Improved waitlist and comparable post-transplant outcomes in simultaneous heart-kidney transplantation under the 2018 heart allocation system.

OBJECTIVE: This study aimed to investigate the clinical trends and the impact of the 2018 heart allocation policy change on both waitlist and post-transplant outcomes in simultaneous heart-kidney transplantation in the United States. METHODS: The United Network for Organ Sharing registry was queried to compare adult patients before and after the allocation policy change. This study included 2 separate analyses evaluating the waitlist and post-transplant outcomes. Multivariable analyses were performed to determine the 2018 allocation system's risk-adjusted hazards for 1-year waitlist and post-transplant mortality. RESULTS: The initial analysis investigating the waitlist outcomes included 1779 patients listed for simultaneous heart-kidney transplantation. Of these, 1075 patients (60.4%) were listed after the 2018 allocation policy change. After the policy change, the waitlist outcomes significantly improved with a shorter waitlist time, lower likelihood of de-listing, and higher likelihood of transplantation. In the subsequent analysis investigating the post-transplant outcomes, 1130 simultaneous heart-kidney transplant recipients were included, where 738 patients (65.3%) underwent simultaneous heart-kidney transplantation after the policy change. The 90-day, 6-month, and 1-year post-transplant survival and complication rates were comparable before and after the policy change. Multivariable analyses demonstrated that the 2018 allocation system positively impacted risk-adjusted 1-year waitlist mortality (sub-hazard ratio, 0.66, 95% CI, 0.51-0.85, P < .001), but it did not significantly impact risk-adjusted 1-year post-transplant mortality (hazard ratio, 1.03; 95% CI, 0.72-1.47, P = .876). CONCLUSIONS: This study demonstrates increased rates of simultaneous heart-kidney transplantation with a shorter waitlist time after the 2018 allocation policy change. Furthermore, there were improved waitlist outcomes and comparable early post-transplant survival after simultaneous heart-kidney transplantation under the 2018 allocation system.

Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors.

OBJECTIVE: To quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. METHODS: The United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. RESULTS: A total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score-matched cohorts of DBD and DCD recipients. CONCLUSIONS: The use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.

Concomitant Use of VA-ECMO and Impella Support for Cardiogenic Shock.

Background: VA-ECMO with concomitant Impella support (ECpella) is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with ECpella support have not been well-described. Methods: This study was a retrospective, single-center analysis of patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with ECpella from December 2020 to January 2023. Primary outcomes included 90-day survival post-discharge and destination after support. Secondary outcomes included complications post-ECpella support. Results: A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival 90 days post-discharge (p = .267) with similar destinations after ECpella support (p = .220). Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (p=.013; p = .030). Patients with initial Impella support were more likely to survive ECpella support and be bridged to transplant (p=.033) and less likely to have a cerebrovascular accident (p=.016). Sub-analysis of ADHF-CS patients into acute-on-chronic decompensated heart failure and de novo heart failure demonstrated no difference in survival or destination. Conclusion: ECpella can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS in patients with ECpella support. Patients with initial Impella support are more likely to survive ECpella support and bridge to transplant. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with ECpella support.

Redo orthotopic heart transplantation in the current era.

