OPTN/SRTR 2021 Annual Data Report: Heart.

The past 5 years have posed challenges to the field of heart transplantation. The 2018 heart allocation policy revision was accompanied by anticipated practice adjustments and increased use of short-term circulatory support, changes that may ultimately serve to advance the field. The COVID-19 pandemic also had an impact on heart transplantation. While the number of heart transplants in the United States continued to increase, the number of new candidates decreased slightly during the pandemic. There were slightly more deaths following removal from the waiting list for reasons other than transplant during 2020, and a decline in transplants among candidates listed as status 1, 2, or 3 compared with the other statuses. Heart transplant rates decreased among pediatric candidates, most notably among those younger than 1 year. Despite this, pretransplant mortality has declined for both pediatric and adult candidates, particularly candidates younger than 1 year. Transplant rates have increased in adults. The prevalence of ventricular assist device use has increased among pediatric heart transplant recipients, while the prevalence of short-term mechanical circulatory support, particularly intra-aortic balloon pump and extracorporeal membrane oxygenation, has increased among adult recipients.

Improving cardiovascular outcomes for patients with heart failure in sub-Saharan Africa: conference proceedings of the 2022 Nigerian Cardiovascular Symposium.

The Nigerian Cardiovascular Symposium is an annual conference held in partnership with cardiologists in Nigeria and the diaspora to provide updates in cardiovascular medicine and cardiothoracic surgery with the aim of optimising cardiovascular care for the Nigerian population. This virtual conference (due to the COVID-19 pandemic) has created an opportunity for effective capacity building of the Nigerian cardiology workforce. The objective of the conference was for experts to provide updates on current trends, clinical trials and innovations in heart failure, selected cardiomyopathies such as hypertrophic cardiomyopathy and cardiac amyloidosis, pulmonary hypertension, cardiogenic shock, left ventricular assist devices and heart transplantation. Furthermore, the conference aimed to equip the Nigerian cardiovascular workforce with skills and knowledge to optimise the delivery of effective cardiovascular care, with the hope of curbing 'medical tourism' and the current 'brain drain' in Nigeria. Challenges to optimal cardiovascular care in Nigeria include workforce shortage, limited capacity of intensive care units, and availability of medications. This partnership represents a key first step in addressing these challenges. Future action items include enhanced collaboration between cardiologists in Nigeria and the diaspora, advancing participation and enrollment of African patients in global heart failure clinical trials, and the urgent need to develop heart failure clinical practice guidelines for Nigerian patients.

Mortality And Morbidity Burden Of Covid-19 Infection In Left Ventricular Assist Device Patients

Introduction: COVID-19 pandemic has resulted in more than 6.1 million deaths and more than 480 million infections worldwide (1). Left ventricular assist device patients (LVAD) with their multiple co-morbidities are at high risk for morbidity and mortality from the COVID-19 infection. Few studies and case reports demonstrating the outcomes of COVID-19 infection in LVAD patients have been published, with the most recent study in 2021 (2-4). However, none of these studies spanned the entire stretch of the pandemic. Hypothesis: : COVID-19 infection would result in significant mortality and multi-system complications among patients with an LVAD. Method(s): IRB approval was obtained for our retrospective cohort study. 225 LVAD patients across two large centers in Texas, USA were screened for COVID-19 infection from December 1, 2019 to February 28, 2022. 68 events of COVID-19 infection were identified among 64 patients. One patient was excluded due to false positive test and 3 patients were infected twice and counted as separate events. Outcomes including mortality, respiratory failure, bleeding, and thromboembolic complications were assessed. Result(s): Baseline characteristics and results are summarized in Table 1. 51% of the patients needed hospitalization or emergency department visit for COVID infection. Five patients were intubated (7.4%). 6 patients developed chronic hypoxic respiratory failure requiring outpatient supplemental oxygen. 4 patients suffered from ventricular tachycardias while three other patients had Implantable cardioverter Defibrillator (ICD) shocks during COVID infection. 9 patients had epistaxis or gastrointestinal bleeding within 1 month of testing COVID positive. One HM2 patient had confirmed LVAD outflow cannula thrombus on CT heart and another patient with HeartWare had confirmed inflow cannula thrombus requiring emergent exchange to HM3 due to pump stoppage. Three patients suffered a stroke (5%). No events of pulmonary emboli or DVTs were noted. The mortality rate among this cohort was 14% (9 out of 64 patients). Four patients died during the same hospitalization. 33% had HM2 and 67% had HM3 LVADs, making a mortality rate of 37% (3 out of 8) for HM2 patients and 9% for HM3 (6 out of 55). 88% were males, 56% were African Americans, 67% had NICM, and 78% had at least moderate RV dysfunction at baseline. Conclusion(s): COVID-19 infection resulted in significant mortality and complications including stroke, pump thrombus, arrhythmias, respiratory failure, and bleeding events among LVAD patients.Copyright © 2022

