonparametric testing. Determination of IT cutoffs for survival analysis was performed using Contal and O'Quigley univariable method and Vito Muggeo multivariable segmented modeling. Results Univariable and multivariable IT threshold determination revealed a cutoff at about 3 h. The hourly increase in survival risk with ≥3 h IT is asymmetrically experienced at the early 90 days (hazard ratio [HR] = 1.29, p < .001) and up to 1‐year time point (HR = 1.16, p < .001). Beyond 1 year the risk of prolonged IT is less impactful (HR = 1.04, p = .022). Longer IT was associated with more postoperative complications such as stroke (2.7% vs. 2.3, p = .042), dialysis (11.6% vs. 9.1%, p < .001) and death from primary graft dysfunction (1.8% vs. 1.2%, p < .001). O blood type donor hearts with IT ≥ 3 h has significantly increased hourly mortality risk at 90 days (HR = 1.27, p < .001), 90 days to 1 year (HR = 1.22, p < .001) and >1 year (HR = 1.05, p = .041). For non‐O blood types with ≥3 h IT hourly mortality risk was increased at 90 days (HR = 1.33, p < .001), but not at 90 days to 1 year (HR = 1.09, p = .146) nor ≥1 year (HR = 1.08, p = .237). Conclusions The donor heart IT threshold for survival determined from unbiased statistical modeling occurs at 3 h. With longer preservation times, transplantation with O donor hearts was associated with worse survival.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Ann Arbor, Michigan, USA
| | - Donald Likosky
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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Crespo-Leiro MG, Costanzo MR, Gustafsson F, Khush KK, Macdonald PS, Potena L, Stehlik J, Zuckermann A, Mehra MR. Heart transplantation: focus on donor recovery strategies, left ventricular assist devices, and novel therapies. Eur Heart J 2022; 43:2237-2246. [PMID: 35441654 DOI: 10.1093/eurheartj/ehac204] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 04/06/2022] [Indexed: 12/18/2022] Open
Abstract
Heart transplantation is advocated in selected patients with advanced heart failure in the absence of contraindications. Principal challenges in heart transplantation centre around an insufficient and underutilized donor organ pool, the need to individualize titration of immunosuppressive therapy, and to minimize late complications such as cardiac allograft vasculopathy, malignancy, and renal dysfunction. Advances have served to increase the organ donor pool by advocating the use of donors with underlying hepatitis C virus infection and by expanding the donor source to use hearts donated after circulatory death. New techniques to preserve the donor heart over prolonged ischaemic times, and enabling longer transport times in a safe manner, have been introduced. Mechanical circulatory support as a bridge to transplantation has allowed patients with advanced heart failure to avoid progressive deterioration in hepato-renal function while awaiting an optimal donor organ match. The management of the heart transplantation recipient remains a challenge despite advances in immunosuppression, which provide early gains in rejection avoidance but are associated with infections and late-outcome challenges. In this article, we review contemporary advances and challenges in this field to focus on donor recovery strategies, left ventricular assist devices, and immunosuppressive monitoring therapies with the potential to enhance outcomes. We also describe opportunities for future discovery to include a renewed focus on long-term survival, which continues to be an area that is under-studied and poorly characterized, non-human sources of organs for transplantation including xenotransplantation as well as chimeric transplantation, and technology competitive to human heart transplantation, such as tissue engineering.