OBJECTIVE: This study aims to investigate the trends, outcomes, and risk factors for mortality after redo orthotopic heart transplantation. METHODS: The United Network for Organ Sharing registry was used to identify adult orthotopic heart transplantation recipients from 2000 to 2020 and stratify into primary and redo cohorts. Five-year post-transplant survival was compared between 2 propensity-matched cohorts. Multivariable modeling was performed to identify risk-adjusted predictors of redo post-transplant mortality, both conditional and nonconditional on shorter-term survival. RESULTS: A total of 40,711 recipients were analyzed, 39,657 (97.4%) primary and 1054 (2.6%) redo. Redo recipients had a lower median age and were more frequently bridged with intravenous inotropes, intra-aortic balloon pump, or extracorporeal membrane oxygenation (all P < .05). One- and 5-year survivals were lower after redo orthotopic heart transplantation (90.0% vs 83.4% and 77.6% vs 68.6%, respectively) and remained lower after comparing 2 propensity-matched cohorts. Multivariable modeling found factors such as increasing donor age and graft ischemic times, along with pretransplant mechanical ventilation and blood transfusion, to negatively affect 90-day survival. Contingent on 1-year survival, donor factors such as hypertension (hazard ratio, 1.51; 95% confidence interval, 1.15-2.00, P = .004) and left ventricular ejection fraction less than 50% (hazard ratio, 2.22, 95% confidence interval, 1.16-4.24, P = .016) negatively affected survival at 5 years. CONCLUSIONS: Although infrequently performed, redo orthotopic heart transplantation remains associated with worse post-transplant outcomes compared with primary orthotopic heart transplantation. Although several high-risk features were identified to affect post-retransplant outcomes in the acute perioperative period, donor characteristics such as hypertension and decreased ejection fraction continue to have lasting negative impacts in the longer term.

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND: Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects. METHODS: A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs). RESULTS: In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010). CONCLUSIONS: The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

Intra-Aortic Balloon Pump Bridging to Heart Transplantation: Impact of the 2018 Allocation Change.

BACKGROUND: This study evaluates the impact of the 2018 allocation policy change on outcomes of orthotopic heart transplantation (OHT) in patients bridged with intra-aortic balloon pumps (IABPs). METHODS: Adult (≥18 years) patients undergoing OHT between 2013 and 2019 who were bridged with an IABP were stratified based on temporal relation to the policy change. Univariate analysis was used to compare baseline characteristics and postoperative outcomes. Multivariate Cox regression analysis was used to estimate risk-adjusted predictors of post-transplant mortality. RESULTS: A total of 1342 (8.6%) OHT patients were bridged with an IABP during the study period. Rates of bridging with IABP to OHT increased significantly after the policy change (7.0% versus 24.9%, P<0.001). The mean recipient age was 54.1±12.1 years with 981 (73.1%) patients being male. Baseline characteristics were similar between the 2 groups whereas post-policy change patients spent fewer days on the waitlist (15 versus 35 days, P<0.001), had longer ischemic times (3.5 versus 3.0 hours, P<0.001), and received organs from a greater distance (301 versus 105 miles, P<0.001). By multivariable analysis, days on the waitlist (for every 30 days; odds ratio, 1.01 [95% CI, 1.00-1.02], P=0.031) and diabetes mellitus (odds ratio, 1.87 [95% CI, 1.16-3.02], P=0.011) emerged as significant predictors of post-transplant mortality. After the policy change, waitlisted patients requiring IABP support were more likely to survive to transplant (76.4 versus 89.8%, P<0.001). CONCLUSIONS: IABP utilization has increased over 3-fold since the 2018 policy change with improved waitlist outcomes and comparable post-OHT survival. Thus, bridging patients to OHT with IABPs appears to be an effective strategy in the current era.

DNA Sequencing of Type Material Reveals Pneophyllum marlothii comb. nov. from South Africa and P. discoideum comb. nov. (Chamberlainoideae, Corallinales, Rhodophyta) from Argentina.

A partial rbcL sequence from the type material of Spongites discoideus from southern Argentina showed that it was distinct from rbcL sequences of South African specimens to which that name had been applied based on morpho-anatomy. A partial rbcL sequence from an original syntype specimen, herein designated the lectotype, of Lithophyllum marlothii, type locality Camps Bay, Western Cape Province, South Africa, was identical to rbcL sequences of South African field-collected specimens assigned to S. discoideus. Based on phylogenetic analyses of rbcL and/or psbA sequences, both of these species belong in Pneophyllum and are transferred there as P. discoideum comb. nov. and P. marlothii comb. nov. The two species exhibit a distinct type of development where thick, secondary, monomerous disks are produced from thin, primary, dimerous crusts. Whether this type of development represents an example of convergent evolution or is characteristic of a clade of species within Pneophyllum remains to be resolved.

New diagnostic characters for the order Sporolithales (Corallinophycidae, Rhodophyta).