Comparison of COVID-19 clinical course between LVAD recipients implanted before and during COVID-19 pandemic

Background: Left ventricular assist devices (LVAD) recipients are particularly vulnerable to cardiac- and non-cardiac related complications. COVID- 19 pandemic disorganized virtually all aspects of life, affecting the health care systems and impeded its availability. Yet, patients with advanced heart failure (HF) implanted with LVADs had to cope with restricted access to specialized HF centers and as well as COVID-19 infection. The course of COVID-19 in LVAD population is largely unknown. Aim(s): We sought to verify whether there are any differences in COVID- 19 course in LVAD recipients implanted before and during COVID-19 pandemic. Method(s): Between October 2015 and December 2019 (pre-COVID-19 era=group 1) 71 patients and since January 2020 to December 2021 (COVID-19 era=group 2) 31 patients were implanted with LVAD in a tertiary center in Poland. Of note, at the beginning of COVID-19 era (since 1st/Jan/2020) there were alive 39 (55%) previously implanted LVAD patients. The censor date for this analysis was 31st December 2021. Result(s): COVID-19 occurred in a similar percentage in both groups (group 1 - 39% vs. group 2 - 32%;p=0,4;however, more patients from group 1 required hospitalization [12 (80%) vs. 6 (60%);p<0.05] (Table 1). Blood oxygen saturation (SpO2) and mean arterial pressure (MAP) were lower in the group 1 in comparison to group 2 (86.5 vs. 95% and 69 vs. 79 mmHg;respectively, both p<0.05);however, respiratory and heart rates were similar. There were significant differences of white blood count (WBC) and their subpopulations between both groups. As for inflammatory markers, both procalcytonine and interleukin 6 (IL-6) were significantly higher in the group 1 (3.6 vs. 06 ng/ml and 112.5 vs. 87 pg/ml;respectively;both p<0.05);however CRP levels were similar. All patients from group 1 required oxygen therapy [12 (100%) vs. 4 (66.7%);p<0.05]. Intravenous inotropes were also more commonly used in patients from group 1 [10 (83%) vs. 2 (33%);p<0.05];however, other standard COIVD-19 therapies were similarly utilized in both groups. Two (5.1%) patients from group 1 and 1 (3.2%) patient from group 2 (p=0.29) died due to COVID-19. There were also no differences between non-COVID-19 related deaths between the groups (p=0,63). The vaccination rate against COVID-19 was similar in both groups - 65.7%. Conclusion(s): COVID-19 infections were common in LVAD recipients. Although clinical and laboratory profiles of LVAD recipients implanted before COVID-19 pandemic were worse in comparison to those who were implanted more recently, the actual survival rates were found to be similar. Surprisingly, only two-thirds of LVAD patients decided to undertake vaccine against COVID-19. These initial and single-center observations need to be interpreted with caution until more thorough analyses on more LVAD patients will be released.

Dilated Cardiomyopathy: Unmasking Contributing Etiologies

Background: The role of genetic conditions in the development of cardiomyopathy is well established;however, recognition and referral for genetic testing remains underutilized. Systematic review of complex cases can increase general awareness in this area of practice. Here we describe the case of a patient with resolved severe stress induced cardiomyopathy (SIC), who was ultimately found to have heterozygous transthyretin-mediated amyloidosis (TTRA). Case: A 27-year-old man (family history positive for a brother status post heart transplant) presented with ataxia and cough due to legionella pneumonia. TTE showed left ventricular (LV) diastolic diameter of 6.2cm, LV ejection fraction 20-25%. He suffered rapid decompensation with mixed cardiogenic/septic shock requiring peripheral VA ECMO and Impella-CP placement. Course notable for brief cardiac arrest on hospital day (HD) 2, incidental diagnosis of COVID 19 on HD 14, conversion to VV ECMO on HD 15, and ECMO decannulation on HD 23. Repeat TTE prior to discharge showed normalization of biventricular function. Discussion(s): Despite resolution of refractory shock and normalization of biventricular function prior to discharge, the TTE finding of mild LV dilation and strong family history prompted outpatient pursuit of genetic testing which revealed a heterozygous TTRA mutation (val142ile). Work-up to assess cardiac involvement included: a 99m-technetium pyrophosphate scintigraphy found to be indeterminate, an aborted endomyocardial biopsy due to inability to smoothly advance a bioptome (presumably related to ECMO cannulation), and a cardiac MRI (pending at the time of this submission). If a cardiac phenotype is discovered, the patient will be started on targeted treatment of cardiac amyloid. Screening of first-degree family members has been initiated. Conclusion(s): Given the current state of under-diagnosis of genetic cardiomyopathies and its association with significant morbidity and mortality, it is prudent to consider genetic testing in young patients based on clinical history. Examples of clinical scenarios to prompt further testing include: anatomical findings (i.e. cardiac chamber enlargement, left ventricular hypertrophy), family history of cardiomyopathy, or clinical markers suggestive of alternative diagnoses (i.e. neuropathy, renal insufficiency, mediastinal lymphadenopathy). This thoughtful and algorithmic use of genetic testing may help improve long-term patient outcomes given improvements in both detection, family screening, and treatment for disease-specific cardiomyopathies.Copyright © 2022