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Affiliation(s)
- Maria Generosa Crespo-Leiro
- Department of Cardiology, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomedica A Coruña (INIBIC), Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), As Xubias 84, 15006 A Coruña, Spain
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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Baran DA, Jaiswal A, Hennig F, Potapov E. Temporary Mechanical Circulatory Support: Devices, Outcomes and Future Directions. J Heart Lung Transplant 2022; 41:678-691. [DOI: 10.1016/j.healun.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
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Ex-Vivo Preservation with the Organ Care System in High Risk Heart Transplantation. Life (Basel) 2022; 12:life12020247. [PMID: 35207534 PMCID: PMC8877453 DOI: 10.3390/life12020247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: Ex vivo organ perfusion is an advanced preservation technique that allows graft assessment and extended ex situ intervals. We hypothesized that its properties might be especially beneficial for high-risk recipients and/or donors with extended criteria. Methods: We reviewed the outcomes of 119 consecutive heart transplant patients, which were divided into two groups: A (OCS) vs. B (conventional). Ex vivo organ perfusion was performed using the Organ Care System (OCS). Indications for OCS-usage were expected ischemic time of >4 h or >2 h plus given extended donor criteria. Results: Both groups included mostly redo cases (A: 89.7% vs. B: 78.4%; p = 0.121). Incidences of donors with previous cardiac arrest (%) (A: 32.4 vs. B: 22.2; p < 0.05) or LV-hypertrophy (%) (A: 19.1 vs. B: 8.3; p = 0.119) were also increased in Group A. Ex situ time (min) was significantly longer in Group A (A: 381 (74) vs. B: 228 (43); p < 0.05). Ventilation time (days) (A: 10.0 (19.9) vs. B: 24.3 (43.2); p = 0.057), postoperative need for ECLS (%) (A: 25.0 vs. B: 39.2; p = 0.112) and postoperative dialysis (chronic) (%) (A: 4.4 vs. B: 27.5; p < 0.001) were numerically better in the OCS group, without any difference in the occurrence of early graft rejection. The 30-d-survival (A: 92.4% vs. B: 90.2%; p = 0.745) and mid-term survival were statistically not different between both groups. Conclusions: OCS heart allowed safe transplantation of surgically complex recipients with excellent one-year outcomes, despite long preservation times and unfavourable donor characteristics. Furthermore, we observed trends towards decreased ventilation times and fewer ECLS treatments. In times of reduced organ availability and increasing recipient complexity, OCS heart is a valuable instrument that enables otherwise infeasible allocations and contributes to increase surgical safety.
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Srinivasan AJ, Seese L, Mathier MA, Hickey G, Lui C, Kilic A. Recent Changes in Durable Left Ventricular Assist Device Bridging to Heart Transplantation. ASAIO J 2022; 68:197-204. [PMID: 33788800 DOI: 10.1097/mat.0000000000001436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study evaluates the impact of the recent United Network for Organ Sharing (UNOS) allocation policy change on outcomes of patients bridged with durable left ventricular assist devices (LVADs) to orthotopic heart transplantation (OHT). Adults bridged to OHT with durable LVADs between 2010 and 2019 were included. Patients were stratified based on the temporal relationship of their OHT to the UNOS policy change on October 18, 2018. The primary outcome was early post-OHT survival. In total, 9,628 OHTs were bridged with durable LVADs, including 701 (7.3%) under the new policy. Of all OHTs performed during the study period, the proportion occurring following durable LVAD bridging decreased from 45% to 34% (p < 0.001). The more recent cohort was higher risk, including more extracorporeal membrane oxygenation bridging (2.6% vs. 0.3%, p < 0.001), more mechanical right ventricular support (9.7% vs. 1.4%, p < 0.001), greater pretransplant ICU admission (22.8% vs. 8.7%, p < 0.001) more need for total functional assistance (62.8% vs. 53.0%, p < 0.001), older donor age (33.3 vs. 31.7 years, p < 0.001), and longer ischemic times (3.38 vs. 3.13 hours, p < 0.001). Despite this, early post-OHT survival was comparable at 30 days (96.1% vs. 96.0%, p = 0.89), 90 days (93.7% vs. 94.0%, p = 0.76), and 6 months (91.0% vs. 93.0%, p = 0.96), findings that persisted after risk-adjustment. In this early analysis, OHT following bridging with durable LVADs is performed less frequently and in higher risk recipients under the new allocation policy. Despite this, short-term posttransplant outcomes appear to be unaffected in this patient cohort in the current era.
