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Silvestry S, Leacche M, Meyer DM, Shudo Y, Kawabori M, Mahesh B, Zuckermann A, D’Alessandro D, Schroder J. Outcomes in Heart Transplant Recipients by Bridge to Transplant Strategy When Using the SherpaPak Cardiac Transport System. ASAIO J 2024; 70:388-395. [PMID: 38300893 PMCID: PMC11057488 DOI: 10.1097/mat.0000000000002137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
The last several years have seen a rise in use of mechanical circulatory support (MCS) to bridge heart transplant recipients. A controlled hypothermic organ preservation system, the SherpaPak Cardiac Transport System (SCTS), was introduced in 2018 and has grown in utilization with reports of improved posttransplant outcomes. The Global Utilization And Registry Database for Improved heArt preservatioN (GUARDIAN)-Heart registry is an international, multicenter registry assessing outcomes after transplant using the SCTS. This analysis examines outcomes in recipients bridged with various MCS devices in the GUARDIAN-Heart Registry. A total of 422 recipients with donor hearts transported using SCTS were included and identified. Durable ventricular assist devices (VADs) were used exclusively in 179 recipients, temporary VADs or intra-aortic balloon pump (IABP) in 197, and extracorporeal membrane oxygenation (ECMO) in 14 recipients. Average ischemic times were over 3.5 hours in all cohorts. Severe primary graft dysfunction (PGD) posttransplant increased across groups (4.5% VAD, 5.1% temporary support, 21.4% ECMO), whereas intensive care unit (ICU) length of stay (18.2 days) and total hospital stay (39.4 days) was longer in the ECMO cohort than the VAD and IABP groups. A comparison of outcomes of MCS bridging in SCTS versus traditional ice revealed significantly lower rates of both moderate/severe right ventricular (RV) dysfunction and severe PGD in the SCTS cohort; however, upon propensity matching only the reductions in moderate/severe RV dysfunction were statistically significant. Use of SCTS in transplant recipients with various bridging strategies results in excellent outcomes.
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Affiliation(s)
- Scott Silvestry
- From the Department of Cardiothoracic Surgery, AdventHealth Transplant Institute, Orlando, Florida
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Corewell Health (Formerly Spectrum Health), Grand Rapids, Michigan
| | - Dan M. Meyer
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Masashi Kawabori
- Cardiovascular Center, Department of Surgery, Tufts Medical Center, Boston Massachusetts
| | - Balakrishnan Mahesh
- Division of Cardiac Surgery, Heart & Vascular Institute, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Andreas Zuckermann
- Department for Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - David D’Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jacob Schroder
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
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Bakhtiyar SS, Sakowitz S, Ali K, Verma A, Cho NY, Chervu NL, Benharash P. Expanding the heart donor pool: Can left ventricular assist devices substitute for marginal donor heart allografts? Surgery 2023; 173:1329-1334. [PMID: 36959074 DOI: 10.1016/j.surg.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/03/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Generally, heart transplantation with marginal donor allografts is reserved for a subset of high-risk patients. However, given the improved survival rates for patients on left ventricular assist devices, it is worth analyzing if they could potentially substitute for marginal donor allografts. This study aimed to compare survival outcomes of waitlisted patients with left ventricular assist devices who did not undergo heart transplantation to those who underwent heart transplantation with marginal allografts. METHODS This was a retrospective cohort study of adults (≥18 years) listed for heart transplantation between 2010 and 2022 in the Organ Procurement and Transplantation Network database. A previously validated risk score was used to define marginal donor organs. The primary outcome was death after transplantation or on the waitlist, as appropriate. RESULTS Of 5,713 patients with left ventricular assist devices, 4,683 (82%) comprised the left ventricular assist devices group and 1,030 (18%) the marginal group. The marginal cohort was older (57 [49-64] vs 55 [45-62] years, P < .001), similarly female (26 vs 24%, P = .16), and less often White (51 vs 60%, P < .001). Relative to the left ventricular assist devices group, the marginal group demonstrated higher 5-year survival from 2010 to 2014 (81 vs 43%, P < .001) and from 2015 to 2019 (77 vs 66%, P < .001). After adjustment, marginal patients demonstrated a significantly reduced hazard of 5-year mortality for those listed from 2010 to 2014 (hazard ratio 0.25, confidence interval 0.20-0.31; P < .001) and from 2015 to 2019 (hazard ratio 0.46, confidence interval 0.37-0.57; P < .001). CONCLUSION Our study validates the superiority of transplantation relative to left ventricular assist devices but also underscores the survival benefit of heart transplantation with marginal donor allografts, even in high-risk patients.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA. https://twitter.com/SaraSakowitz
