Bridge to heart transplantation in patients with cardiogenic shock: a 20-year experience with two different surgical strategies

Prognostic Value of APACHE IV Score in Patients Bridged to Heart Transplantation on ECMO

BACKGROUND

Methods for risk stratification of candidates for heart transplantation (HTx) supported by extracorporeal membrane oxygenation (ECMO) are limited. We evaluated the reliability of the APACHE IV score to identify the risk of mortality in this patient subset in a multicenter study.

METHODS

Between January 2010 and December 2022, 167 consecutive ECMO patients were bridged to HTx; they were divided into two groups, according to a cutoff value of APACHE IV score, obtained by receiver operating characteristic curve analysis for 90-day mortality. Kaplan-Meier survival curves were plotted, and compared through the log-Rank test. Cox regression model was used to estimate which factors were associated with survival.

RESULTS

The 90-day mortality prediction of the APACHE IV score showed an area under the curve of 0.87 (95% CI: 0.80-0.94), with a cutoff value of 49 (specificity 91.7%-sensibility 69.6%). 125 patients (74.8%) showed an APACHE IV score value < 49 (Group A), and 42 (25.2%) ≥ 49 (Group B). 90-day mortality was 11.2% in Group A and 76.2% in Group B (p < 0.01). Survival at 1 and 5 years was 85.5%, 77% versus 23.4%, 23.4% (p < 0.01) in Groups A and B. Mortality correlated at univariable analysis with recipient age, body mass index, mechanical ventilation, APACHE IV score, and platelets number. At multivariable analysis only APACHE IV score (HR: 1.07 [1.05-1.09, 95% CI]) independently affected survival.

CONCLUSIONS

The APACHE IV score represents a powerful predictor of survival in patients bridged to HTx on ECMO support, and could guide candidacy of patients on ECMO.

Updates in heart failure: sodium glucose co-transporter 2 inhibitors and beyond – major changes are coming

Prevalence of heart failure is increasing worldwide mainly due to the ageing of the population and the improvement in diagnosis and treatment. In recent years, huge progress has been made in the management of heart failure patients. A new definition of chronic heart failure based on left ventricular ejection fraction and its possible trajectories has been reported. New drug classes have been introduced for the treatment of chronic heart failure. In particular, the prognostic benefit of sodium glucose co-transporter 2 inhibitors was demonstrated across all the heart failure phenotypes. Therapies for patients with advanced heart failure (long-term mechanical circulatory supports and heart transplantation) are now indicated also in the case of mild-to-moderate symptoms but with high risk of progression. In patients with acute heart failure, monitoring of urinary sodium and the use of acetazolamide may lead to better decongestion. Importantly, pre- and postdischarge assessment should lead to optimal treatment. Devices and telemonitoring can also be of help. Cardiovascular and noncardiovascular comorbidities are major determinants of the clinical course and need proper management. This review will summarize these important advances.

Outcomes With Left Ventricular Assist Device in End-Stage Renal Disease: A Systematic Review

Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from mechanical circulatory support (MCS). Unfortunately, renal function may result after left ventricular assist device (LVAD) implantation. The purpose of this study is to examine the outcomes of advanced heart failure patients with end-stage renal disease (ESRD) requiring mechanical circulatory support as a bridge to transplant (BTT) or destination therapy (DT). We searched Medline, Embase, and Cochrane in September 2021. The following keywords were used: left ventricular assist device or LVAD and end-stage renal disease or ESRD. Our study included case reports, case series, descriptive studies, and randomized control trials. Review articles, guidelines, systematic reviews, and meta-analyses were excluded. We also excluded pediatric cases. We identified 278 articles; 92 were duplicated, 186 articles entered the screening phase, and 133 articles were excluded by title and abstract. After the full-text screening, 40 articles were excluded. This systematic review included 13 articles. Among the contraindications to LVAD implantation, a general contraindication is for patients found to have stage 4 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR): <30 mL/minute/1.73 m²), while those on dialysis are an absolute contraindication LVAD implantation. Despite the limited data and publications on LVADs in patients with ESRD, LVAD implantation as a bridge to transplantation or destination therapy may be considered in selected patients without increasing morbidity and mortality. Therefore, shared decision-making around the treatment of advanced heart failure with these patients and the care team is essential.

Patient selection for heart transplant: balancing risk

PURPOSE OF REVIEW

Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation.

RECENT FINDINGS

Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply.

SUMMARY

The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.