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Affiliation(s)
- Amudan J Srinivasan
- From the Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Seese
- From the Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael A Mathier
- The Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin Hickey
- The Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cecillia Lui
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Arman Kilic
- From the Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Zhou AL, Etchill EW, Giuliano KA, Shou BL, Sharma K, Choi CW, Kilic A. Bridge to transplantation from mechanical circulatory support: a narrative review. J Thorac Dis 2022; 13:6911-6923. [PMID: 35070375 PMCID: PMC8743412 DOI: 10.21037/jtd-21-832] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Objective To highlight recent developments in the utilization of mechanical circulatory support (MCS) devices as bridge-to-transplant strategies and to discuss trends in MCS use following the changes to the United Network for Organ Sharing (UNOS) heart allocation system. Background MCS devices have played an increasingly important role in the treatment of heart failure patients. Over the past several years, technological advancements have led to new developments in MCS devices and expanding indications for MCS use. In October of 2018, the UNOS heart allocation policy was revised to prioritize higher-urgency patients, including those supported with temporary MCS devices. Since then, changes in trends of MCS utilization have been observed. Methods Articles from the PubMed database regarding the use of MCS devices as bridge-to-transplant strategies were reviewed. Conclusions Over the past decade, utilization of temporary MCS devices, which include the intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), and extracorporeal membrane oxygenation (ECMO), has become increasingly common. Recent advancements in MCS include the development of pVADs that can fully unload the left ventricle (LV) as well as devices designed to provide right-sided support. Technological advancements in durable left ventricular assist devices (LVADs) have also led to improved outcomes both on the device and following heart transplantation. Following the 2018 UNOS heart allocation policy revision, the utilization of temporary MCS in advanced heart failure patients has further increased and the proportion of patients bridged directly from a temporary MCS device has exponentially risen. However, following the start of the COVID-19 pandemic, the trends have reversed, with a decrease in the percentage of patients bridged from a temporary MCS device. As long-term data following the allocation policy revision becomes available, future studies should investigate how trends in MCS use for patients with advanced heart failure continue to evolve.
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Affiliation(s)
- Alice L Zhou
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katherine A Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chun W Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Mastoris I, Tonna JE, Hu J, Sauer AJ, Haglund NA, Rycus P, Wang Y, Wallisch WJ, Abicht TO, Danter MR, Tedford RJ, Fang JC, Shah Z. Use of Extracorporeal Membrane Oxygenation as Bridge to Replacement Therapies in Cardiogenic Shock: Insights From the Extracorporeal Life Support Organization. Circ Heart Fail 2022; 15:e008777. [PMID: 34879706 PMCID: PMC8763251 DOI: 10.1161/circheartfailure.121.008777] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND There has been increasing use of extracorporeal membrane oxygenation (ECMO) as bridge to heart transplant (orthotopic heart transplant [OHT]) or left ventricular assist device (LVAD) over the last decade. We aimed to provide insights on the population, outcomes, and predictors for the selection of each therapy. METHODS Using the Extracorporeal Life Support Organization Registry between 2010 and 2019, we compared in-hospital mortality and length of stay, predictors of OHT versus LVAD, and predictors of in-hospital mortality for patients with cardiogenic shock that were bridged with ECMO to OHT or LVAD. One hundred sixty-seven patients underwent LVAD versus 234 patients who underwent OHT. RESULTS The overall use of ECMO has increased from 1.7% in 2010 to 22.2% in 2019. Mortality was similar between groups (LVAD: 28.7% versus OHT: 29.1%) while length of stay was longer for OHT (LVAD: 49.6 versus OHT: 59.5 days, P=0.05). Factors associated with OHT included prior transplant (odds ratio [OR]=31.26 [CI, 3.84-780.5]), use of a temporary pacemaker (OR=6.5 [CI, 1.39-50.15]), and increased use of inotropes on ECMO (OR=3.77 [CI, 1.39-11.07]), whereas LVAD use was associated with weight (OR=0.98 [CI, 0.97-0.99]), cardiogenic shock presentation (OR=0.40 [CI, 0.21-0.78]), previous LVAD (OR=0.01 [CI, 0.0001-0.22]), respiratory failure (OR=0.28 [CI, 0.11-0.70]), and milrinone infusion (OR=0.32 [CI, 0.15-0.67]). Older age (OR=1.07 [CI, 1.02-1.12]), cannulation bleeding (OR=26.1 [CI, 4.32-221.3]), and surgical bleeding (OR=6.7 [CI, 1.26-39.9]) in patients receiving LVAD and respiratory failure (OR=5 [CI, 1.17-23.1]) and continuous renal replacement therapy (OR=3.82 [CI, 1.28-11.9]) in patients receiving OHT were associated with increased mortality. CONCLUSIONS ECMO use as a bridge to advanced therapies has increased over time, with more patients undergoing LVAD than OHT. Mortality was equal between the 2 groups while length of stay was longer for OHT.