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA. https://twitter.com/arjun_ver
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California-Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, University of California-Los Angeles, CA. https://twitter.com/CoreLabUCLA
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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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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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Goldberg RL, Freed KE, Klemans N, Fioretti R, Choi CW, Kilic A, Adamo L, Florido R, Sharma K, Gilotra NA, Hsu S. Angiotensin Receptor-Neprilysin Inhibition Improves Blood Pressure and Heart Failure Control in Left Ventricular Assist Device Patients. ASAIO J 2021; 67:e207-e210. [PMID: 33883502 PMCID: PMC10905643 DOI: 10.1097/mat.0000000000001435] [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] [Indexed: 10/21/2022] Open
Abstract
Angiotensin receptor-neprilysin inhibitors (ARNIs) greatly benefit functional capacity and longevity in heart failure with reduced ejection fraction (HFrEF). Angiotensin receptor-neprilysin inhibitors remain underutilized and unstudied, however, in left ventricular assist device (LVAD) recipients, in spite of their underlying HFrEF. In this case series, we studied the feasibility and short-term efficacy of ARNI utilization in 21 LVAD patients. Angiotensin receptor-neprilysin inhibitor initiation was successful in most, resulting in significant consolidation of blood pressure (BP) medical management and marked improvements in both functional capacity and diuretic requirements. Angiotensin receptor-neprilysin inhibitors are safe, feasible, and within a short timeframe benefit BP and heart failure control in LVAD recipients.
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Affiliation(s)
- Rachel L. Goldberg
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin E. Freed
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nancy Klemans
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Fioretti
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun W. Choi
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luigi Adamo
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roberta Florido
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A. Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Wieselthaler GM, Klein L, Cheung AW, Danter MR, Strueber M, Mahr C, Mokadam NA, Maltais S, McGee EC. Two-Year Follow Up of the LATERAL Clinical Trial: A Focus on Adverse Events. Circ Heart Fail 2021; 14:e006912. [PMID: 33866829 PMCID: PMC8059760 DOI: 10.1161/circheartfailure.120.006912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The LATERAL trial validated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare HVAD System, leading to Food and Drug Administration approval. We sought to analyze 24-month adverse event (AE) rates, including a temporal analysis of the risk profile, associated with the thoracotomy approach for the HVAD system. METHODS AEs from the LATERAL trial were evaluated over 2 years postimplant. Data was obtained from the Interagency Registry for Mechanically Assisted Circulatory Support database for 144 enrolled United States and Canadian patients. Temporal AE profiles were expressed as events per patient year. RESULTS During 162.5 patient years of support, there were 25 driveline infections (0.15 events per patient year), 50 gastrointestinal bleeds (0.31 events per patient year), and 21 strokes (0.13 events per patient year). Longitudinal AE analysis at follow-up intervals of <30 and 30 to 180 days, and 6 to 12 and 12 to 24 months revealed the highest AE rate at <30 days, with a decrease in total AEs within the first 6 months. After 6 months, most AE rates either stabilized or decreased through 2 years, including a 95% overall freedom from disabling stroke. CONCLUSIONS Two-year follow-up of the LATERAL trial revealed a favorable morbidity profile in patients supported with the HVAD system, as AE rates were more likely to occur in the first 30 days postimplant, and overall AE rates were significantly reduced after 6 months. Importantly, 2-year freedom from disabling stroke was 95%. These data further support the improving AE profile of patients on long-term HVAD support. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02268942.
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Affiliation(s)
- Georg M Wieselthaler
- Division of Cardiothoracic Surgery (G.M.W.), University of California San Francisco Medical Center, CA
| | - Liviu Klein
- Department of Medicine (L.K.), University of California San Francisco Medical Center, CA
| | - Anson W Cheung
- Department of Surgery, St. Paul's Hospital, Vancouver, British Columbia (A.W.C.)
| | - Matthew R Danter
- Department of Cardiac Surgery, University of Kansas Medical Center (M.R.D.)
| | - Martin Strueber
- Department of Cardiovascular and Thoracic Surgery, Baptist Heart Institute, Memphis, TN (M.S.)
| | - Claudius Mahr
- Division of Cardiology, University of Washington Medical Center, Seattle (C.M.)