An Unusual Case of Cardiogenic Shock in a Cardio-Oncologic Patient

Background Graft versus host disease (GVHD) most often occurs 100-365 days after hematopoietic stem cell transplant (HSCT). Manifestations most often are dermatologic, hepatic or pulmonic, and are rarely cardiac. We present a unique case of GVHD inducing cardiogenic shock necessitating advanced heart failure therapies. Case This is a 34 year-old male with a history of acute lymphoblastic leukemia who completed chemoradiation and HSCT from an HLA perfect sibling in 1992. In May 2020, he presented with dyspnea for 6 weeks. An echocardiogram at that time showed an EF of 10% and severe biventricular dilatation. He was originally hospitalized at an outside institution for hypoxia where a left heart catheterization showed normal coronaries and goal directed therapy was initiated. After 2 negative COVID tests, he was discharged with a LifeVest. One month later, despite medication compliance, he returned in cardiogenic shock after his LifeVest was activated for ventricular tachycardia (VT). Decision-making He was started on inotropic therapy and an intra-aortic balloon pump (IABP) was placed 1:1 prior to transfer to our tertiary center. After support was started, a right heart catheterization showed a right atrial pressure of 13 mmHg, a wedge of 17, and a cardiac index of 2.6. His course was complicated by VT storm. Differentials for his non-ischemic cardiomyopathy (NICMO) included myocarditis (viral vs. giant cell) with a possible component of chemotherapy/radiation induced NICMO. Immediate AHFT work-up was started. He was unable to be weaned off his IABP or inotropic support. The decision was made to pursue emergent left ventricular assist device placement (LVAD) and achieve a definitive diagnosis with a core biopsy. Pathology resulted with myocyte hypertrophy, chronic inflammation with eosinophils concerning for chronic GVHD. Conclusion There have only been a handful of case reports describing cardiac manifestations of GVHD, and none with NICMO and cardiogenic shock requiring an LVAD. Despite this, suspicion should remain present for GVHD in HSCT patients regardless of time frame from oncologic therapies or specificity of HLA match when presenting in cardiogenic shock.Copyright © 2023 American College of Cardiology Foundation

Successful Use of Biventricular Assist Devices in Fulminant Myocarditis

Background Fulminant myocarditis can cause biventricular dysfunction with a mortality rate over 40%. We report a case with severe biventricular failure due to fulminant myocarditis that was successfully supported by left and right ventricular assist devices. Case A 65-year-old woman presented with chest pain, abdominal pain and diarrhea. She was hypotensive and labs revealed elevated troponin-T of 13.5 ng/mL and lactate of 4.3 mmol/L. She was positive for COVID by antigen testing. She was started on multiple vasopressor infusions and admitted to the intensive care unit. Echocardiogram revealed a severely reduced left ventricular ejection fraction of 15% and severe global hypokinesis. The following day, she developed a wide complex tachycardia that was refractory to amiodarone, lidocaine and multiple defibrillation attempts. She was transferred emergently to the cardiac cath lab where coronary angiography revealed an isolated 70% stenosis of the distal left circumflex artery. A Swan-Ganz catheter was placed that yielded a cardiac index by Fick of 1.2 L/min/m2, systemic vascular resistance of 1270 dynesseccm-5 and mixed venous oxygen saturation of 35%. Decision was made to emergently insert an Impella CP device. That evening, she developed complete heart block and transvenous pacing wire was inserted. Due to frequent suction alarms, decision was made to insert ProtekDuo device, which resulted in hemodynamic stabilization. A temporary coronary sinus pacing lead for atrial capture was inserted to improve atrioventricular synchrony. After several days of monitoring, repeat echocardiogram showed complete recovery of biventricular function and Impella CP and ProtekDuo devices were removed. Decision-making The decision of early implantation of ProtekDuo device was made to provide adequate blood flow to the left ventricular assist device for hemodynamic support. In addition, increased atrioventricular synchrony via insertion of temporary coronary sinus pacing wire improved cardiac output. Conclusion Fulminant myocarditis involving biventricular dysfunction can be supported by the use of simultaneous left and right ventricular assist devices.Copyright © 2023 American College of Cardiology Foundation