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Affiliation(s)
- Ioannis Mastoris
- Department of Cardiovascular Medicine (I.M., A.J.S., N.A.H., Z.S.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery (J.E.T.), Department of Surgery, University of Utah Health, Salt Lake City
- Division of Emergency Medicine (J.E.T.), Department of Surgery, University of Utah Health, Salt Lake City
| | - Jinxiang Hu
- Department of Biostatistics (J.H., Y.W.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Andrew J. Sauer
- Department of Cardiovascular Medicine (I.M., A.J.S., N.A.H., Z.S.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Nicholas A. Haglund
- Department of Cardiovascular Medicine (I.M., A.J.S., N.A.H., Z.S.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI (P.R.)
| | - Yu Wang
- Department of Biostatistics (J.H., Y.W.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - William J. Wallisch
- Department of Anesthesiology (W.J.W.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Travis O. Abicht
- Department of Cardiothoracic Surgery (T.O.A., M.R.D.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Matthew R. Danter
- Department of Cardiothoracic Surgery (T.O.A., M.R.D.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (R.J.T.)
| | - James C. Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.C.F.)
| | - Zubair Shah
- Department of Cardiovascular Medicine (I.M., A.J.S., N.A.H., Z.S.), University of Kansas Health System, University of Kansas School of Medicine, Kansas City
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Brocklebank PW, Kwon JH, Hashmi ZA, Inampudi C, Houston BA, Witer LJ, Tedford RJ, Kilic A. The impact of changes in renal function during waitlist time on outcomes after heart transplantation. J Card Surg 2021; 37:590-599. [PMID: 34967979 DOI: 10.1111/jocs.16188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/16/2021] [Accepted: 11/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM This study evaluated the impact of changes in renal function during the waitlist period on posttransplant outcomes of orthotopic heart transplantation (OHT). METHODS The United Network for Organ Sharing registry was used to identify adult patients undergoing isolated OHT from 2010 to 2020. Patients were stratified by whether their National Kidney Foundation chronic kidney disease (CKD) stage improved, worsened, or remained unchanged between listing and transplantation. Univariate analysis and multivariable Cox regression were conducted to determine whether a change in estimated glomerular filtration rate (eGFR) or change in CKD stage predicted 1-year mortality after OHT. RESULTS Of 22,746 patients, the majority of patients remained in the same CKD stage (59.6%), and the frequencies of patients progressing to improved (19.3%) and worsened (21.1%) CKD stages were similar. Temporary mechanical circulatory support (MCS) was associated with improved CKD stage and durable MCS with worsened CKD stage (p < .001). Post-OHT dialysis was most common in patients with worsened CKD stage (13.2%) and least common in the improved cohort (9.4%) (p < .001). Kaplan-Meier unadjusted 1-year survival rates after OHT were similar between CKD change groups (log-rank p = .197). Multivariable analysis demonstrated no risk-adjusted effect of change in eGFR (p = .113) or change in CKD stage (p = .076) on 1-year mortality after OHT. CONCLUSIONS Approximately 20% of patients improve CKD stage and 20% worsen CKD stage between listing and OHT, with the remaining 60% having unchanged CKD stage. Worsening CKD stage predicts increased likelihood of post-OHT dialysis, but CKD stage change does not predict 1-year survival following OHT.