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Ohio State University Wexner Medical Center, Columbus (N.A.M.)
| | - Simon Maltais
- Cardiac Surgery, Los Robles Regional Medical Center, Thousand Oaks, CA (S.M.)
| | - Edwin C McGee
- Department of Thoracic and CV Surgery, Loyola University Medical Center, Maywood, IL (E.C.M.)
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Nezami FR, Khodaee F, Edelman ER, Keller SP. A Computational Fluid Dynamics Study of the Extracorporeal Membrane Oxygenation-Failing Heart Circulation. ASAIO J 2021; 67:276-283. [PMID: 33627601 PMCID: PMC8130419 DOI: 10.1097/mat.0000000000001221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly deployed to provide percutaneous mechanical circulatory support despite incomplete understanding of its complex interactions with the failing heart and its effects on hemodynamics and perfusion. Using an idealized geometry of the aorta and its major branches and a peripherally inserted return cannula terminating in the iliac artery, computational fluid dynamic simulations were performed to (1) quantify perfusion as function of relative ECMO flow and (2) describe the watershed region produced by the collision of antegrade flow from the heart and retrograde ECMO flow. To simulate varying degrees of cardiac failure, ECMO flow as a fraction of systemic perfusion was evaluated at 100%, 90%, 75%, and 50% of total flow with the remainder supplied by the heart calculated from a patient-derived flow waveform. Dynamic boundary conditions were generated with a three-element lumped parameter model to accurately simulate distal perfusion. In profound failure (ECMO providing 90% or more of flow), the watershed region was positioned in the aortic arch with minimal pulsatility observed in the flow to the visceral organs. Modest increases in cardiac flow advanced the watershed region into the thoracic aorta with arch perfusion entirely supplied by the heart.
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Affiliation(s)
- Farhad Rikhtegar Nezami
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Farhan Khodaee
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Elazer R Edelman
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Cardiovascular Medicine), Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven P Keller
- From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Medicine (Pulmonary and Critical Care Medicine), Brigham and Women's Hospital, Boston, Massachusetts
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Reul RM, Zhang TS, Rana AA, Rosengart TK, Goss JA. Consistent improvements in short- and long-term survival following heart transplantation over the past three decades. Clin Transplant 2021; 35:e14241. [PMID: 33524177 DOI: 10.1111/ctr.14241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/11/2021] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite noted improvements in short-term survival outcomes following orthotopic heart transplantation (OHT), review of the relevant literature suggests little improvement in long-term outcomes for patients surviving beyond 1 year. METHODS All OHT cases performed between 1989 and 2019 within the United Network for Organ Sharing (UNOS) database were reviewed. Adults who underwent isolated OHT were included in a 1-year survival analysis. Those who survived at least 1 year post-transplant were included in a long-term survival analysis. Demographic factors were assessed using Students' t test and chi-square analysis. Survival trends and risk factors were assessed using the Kaplan-Meier and the Cox regression analysis, respectively. RESULTS A total of 53 265 and 46 372 recipients were included in the short-term and long-term cohorts, respectively. In an adjusted analysis, the reference implant era 2014-2019 had significantly better short-term survival outcomes when compared with earlier implant eras: 1989-1993 (HR: 2.92), 1994-1998 (HR: 1.53), 1999-2003 (HR: 1.27), 2004-2008 (HR: 1.11), and 2009-2013 (HR: 1.02). The same trend was recognized for long-term outcomes: 1989-1993 (HR: 1.87), 1994-1998 (HR: 1.27), 1999-2003 (HR: 1.09), and 2004-2008 (HR: 1.03). CONCLUSIONS Despite increases in multiple traditional risk factors, both short-term and long-term survival outcomes have consistently improved over the past 30 years, suggesting other factors are contributing to improved outcomes in recent eras.