Evaluating Outcomes of Extracorporeal Life Support Use in Peripartum Patients: A Single Institution Experience

Background Indications and practice of extracorporeal membrane oxygenation (ECMO) use in pregnant patients are known;however, there is minimal evidence outside of meta-analysis and case series that comprehensively documents the outcomes. This study systematically evaluates the outcomes of ECMO utilization for peripartum patients in the setting of respiratory and/or cardiovascular failure. Methods All peripartum patients from 2018 to 2021 from a single center were screened to see if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. 15 patients met inclusion criteria of requiring ECMO while pregnant or up until 6 weeks postpartum. The patient demographics;operative details;ECMO registry data;critical care characteristics;adverse events per the codes for extracorporeal life support complications;and adverse outcome for maternal, fetus, and neonates were all collected. Results The cohort studied had a mean age of 30.3 years old, was racially diverse, and had few preexisting medical conditions before pregnancy. ECMO was indicated in 10/15 patients due to COVID-19 and 4/15 patients due to cardiac disease. ECMO was intended to be a bridge to recovery for 14/15 patients of which 11/14 patients recovered to discharge. The temporary ventricular decompression therapies used in VA ECMO patients were limited to the Protek Duo Right Ventricular Assist Device and TandemHeart device. No patients required transplantation or a durable mechanical device. Notable complications: 1 intrauterine fetal demise from placental malperfusion before ECMO was started;4 maternal deaths, of which 3 were related to ECMO;4 cardiac arrest events;1 limb ischemia event after ECMO cannulation;4 cannulation site hematomas;0 cannulation site hemorrhage;1 cardiac arrhythmia event;2 patients comprised all the intracranial hemorrhage events;and 2 patients comprised all the Gastrointestinal hemorrhage events. Conclusion To our knowledge;this is the first comprehensive documentation of adverse events in peripartum patients describing maternal, fetal, neonatal, and ECMO related outcomes. This data provides a standard format to evaluate risks of ECMO use in peripartum patients.Copyright © 2023 American College of Cardiology Foundation

Ventricular Assist Devices: Challenges of the One-device Era.

Heart failure (HF) is linked to to high mortality rates and recurrent hospitalisations despite medical and device-based achievements. The use of left ventricular assist devices (LVADs) has improved survival among patients with advanced HF. Significant progress has been achieved with the new generation of continuous-flow devices, particularly with the fully magnetically levitated HeartMate 3. In June 2021, Medtronic announced the abrupt withdrawal of the HeartWare device from the market. This decision has introduced a new era in which the field of mechanical support for advanced HF patients is dominated by a single device - the HeartMate 3. The direct clinical and economic consequences of this change will necessitate new surgical considerations. Because of the expected need for HeartWare device replacement in small patients, new surgical techniques and device adaptation will be needed. The new single-device era will hopefully encourage scientists and engineers to create innovations in the advanced HF arena. Special considerations should be taken during the COVID-19 pandemic when treating patients with LVADs.

The Society of Thoracic Surgeons Intermacs 2022 Annual Report: Focus on 2018 Heart Transplant Allocation System.

The thirteenth annual report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) highlights outcomes for 27,314 patients receiving continuous flow durable left ventricular assist devices (LVAD) over the last decade (2012-2021). In 2021, 2,464 primary LVADs were implanted, representing a 23.5% reduction in the annual volume compared to peak implantation in 2019 and an ongoing trend from the prior year. This decline is likely a reflection of the untoward effects of the COVID-19 pandemic and the change in the US heart transplant allocation system in 2018. The last several years have been characterized by a shift in device indication and type with 81.1% of patients now implanted as destination therapy and 92.7% receiving an LVAD with full magnetic levitation in 2021. However, despite an older, more ill population being increasingly supported pre-implant with temporary circulatory devices in the recent (2017-2021) vs prior (2012-2016) eras, the 1- and 5-year survival continues to improve at 83.0% and 51.9%, respectively. The adverse events profile has also improved, with significant reduction in stroke, gastrointestinal bleeding, and hospital readmissions. Finally, we examined the impact of the change in heart transplant allocation system in 2018 on LVAD candidacy, implant strategy, and outcomes. In the competing outcomes analysis, the proportion of transplant eligible patients receiving a transplant has declined from 56.5% to 46.0% at 3 years, while the proportion remaining alive with ongoing support has improved from 24.1% to 38.1% at 3 years, underscoring the durability of the currently available technology.