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Affiliation(s)
- Paul W Brocklebank
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chakradhari Inampudi
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian A Houston
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lucas J Witer
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Shaw TB, Morton J, Deschner WP, Mohammed A, Copeland H. Impella 5.0: An intermediate strategy for bridging a patient from infected durable LVAD to cardiac transplant. J Card Surg 2021; 37:685-687. [DOI: 10.1111/jocs.16186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Taylor B. Shaw
- Department of Surgery University of Mississippi Medical Center Jackson Mississippi USA
| | - John Morton
- Division of Cardiothoracic and Vascular Surgery Lutheran Hospital Fort Wayne Indiana USA
| | - William P. Deschner
- Division of Cardiothoracic and Vascular Surgery Lutheran Hospital Fort Wayne Indiana USA
| | - Asim Mohammed
- Division of Cardiology, Advance Heart Failure, Heart Transplant Lutheran Hospital Fort Wayne Indiana USA
| | - Hannah Copeland
- Division of Cardiothoracic and Vascular Surgery, Heart Transplant, Mechanical Circulatory Support and ECMO, Lutheran Hospital Indiana University School of Medicine ‐ Fort Wayne (IUSM‐FW) Fort Wayne Indiana USA
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Stehlik J, Christie JD, Goldstein DR, Amarelli C, Bertolotti A, Chambers DC, Dorent R, Gonzalez-Vilchez F, Parameshwar J, Perch M, Zuckermann A, Coll E, Levy RD, Atik FA, Gomez-Mesa JE, Moayedi Y, Peled-Potashnik Y, Schultz G, Cherikh W, Danziger-Isakov L. The evolution of the ISHLT transplant registry. Preparing for the future. J Heart Lung Transplant 2021; 40:1670-1681. [PMID: 34657795 DOI: 10.1016/j.healun.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Jason D Christie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel R Goldstein
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cristiano Amarelli
- Department of Cardiac Surgery and Transplants, Monaldi, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Alejandro Bertolotti
- Transplant Department, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | | | - Richard Dorent
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine Cedex, France
| | - Francisco Gonzalez-Vilchez
- Servicio de Cardiología. Hospital Universitario Marques de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Jayan Parameshwar
- NHS Blood and Transplant and Advanced Heart Failure and Heart Transplant Service, Royal Papworth Hospital, Cambridge, UK
| | - Michael Perch
- Department of Cardiology, Heartcenter Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Robert D Levy
- Department of Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Fernando A Atik
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | - Juan Esteban Gomez-Mesa
- Juan Gomez - Cardiology service, Fundación Valle del Lili and Universidad Icesi, Cali, Colombia
| | - Yasbanoo Moayedi
- Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Yael Peled-Potashnik
- Cardiothoracic and Vascular Center, Yael Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Greg Schultz
- International Society for Heart and Lung Transplantation, Addison, Texas
| | - Wida Cherikh
- United Network for Organ Sharing, Richmond, Virginia
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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Hoffman JRH, Larson EE, Rahaman Z, Absi T, Levack M, Balsara KR, McMaster W, Brinkley M, Menachem JN, Punnoose LR, Sacks SB, Wigger MA, Zalawadiya SK, Stevenson LW, Schlendorf KH, Lindenfeld J, Shah AS. Impact of increased donor distances following adult heart allocation system changes: A single center review of 1-year outcomes. J Card Surg 2021; 36:3619-3628. [PMID: 34235763 DOI: 10.1111/jocs.15795] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. METHODS In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. RESULTS A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006). CONCLUSIONS Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emilee E Larson
- Section of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn R Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark A Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Coeckelenbergh S, Valente F, Mortier J, Engelman E, Roussoulières A, El Oumeiri B, Antoine M, Van Obbergh L, Taccone FS, Vanden Eynden F, Stefanidis C. Long-Term Outcome After Venoarterial Extracorporeal Membrane Oxygenation as Bridge to Left Ventricular Assist Device Preceding Heart Transplantation. J Cardiothorac Vasc Anesth 2021; 36:1694-1702. [PMID: 34330577 DOI: 10.1053/j.jvca.2021.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine if venoarterial extracorporeal membrane oxygenation (VA ECMO) as a bridge to left ventricular assist device (LVAD) in heart transplant (HT) candidates (ie, double bridge to HT) was associated with increased morbidity and mortality when compared to LVAD bridging to HT (ie, single bridge to HT). DESIGN A retrospective analysis of patients undergoing LVAD support from 2011 to 2020. A Kaplan-Meier survival curve and Cox-Mantel hazard ratios (HR) were calculated during LVAD support and after HT. Postoperative complications were collected. SETTING University Hospital Erasme. PARTICIPANTS HT candidates requiring LVAD. INTERVENTIONS VA ECMO bridging to LVAD (ECMO-LVAD group [n = 24]) versus LVAD (LVAD group [n = 64]). MEASUREMENTS AND MAIN RESULTS Eighty-eight patients underwent HeartWare LVAD (HVAD, Medtronic) placement. Survival to hospital discharge and during the entire study period were lower in the ECMO-LVAD group (66.7% v 92.2%; p = 0.0027, and 37.5% v 62.5%; p = 0.035, respectively). Overall HR of death was 2.46 (95% confidence interval [CI]: 1.13-5.37; p = 0.005) in the ECMO-LVAD group and remained elevated throughout their time on LVAD support (HR 3.24 [95% CI: 1.15-9.14]; p = 0.0036). However, in patients who underwent HT (n = 50), mortality was similar between groups (HR 1.33 [95% CI: 0.33-5.31]; p = 0.66). Postoperative complications were more frequent in the ECMO-LVAD group (infection = 83.3% v 51.6%, p = 0.007; renal replacement therapy = 45.8% v 9.4%, p = 0.0001; post-LVAD ECMO = 25.0% v 1.6%; p = 0.0003). CONCLUSIONS VA ECMO as a bridge to LVAD support before HT was associated with increased morbidity and mortality during LVAD support. However, in patients who underwent HT, outcomes were similar regardless of VA ECMO bridging.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Federica Valente