The diagnosis of the order Sporolithales is currently restricted to tetrasporangial anatomy. Until recently, there were few reports about gametangial, and more specifically carposporangial material for the Sporolithales. This study provides the first detailed observations of the anatomy of the mature carposporophyte phase from three species of Sporolithales commonly found in rhodolith beds from Brazil: Sporolithon episporum, S. ptychoides, and Sporolithon sp. Using these observations, along with previously published descriptions and illustrations from other representative species in the order, a comparison was made with the other three orders (Corallinales, Hapalidiales, and Rhodogorgonales) of the Corallinophycidae. We amend the diagnosis of the order Sporolithales to include the anatomy of the mature carposporophyte as follows: carposporangial conceptacles that lack a central fusion cell, but instead with numerous, short, one to two-celled, filaments that bear oblong terminal carposporangia that are distributed across the conceptacle chamber floor and walls.

Population and development beyond the first demographic transition: a focus on the experience of east and southeast Asian countries / População e desenvolvimento além da primeira transição demográfica: discussão da experiência de países do leste e sudeste da Ásia / Población y desarrollo más allá de la primera transición demográfica: discusión sobre la experiencia de países del este y sudeste asiático

This paper covers a wide scope, focusing on some trends in East and Southeast Asia that may be of interest to Latin America. The first demographic transition has essentially been completed in both regions. The issue is what should now be the focus of our consideration of population and development? East Asian countries are now stressing issues of ultra-low fertility, and policies to raise fertility. They are not comfortable with the prospect of making up future deficits through international migration. The paper also deals briefly with studies of dynamics of change in mega-urban regions, and argues that comparative studies on Latin America and Asia could be valuable. Issues of poverty, development, and equity are then addressed, with particular emphasis on the role of education as a key to equality and development. One dilemma is that in East Asia, the generally commendable obsession with education is one factor making for very low levels of fertility. Finally, the paper touches on population and environmental issues.

Este artigo é bastante abrangente e se concentra em algumas tendências do Leste e Sudeste da Ásia que podem ser de interesse para a América Latina. A primeira transição demográfica foi concluída em essência em ambas as regiões. A questão atual é qual deve ser o foco de nossa atenção em população e desenvolvimento? Atualmente, os países da Ásia Oriental estão enfatizando as questões de fecundidade ultrabaixa e políticas para fomentar a fecundidade. Esses países não se sentem à vontade com a perspectiva de compensar déficits futuros por meio de migração internacional. Este artigo também discute de forma resumida os estudos de dinâmica de mudança em regiões megaurbanas, e defende a ideia de que estudos comparando a América Latina e a Ásia poderiam ser de grande importância. Em seguida, são discutidas as questões da pobreza, desenvolvimento e equidade, com especial ênfase no papel da educação como fator-chave para a equidade e o desenvolvimento. Um dos dilemas é que a obsessão, em geral admirável, da Ásia Oriental com educação é um dos fatores que determinam os índices muito baixos de fecundidade. Por fim, o artigo aborda questões populacionais e ambientais.

Este artículo es bastante englobador, y se concentra en algunas tendencias del Este y Sudeste asiático que pueden resultar de interés para América Latina. La primera transición demográfica concluyó en esencia en ambas regiones. La cuestión actual es cuál debe ser el foco de nuestra atención en población y desarrollo. Actualmente, los países de Asia Oriental están dando énfasis a las cuestiones de fertilidad ultrabaja y políticas para fomentar la fertilidad. Esos países no se sienten a gusto con la perspectiva de compensar déficits futuros a través de la migración internacional. Este artículo también discute de forma resumida los estudios de dinámica de cambios en regiones megaurbanas, y defiende la idea de que estudios comparando América Latina y Asia podrían ser de gran importancia. A continuación, se discuten las cuestiones de pobreza, desarrollo y equidad, con especial énfasis en el papel de la educación como factor clave para la equidad y el desarrollo. Uno de los dilemas es que la obsesión, en general admirable, de Asia Oriental con la educación es uno de los factores que determina los índices tan bajos de fertilidad. Finalmente, el artículo aborda cuestiones poblacionales y ambientales.