Exergaming in patients with a left ventricular assist device: a feasibility study.

AIMS: Exercise games (exergames) have been recently proposed as a mode of facilitating physical activity in patients with chronic diseases. Although patients supported with left ventricular assist devices (LVADs) benefit from physical activity, specific LVAD-related issues hinder their ability to exercise properly. The objective of this study was to assess the feasibility and safety of exergaming in LVAD-supported patients. METHODS AND RESULTS: Eleven LVAD-supported patients were enrolled in a 4 week exergaming programme using Nintendo Wii console with five sport games. Patients were instructed to play for 30 min a day, 5 days a week. Data on exercise capacity and exergaming were collected by using the 6 min walk test (6MWT) and a daily self-report diary, respectively. Feasibility of using the console and its safety was assessed by a semi-structured patient interview. Quality of life was assessed by the Minnesota Living with Heart failure Questionnaire (MLHFQ) and the Cantril's Ladder of Life. Safety was assessed by patient's report in interview and diary. The study group consisted of 10 male patients and 1 female patient, mean age of 67 ± 7 years, of whom 10 were supported with the HeartMate 3 LVAD for a median of 10 (interquartile range 3, 21) months. Baseline exercise capacity assessed by the 6MWT ranged from 240 to 570 m (mean 448 ± 112). After 4 weeks of exergaming, 6MWT distance increased from a mean of 448 ± 112 (evaluated in six patients) to 472 ± 113 m (P = 0.023). Patients' Cantril's Ladder of Life score improved numerically from an average of 6.13 to 7.67, as did their MLHFQ score from 45.9 ± 27 to 38.7 ± 18, with higher and lower scores, respectively, reflecting higher quality of life. No specific LVAD-related safety issues regarding exergaming were reported. CONCLUSIONS: Exergaming was found to be a safe and feasible mode for encouraging physical activity in LVAD-supported patients and carries a potential for improving exercise capacity and quality of life in these patients. Larger scale studies are warranted to further investigate the effect of exergaming in this patient population.

Outcomes of COVID-19 in heart failure, LVAD, and heart transplant patients in an advanced heart failure practice.

Background: Patients with heart failure face increased morbidity and mortality when infected with COVID-19. The objective of this study was to evaluate the outcomes of patients with Heart Failure (HF), Left Ventricular Assist Devices (LVADs), or Heart Transplants (HTx) diagnosed with COVID-19 within an advanced HF practice. Methods: Out of 2635 patients followed, 96 patients were diagnosed with COVID-19 between March 2020 and January 2021. Median hospital length of stay (LOS), requirement for mechanical ventilation (MV), and mortality rate were evaluated. Results: The distribution of COVID-19 among the 96 patients was: HF = 43 (45 %), LVAD = 16 (17 %) and HTx = 37 (38 %). Among 43 HF patients, 5 (12 %) died, 18 (42 %) required hospitalization with an LOS of 7 days, 5 (12 %) required ICU and 4 (9 %) required MV. Of the 16 LVAD patients, 2 (13 %) died, 8 (50 %) required hospitalization with an LOS of 11 days, 3 (19 %) required ICU and 3 (19 %) required MV. Among 37 HTx patients, 7 (19 %) died, 23 (62 %) required hospitalization with an LOS of 9 days, 6 (16 %) required ICU and 6 (16 %) required MV. Conclusion: This report is among the first to describe the impact of COVID-19 on a diverse advanced HF practice. It highlights the risks associated with COVID-19 faced by the HF, LVAD and HTx patients. A 90-day mortality rate of 19 % with HTx patients acquiring COVID-19 is ominous as is a mortality rate of 12 % each for HF and LVAD patients. This clinical impact should serve as a reminder of unique challenges with these populations.