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Julien Mortier
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Edgard Engelman
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium; EW Data Analysis, Brussels, Belgium
| | - Ana Roussoulières
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Bachar El Oumeiri
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martine Antoine
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédéric Vanden Eynden
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Constantin Stefanidis
- Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Kolodziej AR, Vaidya GN, Reddy N, Birks EJ. Mechanical circulatory support in pre and postheart transplant period. Curr Opin Organ Transplant 2021; 26:273-281. [PMID: 33938463 DOI: 10.1097/mot.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Progression of heart failure (HF) and its unpredictable and volatile nature, often requires advanced therapies including heart transplant. Mechanical circulatory support plays an integral part in the advanced treatment options. This technology can be deployed in several ways, particularly in the preparation and patient optimization for heart transplants. This article discusses the use of temporary and durable devices and their deployment strategies in the pre and posttransplant period. RECENT FINDINGS Recently temporary mechanical support devices have allowed us to improve survival to transplant as well as posttransplant. Early implementation of temporary devices both for stabilization of advanced HF patients being considered for transplant as well as those with posttransplant primary graft dysfunction (although utilization of extracorporeal membrane oxygenation has repeatedly shown to be associated with worse outcomes compared to the other devices discussed), is reflective of the degree of disease progression in these patients. The outcomes of patients supported with durable devices have significantly improved with advancing technology. HeartMate 3 device has not only been shown to improve survival as well as the quality of life but in comparison to its predecessor, has been shown to decrease the morbidity associated with this technology. SUMMARY Both temporary and durable devices are now associated with improved survival and allow us to transplant patients in a more stable and safer manner with fewer adverse events. Based on the new United Network of Organ Sharing allocation system, it allows us to upgrade those who do not have the luxury of time to wait for a transplant. Primary graft dysfunction now also can be assisted with those devices, which is reflected in improved survival of posttransplant patients.
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45
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Nordan T, Critsinelis AC, Mahrokhian SH, Kapur NK, Thayer KL, Chen FY, Couper GS, Kawabori M. Bridging With Extracorporeal Membrane Oxygenation Under the New Heart Allocation System: A United Network for Organ Sharing Database Analysis. Circ Heart Fail 2021; 14:e007966. [PMID: 33951934 DOI: 10.1161/circheartfailure.120.007966] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of the new donor heart allocation system on survival following bridging to transplantation with venous-arterial extracorporeal membrane oxygenation remains unknown. The new allocation system places extracorporeal membrane oxygenation-supported candidates at the highest status. METHODS The United Network for Organ Sharing database was queried for adults bridged to single-organ heart transplantation with extracorporeal membrane oxygenation from October 2006 to February 2020. Association between implementation of the new system and recipient survival was analyzed using Kaplan-Meier estimates, Cox proportional hazards models, and propensity score matching. RESULTS Of 364 recipients included, 173 and 191 were transplanted under new and old systems, respectively. Compared with the old system, waitlist time was halved under the new system (5 versus 10 days, P<0.01); recipients also demonstrated lower rates of prior cardiac surgery (32.9% versus 44.5%, P=0.03) and preoperative ventilation (30.6% versus 42.4%, P=0.02). Unadjusted 180-day survival was 90.2% (95% CI, 84.7%-94.2%) and 69.6% (95% CI, 62.6%-76.1%) under the new and old systems, respectively. Cox proportional hazards analysis demonstrated listing and transplantation under the new system to be an independent predictor of post-transplant survival (adjusted hazard ratio, 0.34 [95% CI 0.20-0.59]). Propensity score matching demonstrated a similar trend (hazard ratio, 0.36 [95% CI, 0.19-0.66]). Candidates listed under the new system were significantly less likely to experience waitlist mortality or deterioration (subhazard ratio, 0.38 [95% CI, 0.25-0.58]) and more likely to survive to transplant (subhazard ratio, 4.29 [95% CI, 3.32-5.54]). CONCLUSIONS Recipients transplanted following extracorporeal membrane oxygenation bridging to transplantation under the new system achieve greater 180-day survival compared with the old and demonstrate less preoperative comorbidity. Waitlist outcomes have also improved significantly under the new allocation system.