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Affiliation(s)
- Ross M Reul
- Baylor College of Medicine, Houston, TX, USA
| | | | - Abbas A Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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10
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Impact of New UNOS Allocation Criteria on Heart Transplant Practices and Outcomes. Transplant Direct 2020; 7:e642. [PMID: 33335981 PMCID: PMC7738116 DOI: 10.1097/txd.0000000000001088] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/27/2020] [Indexed: 01/01/2023] Open
Abstract
Background In October 2018, a new heart allocation policy was implemented with intent of prioritizing the sickest patients and decreasing waitlist time. We examined the effects of the new policy on transplant practices and outcomes 1 year before and 1 year after the change. Methods Transplant recipients from October 2017 to September 2019 at our institution were identified and divided into 2 cohorts, a preallocation and postallocation criteria change. Patient demographics, clinical data, and bridging strategy were assessed. Early outcomes including ischemic time, severe primary graft dysfunction, need for renal replacement therapy, and duration of hospital stay were investigated. Results In the 12 months before the change, 38 patients were transplanted as compared to 33 patients in the 12 months after the change. The average wait-time to transplant decreased after the allocation change (49 versus 313 d, P = 0.02). Patients were more likely to be bridged with an intra-aortic balloon pump (45% versus 3%) and less likely to be supported with a durable left ventricular assist device (LVAD) after the change (24% versus 82%). There was an increase in total ischemic time after the change (177 versus 117 min, P ≤ 0.01). There were no significant differences in other early posttransplant outcomes. Conclusions Implementation of the new allocation system for heart transplantation resulted in dramatic changes in the bridging strategy utilized at our institution. Temporary mechanical support usage increased following the change and the number of recipients supported with durable LVADs decreased. Early posttransplant outcomes appear similar.
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices. J Heart Lung Transplant 2020; 38:677-698. [PMID: 31272557 DOI: 10.1016/j.healun.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 01/21/2023] Open
Abstract
Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.
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Affiliation(s)
- Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Ersilia M DeFilippis
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Monica Colvin
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chad E Darling
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Tonya Elliott
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Eman Hamad
- Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian C Hiestand
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | | | - Keyur B Shah
- VCU Pauley Heart Center, Richmond, Virginia, USA
| | - Juliane Vierecke
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Whitbread JJ, Giuliano KA, Etchill EW, Suarez-Pierre AI, Lawton JS, Hsu S, Sharma K, Choi CW, Higgins RSD, Kilic A. An Analysis of Waitlist Inactivity Among Patients With Ventricular Assist Devices. J Surg Res 2020; 260:383-390. [PMID: 33261857 DOI: 10.1016/j.jss.2020.11.010] [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: 07/08/2020] [Revised: 09/08/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ventricular assist devices (VADs) are commonly used mechanical circulatory support for bridge to transplant therapy in end-stage heart failure; however, it is not understood how VADs influence incidence of waitlist inactive status. We sought to characterize and compare waitlist inactivity among patients with and without VADs. METHODS Using the Organ Procurement and Transplantation Network database, we investigated the VAD's impact on incidence and length of inactive periods for heart transplant candidates from 2005 through 2018. We compared median length of inactivity between patients with and without VADs and investigated inactivity risk with time-to-event regression models. RESULTS Among 46,441 heart transplant candidates, 32% (n = 14,636) had a VAD. Thirty-eight percent (n = 17,873) of all patients experienced inactivity, of which 42% (7538/17,873) had a VAD. Median inactivity length was 31 d for patients without VADs and 62 d for VAD patients (P < 0.0005). Multivariable analysis showed no significant difference in risk of inactivity for deteriorating conditions between patients with and without VADs after controlling for demographic and baseline clinical variables. A larger proportion of patients without VADs were inactive for deteriorating conditions than VAD patients (54%, n = 8242/15,221 versus 32%, n = 3583/11,086, P < 0.001). Ten percent (1155/11,086) of VAD patients' inactive periods were for VAD-related complications. CONCLUSIONS Although VAD patients were inactive longer and had an overall increased risk of any-cause inactivity, their risk of inactivity for deteriorating condition was not significantly different from patients without VADs. Furthermore, VAD patients had a smaller proportion of inactivity periods due to deteriorating conditions. Thus, VADs are protective from morbidity for waitlist patients.
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Affiliation(s)
| | - Katherine A Giuliano
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland
| | - Eric W Etchill
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Chun W Choi
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland
| | - Robert S D Higgins
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Johns Hopkins Hospital, Cardiac Surgery, Baltimore, Maryland.
