Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety.

BACKGROUND: The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history. METHODS: The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors. RESULTS: The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001). CONCLUSIONS: Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.

Prospective validation of the SCAI shock classification: Single center analysis.

BACKGROUND: The Society for Cardiac Angiography and Interventions (SCAI) Shock Classification has been retrospectively validated by several groups. We sought to prospectively study outcomes of consecutive patients with reference to initial SCAI Shock Stage and therapeutic strategy as well as 24 hr SCAI Shock Stage reassessment. METHODS: Kaplan Meier method was used to describe survival and Cox Proportional hazards modeling used to assess predictors of survival. RESULTS: Over an 18-month period, 166 patients were referred for evaluation. Demographics, hemodynamics, and most laboratory findings were similar between SCAI stages, which were assigned by the team. Initial SCAI Stage was a strong predictor of survival. Thirty-day survival was 100, 65.4, 44.2, and 60% for patients with initial SCAI shock stage B, C, D, and E respectively (p = .0004). Age and initial SCAI Shock Stage were shown to be the strongest predictors of survival by Cox proportional hazards. Mode of mechanical circulatory support (MCS) or lack of such was not a predictor of outcome. Shock stage at 24 hr was also examined. Thirty-day survival was 100, 96.7, 66.9, 21.6, and 6.2% for patients with 3-4 SCAI stage improvement, 2 stage improvement, 1 stage improvement, no change in SCAI stage and worsening of SCAI stage respectively (p < .0001). CONCLUSIONS: Initial SCAI Shock stage predicts the survival of unselected patients with a variety of MCS interventions and medical therapy alone. The 24-hr reassessment of shock stage further refines the prognosis.

Outcomes of hemodynamic support with Impella in very high-risk patients undergoing balloon aortic valvuloplasty: Results from the Global cVAD Registry.

BACKGROUND: Reports on the role of hemodynamic support devices in patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction undergoing balloon aortic valvuloplasty (BAV) are limited. METHODS: Patients were identified from the cVAD registry, an ongoing multicenter voluntary registry at selected sites in North America that have used Impella in >10 patients. RESULTS: A total of 116 patients with AS who underwent BAV with Impella support were identified. Mean age was 80.41±9.03years and most patients were male. Mean STS score was 18.77%±18.32, LVEF was 27.14%±16.07, and 42% underwent concomitant PCI. In most cases Impella was placed electively prior to BAV, whereas 26.7% were placed as an emergency. The two groups had similar baseline characteristics except for higher prevalence of CAD and lower LVEF in the elective group, and higher STS score in the emergency group. Elective strategy was associated higher 1-year survival compared to emergency placement (56% vs. 29.2%, p=0.003). One-year survival was higher when BAV was used as a bridge to definitive therapy as opposed to palliative treatment (90% vs. 28%, p<0.001). On multivariate analysis, STS score and aim of BAV (bridge to definitive therapy vs. palliative indication) were independent predictors of mortality. CONCLUSION: In this large cohort of patients with AS and severe LV dysfunction undergoing BAV, our results demonstrates feasibility and promising long-term outcomes using elective Impella support with the intention to bridge to a definitive therapy.

Incidence of Hemolysis in Patients with Cardiogenic Shock Treated with Impella Percutaneous Left Ventricular Assist Device.

Impella assist devices have been increasingly used in cardiogenic shock (CS). This study aims to assess the incidence of hemolysis when Impella support is used longer than 6 hours in CS. We retrospectively studied all patients who required Impella between April 2009 and September 2013. Demographic data and hemolysis indicators were sampled and analyzed using paired t-test. A total of 118 devices were placed and 40 used longer than 6 hours. The average time of support was 86.63 hours, and the 30 and 90 days of survival were 65% and 60%, respectively. After 24 hours of support, the hemoglobin (Hb) decreased significantly despite 17% of patients receiving blood transfusion (p = 0.0001). By the time of removal, 65% of patients were transfused to maintain a Hb of 10 mg/dl (p = 0.0014). The lactate dehydrogenase (LDH) increased to 5,201 U/L (n = 22; p = 0.0096), the bilirubin to 5.6 mg/dl (p = 0.008), and the haptoglobin level was 15.4 mg/dl (n = 25). The cumulative incidence of hemolysis was 62.5%. Hemolysis is a common occurrence in patients with long-term Impella support for CS, evaluated by the persistent decline in Hb and haptoglobin as well as increase in LDH and bilirubin. Strict monitoring of hemolysis parameters at baseline and at frequent intervals is crucial.