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Affiliation(s)
- Taylor Nordan
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | | | - Shant H Mahrokhian
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Navin K Kapur
- Department of Cardiology (N.K.K., K.L.T.), Tufts Medical Center, Boston, MA
| | - Katherine L Thayer
- Department of Cardiology (N.K.K., K.L.T.), Tufts Medical Center, Boston, MA
| | - Frederick Y Chen
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Gregory S Couper
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Masashi Kawabori
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
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46
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Hernandez-Montfort J, Sinha SS, Thayer KL, Whitehead EH, Pahuja M, Garan AR, Mahr C, Haywood JL, Harwani NM, Schaeffer A, Wencker D, Kanwar M, Vorovich E, Abraham J, Burkhoff D, Kapur NK. Clinical Outcomes Associated With Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock. Circ Heart Fail 2021; 14:e007924. [PMID: 33905259 DOI: 10.1161/circheartfailure.120.007924] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. METHODS Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. RESULTS Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (P<0.01 for all). Biventricular and isolated left ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in patients with HF-CS experiencing in-hospital death. Intraaortic balloon pump was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving >1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA=<0.001). CONCLUSIONS Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.
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Affiliation(s)
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | - Katherine L Thayer
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | | | - Mohit Pahuja
- Medstar Georgetown University Hospital, Washington, D.C. (M.P.)
| | | | - Claudius Mahr
- University of Washington Medical Center, Seattle (C.M.)
| | - Jillian L Haywood
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | | | - Detlef Wencker
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, TX (D.W.)
| | | | | | | | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
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47
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Impact of the Coronavirus Disease 2019 Pandemic on Utilization of Mechanical Circulatory Support As Bridge to Heart Transplantation. ASAIO J 2021; 67:382-384. [PMID: 33417334 DOI: 10.1097/mat.0000000000001387] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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48
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Mullan CW, Chouairi F, Sen S, Mori M, Clark KAA, Reinhardt SW, Miller PE, Fuery MA, Jacoby D, Maulion C, Anwer M, Geirsson A, Mulligan D, Formica R, Rogers JG, Desai NR, Ahmad T. Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy. JACC-HEART FAILURE 2021; 9:420-429. [PMID: 33714748 DOI: 10.1016/j.jchf.2021.01.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system. BACKGROUND Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated. METHODS This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change. RESULTS A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p < 0.001). The proportion of patients with LVAD at time of transplant decreased from 47% to 14%. Before the change, the majority were Status 1A (75.8%) at transplantation; afterward, most were Status 2/3 (67.8%). Transplantation rates were not different (85.4% vs. 83.6%; p = 0.225), but waitlist time decreased in the post period (82 vs. 65 days; p = 0.004). Donors were more likely to be high risk (39.0% vs. 32.2%; p = 0.005), and both ischemic times and distance traveled increased (3.4 h vs. 3.1 h; p < 0.001; 199 miles vs. 82 miles; p < 0.001). Waitlist survival did not change, but post-transplantation survival was worse in patients with BTT post-change (p < 0.001). CONCLUSIONS The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation.