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Hanff TC, Harhay MO, Kimmel SE, Molina M, Mazurek JA, Goldberg LR, Birati EY. Trends in Mechanical Support Use as a Bridge to Adult Heart Transplant Under New Allocation Rules. JAMA Cardiol 2020; 5:728-729. [PMID: 32293645 PMCID: PMC7160744 DOI: 10.1001/jamacardio.2020.0667] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/30/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas C. Hanff
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Michael O. Harhay
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Stephen E. Kimmel
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Maria Molina
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Jeremy A. Mazurek
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Lee R. Goldberg
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Edo Y. Birati
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
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Merlo A, Bhatia M. Pro: The New Heart Allocation System Is a Positive Change in the Listing of Patients Awaiting Transplant. J Cardiothorac Vasc Anesth 2020; 34:1962-1967. [PMID: 32253089 DOI: 10.1053/j.jvca.2020.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/23/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Aurelie Merlo
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC.
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15
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Nayak A, Dong T, Ko YA, Chesnut N, Pekarek A, Cole RT, Bhatt K, Gupta D, Burke MA, Laskar SR, Attia T, Smith AL, Vega JD, Morris AA. Validating patient prioritization in the 2018 Revised United Network for Organ Sharing Heart Allocation System: A single-center experience. Clin Transplant 2020; 34:e13816. [PMID: 32031719 PMCID: PMC7117873 DOI: 10.1111/ctr.13816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
The 2018 Revised United Network for Organ Sharing Heart Allocation System (HAS) was proposed to reclassify status 1A candidates into groups of decreasing acuity; however, it does not take into account factors such as body mass index (BMI) and blood group which influence waitlist (WL) outcomes. We sought to validate patient prioritization in the new HAS at our center. We retrospectively evaluated patients listed for heart transplantation (n = 214) at Emory University Hospital from 2011 to 2017. Patients were reclassified into the 6-tier HAS. Multistate modeling and competing risk analysis were used to compare outcomes of transplantation and WL death/deterioration between new tiers. Additionally, a stratified sensitivity analysis by BMI and blood group was performed. Compared with tier 4 patients, there was progressively increasing hazard of WL death/deterioration in tier 3 (HR: 2.52, 95% CI: 1.37-4.63, P = .003) and tier 2 (HR: 5.03, 95% CI: 1.99-12.70, P < .001), without a difference in transplantation outcome. When stratified by BMI and blood group, this hierarchical association was not valid in patients with BMI ≥30 kg/m2 and non-O blood groups in our cohort. Therefore, the 2018 HAS accurately prioritizes the sickest patients in our cohort. Factors such as BMI and blood group influence this relationship and iterate that the system can be further refined.
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Affiliation(s)
- Aditi Nayak
- Emory University School of Medicine, Atlanta, GA
| | - Tiffany Dong
- Emory University School of Medicine, Atlanta, GA
| | - Yi-An Ko
- Emory Rollins School of Public Health, Atlanta, GA
| | | | - Ann Pekarek
- Emory University School of Medicine, Atlanta, GA
| | | | - Kunal Bhatt
- Emory University School of Medicine, Atlanta, GA
| | - Divya Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Tamer Attia
- Emory University School of Medicine, Atlanta, GA
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16
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Seese L, Hickey G, Keebler ME, Mathier MA, Sultan I, Gleason TG, Toma C, Kilic A. Direct bridging to cardiac transplantation with the surgically implanted Impella 5.0 device. Clin Transplant 2020; 34:e13818. [DOI: 10.1111/ctr.13818] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 02/04/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Gavin Hickey
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Division of Cardiology University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Mary E. Keebler
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Division of Cardiology University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Michael A. Mathier
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Division of Cardiology University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Division of Cardiology University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh Pennsylvania
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17