Mechanical Circulatory Support for Multisystem Inflammatory Syndrome in Children (MIS-C): A Single Center Case Series

Purpose: Multisystem inflammatory syndrome in children (MIS-C) is a rare but life-threatening complication of SARS-CoV-2 that is characterized by a hyperinflammatory state leading to multiorgan dysfunction. With prompt initiation of appropriate medical management, patients fair well with resolution of the hyperinflammatory state and recovery of end-organ function. However, a small subset of patients with MIS-C develop progressive end-organ dysfunction necessitating mechanical circulatory support (MCS). This case series describes a single center experience of MCS for MIS-C. Methods: This is a retrospective case series of patients diagnosed with MIS-C who required MCS between May 2020-February 2022 at Texas Children's Hospital. The study was conducted under institutional review board approval. Results: During the study period, 291 patients were diagnosed with MISC. Of those, 6 required MCS: 4 were placed on VAECMO with 1 patient additionally requiring a left ventricular assist device (LVAD), 1 required solely LVAD support, and 1 required VV-ECMO in the setting of pulmonary hemorrhage. In 5 of the 6 patients, the primary indication for MCS was a hemodynamically significant tachyarrythmia. Echocardiography showed worsening of global longitudinal strain (GLS) prior to cannulation in those patients in which it was measured. 5 of the 6 patients survived to hospital discharge. 2 patients required emergent fasciotomies and subsequent limb amputation. Immunomodulation with anakinra before MCS correlated with shorter intensive care length of stay. Outpatient follow-up was conducted in the MIS-C clinic, ranging from 1 to 15 months since discharge, with notable normalization of cardiac function and no additional adverse events. Conclusion: Overall, the need for MCS in patients diagnosed with MIS-C is uncommon and outcomes seem favorable. The development of tachyarrhythmias and worsening GLS may be risk factors for MCS. These findings need to be validated with larger, multicenter studies. Prospective studies of early therapeutic intervention in MIS-C are also needed.

Self-Measured Doppler Blood Pressure Readings in Continuous-Flow LVAD Patients are Reliable

Background: Blood pressure (BP) management is imperative in reducing risk of adverse events in continuous flow (CF) left ventricular assist device (LVAD) patients. The gold standard for non-invasive blood pressure (BP) measurement in these patients is Doppler ultrasound, which requires training and dexterity and is not routinely used in the outpatient setting. In the current COVID-19 pandemic era, telehealth assessment has become mandatory to assess and monitor patients. At our institution, we have issued all CF-LVAD patients with a Doppler ultrasound device and an oscillometric BP monitor, and provided training to correctly use these devices. Accuracy of BP measurements in this setting has not been confirmed. Aim: We examined whether Doppler BP obtained by CF-LVAD patients (pts) correlates to Doppler BP obtained by health care workers (HCWs). Methods: CF-LVAD pts were recruited between November 2020 and January 2022. During these routine outpatient follow-up visits, Doppler BP measurements were obtained simultaneously and independently by pts and HCW. BP was taken in a comfortable seating position following 5 minutes rest. Results: A total 223 pairs of simultaneous patient Doppler BP readings and HCW Doppler BP readings were obtained from 38 CF-LVAD patients (87% male, mean age at implant 52 + 14 years, 15 HeartMate3 and 23 HeartWare HVAD, with support duration range 28 - 3492 days). Patient Doppler BP (average 85.9 + 9.8 mmHg) correlated closely with HCW Doppler BP (average 86.1 + 9.6 mmHg), r2=0.90, p<0.0001. There was no significant difference between BP taken by the patient and HCW (p=0.4). The mean difference between the two methods was -0.17 mmHg and the standard deviation was 0.22 mmHg (figure) using Bland-Altman analysis. Conclusions: These results demonstrate that in our patient-population, Doppler-derived blood pressure measurements in CF-LVAD patients were accurate and reliable. This supports the routine use of home Doppler BP measurement and monitoring by CF-LVAD patients, especially in the telehealth era. (Figure Presented).