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Affiliation(s)
- Clancy W Mullan
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Fouad Chouairi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine A A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Fuery
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Mulligan
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard Formica
- Division of Transplantation, Yale School of Medicine, New Haven, Connecticut, USA; Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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49
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Finnan MJ, Bakir NH, Itoh A, Kotkar KD, Pasque MK, Damiano RJ, Moon MR, Ewald GA, Schilling JD, Masood MF. 30 Years of Heart Transplant: Outcomes after Mechanical Circulatory Support from a Single Center. Ann Thorac Surg 2021; 113:41-48. [PMID: 33675715 DOI: 10.1016/j.athoracsur.2021.01.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/31/2020] [Accepted: 01/19/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Survival after bridge to transplant with mechanical circulatory support (MCS) has yielded varying outcomes based on device type and baseline characteristics Continuous flow left ventricular assist devices (CF-LVADs) have significantly improved waitlist mortality, but recent changes to the transplant listing criteria have dramatically altered the use of MCS for bridge to transplant. METHODS Orthotopic heart transplants from 1988-2019 at our institution were retrospectively reviewed and stratified by pre-transplant MCS status into CF-LVAD (n=224), Pulsatile LVAD (n=49), temporary MCS (n=71), and primary transplant (n=463) groups. Patients transplanted after the approval of CF-LVAD for bridge to transplant and before the 2018 allocation policy changes underwent subgroup analysis to evaluate predictors of survival and complications in a contemporary cohort. RESULTS Rates of primary transplant declined from 88% to 14% over the course of the study. No significant difference in survival was detected in the cohort stratified by MCS status (P=0.18). In the modern era, survival for CF-LVAD and temporary MCS patients was non-inferior to primary transplant (P=0.22). Notable predictors of long-term mortality included lower body mass index, peripheral vascular disease, prior coronary artery bypass graft, ABO non-identical transplant, and increased donor age (all P<0.02). There were no differences in major postoperative complications. CONCLUSIONS CF-LVAD has grown to account for the majority of transplants at our center in the last decade with no adverse effect on survival or postoperative complications. Temporary MCS has increased following the 2018 listing criteria change with acceptable early outcomes.
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Affiliation(s)
- Michael J Finnan
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Nadia H Bakir
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Akinobu Itoh
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Kunal D Kotkar
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Michael K Pasque
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ralph J Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Marc R Moon
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Gregory A Ewald
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Joel D Schilling
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri; Department of Pathology and Immunology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Muhammad F Masood
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri.
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50
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Loyaga-Rendon RY, Fermin D, Jani M, Gonzalez M, Grayburn R, Lee S, Dickinson MG, Manandhar-Shrestha NK, Boeve T, Jovinge S, Leacche M. Changes in heart transplant waitlist and posttransplant outcomes in patients with restrictive and hypertrophic cardiomyopathy with the new heart transplant allocation system. Am J Transplant 2021; 21:1255-1262. [PMID: 32978873 DOI: 10.1111/ajt.16325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
Historically, patients with restrictive (RCM) and hypertrophic cardiomyopathy (HCM) experienced longer wait-times for heart transplant (HT) and increased waitlist mortality. Recently, a new HT allocation system was implemented in the United States. We sought to determine the impact of the new HT system on RCM/HCM patients. Adult patients with RCM/HCM listed for HT between November 2015 and September 2019 were identified from the UNOS database. Patients were stratified into two groups: old system and new system. We identified 872 patients who met inclusion criteria. Of these, 608 and 264 were classified in the old and new system groups, respectively. The time in the waitlist was shorter (25 vs. 54 days, P < .001), with an increased frequency of HT in the new system (74% vs. 68%, P = .024). Patients who were transplanted in the new system had a longer ischemic time, increased use of temporary mechanical circulatory support and mechanical ventilation. There was no difference in posttransplant survival at 9 months (91.1% vs. 88.9%) (p = .4). We conclude that patients with RCM/HCM have benefited from the new HT allocation system, with increased access to HT without affecting short-term posttransplant survival.
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Affiliation(s)
- Renzo Y Loyaga-Rendon
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - David Fermin
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Milena Jani
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Matthew Gonzalez
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Ryan Grayburn
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Sangjin Lee
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Michael G Dickinson
- Advanced Heart Failure Section, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | | | - Theodore Boeve
- Division of Cardio Thoracic Surgery, Spectrum Health, Grand Rapids, Michigan
| | - Stefan Jovinge
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, Michigan.,DeVos Cardiovascular Research Program, Van Andel Institute/Spectrum Health, Grand Rapids, Michigan.,Cardiovascular Institute, Stanford University, Palo Alto, California
| | - Marzia Leacche
- Division of Cardio Thoracic Surgery, Spectrum Health, Grand Rapids, Michigan
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