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Seese L, Hickey G, Keebler ME, Mathier MA, Sultan I, Gleason TG, Wang Y, Kilic A. Temporary left ventricular assist devices as a bridge to heart transplantation. J Card Surg 2020; 35:810-817. [PMID: 32092194 DOI: 10.1111/jocs.14466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND To create equitable access to donor organs for the highest mortality patients, the cardiac transplant allocation system now prioritizes patients with surgically implanted temporary left ventricular assist devices (T-LVADs). The outcomes following a direct bridge from a T-LVAD to orthotopic heart transplant (OHT) are not well delineated. AIM This study investigates the T-LVAD waitlist outcomes and compares the posttransplant outcomes in patients bridged to OHT with surgically implanted T-LVADs to patients bridged with durable continuous-flow left ventricular assist devices (CF-LVADs). METHODS Adults recorded in the United Network for Organ Sharing registry bridged to OHT with a durable CF-LVAD and T-LVADs, with or without temporary right ventricular assist devices (T-RVADs), between 2010 and 2018 were included. Propensity matching and multivariable Cox regression were utilized to compare outcomes. RESULTS Of 504 patients waitlisted with T-LVADs, the majority were transplanted (50%), bridged to CF-LVAD (17%), or recovered (9%). A total of 9047 recipients were bridged to OHT during the study period with 8875 CF-LVADs and 172 T-LVADs. Early survival in propensity-matched T-LVAD ± T-RVAD patients was similar to CF-LVAD ± T-RVAD patients but reduced at a 1-year follow-up. This difference in survival at 1-year follow-up was attributable to significantly reduced survival in patients with combined T-LVAD + T-RVAD support when compared with CF-LVAD, isolated T-LVAD and combined CF-LVAD + T-RVAD support (80% vs 90% vs 90% vs 91%; P = .005). CONCLUSIONS This study demonstrates that most patients waitlisted with a T-LVAD are successfully bridged to durable therapy or recover, and those bridged to OHT have acceptable posttransplant outcomes, particularly when T-RVADs are not required.
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Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary E Keebler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael A Mathier
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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18
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Maeda K, Lee AM. Commentary: Arrhythmia surgery at the time of left ventricular assist device implant-use of caution. JTCVS Tech 2020; 1:60-61. [PMID: 34317715 PMCID: PMC8288721 DOI: 10.1016/j.xjtc.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Anson M Lee
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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19
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Iyengar A, Han J, Helmers M, Kelly JJ, Patrick W, Chung JJ, Goel N, Birati EY, Atluri P. Relationship Between Change in Heart Transplant Volume and Outcomes: A National Analysis. J Card Fail 2019; 26:515-521. [PMID: 31770633 DOI: 10.1016/j.cardfail.2019.11.023] [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: 06/29/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Although volume-outcome relationships in transplantation have been well-defined, the effects of large changes in center volume are less well understood. The purpose of the current study was to examine the impact of changes in center volume on outcomes after heart transplantation. METHODS Retrospective analysis was performed of adult patients undergoing heart transplant between 2000 and 2017 identified in the United Network for Organ Sharing database. Exclusions included annual volume <10. Patients were grouped according to percentage change in center volume from the previous year. Multivariable Cox regression models were adjusted for the significant preoperative variance identified on univariate analyses. RESULTS Of the 29,851 transplants during the study period, 64% were at centers with stable volume (±25% annual change), whereas 10% were performed at contracting (-25% change or more) and 26% were performed at growing (+25% change or more) centers. Average volume was lower with contracting centers compared with stable or growing programs (21 vs 36, P< .001). Thirty-day mortality was greater in decreasing centers (6% vs 4%, P < .001), with more acute rejection treatments at 1y (27% vs 24% P < .001). The adjusted risk of mortality among contracting centers was 1.25 ([1.07-1.46], P= .004), whereas growing centers had unaffected risk (0.90 [0.79-1.02], P= .103). Causes of death were similar between groups. CONCLUSIONS Rapid growth of transplant center volume has occurred at select centers in the United States without decrement in programmatic outcomes. Decreasing center volume has been associated with poorer outcomes, although the causative nature of this relationship requires further investigation.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer J Chung
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Goel
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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Gautier SV, Zacharevich VM, Khalilulin TA, Shevchenko AО, Poptsov VN, Ahmadzai RL, Goltz AM, Zakiryanov AR, Koloskova NN, Zacharevich NY, Nikitina EА, Pozdnyakov OA, Kiryakov KS. Heart transplantation as a radical method of restoring the quality of life in recipients with end-stage heart failure. ACTA ACUST UNITED AC 2019. [DOI: 10.15825/1995-1191-2019-2-7-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- S. V. Gautier
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation; I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovsky University)
| | - V. M. Zacharevich
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation; I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovsky University)
| | - T. A. Khalilulin
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation; I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovsky University)
| | - A. О. Shevchenko
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation; I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovsky University)
| | - V. N. Poptsov
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - R. L. Ahmadzai
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - A. M. Goltz
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - A. R. Zakiryanov
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - N. N. Koloskova