Platelet Function at the Intersection of the COVID-19 “Cytokine Storm” and Mechanical Circulatory Support

Purpose: Release and circulation of pro-inflammatory cytokines or “cytokine storm,” a pathophysiologic component of severe COVID-19, is associated with thrombosis and clot embolization. Compromised patients often require extracorporeal oxygenation and mechanical circulatory support (MCS), imparting blood flow disturbances and exogenous shear stress, further amplifying thrombotic potential. Central in these processes is the platelet. The dynamic interaction of MCS flow/shear and inflammatory cytokines and their propensity for altering platelet function remains unknown. We hypothesized that platelet function is modified in an MCS + pro-inflammatory cytokine environment. We examined platelet aggregation as a function of time, exposing platelets to COVID-19-associated cytokines under MCS flow in vitro. Methods: An Impella5.5® was affixed in a closed loop and positioned with outflow cannula in a 1-inch tube region, maintained at differential 60mmHg pressure. Alternatively, a CentriMag® was affixed in series with a similar closed loop. Porcine PRP, obtained via centrifugation of fresh, ACD-A anticoagulated whole blood was used as circulating fluid. A cytokine “COVID cocktail” of porcine IL-6 (4.5 ng/mL), IL-1β (0.5 ng/mL), IL-8 (2.7 ng/mL), and TNFα (1 ng/mL) was added to PRP and circulated at 5 L/ min. After 5, 60 and 240min of circulation, platelet samples were taken and measured for aggregation with ADP (20uM), and expression of activation markers (CD62P, AnnV) via flow cytometry. Samples were measured in duplicate from N ≥ 2 pigs per experiment. Results: The addition of COVID Cocktail cytokines led to an increase in overall aggregability of platelets over time. In contrast, the addition of shear via MCS devices led to a decrease in platelet aggregability despite Cytokine addition (Fig 1). Notably, platelet aggregability was more greatly reduced with CentriMag (85% reduction) than with Impella (65% reduction). There was no significant difference in platelet activation (AnnV binding, CD62P exposure) between CentriMag and Impella 5.5 in the cytokine environment. (Figure Presented).

Left ventricular assist device implantation following multisystem inflammatory syndrome in children due to SARS-CoV-2.

Multisystem inflammatory syndrome in children (MIS-C) is rare, however, severe hyperinflammatory condition in children generally weeks after acute SARS-CoV-2 infection. A subset of MIS-C patients is presented with severe heart failure. We hereby report 8-year-old girl presenting acute severe left ventricular failure. Various medical treatments including inotropic agents and drugs related to SARS-CoV-2 infection and MIS-C were applied. However, venoarterial extracorporeal membrane oxygenation (ECMO) was needed to be performed. Due to unsuccessful attempts for ECMO weaning, left ventricular assist device was implanted to the patient with temporary right ventricular support from ECMO.

COVID-19 in patients with left ventricular assist device

Background. Coronavirus infection (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with cardiovascular disease especially patients with advanced heart failure are at particularly high risk of morbidity and mortality. Patients with left ventricular assist device (LVAD) represent a unique population at risk because of comorbidities and functionally compromised immunity. Аim of this article was to analyze clinical cases of COVID-19 among LVAD patients of the Republic of Kazakhstan. Material and methods. Characteristics of LVAD patients of the Republic of Kazakhstan who developed COVID-19 between March 2020 and August 2021, initial manifestations of the disease, comorbidities, complications and clinical outcomes were collected and analyzed. Results. A total of 177 patients with LVAD who were supported and registered by the NAO “National Scientific Cardiac Surgery Center” were interviewed. 41 (23.2%) patients had classic COVID-19 symptoms. The mean age of the patients was 55 years (interquartile range, 17-75), and 9 (21.9%) patients were female. The majority of patients (n=36, 87.8%) were implanted with LVAD HeartMate 3. The largest number, 19 (46%) patients, were patients with dilated cardiomyopathy (DCM). The time of LVAD support ranged from 1 month to 83 months before the onset of symptoms and diagnosis of COVID-19. 13 (31.7%) patients required hospitalization due to decreased oxygen saturation (less than 94%) and oxygen deprivation. 3 patients (1.7% among 177 supported patients and 7.3% among patients with COVID-19) required care and treatment in an intensive care unit. Conclusion. We presented an analysis of clinical cases in LVAD patients with COVID-19 in Kazakhstan. To note, there are no guidelines for management and treatment, no data related to the clinical course of COVID-19 in patients on LVAD support to date. Close monitoring of clinical status, anticoagulation and frequent collection of device parameters and DL exit site images, precautionary measures consideration, early diagnosis, timely initiated treatment, supportive psychological care, multidisciplinary approach and rigorous follow-up are crucial in the management of LVAD patients with COVID-19.

Outcomes of patients with left ventricular assist device infected with SARS-CoV-2.