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - N. Y. Zacharevich
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - E. А. Nikitina
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - O. A. Pozdnyakov
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
| | - K. S. Kiryakov
- V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Ministry of Healthcare of the Russian Federation
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices. J Card Fail 2019; 25:494-515. [DOI: 10.1016/j.cardfail.2019.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
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Abstract
PURPOSE OF REVIEW Organ allocation is a highly complex process with significant impact on outcomes of donor organs and end-stage organ disease patients. Policies governing allocation must incorporate numerous factors to meet stated objective. There have been significant alterations and ongoing discussion about changes in allocation policy for all solid organs in the United States. As with any policy change, rigorous evaluation of the impact of changes is important. RECENT FINDINGS This manuscript discusses metrics to consider to evaluate the impact of organ allocation policy that may be monitored on an ongoing basis including examples of research evaluating current policies. Potential metrics to evaluate allocation policy include the effectiveness, efficiency, equity, costs, donor rates, and transparency associated with the system. SUMMARY Ultimately, policies will often need to adapt to secular changes in donor and patient characteristics, clinical and technological advances, and overarching healthcare polices. Providing objective empirical evaluation of the impact of policies is a critical component for assessing quality of the allocation system and informing the effect of changes. The foundation of organ transplantation is built upon public trust and the dependence on the gift of donor organs, as such the importance of the most appropriate organ allocation policies cannot be overstated.
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Responding to Ventricular Assist Device Recalls: An Ethical Guide for Mechanical Circulatory Support Programs. ASAIO J 2019; 66:363-366. [PMID: 31045923 DOI: 10.1097/mat.0000000000001005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We discuss the ethical responsibilities of mechanical circulatory support (MCS) programs in the context of cardiac device recalls, particularly the near-simultaneous recalls of Abbott HeartMate 3 left ventricular assist device (VAD) and Medtronic HVAD devices in 2018. We consider MCS programs' ethical responsibilities toward patients who already have VADs and their caregivers, as well as the impact of recalls on informed consent and shared decision-making in patients under consideration for new VADs. Timely communication to affected patients is imperative throughout the recall process. MCS programs are required to notify existing VAD patients about the nature and likelihood of risk. A press release from the device manufacturer or other press reports may occur before MCS teams learn about the recall. This leads to a disclosure gap, where the programs are actively deciding on an appropriate action plan while simultaneously fielding patient concerns. From an ethics standpoint, if all device users are owed the recall information from the manufacturer, all patients are owed the information from their treating team. The question is what to disclose specifically, and how.
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Kreuziger LB, Massicotte MP. Adult and pediatric mechanical circulation: a guide for the hematologist. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:507-515. [PMID: 30504351 PMCID: PMC6245997 DOI: 10.1182/asheducation-2018.1.507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Mechanical circulatory support (MCS) is the overarching term that encompasses the temporary and durable devices used in patients with severe heart failure. MCS disturbs the hematologic and coagulation system, leading to platelet activation, activation of the contact pathway of coagulation, and acquired von Willebrand syndrome. Ischemic stroke and major hemorrhage occur in up to 30% of patients. Hematologists are an essential part of the MCS team because they understand the delicate balance between bleeding and clotting and alteration of hemostasis with antithrombotic therapy. However, prior to this important collaborative role, learning the terminology used in the field and types of MCS devices allows improved communication with the MCS team and best patient care. Understanding which antithromobotic therapies are used at baseline is also required to provide recommendations if hemorrhage or thrombosis occurs. Additional challenging consultations in MCS patients include the influence of thrombophilia on the risk for thrombosis and management of heparin-induced thrombocytopenia. This narrative review will provide a foundation to understand MCS devices how to prevent, diagnose, and manage MCS thrombosis for the practicing hematologist.
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Affiliation(s)
- Lisa Baumann Kreuziger
- Division of Hematology, Department of Medicine, BloodCenter of Wisconsin, Medical College of Wisconsin, Milwaukee, WI; and
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25
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Rao P, Smith R, Khalpey Z. Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. JACC-HEART FAILURE 2018; 6:887. [DOI: 10.1016/j.jchf.2018.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022]
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