Background: The aim of this study was to describe clinical characteristics, course, and outcomes of the novel coronavirus disease 2019 (COVID-19) in heart failure patients with left ventricular assist device. Methods: Between November 2020 and August 2021, a total of 20 patients (18 males, 2 females; mean age: 57.0+10.0 years; range, 30 to 71 years) with left ventricular assist device and who were diagnosed by the COVID-19 polymerase chain reaction testing were included. For each patient, disease-related factors were evaluated including presence of hospitalization, home quarantine, presence of lung damage, antiviral medication strategy, symptomatology and complications following COVID-19. Results: Seven patients 35% patients died in our cohort following the COVID-19. All these patients experienced variety of complications following COVID-19 including subarachnoid hemorrhage and right heart failure. Three patients were already hospitalized due to COVID-19 and decompensated progressively, resulting in death on Days 14, 4, and 7 after the initial diagnosis. Conclusion: COVID-19 seems to be an important cause of mortality in patients with LVAD who have borderline cardiopulmonary function. Great care should be taken to avoid interruption in routine follow-ups with these patients, since they present a more sensitive population.

Improvement in Coronary Allograft Vasculopathy Following Treatment with a Regimen Including Extracorporeal Photophoresis in a Heart Transplant Recipient

Introduction: Extracorporeal photophoresis (ECP) has been used for select heart transplant (HT) recipients with acute cellular rejection, recurrent or refractory rejection, antibody-mediated rejection (AMR) and as prophylactic therapy. Effects of ECP on coronary allograft vasculopathy (CAV) are not as well-described. Case Report: A 48 year-old man with a history of familial cardiomyopathy required left ventricular assist device therapy and ultimately HT in 2001. He developed ISHLT CAV 1 (40% stenosis of LCx and RCA) with severe microvascular dysfunction detected on PET scan (MFR Total 1.14, LAD 1.11, LCx 0.98, RCA 1.40). He was started on treatment with everolimus, but progressive chronic kidney disease necessitated a change back to mycophenolate mofetil. Following this change, his chronic Class II DSA increased significantly and his renal function worsened requiring dialysis, during which time he also had COVID-19. He then presented in cardiogenic shock with ISHLT CAV 3 and pAMR 2 in July 2020 and was treated with an IABP, plasmapheresis, and thymoglobulin. He had recurrent pAMR 2 three months later, for which he was treated with plasmapheresis, bortezomib, rituximab, and ECP. Prior to initiation of ECP, his coronary angiogram demonstrated rapidly progressive ISHLT CAV 3 (80% proximal LAD, 80% ostial LCx, 70% OM1, and 80% mid RCA). Right heart catheterization demonstrated restrictive filling pressures and echocardiogram demonstrated normal graft systolic function. Four months following initiation of ECP therapy, repeat coronary angiography showed improvement of his CAV: the stenosis in the pLAD had regressed to 50%, the proximal LCX stenosis had regressed to 50%, and disease in the distal circumflex artery had also improved (Figure). In our patient, ECP along with multiple other therapies was associated with significant regression of CAV. Even many years post-HT, CAV may be amenable to some therapies.

Isolated Durable LVAD Bridge to Transplant: Institutional Review Following 2018 Allocation Changes

Purpose: The purpose of this study was to compare our institutional experience using durable left ventricular assist devices (dLVADs) as a bridge to transplant before and after the 2018 heart allocation policy change. Methods: Since the allocation change, 29 patients have been bridged to heart transplantation with an isolated dLVAD at our institution. We matched these patients with the most recent 29 consecutive patients bridged to heart transplantation with isolated dLVAD. Baseline pretransplant characteristics and comorbidities were compared between cohorts. Incidence of posttransplant complications, intensive care unit and hospital lengths of stay were compared, as well as 90-day mortality. Results: Annual number of recipients bridged to transplant using a dLVAD declined after the first year following the allocation policy change (Figure A). Median age, body mass index, and distributions of primary heart failure etiology and dLVAD usage were similar between cohorts. The new policy cohort had a higher incidence of female recipients (21% vs 3%;P=0.044), but a lower incidence of patients maintained on intravenous inotropic therapy at time of transplant (3% vs 21%;P=0.044). Rates of prolonged mechanical ventilation, re-intubation, stroke and renal failure were comparable between cohorts. Intensive care unit length of stay and hospital length of stay were also similar. At 90 days, the new policy cohort experienced higher mortality (21% vs 3%;P=0.044) (Figure B). Conclusion: From our institutional experience, there appears to be continual decline in patients bridged with dLVAD following the allocation policy change. While rates of many postoperative complications appear comparable to the prior era, short-term mortality appears to be higher. Changes in the heart transplant allocation system have resulted in changes in donor availability and selection for recipients with durable LVADs. These changes, along with the impact of the COVID-19 pandemic, may be responsible for these observations.